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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11,283
| 191,341
|
22024
|
Discharge summary
|
report
|
Admission Date: [**2160-9-10**] Discharge Date: [**2160-9-26**]
Date of Birth: [**2084-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
inreased SOB and fatigue
Major Surgical or Invasive Procedure:
[**2160-9-12**] Aortic valve replacement with a 25 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial tissue heart valve. Coronary artery bypass grafting
times 3 with the left internal mammary artery grafted to the
left anterior descending with reverse saphenous vein graft to
the ramus intermedius branch and marginal branch and circumflex.
Placement of intra-aortic balloon pump.
History of Present Illness:
Mr. [**Known lastname **] is a 76-year-old male who is known to have severe
aortic insufficiency with worsening heart failure, shortness of
breath, dyspnea on exertion. He underwent cardiac
catheterization that showed severe three-
vessel disease. He has a history of a v-fib arrest in the past
and a diminished ejection fraction estimated at about 25-30%.
He is status post placement of an AICD. He also suffers from
chronic atrial fibrillation as well. He is presenting for
high-risk aortic valve replacement and coronary artery bypass
operation.
Past Medical History:
1. Cardiac history as above
2. Left hip fracture with no surgical intervention
3. Iron deficiency anemia
4. GERD
5. Renal Insufficiency
6. CAD
7. A Fib
8. HTN
9. CHF
10. ^ cholesterol
11. VFib arrest with AICD
Social History:
Pt lives with his significant other. [**Name (NI) **] is a retired carpenter.
He is Jehova's witness and declines all blood products. No ETOH,
tobacco, or drugs.
Family History:
[**Name (NI) 1094**] brother had a 4 vessel CABG in his 40s.
Physical Exam:
Vitals:97.9 HR 82 Afib 112/76 94% RAsat :EXAM [**9-26**] at discharge
General:
HEENT:
Neck:no JVD
Chest:CTA bilat with decreased BS at bases
Heart:[**Last Name (un) **] no murmur
Abd:soft, nt, nd
Ext:2+ LLE edema with erythema; trace edema RLE with
Pulese:
Neuro:A X O , nonfocal exam
Pertinent Results:
[**2160-9-25**] 06:58AM BLOOD WBC-11.7* RBC-4.10* Hgb-12.0* Hct-36.8*
MCV-90 MCH-29.4 MCHC-32.7 RDW-15.5 Plt Ct-183
[**2160-9-25**] 06:58AM BLOOD Glucose-70 UreaN-32* Creat-1.7* Na-138
K-4.5 Cl-100 HCO3-26 AnGap-17
[**2160-9-18**] 09:47AM BLOOD HEPARIN DEPENDENT ANTIBODIES - negative
[**2160-9-26**] 06:50AM BLOOD WBC-9.5 Hct-33.4*
[**2160-9-11**] 01:20PM BLOOD WBC-7.8 RBC-4.38* Hgb-13.6* Hct-39.2*
MCV-90 MCH-31.1 MCHC-34.8 RDW-15.5 Plt Ct-147*
[**2160-9-26**] 06:50AM BLOOD PT-21.0* INR(PT)-3.2
[**2160-9-26**] 06:50AM BLOOD UreaN-29* Creat-1.8* K-4.3
[**2160-9-11**] 01:20PM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**9-10**] and underwent cardiac
catheterization. Coronary angiography revealed a right dominant
system and severe three vessel disease. The LMCA had severe
diffuse disease with 70% stenosis in the mid vessel. The D1 had
70% stenosis at the mid segment. The LCX had severe diffuse 80%
stenosis proximally and 70% stenosis distally after the OM2
takeoff. The RCA was not evaluated due to known total
occlusiosn. The aortography revealed 4+ aortic insufficiency.
Based on the above results, cardiac surgery was consulted and
further evaluation was performed. Underwent AVR/CABG X3 / IABP
placement on [**9-12**] and transferred to CSRU in stable condition.
(Chart from [**9-10**] to [**9-19**] is missing - medical records was
notified ).IABP was removed in the unit postoperatively.He spent
several additional days in the CSRU for management of diuresis
and rhythm. Chest tubes and pacing wires were removed after the
patient transferred to the floor. He continued to work on
ambulation and pulmonary toilet while remaining in atrial
fibrillation over the next several days. Adjustments were made
in his BP meds and to optimize diuresis. He was restarted on
coumadin with goal INR 2.0-2.5. On day of discharge [**9-26**] (please
see exam), INR 3.2, so coumadin dose for today will be held. Pt.
is to have VNA blood draw in AM [**9-27**] and follow-up with Dr.
[**Last Name (STitle) 11493**] for dosing for tomorrow. Discharged to home with VNA
services on [**9-26**].
Medications on Admission:
Mucomyst ( stopped [**9-12**])
ASA 325 mg qd
Colace
Folic Acid
Lasix 20 mg QD
Toprol XL 200 mg qd
Protonix
SL Nitrostat prn
Ambien prn
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
Disp:*60 Capsule(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for INR goal 2.0-2.5 for prn days: hold today [**9-26**]: goal
INR 2.0-2.5.
Disp:*40 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY
(Daily).
Disp:*30 Packet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*1*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
s/p AVR(#25 CE pericardial)CABGx#(LIMA->LAD,SVG->OM,SVG->Ramus)
PMH: CAD, HTN, ^chol, Afib, VF arrest s/p ICD placement,
CRI(1.5-2.2) Lft hip fx, anemia, GERD, bil cataracts, HOH
Discharge Condition:
Good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
wound clinic in 1 week on [**Hospital Ward Name 121**] 11
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**Last Name (STitle) 11493**] in 2 weeks- daily coumadin dosing /INR follow-up
[**Telephone/Fax (1) 11650**]
Completed by:[**2160-9-26**]
|
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icd9cm
|
[
[
[]
]
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icd9pcs
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5923, 5957
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2732, 4242
|
300, 698
|
6180, 6187
|
2089, 2709
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6388, 6630
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5978, 6159
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4268, 4404
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6211, 6365
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1783, 2070
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236, 262
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726, 1278
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1300, 1511
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1527, 1690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,469
| 107,325
|
34524
|
Discharge summary
|
report
|
Admission Date: [**2123-4-29**] Discharge Date: [**2123-5-12**]
Date of Birth: [**2072-4-26**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Latex / morphine / Sulfa (Sulfonamide Antibiotics)
/ Codeine
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Nonunion C45
Major Surgical or Invasive Procedure:
Stage 1
1. Exploration of spinal fusion C4-C5.
2. Removal of hardware C4-C5.
3. Open deep biopsy, bone.
4. C4 partial corpectomy.
5. C5 vertebral body partial excision, removal of intrinsic
lesion.
6. Allograft for fusion.
7. C4-C5 arthrodesis.
Stage 2:
1. Exploration of spinal fusion C4-C5, C5-C6, C6-C7.
2. C4-C5 bilateral hemilaminotomy.
3. Posterior cervical fusion C4-C5.
4. Instrumentation C4 to C5.
5. Allograft for fusion.
6. Iliac crest bone graft for fusion.
History of Present Illness:
In summary, she is a 50-year-old female who underwent anterior
cervical discectomy and fusion, [**2122-6-12**], for treatment of disc
segment disease. She developed postoperative infection,
osteomyelitis, requiring suppressive antibiotics. For that
reason in part she wants to become a candidate for hardware
removal with a goal of eradicating her infection.
We did perform a CT scan for her on [**2123-3-9**] to assess the
status of her fusion. She also want flexion and extension
radiographs. Both her CT scan and flexion and extension
radiographs are most consistent with a nonunion. Since she did
not have a healed spinal fusion, revision surgery treatment will
require a two-staged approach.
We discussed at length the surgical strategy and also the
rationale for surgery. We discussed the alternatives, risks and
benefits of both surgical and ongoing nonsurgical care. With
the
goal of eradicating infection, ultimately hopefully desisting
the
use of antibiotics, she has elected to undergo surgical
treatment.
This would be a two-staged approach.
The first stage would be anterior cervical hardware removal at
C4-C5 with debridement of the surgical site. This would then
allow cultures to also be taken, and first to follow her
inflammatory markers as an inpatient following that surgery.
She
would then be treated with postoperative antibiotics. If
postoperative antibiotics offer to have a normal decline in her
CRP trend, we may then pursue posterior spinal fusion with iliac
crest bone graft in the same hospitalization. If further
antibiotics are required, with infectious disease consultation
as
an inpatient, then we would do a second staged surgery for her
some weeks in the future after the goals of _____ sepsis have
been achieved in order to decrease the risk of potential wound
infection in her posterior cervical spine.
Past Medical History:
HTN
HL
.
PAST SURGICAL HISTORY
s/p revision ACDF C4-5 and s/p washout
S/P ACDF C5-C6 and C6-C7 3 years ago.
Tubal ligation
Lithotripsy
Cholecystectomy
Partial hysterectomy
Salivary gland removal
Social History:
nc
Family History:
nc
Physical Exam:
intact neuro
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the Stage 1 procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued per ID recommendations. Initial postop pain was
controlled with a PCA.
[**4-30**]: Code blue for unresponsive/apneic episode. O2 sat 35%, but
with poor wave form. Pt never lost pulse. Arousable by sternal
rub. Alert after dose of narcan. Transferred to SICU for close
monitoring
[**5-1**]: Transferred to floor without event
[**5-3**]: Stage 2 surgery was done (Posterior cerivcal fusion)
[**5-4**]: Overnight: temp from 99.9 to 101.7
[**5-5**]: HVAC drain was remioved. PCA and foley were discontinued.
[**5-6**]: Change Antibiotic to Vancomycin per ID
[**5-7**]: Tmax 100
[**5-8**]: PICC line was placed.
[**5-10**]: Vanco trough low. Dose adjusted (increased)
[**5-11**]: Vanco trough 13.9.
Diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet.
Physical therapy was consulted for mobilization OOB to ambulate.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
Gabapentin 1200''', Toprol XL 50', OMeprazole 20', ZOfran prn,
Seroquel 100hs, simvastatin 40', cetirizine 1-', Colace prn,
Minocycline 50'', Vitamin D qweek, levothyroxine 25mcg',
Cymbalta 20'', Lasix 20', Tomapax 25hs, Terazosin 2mg hs, Zoloft
50', sertraline 50', lorazepam 0.5'''
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at
bedtime)) as needed for constipation.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*80 Tablet(s)* Refills:*0*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. prazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
14. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
18. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 8H (Every 8 Hours).
Disp:*180 Recon Soln(s)* Refills:*1*
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
20. Outpatient Lab Work
Weekly tests
1. ESR CRP
2. CBC diff
3. BUN Cr
4. VAnco trough
Results fax to ID RNs at [**Numeric Identifier 10738**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. C4-C5 suspected nonunion.
2. C4-C5 suspected osteomyelitis.
3. Retained hardware.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Immediately after the operation:
- Activity:You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Swallowing: Difficulty swallowing is not uncommon after
this type of surgery. This should resolve over time. Please
take small bites and eat slowly. Removing the collar while
eating can be helpful ?????? however, please limit your movement of
your neck if you remove your collar while eating.
- Cervical Collar / Neck Brace: You need to wear the brace
at all times until your follow-up appointment which should be in
2 weeks. You may remove the collar to take a shower. Limit
your motion of your neck while the collar is off. Place the
collar back on your neck immediately after the shower.
- Wound Care:Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline x rays and answer any questions.
o We will then see you at 6 weeks from the day of the
operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
see discharge instructions
Treatments Frequency:
see discharge instructions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2123-5-18**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2123-5-18**] 11:15
OPAT attending visit [**5-25**] and [**6-15**] [**Location (un) **]
All questions regarding antibiotics please call [**Numeric Identifier 79307**].
PLease call above number for ID FU appointment
|
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56,757
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52461
|
Discharge summary
|
report
|
Admission Date: [**2122-7-22**] Discharge Date: [**2122-8-7**]
Date of Birth: [**2042-1-17**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13565**]
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a 80y/o M with a PMH of CAD, HTN, PVD, COPD
admitted to neurology service for new onset seizure now
transferred to MICU following bradycardic arrest. Per admission
note, the patient lives at a NH and was found to have leftward
eye deviation after eating breakfast this am, followed by
generalized tonic-clonic activity. Unclear duration of symptoms.
He was given 1mg Ativan, was noted to have incontinence of bowel
and bladder, however this is his baseline. Reported to be
post-ictal for approx 10 minutes with minimal verbal output.
There was question of L sided weakness at this time. There is no
previous history of seizure.
.
He was admitted to neurology service with preliminary workup
including Head CT negative. On the evening of transfer, Code
Blue was called at approx. 2am for asystole. Chest compressions
were briefly administered ~1min prior to code team arrival. Per
report the patient had bradycardia followed by asystole with
spontaneous return of circulation. The patient was intubated for
agonal breathing. 2PIV and L femoral line were placed. He
received ativan 2 mg without response. The patient was given 1mg
atropine for bradycardia to rate of the 30s with improvement in
HR to 70s. BP stable throughout. ECG without ischemic changes.
He is now transferred to the MICU for further management.
Past Medical History:
CAD
COPD
B/L hip fx and R hip replacement
BPH w/ obstructive uropathy
Mood d/o
PVD
Osteoporosis
HTN
GERD
Anemia
Mild dementia
Social History:
(+) tobacco, 5 cigarettes per day x 60 years, quit 1 yr ago.
Social EtOH. No drugs. Formerly in Marines. Now lives at [**Location **].
Family History:
Per admission note denies including specifically any hx of
seizure
Physical Exam:
Vitals: 98.6, BP 126/58, HR 63, RR 14, O2 100% on FI02 50%
Gen: intubated and sedated
HEENT - pupils pinpoint and reactive
CV: bradycardic, regular, no MRG
Resp: CTAB, no WRR
Abd: soft, NT/ND, NABS
Ext: no LE edema
Neuro: withdrawals all extremities to painful stimuli, moving
all ext. spontaneously
.
Examination on transfer from the ICU [**7-24**]:
.
GENERAL: mildly agitated
HEENT: Normocephalic, atraumatic. + conjunctival erythema. No
scleral icterus. MM dry. OP clear. Neck Supple, No LAD, No
thyromegaly. No nuchal rigidity
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: Scattered upper and lower extremity ecchymoses.
.
Neurologic:
-Mental Status: Alert, but inattentive. "[**2116**], [**Location **],
[**Month (only) 216**]" Unable relate history. Stated DOW forward but got stuck
on Wednesday when going in reverse. Language is dysarthric with
intact repetition. Speech was dysarthric but patient was notably
adentious. Able to follow simple one step commands but was
easily distracted from a given task. No evidence of neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: Pinpoint but ERRL 1.5 to 1mm and reactive.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: unable to test do to exam cooperation
XII: Tongue protrudes in midline.
.
-Motor: Moves all extremities spontaneously but too inattentive
to test strength.
.
-Sensory: No apparent deficits to light touch.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 1 1
R 3 3 3 1 1
Plantar response was flexor bilaterally.
.
-Coordination: Pt with bilateral action tremor r>l. Unable to
attend to FNF testing.
.
-Gait: Pt in restraints; gait deferred
Exam at time of discharge:
General: NAD, pleasant but disoriented to place
Pulm: CTA b/l, except at decr. sounds at right base
CV: S1,S1 nl, no g/m/r
Abd: soft, NT, ND, PEG in place, no drainage, c/d/i dressing.
The T-fasteners will fall out on their own in approximately six
weeks.
Ext: warm, dry, no edema
Neuro:
MSE: Please note, this exam will fluctuate based on time of day
(early AM - patient may present w/ somnolence that resolves to
exam listed below by late morning) Alert, awake. Oriented to
year, and month, but not date. Normal speech allowing for
dentures. No aphasia. Anomia to low frequency objects (watch
band). Able to perform DOW backwards, but not [**Doctor Last Name 1841**] backwards.
Knows some current events: [**Initials (NamePattern5) **] [**Last Name (NamePattern5) **]. [**Doctor Last Name 57176**] death. No
paraphasic errors, no L/R confusion.
CN: VF intact to threat. PERRL 2-1.5mm b/l. No nystagmus.
Face symmetric allowing for lack of dentures. Hearing impaired
to finger rub b/l. Palate midline, Tongue midline, shoulder
shrug intact.
Motor: Strength 4+/5 in UEs throughout, including FEs. LEs 4-/5
at R IP (site of prior hip replacement), L IP [**3-8**]. 4+/5 in the
remainder of LE m. groups.
Sensory: intact to LT in UE and LE. Could not assess
reproducibly in remainder due to inattention.
Coordination: FNF moderate end of movement dysmetria b/l. Trace
asterixis. Can not perform HKS.
Gait: patient in wheel chair at baseline.
Pertinent Results:
Laboratory studies on admission:
[**2122-7-22**] 10:35AM GLUCOSE-140* UREA N-16 CREAT-0.9 SODIUM-134
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-30 ANION GAP-11
[**2122-7-22**] 10:35AM ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-241
CK(CPK)-61 ALK PHOS-45
[**2122-7-22**] 10:35AM TOT PROT-6.2* ALBUMIN-3.9 GLOBULIN-2.3
CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2122-7-22**] 10:35AM CK-MB-NotDone cTropnT-<0.01
[**2122-7-22**] 10:35AM TOT PROT-6.2* ALBUMIN-3.9 GLOBULIN-2.3
CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.7
[**2122-7-22**] 10:35AM TSH-6.3*
[**2122-7-22**] 10:35AM FREE T4-1.2
[**2122-7-22**] 10:35AM WBC-4.2 RBC-4.18* HGB-12.4* HCT-38.3* MCV-92
MCH-29.7 MCHC-32.5 RDW-14.8
[**2122-7-22**] 10:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2122-7-22**] 10:35AM PT-12.5 PTT-26.8 INR(PT)-1.1
[**2122-7-22**] 10:35AM PLT COUNT-106*
Laboratory findings at time of discharge
AED levels:
[**2122-7-22**] 10:35AM BLOOD Valproa-45*
[**2122-7-24**] 04:24AM BLOOD Valproa-102*
[**2122-7-25**] 04:31AM BLOOD Valproa-75
[**2122-7-27**] 06:00AM BLOOD Valproa-93
[**2122-7-29**] 06:26AM BLOOD Valproa-63
Valproate [**2122-8-5**] 04:51AM 61
Microbiology:
BCx [**7-22**], [**7-24**], [**7-28**] - pending
UCx [**7-24**] - no growth
CSF - smear pending, Cx - pending
CSF:
[**2122-7-29**] 10:54AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2685*
Polys-58 Lymphs-30 Monos-9 Eos-2
[**2122-7-29**] 10:54AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-276*
Polys-73 Lymphs-20 Monos-7
[**2122-7-29**] 10:54AM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-77
Lab studies at time of discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2122-8-6**] 06:12AM 8.5 3.05* 9.2* 28.3* 93 30.1 32.5 15.2
212
HEMOLYTIC WORKUP Ret Aut
[**2122-8-3**] 07:16PM 3.6*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-8-6**] 06:12AM 73 15 0.6 132* 4.6 95* 34* 8
CHEMISTRY TotProt Albumin Calcium Phos Mg
[**2122-8-6**] 06:12AM 2.8* 8.3* 2.9 2.1
Imaging/Studies:
CT head: [**7-22**] - IMPRESSION:
No acute intracranial abnormality.
In light of no comparison study, findings may represent normal
pressure
hydrocephalus versus age appropriate atrophy as described above.
Clinical
correlation is recommended.
CXR [**7-22**] - Bilateral lower lobe atelectasis
ECHO [**7-23**] - IMPRESSION: Regional left ventricular systolic
dysfunction consistent with coronary artery disease. Moderate
aortic stenosis. Mild to moderate aortic regurgitation. Moderate
eccentric mitral regurgitation.
MRI head [**7-5**] - IMPRESSION:
1. Ventriculomegaly which is although out of proportion for
sulci with
dilatation of the temporal horns, is likely due to atrophy in
presence of
widening of the choroidal fissure. However, the appearances
could still be
consistent with normal pressure hydrocephalus in proper clinical
setting.
2. Extensive small vessel disease is seen in the periventricular
and
subcortical white matter and pons.
3. No evidence of acute infarct or enhancing mass lesion.
CXR [**7-30**] - Opacification involving the lower half of the right
hemithorax.
This is consistent with elevation of the hemidiaphragm,
atelectasis and
effusion.
At the right base, there is increasing opacification in a
somewhat triangular
configuration adjacent to the heart border. This most likely
represents
atelectasis, though the possibility of supervening pneumonia can
certainly not
be excluded.
CXR [**8-6**] -
FINDINGS: AP single view of the chest obtained with patient in
sitting semi- upright position is analyzed in direct comparison
with a similar portable chest examination of [**2122-7-30**].
Previously described cardiomegaly and bilateral pleural
effusions remain. No new parenchymal infiltrates are identified.
Pleural effusions obliterate diaphragmatic contours and blunt
lateral pleural sinuses. The previously suspected density on the
right base ([**7-30**]) is now seen to include air-filled colonic
flexure resulting in diaphragmatic elevation. Thus, the previous
diagnosis of pneumonia is doubtful. No pneumothorax has
developed. NG tube reaches below diaphragm including side port.
Portions of pigtail catheter are seen in upper abdomen.
Brief Hospital Course:
MICU course: While in the ICU the patient was noted to have
elevated BP's with low HR during the day. MRI was obtained which
showed significant atrophy but no evidence of acute stroke. He
was Extubated on [**7-23**]. He was started on a higher dose of
depakote for possible seizure activity. On [**7-24**], the patient was
noted to be febrile to 102.5 axillary. His CXR showed R sided
effusion, but no definitive infiltrate. He was started
vancomycin, pip/tazo for empiric treatment of a likely
ventilator associated pneumonia. Despite his fevers and
hypertension, the patient did well overall and was felt to be
stable for transfer back to neurology.
.
On transfer, he was reported to be midly agitated but
directable. He denied headache, neck pain, chest pain, or
abdomninal pain or any other complaint.
Neurological examination on transfer was remarkable for mild
agitation, with patient alert, but inattentive. "[**2116**], [**Last Name (LF) **], [**First Name3 (LF) 216**]." He was unable to relate history. Could not
perform DOW in reverse. Repetition was intact. Speech was felt
to be dysarthric, but patient was notably adentious. Able to
follow simple one step commands but was easily distracted from a
given task. No evidence of neglect.
.
Pinpoint pupils but ERRL 1.5 to 1mm, EOMI without nystagmus,
facial sensation intact to LT, he had no facial droop, palate
was symmetrical and tongue was midline. He moved all
extremities spontaneously but too inattentive to test strength.
Sensation was intact to LT, grossly. He was hyperreflexic in
UEs symmetrically and hyporeflexic in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28147**]. Toes
were downgoing and he had a b/l action tremor. FNF, HTS or gait
could not be assessed (at baseline patient is wheelchair bound).
The following is a summary of patient's course based on each
problem.
# Bradycardia. It was unclear whether patient experienced a
bradycardic arrest or a PEA arrest, unfortunately no clear
documentation exists. He did have bradycardia to 50s on
telemetry, reported verbally as 30s, accompanied by LOC and
possible hemodynamic compromise on [**2122-7-23**]. He had a mild QT
prolongation though there was no report of ventricular
tachycardia/torsades. On the floor at time of transfer, he was
persistently tachycardic with high load of atrial ectopy. His
CE were wnl and Echo showed severe dCHF but no valvular changes,
no global wall motion abnormality accounting for bradycardia.
Cardiology was consulted who felt as above. Since patient was
on atenolol 50 mg po bid, he was switched to acebutolol, a
beta-blocker with "intrinsic sympathomimetic activity to control
his high load of atrial ectopy without precipitating severe
bradycardia." At 200 mg po bid, patient's HR decreased to
60-70s with occasional decrease to high 40s without pauses or
symptomatic hypotension. Indeed, patient was hypertensive and
required increase of lisinopril to 20 mg po. He remained
hemodynamically stable thereafter, and unfortunately no clear
understanding of the event causing hemodynamic instability was
ever established. There were no signficant pauses on telemetry.
# ? Seizure. Patient underwent evaluation (as listed below).
There was initial concern for complex partial seizure with
secondary generalization and subsequent mild [**Doctor Last Name 555**] paralysis on
admission. There were no clear precipitating factors for the
seizure. He has no known epilepsy risk factors. He is on
Depakote but has no prior history of seizures. By the time he
arrived in the emergency room, he
seemed to be at his neurologic baseline.
His EEG on [**7-22**] showed mild encephalopathy and then was normal
on [**7-24**]. It was presumed that he had a parital complex seizure
with secondary generalization this his depakote level was
increased (initially used for a mood disorder). His MRI showed
showed ventriculomegaly mildly out of proportion to diffuse
atrophy, extensive small vessel disease in the periventricular
and subcortical white matter and pons, and no acute areas of
ischemia. His TFTs were wnl. His valproate level at time of
discharge was 61. He will require treatment with VPA given the
suspected seizure, his dosages at 1000mg HS and 750mg qAM daily.
His goal should be above 55 and below 90.
# Encephalopathy. Pt remained disoriented on transfer to
Neuroloy floor. His baseline reported by his son included being
oriented to time in all three domains, and place. He was able to
carry on a meaninful conversation regarding a topic of his
choice (i.e. music, television), but has not been able to
discuss issues such as politics for over a year (he was a former
intelligence data miner for US government). He was independent
with feeding and most toileting and was mobile in a wheechair in
a [**Hospital1 1501**]. He had some difficulty with memory of current events.
The etiology of his dementia was not clear.
During [**7-25**] - [**7-27**] patient continued to have waxing and [**Doctor Last Name 688**]
level of alertness (at times requring gentle noxious stimulation
to arouse, at times responsive to voice). He continued to have
deficits in attention and had difficulty participating in the
motor and sensory exams. He was treated for VAP (as noted
above), his UAs have been negative, as well as BCx and UCx to
date. A repeat CT head was performed on [**7-28**] due to
obtundation, showing no change, with resolution without
treatment. It was felt that the cause of his encephalopathy was
due to an infectious (VAP) source and metabolic derangements
(metabolic alkalosis) in setting of hospitalization. However,
to rule out aseptic meningitis or pleocytosis as etiology of
encephalopathy, LP was perfomed, showing 1 WBC, PMN predominance
and [**Telephone/Fax (1) 108375**] RBCs, low protein and nl glucose. His CSF fluid
cytology was negative. Based on this, it was felt that his
encephalopathy was most like a delirium in a setting of an
underlying dementia with causative agents being an infection
(VAP) and metabolic abnormalities (metabolic alkalosis and
respiratory acidosis). His clonopin and mirtazapine were
discontinued due to encephalopathy. His Donepezil was restarted
on [**2122-8-5**]. Further evluation showed RPR showed a non-reactive
assay.
# COPD and morning hypopnea. Patient has COPD at baseline and
requires 1-2L NC oxygen at home while in a wheechair. Upon
intubation, his hypercarbia resolved and when extubated, his pH
remained within normal limits and he required intermittent
nebulizer treatments. While on the neurology floor, however, it
was further noted that patient had morning respiratory acidosis
and hypercapnia suggestive of sleep related hypoventillation.
This lead to decreased morning alertness with patient requiring
a sternal rub for responsiveness. Nightime apneas and hypopneas
was documented with continuous pulse oxymetry (frequent
desaturations and apneic episodes during nighttime). As the day
continued and patient became more awake with improving
ventilation. His pH subsequently increased to normal range
(actually into alkalotic range, see below) and his pCO2
decreased to high 40s (felt to be his baseline due to COPD),
documented with ABGs. Due to this, patient was placed on BiPAP
with initial settings of [**11-8**]. With this treatment, his am
alertness improved significantly.
# Metabolic alkalosis. Developed over [**7-26**] - [**7-28**]. Felt to be
due to post-hypercapnic metabolic alkalosis (during the code) as
well as chronic metabolic alkalosis as compensation for chronic
respiratory acidosis in setting of chronic COPD (see above).
Patient required temporary treatment with Acetozolamide x 2
days. With this treatment, his HCO3 returned to 30-34 range,
felt to be his baseline HCO3.
# Hyponatremia. On [**8-2**], patient was noted to have developed
hyponatremia to 128 (134 on admission) in setting of
post-acetozolamide diuresis. Una was < 10 and Uoxm was 480 and
patient was hypovolemic. However, as his volume was repleted w/
NS, his Na improved to 132 temporarily, however returned to 128
despite euvolemia. Una was 78 and Uosm was 490. Given
euvolemia, and recent VAP and COPD, SIADH was felt to be the
leading diagnosis. Free water was withheld TFs as well as NS
was withheld.
# Anemia. Normocytic. HCT 38 on admission, likely
hemoconcentrated. HCT decreased to 28-30 during hospitalization
and remained at that level during the last 3 days of
hospitalization. Most likely due to aggressive fluid
adminstration and phlebotomy (nearly [**Hospital1 **] labs for 10 days).
Guiac negative. No clinical evidence of UGIB or LGIB on exams.
Fe studies showed low TIBC but were otherwise normal, making ACD
most likely underlying etiology, but not responsible for the
change during hospital stay. Folate, B12 were nl, as was TSH.
He will need a repeat HCT on admission to LTAC and weekly
thereafter if maintains hemodynamic stability. Due to concern
for over-phlebotomy, laboratories were not drawn on [**8-7**].
# FEN. Patient required TF after intubation. He was evaluated
by speech and swallow on two separate occasions one week appart,
and was noted to have aspiration on both of those occasions.
Due to this, patient underwent a PEG placement on [**2122-8-5**]. Hi
was treated with TF. There were no complications of PEG
placement.
Outstanding issues:
- Speech and swallow reevaluation and nutrition consultation to
ensure adequate intake. PEG removal when cleared by S and S and
PO intake improves.
- Monitoring of HCT at time of admission and weekly thereafter,
with guiacs of stools for potiential bleed.
- Monitoring and treatment of hyponatremia, felt to be SIADH
- Monitoring and treatment of AM hypopnea with BiPAP (patient
does have AM somnolence)
- Continuing treatment with VPA for seizures. Patient will
require neurology follow up and weekly CBC and Chem 10 for
monitoring of AEs of VPA
Medications on Admission:
actonel 35 mg Qweek
Klonopin 0.25 mg Qday
Depakote 500/750 mg [**Hospital1 **]
Lactulose 30 mL [**Hospital1 **]
Albuterol nebs Q6hrs
Aricept 10 mg QHS
Flomax 0.4 mg Qday
Mirtazapine 7.5 mg QHS
Senna 2 tabs QHS
Zocor 10 mg Qday
Colace 100 mg Qday
iron 325 mg Qday
Lisinopril 10 mg Qday
Omeprazole 20 mg Qday
Atenolol 50 mg [**Hospital1 **]
MVI Qday
Flovent 2 puffs [**Hospital1 **]
Bisacodyl PRN
Tylenol PRN
NTG 0.4 mg SL PRN
.
Medications on Transfer:
Clonazepam 0.25 mg PO DAILY
Divalproex (DELayed Release) 500 mg PO QAM
Divalproex (DELayed Release) 750 mg PO QHS
Donepezil 10 mg PO QHS
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Tamsulosin 0.4 mg PO DAILY
Mirtazapine 7.5 mg PO QHS
Senna 2 TAB PO QHS
Simvastatin 10 mg PO DAILY
Docusate Sodium 100 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Lisinopril 10 mg PO DAILY
Omeprazole 20 mg PO DAILY
Atenolol 50 mg PO BID
Multivitamins 1 TAB PO DAILY
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
Nitroglycerin SL 0.4 mg SL PRN angina
.
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Acebutolol 200 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
4. Valproic Acid 250 mg Capsule [**Hospital1 **]: Three (3) Capsule PO QAM
(once a day (in the morning)).
5. Valproic Acid 250 mg Capsule [**Hospital1 **]: Four (4) Capsule PO QHS
(once a day (at bedtime)).
6. Donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
7. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. Actonel With Calcium 35 mg-500 mg (1250 mg) Tablets, Dose
Pack [**Hospital1 **]: One (1) Tablets, Dose Pack PO Q Mon ().
9. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
12. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1)
Sublingual prn chest pain.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
17. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
18. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a day
(at bedtime)).
19. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY
(Daily).
20. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
22. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
24. Lab work
CBC and Chem 10, LFTs on arrival to LTAC and weekly thereafter.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Possible seizure, cardiac arrest (bradycardic versus
PEA - unclear based on available data), ventilator associated
pneumonia, metabolic alkalosis, nocturnal hypopnea
Secondary: PVD, CAD, HTN, Dementia, COPD, Osteoporosis
Discharge Condition:
Seizure free, mild hospital setting delirium
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of a possible seizure.
While in the hospital, you had a cardiac arrest. You were
successfully resuscitated. However your course was complicated
by Ventilator Associated Pneumonia, sinus tachycardia, metabolic
alkalosis, nocturnal hypopnea and hypercapnea as well as
delirium.
For your pneunomia you were treated with antibiotics. For your
tachycardia your heart rate medication was changed. For your
metabolic acidosis you were treated with acetozolamide and for
your hopopnea, you required BiPAP. Finally, your delirium was
felt to be due to pneumonia, arrest and being hospitalized.
Investigations of all other causes (including lumbar puncture
and EEGs) were negative.
For your suspected seizure activity, your valproic acid dosing
was increased to provide protection from further seizures.
There were multiple changes made to your medications, please
refer to discharge worksheet for the final list.
Should you develop further seizures, loss of conscioussness,
fevers, cough, abdominal pain, weakness, numbness, difficulty
with speech or any other symptom concerning to you, please call
the physician on staff or go to the emergency room.
Followup Instructions:
Please follow up with your primary care provider, [**Name10 (NameIs) **],[**Doctor Last Name **],
please call [**Telephone/Fax (1) 608**] to make a an appointment for follow up
within 2 weeks of discharge from the hospital/rehabilitation
facility.
Please call the office of Dr. [**First Name (STitle) **] [**Name (STitle) 15751**] and Dr. [**Last Name (STitle) **] to
set up a follow up appointment within one month of your
discharge, please call ([**Telephone/Fax (1) 5088**].
Completed by:[**2122-8-7**]
|
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46,497
| 159,261
|
54479
|
Discharge summary
|
report
|
Admission Date: [**2145-11-11**] Discharge Date: [**2145-11-19**]
Date of Birth: [**2061-6-13**] Sex: M
Service: SURGERY
Allergies:
Aspirin / Ace Inhibitors
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Chronic Cholecystitis
Major Surgical or Invasive Procedure:
[**2145-11-11**]:
Laparoscopic converted to open cholecystectomy and
intraoperative cholangiogram.
[**2145-11-12**]:
Re-exploration of abdomen, evacuation of hematoma, washout and
closure.
History of Present Illness:
Mr [**Known lastname **] is an 84 y/o male who had cholecystitis in the summer.
He was treated with a percutaneous cholecystostomy tube. This
tube fell out and he had a subsequent episode of gram-negative
sepsis, which was treated with antibiotics and no further
drainage. His gallbladder grew Streptococcus anginosus, milleri
group and Clostridium perfringens. He has no pain today, but he
is sent for consideration of elective cholecystectomy to prevent
future complications of his gallbladder.
Past Medical History:
PMH: Prostate cancer, skin cancer, afib, GERD, HTN, DVT and
pulmonary embolism, hypercholesterolemia, peptic ulcer disease,
restless legs syndrome, peripheral vascular disease,
diverticulosis, hx cholecystitis s/p percutaneous
cholecystostomy tube placement.
PSH: Prostatectomy, skin cancer removals
[**Last Name (un) 1724**]: lovenox 100'', diltiazem ER 120, hydrochlorothiazide 25,
metoprolol 150'', omeprazole 40, Vitamin D3 1000u, coumadin 2.5'
Social History:
Widower. Lives alone, performing most ADL and IADLs
independently. No current or past tobacco use. No use of alcohol
or other substances. Son is Health [**Name (NI) **] Proxy.
Family History:
Brother died suddenly at 33
Physical Exam:
Discharge Physical Exam:
VS: 97.7 74 137/69 18 99RA
Gen: NAD, AOx3
Cardiac: RRR
Pulm: CTAB, no resp distress
Abd: Non-tender to palpation, firm, distended
Wound: CD&I, R subcostal incision with staples in place; ~5cm
area in middle portion wound open with packing in place; fascia
intact; drainage serosanguinous (minimal); wound with resolving
erythema
Extremities: No CCE
Pertinent Results:
Admission Labs:
[**2145-11-11**] 08:12PM BLOOD Hct-39.8*
[**2145-11-12**] 12:16AM BLOOD Hct-39.5*
[**2145-11-12**] 05:10AM BLOOD WBC-16.7* RBC-3.94* Hgb-12.1* Hct-34.7*
MCV-88# MCH-30.6 MCHC-34.7 RDW-14.9 Plt Ct-177#
[**2145-11-12**] 09:54AM BLOOD Hct-30.1*
[**2145-11-12**] 05:10AM BLOOD Neuts-87* Bands-0 Lymphs-9* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2145-11-12**] 05:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2145-11-12**] 04:10AM BLOOD PT-16.6* PTT-28.0 INR(PT)-1.5*
[**2145-11-12**] 05:10AM BLOOD PT-15.5* PTT-26.2 INR(PT)-1.4*
[**2145-11-12**] 04:10AM BLOOD Fibrino-263
[**2145-11-11**] 08:12PM BLOOD Na-137 K-4.4 Cl-101
[**2145-11-12**] 05:10AM BLOOD Glucose-179* UreaN-28* Creat-1.8* Na-136
K-5.1 Cl-102 HCO3-21* AnGap-18
[**2145-11-12**] 05:10AM BLOOD ALT-38 AST-67* CK(CPK)-509* AlkPhos-93
TotBili-0.9
[**2145-11-12**] 12:30PM BLOOD CK(CPK)-905*
[**2145-11-12**] 05:10AM BLOOD CK-MB-7 cTropnT-<0.01
[**2145-11-12**] 12:30PM BLOOD CK-MB-9 cTropnT-<0.01
[**2145-11-11**] 08:12PM BLOOD Albumin-3.8 Mg-1.7
[**2145-11-12**] 05:10AM BLOOD Albumin-3.2* Calcium-9.3 Phos-5.8*#
Mg-2.1
[**2145-11-12**] 04:01AM BLOOD Type-ART FiO2-100 pO2-338* pCO2-47*
pH-7.28* calTCO2-23 Base XS--4 AADO2-337 REQ O2-61
Intubat-INTUBATED Vent-CONTROLLED
[**2145-11-12**] 04:01AM BLOOD Glucose-196* Lactate-5.1* Na-134 K-5.7*
Cl-103
[**2145-11-12**] 04:01AM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-98
[**2145-11-12**] 04:01AM BLOOD freeCa-1.03*
[**2145-11-11**] Cholangiogram:
INTRA-OPERATIVE CHOLANGIOGRAM: Four intra-operative fluoroscopic
views were obtained. There is contrast seen within the
gallbladder with multiple filling defects likely representing
gallstones. Contrast is seen in the visualized portion of the
common bile duct, however the distal-most portion and duodenum
are not seen on these views. Contrast is also seen in the cystic
duct and hepatic ducts without any filling defects. Please see
operative note for further details.
[**2145-11-12**] EKG
Atrial fibrillation with fast ventricular response. Non-specific
ST segment abnormality. Compared to the previous tracing of
[**2145-11-4**] there is an increase in ventricular response rate.
[**2145-11-12**] Lower Extremity Venous U/S
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Right [**Hospital Ward Name 4675**] cyst.
Discharge Labs:
[**2145-11-19**] 09:15AM BLOOD WBC-9.5 RBC-3.74* Hgb-11.1* Hct-35.2*
MCV-94 MCH-29.7 MCHC-31.5 RDW-14.8 Plt Ct-423
[**2145-11-19**] 06:35AM BLOOD PT-26.9* INR(PT)-2.6*
PATHOLOGY:
Hemorrhagic acute and chronic cholecystitis
Brief Hospital Course:
The patient was admitted to the west 3 surgery service on
[**2145-11-11**] and
went to the OR for a laparoscopic converted to open
cholecystectomy. Patient tolerated procedure well and was
transferred to the PACU extubated with foley, NGT and JP drain
in RUQ. Approximately 3-4 hours postop patient w significant
sanguinous output from JP and hypotenstion. Taken back to OR
for exploratory laparotomy that revealed ~1500cc clot in
abdomen. Abdomen washed out but no active hemorrhage at this
point. Taken from OR to SICU in on intubated/sedated on
pressors with foley, NGT and R abdominal JP drain.
Neuro: Patient extubated [**11-12**] and sedation was d/c'd at that
time. The patient received then received Dilaudid IV/PCA with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: Patient w HTN and rate controlled afib at baseline on
significant diltiazem/metoprolol regimen. On arrival to SICU pt
on neo gtt which was weaned off [**11-12**]. Patient was tachycardic
w intermittent hypotension w afib in SICU and, as patient would
not tolerate po medications, a diltiazem gtt was started when
patient was refractory to IV lopressor/diltiazem. [**2049-11-11**] dilt
gtt titrated to effect with supplemental lopressor IV utilized.
PO regimen was initiated [**11-14**] and up titrated to home regimen
as tolerated. The patient was stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: Arrived ICU intubated. Extubated [**11-12**].
Supplemental O2 was given as needed. Weaned off with
ambulationa and pulmonary toilet. Pulmonary toilet including
incentive spirometry and early ambulation were encouraged. The
patient was stable from a pulmonary standpoint; vital signs were
routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids
continuously with intermittent boluses as needed to support BP
and urine output. Had an NGT which put out modest amount
bilious output. NGT d/c'd [**11-14**]. Diet was subsequently
advanced as tolerated as bowel function returned and abdominal
distention improved. He was also started on a bowel regimen to
encourage bowel movement. Patient w BMs x 5 [**11-18**] and C. diff
sent as a precaution. Rehab will be [**Month/Year (2) 653**] if C. diff
positive.
LFTs were checked postoperately with no evidence of hepatic
injury intraoperatively. JP drain put out minimal
serosanguinous output which was negative for biloma. JP was
removed [**11-16**] as output had decreased significantly.
Postop, attempt at foley placement was made unsuccessfully.
Urology was consulted given history of prostatectomy. Urology
placed foley but noted significant urethral stricture. GU
requested foley stay in until follow up in their clinic for
cystoscopy and monitored trial of void. Early postop urine
output was marginal and required multiple crystalloid/colloid
fluid boluses. [**11-15**] and [**11-16**] lasix was given to assist in
diuresis. This was done with good effect. Patient has
arrangement to meet with GU for clinic visit as scheduled.
Intake and output were closely monitored.
ID: Pre-operatively, the patient was given appropriate
antibiotic prophylaxis. Abx were continued for 24 hours postop.
[**11-17**] patient was noted to have significant R subscostal
incision erythema. Wound was opened at bedside with ~60cc
purulence expressed. Wound was packed and patient started on
ancef. Gram stain was negative. Culture pending at time of
discharge. Patient improving on ancef and will continue to
complete a seven day course for wound infection. The patient's
temperature was closely watched for signs of infection.
HEME: Patient is on coumadin at baseline for hx DVT/PT. Bridged
w lovenox preop. Received lovenox in preop holding area.
Following postop bleed all anticoagulation held. Serial hct's
checked. LENIs checked in SICU which were negative. HSQ
resumed [**11-12**]. Coumadin resumed [**11-15**]. Patient therapeutic at
time of discharge. INR to be checked at rehab and coumadin
dosed appropriately for goal INR [**3-4**]. INR to be followed by PMD
as outpatient. Patient to see PMD within three days of
discharge from rehab.
At the time of discharge on [**2145-11-19**], the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
[**Last Name (un) 1724**]: lovenox 100'', diltiazem ER 120, hydrochlorothiazide 25,
metoprolol 150'', omeprazole 40, Vitamin D3 1000u, coumadin 2.5'
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
10. cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous
every eight (8) hours for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
1. Chronic Cholecystitis
2. Urinary retention
3. Postoperative wound infection
4. History of DVT/PE
5. Acute kidney injury (now resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the West 3 Surgery service at [**Hospital1 771**]. While you were here we removed your
gallbladder. We also noticed that your wound was becoming
infected so we opened up the incision and started you on
antibiotics.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new
medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may
not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed,
but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and
drink adequate amounts of fluids. Avoid strenuous physical
activity
and refrain from heavy lifting greater than 10 lbs., until you
follow-up with your surgeon, who will instruct you further
regarding
activity restrictions. Please also follow-up with your primary
care
physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you
have increased pain, swelling, redness, or drainage from the
incision
site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.
Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please
remove any remaining strips 7-10 days after surgery.
You were sent home with a Bladder Catheter in place. The
urologists have indicated they would like you to keep this in
place until you follow up in clinic with Dr. [**Last Name (STitle) 261**]. We have
made you an appointment for this follow up as indicated below.
Thank you for letting us participate in your care. We wish you a
speedy recovery.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2145-11-24**] at 8:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: MONDAY [**2145-11-29**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Please make an appointment with your primary care physician
within three days of discharge from rehab for INR check. It is
critical that you do this. Contact information is below.
Name: [**Last Name (LF) 58**], [**First Name7 (NamePattern1) 4559**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 3329**]
Fax: [**Telephone/Fax (1) 16236**]
Completed by:[**2145-11-19**]
|
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|
1787, 2145
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,040
| 114,673
|
51309+59334
|
Discharge summary
|
report+addendum
|
Admission Date: [**2134-1-26**] Discharge Date: [**2134-2-8**]
Date of Birth: [**2063-11-12**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: This is a 70 year old male with upper
gastrointestinal bleed and alcohol withdrawal, transferred to
[**Hospital1 69**] at the request of family
and intubated on transfer for airway protection.
HISTORY OF PRESENT ILLNESS: The patient presented to [**Hospital3 **] Medical Center by the family with concern for three
to four days of multiple falls due to worsening balance, gait
abnormality, intermittent slurred speech and word finding
difficulties and expressive aphasia. The patient stated he
"didn't feel right". The patient denied any head trauma,
loss of consciousness, dizziness. Cardiac and neurologic
review of systems are negative, although the family noted a
recent change in his personality and increased alcohol
consumption. In addition, the patient noted black stool
times one week, cough productive of yellow sputum times three
days. The patient's vital signs were normal in the Emergency
Department. His laboratories were notable for a hematocrit
of 26.0, potassium 5.6, blood urea nitrogen 61, creatinine
1.5. Chest x-ray showed a 7.0 centimeter lesion in the
posterior right upper lobe, thought to be a rounded mass
versus collapsed lung distal to an endobronchial lesion.
Head CT showed multiple small calcified ring enhancing
lesions, with the differential diagnoses of metastases,
syssarcosis or abscesses.
For the patient's lung and brain masses, the patient was
started on intravenous Dilantin on the advice of neurology,
and a chest CT was ordered.
With regards to his upper gastrointestinal bleed, his
hematocrit dropped from 26.0 to 22.0 in the first night with
occult blood positive stool. Gastric lavage was negative.
Upper endoscopy showed superficial linear erosions in the
lower third of the esophagus, mild nonerosive gastritis and
duodenitis with no erosions or bleeding. He continued to
have orthostatic hypotension. He received a total of three
units of packed red blood cells, and then was transferred to
the Intensive Care Unit. His hematocrit was stable since the
evening of [**2134-1-24**]. The plan was to repeat the colonoscopy
after his alcohol withdrawal had resolved.
For his alcohol withdrawal, he was started on Oxazepam
protocol and given multivitamin Thiamine and Folate. He
became agitated on [**2134-1-23**], requiring posy and restraints.
On [**2134-1-24**], he became hypertensive to 210/130, requiring
control with Nitroglycerin paste and Clonidine. He was
transferred to [**Hospital1 69**] at the
request of the family. In order to stabilize for transfer,
he required sedation with Propofol and consequent
endotracheal intubation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease.
3. Nephrolithiasis.
4. Hiatal hernia.
5. Tobacco abuse.
6. Alcohol abuse.
7. High cholesterol.
8. Seasonal allergies.
9. Colonic tubular adenoma, status post colonoscopy in
[**2131-2-27**].
OUTPATIENT MEDICATIONS:
1. Lisinopril 40 mg p.o. once daily.
2. Simvastatin 40 mg p.o. once daily.
3. Fexofenadine.
4. Aspirin 325 mg p.o. once daily.
5. Potassium Chloride 20 meq p.o. once daily.
6. Multivitamin.
7. Folate.
TRANSFER MEDICATIONS:
1. Protonix 40 mg intravenous twice a day.
2. Gatifloxacin 40 mg intravenous once daily.
3. Dilantin 100 mg intravenous three times a day.
4. Diltiazem 7.5 mg intravenous four times a day.
5. Diazepam 10 mg intravenous q2hours and 10 mg intravenous
q2hours p.r.n.
6. Clonidine 0.1 mg patch.
7. Propofol drip.
8. Nitroglycerin paste two inches.
9. Haldol 2 to 4 mg intravenous q2-3hours.
SOCIAL HISTORY: The patient is a retired rocket scientist,
currently a part-time teacher at [**University/College 5130**] [**Location (un) **]. On
admission to [**Hospital3 **] Medical Center, he admitted to
drinking twenty shots of vodka per day, Cage questionnaire
was positive. The patient has a significant smoking history
of three packs per day times twenty to forty years.
PHYSICAL EXAMINATION: Vital signs revealed temperature 98.8,
pulse 73, blood pressure 111/palpable. In general, the
patient is an intubated elderly male who occasionally
struggles against restraints. Possible mild palmar erythema
but no spider nevi or caput medusa. Head, eyes, ears, nose
and throat - pink conjunctiva, no icterus, pupils are equal,
round, and reactive to light and accommodation. The neck
revels seven centimeter jugular venous distention above the
right atrium. Cor - regular rate and rhythm with physiologic
splitting of S2. The lungs are clear to auscultation
bilaterally. The abdomen is positive bowel sounds, soft,
nondistended, no flank dullness or fluid wave. Liver
palpable two centimeters below the right costal margin.
Extremities - good peripheral pulses, no cyanosis, clubbing
or edema.
LABORATORY DATA: White blood cell count 7.6, hematocrit
32.1, platelets 259,000. Prothrombin time 13.8, INR 1.3,
partial thromboplastin time 30.1. Sedimentation rate 55.
Sodium 140, potassium 3.9, chloride 107, bicarbonate 22,
blood urea nitrogen 11, creatinine 0.8, glucose 114, ALT 10,
AST 18, alkaline phosphatase 78, total bilirubin 0.6, albumin
3.0, calcium 8.0, phosphorus 3.4, magnesium 1.8.
CT of the brain with and without contrast revealed hyperdense
edema in both temporal lobes. Hyperdensity in superior left
parietal lobe. Small areas of calcification in the right
temporal lobe and bilateral frontal and parietal lobes.
HOSPITAL COURSE: In short, this is a 70 year old male with
new brain lesions, apparent lung mass with endobronchial
obstruction, ETOH withdrawal requiring deep Propofol sedation
and endotracheal intubation for interhospital transfer.
1. Oncology - As already noted, the patient was noted to
have right upper lobe endobronchial mass on chest x-ray
concerning for carcinoma, especially given the findings of
what appeared to be multiple brain metastases no head CT. CT
of the chest, abdomen and pelvis revealed a large right upper
lobe mass, two liver lesions in the right lobe, pancreatic
mass in the body of the pancreas, read as principal lung
neoplasm, with metastatic foci. Head CT from [**2134-1-26**],
showed metastatic lesions in the frontal, parietal and
temporal lobes, with moderate edema, minimal mass effect and
some calcification. The patient received bronchoscopy. The
pathology on the bronchoscopy was consistent with nonsmall
cell lung cancer. Given these imaging findings and the
patient's changed mental status, he was given a very poor
prognosis with his Stage IV nonsmall cell lung cancer. The
patient was seen by oncology. He was also seen by radiation
oncology. There was general agreement that head radiation
therapy would be the initial starting point for palliative
treatment. However, because the family was able to
communicate with the patient and actually saw some
improvement in his mental status over the past several weeks,
especially since extubation, they decided to hold off on head
radiation therapy, understanding that radiation therapy while
it could provide further improvement in his mental status, it
could also have negative effect too. Instead, the patient
was kept on Dexamethasone which was eventually tapered down
to 4 mg four times a day.
2. Mental status changes - Once the patient was extubated, he
initially was still quite somnolent, giving only one word
answers. Over the period of about one week, however, the
patient became much more alert. He was always oriented to
person, some times to place, but this was variable. He was
never oriented to time and his attention was severely
impaired. The patient's mental status changes most probably
can be attributed to his multiple brain metastases, however,
it is odd that the patient did not show any focal signs even
with a greatly limited neurologic examination. Other sources
of mental status change included high Ativan load with poor
clearing, effect of Dilantin, Wernicke's syndrome. There is
also concern for carcinomatosis meningitis, however, given
that the patient was improving, this was not worked up. The
patient's Dilantin was stopped, but his steroids were
continued. Head magnetic resonance scan on [**2134-1-31**], showed
multiple foci of enhancement, edema in both cerebral
hemispheres, posterior fossa consistent with metastatic
disease, no hydrocephalus, mass shift, hemorrhage or left
meningeal enhancement that might suggest meningitis. Once
again, the family held off on head radiation therapy given
the patient's improving mental status. They were willing to
give it a try, however, should his mental status deteriorate.
3. Alcohol withdrawal - The patient did not show any sign of
withdrawal once he was extubated. He was kept on Clonidine
at 0.5 mg p.o. twice a day.
4. Gastrointestinal bleed - The patient's hematocrit was
noted to decrease from 30.7 to 27.5 on [**2134-1-31**]. However,
the patient did not overtly pass any blood, and his
hematocrit remained stable.
5. FEN - Initially once he was extubated, the patient had a
nasogastric tube. He received swallowing evaluation with
nasogastric tube in place and was noted to be a silent
aspirator. However, once the nasogastric was removed, repeat
video swallowing study revealed that he, in fact, was not
aspirating. The patient was kept on aspiration precautions
given his waxing and [**Doctor Last Name 688**] mental status. He was kept on
pureed solids and thin liquids with one to one supervision.
6. Psychiatric - The patient was noted to have reversed
sleep/wake cycles. He was asleep most of the day but was up
a lot of the night trying to get out of bed. For this
reason, he required a sitter which further complicated his
disposition planning. The patient was written for low dose
Ambien at night as needed to help him sleep.
CONDITION ON DISCHARGE: Fair.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding scale.
2. Protonix 40 mg p.o. once daily.
3. Folate 1 mg p.o. once daily.
4. Thiamine 100 mg p.o. once daily.
5. Multivitamin one tablet p.o. once daily.
6. Lisinopril 40 mg p.o. once daily.
7. Clonidine 0.5 mg p.o. twice a day.
8. Dexamethasone 4 mg p.o. four times a day.
9. Lopressor 25 mg p.o. twice a day.
10. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia.
DISCHARGE INSTRUCTIONS: At this point in time, it is unclear
which facility the patient will be going to. The family does
not feel that they can handle the patient on their own. The
patient will likely go to Hospice care.
DISCHARGE DIAGNOSES:
1. Metastatic nonsmall cell lung cancer.
2. Mental status changes, likely secondary to brain
metastases.
3. Alcohol withdrawal.
4. Gastrointestinal bleed.
5. Hypertension.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2134-2-6**] 23:10
T: [**2134-2-7**] 09:41
JOB#: [**Job Number **]
Name: [**Known lastname 17351**], [**Known firstname **] Unit No: [**Numeric Identifier 17352**]
Admission Date: [**2134-1-26**] Discharge Date: [**2134-2-11**]
Date of Birth: [**2063-11-12**] Sex: M
Service:
ADDENDUM TO DISCHARGE SUMMARY
HOSPITAL COURSE:
1. Mental status: The patient continued to have improving
mental status throughout the remainder of his hospital stay
with fewer episodes of agitation at night. However, the
patient continued to remain confused and disoriented. He was
continued on a one to one sitter to prevent him from
wandering off the floor. The medical team and consulting
neurologist felt that these continued mental status changes
were most consistent with diffuse cerebral edema secondary to
metastatic disease. His metabolic panel was repeated and
normal. His neurological examination had no focal deficits
at the time of discharge. He was started on Risperidone 0.5
mg q.h.s. prior to discharge.
2. Alcohol withdrawal: The patient had a history of alcohol
withdrawal. However, the patient's Clonidine was
discontinued prior to discharge. The patient displayed no
evidence of alcohol withdrawal at this time.
MEDICATIONS ON DISCHARGE: Please refer to page one.
DISCHARGE STATUS: To rehab.
DISCHARGE INSTRUCTIONS:
1. If the patient's mental status deteriorates and family
wishes to pursue radiation therapy the patient's family is to
contact Radiation/Oncology at [**Telephone/Fax (1) 17353**].
2. If the patient has evidence of gastrointestinal bleed he
should be evaluated by Gastroenterology.
3. The patient's mental status should be followed by rehab
neurologist.
4. The patient is to follow up with Dr. [**Last Name (STitle) 8041**] in two
weeks.
[**First Name8 (NamePattern2) 77**] [**First Name4 (NamePattern1) 1495**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8396**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2134-5-13**] 07:29
T: [**2134-5-14**] 09:20
JOB#: [**Job Number 17354**]
|
[
"162.3",
"578.9",
"305.00",
"535.50",
"291.81",
"518.81",
"198.3",
"197.8",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10588, 11300
|
12243, 12300
|
11317, 11321
|
12324, 13106
|
3058, 3267
|
4092, 5537
|
159, 353
|
3289, 3686
|
382, 2763
|
11337, 12216
|
2785, 3034
|
3703, 4069
|
9915, 9922
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,205
| 150,067
|
41234
|
Discharge summary
|
report
|
Admission Date: [**2128-5-14**] Discharge Date: [**2128-5-19**]
Date of Birth: [**2075-3-28**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
HCC, Gallbladder polyp
Major Surgical or Invasive Procedure:
[**2128-5-14**] Segment 3 mass resection,
cholecystectomy, intraoperative ultrasound.
History of Present Illness:
Per Dr.[**Initials (NamePattern4) 1369**] [**Last Name (NamePattern4) **] note as follows:
53-year-old Asian male with chronic HBV infection who has been
followed for hepatoma screening and a 5-mm gallbladder polyp.
An ultrasound on [**2128-2-16**], demonstrated a suspicious
lesion in the right lobe of his liver. The liver biopsy on
[**2128-2-18**], was negative for malignancy. He had a
mildly elevated AFP to 13.4 on [**2-16**]. An MRI on
[**2128-3-11**], demonstrated an irregular arterial phase
rim enhancing mass within segment 3 of the liver suggestive
of a hepatoma. An EUS on [**2128-4-12**], demonstrated an
irregular mass in the left lobe of the liver that was
hypoechoic, heterogeneous and solid measuring 17 x 20 mm. A
fine-needle aspiration was performed and it was interpreted
as moderately-differentiated hepatocellular carcinoma. He is
now brought to the operating room after informed consent was
obtained for segment 3 mass resection and cholecystectomy.
His preoperative AFP had increased to 99.1. He had a normal
hematocrit of 40.2, platelets 182,000, AST 29, ALT 40,
alkaline phosphatase 50 and total bilirubin 0.3, albumin 5.1.
Past Medical History:
diabetes mellitus, HBV, h/x of a 5-mm gallbladder polyp. No
prior surgical history.
.
Social History:
married and has two children. He is currently unemployed.
Family History:
mother-75 and healthy.
father died at age 58 of unknown causes.
Physical Exam:
Vitals: The patient was afebrile, nontachycardic, nontachypneic.
Gen:AAOx3. NAD
Card: RRR.
Pulm: [**Last Name (un) **] sounds present b/l.
Abd: Soft. Appropriately tender in the epigastrum and RUQ.
Incision c/d/i
Estremities: No edema. Good capillary refill.
Pertinent Results:
[**2128-5-14**] 10:45AM BLOOD WBC-12.7*# RBC-4.66 Hgb-14.4 Hct-41.7
MCV-90 MCH-30.9 MCHC-34.4 RDW-12.3 Plt Ct-197
[**2128-5-18**] 04:30AM BLOOD WBC-5.8 RBC-3.85* Hgb-12.0* Hct-34.3*
MCV-89 MCH-31.1 MCHC-34.9 RDW-12.3 Plt Ct-199
[**2128-5-16**] 06:05AM BLOOD PT-13.8* PTT-30.1 INR(PT)-1.2*
[**2128-5-18**] 04:30AM BLOOD Glucose-198* UreaN-11 Creat-0.7 Na-136
K-4.0 Cl-95* HCO3-28 AnGap-17
[**2128-5-18**] 04:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
Brief Hospital Course:
On [**2128-5-14**], he underwent a Segment 3 mass resection,
cholecystectomy, intraoperative ultrasound. The patient was
admitted to the Hepatobiliary Surgical Service. After a brief,
uneventful stay in the PACU, the patient arrived on the floor
NPO, on IV fluids and antibiotics, with a foley catheter, and
having receieved IT morphine for pain control. The patient was
hemodynamically stable.
Neuro: The patient received IT morphine and subsequently a
dilaudid PCA with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Once it wwas ensured that the patietn was tolerating
a diet, his home dose of metforming was also restarted.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted as necessary. Home
metformin was restarted once patientw as eating.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during his stay on the
surgical floor.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
metformin 850 mg p.o. twice daily and entecavir 1 mg p.o. daily
Discharge Medications:
1. entecavir 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
HCC
Segment III liver resection and ccy
DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fevers, chills, nausea, vomiting, increased abdominal pain or
distension, incision redness/bleeding/drainage or
constipation/diarrhea
You may shower
No heavy lifting/straining
No driving while taking pain medication
Followup Instructions:
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator for Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 673**], will
call you with a follow up appointment in 1 week
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2128-5-24**]
|
[
"327.21",
"575.6",
"155.0",
"338.18",
"070.32",
"571.5",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"50.22"
] |
icd9pcs
|
[
[
[]
]
] |
5262, 5268
|
2635, 4868
|
325, 413
|
5355, 5355
|
2165, 2612
|
5851, 6213
|
1804, 1870
|
4982, 5239
|
5289, 5334
|
4894, 4959
|
5506, 5828
|
1885, 2146
|
263, 287
|
441, 1601
|
5370, 5482
|
1623, 1711
|
1727, 1788
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,358
| 158,829
|
18207
|
Discharge summary
|
report
|
Admission Date: [**2171-10-8**] Discharge Date: [**2171-10-14**]
Date of Birth: [**2117-12-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Incisional hernia
Major Surgical or Invasive Procedure:
Status Post Incisional Hernia Repair
History of Present Illness:
The patient is a 53-year-old male with a history of a giant
incisional hernia, status post gastric bypass in [**2167**],
complicated by perforated ulcer in 02/[**2168**]. Pt has begun having
increased discomfort with plans for repair.
Past Medical History:
Hypertension,
Diabetes Mellitus,
Depression,
Degenerative joint disease
Dyslipedemia
asthma/bronchitis
Chronic back pain
Osteoarthritis
Obesity
Gerd
Hepatitis A
Social History:
Ex nurse, works in real estate now. Married.
Family History:
Non contributory
Physical Exam:
PHYSICAL EXAM:
GEN: NAD, A&Ox3
CV: RRR, no murmurs, rubs, gallops
PULM: CTAB, mild decreased breath sounds at bases bilaterally
ABD: Soft, Non-distended. TTP peri midline incision site.
Incision site intact without wound dehiscense. JP drains x4
intact with sanguinous drainage. Binder intact.
Pertinent Results:
LABORATORY RESULTS:
[**2171-10-8**] 06:26PM BLOOD WBC-13.7*# RBC-3.46* Hgb-10.4*# Hct-30.1*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.0 Plt Ct-201
[**2171-10-9**] 12:04AM BLOOD WBC-8.4 RBC-3.12* Hgb-9.3* Hct-27.0*
MCV-87 MCH-29.7 MCHC-34.3 RDW-15.2 Plt Ct-166
[**2171-10-9**] 03:05AM BLOOD WBC-8.3 RBC-3.66* Hgb-11.0* Hct-31.5*
MCV-86 MCH-29.9 MCHC-34.8 RDW-15.2 Plt Ct-187
[**2171-10-9**] 09:14AM BLOOD Hct-30.1*
[**2171-10-9**] 11:54PM BLOOD WBC-8.9 RBC-3.17* Hgb-9.5* Hct-27.3*
MCV-86 MCH-30.0 MCHC-34.8 RDW-15.8* Plt Ct-153
[**2171-10-10**] 04:00AM BLOOD Hct-27.9*
[**2171-10-10**] 01:30PM BLOOD Hct-32.2*
[**2171-10-10**] 06:03PM BLOOD Hct-33.4*
[**2171-10-10**] 09:58PM BLOOD Hct-29.6*
[**2171-10-11**] 01:55AM BLOOD WBC-10.7 RBC-3.48* Hgb-10.3* Hct-30.4*
MCV-87 MCH-29.5 MCHC-33.9 RDW-15.5 Plt Ct-183
[**2171-10-8**] 06:26PM BLOOD Glucose-162* UreaN-6 Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-25 AnGap-14
[**2171-10-9**] 03:05AM BLOOD Glucose-159* UreaN-7 Creat-0.6 Na-136
K-4.4 Cl-105 HCO3-26 AnGap-9
[**2171-10-9**] 11:54PM BLOOD Glucose-136* UreaN-11 Creat-1.0 Na-137
K-4.0 Cl-103 HCO3-27 AnGap-11
[**2171-10-10**] 06:03PM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-136
K-4.1 Cl-101 HCO3-28 AnGap-11
[**2171-10-11**] 01:55AM BLOOD Glucose-139* UreaN-6 Creat-0.6 Na-135
K-4.4 Cl-101 HCO3-27 AnGap-11
[**2171-10-10**] 04:00AM BLOOD CK(CPK)-2866*
[**2171-10-10**] 01:30PM BLOOD CK(CPK)-2860*
[**2171-10-10**] 06:03PM BLOOD CK(CPK)-2491*
[**2171-10-11**] 01:55AM BLOOD CK(CPK)-1684*
[**2171-10-10**] 04:00AM BLOOD CK-MB-8 cTropnT-<0.01
[**2171-10-10**] 01:30PM BLOOD CK-MB-10 MB Indx-0.3 cTropnT-<0.01
[**2171-10-10**] 06:03PM BLOOD CK-MB-9 cTropnT-<0.01
[**2171-10-11**] 01:55AM BLOOD CK-MB-6 cTropnT-<0.01
[**2171-10-8**] 06:26PM BLOOD Calcium-7.5* Phos-3.7 Mg-1.4*
[**2171-10-9**] 03:05AM BLOOD Mg-2.1
[**2171-10-9**] 09:14AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.8
[**2171-10-9**] 11:54PM BLOOD Calcium-7.5* Phos-2.7 Mg-1.9
[**2171-10-10**] 04:00AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.9
[**2171-10-10**] 06:03PM BLOOD Calcium-7.5* Phos-2.2* Mg-1.8
[**2171-10-11**] 01:55AM BLOOD Calcium-7.4* Phos-2.1* Mg-1.8
[**2171-10-8**] 02:17PM BLOOD Glucose-192* Lactate-2.3* Na-136 K-3.9
Cl-99*
[**2171-10-8**] 06:34PM BLOOD Glucose-160* Lactate-3.3*
[**2171-10-9**] 02:20AM BLOOD Lactate-1.8
STUDIES:
EKG [**2171-10-9**]: Sinus tachycardia. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2171-9-25**] the rate has
increased.
CT ABD [**2171-10-9**]: IMPRESSION:
1. Dilated, air-filled transverse colon with non-dilated small
bowel is
consistent with colonic ileus.
2. NG tube is in normal position with its tip projecting over
the gastric
fundus.
CXR [**2171-10-10**]: There are low lung volumes. Right middle lobe and
right lower lobe atelectasis (almost collapsed) have worsened.
Small linear atelectasis in the left mid lung is new. NG tube
tip is difficult to evaluate and cannot be followed further down
the distal esophagus; of note, in prior radiograph of the
abdomen, the tip was in the stomach.
Brief Hospital Course:
This is a 53 yo M admitted s/p incisional hernia repair with
mesh [**2171-10-8**]. The pt was brought to the TSICU intubated for
post op monitoring. Pt was requiring high vent pressures and
phenylephrine post op. Pt had thoracic epidural catheter for
pain control and followed by acute pain service. 2U PRBC given
after repeat hct 30->27. Pt became hypotensive and epidural was
held overnight. HCt up to 34 post-transfusion. The pt was then
extubated the following day and transfered to the floor.
The pt spiked a temperature of 101.5 night of [**2171-10-9**].
Temperature returned to 99.5 spontaneously with deep
inspiration. CXR suggests likely atelectasis. The pt then
triggered on the morning of [**2171-10-10**] for SBP 60/palp, HR 128.
Epidural was stopped. 1.5 L NS bolus. SBP 95/50. Hct 32.2 ->
33.4 -> 29.6. Returned to OR evening [**10-10**] for ex-lap/washout
[**12-24**] suspicion of bleeding. No signs of bleeding noted.
Patient continued to do well without further events. He was
progressed to a bariatric stage 5 diet. His pain is well
controlled with po meds. There is one Jp drain in place. We will
send him home on keflex and return to clinic on [**2171-10-23**].
Medications on Admission:
prozac, xanax, zocor, cardura, B12, MVI
Discharge Medications:
1. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. 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:*0*
8. Calcium Citrate-Vitamin D3 315-200 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
9. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Multivitamins with Minerals Tablet Sig: One (1) Tablet
PO once a day.
11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Incisional Hernia
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-5**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower 48 hours after surgery, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
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 or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor or nurse practitioner if the amount increases
significantly or changes in character.
*Be sure to empty the drain frequently. Record the quality and
quantity of the output daily.
*You may shower; wash the area gently with warm, mild soapy
water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 2723**]
Date/Time:[**2171-10-23**] 09:45am. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 6693**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 17996**] (PCP) in [**12-25**] weeks.
Completed by:[**2171-10-14**]
|
[
"278.00",
"250.00",
"715.90",
"V12.09",
"568.0",
"998.12",
"401.9",
"518.0",
"V45.86",
"272.4",
"997.39",
"311",
"E878.8",
"493.90",
"530.81",
"458.29",
"552.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
6827, 6833
|
4246, 5431
|
301, 340
|
6914, 6923
|
1217, 4223
|
9274, 9680
|
869, 887
|
5522, 6804
|
6854, 6854
|
5457, 5499
|
6947, 8145
|
917, 1198
|
244, 263
|
8157, 9251
|
368, 605
|
6873, 6893
|
627, 790
|
806, 853
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,724
| 189,245
|
10763+56175
|
Discharge summary
|
report+addendum
|
Admission Date: [**2183-3-2**] Discharge Date: [**2183-3-9**]
Date of Birth: [**2101-5-27**] Sex: F
Service: VSU
CHIEF COMPLAINT: Nonhealing right lateral malleolus ulcer
and right second toe ulceration.
HISTORY OF PRESENT ILLNESS: This patient with known chronic
peripheral vascular disease, claudication and a nonhealing
right ankle ulceration. She was seen by Dr. [**Last Name (STitle) 1391**]
previously and had an arteriogram [**2179-10-2**] which
demonstrated occlusion of the right superficial femoral
artery with significant vessel running via the right
peroneal. The patient neglected to follow up with Dr.
[**Last Name (STitle) 1391**] for reconstruction surgery. Since she has an unclear
history of wound care but suffice to say that currently the
right foot ulceration has been present x2 months. Ambulation
is limited secondary to ulcer and pain. Claudication cannot
be assessed. The patient has no constitutional symptoms. She
denies amaurosis, light-headedness, palpitations, rigors,
dysuria, substernal chest pain, shortness of breath, dyspnea
on exertion or orthopnea. She is now admitted for evaluation
of her ischemic ulcerations.
PAST MEDICAL HISTORY: Past illnesses: Peripheral vascular
disease, status post bilateral lower extremity angiogram in
[**2180-10-2**] for right ankle ulceration, history of ischemic
heart disease with myocardial infarction in [**2179-1-30**],
status post coronary artery bypass graft x3 and [**2178-12-2**]
status post angioplasty of coronary arteries with stenting in
[**2178**]. History of pontine infarct on the right [**2179-1-30**],
history of hypercholesterolemia, history of breast cancer on
the left.
ALLERGIES: Iodine containing agents causes a rash.
MEDICATIONS ON ADMISSION: Aspirin 81 mg daily, Lipitor 20 mg
daily, atenolol 25 mg b.i.d., Colace 100 mg b.i.d., Imdur 100
mg daily.
PHYSICAL EXAMINATION: Vital signs; 97.1, 69, 18, blood
pressure 136/74, oxygen saturation 99% on room air. General
appearance: Alert Hispanic female in no acute distress.
Carotids are without bruits and palpable bilaterally. Lungs
are clear to auscultation. Heart is regular rate and rhythm.
Abdomen is soft, nontender, nondistended. Pulse examination
shows palpable femorals bilaterally, Palpable popliteal
artery on the left, [**Year (4 digits) **] popliteal artery on the
right. The pedal pulses are [**Year (4 digits) **] signals bilaterally.
There is a right lateral malleolus 2 cm ulceration without
erythema with fibrinous base. The right second toe is with a
2 mm punctate ulcer on the medial DIP without erythema.
HOSPITAL COURSE: The patient was admitted to the vascular
service. Routine laboratories were obtained. White count was
7.0, hematocrit 37.5, platelets 276,000. Coags were normal.
BUN 16, creatinine 0.8, potassium 4.2. Urinalysis is
negative. Chest x-ray showed no active cardiopulmonary
disease. Electrocardiogram was with a sinus rhythm with a V
rate of 63 with interventricular conduction defect, right
ventricular hypertrophy and low QRS voltages in the
pericardial leads. There were no acute changes. The patient
was begun on vanco, Cipro and Flagyl. She was IV hydrated for
anticipated diagnostic arteriogram. Cardiology was requested
to see the patient in anticipation for surgery. They felt
that given her current functional status she is at an
increased but acceptable risk for planned vascular surgery.
Recommended beta blockade and nitrates to maintain systolic
blood pressure less than 140 and heart rate of 60 to 80,
continue statins and aspirin. The patient's arteriogram was
done without complication. This study demonstrated the inflow
was patent and there was an occluded proximal superficial
femoral artery. There was a mild to moderate 50% stenosis at
the tibial peroneal trunk. The AT and posterior tibial
arteries were occluded. The peroneal artery was widely
patent. The distal AT and DP reconstituted and were patent.
There were no plantar vessels seen. The patient proceeded to
elective revascularization. On [**2183-3-4**] she had a right
common femoral artery to above knee popliteal bypass graft
with 8 mm ringed Dacron. She tolerated the procedure well.
She had a faint posterior tibial pulse in the operating room
and arrival to the post anesthesia care unit. She was
extubated in the operating room. She remained hemodynamically
stable and was transferred to the VICU for continued
monitoring and care. Postoperative day 1 there were no
overnight events. Her antibiotics were discontinued. She had
a palpable DP bilaterally and [**Name (NI) **] PTs bilaterally.
Postoperative hematocrit was 32.9. BUN and creatinine
remained stable at 10 and 0.7. Her fluids were HEP-Locked.
She was reinstituted on her home medications. She was auto
diuresing. Her diet was advanced as tolerated. Her aspirin,
Plavix and subcutaneous heparin were continued. Patient would
be de-lined later in the afternoon and transferred to a
regular nursing floor if diuresis continues. Postoperative
day #2 the Foley was discontinued at midnight. The patient
was ambulating. Physical therapy was requested to see the
patient. Her central line was discontinued after peripheral
line was placed. The patient will be discharged to rehab
versus home after being evaluated by physical therapy and
when medically stable.
DISCHARGE MEDICATIONS: Include aspirin 81 mg daily,
arlestatin 20 mg daily, isosorbide mononitrate 120 mg daily,
Plavix 75 mg daily, oxycodone/acetaminophen 5/325 tablets 1
to 2 q 4 to 6 hours p.r.n. for incisional pain, atenolol 25
mg b.i.d., Colace 100 mg b.i.d. This should be continued
while patient is on narcotics for pain control, Senna 8.6 mg
tablets b.i.d. p.r.n.
DISCHARGE INSTRUCTIONS: Patient may shower but no tub baths,
may ambulate essential distances only. She should keep the
affected leg elevated when sitting. She should call our
office if she develops a fever greater than 101.5 or if the
wound deteriorates in appearance or increases in erythema or
drainage. Patient should follow up with Dr. [**Last Name (STitle) 1391**] 2 weeks
post discharge.
DISCHARGE DIAGNOSES:
1. Right lateral malleolar and right fifth toe ischemic
ulcerations, nonhealing.
2. History of documented peripheral vascular disease.
3. History of ischemic heart disease, status post coronary
artery bypass graft x3 in [**2176-12-2**].
4. Status post coronary angioplasty with stenting in [**2178**].
5. History of myocardial infarction in [**2178**].
6. History of pontine cerebral infract in [**2178**].
7. History of hyperlipidemia.
8. History of left breast carcinoma.
MAJOR SURGICAL PROCEDURES: Included diagnostic arteriogram
with right leg runoff on [**2183-3-4**] and a right common
femoral to above knee bypass graft with 8 mm ringed Dacron
graft on [**2183-3-4**].
DISCHARGE CONDITION: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2183-3-6**] 09:42:37
T: [**2183-3-6**] 10:29:26
Job#: [**Job Number 35193**]
Name: [**Known lastname 6257**],[**Known firstname 6258**] G. Unit No: [**Numeric Identifier 6259**]
Admission Date: Discharge Date:
Date of Birth: [**2101-5-27**] Sex: F
Service: SURGERY
Allergies:
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2183-3-7**] after evaluation by physical thearphy and case manadment
pantienty was ammendable to go to rheb. Bed was avaible and
patient was transfered to rehab in stable condition..
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2183-3-10**]
|
[
"707.13",
"412",
"V10.3",
"272.0",
"V45.81",
"707.15",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29",
"88.42",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
7658, 7862
|
6826, 7635
|
6109, 6804
|
5340, 5691
|
1766, 1874
|
2617, 5316
|
5716, 6088
|
1897, 2599
|
152, 227
|
256, 1175
|
1198, 1739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,237
| 129,074
|
13006
|
Discharge summary
|
report
|
Admission Date: [**2126-6-4**] Discharge Date: [**2126-6-11**]
Date of Birth: [**2068-7-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
malaise, decreased appetite
Major Surgical or Invasive Procedure:
s/p MVR for endocarditis (27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical Valve) [**6-5**]
History of Present Illness:
57 yo F with 6 eek history of fatigue and LLE pain, was found to
have positive blood cultures while undergoing workup at OSH.
[**Last Name (un) 39843**] shoed 4+MR [**First Name (Titles) **] [**Last Name (Titles) **] vegetation. She was transferred to [**Hospital1 **]
for further care, and then was discharged with 6 weeeks of
antibiotics. No presents for MVR.
Past Medical History:
Endometrial Cancer 8 years ago - s/p
hysterectomy/chemo/radiation
Cholystectomy [**2121**]
Hemorroids
Peripheral arterial disease - related to radiation
Social History:
Married. Denies ETOH, smoking, drugs. Competetive ballroom
dancer. Works in husbands office.
Family History:
Non-contributory
Physical Exam:
Neuro non-focal
CV RRR 6/6 SEM
Lungs CTAB
Abdomen soft, NT/ND
Extrem warm, without edema
Pertinent Results:
[**2126-6-10**] 03:59AM BLOOD Hct-29.9*
[**2126-6-9**] 05:20AM BLOOD WBC-9.9 RBC-3.33*# Hgb-9.8*# Hct-29.1*
MCV-87 MCH-29.3 MCHC-33.5 RDW-16.2* Plt Ct-265
[**2126-6-11**] 05:11AM BLOOD PT-27.1* PTT-99.8* INR(PT)-2.7*
[**2126-6-10**] 03:59AM BLOOD PT-19.0* PTT-81.6* INR(PT)-1.8*
[**2126-6-9**] 12:22PM BLOOD PT-18.1* PTT-32.1 INR(PT)-1.7*
[**2126-6-11**] 05:11AM BLOOD K-3.9
[**2126-6-10**] 03:59AM BLOOD UreaN-12 Creat-0.8 K-4.4
Radiology Report CHEST (PORTABLE AP) Study Date of [**2126-6-8**] 9:12
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2126-6-8**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 39844**]
Reason: assess for mediastinal widening
[**Hospital 93**] MEDICAL CONDITION:
57 year old woman s/p mitral valve repair for endocarditis,
now with dropping
hct
REASON FOR THIS EXAMINATION:
assess for mediastinal widening
Final Report
CHEST RADIOGRAPH
INDICATION: Status post valve repair, questionable mediastinum
widening.
COMPARISON: [**2126-6-7**].
FINDINGS: As compared to the previous examination, there are
minimal
bilateral pleural effusions. Otherwise, there are no
radiographic changes,
notably the mediastinum shows unchanged and normal width.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 39845**] (Complete)
Done [**2126-6-5**] at 10:39:58 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2068-7-25**]
Age (years): 57 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Endocarditis. Left ventricular function. Mitral
valve disease.
ICD-9 Codes: 424.90, 424.0, 424.2
Test Information
Date/Time: [**2126-6-5**] at 10:39 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 2.4 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. [Intrinsic LV systolic
function likely depressed given the severity of valvular
regurgitation.] Hyperdynamic LVEF >75%.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Moderate-sized vegetation on mitral valve. No
mitral valve abscess. Eccentric MR jet. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
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.
Conclusions
PREBYPASS
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%)[ however intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] . Right ventricular chamber size and free wall
motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque.. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. There is a
moderate-sized vegetation on the anterior leaflet of the mitral
valve. No mitral valve abscess is seen. An eccentric,
posteriorly directed jet of Severe (4+) mitral regurgitation is
seen.
POSTBYPASS
LV systolic function is now mildly globally impaired. LVEF
45-50%. There is a well seated, well functioning bileaflet
mechanical (27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]) in the mitral position. There is
valvular MR which is normal in quantity and location (washing
jets) for this type of prosthesis. There is trace perivalvular
MR along the intratrial septum. RV systolic function remains
normal.
Brief Hospital Course:
She was admitted to cardiac surgery. On [**6-5**] she was taken to the
operating room where she underwent a MVR. She was transferred to
the ICU in stable condition. She was extuabted later that day.
She continued on ampicillin and gentamicin until cultures were
finalized negative. She was started on coumadin and heparin for
her mechanical valve. She was transferred to the floor on POD
#1. She awaited therapeutic INR and was ready for discharge home
on POD #6.
Coumadin to be followed by the [**Doctor Last Name **] hospital coumadin clinic,
confirmed with Dr. [**Last Name (STitle) 39846**] office and with [**Doctor First Name **] at [**Hospital 1263**]
Hospital on [**6-11**].
Medications on Admission:
Carvedilol 3.125", lasix 20 qod, Citalopram 10', Vit E 400', MVI
1', FeSo4 325'
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Coumadin 5 mg Tablet Sig: INR 3-3.5 Tablets PO once a day:
Dose based on goal INR 3-3.5.
Disp:*60 Tablet(s)* Refills:*2*
4. Coumadin 2 mg Tablet Sig: INR 3-3.5 Tablets PO once a day:
Dose based on goal INR 3-3.5.
Disp:*60 Tablet(s)* Refills:*2*
5. coumadin dose
Please take 7.5mg on [**6-11**], blood to be drawn [**6-12**], further dosing
to be managed by the [**Hospital 1263**] Hospital [**Hospital 197**] Clinic (per Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 39847**].
You have received prescriptions for 2 different doses of
coumadin- 5mg and 2mg.
6. Outpatient [**Name (NI) **] Work
PT, INR as needed for coumadin dosing.
Results to Dr. [**Last Name (STitle) **], p- [**Telephone/Fax (1) 39848**].
Goal INR: 3-3.5
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*0*
8. 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*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 3 days.
Disp:*qs qs* Refills:*0*
12. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
13. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**]
Discharge Diagnosis:
MV endocarditis s/p MVR
Endometrial CA s/p hyst/chemo/rad, hernia repair, CCY,
hemorrhoids
Discharge Condition:
good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week,
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] T [**Telephone/Fax (1) 39848**] 2 weeks
Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2126-7-23**]
11:00
Dr. [**Last Name (STitle) **] 4 weeks
Labs: PT, INR first draw [**6-12**], results to [**Hospital 1263**] Hospital
[**Hospital 197**] Clinic (per Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 39847**] goal INR 3-3.5
for mechanical mitral valve
Completed by:[**2126-6-11**]
|
[
"E849.8",
"424.0",
"E879.2",
"041.04",
"V10.42",
"285.9",
"443.9",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"99.04",
"88.72",
"38.93",
"39.63"
] |
icd9pcs
|
[
[
[]
]
] |
8988, 9086
|
6324, 7009
|
348, 474
|
9221, 9228
|
1313, 2008
|
9541, 10062
|
1170, 1188
|
7139, 8965
|
2048, 2133
|
9107, 9200
|
7035, 7116
|
9252, 9518
|
1203, 1294
|
281, 310
|
2165, 6301
|
502, 865
|
887, 1041
|
1057, 1154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,474
| 106,798
|
13619+56474
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-4-9**] Discharge Date: [**2133-4-29**]
Date of Birth: [**2068-8-29**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Aortic stenosis and aortic insufficiency as
well as right coronary artery stenosis.
HISTORY OF PRESENT ILLNESS: Patient is a 64-year-old
dialysis-dependent male without any history of angina, who
experienced increasing shortness of breath for about one year
prior to [**2133-3-15**]. Patient had been noted to have
noncritical aortic stenosis about five years ago during a
routine cardiac evaluation. During routine followup
transthoracic echocardiogram performed in [**2133-2-12**],
the patient was noted to have critical aortic stenosis and
aortic insufficiency.
The patient then underwent a cardiac catheterization, which
revealed right coronary artery stenosis. The patient did
complain of some lightheadedness over the prior 1-3 months.
The patient denied having any symptoms suspicious for
transient ischemic attacks or cerebrovascular accident.
PAST MEDICAL HISTORY: End-stage renal disease secondary to
polycystic kidney disease (on dialysis via a Permacath on
Mondays, Wednesdays, and Fridays).
PAST SURGICAL HISTORY:
1. Multiple access procedures including A-V fistulas and A-V
grafts.
2. Status post right nephrectomy in [**2108**].
3. Abdominal hernia repair.
4. Partial colon resection in [**2120**] for diverticulosis.
5. Status post failed kidney transplant in [**2109**] at [**University/College 18328**]Medical Center.
6. Status post parathyroidectomy.
ALLERGIES: Patient has a severe contrast allergy and is also
allergic to penicillin, gentamicin, and Keflex as well as
cephalosporins.
MEDICATIONS ON ADMISSION:
1. PhosLo 638 mg to take five tablets 3x a day.
2. Renagel 1600 mg t.i.d.
3. Nephrocaps one tablet q.d.
4. Colace 100 mg p.o. q.d.
5. Prilosec 20 mg p.o. q.d.
PHYSICAL EXAM ([**2133-3-26**]): Patient's physical exam was
notable for carotid bruits worse on the right than on the
left. His heart rate was regular with a systolic rumble.
Lungs were clear. Abdomen was soft and nontender with some
well-healed surgical scars at the midline, right lower
quadrant, and subcostally. There were no palpable masses.
Patient had left groin Permacath. Patient had some venous
stasis changes of both lower extremities, but with palpable
dorsalis pedis pulses bilaterally. The patient also had a
right arm A-V graft in place.
HOSPITAL COURSE: Patient was admitted to the [**Hospital1 18**] on
[**2133-4-9**], and underwent an aortic valve replacement with #25
[**Last Name (un) 41101**] valve. The patient also underwent coronary artery
bypass grafting from the saphenous vein graft to the right
coronary artery. The procedure was performed without
complications, and the patient was as is routine, transferred
to the Cardiac Surgery Intensive Care Unit while intubated.
The patient was extubated awhile after arriving to the
Intensive Care Unit. At the time, the patient was alert and
moving all extremities. His blood gases were good and
appeared in no distress. Within a few minutes after being
extubated, however, the patient decompensated and became
apneic with a decrease in his oxygen saturations. The
patient required reintubation and was evaluated by the
Neurology service.
Following evaluation, the patient's event was believed to be
secondary to respiratory arrest contributed by the need to be
supine with his groin line as well as his previously
undiagnosed history of sleep apnea. Patient showed no
neurological deficits after the reintubation and quickly
returned to baseline neurologic function. No immediate
imaging was deemed necessary.
A bronchoscopy was performed revealing minimal mucus and
essentially clear airways. Patient underwent hemodialysis on
postoperative day #1. Patient was ultimately extubated on
postoperative day #2 without event.
On postoperative day two, the patient underwent another
session of hemodialysis, and was noted to have frequent
premature atrial contractions subsequently changing to atrial
fibrillation at a rate of 140. The patient was bolused with
amiodarone and started on a drip. The patient returned to
sinus rhythm shortly after. The patient remained on Levophed
drip. The patient had been empirically started on
levofloxacin antibiotic regiment for possible pneumonia given
some thick copious mucus. This patient was afebrile and had
a normal white count.
Over the following few days, the patient had brief episodes
of atrial fibrillation, though revert to sinus rhythm with
amiodarone boluses. A Heparin drip was started and plans
were made for anticoagulation with Coumadin. The patient
remained on a Levophed drip to support his blood pressure
with goal systolic blood pressures in the 90s-100s.
Patient was ultimately weaned off of his Levophed on
postoperative day #7. His systolic blood pressure remained
low mainly in the 90s, but the patient seemed to tolerate
this well. The patient was transferred out of the ICU on
postoperative day #8. The patient remained on hemodialysis
and ultrafiltration to try and offload some of the volume the
patient had gained intraoperatively.
Patient was ultimately started on Coumadin on [**2133-4-17**].
Within three days, the patient's INR was 2.5 following doses
of 2 mg, 2 mg, and 1 mg. Patient completed a 14-day course
of levofloxacin and was started on clindamycin for some lower
extremity erythema. Patient was noted to have small Stage II
decubitus ulcer on [**2133-4-23**], and wound care consult was
requested with the recommendation made for Duoderm gel and
thin Duoderm wafer dressings to the wound as well as frequent
positioning changes.
Patient had remained in normal sinus rhythm with no further
episodes of atrial fibrillation since transferred from the
Intensive Care Unit. He was on amiodarone by mouth.
By postoperative day 20, the patient was deemed ready for
discharge to rehab facility. But by the time of discharge,
the patient's pain was well controlled and his respiratory
status was stable. His estimated dry weight was 87 kg, and
on the day prior to discharge, had a predialysis weight of
94.1 kg. Four kg of fluid was taken off that day.
Patient had been seen by Physical Therapy while in house and
on ambulation remained somewhat unsteady and weak, requiring
the assist of two people for safe ambulation. The patient's
sternal incision was healing well with Steri-Strips in place.
Patient also had some left lower extremity incisions, which
appeared to be healing well with a few small blisters.
A transthoracic echocardiogram had been performed on
approximately [**2133-4-29**] to confirm the absence of thrombus in
the patient's heart. The transthoracic echocardiogram
revealed no such thrombus, and the decision was made to cease
further anticoagulation on the patient and his Coumadin was
discontinued. The benefits and risks of further Coumadin
therapy had been reviewed, and further treatment was deemed
unnecessary given that the patient had been in normal sinus
rhythm for much of his hospitalization and that his atrial
fibrillation could have been attributed to his significant
fluid overload immediately after the surgery.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Aortic stenosis.
2. Aortic insufficiency.
3. End-stage renal disease.
4. Coronary artery disease.
5. Atrial fibrillation.
6. Sacral decubitus ulcer.
7. Lower extremity cellulitis.
8. Respiratory arrest.
9. Sleep apnea.
FOLLOWUP: Patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
within 1-2 weeks following discharge. The patient is also to
followup with his primary care physician [**Name Initial (PRE) 176**] 1-2 weeks
following discharge. The patient will need to setup an
appointment with his outpatient cardiologist in [**2-13**] weeks
following discharge. The patient will also need to setup an
appointment with a Sleep Clinic for further evaluation of his
sleep apnea.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Dulcolax 10 mg p.r. q.d. prn.
4. Calcium acetate 1334 mg p.o. t.i.d. with meals.
5. Colace 100 mg p.o. b.i.d.
6. Milk of magnesia 30 mL p.o. q.h.s. prn.
7. Percocet 1-2 tablets p.o. q.4h. prn.
8. Protonix 40 mg p.o. q.24h.
9. Sevelamer 1600 mg p.o. t.i.d.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2133-4-29**] 11:32
T: [**2133-4-29**] 12:17
JOB#: [**Job Number 41102**]
(cclist)
Name: [**Known lastname 7415**], [**Known firstname **] Unit No: [**Numeric Identifier 7416**]
Admission Date: [**2133-4-9**] Discharge Date: [**2133-5-15**]
Date of Birth: [**2068-8-29**] Sex: M
Service: Cardiothoracic
Please see patient's previous dictation that brings you
though [**4-29**].
The patient remained in the hospital following [**4-29**] for
a right saphenous vein graft harvest site cellulitis. He was
seen by the Plastic Surgery service, who felt that there was
mild epidermolysis with no fluctuance or pus and no evidence
for deep infection with the recommendation that the patient
be followed with Xeroform dressings and dry sterile dressing.
Patient was also seen by the Infectious Disease staff at that
time given his recent aortic valve replacement and their
recommendations were to begin clindamycin as well as Levaquin
for broad-spectrum antibiotic coverage. Ultimately, the
culture was MRSA and the patient was begun on linezolid.
After a week of conservative treatment with wet-to-dry saline
and Duoderm dressings, the wound showed no improvement and
the patient was then seen by the Vascular Surgery service,
who on [**5-8**], which was positive day 29, the patient was
brought to the operating room for an excisional debridement
of the right saphenous vein graft wound. The patient
tolerated the debridement well and was returned to [**Hospital Ward Name **] 2 for
continued care.
Following the debridement, the Vascular service placed a VAC
assisted device into the wound bed on postoperative day
three. The VAC dressing was removed and replaced by Vascular
team. The patient continued to do well postoperatively.
Throughout the next week, he remained on [**Hospital Ward Name **] 2. Continued
to be followed by Vascular Surgery as well as Infectious
Diseases, the Renal service, and Cardiothoracic Surgery
services. His wound continued to show slow improvement, and
on postoperative day 33, it was decided that the patient
would be stable and ready to be transferred to rehabilitation
on the following morning.
At the time of this dictation, the patient's physical exam is
as follows: Temperature 97.5, heart rate 71, sinus rhythm,
blood pressure 104/50, respiratory rate 20, and O2 saturation
99% on room air. General: In no acute distress.
Respiratory: Clear to auscultation bilaterally. Cardiac:
regular rate and rhythm, S1, S2. His stapled wound is
healing well with a dry sterile dressing over it. Abdomen is
soft, nontender, and nondistended. Extremities with chronic
skin color changes from peripheral vascular disease. Right
lower extremity with VAC dressing in place. Sacral pressure
ulcer with Duoderm dressing in place.
LABORATORY DATA: White count 7.9, hematocrit 34, platelets
190. Sodium 138, potassium 4.8, chloride 99, CO2 28, BUN 37,
creatinine 5.3, glucose 97, calcium 9.2, phosphorus 3.4.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft x1 with saphenous vein graft to the right coronary
artery.
2. Aortic stenosis status post aortic valve replacement with
a #25 tissue valve.
3. End-stage renal disease.
4. Atrial fibrillation.
5. Right lower extremity saphenous vein graft site soft
tissue infection requiring excisional debridement and
vacuum-assisted device, dressing placement.
6. Status post right nephrectomy for polycystic kidney
disease.
7. Status post partial colectomy for diverticulitis.
8. Status post failed kidney transplant.
9. Status post abdominal hernia repair.
10. Status post parathyroidectomy.
DISCHARGE MEDICATIONS:
1. Linezolid 600 mg q.d. x4 weeks.
2. Amiodarone 200 mg q.d.
3. Enteric-coated aspirin 325 mg q.d.
4. Calcium acetate 1334 mg t.i.d.
5. Sevelamer 1600 mg t.i.d.
6. Pantoprazole 40 mg q.d.
7. Lactulose 30 cc q.d.
8. Afrin nasal spray b.i.d. x3 days to end on [**5-15**].
9. Benadryl 25 mg b.i.d. x3 days to end on [**5-15**].
10. Colace 100 mg b.i.d.
11. Nephrocaps one q.d.
12. Is also taking prn medications including Percocet 5/325
1-2 tablets q.4h. and Dulcolax 10 mg/rectum q.d. prn.
FOLLOW-UP INSTRUCTIONS: Patient is to followup have Vascular
Surgery service, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] two weeks following his
discharge from [**Hospital1 536**]. Follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71**] six weeks following his discharge
from [**Hospital1 8**]. Follow up with the Renal service for continued
hemodialysis.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**Name8 (MD) 3027**]
MEDQUIST36
D: [**2133-5-14**] 14:41
T: [**2133-5-15**] 04:51
JOB#: [**Job Number 7417**]
|
[
"799.1",
"585",
"996.81",
"790.7",
"682.6",
"998.59",
"V45.1",
"424.1",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"96.07",
"99.05",
"88.72",
"36.11",
"99.04",
"96.04",
"89.64",
"96.71",
"35.22",
"99.07",
"00.14",
"39.61",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7239, 7248
|
11600, 12248
|
12271, 12760
|
1715, 2436
|
2454, 7217
|
1208, 1689
|
172, 257
|
286, 1031
|
12785, 13467
|
1054, 1185
|
11572, 11579
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,364
| 133,394
|
23693
|
Discharge summary
|
report
|
Admission Date: [**2111-3-12**] Discharge Date: [**2111-3-13**]
Date of Birth: [**2060-9-18**] Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
50 yo male, h/o CAD s/p stent to LAD in [**2106**],
Hypercholesterolemia, DM, cocaine abuse, presenting with chest
pain. He states he had onset of this pain today; described as
anterior chest pain with radiation to right shoulder, [**9-7**], was
increasing over the course of 45 minutes to 1 hour (occurred
after arrested). He states that he also felt SOB and diaphoretic
but denies n/v/palpitations. He reports that the pain was
increasing in intensity. He was brought to [**Hospital3 **]
where he was found to have positive urine cocaine, EKG with new
2-[**Street Address(2) 2051**] elevations in the anterior leads (v2-5) and some ST
depressions in II, III, AvF. He was given lopressor 5 mg x 2
(3rd dose given by [**Location (un) **], 5 mg morphine, ativan, nitro gtt,
heparin, and integrillin. Pain was [**12-8**] at time of transfer.
In the cath lab, he was found to have hazy plaque in LAD (prior
stent), 80% hazy plaque in circumflex, and a totally occluded
PLB (with collaterals). 1 cypher stent was place in the LAD
while 2 were placed in Lcx. Right system was not intervened
upon, for the PLB was unable to be crossed by wire. He was
transferred to the CCU for observation.
Past Medical History:
1. CAD, s/p MI in [**2106**] with stenting of LAD
2. Hypercholesterolemia
3. DM
Social History:
Lives with friend
History of cocaine use, most recent use day of admission
Etoh use, [**1-1**] drinks/day, most recently on day of admission
Former smoker, quit 4 yrs ago, 30 pack year history
Arrested on day of admission for soliciting prostitute
(undercover police officer), currently in police custody
Family History:
No CAD in 1st degree relatives. [**Name (NI) **] sudden death
Physical Exam:
VS: 94.1 130/81 71 21 99% 4L NC
Gen: somnolent, pleasant male, lying in bed
HEENT: PERRL, some dried blood on lips, tongue
Neck: no LAD, ?enlarged parotid glands bilaterally
CV: RRR, nl s1/s2, with S4, no m/r
Lungs: CTA bilaterally, no w/r/r
Abdomen: protuberant, nt/nd, nabs
Right groin: with sheath in place
Extr: DP/PT 2+ bilaterally, no c/c/e
Pertinent Results:
Catheterization on [**2111-3-12**]:
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.87 m2
HEMOGLOBIN: 14 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 18/17/13
RIGHT VENTRICLE {s/ed} 45/18
PULMONARY ARTERY {s/d/m} 45/22
PULMONARY WEDGE {a/v/m} 21/22/20
AORTA {s/d/m} 97/66/81
**CARDIAC OUTPUT
HEART RATE {beats/min} 88
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 32
CARD. OP/IND FICK {l/mn/m2} 7.3/3.9
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 745
**% SATURATION DATA (NL)
SVC LOW 81
PA MAIN 81
AO 98
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA: NORMAL
2) MID RCA: NORMAL
2A) ACUTE MARGINAL: NORMAL
3) DISTAL RCA: NORMAL
4) R-PDA: NORMAL
4A) R-POST-LAT: DISCRETE 100
4B) R-LV: NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN: NORMAL
6) PROXIMAL LAD: ULCERATED
6A) SEPTAL-1: NORMAL
7) MID-LAD: NORMAL
8) DISTAL LAD: NORMAL
9) DIAGONAL-1: NORMAL
10) DIAGONAL-2: NORMAL
12) PROXIMAL CX: DISCRETE 80
13) MID CX: NORMAL
13A) DISTAL CX: NORMAL
14) OBTUSE MARGINAL-1: NORMAL
15) OBTUSE MARGINAL-2: NORMAL
16) OBTUSE MARGINAL-3: NORMAL
Proximal LAD with hazy ulceration, proximal circumflex with 80%
hazy, totally occluded PLB with collaterals
1 cypher stent placed in LAD, 2 cypher stents placed in Left
Circ
Echo: [**2111-3-12**]:
"Conclusions:
1. The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis to akinesis with some
sparing of basal wall motion. Overall left ventricular systolic
function is severely depressed.
2. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen."
[**2111-3-12**] 10:40PM GLUCOSE-180* UREA N-10 CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-30* ANION GAP-12
[**2111-3-12**] 10:40PM CK(CPK)-137
[**2111-3-12**] 10:40PM CK-MB-4 cTropnT-<0.01
[**2111-3-12**] 10:40PM CALCIUM-8.6 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2111-3-12**] 10:40PM WBC-9.1 RBC-4.08* HGB-12.7* HCT-35.7* MCV-88
MCH-31.0 MCHC-35.4* RDW-12.7
[**2111-3-12**] 10:40PM PLT COUNT-253
Brief Hospital Course:
1. CAD: presented with anginal symptoms and EKG changes
(STEMI), with cardiac catheterization revealing lesions in LAD,
LcX, and PLB. Unclear if hazy lesions significant or if this
was cocaine induced vasospasm. LAD and LCX were stented, but
PLB could not be crossed by guidewire (were collaterals).
- continue ASA, statin, Plavix; will hold BB given recent
cocaine use (?can consider labetalol if necessary), Integrillin
for 18 hours
- CK negative. TN WNL.
- post cath check normal
2. CHF: EF 25% on Echo, states he takes lasix at home
- Started lisinopril.
- Consider repeat Echo in 1 month and [**Hospital1 **]-V/ICD per discretion of
primary cardiologist.
- kept euvolemic and monitored for signs of overload
- Low Na diet with 1 liter fluid restriction
- may need to diurese based on clinical status, swan numbers
3. Rhythm: No ectopy post cath/MI
4. DM: on metformin at home, will hold given cath/dye adn cover
with SSI
5. Cocaine use: last use this morning, no BB given this;
considered using CCB/phentolamine if chest pain recurs.
-- Will discuss beta-blocker risks and benefits with primary
cardiologist
-- Pt advised of medical risks of using cocaine
6. EtOH use: unclear how much, monitor on [**Name (NI) 60563**] for signs of
withdrawal, ativan prn
-- CIWAs were 0 throughout admission
7. Hyperlipidemia: on lipitor 80. LDL 79, HDL 51
8. Social: in police custody, with 24hr guard, handcuffed to
bed
9. FEN: cardiac diet, watch for aspiration given somnolent
status at this time, ck and replete Mg/K/Ca aggressively
10. Code: FULL
11. Dispo: back to prison; ?extradition to [**State 5887**]
Medications on Admission:
Lipitor 80
Coreg
ASA 81 mg
Lasix
Glucophage
ALL: Vicodin-?rash
Discharge Medications:
1. Please continue your previous diabetes medications
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).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 60564**]Correctional Facility
Discharge Diagnosis:
Cocaine Abuse
ST Elevation Myocardial Infarction
Discharge Condition:
stable
Discharge Instructions:
Please notify nurses, doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] workers of
chest pain, shortness of breath, palpitations or
lightheadedness. Cocaine use has been associated with an
increased risk of heart attacks, stroke and death. You must
continue to take plavix. Please discuss the use of
beta-blockers with your cardiologist. Beta-blockers should not
be used while using cocaine.
Followup Instructions:
Please follow-up with your cardiologist within 2 weeks of
leaving the hospital.
Please follow-up with your primary doctor within 2 weeks of
leaving the hospital.
Completed by:[**2111-3-13**]
|
[
"428.0",
"272.4",
"305.00",
"414.01",
"250.00",
"V15.82",
"410.81",
"272.0",
"412",
"305.60",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.56",
"36.07",
"36.05",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
6987, 7060
|
4643, 6273
|
279, 304
|
7153, 7161
|
2426, 4620
|
7629, 7823
|
1971, 2035
|
6387, 6964
|
7081, 7132
|
6299, 6364
|
7185, 7606
|
2050, 2407
|
229, 241
|
332, 1526
|
1548, 1632
|
1648, 1955
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,747
| 174,186
|
12978
|
Discharge summary
|
report
|
Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-12**]
Date of Birth: [**2080-6-29**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
right upper extremity weakness
Major Surgical or Invasive Procedure:
[**2142-1-11**] Diagnostic cerebral angiogram
History of Present Illness:
61M with PMH significant for cardiac artery aneurysm and
aortic valve repair (on coumadin) presents to ED with c/o
intermittent RUE weakness and numbness for 3 days. Patient was
in
his usual state of health until 3 days ago when he noted that
his
right arm felt heavy while it was laying on his lap. He tried to
raise his right arm, but was unable to do so. This epsidoes
lasted approximately 10 minutes and resolved. He was
asymptomatic
2 days ago and throughout the day yesterday. Last night [**1-7**], he
noted the onset of symptoms again with weakness and numbness in
his arm. He went to sleep but when he awoke the symptoms were
still present. He called his cardiologist, who recommended that
he come to the ED for further eval. No HA. No visual changes. No
CP/SOB. No n/v/d. No gait instability or difficulty.
Past Medical History:
Aortic pseudoaneurysm
Aortic Stenosis
s/p Redo Sternotomy, pseudoaneurysm repair, AVR (mechanical)
- Congential aortic stenosis s/p Open valvulplasty [**2091**] and
Bentall [**2132**]
- Ascending aortic aneurysm
- Benign prostatic hypertrophy
- Erectile dysfunction
- Hypertension
- Aortic valvuloplasty [**2091**]
- Redo Sternotomy/Bentall/Prox.Arch repl. (homograft to
Gelweave)) [**2132**] (Dr. [**Last Name (STitle) 1290**]
- Vasectomy
Social History:
Lives with: Wife
Occupation: [**Name2 (NI) **] works for a federal agency that performs audits
and financial analyses of federal contractors.
Cigarettes: Smoked no [] yes [X] Hx: Quit [**2132**]
ETOH: < 1 drink/week [X]
Illicit drug use: None
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 1 GCS E: 4 V:5 M:6
O: T: 98.3 BP: 118/83 HR: 60 R 16 O2Sats 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength 4/5 Right Upper extremity otherwise [**4-14**]
throughout. slight Right pronator drift
Sensation: Intact to light touch
Reflexes: B T Br
Right 1+ 1+
Left 1+ 1+
Toes downgoing bilaterally
ON DISCHARGE:
Awake, alert, oriented x3, short term memory deficit, slow
speech, MAE, slight R pronator drift
Pertinent Results:
Atrial fibrillation with a rapid ventricular response. Right
axis deviation.
Prior anteroseptal myocardial infarction. Compared to the
previous tracing
of [**2141-10-11**] there has been some resolution of the anterolateral
ST-T wave
abnormalities consistent with an ischemic process. The
ventricular response has
increased. Otherwise, no diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 0 102 374/424 0 100 41
[**2142-1-8**] FINDINGS:
The arteries of anterior circulation including bilateral
intracranial internal carotid, anterior and middle cerebral
arteries appear normal.
The basilar artery, intracranial vertebral arteries, and
bilateral posterior cerebral arteries appear normal.
There is no evidence of focal flow limiting stenosis, occlusion,
or aneurysm.
Subarachnoid hemorrhage is noted in the left superior frontal
region which is unchanged since the prior study.
The visualized paranasal sinuses and mastoid air cells appear
normal.
IMPRESSION:
1. No evidence of stenosis, occlusion, or aneurysm in arteries
of head.
2. Subarachnoid hemorrhage in the left superior frontal region
which is
unchanged since the prior study.
MR head without and with contrast is advised to rule out other
causes of
subarachnoid hemorrhage like cortical vein thrombosis.
[**2142-1-8**]
FINDINGS: cxr
There is tortuosity of the aorta. There is no pleural effusion
and no
pneumothorax. The cardiomediastinal silhouette and hila are
normal. Patient is status post median sternotomy.
There is no evidence of pneumonia.
IMPRESSION:
No acute cardiothoracic process.
[**2142-1-11**] CEREBRAL ANGIOGRAM:
Negative
Brief Hospital Course:
Mr. [**Known lastname 3646**] was admitted to the surgical intensive care unit
Neurosurgery service for
serial neurological examinations and workup. The Neurology team
was called to evaluate and an EEG was performend revealling no
seizure activity. A CTA was negative for aneurysm. Coumadin was
held and daily labs were checked to trend patient's INR.
Patient was transferred to the floor on [**2142-1-9**] and underwent a
cerebral angiogram on [**2142-1-11**] after his INR was under 2.0. The
procedure was uneventful and did not demonstrate a cause for the
sah.
His post operative exam was stable. It was confirmed with his
cardiologist that his coumadin could be restarted. He was
evaluated by PT/OT and discharge planning was initiated.
He was cleared for discharge with outpatient OT.
Medications on Admission:
aspirin 81 mg daily, warfarin 2.5 mg daily, metoprolol tartrate
37.5 mg daily
and ranitidine
goal INR is 2.0-2.5 according to his wife.
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
Disp:*10 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
Medications:
?????? 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:
?????? When you go home, 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
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
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 our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
*** Please continue Coumadin dosing and follow-up with your PCP
regarding dosing. INR goal is 2.0-2.5 ***
*** You do not need to take Aspirin per your cardiologist ***
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
?????? We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain
Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you
have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**]
[**Last Name (NamePattern1) 16368**].
Completed by:[**2142-1-12**]
|
[
"V43.3",
"401.9",
"V58.61",
"V45.81",
"600.00",
"430",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
6778, 6784
|
5166, 5963
|
336, 384
|
6852, 6852
|
3397, 5143
|
9028, 9686
|
1970, 1988
|
6150, 6755
|
6805, 6831
|
5989, 6127
|
7002, 7917
|
7943, 9005
|
2018, 2366
|
3280, 3378
|
266, 298
|
412, 1229
|
2551, 3266
|
6867, 6978
|
1251, 1693
|
1709, 1954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,641
| 150,433
|
20384
|
Discharge summary
|
report
|
Admission Date: [**2185-6-9**] Discharge Date: [**2185-6-16**]
Date of Birth: [**2106-6-3**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Quinidine/Quinine & Derivatives
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
Percutaneously cholecystostomy tube placement and removal
Midline IV placement
History of Present Illness:
79M PMH CHF EF 20%, CAD, COPD, dementia transferred from [**Location (un) 54655**] NH with hypoxia 60% - patient initially placed on NRB but
titrated down and 100% on 2L evaluation by EMT. The patient had
complained of epigastric/right-sided abdominal pain x 24 hours
per NH records. The patient complained of left sided CP x 5
minutes to EMT, resolving without intervention.
.
In the ED, initial VS: T: 97.0 BP: 98/46 HR: 58 RR: 36 O2sat:
98%RA.
Temperature rose to 102.2 (rectal) and SBP drifted down to 70s.
Patient was given NS x 3L, started on peripheral dopamine
(13cc/hr - 5ucg/kg). WBC 14.9 with 97% neutrophils, lactate 4.1,
INR 7.8. Patient was given vitamin K 10 mg IV and FFP x 2 units.
CT torso showed findings consistent with acute cholecystitis,
small left-sided pleural effusion. Patient given
ceftriaxone/azithromycin/ vancomycin/flagyl. EKG V-paced but new
TWI V2-V6. Cardiology was consulted and felt the EKG was
concerning. Patient was given ASA, and as coumadin was
supratherapeutic, no heparin was given. UA negative and guaiac
negative at that time.
.
On arrival to the MICU, patient [**Location (un) **] any pain. ROS limited by
dementia.
Past Medical History:
1. Chronic systolic and diastolic heart failure (EF 25% in [**2182**])
2. Coronary artery disease
3. Chronic obstructive pulmonary disease
4. Paroxysmal atrial fibrillation on coumadin
5. Tachy brady syndrome s/p [**Year (4 digits) 4448**]
6. Arthritis
7. Tibial fracture status post replacement
8. Right carotid artery stenosis
9. Transient ischemic attack with left-sided weakness [**4-/2181**]
10. Chronic renal insufficiency with last baseline creatinine in
our system 1.6 [**2182**]
11. Dementia
12. Chronic stasis dermatitis
13. H/o alcohol abuse
14. PVD
Social History:
Lives at [**Location (un) **] nusing facility. Used to smoke 2 PPD since
age 12 and quit few years ago. History of EtOH abuse.
Family History:
NC
Physical Exam:
VS: T: 97.5 (ax) BP: 90/44 (peripheral dopamine 5ucg/kg) P: 67
RR: 29 O2sat: 100%RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MM dry
NECK: Supple, no LAD, no carotid bruits
CV: Distant heart sounds, RRR, nl s1, s2, no m/r/g
PULM: Crackles L > R
ABD: Soft, NT, ND, + BS, no HSM, no RG
RECTAL: Guaiac negative in ED
EXT: Warm, dry, +2 distal pulses BL, venous stasis changes R
shin
NEURO: Alert & oriented x 2, CN II-XII grossly intact, moving
all extremities well
Pertinent Results:
Admission labs:
[**Age over 90 **]|103|44
-----------<112
5.1|23|2.3
Comments: K: Hemolysis Falsely Elevates K
estGFR: 28/33 (click for details)
CK: 84 MB: 4 Trop-T: 0.17
Ca: 8.2 Mg: 1.7 P: 2.9
ALT: 13 AP: 97 Tbili: 0.4 Alb: 3.4
Lip: 18
11.0
14.9>--<369
33.5
N:96.8 Band:0 L:1.6 M:1.0 E:0.5 Bas:0.2
PT: 57.8 PTT: 74.5 INR: 6.8
Lactate:1.6
EKG: V-paced at 64, new TWI V2-V6 compared to previous
CT Torso [**6-9**]: 1. Acute cholecystitis with impacted 3-mm
gallbladder neck stone and dependent stones.
2. Calcified outpouching at the aortic isthmus without evidence
of mediastinal hemorrhage or intramural hematoma, unchanged
since prior study.
3. Left pleural effusion, smaller than [**2182-11-9**].
4. Centrilobular patchy opacities in the basilar LLL and
inferior segment of lingula with tracheobronchial debris,
raising the possibility of aspiration.
.
CT HEAD W/O CONTRAST
Reason: r/o bleed
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with dementai and [**Last Name (un) 54656**] TWI on EKG concerning for
bleed
REASON FOR THIS EXAMINATION:
r/o bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 79-year-old man with dementia and T-wave inversion
on EKG concerning for bleed.
COMPARISON: [**2181-4-30**] and [**2181-4-27**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: No acute intracranial hemorrhage, mass effect or shift
of normally midline structures is noted. There are no acute
major vascular territorial infarcts. Moderately severe
prominence of sulci and the ventricles compatible with
age-associated involutionary changes is evident. Osseous
structures are unremarkable. No acute fractures are noted.
Visualized soft tissue structures are within normal limits.
IMPRESSION: No intracranial hemorrhage or edema.
.
[**2185-6-9**] 11:30 pm FLUID,OTHER CHOLECYSTOSTOMY.
GRAM STAIN (Final [**2185-6-10**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 54657**] @ 0454 ON [**2185-6-10**].
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2185-6-13**]):
ESCHERICHIA COLI. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2185-6-9**] 11:50 am BLOOD CULTURE
**FINAL REPORT [**2185-6-12**]**
Blood Culture, Routine (Final [**2185-6-12**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2185-6-10**]):
REPORTED BY PHONE TO MACAULLY GRISSITH @ 0635 ON [**2185-6-10**].
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2185-6-10**]): GRAM
NEGATIVE ROD(S).
.
Discharge Labs:
[**2185-6-13**] 06:15AM BLOOD WBC-10.8 RBC-3.41* Hgb-9.9* Hct-30.9*
MCV-91 MCH-29.1 MCHC-32.1 RDW-13.4 Plt Ct-308
[**2185-6-14**] 06:30AM BLOOD WBC-13.6* RBC-3.82* Hgb-11.3* Hct-35.0*
MCV-92 MCH-29.4 MCHC-32.2 RDW-13.8 Plt Ct-393
[**2185-6-14**] 06:30AM BLOOD Neuts-74.2* Lymphs-13.5* Monos-5.2
Eos-6.7* Baso-0.5
[**2185-6-12**] 07:15AM BLOOD FDP-10-40
[**2185-6-12**] 07:15AM BLOOD Fibrino-658*#
[**2185-6-12**] 07:15AM BLOOD Ret Aut-1.7
[**2185-6-14**] 06:30AM BLOOD Glucose-92 UreaN-41* Creat-1.9* Na-147*
K-5.1 Cl-110* HCO3-30 AnGap-12
[**2185-6-13**] 06:15AM BLOOD Lipase-32
[**2185-6-9**] 11:38AM BLOOD cTropnT-0.17*
[**2185-6-10**] 04:18AM BLOOD CK-MB-4 cTropnT-0.07*
[**2185-6-14**] 06:30AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
[**2185-6-13**] 06:15AM BLOOD Albumin-3.0* Calcium-7.8* Phos-2.6*
Mg-2.0
[**2185-6-12**] 07:15AM BLOOD calTIBC-208* VitB12-724 Folate-9.1
Hapto-273* Ferritn-149 TRF-160*
[**2185-6-12**] 07:15AM BLOOD Cortsol-16.5
[**2185-6-9**] 06:22PM BLOOD Lactate-1.6
.
Brief Hospital Course:
# Septic shock/cholecystitis: Resolving. On admission, met
criteria for septic shock given temperature >38.5??????C and WBC
count of >12,000 cells/mL; lactate >2 mmol/L; systemic mean BP
of <60 mm Hg and need for dopamine. Source was most likely
biliary given CT findings and gram negative rod bacteremia.
Patient was seen by surgery who felt he was not a surgical
candidate. The patient initially required brief peripheral
dopamine, but became hemodynamically stable within 12 hours and
it was discontinued. He was intially treated with broad
spectrum antibiotics which were changed to ceftriaxone as both
gallbladder drainage and blood cultures grew
ceftriaxone-sensitive E. Coli. A percutaneous cholecystostomy
tube was placed under ultrasound guidance on [**2185-6-9**] which has
continued to drain serosanguinous/bilious fluid since placement.
It was then pulled out of place during repositioning of
patient. After speaking with radiology and surgical consulting
teams, as the patient was clinically well, with improving liver
tests, and given the morbidity of replacing the tube and
reversing his INR, the decision was made to defer replacement of
the tube. In addition, ERCP was consulted who felt that he was
not a candidate at this time for ERCP given lack of obstructive
symptoms. He will be treated with a total 2 week course of
ceftriaxone (day 1=[**2185-6-9**]). He has a midline in place which
should be removed once antibiotic course is completed. Liver
function tests trended down throughout his hospital course.
The patient was hemodynamically stable for the remainder of his
hospitalization.
.
# Anemia: Baseline appears to be around 30 based on OMR from the
last several years, though per [**Location (un) **], his most recent Hct's
have been around 37. On admission, was 33.5, dropped to 25 and
has been stable and improving since transfer to the medicine
floor. No evidence of bleeding, guaiac has been negative.
Fibrinogen, FDP, LDH, haptoglobin, reticulocyte count without
evidence of hemolysis. Tbili within normal limits. Iron studies
showed iron deficiency and possibly anemia of inflammation,
though ferritin not elevated, B12 and folate wnl. Patient did
not require any blood transfusions during admission.
.
# Chronic obstructive pulmonary disease: Good oxygen saturations
on room air and minimal evidence of COPD on CT chest. He was
continued on outpatient Montelukast with albuterol and atrovent
nebulizers as well as Advair inhaler. Patient did not require
BiPap or intubation. He was transitioned back to MDI inhalers
on discharge.
.
# Eosinophilia: Absolute count around 1000 and stable. Likely
due to ceftriaxone as no other new medications. Patient did not
have any signs or symptoms of allergic reaction. Urine
eosinophils were negative. It was monitored and patient was
continued on his current medications. This should be evaluated
within the next few days to ensure no significant increase in
peripheral eosinophils.
.
# Chronic systolic heart failure: EF 25% on most recent pMIBI in
[**2182**]. Was initially hypovolemic due to sepsis and received
several liters of fluid. Beta blocker was restarted once blood
pressure stabilized, and ACEI at low dose was started for
afterload reduction. Patient was stable on this regimen.
.
# Acute on chronic renal failure: Creatinine 2.3 on admission,
improved after volume resuscitation. Likely partially prerenal
given Na 10 on admission, though only mild improvement after
fluids. Creatinine 1.7 at NH in [**5-17**]. Creatinine improved to
baseline of 1.7 during admission after resuscitation and
resuming PO intake.
.
# Atrial fibrillation: Status post PPM for tachy/brady syndrome.
On coumadin as outpatient. Initially with supratherapeutic INR
which was reversed for CCY tube placement. Now therapeutic on
home regimen of 3mg 5 days per week. Rate-controlled with
V-paced rhythm. Continuing beta blocker.
.
# Erosive gastritis: By report from NH, patient maintained on
PPI during admission.
.
# FEN: Ground diet, thin liquids, aspiration precautions.
.
# PPx: Coumadin, bowel regimen. Patient was on SC heparin until
INR therapeutic.
.
# CODE: DNR but can intubate for reversible causes
.
# COMMUNICATION: Next of [**Doctor First Name **] = nephew [**Name (NI) **] [**Name (NI) 18329**],
[**Telephone/Fax (1) 54658**]
Medications on Admission:
Albuterol-Ipratropium 2 PUFF IH Q4H:PRN SOB, wheeze
Montelukast Sodium 10 mg PO DAILY
Namenda *NF* 10 mg Oral [**Hospital1 **]
Aspirin 81 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Zocor 20 mg PO DAILY
Lopressor 25 mg PO DAILY
Actonel 35 mg PO WEEKLY
Magnesium oxide 400 mg PO DAILY
Calcium and vitamin D supplementation
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
insomnia.
13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gm Intravenous Q24H (every 24 hours) for 6 days.
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) INH Inhalation [**Hospital1 **] (2 times a day).
15. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) INH Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,WE,TH,FR): Please adjust dosing based on INR.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 16166**] Facility - [**Location (un) 538**]
Discharge Diagnosis:
Acute Cholecystitis
E. Coli bactermia - septic shock
Acute on chronic renal failure
Erosive gastritis
Nonthrombotic troponin elevation
Acute exacerbation of COPD
Paroxysmal atrial fibrillation
SSS s/p PM
Chronic systolic heart failure
Non-ischemic cardiomyopathy
Dementia
Poor functional status
Hypernatremia
Supratherapeutic INR
Anemia NOS
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You were found to have cholecystitis and bacteria in your blood.
You had a tube placed to drain your gallbladder which was in for
6 days. You will be treated with a total of 14 days of IV
antibiotics for your infection. It is very important that you
continue to follow with your primary care physician.
If you develop chills, fevers, abdominal pain, weight loss,
severe diarrhea, shortness of breath, chest pain or other
concerning symptoms, please go to the Emergency Room or call
your physician as soon as possible.
Followup Instructions:
Please follow with your physician within the next week. You can
call [**Telephone/Fax (1) 250**] to set up this appointment. You should also
follow with the physician at [**Location (un) **].
In addition you should keep the following appointment.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2185-7-18**]
11:00
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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14291, 14374
|
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|
314, 395
|
14759, 14784
|
2882, 2882
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|
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14808, 15329
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6761, 7752
|
2353, 2863
|
262, 276
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3949, 6744
|
423, 1588
|
2898, 3790
|
1610, 2174
|
2190, 2318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,428
| 133,668
|
1700
|
Discharge summary
|
report
|
Admission Date: [**2105-4-6**] Discharge Date: [**2105-4-9**]
Date of Birth: [**2033-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
CC:[**CC Contact Info 9774**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo M with h/o HL, HTN, CAD with IMI s/p 4v CABG ('[**93**])
presenting s/p cath with severe pulmonary arterial hypertension,
low CI. Patient has long h/o CAD s/p IMI [**8-/2093**] with inferior
fixed defect on stress test and akinesis at cath, s/p 4v CABG
[**12/2093**] with LIMA-> LAD, SVG -> OM -> Diag and SVG-RCA. He has
been off cardiovascular meds for > 5 years and has been lost to
CV follow-up. 2 months ago, the patient first caught a cold
with a sore throat, bad taste in back of throat, and DOE. No
fevers, chills, CP. Since then he has had waxing and [**Doctor Last Name 688**]
symptoms, and over the last 2-4 weeks, the patient was noticed
to have decreased exercise tolerance due to increased DOE. No
sypmtoms at rest or to bathroom, but SOB climbing 15 steps.
Also noted some increased abdominal distention, and wife noticed
[**Name2 (NI) **] edema. Symptoms have progressed subacutely causing the
patient to present to the ED on [**4-2**] at [**Location (un) 620**] where BP was
increased to 182/90, he had an elevated d-dimer (1.96 -high) and
slightly elevated troponin x 3 (0.011-> 0.02 -> 0.016). A CTA
was negative for PE. He was diuresed with lasix 20 mg IV x 2
with improvement in SOB and transferred to [**Hospital1 18**] for cath to
evaluate for subendocardial NSTEMI. At Cath, he was found to
have CO 4.06, CI 1.91, RA 28/28/21, RV 67/26, PA 67/38/49, PCW
38/41/33. Coronary angiography demonstrated LM - mild tapering,
LAD proximal 90% then totally occluded, Lcx mid total occlusion
after OM1 with distal reconstitution via collaterals, RCA
proximal occlusion, and patent SVG-AM-RCA, Y-SVG-D1 and OM2,
LIMA-LAD. He was transferred post-cath to the CCU for diuresis.
.
ROS: No nausea, vomiting, + irregular BMs, no black or bloody
stools, no weight loss, + decreased appetite at times, no night
sweats. No PND, orthopnea
Past Medical History:
CAD s/P IMI [**8-/2093**] s/p 4v CABG [**12/2093**]
acute cholecystitis s/p lap chole [**9-5**]
HTN
HL
Social History:
SH: Patient owns an adhesives company. Quit smoking after CABG
in '[**93**] - before that 10 years of Cigars and 10 years of
cigarettes. [**2-2**] glasses of cabernet each day.
Family History:
FH: non-contributory. no FH of CAD, CHF or CVA.
Physical Exam:
VS: 97.5 70 121/48 PA 68/32 17-21 100% 3L
Gen: Obese man lying in bed in NAD
HEENT: PERRL, EOMI, OP clear, MMM
Neck: JVP at jaw line
CV: RRR, nl s1, s2 no m/g/r
Lungs: dependent crackles on L
Abd: BS+, soft, NT, slightly distended, no shifting dullness or
fluid wave
Ext: 1+ edema to 1/3 up calf, 2+ DP, dopplerable PT bilaterally
Neuro: CN 2-12 intact
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2105-4-9**] 06:45AM 9.0 3.70* 12.6* 37.0* 100* 34.0* 34.0
13.3 185
[**2105-4-8**] 03:45AM 8.8 3.73* 13.1* 37.5* 101* 35.0* 34.8
13.4 182
[**2105-4-7**] 04:24AM 8.8 3.72* 12.7* 37.3* 101* 34.2* 34.0
13.3 191
[**2105-4-6**] 08:50PM 8.4 3.97* 13.8* 40.1 101* 34.8* 34.5 13.4
202
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2105-4-6**] 08:50PM 170 [**Telephone/Fax (2) 9775**]
TSH 2.6
CRP 27.1* - apparently developed fever day after discharge and
was admitted to [**Hospital1 **]
Cath [**2105-4-6**]
INDICATIONS FOR CATHETERIZATION:
CHF
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 8 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 2 saphenous vein bypass grafts was
performed using
a 5 French right [**Last Name (un) 2699**] catheter, multi-purpose catheter, and
AL1
catheter with manual contrast injections.
Arterial Conduit Angiography: of a left internal mammary artery
graft
was performed using a preformed [**Female First Name (un) 899**] catheter, with manual
contrast
injections.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.13 m2
HEMOGLOBIN: 13.4 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 28/28/21
RIGHT VENTRICLE {s/ed} 68/28
PULMONARY ARTERY {s/d/m} 68/38/50
PULMONARY WEDGE {a/v/m} 38/41/32
LEFT VENTRICLE {s/ed} 128/32
AORTA {s/d/m} 128/82/84
**CARDIAC OUTPUT
HEART RATE {beats/min} 65
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 36
CARD. OP/IND FICK {l/mn/m2} 4.1/1.9
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1229
PULMONARY VASC. RESISTANCE 351
**% SATURATION DATA (NL)
SVC LOW 55
PA MAIN 59
AO 95
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 0.21
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 20
6) PROXIMAL LAD DISCRETE 90
7) MID-LAD DISCRETE 100
12) PROXIMAL CX DISCRETE 20
13) MID CX DISCRETE 100
14) OBTUSE MARGINAL-1 DISCRETE 20
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 DISCRETE 20
29) SVBG #2 DISCRETE 20
30) SVBG #3 NORMAL
32) LIMA NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 31 minutes.
Arterial time = 0 hour 55 minutes.
Fluoro time = 34 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 125 ml
Premedications:
ASA 325 mg P.O.
Fentanyl 25mcgIV
Versed 0.5mgIV
Lasix 20mgIV
Anesthesia:
1% Lidocaine subq.
Cardiac Cath Supplies Used:
200CC MALLINCRODT, OPTIRAY 200CC
COMMENTS: 1. Selective coronary angiography of this right
dominant
system revealed severe 3 vessel native coronary disease. The
LMCA
had mild tapering. The LAD had a proximal 90% lesion and became
occluded
mid vessel. The LCX had a mid total occlusion after OM1 with
distal
reconstitution via vasa collaterals. The RCA was proximally
occluded.
2. Left ventriculography was deferred given high filling
pressures.
3. Resting hemodynamics revealed a severely elevated mean wedge
of
32mmHg. Cardiac index was low at 1.9 l/min/m2.
4. Graft angiography revealed a patent LIMA to LAD. The SVG to
AM to PDA
had mild plaquing. It supplied the distal right circulation
showing an
distally occluded RCA just cephalad to the origins of RPDA and
PRL.
There was an 80% lesion in the grafted AM with distal abrupt
tapering
into a smaller caliber distal vessel. The Y SVG graft to D1 and
OM2
contained mild luminal irregularities in the SVG to OM portion
with
retrograde perfusion into the distal AV groove CX and into the
mid AV
groove CV with vasa slow collateral filling of a higher OM.
There was
diffuse mild plaquing in the SVG to D1.
5. At the end of the case, the venous sheath was sewn in place
and the
pulmonary artery catheter left in place for monitored CHF
therapy in the
CCU.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate systolic and diastolic ventricular dysfunction.
3. Patent SVG and LIMA grafts.
4. Severely elevated PCPW.
EKG [**2105-4-6**]
Sinus arrhythmia with frequent multifocal PVCs
Inferior infarct - age undetermined
Poor R wave progression
Since previous tracing, no significant change
CXR [**2105-4-7**]
COMPARISON: Earlier, same day at 7:58 a.m.
FINDINGS: Single bedside semi-upright AP exam demonstrates
Swan-Ganz catheter, looped within the right atrium, with tip
overlying the left main pulmonary artery. The heart remains
enlarged, and mild CHF persists. No pneumothorax is seen.
IMPRESSION: Swan-Ganz catheter looped within the right atrium.
Findings discussed by telephone with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2418**] at
3:30 p.m. on [**2105-4-7**].
.
[**2105-4-7**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. S/p myocardial
infarction. Pulmonary artery systolic hypertension.
Height: (in) 71
Weight (lb): 205
BSA (m2): 2.13 m2
BP (mm Hg): 122/77
HR (bpm): 67
Status: Inpatient
Date/Time: [**2105-4-7**] at 11:54
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W009-1:15
Test Location: West CCU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 900**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *7.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 6.5 cm
Left Ventricle - Fractional Shortening: *0.10 (nl >= 0.29)
Left Ventricle - Ejection Fraction: *<= 20% (nl >=55%)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Pressure Half Time: 665 ms
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave Deceleration Time: 174 msec
TR Gradient (+ RA = PASP): *28 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thickness. Severely dilated LV cavity.
Severe global LV
hypokinesis. TVI E/e' >15, suggesting PCWP>18mmHg. No LV
mass/thrombus.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall
hypokinesis.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate
([**2-2**]+) MR.
TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Based on [**2096**] 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. Echocardiographic results were reviewed
by telephone with the houseofficer caring for the patient.
Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated with severe global hypokinesis. Tissue velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure (PCWP>18mmHg). No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild to moderate ([**2-2**]+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Biventricular cavity enlargement with severe left
ventricular
systolic dysfunction c/w multivessel CAD or other diffuse
process.
Mild-moderate mitral regurgitation. Pulmonary artery systolic
hypertension.
Based on [**2096**] 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.
.
Brief Hospital Course:
71 yo man with h/o hyperlipidemia, HTN, CAD with IMI s/p 4v CABG
('[**93**]) presenting with dyspnea on exertion now s/p cath with
clean grafts, severe pulmonary arterial hypertension, elevated
wedge pressure and low CI. In the CCU, the pulmonary artery
catheter was initially left in place to aid with diuresis, but
was pulled on HD3 when the pressure tracings dampened. He was
diuresed aggressively with lasix 40-80 mg IV with good UOP and
resolution of his lower extremity edema and significant
improvement in his DOE. He was also ruled out for an MI with
cardiac enzymes x 2 with a flat troponin of 0.02. Telemetry
showed frequent PVCs, but he was asymptomatic. His electrolytes
were repleted as needed. A TTE showed dilatation of the LV with
severe global hypokinesis and EF 20%. He was continued on
aspirin 325 QD and started on coreg 6.25 mg [**Hospital1 **], lisinopril 5 mg
QD, zetia 10 mg QD (given previous muscle pains with statins),
spironolactone 25 mg QD, digoxin 0.125 mg QD and lasix 80 mg QD.
He will get his electrolytes and digoxin level checked at his
PCP's office within 1 week to be followed up by his PCP's nurse.
EP was consulted regarding placement of an ICD; however, the
patient wanted to defer ICD placement during this
hospitalization. EP recommended a repeat TTE (transthoracic
echocardiogram) in [**3-6**] months and follow-up with EP after the
TTE. They also recommended checking a TSH, which was normal at
2.6, and a CRP, which was elevated at 27.1 to be followed-up by
his outpatient cardiologist.
Medications on Admission:
Multivitamin
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. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive Heart Failure
Coronary Artery Disease
Discharge Condition:
good, not short of breath
Discharge Instructions:
No heavy lifting or driving for 1 week.
Please check your weights daily and report to your doctor a
change in your weight of > 3 lbs.
Please eat a low salt diet, < 3 g per day.
Please keep all follow-up appointments.
Please take all medications as prescribed.
Please seek medical attention if you develop shortness of
breath, chest pain, nausea, vomiting, lightheadedness or have
any other concerning symptoms.
Followup Instructions:
You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 8506**] for [**4-21**] at 4:15 PM at [**Doctor Last Name 9776**] in [**Location (un) 1411**],
MA. Please ask him to check your potassium, BUN, creatinine and
magnesium level at that time. It was communicated with his wife
(and his wife stated that she would pass on the message), that
he should discuss with his PCP or cardiologist the need for
antibiotic prophylaxis prior to dental work and minor
procedures.
You will be called with a follow-up appointment with Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **] (cardiology - [**Telephone/Fax (1) 4105**] in [**Location (un) 620**]) at [**Hospital1 **]-[**Location (un) 620**] for within 2-4 weeks.
You have an appointment for an echocardiogram at the [**Hospital Ward Name 23**]
building, [**Hospital1 69**], [**Hospital Ward Name 516**] on
the [**Location (un) 436**], Cardiac Services, for [**5-11**] at 11 AM. Please
call [**Telephone/Fax (1) 128**] if you would like to reschedule.
Please make a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **]
electrophysiologist, to discuss placing a defibrillator at ([**Telephone/Fax (1) 5425**] within 4-6 weeks after you have received your
echocardiogram and appointment with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2105-4-12**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.52",
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] |
icd9pcs
|
[
[
[]
]
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14897, 14903
|
12398, 13943
|
341, 348
|
14996, 15024
|
3016, 3609
|
15483, 17084
|
2577, 2628
|
14006, 14874
|
14924, 14975
|
13969, 13983
|
7645, 8506
|
15048, 15460
|
8532, 12375
|
2643, 2997
|
5919, 7628
|
3642, 5900
|
273, 303
|
376, 2239
|
2261, 2365
|
2381, 2561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,049
| 100,364
|
47289
|
Discharge summary
|
report
|
Admission Date: [**2124-1-24**] Discharge Date: [**2124-3-8**]
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Increasing SOB
Major Surgical or Invasive Procedure:
[**2124-1-27**] cardiac catheterization
[**2124-2-3**] Redo sternotomy, MVR (#31 [**Company **] mosaic tissue
valve), TV Repair (#32 CE band)
[**2-25**] Trach/PEG
[**3-3**] Tunneled Left subclavian HD Cath
History of Present Illness:
HPI: 85 yo M w/MMP including CAD s/p CABG, CRI, HTN presents
with SOB. Pt was recently in the hospital on [**12-28**] [**1-14**] to
mechanical fall. He was d/c and sent to rehab. At rehab, pt
states feeling well until the end of last week when he felt he
was "full of fluid." He described having to stop after 40 feet
walking b/c of SOB (baseline >80 feet), requiring O2 during
night time (pt able to sleep with one pillow), an sense of
increased abd distention, and increased lower extremity edema.
.
While in the EMED, he received a total of 80 mg of IV lasix and
had a total of 1000 cc of Uop at noon.
.
He denies, PND,denies cough, fever, fatigue, chest pain,
dizziness, HA, or sick contacts.
.
Of note, he had a LLL PNA diagnosed in [**12-17**], and he just
finished treatment with augmentin for 14 days.
Past Medical History:
1. CAD s/p MI
- CABG [**2106**] and 2 vessel redo in [**2113**].
- [**10-16**] PMIBI: No anginal symptoms.No significant interval
change. oderate fixed inferior wall defect and moderate apical
defect with a small amount of reversibility. Inferior wall
hypokinesis. Calculated ejection fraction of 56%.
2. Ischemic cardiomyopathy
- TTE [**10-16**] TTE: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated, symm LVH, EF >55%,
aortic root mildly dilated, trace AR, 3+ MR, mild PA sys HTN
2. Endocarditis [**2114**] Strep salivarius
3. 2:1 Wenckebach block s/p v-pacer
4. BPH
5. Pseudocyst L knee
6. s/p hernia repair, x3 surgeries
7. s/p appy
8. HTN
9. CRI (baseline 1.6-1.8)
10. LLE cellulitis
11. Gout
12. Emphysema
13. R colon cancer s/p colectomy
14. Parkinson's disease (followed by Dr. [**Last Name (STitle) **]
15. PVD w/ claudication symptoms
16. Chronic venous stasis
17. Hypercholesteroemia.
Social History:
Lives with son although has been in and out of inpatient rehab
facilities over past 2 months. remote 1 year history of cigar
use, quit. Drinks occasional alcohol, 1 small glass of wine per
night, can go days without drinking etoh. Denies other drug
use. Works 3hours/week in insurance.
.
Family History:
brother-80 YO deceased, MI
two sisters have CAD
Physical Exam:
PE: on admission
VS: Tm: 96.1 Tc 96.1 BP: 118/72 HR: 88 O2sat: 94% on 2L
Weight [**1-24**]: 251.1 lbs
General: Aox3. In NAD.
Pulm: bibasilar crackles. Decreased breath sounds L>>R.
CV: holosystolic murmur best heard at the apex. nl S1/S2. JVP is
at the jaw line ~ 11 cm.
GI: distended. Nl BS+. No tenderness.
Ext: 3 + pitting edema. Redness over both lower extremities,
consistent with venous stasis.
Skin: redness over sacral region and scrotum. Pt getting daily
washing with saline and nystatin powder on scrotum, and xeroderm
over sacrum.
PE prior to leaving medicine floor:
General: Aox3. In NAD.
Pulm: Bibasilar crackles. CTAB anteriorly
CV: holosystolic murmur best heard at the apex. nl S1/S2.
GI: soft and non-tender.
GU: 3+ scrotal edema. Foley in place ([**1-27**]).
Ext: 2 + pitting edema. Redness over both lower extremities,
consistent with venous stasis.
Skin: redness over sacral region and scrotum. Pt getting daily
washing with saline and nystatin powder on scrotum, and xeroderm
over sacrum. R femoral dressing is intact, no hematoma, no
drainage, no pus, no erythema (cath done on [**1-27**]).
Pertinent Results:
[**2124-3-8**] 01:30AM BLOOD WBC-10.5 RBC-2.96* Hgb-8.8* Hct-27.7*
MCV-94 MCH-29.8 MCHC-31.8 RDW-16.7* Plt Ct-237
[**2124-3-7**] 02:52AM BLOOD WBC-11.4* RBC-2.96* Hgb-8.9* Hct-27.8*
MCV-94 MCH-30.1 MCHC-32.1 RDW-16.9* Plt Ct-267
[**2124-3-8**] 01:30AM BLOOD Plt Ct-237
[**2124-3-8**] 01:30AM BLOOD PT-14.3* PTT-30.7 INR(PT)-1.3*
[**2124-3-8**] 01:30AM BLOOD UreaN-35* Creat-3.0*# Na-143 K-3.6 Cl-105
HCO3-30 AnGap-12
[**2124-3-7**] 02:52AM BLOOD Glucose-115* UreaN-64* Creat-4.6* Na-138
K-4.7 Cl-103 HCO3-25 AnGap-15
[**2124-3-1**] 04:15AM BLOOD ALT-9 AST-18 LD(LDH)-210 AlkPhos-195*
Amylase-104* TotBili-0.5
Portable chest [**2-28**] Tracheostomy tube remains in standard
position. Permanent pacemaker is unchanged in position, with
proximal coiling of one of the leads in the right
supraclavicular area. Heart is enlarged but stable in size.
Pulmonary vascular engorgement and perihilar haziness are
unchanged. Multifocal areas of atelectasis show slight
improvement, particularly in the right lower lobe. Left
retrocardiac opacity and adjacent left pleural effusion are
unchanged. Small right pleural effusion is also stable.
[**2-28**] CT Head w/o contrast
IMPRESSION:
1. No hemorrhage or mass effect.
2. Chronic microvascular ischemia.
3. Paranasal sinus mucosal disease.
4. Unchanged expansion of the diploic space of the left parietal
bone which may be secondary to Paget's disease.
[**3-2**] EEG
IMPRESSION: This is an abnormal EEG due to the independent, at
times
synchronous, frontocentral slowing with broad-based phase
reversals, as
well as the slow and disorganized background and bursts of
generalized
slowing. This suggests bilateral frontocentral subcortical
dysfunction,
as well as similar regions of cortical irritability. The slow
and
disorganized background and bursts of generalized slowing
suggest an
encephalopathy, which may be seen with infections, toxic
metabolic
abnormalities, ischemia or medication effect.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted with a CHF exacerbation. He was diuresed
and began feeling better. CT surgery was consulted for his MR
and TR. Cardiac cath on [**1-27**] showed severe 3VD with a patent
LIMA-LAD, severe disease in SVG->OM and occluded SVG->RCA. He
was placed on cipro for a UTI. Dental medicine cleared him for
surgery. He awaited improving creatinine before going to the
operating room on [**2124-2-3**] where he underwent a redo,
redo-sternotomy, MVR with #31 [**Company **] mosaic tissue valve & TV
Repair with 32 mm CE band. He was transferred to the CSRU in
critical but stable condition on epinephrine, levophed,
vasopressin, and propofol. His epi was weaned off and he was
started on natrecor for diuresis. He was extubated on POD #2.
The remaining vasoactive drips were weaned to off on POD #3 and
he was diuresed with lasix. He continued to be followed by
cardiology. He was seen by speech and swallow who recommended
pureed solids and thin liquids with PO meds. He was transferred
to the floor on POD #5. He was cdiff positive on [**2-9**] and was
started on flagyl. He was readmitted to the CSRU on [**2-9**] for
respiratory distress and decreased urine output. He was treated
with nebulizers with little result and required reintubation. He
was seen by mephrology later that same day for anuria and rising
creatinine. He was started on vasopressin and neosynphrine for
hypotension. His neo and vasopressin weaned to off on [**2-11**]. His
creaintine and urine output continued to improve. He was again
extubated on [**2-12**]. On [**2-14**], he had recurrent ATN, required
reintubation for suspected aspiration and pressors again. He
also had afib. He was started on CVVH. He was seen by ID and
was started on cefepime and vanco. On [**2-21**] he was again
extubated and his CVVH was dc'd. A dobhoff tube wsa placed and
he was started on tube feeds. PICC line placed [**2-22**]. Antibiotics
(vanco/cefepime) for presumed hospital acquired pneumonia dc'd
on [**2-23**]. He completed his course of flagyl.
Urine output continued to wax and wane and he was again seen by
renal, repiratory status [**Last Name (un) **] began to deteriorate. He was seen
by thoracic surgery for consideration of trach and PEG which
were placed n [**2-25**]. He was seen by neurology on [**2-27**] for
stiffness which ws thought to be metabolic. Head CT was
negative. He was restarted on dialysis on [**3-1**] and an HD cath
was placed on [**3-3**]. He was last dialyzed on [**3-7**] and will need
HD on [**3-9**].
Medications on Admission:
1. Aspirin 81 mg Tablet2.
2. Allopurinol 100 mg
3. Simvastatin 40 mg Tablet QD
4. Ferrous Sulfate 325 (65) mg QD
5. Lisinopril 10 mg Tablet QD
6. Furosemide 80 mg Tablet [**Hospital1 **]
7. Atenolol 25 mg Tablet QD
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed. Tablet(s)
2. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
3. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day): periarea.
11. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
13. Erythromycin 5 mg/g Ointment [**Hospital1 **]: One (1) Ophthalmic QID (4
times a day).
14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
MR, TR, CAD
Gout
CRI (2.1)
SBE
2:1 heart block s/p PPM
BPH
HTN
LE cellulitis
lipids
emphysema
colon ca
parkinsons
PVD with claudication
venoud stasis
s/p CABG [**2106**], [**2113**]
hernia repair
colectomy
Discharge Condition:
stable
Discharge Instructions:
Call with fever, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five in one week.
No baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds.
Followup Instructions:
Please make appointments:
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 1147**] 2 weeks
Already scheduled appointments:
Provider: [**Name10 (NameIs) 9894**] [**Name11 (NameIs) **] 4 PAIN MANAGEMENT CENTER
Date/Time:[**2124-5-5**] 10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2124-3-8**]
|
[
"518.5",
"414.01",
"428.0",
"332.0",
"507.0",
"403.91",
"286.9",
"397.0",
"424.0",
"599.0",
"414.02",
"486",
"492.8",
"V53.31",
"008.45",
"274.9",
"585.6",
"427.31",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"00.13",
"35.14",
"34.91",
"39.95",
"31.1",
"96.72",
"38.95",
"33.24",
"96.04",
"43.11",
"88.72",
"38.93",
"88.57",
"39.61",
"35.23",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9993, 10073
|
5714, 8245
|
235, 443
|
10323, 10332
|
3750, 5691
|
10584, 10961
|
2550, 2599
|
8511, 9970
|
10094, 10302
|
8271, 8488
|
10356, 10561
|
2614, 3731
|
181, 197
|
471, 1282
|
1304, 2222
|
2238, 2534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,816
| 121,113
|
32175
|
Discharge summary
|
report
|
Admission Date: [**2189-7-23**] Discharge Date: [**2189-7-26**]
Date of Birth: [**2127-3-21**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
SOB & Hemoptysis
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy,Needle aspiration, endobronchial biopsy
IR ablation pulmonary vessels
History of Present Illness:
62 M w/ COPD & LUL pedunculated [**Hospital **] transferred to [**Hospital1 18**] from
OSH ([**Hospital3 3583**]) after hemoptysis X 5 days
+SOB -CP -N/V +coughing +blood tinged sputum
no recent weight change
Past Medical History:
COPD, LUL pedunculated mass on CT, PTSD, chronic back pain
Social History:
30-40 pk yrs unfiltered cigarettes/no EtOH/no drugs
Family History:
father died of CVA
mother died of emphysema
Physical Exam:
NAD, AAOx3
HEENT no LAD
heart RRR no M/R/G
lungs +B diffuse crackles
abdomen +BS S/NT/ND
Ext no C/C/E
Pertinent Results:
[**2189-7-23**] 09:35PM HCT-33.7*
[**2189-7-23**] 08:41PM GLUCOSE-116* UREA N-18 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14
[**2189-7-23**] 08:41PM CK(CPK)-188*
[**2189-7-23**] 08:41PM CK-MB-13* MB INDX-6.9* cTropnT-<0.01
[**2189-7-23**] 08:41PM CALCIUM-8.8 PHOSPHATE-2.1* MAGNESIUM-2.7*
[**2189-7-23**] 08:41PM WBC-20.4* RBC-3.57* HGB-11.8* HCT-35.4*
MCV-99* MCH-33.0* MCHC-33.2 RDW-14.0
[**2189-7-23**] 08:41PM PLT COUNT-265
[**2189-7-23**] 08:41PM PT-11.4 PTT-22.3 INR(PT)-1.0
CHEST XR (PORTABLE AP) [**2189-7-24**] 3:50 AM
Multifocal pneumonia. Emphysema
CT CHEST W/CONTRAST [**2189-7-26**] 5:13 PM
1. Again findings suggestive of aspiration and/or hemorrhage in
the dependent upper lobes bilaterally and left lower lobe
posteriorly.
2. Centrilobular emphysema.
3. Hepatic steatosis.
[**2189-7-23**] 9:21:18 PM ECG
Sinus rhythm. Normal ECG
Brief Hospital Course:
1. Hemoptysis
-NG tube placed & MI workup & CXR
-CBC, chem 10, T&C sent
-transfer to SICU & intubated
-To OR the following day for Rigid Bronchoscopy,Needle
aspiration, endobronchial biopsy, & IR ablation pulmonary
vessels(Dr. [**Last Name (STitle) **]
-pathology sent for aspirate & biopsy
-CTA chest r/o AV malformation (-AVM)
-D/C 'ed home with instructions to followup in 4 weeks
Medications on Admission:
Paxil 40', Trazodone 100', Seroquel 200', Topamax 200', Albuteol
prn, Spiriva prn, solu-medrol 60 q8hrs, Zosyn 3.375 q6hrs
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation q2h as needed for 4 weeks.
Disp:*qs qs* Refills:*0*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation once a day as needed for copd for 4
weeks.
Disp:*qs Cap(s)* Refills:*0*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day) as
needed for copd for 4 weeks.
Disp:*qs Disk with Device(s)* Refills:*0*
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*qs Patch 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
pulmonary hemorrhage
Discharge Condition:
good
Discharge Instructions:
Please take all medications as prescribed.
It is recommended that you quit smoking cigarettes
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, shortness of
breath, abdominal pain, diarrhea, or vomitting/coughing up
blood.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks (Interventional Pulm. clinic
@ [**Telephone/Fax (1) 3020**])
At your follow-up appointment you will receive the following:
1.Chest CT w/autofluorescence
2.Flexible Bronchoscopy
3.Pulmonary Function Tests (PFTs)
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2189-7-26**]
|
[
"786.3",
"724.5",
"309.81",
"786.6",
"338.29",
"305.1",
"571.8",
"518.81",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"96.71",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
3098, 3104
|
1896, 2283
|
297, 388
|
3169, 3176
|
975, 1873
|
3508, 3918
|
793, 838
|
2456, 3075
|
3125, 3148
|
2309, 2433
|
3200, 3485
|
853, 956
|
241, 259
|
416, 626
|
648, 708
|
724, 777
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,728
| 175,079
|
7003
|
Discharge summary
|
report
|
Admission Date: [**2201-4-24**] Discharge Date: [**2201-5-2**]
Date of Birth: [**2137-6-18**] Sex: M
Service: MEDICINE
Allergies:
Quinolones
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
1. arterial line placed
2. bronchoscopy
History of Present Illness:
63 yo M h/o HLD, BPH, ETOH abuse, has had dry cough for several
months. Seen by ENT at [**Hospital **] and dx with atrophic
rhinitis. Saw pcp [**4-6**] who ordered chest xray. CXR suggestive of
RML PNA and possible post obstructive PNA. Patient was scheduled
to have repeat imaging following the weekend however wife was
concerned and brought him to ED for evaluation. Repeat CXR today
showed persistant RML opacity, c/f underlying mass. CT Scan
showed 3.6 cm in lungs and liver and osseus mets.
In the ED, initial vs were: T98.8 P85 BP179/89 R18 O2 sat100%.
Patient was given CTX and levo for post obstructive PNA. Seen by
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in ED who informed patient and wife of possible cancer
dx. Patient was admitted to floor where he complained of RUE
pain before having a [**12-28**] minute tonic/clonic seizure witness by
his wife. A code Blue was called. He did not recieve ativan or
other anti-epiletics. His seizure resolved spontaneously. He was
intubated for airway protection and taken for emergent head CT.
.
Per report from his wife his [**Name2 (NI) **] pressure has been creeping up
all day to the 160's sytolic. No reports of HA, dizzyness or
other focal neurologic disorders. No nausea or vommiting.
Past Medical History:
Right kidney cysts
Nephrolithiasis
Social History:
- Tobacco: former smoker
- Alcohol: history of EToh use. No recent use
- Illicits: unknown
Family History:
His twin brother died of a coronary occlusion and his older
brother died at age 38 of AIDS. His father died of coronary
disease at age 58 and mother of breast cancer at age 84.
Physical Exam:
ADMISSION:
Initial ICU admission physical exam:
Intubated, sedated.
BP 116/66 HR 93 RR 18 99% O2 sat on PSV 10/5 FIo2 0.5
Lungs clear anteriorly
CV RRR distinct S1 and S2
Abdomen soft, nontender
Extremities warm
Neuro exam not noted
Discharge physical exam
VSS
Lungs clear
CV RRR
No pronator drift
Ataxic gait
Mental status close to baseline.
Pertinent Results:
ADMISSION LABS:
[**2201-4-24**] 06:55PM GLUCOSE-94 UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2201-4-24**] 06:55PM WBC-9.4 RBC-4.51* HGB-13.1* HCT-37.7* MCV-84
MCH-29.1 MCHC-34.9 RDW-13.0
[**2201-4-24**] 06:55PM NEUTS-62.0 LYMPHS-20.1 MONOS-8.6 EOS-8.3*
BASOS-0.9
[**2201-4-24**] 06:55PM PLT COUNT-197
.
DISCHARGE LABS:
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] WBC-19.2* RBC-4.71 Hgb-13.8* Hct-40.1
MCV-85 MCH-29.3 MCHC-34.4 RDW-13.3 Plt Ct-175
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] Plt Ct-175
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] Glucose-145* UreaN-27* Creat-1.1 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] ALT-44* AST-19 AlkPhos-154* TotBili-0.5
.
STUDIES:
.
CXR [**4-24**]:
IMPRESSION: Persistent right middle lobe opacities. Although the
patient has not undergone interval treatment for pneumonia, per
discussion with the referring physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26216**],
there is concern for underlying mass lesion. Recommend CT for
further evaluation.
.
CT CHEST [**4-24**]:
IMPRESSION:
1. Obstructing right middle lobe mass, with post-obstructive
pneumonia and
ipsilateral bronchovascular spread.
2. Innumerable hepatic and osseous metastases.
3. Suspicious 1.2-cm soft tissue nodule in the right upper renal
pole.
This constellation of findings is highly suggestive of stage IV
metastatic
lung cancer.
.
CTAP [**4-24**]:
IMPRESSION:
1. Obstructing right middle lobe mass, with post-obstructive
pneumonia and
ipsilateral bronchovascular spread.
2. Innumerable hepatic and osseous metastases.
3. Suspicious 1.2-cm soft tissue nodule in the right upper renal
pole.
.
MRI [**4-25**]:
IMPRESSION: Findings are consistent with multiple brain
metastases in the
supra- and infratentorial region. Mild surrounding edema seen.
No midline
shift or hydrocephalus.
.
Bone scan [**5-1**]:
Multiple increased areas of uptake in the spine, left shoulder,
ribs and pelvis consistent with metastatic disease.
.
Pathology:
Liver biopsy [**4-27**]: Needle biopsy of liver: Hepatic parenchyma
only. No metastatic carcinoma seen.
Liver biopsy [**4-28**]: Needle biopsy of liver: Metastatic
adenocarcinoma. Tumor cells stain strongly and diffusely for CK7
and TTF1, very focally for CK20, and do not stain for CK5/6. The
findings are consistent with a tumor of lung origin.
Also [**4-28**]:
FNA, and touch prep of core, liver:
POSITIVE FOR MALIGNANT CELLS, CONSISTENT WITH CARCINOMA.
Note: This is a non-small ccell carcinoma. The site of
origin cannot be determined based on cytomorphology. See
core biopsy S11-[**Numeric Identifier 26217**] for further discussion.
.
EEGS:
[**4-25**]: This is an abnormal continuous EEG due to the presence of
a
burst suppression pattern where the bursts consist of a mixed
alpha/beta
frequency activity seen with an anterior predominance. This
pattern is
suggestive of a spindle coma which may be secondary to
medication
effects (most commonly benzodiazepines, barbiturates, or
tricyclics).
Alternatively, if seen after diffuse hypoxic injury, it portends
an
extremely poor prognosis. There were no focal abnormalities or
epileptiform features seen.
.
[**4-26**]:This is an abnormal continuous EEG due to the presence of
prolonged periods of generalized, mixed theta and delta
frequency
slowing interrupted by occasional periods of alpha frequency
activity
with an anterior predominance. This pattern is suggestive of a
moderate
to severe diffuse encephalopathy commonly seen with medication
effect,
metabolic disturbance, or infection. Compared to the previous
tracing,
the periods of mixed theta and delta slowing are more prolonged
and
frequent possibly consistent with a lightening of sedation
effect.
There are no focal abnormalities or epileptiform features seen.
.
[**4-27**]: This is an abnormal 24-hour video EEG due to the slow and
disorganized background of [**4-1**] Hz with bursts of generalized
delta
frequency slowing, indicative of a moderate encephalopathy.
Again seen
were periods of generalized mixed alpha and beta frequency
activity,
which were far less prolonged and noticeable than the previous
day's
recording. These findings represent an improvement in the
background
compared to the previous day's recording. However, rare
generalized
sharp and slow wave discharges were seen and indicate
generalized
cortical irritability. No clear electrographic seizures were
seen.
.
[**4-28**]: This is an abnormal EEG telemetry due to the presence of a
disorganized, mixed alpha and theta frequency background,
alternating
with periods of [**12-28**] Hz frontally predominant generalized detla
slowing.
This pattern is indicative of a moderate encephalopathy,
commonly seen
with medication effect, metabolic disturbance, or infection. In
addition, the frequent periods of generalized rhythmic delta
activity
with embedded sharp waves are suggestive of a diffuse cortical
irritability, these were less prominent than the previous day's
recording. There were no definite electrographic seizures seen.
.
MICRO:
Bcx: negative
BAL:
[**2201-4-25**] 12:21 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2201-4-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2201-4-27**]): NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2201-4-27**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
Sputum [**4-28**]:
GRAM STAIN (Final [**2201-4-27**]):
[**10-20**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2201-4-29**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
Pending tests:
ACID FAST CULTURE (Preliminary): pending
Dilantin level [**5-1**]
Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname **] is a 63 yo man with prior history of etoh abuse and
smoking, transferred from ICU after admission to the medical
service with pneumonia, and found to have a post obstructive
pneumonia with a lung mass. CT also showed liver and osseous
metastases. Course complicated by a seizure on the floor, for
which he was intubated for airway protection and transferred to
the MICU. Brain MRI showed brain metastases. He was loaded
with phenytoin, as well as keppra and decadron. His course was
also notable for an acute delirium, subsequently resolved.
While hospitalized, he was seen by neurology, neuro-oncology,
radiation oncology, and medical oncology. He was started on
brain XRT and will follow up with oncology for chemotherapy
initiation and discussion of further steps after discharge.
.
Hospital course by problem:
.
# Metastatic lung cancer: Pt had mets suggested by CTAP to liver
& bone, and mets in brain by MRI. Liver biopsy was performed
twice, with the second biopsy revealing metastatic lung cancer.
Bone scan revealed multiple areas of ossesous metastatic
disease, including ribs, left shoulder, bilateral pelvis and
spine. Oncology was consulted and he will follow up with them
as an outpatient (appt still pending) to discuss chemotherapy
after his brain radiation is completed. Neuro-Oncology was
involved by Neuro and he will have repeat MRI and neurology
follow up in 1 month.
.
# Seizure with brain metastases: He had a seizure shortly after
presentation, and was seen by neurology. It was attributed to
metastatic disease and lowered seizure threshhold due to
florquinolone usage. He was treated with AED's, and neurology
was consulted. Pt had CT head demonstrating vasogenic edema. MRI
brain showed brain metastases. He appeared to be seizing on
Keppra on HOD#1. Keppra was increased; he was loaded with
Dilantin & started on Decadron for edema. An EEG was placed and
showed high cortical irritability but no further seizures. Pt
was weaned off propofol and maintained on antiepileptics. After
discharge from the ICU, he had no further seizure activity. He
was seen by radiation oncology and underwent whole brain
radiation starting on [**4-30**] without complications. He will have a
total of 10 treatments. Given prolonged decadron treatment, he
was started on a PPI, bactrim TIW, calcium and vitamin D. He
was discharged on keppra 1500 mg po bid
.
# Acute respiratory distress: Intubated for airway protection in
setting of seizures. Vent was kept overnight given need to
ensure adequate antiepileptic coverage prior to discontinuation
of propofol. Pt was extubated on [**4-26**] without complication.
.
# Post obstructive Pneumonia: As suggested by CT. Pt with recent
reported fevers, but only low grade temps in MICU. He was placed
on Vanc/Zosyn for coverage. He was treated for 8 days, with no
fevers. Cultures were negative.
.
# Acute delirium. While in the ICU, he developed an acute
delirium after extubation. He slowly cleared and returned to
his baseline. The cause was likely multifactorial with
infection, steroids, and ICU-related.
.
# Lactic acidosis: Most likley etiology is [**1-28**] to seizure. As
above, possibly also related to lung source; however lactate
quickly came down once AEDs started and treated with IVF's. Pt
was ruled-out for MI with serial cardiac enzymes. Lactic
acidosis resolved.
.
# Steroid induced hyperglycemia: HE was started on ISS as on
decadron, and then transitioned to po glipizide, with glucometer
monitoring. He will have VNA teaching regarding glucose testing
in the next 2 days.
.
Outstanding tests at discharge:
dilantin level pending
AFB culture pending
.
Transitional issues:
1. Oncology follow up: He will need oncology follow up in the
next 2 weeks after completing radiation.
2. Home services: HE will have home PT as well as home nursing
services.
Medications on Admission:
Lipitor 10mg
Flomax
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*30 Tablet(s)* Refills:*1*
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
5. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*1*
6. levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*1*
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
10. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*1*
11. Prilosec 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:*1*
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
13. Glucometer
Check [**Month/Day (2) **] sugar twice daily, first thing in the morning and
then before dinner.
Dispense #1
No refills.
14. Lancets
Use as directed to test sugar.
Dispense: 1 month's supply
1 Refill
15. Test strips
Use as directed, twice daily.
Dispense #100
1 refill
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Seizure
Post obstructive pneumonia
Metastatic lung cancer
Acute delirium
Gait instability
Discharge Condition:
Ataxic gait, some slowed responses, requires walker for
ambulation
Discharge Instructions:
You were admitted with a cough, and then subsequently had a
seizure. The evaluation that we did found metastatic cancer
originating in your lungs, and also in your bones, liver and
brain. You started on radiation therapy for your brain
metastases, and will follow up with the oncologists in the next
few weeks to discuss chemotherapy. As your gait remains
unsteady, you should have someone within you whenever possible,
and use a walker to walk with.
.
Your [**Location (un) **] sugar is high due to the steroids. You should check
your [**Location (un) **] sugar twice a day and keep track. The visiting nurses
will teach you how to use the glucometer machine. Do not worry
about it until tomorrow.
.
New medications:
Start DECADRON 4 mg po every 6 hours (brain swelling)
Start KEPPRA 1500 mg twice daily (seizures)
Start PHENYTOIN 100 mg three times daily (SEIZURES)
Start Sulfameth/Trimethoprim DS 1 TAB 3X/WEEK (MO,WE,FR)
(INFECTION REDUCTION)
Start Calcium Carbonate 500 mg PO/NG TID (BONES)
Start Vitamin D 800 UNIT PO/NG DAILY (BONES)
Start PRILOSEC 20 mg po daily (ULCER PREVENTION)
Start TRAZODONE 50 MG po qhs (SLEEP)
Start GLYBURIDE 2.5 mg po twice daily. (HIGH SUGARS)
Start TYLENOL 500 mg 1-2 tabs, up to 4 tablets per day, for pain
Followup Instructions:
Radiation therapy - Monday, 9AM
.
Department: INTERNAL MEDICINE
When: MONDAY [**2201-5-11**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**0-0-**]
We are working on a follow up appointment with
Hematology/Omcology within 1 week. You will be called at home
with the appointment. If you have not heard from the office
within 2 days or have any questions, please call the number
above.
Department: RADIOLOGY
When: MONDAY [**2201-6-8**] at 1:55 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2201-6-8**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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21,575
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30146
|
Discharge summary
|
report
|
Admission Date: [**2102-1-8**] Discharge Date: [**2102-1-22**]
Date of Birth: [**2043-11-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
transfer from OSH for further management of liver, renal, and
vascular surgery issues
Major Surgical or Invasive Procedure:
Dialysis lines
skin biopsies X 2
History of Present Illness:
This is a 58 year old man with a complicated history including
CAD, cardiomyopathy (EF 39%), afib, DM, who presented to an OSH
on [**2101-12-30**] with leg pain and swelling. History is obtained from
the patient, his family, and OSH medical records. Mr. [**Known lastname 71839**]
had apparently injured his R leg by bumping it while getting on
his tractor in [**9-26**] and developed a wound. He was diagnosed
with cellulitis and treated with Keflex for 2 weeks with no
improvement. The wound was later debrided three times by
vascular surgery at [**Hospital3 **] but still did not improve.
He was then admitted in late [**Month (only) 404**]/early [**Month (only) 956**] to [**Hospital **] with L leg necrotic areas. Biopsy revealed a
thrombotic embolic process and he was started on vanco and
ceftaz.
.
He was transfused several units PRBC for anemia. Blood cultures
then returned with gram + bacteria and he was switched to
Unasyn. The patient was then noted to become jaundiced with
total bili 5.2 and direct bili 3.8. GI was consulted. RUQ U/S
revealed multiple stones. ERCP showed no stones in the ducts.
LFTs remained elevated. HCV antibody was positive, but viral
load negative. Cryoglobulins were checked on a previous
admission (due to concern for vasculitis) but were negative.
The patient was eventually discharged home on oral antibiotics
for outpatient wound care.
.
Within one week, his leg again became enlarged and swollen and
the patient was referred to the ED and admitted on [**2101-12-30**] with R
leg cellulitis and necrotic areas of the L leg. He was started
on Kefzol and DVT was ruled out. Cultures of the leg came back
positive for MRSA. Question of coumadin skin necrosis was
raised, but then felt unlikely as pt had been on coumadin for 5
years. Per OSH notes, transfer to a tertiary care center was
first considered on [**1-2**] for plastic surgery management of LE
wounds.
.
Amiodarone was discontinued due to elevated LFTs. Ammonia level
was in the 60s and lactulose was started. Of note, the patient
also developed hypoglycemia, believed to be due to oral DM meds.
This improved when meds were held and D5W or D10W were given.
The patient then developed hyponatremia that was felt due to
these hypotonic fluids. Nephrology was consulted for ARF and
hyponatremia. They suggested increasing doses of lasix along
with albumin (pt's albumin level was 1.4 at this point) and
switching to D10NS.
.
On [**1-3**] the patient was noted to be wheezy. Pulmonary was
consulted due to concern for an upper-airway lesion. CT neck
showed now airway compromise. Pulmonary felt that wheezing was
more likely than actual upper airway stridor. PFTs and CT were
recommended. Not clear if CT was done at that time, but CTA was
done on [**1-8**] and ruled out PE. Did show a R base pna. On [**1-6**]
the patient was apparently transferred to the ICU for a CHF
exacerbation. This is not well-documented in the notes, but the
family notes that the patient was increasingly SOB despite
increasing doses of lasix. He was eventually put on a lasix
gtt.
.
According to the report given to the nurse, the patient has
undergone hemodialysis for the last 2 days ([**1-7**] & [**1-8**]), with
4.3L taken off yesterday and 5L today (this is not mentioned in
OSH records). The patient reports feeling much better
respiratory-wise following dialysis. Most recent ABG by report
was 7.34/48/69 on 2L nc. Apparently hepatorenal syndrome has
been considered as the etiology for worsening renal failure.
Today ([**1-8**]), hct noted to be 24.4, and patietn was transfused
2U PRBC prior to transfer.
.
According to the family, the reasons for transfer to [**Hospital1 18**] (on
[**1-8**]) are for vascular vs. plastic surgery evaluation for his
legs, renal evalation for renal failure requiring HD, and liver
transplant team evaluation, although they are aware he is not a
transplant candidate at this time (obese and actively infected).
Past Medical History:
paroxysmal atrial fibrillation (on coumadin as outpt)
CHF/cardiomyopathy EF 39%
HTN
obesity
DM2
hypercholesterolemia
cirrhosis (possibly [**12-23**] HCV vs. fatty liver)
chronic renal insufficiency (Cr 2.6 in [**10-26**])
Social History:
Retired, lives with wife and sons. Nonsmoker, drinks 2-3 vodka
and tonics a few times a week.
Family History:
nc
Physical Exam:
VS: 99.6, HR 82, BP 128/58, RR 24, O2sat 100% on 3L nc
Gen: anxious appearing man in NAD
HEENT: PERRL, +scleral icterus, MMM, OP clear
Neck: supple
Lungs: few crackles at bases, R>L
Heart: RRR, soft II/VI systolic murmur at apex
Abd: +BS, soft, obese, NT, mildly distended.
Extrem: 1+ edema b/l. Necrotic ulcers over both pretibial
regions. Areas of black eschar R>L with also some smaller open
areas draining serosanguinous fluid. Mild surrounding erythema.
Neuro: Alert and oriented to self, to "hospital". CN2-12
grossly intact. Moving all 4 extremities. +asterixis.
Pertinent Results:
[**2102-1-8**] 11:22PM BLOOD WBC-13.0* RBC-3.10* Hgb-9.4* Hct-28.6*
MCV-92 MCH-30.3 MCHC-32.8 RDW-18.1* Plt Ct-137*
[**2102-1-8**] 11:22PM BLOOD Neuts-90* Bands-2 Lymphs-2* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2102-1-8**] 11:22PM BLOOD PT-30.4* PTT-49.9* INR(PT)-3.2*
[**2102-1-8**] 11:22PM BLOOD Glucose-197* UreaN-53* Creat-3.4* Na-135
K-4.5 Cl-100 HCO3-28 AnGap-12
[**2102-1-8**] 11:22PM BLOOD ALT-16 AST-50* LD(LDH)-166 AlkPhos-116
Amylase-30 TotBili-7.7*
[**2102-1-8**] 11:22PM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.0 Mg-2.5
[**2102-1-13**] 05:57AM BLOOD calTIBC-65* Ferritn-360 TRF-50*
[**2102-1-9**] 05:42PM BLOOD Cryoglb-NO CRYOGLO
[**2102-1-12**] 06:48AM BLOOD Triglyc-147 HDL-19 CHOL/HD-7.4 LDLcalc-93
[**2102-1-10**] 12:42PM BLOOD PTH-68*
[**2102-1-8**] 11:22PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2102-1-9**] 06:14PM BLOOD ANCA-NEGATIVE
[**2102-1-10**] 08:19AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2102-1-9**] 05:13PM BLOOD CRP-43.0*
[**2102-1-12**] 06:48AM BLOOD IgG-1713*
[**2102-1-9**] 05:13PM BLOOD C3-85* C4-12
....
Abd US ([**2102-1-10**]): 1. Coarsened and slightly nodular echotexture
of the liver without focal liver lesions. Trace amount of
ascites. No varices. Splenomegaly. 2. Gallstones and gallbladder
sludge.
.
CXR ([**2102-1-9**]): 1. Left subclavian central line tip at distal
SVC/RA junction. No pneumothorax. 2. Patchy opacity at both
bases, question atelectasis versus infiltrate, in the setting of
low inspiratory volumes.
.
TTE-The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is mildly dilated. Free wall motion
could not be assessed. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not
present. There is no valvular aortic stenosis. The increased
transaortic gradient is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
...
CT Lower extremities:
FINDINGS:
Extensive vascular calcifications are present throughout the
pelvis and lower extremities including several of the smaller
end arterioles.
Subcutaneous edema is present most notably about both knees as
well as both ankles. No focal fluid collections are identified,
however, evaluation for this entity is limited without
intravenous contrast.
There are no fractures, dislocations, or bone abnormalities.
Small joint effusion is present at the right knee.
Limited images through the contents of the pelvis demonstrate
rectal and Foley catheters.
Muscle atrophy is noted with fatty infiltration of the hamstring
musculature as well as medial gastrocnemius muscles.
IMPRESSION:
1) Extensive vascular calcification throughout the pelvis and
lower extremities. This is a nonspecific findings and can be
seen in calciphylaxis and extensive atherosclerotic disease.
2) Subcutaneous edema in both lower extremities particularly
about both knees and ankles without large skin defects or fluid
collections.
....
Bone Scan:
IMPRESSION: 1) Uptake in the femoral vessels in the thighs
bilaterally may
represent residual blood pool activity or vascular
calcifications. If indicated,urther evaluation with a
noncontrast CT scan may be performed. 2) Faint uptake
posteriorly near the proximal left femur may represent
degenerative change or soft tissue uptake/calcification. 3) No
definite abnormal uptake in the calves.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 71840**],[**Known firstname **] [**2043-11-16**] 58 Male [**Numeric Identifier 71841**] [**Numeric Identifier 71842**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 63180**]/mtd
SPECIMEN SUBMITTED: 4 mm punch Bx - right pretibia.
Procedure date Tissue received Report Date Diagnosed
by
[**2102-1-14**] [**2102-1-15**] [**2102-1-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/cma??????
************This report contains an addendum***********
DIAGNOSIS
Skin, leg, right pretibial; punch biopsy (A):
Preliminary findings:
Vascular calcification involving larger caliber cutaneous
vessels (see comment).
Comment: Initial sections show a punch biopsy spanning the
full thickness of the epidermis and dermis to include the more
superficial portion of the panniculus. There is epidermal
atrophy, dermal fibrosis and calcification of larger caliber
vessels in the deep dermis and septae of the superficial
subcutaneous fat. Calcification of small to medium vessels in
the adipose tissue lobules is not appreciated. However, given
the placement of the biopsy site and the relatively small amount
of panniculus available for evaluation, calciphylaxis cannot be
excluded on the basis of this biopsy. If there is continuing
clinical concern for calciphylaxis, re biopsy to include more
panniculus may be appropriate as clinically indicated. There is
no evidence of vasculitis in the levels so far examined.
Additional tissue levels and special stains will be performed
and the results issued in a final report. Reviewed by Dr. [**Last Name (STitle) **].
ADDENDUM: Additional levels have been examined and the
findings remain unchanged. No fungal organisms are identified
on PAS, PAS-D or GMS stains and bacterial organisms are not
identified in the dermis or subcutis on Gram staining. The
initial findings were discussed with Dr. [**Last Name (STitle) **] on [**2102-1-16**].
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 71840**],[**Known firstname **] [**2043-11-16**] 58 Male [**Numeric Identifier 71843**] [**Numeric Identifier 71842**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **],
[**Last Name (LF) 71844**],[**First Name3 (LF) 19267**]/mtd
SPECIMEN SUBMITTED: SKIN BX, LEFT LEG (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2102-1-18**] [**2102-1-18**] [**2102-1-20**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/bef??????
Previous biopsies: [**Numeric Identifier 71841**] 4 mm punch Bx - right pretibia.
DIAGNOSIS:
Skin and subcutaneous tissue, left leg; biopsy (A-C):
Focal calcification within walls of small subcutaneous
vessels (see comment).
Comment. Initial and multiple additional tissue levels have
been examined. There is focal calcification with a concentric
pattern within the walls of a few subcutaneous vessels. These
are present in panniculus which underlies an area of epidermal
and dermal necrosis associated with acute inflammation. In the
correct clinical setting these findings are suggestive of
calciphylaxis. The calcification is not well developed in this
biopsy. This may reflect placement of the biopsy site or
alternatively, could represent an evolving lesion. In addition,
there is calcification and partial occlusion of a much larger
vessel in the subcutis which shows changes consistent with
atherosclerosis. Part of the included epidermis and superficial
dermis is necrotic and associated with underlying acute
inflammation. Both fungal and bacterial forms are present on the
surface of the necrotic epidermis, seen on GMS and PAS-D and
Gram stains, respectively. Fungi also extend into the most
superficial dermis. The findings are consistent with superficial
colonization of the necrotic tissue. No stainable fungi or
bacteria are identified within the acutely inflamed deeper
dermis. Clinical correlation is recommended.
The preliminary findings were reviewed with Dr. [**Last Name (STitle) **] on
[**2102-1-19**]. The final results were phoned to Dr. [**Last Name (STitle) **] by Dr.
[**Last Name (STitle) **] on [**2102-1-20**] at approximately 1730 hrs. Sections have been
reviewed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] and Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
CT ABDOMEN W/O CONTRAST [**2102-1-17**] 5:49 PM
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
Reason: CT torso without contrast to evaluate for calcification
of v
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with ?calciphylaxis
REASON FOR THIS EXAMINATION:
CT torso without contrast to evaluate for calcification of
vessels to kidneys/liver
CONTRAINDICATIONS for IV CONTRAST: renal failure
INDICATION: 58-year-old male with calciphylaxis. Evaluate for
calcification of vessels.
COMPARISON: None.
TECHNIQUE: Non-contrast multidetector CT acquired axial images
of the chest, abdomen and pelvis from the thoracic inlet to the
pubic symphysis. Coronal and sagittal reformatted images were
obtained.
CT OF THE CHEST NONCONTRAST: There is a small right pleural
effusion and adjacent compressive atelectasis. Consolidation is
seen within the left lower lobe. The heart and great vessels are
unremarkable. There is no pericardial effusion. Note is made of
soft tissue superior to the vocal cords on a single image, which
is incompletely assessed and recommend correlation with clinical
findings. No pathologically enlarged axillary or mediastinal
nodes are apparent.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Liver shows no
focal lesions. A mildly distended gallbladder containing
numerous gallstones is seen. There is no pericholecystic fluid
or gallbladder wall edema to suggest cholecystitis. The adrenal
glands, spleen, stomach, pancreas, intra-abdominal loops of
large and small bowel are within normal limits. Multiple low
density lesions are seen within bilateral kidneys, too small to
characterize but likely to represent cysts. Residual contrast is
seen within the kidneys and collecting system. There is no
hydronephrosis or hydroureter. No intraabdominal free fluid or
free air is detected. No enlarged retroperitoneal or mesenteric
lymph nodes are evident. Vascular calcifications are noted
within the abdominal aorta, iliac arteries, celiac artery and
branches. Small foci of high attenuation is seen throughout the
subcutaneous tissue of the abdomen, likely representing
injection sites. Note is made of a left subclavian central
venous catheter with tip at the atriocaval junction.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum and
sigmoid colon are unremarkable. The bladder is decompressed.
Intrapelvic loops of small bowel are unremarkable. Free fluid is
seen within the pelvis. No pathologically enlarged pelvic or
inguinal lymph nodes are appreciated.
BONY WINDOWS: No suspicious lytic or sclerotic lesion is
identified. Multilevel degenerative changes are seen throughout
the thoracolumbar spine.
IMPRESSION:
1. Small right pleural effusion and adjacent compressive
atelectasis. Consolidation in the left lung base, concernig for
infectious etiology.
2. Cholelithiasis without evidence of cholecystitis.
3. Multiple hypodensities within bilateral kidneys, too small to
charaterize, but most likely representing cysts.
4. Soft tissue seen above the vocal cords on a single slice,
incompletely assessed for which correlation with clinical
findings is recommended.
5. Vascular calcifications within the aorta, iliac artery,
celiac artery and branches.These findings are reviewed in light
of the patients diagnosis of Calciphylaxis.I have reviewed the
literature for information on the distribution of calcium
deposits in calciphylaxis. On the current CT images, we cannot
reliably differentiate mural and medial calcification, but the
distribution in this case is unusual, as there is almost
complate sparing of the aorta and SMA with severe involvement
elsewhere.In addition, there appears to be little "soft plaque"
or non-calcified plaque suggesting that this is predominantly a
non-atherosclerotic process.If I find any further information in
the literature I will issue an addendum
Brief Hospital Course:
A/P: This is a 58 year old man with CHF, afib, possible HCV, LE
cellulitis who is transferred from an OSH for further management
of LE cellulitis and ulcers, acute on chronic renal failure, and
cirrhosis.
.
# LE cellulitis/ulcers: vasculitis vs. DM ulcer. +MRSA at OSH.
Biopsy done at OSH apparently showed vessel thrombosis.
Coumadin skin necrosis was considered a possibility, but
unlikely since pt has been on coumadin several years.
Cryoglobulins negative (in setting of positive HCV Ab). DVT
ruled out at OSH. Further evaluation by consulting services
felt that the appearance and history was consistent with
calciphylaxis. And in review of the records, it appears that
the patient had several days of elevated corrected calcium at
the outside hospital preceeding his renal failure which could
have contributed to his current condition. In this thought, the
patient was continued on vancomycin (dosed by level after
dialysis) for prophylaxis of the previously know MRSA
colinization. Since it is also sensitive to bactrim, patient
could be continued on this as outpatient prophylaxis. Initial
biopsy was done on [**1-15**] which was indeterminate, but a second
biopsy eventually showed calciphylaxis. He was started on
sodium thiosulfate treatment on days of dialysis.
.
# Hepatic Dysfxn: Thought by hepatology to be secondary to
decompensated NASH though alcoholic hepatitis cannot be ruled
out. Patient's synthetic continued to worsen. Patient carries
diagnosis of cirrhosis, etiology not clear, and never had liver
bx or U/S findings c/w cirrhosis. Ultrasound showed fatty
infiltration of liver. LFTs have been mildly elevated, bili
more so (now 7.7). Albumin is low at 2.9, INR elevated.
Hepatitis serolgies were performed and negative. Additionally
patient did not have lab support of autoimmune hepatitis.
Patient was maintianed on vitamin K, lactulose with some
improvement. As well patient received octreotide, midodrine and
albumin for treatment of possible hepatorenal syndrome.
.
# Acute on Chronic renal failure: Recent baseline creatinine
2.0-2.6 in [**2101-10-2**]. 3.4 on admission (post-HD) and now 4.8.
s/p HD at OSH. Hepatorenal syndrome has been raised as a
possible etiology, however, no definite evidence at this time.
More likely prerenal w/ ATN also possible, particularly in the
setting of aggressive lasix diuresis. Also had CTA at OSH w/
dye load; however, unclear if prior to or after HD initiated.
Patient received 2U PRBC prior to transfer, which should help
with hydration. abd U/S at OSH showed no obstructive uropathy.
Patient continued on dialysis.
.
# Pneumonia: Patient had SOB and was in ICU at OSH for most
likely CHF exacerbation. R base consolidation noted on CTA at
OSH (wet read). Pnemumonia was empirically treated with levo
and flagyl and improved after >10 day course.
.
# CHF: Was in ICU at OSH for apparent CHF exacerbation.
Improved s/p HD. Renal following, but no acute indication for
HD currently. Currently stable. Holding lasix for now.
.
# Afib: h/o PAF. Previously on coumadin, but now on hold due to
question of coumadin skin necrosis as well as liver failure and
auto-anticoagulation. Currently in SR. Continue BB (at
decreased dose). Holding amiodarone due to abnormal LFTs.
.
Pt. continued to have worsening liver failure and on [**1-21**] was
hypotensive at dialysis so dialysis had to be stopped. The next
day he became more and more tachypneic with e/o metabolic
acidosis. He had ABG of 7.19*/ 45/42, thought to be [**12-23**] anion
gap metabolic acidosis from sodium thiosulfate in addition to
resiratory acidosis [**12-23**] tiring. He was initially transferred to
ICU, but soon thereafter, family meeting was convened and
decision was made to transition to comfort measures only. Pt.
had all meds d/c'd other than morphine drip and scopolamine. He
passed away peacefully that evening of respiratory failure with
the proximal cuase being liver and renal failure
Medications on Admission:
amiodarone 200 daily
amaryl 2mg daily
percocet prn
lopressor 100mg [**Hospital1 **]
lasix 40 [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Liver failure
Renal failure
.
Diabetes
Calciphylaxis
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,287
| 195,530
|
9024+9025+9026
|
Discharge summary
|
report+report+report
|
Admission Date: [**2122-9-10**] Discharge Date: [**2122-9-23**]
Date of Birth: [**2061-9-22**] Sex: F
Service: SURGERY
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Exploratory Laparotomy with lysis of adhesions
History of Present Illness:
Mrs. [**Known lastname 2643**] is a 60 yo F with alcoholic cirrhosis, recently
admitted for initiation of V.A.C. therapy for a midline
abdominal
wound from her verntral hernia repair with mesh. She noted the
rather abrupt onset of progressively worsening RUQ pain with
radiation over the subcostal margin into the left upper
quadrant.
The pain was previously [**10-2**] before getting dilaudid but has
currently mostly subsided. She is pain free when I examine her.
SHe continues to have ostomy output and there is air in the bag
with some brown/green liquid stool. She cannot relate whether
the
output has increased or decreased. She called the transplant
coordinators and related chest pain, but this is not present
currently and she denies chest pain or shortness of breath
earlier in the day. For this, she was sent to the ED for
evaluation.
ROS: + N (on home zofran dose, stable), pain as in HPI,
subjective decrease in urine output, sense of cold intolerance
but this is baseline for here, decreased appetite, poor po
intake
- fevers, vomiting, headache, CP, SOB
Past Medical History:
1. EtOH abuse x15 yrs: last drink [**2122-2-28**]
2. Cirrhosis: c/b ascites, esophageal varices w/o hemorrhage
3. Hx of ischemic colitis
4. Asthma
5. Gastric ulcers
6. Hypothyroidism
7. Chronic diarrhea
8. Depression
PSH:
1. gastric bypass 14 years ago
2. multiple incisional hernia operations
3. hysterectomy for endometriosis and "cell abnormality"
4. exploratory laparotomy with lysis of adhesions, right
colectomy, end ileostomy [**2122-7-10**]
Social History:
Quit smoking 25 years ago.
Last drink ETOH [**2122-2-28**].
Denies drugs.
Lives with husband who is s/p renal transplant from daughter.
[**Name (NI) 4906**] works a lot so patient is often home alone without help
to care for herself. Mentioned only 2 daughters, but other notes
say four children, one of which is estranged. Has grandson 6 y/o
who she helps to take care of. Currently unemployed. Has worked
in billing and collections in past.
Family History:
Father, brother and uncle have [**Name (NI) 3729**]. +family history of
Crohn's.
Physical Exam:
98.0 77 106/82 18 99% RA
NAD
RRR, no MRG
CTA B, no WRR
S/NT/ND, V.A.C. in place in superior aspect of her midline
abdominal wound approximately 1x1 cm.
trace lower extremity edema
Pertinent Results:
On Admission: [**2122-9-9**]
WBC-6.3 RBC-3.18* Hgb-10.0* Hct-29.3* MCV-92 MCH-31.5 MCHC-34.2
RDW-18.3* Plt Ct-129*
PT-14.9* PTT-33.6 INR(PT)-1.3*
Glucose-120* UreaN-24* Creat-1.7* Na-132* K-3.7 Cl-105 HCO3-15*
AnGap-16
ALT-20 AST-33 CK(CPK)-22* AlkPhos-95 TotBili-1.8* Lipase-27
Albumin-4.1 Calcium-10.4* Phos-3.8 Mg-1.4*
Brief Hospital Course:
60 y/o female well known to surgical service who was admitted
from home with abdominal pain. An abdominal/pelvis CT
demonstrated decreased ascites and patent venous system,
partially distended gallbladder, without wall edema. (No
findings specific for acute cholecystitis) and intact ileostomy,
without evidence of bowel obstruction. KUB showed diffusely
distended loops of small bowel suggestive of ileus, without
evidence of high grade obstruction. Early obstruction was not
excluded and there was no free intraperitoneal air. Over the
next 24 hours, there was no ostomy output with worsening
abdominal pain. An NG tube was placed, but did not drain any
gastric contents. Repeat KUB was showed increased dilatation of
the small bowel. Based on these findings, she was taken to the
OR and underwent exploratory laparotomy with lysis of adhesions
for a small bowel obstruction. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Operative findings noted the transverse colon and omentum were
stuck to the previously placed mesh with very vascularized
adhesions. Attempts to free this area resulted in significant
blood loss. Running of the small bowel demonstrated a tight
adhesion causing kinking of the bowel with distal decompressed
bowel and proximal dilated bowel. This was thought to the source
of obstruction and was lysed. PLease refer to operative note for
further surgical detail. 3 units of RBC, 2 units FFP and albumin
were administered during the procedure. Postop, he was
transferred to the SICU intubated and on neosynephrine. Ostomy
was functioning postop with stool output.
She remained in the ICU until POD 6. She was noted to have
decreased urine output, with creatinine which was 1.7 on
admission was slow to return to her baseline of 0.5. She was
supported with fluids and pressors. TPN was started on POD 4.
Pressors were weaned off. After extubation, she was very
agitated and received ativan and haldol prn. She was tachycardic
but never febrile. Mental status slowly improved, home psych
medications (Remeron and Paxil)were restarted and she was stable
for transfer out of SICU to the Med-[**Doctor First Name **] unit on postop day 7.
Lasix and spironolactone (lower doses than home)were resumed.
Diet was advanced and tolerated, but kcals were insufficient
therefore, an EGD was performed without sedation on [**9-18**] with
placement of a bridled postpyloric feeding tube. Tube feeds were
begun (peptamen 1.5 with goal of 50ml/day). Of note, no varices
were noted during EGD. Later that day, she experienced visual
hallucinations (seeing bugs everywhere) and attempted to get out
of bed independently, but fell to floor onto left side
experiencing incision bleeding/hematoma, traumatic foley
removal, bleeding from stoma and complaints of left shoulder/hip
discomfort. Stomal bleeding stopped with change of pouch. Hct
and vital signs remained stable. She did not strike her head.
Xrays of her left shoulder and left hip were obtained secondary
to pain. These were negative for fracture. Shoulder Xray
reveaved an unusual appearance to the humeral head and neck,
raising the possibility of a prior fracture involving the
greater tuberosity of the humerus. Hip and shoulder pain
resolved.
Physical therapy evaluated and recommended rehab. A bed was
available at [**Hospital3 **] and she will transfer there today.
Of note, she did experience stomal bleeding (at 11 o'clock)on
the day of discharge. This resolved with pressure. She is known
to have peristomal varices.
She also developed a red, slightly raised rash on upper/inner
thighs and right antecubital area as well as crease of right eye
from unclear etiology. Hydrocortisone was applied to her legs as
well as sarna with decrease pruritus. Please monitor rash.
Medications on Admission:
Spironolactone 150 mg daily, Lasix 80 mg daily, Cipro 500 mg
daily, Levothyroxine 50 mcg daily, mirtazapine 15 mg daily
(hs),Nadolol 20 mg daily, Omeprazole 40 mg daily, Zofran PO [**1-24**]
tabs, prn nausea, paroxetine 30 mg daily, MVI daily, Ativan 0.5
mg hs prn
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: follow
sliding scale Injection every six (6) hours.
2. Glucagon (Human Recombinant) 1 mg Recon Soln [**Month/Day (2) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. Rifaximin 550 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
4. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
5. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
7. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Month/Day (2) **]:
One (1) ML Inhalation q4hr () as needed for wheezing.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Paroxetine HCl 20 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY
(Daily).
10. Mirtazapine 15 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1)
Tablet, Rapid Dissolve PO HS (at bedtime).
11. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
12. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Hydrocortisone 0.5 % Cream [**Last Name (STitle) **]: One (1) Appl Topical TID (3
times a day) as needed for pruritis/rash: to leg rash.
15. Camphor-Menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
PRN (as needed) as needed for itch, rash: rash.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Last Name (STitle) **]: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily):
hold for K+> 5.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Small bowel obstruction
delerium, resolved
malnutrition
peristomal bleeding, resolved
Discharge Condition:
Stable/Fair
A+Ox3
Ambulatory with assist
Discharge Instructions:
You will be transferred to [**Hospital3 **]
Please call Dr.[**Name (NI) 8584**] office at [**Telephone/Fax (1) 673**] if you
experience any of the warning signs listed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-10-1**] 3:00
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2122-10-29**]
9:20
Completed by:[**2122-9-23**] Admission Date: [**2122-9-24**] Discharge Date: [**2122-9-27**]
Date of Birth: [**2061-9-22**] Sex: F
Service: SURGERY
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 61 y/o female discharged on [**9-23**] s/p
exploratory laparotomy and lysis of adhesions. Pt presented to
the [**Hospital1 18**] ED with the complaint of RLQ abdominal pain. Pain is
sharp, stabbing, and comes and goes rapidly. Complains of nausea
but no vomiting. Her
ostomy is functioning well. She was started on colace at Rehab.
ROS is otherwise negative with no SOB, chest pain, cough,
fevers/chills, etc
Past Medical History:
EtOH abuse x15 yrs: last drink [**2122-2-28**],
Cirrhosis: c/b ascites,
esophageal varices w/o hemorrhage,
Hx of ischemic colitis,
Asthma,
Gastric ulcers,
Hypothyroidism,
Chronic diarrhea,
Depression
Social History:
Quit smoking 25 years ago, no EtOH, no illicits. Lives w
husband who is s/p renal transplant, has 2 daughters.
Unemployed
Family History:
ETOH
Crohn's.
Physical Exam:
Gen: NAD, AOx3
CV: RRR no MRG
RESP: CTAB no WRR
Abd: soft, NT ND, Well healing midline incision from ex lap
without erythema, warmth or exudate. staples in place. RLQ
ostomy pink with clear liquid output. Normal BS.
Ext: no LE edema
Pertinent Results:
[**2122-9-24**] 03:30PM GLUCOSE-108* UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14
[**2122-9-24**] 03:30PM WBC-6.9 RBC-2.84* HGB-8.5* HCT-25.4* MCV-90
MCH-30.1 MCHC-33.6 RDW-18.5*
MICRO:
[**Numeric Identifier 31236**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} 1/2 bottles.
Anaerobic Bottle Gram Stain-FINAL
Brief Hospital Course:
Pt was admitted [**9-24**] to [**Hospital Ward Name 121**] 10 in good condition. Her pain
was adequately controlled on its own. Upon admission, it was
noted that the pt was having increased ostomy output, averaging
nearly 1L per day. Her tube feeding regimen was changed to
Isosource 1.5 75cc/hr from 6p-10a every day, and the ostomy
output decreased appropriately. Of note, upon entrance to the
ED, a set of blood cultures were drawn. One of two bottles were
positive for Gram positive cocci in pairs and chains. Because
of the patient's PMH for VRE, she was started on Linezolid.
On DOD the patient was doing well with no complaints. Her
ostomy output was within normal range. She has been afebrile
with no vital sign abnormalities. She was given instructions on
cycling her tube feeds at home, which she has done before, and
for ostomy and wound care.
Medications on Admission:
Insulin Regular sliding, Rifaximin 550 mg [**Hospital1 **], Ipratropium
Bromide 0.02 % Solution neb Inhalation Q6H (every 6 hours) as
needed for wheeze, Folic Acid 1 mg PO DAILY (Daily). Thiamine
HCl
100 mg PO DAILY, Levalbuterol Inhalation q4hr prn wheezing,
Lansoprazole 30 mg PO DAILY, Paroxetine HCl 30 mg PO DAILY,
Mirtazapine 15 mg qHS, Furosemide 40 mg [**Hospital1 **], Spironolactone 50mg
PO daily, Hydrocortisone 0.5 % Topical TID, Camphor-Menthol
0.5-0.5 % Appl Topical prn itch, rash, Potassium Chloride 40 mEq
PO daily
Discharge Medications:
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
Ciprofloxacin HCl 500 mg PO/NG Q24H
Levothyroxine Sodium 50 mcg PO/NG DAILY
Linezolid 600 mg PO/NG Q12H x 14 days
FoLIC Acid 1 mg PO/NG DAILY
Mirtazapine 15 mg PO/NG HS
Furosemide 40 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Paroxetine 20 mg PO/NG DAILY
HydrOXYzine 25 mg PO/NG Q6H:PRN itching/rash
Spironolactone 25 mg PO DAILY Order date: [**9-25**] @ 1046
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Increased ostomy output
Discharge Condition:
Good
Discharge Instructions:
Please follow up with Dr. [**Last Name (STitle) **] next week. Please cycle your
tube feeds as follows:
Isosource 1.5 formula
Run at 75cc per hour from 6pm to 10am every day
You are taking a medication called Linezolid for bacteria found
on your blood cultures. You will be taking it for a total of 14
days.
Please take all medications as prescribed.
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-1**] 3:00
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2122-10-29**]
9:20
Admission Date: [**2122-10-5**] Discharge Date: [**2122-10-7**]
Date of Birth: [**2061-9-22**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Codeine / Morphine / Rifaximin / Linezolid / Vancomycin
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Drug rash
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. [**Known lastname 2643**] is a 60 year old woman with history of cirrhosis in
setting of alcohol abuse (complicated by ascites with SBP,
esophageal varices without bleed), s/p recent colectomy and
ileostomy for ischemic colitis who is referred from clinic for
change in antibiotic regimen due to drug rash while on
linezolid. She had a right colectomy in [**Month (only) **], followed by an
ex-lap with lysis of adhesions for small-bowel obstruction last
month. She was recently rehospitalized for fever and found to
have enterococcal bacteremia for which she was started on
linezolid on [**9-25**], intended to complete a 14-day course.
.
She then developed an intensely pruritic rash starting on [**9-30**],
covering her entire body (from scalp to feet). As an
outpatient, a PICC line was placed and her antibiotic was
switched to Vancomycin IV. The rash has become worse and more
confluent since then, so she is admitted today for a change in
antibiotics to treat her enterococcus bacteremia.
.
Pt denies any shortness of breath, difficulty swallowing, oral
lesions, or facial edema indicative of a more serious allergic
reactoin.
.
On review of systems, the pt denies fevers/chills, headaches,
dizziness or vertigo, hematemesis, coffee-ground emesis,
dysphagia, odynophagia, heartburn, nausea, vomiting, melena,
hematochezia, cough, wheezing, shortness of breath, chest pain,
palpitations, increasing lower extremity swelling, orthpnea,
paroxysmal nocturnal dyspnea. She does endorse some
light-headedness recently and mild dyspnea on exertion.
Past Medical History:
1. EtOH abuse x15 yrs: last drink was [**2122-2-28**]
2. Cirrhosis: c/b ascites, esophageal varices w/o hemorrhage
3. Last EGD [**2122-5-6**] - showed 1 cord of Grade II varicies
4. Exploratory laparotomy with lysis of adhesions, right
colectomy, end ileostomy [**2122-7-10**]
5. Asthma
6. Gastric ulcers
7. Hypothyroidism
8. Chronic diarrhea (unclear etiology, no response to
mesalamine)
9. Depression
10. h.o. Gastric bypass 14 years ago
11. s/p hysterectomy for endometriosis and "abnormal looking
cells"
Chronic Diarrhea
12. Malnutrition on tube feeds
13. Multiple incisional hernia operations
14. h.o. SBP on Ciprofloxacin
Social History:
Quit smoking 25 years ago. Last drink [**2122-6-23**]. Denies illicit
drug use. Lives with husband who is s/p renal transplant from
daughter. [**Name (NI) 4906**] works a lot so patient is often home alone
without help to care for herself. Mentioned only 2 daughters,
[**Name (NI) **] notes say four children, one of which is estranged. Has
grandson 6 y/o who she helps to take care of. Currently
unemployed and has not seen a social worker/counselor for
depression. Pt worked in billing and collections in past.
Family History:
Father, brother and uncle have [**Name (NI) 3729**]. +family history of
Crohn's.
Physical Exam:
Vitals: T: 97.5 BP: 104/53 P: 93 R: 20 SaO2: 100% on RA
General: Awake, alert and oriented, itching all over and
uncomfortable, pleasant
HEENT: NCAT, PERRLA, EOMI, no scleral icterus, MMM, normal
oro/nasopharynx without lesions or edema
Neck: Soft and supple, no significant JVD or LAD
Pulmonary: soft bibasilar rales, no wheezes or rhonchi
Cardiac: RRR, nl S1/S2, no m/r/g appreciated
Abdomen: soft, diffusely tender, ND, normoactive bowel sounds,
no hepatosplenomegaly or fluid waves suggestive of ascites;
mid-abdominal incision c/d/i but with mild-moderate
serosanguinous drainage; stoma is draining appropriately and
well-healed
Extremities: No cyanosis, ecchymosis; 1+ edema bilaterally,
symmetrical; +DP/PT pulses
Skin: maculopapular rash all over body surfaces including arms,
legs, torso, neck, and scalp; wound vac in place over
epigastrium
Neurologic: Alert, oriented x 3. Cranial nerves II-XII intact.
Strength and sensation grossly intact. No asterixis.
Pertinent Results:
[**2122-10-5**] 08:14PM BLOOD WBC-6.0 RBC-2.59* Hgb-8.2* Hct-23.4*
MCV-90 MCH-31.7 MCHC-35.0 RDW-18.3* Plt Ct-133*#
[**2122-10-6**] 06:12AM BLOOD WBC-6.8 RBC-2.85* Hgb-8.5* Hct-26.2*
MCV-92 MCH-29.8 MCHC-32.4 RDW-17.9* Plt Ct-163
[**2122-10-7**] 09:04AM BLOOD Hct-23.9*
[**2122-10-5**] 08:14PM BLOOD PT-15.7* PTT-37.1* INR(PT)-1.4*
[**2122-10-6**] 06:12AM BLOOD PT-14.4* PTT-35.9* INR(PT)-1.2*
[**2122-10-5**] 08:14PM BLOOD Glucose-112* UreaN-18 Creat-1.0 Na-134
K-2.8* Cl-106 HCO3-15* AnGap-16
[**2122-10-7**] 05:26AM BLOOD Glucose-134* UreaN-15 Creat-0.9 Na-136
K-3.1* Cl-107 HCO3-21* AnGap-11
[**2122-10-5**] 08:14PM BLOOD ALT-13 AST-31 LD(LDH)-178 AlkPhos-101
TotBili-1.5
[**2122-10-7**] 05:26AM BLOOD ALT-13 AST-29 LD(LDH)-163 AlkPhos-143*
TotBili-1.0
[**2122-10-5**] 08:14PM BLOOD Albumin-3.9 Calcium-10.2 Phos-2.5*
Mg-1.5*
[**2122-10-7**] 05:26AM BLOOD Albumin-3.6 Calcium-9.7 Phos-1.7* Mg-1.7
[**2122-10-6**] 06:35AM BLOOD Lactate-2.3*
[**2122-10-6**] 03:25PM BLOOD Lactate-2.7*
[**2122-10-7**] 05:57AM BLOOD Lactate-1.8
.
Blood cultures x 2 ([**2122-10-5**]): no growth to date
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2122-10-7**]):
Feces negative for C.difficile toxin A & B by EIA.
.
Echocardiogram ([**2122-10-7**]): no vegetations seen
Brief Hospital Course:
60 year old woman with history of EtOH cirrhosis (complicated by
ascites with SBP, esophageal varices without bleed), s/p recent
colectomy and ileostomy for ischemic colitis w/ enterococcus
bacteremia while on both vancomycin and linezolid who is
referred from clinic for drug rash, likely secondary to
linezolid.
.
## Enterococcus bacteremia - When initially discovered, this was
treated with rifaximin and linezolid and she consequently
developed the rash days later. Vancomycin was then started on
[**10-1**], without resolution of rash. It remains unclear if this
rash represents allergy to vancomycin as well, given the fact
that a drug rash time course is often variable. She was
switched to ampicillin IV Q6 hours, as the sensitivities
indicated that this antibiotic choice was appropriate, and her
rash continued to improve. A home IV pump was arranged by case
management and she was discharged with her PICC line for home
infusion of ampicillin. An echocardiogram was done to rule out
endocardititis and it did not show any vegetations. She will
need to have follow-up labs (CBC, BUN/Cr) drawn in 1 week to be
sure the antibiotic is not creating any new issues that need to
be addressed. Blood cultures are still pending on discharge as
well.
.
## Hypokalemia - Each morning during this admission, the
patient's K+ level was below the normal range, requiring
supplementation with KCl. This was likely secondary to her high
ostomy output. Even though her spironolactone was uptitrated
from 25mg to 50mg just prior to admission for management of
lower extremity edema, it was decided to discharge her with 20
mEq KCl supplementation daily.
.
## Diarrhea - The patient developed liquidy, green stools. C.
Diff toxin was sent and negative. Since we felt that her
diarrhea was likely due to bacterial overgrowth rather than some
sort of invasive bacterial infection (otherwise asymptomatic),
we discharged her with Lomotil to help form her stools. We felt
that this would also help with her hypokalemia (as above).
.
## Alcohol cirrhosis: Per patient, she had not had an alcoholic
beverage since [**2122-6-23**]. She is currently working on [**7-1**] months
sober outside of the hospital to qualify for possible liver
transplant. We continued her regimen of lasix/spironolactone for
ascites/lower extremity edema management.
.
## History of SBP/ non-bleeding esophageal varices:
Ciprofloxacin 500mg daily and nadolol was continued while she
continues to be on tube feeds at home. She did not develop any
ascites or GI bleeds during the admission.
.
## VNA directives: We confirmed proper placement of the feeding
tube and she should continue to be on tube feeds, on the
schedule she was adhering to prior to admission, per Dr.
[**Last Name (STitle) **]. She will also need continued ostomy and wound care.
Once her IV antibiotic course has finished on [**10-16**], the PICC
line may be removed.
.
## Follow-up: The patient will have the following labs drawn on
[**10-13**]: CBC, K+, and BUN/Cr. These results will be faxed to the
office of Dr. [**First Name8 (NamePattern2) 2943**] [**Name (STitle) 696**], in anticipation of her follow-up
appointment on [**10-14**]. Her blood cultures were also pending upon
her discharge and these will need to be followed-up as well.
Medications on Admission:
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
Ciprofloxacin HCl 500 mg PO/NG Q24H
Levothyroxine Sodium 50 mcg PO/NG DAILY
Vancomycin IV (last dose 5am today)
FoLIC Acid 1 mg PO/NG DAILY
Mirtazapine 15 mg PO/NG HS
Furosemide 40 mg PO BID
Paroxetine 20 mg PO/NG DAILY
Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
4. Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
5. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
6. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H
(every 24 hours).
8. Triamcinolone Acetonide 0.1 % Cream [**Last Name (STitle) **]: One (1) Appl Topical
TID (3 times a day): for rash.
Disp:*1 tube* Refills:*2*
9. Ampicillin Sodium 2 gram Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Injection Q6H (every 6 hours) for 9 days: 14-day course to end
on [**10-16**].
Disp:*36 Recon Soln(s)* Refills:*0*
10. Clotrimazole 1 % Cream [**Month/Year (2) **]: One (1) Appl Vaginal HS (at
bedtime) for 6 days: 7-day course to end on [**10-12**].
Disp:*1 tube* Refills:*0*
11. Potassium Chloride 10 mEq Tablet Sustained Release [**Month/Year (2) **]: Two
(2) Tablet Sustained Release PO once a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
12. Outpatient Lab Work
Please check potassium, BUN, creatinine, CBC on [**2122-10-13**] with
results reported to Dr. [**Last Name (STitle) 696**] Phone:([**Telephone/Fax (1) 1582**]
13. Diphenoxylate-Atropine 2.5-0.025 mg Tablet [**Telephone/Fax (1) **]: One (1)
Tablet PO Q6H (every 6 hours) as needed for high ostomy output.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Enterococcus bacteremia
Secondary diagnosis:
Alcoholic cirrhosis
Hypothyroidism
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure treating you at [**Hospital1 1170**]. You were admitted for an antibiotic adjustment for your
current blood infection, since you had an allergic reaction to
your previous antibiotics. We found a suitable antibiotic for
you (Ampicillin), which you will be taking 4 times a day to
complete a 14-day course until [**10-16**].
We have made the following changes to your medications:
START ampicillin every 6 hours through [**2122-10-16**]
START lomotil every 6 hours as needed for high ostomy output
START potassium supplementation daily (40meQ daily). You need to
start this because of your high ostomy output.
INCREASE aldactone from 25mg to 50mg a day
START clotrimazole cream for 7 days for your yeast infection
Please take the rest of your medications as prescribed.
Have your labs checked on [**2122-10-13**], with results reported to Dr.
[**Last Name (STitle) 696**] if done at an outside hospital lab.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2122-10-14**] at 3:50pm
You no longer need your echocardiogram b/c you had one done as
an inpatient.
|
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icd9cm
|
[
[
[]
]
] |
[
"45.13",
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icd9pcs
|
[
[
[]
]
] |
25472, 25530
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20026, 23318
|
14858, 14864
|
25687, 25687
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18736, 20003
|
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17649, 17731
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25551, 25551
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23344, 23650
|
25838, 26209
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17746, 18717
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26238, 26768
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|
14892, 16450
|
25616, 25666
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25570, 25595
|
2712, 3021
|
25702, 25814
|
16472, 17102
|
17118, 17633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,797
| 118,731
|
29157
|
Discharge summary
|
report
|
Admission Date: [**2110-6-6**] Discharge Date: [**2110-6-12**]
Date of Birth: [**2055-3-2**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Incision hernia
Major Surgical or Invasive Procedure:
[**2110-6-6**] incision hernia repair
History of Present Illness:
Per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] preoperative note as follows:
55-year-old male who is 3 years and 2 months after undergoing an
orthotopic deceased-donor liver [**Last Name (NamePattern1) **] performed on
[**2107-3-4**] for hepatitis C and alcohol-related
cirrhosis. He has developed an incisional hernia near the
confluence of the bilateral subcostal incision and midline
xiphoid extension that has been enlarging and is tender. He
was recently switched from rapamycin to cyclosporin in
preparation for elective repair. Once the wound has healed,
he will be returned to rapamycin therapy. He has provided
informed consent and was brought to the operating room for
primary repair with possible mesh.
Past Medical History:
1. Hepatitis C with cirrhosis s/p OTL in [**2107**]
* 3 years, and 14 days status post liver transplantation
([**2107-3-4**])
* Genotype 1A in [**2105-11-1**]
* VL 453,000 in [**2-/2109**]
* He has been treated on three different occasions with
interferon and
apparently was noncompliant with each of those. Last time
[**2109-1-8**] and developped anemia on rivabirin & IFN.
* EGD: [**2109-5-9**] normal.
* Liver biopsy: On [**2108-8-20**] stage I-II fibrosis and biliary
damage. Repeat biopsy done [**2110-3-19**] and pending.
* History of substance abuse with heroin and alcohol and has
been abstinent for the past four years.
2. History of cholecystectomy in [**2092**].
3. History of kidney stone that required urologic intervention
in [**2104-2-2**].
4. Chronic back pain.
5. Smoking of 30 years
6. Claudication. Prox femoral artery occlusive disease.
7. Osteopenia on BMD done on [**2108-7-31**] of of the lumbar
spine, left hip, femoral neck
8. Asthma. Mild intermittent. Never intubated.
9. [**2110-6-6**] incision hernia repair
Social History:
He is independent. He is abstinent from alcohol, but has history
of severe use. He is on methadone. Lives alone. Used to smoke 6
cigarettes daily and currently denies. History of substance
abuse with heroin/alcohol and has been abstinent
Family History:
Father: DM Type 2
Mother: Deceased, brain tumor
Four brothers, four sisters: Two wtih complications of DM II
Pertinent Results:
[**2110-6-9**] 01:44AM BLOOD PT-13.3 PTT-29.6 INR(PT)-1.1
[**2110-6-11**] 04:30AM BLOOD WBC-4.4 RBC-3.15* Hgb-10.1* Hct-30.1*
MCV-95 MCH-32.0 MCHC-33.5 RDW-14.5 Plt Ct-134*
[**2110-6-11**] 04:30AM BLOOD ALT-15 AST-18 AlkPhos-82 TotBili-0.5
[**2110-6-11**] 04:30AM BLOOD ALT-15 AST-18 AlkPhos-82 TotBili-0.5
Brief Hospital Course:
On [**2110-6-6**], he underwent incision hernia repair. Two
[**Known lastname 1661**]-[**Location (un) 1662**]
drains were placed subcutaneously. Surgeon was Dr. [**First Name (STitle) **] W.
[**Doctor Last Name **]. Two subcutaneous drains were placed. Please refer to
operative note for further details. Postop, potassium was 7.8.
This was treated with iv insulin and dextrose without decrease.
He was transferred to the SICU where he required placement of a
temporary dialysis line and was emergently dialyzed. Potassium
decreased to 4.5.
He also experienced RUL collapse that responded to chest PT and
face tent. Repeat CXR demonstrated improvement. He was
transferred out of the SICU. Diet was slowly advanced. Bowel
function was slow to resume. He was receiving iv dilaudid as
well as half of his home dose of methadone. He was given MOM x2
with results.
Urine output decreased on [**6-9**]. This was treated initially with
lasix with minimal response. He appeared dry and received
several iv boluses of fluid as well as maintenance IV fluid.
Previously ordered home diuretics were stopped. Creatinine
increased to as high as 3.7 on postop day 4 (baseline 1.6-2.0).
Acute on chronic renal failure was felt to be due to
cyclosporine. For this reason, cyclosporine was stopped on [**6-10**]
and Rapamune 1mg daily was started on [**6-11**]. Rapamune level was
2.0 on [**6-12**] and dose was increased to 2mg a day. Creatinine
decreased to 2.2 on postop day 6. Urine output increased to
1375ml/day.
JP drainage was serosanguinous. The left JP was removed on [**6-11**].
The medial JP remained in place. Incision was clean, dry and
intact.
He was ambulating independently at time of discharge. [**Hospital1 1474**]
VNA was arranged. The plan was for him to have a rapamune level
on [**Hospital Ward Name 1826**] 7 on [**6-14**].
Of note,methadone dose was decreased to 2.5mg [**Hospital1 **] as he was on
prn dilaudid for pain. Methadone was increased to 5mg, but
patient experienced respiratory rate of 5. Dose was decreased to
2.5mg [**Hospital1 **] with normalization of respirations.
Medications on Admission:
Albuterol inh 90 mcg prn, cyclosporine 50'', gabapentin 300
qhs, lactulose 10g/15mL 2 tsp po', methadone 5'', nebivolol 5',
pantoprazole EC 40', bactrim ss 400/80', testosterone 5mg patch
daily, ca carbonate 600'', colace prn, senna prn. Prev on
rapamune 1'; held since one month prior to hernia repair.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML 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. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
level check Sat. [**6-14**].
Disp:*60 Tablet(s)* Refills:*2*
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. nebivolol 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Incision hernia repair
h/o liver [**Hospital1 **]
Acute on chronic renal failure
hyperkalemia
RUL collapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever, chills, nausea, vomiting, increased abdominal pain or
distension, jaundice, incision redness/bleeding or drainage.
Empty the JP drain and record all drain outputs. Bring record of
drain outputs to next appointment with Dr. [**Last Name (STitle) **].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2110-6-18**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2110-6-27**] 11:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2110-7-30**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2110-6-13**]
|
[
"733.90",
"V58.69",
"303.93",
"403.91",
"518.0",
"493.20",
"571.5",
"553.21",
"E878.0",
"E849.7",
"276.2",
"585.6",
"440.21",
"276.7",
"E947.8",
"584.9",
"518.81",
"996.82",
"568.0",
"070.54",
"304.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"54.59",
"38.95",
"53.51"
] |
icd9pcs
|
[
[
[]
]
] |
6723, 6778
|
2926, 5023
|
316, 356
|
6928, 6928
|
2595, 2903
|
7466, 8073
|
2465, 2576
|
5378, 6700
|
6799, 6907
|
5050, 5355
|
7079, 7443
|
261, 278
|
384, 1131
|
6943, 7055
|
1153, 2192
|
2208, 2449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,622
| 197,406
|
26614
|
Discharge summary
|
report
|
Admission Date: [**2158-8-22**] Discharge Date: [**2158-8-25**]
Date of Birth: [**2088-2-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fever, Decreased oxygen saturation
Major Surgical or Invasive Procedure:
[**2158-8-23**] scrotal I&D
[**2158-8-25**]: PICC line placement
History of Present Illness:
This is a 70 y/o gentleman s/p ex lap and inguinal hernia
repair on [**7-7**], readmitted on [**7-28**] for increased wound drainage,
a
VAC was placed and the patient was discharged to rehab. The
patient has been followed as an outpatient. The patient was last
seen by Dr. [**First Name (STitle) **] on [**8-11**] where the wound was found to be
granulating well and was not infected (the patient refused the
VAC). For the past few days, the patient has had intermittent
fevers, with a Tmax of 102.5 on [**8-20**]. This AM, the patient had
a
temp of 100.8, Hr 125, BP 96/55, and an O2 sat of 92% on 2L.
The patient denies chills, headache, nausea/vomiting,
constipation/diarrhea, abdominal pain, or increased drainage
from
his wound. The Rehab facility started the patient on
Vanc/Ceftazidime on [**8-20**], CXR today at Rehab does not show focal
infiltrate, the midline IV was removed on [**8-21**], and blood
culture
from [**8-16**] was negative.
Past Medical History:
schizophrenia, prostate Ca (on lupron since [**2154**]), anemia of
chronic disease with macrocytosis, cryptogenic cirrhosis, COPD,
compression fracture, large inguinoscrotal hernia, pyruvate
kinase deficiency, splenomegaly
.
Past Surgical History: CCY, vertebroplasty, ex-lap with
inguinal hernia repair on [**2158-7-7**]
Social History:
Currently at [**Hospital 100**] Rehab, but lives at a group home for his
schizophrenia ([**Street Address(1) 65648**]) which has help daily, but not
at night. Ex-wife [**Name (NI) **] [**Name (NI) 65646**] cell [**Telephone/Fax (1) 65650**], pager
[**Telephone/Fax (1) 65653**]
Smokes 1 PPD for "a long time", approximately 20 years. Reports
prior history of etoh abuse, approximately 10 beers per day for
about 20 years. Denies IVDU.
Family History:
He has 4 sisters that he does not keep in regular contact with.
Unsure of what his parents died from.
Physical Exam:
VS: 98.6 HR 108 BP 104/60 RR 20 97% RA
GEN: NAD, AAOx3
HEENT: no scleral icterus, dry mucus membranes, slightly
cachetic
NECK: supple, trachea midline
CHEST: CTA B/L
HEART: RRR, S1,S2
ABD: soft, mildly distended, 10 cm x 2cm midline wound with
healthy granulation tissue, no erythema, no drainage, BS present
EXT: warm, no edema
NEURO: no focal deficits
Pertinent Results:
On Admission: [**2158-8-22**]
WBC-10.7# RBC-2.93* Hgb-8.8* Hct-26.1* MCV-89 MCH-30.2 MCHC-33.8
RDW-15.5 Plt Ct-347#
PT-14.0* PTT-24.5 INR(PT)-1.2*
Glucose-102* UreaN-16 Creat-0.6 Na-123* K-5.1 Cl-90* HCO3-26
AnGap-12
ALT-65* AST-83* LD(LDH)-367* AlkPhos-583* TotBili-1.5
Albumin-2.5* Calcium-8.5 Phos-2.5* Mg-1.8
At Discharge: [**2158-8-25**]
WBC-5.1 RBC-3.34* Hgb-9.7* Hct-29.6* MCV-89 MCH-29.2 MCHC-32.9
RDW-16.3* Plt Ct-346
PT-13.2 PTT-27.1 INR(PT)-1.1
Glucose-88 UreaN-7 Creat-0.4* Na-133 K-3.6 Cl-100 HCO3-27
AnGap-10
ALT-27 AST-15 LD(LDH)-164 AlkPhos-336* TotBili-0.7
Calcium-8.6 Phos-4.2 Mg-1.6
Brief Hospital Course:
He was admitted to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. CT ABD/Pelvis with IV and PO
contrast was done to assess for occult infection. CT
demonstrated rim-enhancing scotal fluid and gas collection
measures approximately 16.3 x 12.1 x 0.7 cm. He was started on
Vanco and Zosyn after pan culturing.
On [**2158-8-22**], he underwent incision and drainage of scrotum in the
dependent
area for infected peritesticular collection. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. A penrose drain was placed into the incision area.
Vanco and zosyn were continued.
Cultures from the abscess isolated 4+pmn with 3+ GCs,
enterococcus. Diet was resumed. Vital signs remained stable.
Patient self removed midline that was previously placed at
rehab.
PT worked with him and recommended continuation of rehab.
Medications on Admission:
Albuterol inh 2 puff q8hrs , aldendronate 70mg qSun, benztropine
1mg daily, Calcium Carbonate 1300 TID, Ceftazidime 1gm q8hrs,
cholecalciferol 1000u qdaily, colace 100mg [**Hospital1 **], Advair 250/50
q12hr, folic acid 1mg daily, haloperidol 1mg [**Hospital1 **], heparin 5000u
[**Hospital1 **], Insulin SS, lorazepam 2mg qhs, magnesium oxide 400 [**Hospital1 **],
mirtazapine 15mg qhs, MVI daily, polysaccharide iron complex 150
mg daily, risperidone 37.5 IM q14days, sodium chloride 1gm [**Hospital1 **],
thiamine 100mg daily, tiotropium bromide 1puff daily, vancomycin
750mg daily, Tylenol 650 prn, Albuterol neb 2.5mg q6hr prn,
dulcolax 10mg PR daily prn, oxycodone prn polyethylene glycol 17
gm daily prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Scrotal abscess
h/o schizophrenia
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 will be transferred back to [**Hospital 100**] Rehab
Please call [**Telephone/Fax (1) 673**] (surgical office) if any of the warning
signs listed below are experienced
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-8-31**] 3:40
[**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2158-9-12**] 9:30
Completed by:[**2158-8-25**]
|
[
"250.00",
"282.3",
"608.4",
"285.29",
"507.0",
"276.1",
"295.90",
"571.5",
"496",
"185",
"E878.8",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"61.0"
] |
icd9pcs
|
[
[
[]
]
] |
4974, 5040
|
3338, 4213
|
349, 415
|
5118, 5118
|
2712, 2712
|
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|
2216, 2319
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5061, 5097
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3039, 3315
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275, 311
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443, 1398
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2726, 3025
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5133, 5277
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1420, 1645
|
1762, 2200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,645
| 178,902
|
51871
|
Discharge summary
|
report
|
Admission Date: [**2140-9-16**] Discharge Date: [**2140-9-17**]
Date of Birth: [**2102-8-24**] Sex: M
Service: ICU
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
gentleman with C6-C7 quadriplegia, hemorrhoids, and a 3-month
history of rectal bleeding who reportedly awoke in a pool of
bright red blood per rectum around his wheelchair on the day
prior to admission.
The patient went to the commode to clean himself, and he
reports that he sustained a syncopal episode at that time.
The emergency medical technicians reportedly found the
patient unresponsive on the commode with a blood pressure of
90/50 and a heart rate of 82.
On arrival to the [**Hospital1 69**]
Emergency Department, the patient's blood pressure was 88/74
which subsequently increased to the 110 range systolically
but then decreased to the 60s to 70s systolically soon
thereafter. He received 4 liters to 5 liters of normal
saline in the Emergency Department with only 250 cc of urine
output. He refused a blood transfusion. He had
guaiac-positive brown stool in the Emergency Department where
he also complained of lightheadedness, mild dyspnea, and
rectal pain. The patient denied abdominal pain, nausea,
vomiting, or cloudy/foul smelling urine. He denied recent
substance abuse. Of note, the patient performs daily manual
rectal disimpactions.
PAST MEDICAL HISTORY:
1. C6-C7 quadriplegia complicated by a neurogenic bladder
and bowel following a motor vehicle crash in [**2119**].
2. Stage IV chronic decubitus ulcerations.
3. Recurrent urinary tract infections.
4. Peptic ulcer disease.
5. Substance abuse.
6. Positive purified protein derivative treated in the
past.
7. Hemorrhoids.
8. Labile blood pressures.
9. Chronic osteomyelitis of the right ischial tuberosity
treated with six weeks of levofloxacin and metronidazole in
[**2140-5-31**].
10. Depression and impulse control disorder.
ALLERGIES:
1. PENICILLIN (causes angioedema).
2. VANCOMYCIN (causes a rash).
3. GENTAMICIN (causes urticaria).
MEDICATIONS ON ADMISSION:
1. Docusate 200 mg by mouth twice per day.
2. Bupropion 150 mg by mouth twice per day.
3. Gabapentin 100 mg by mouth three times per day.
4. Milk of Magnesia 30 cc by mouth at hour of sleep.
5. Senna two tablets by mouth at hour of sleep.
6. Baclofen 10 mg by mouth four times per day.
7. Combivent 1 to 2 puffs inhaled q.6h. as needed (for
wheezing).
8. Diazepam 5 mg by mouth q.6h. as needed (for anxiety).
9. Ensure one can by mouth three times per day.
10. Super Cereal by mouth every other day.
11. Hydromorphone 3 mg subcutaneously before dressing
changes.
12. Iron sulfate 325 mg by mouth once per day.
13. Multivitamin one tablet by mouth once per day.
14. Pantoprazole 40 mg by mouth once per day.
15. Anusol suppositories per rectum once per day.
SOCIAL HISTORY: The patient lives at the [**Hospital **]. He smokes one pack of cigarettes per day. He
denies alcohol or illicit drug abuse.
PHYSICAL EXAMINATION ON PRESENTATION: On initial physical
examination, the patient's temperature was 96.1 degrees
Fahrenheit, his blood pressure was 52/27, his heart rate was
63, his respiratory rate was 18, and his oxygen saturation
was 99% on room air. The patient was awake, alert, and
oriented times three. He was in no acute distress. He had
slightly dry oral mucosa, and his oropharynx was clear. His
neck was supple without meningismus. His heart was regular
in rate and rhythm. There were normal first heart sounds and
second heart sounds. There were no murmurs, rubs, or
gallops. The lung examination revealed trace left-sided
basilar crackles but were otherwise clear to auscultation
bilaterally. The abdomen was soft. There was mild right
upper quadrant tenderness in the context of globally
decreased sensation. There was a normal liver span. [**Doctor Last Name **]
sign was not present. Extremity examination revealed there
was no peripheral edema. There were healed bilateral lower
extremity ulcerations and abrasions. The extremities were
warm and dry. Rectal examination demonstrated reddish brown
guaiac-positive stool (per the Emergency Department). There
was a mildly foul-smelling well granulated sacral decubitus
ulceration without obvious abscess, drainage, or fluid
collection.
PERTINENT LABORATORY VALUES ON PRESENTATION: Initial
laboratory values demonstrated a white blood cell count of
8.6 (58% neutrophils, 35% lymphocytes, and 3% monocytes), his
hematocrit was 38.7, and his platelets were 275,000. His
mean cell volume was 83. Serum chemistries were
unremarkable. Initial urinalysis was negative. Initial
urine toxicology screen was positive for cocaine.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram demonstrated
a normal sinus rhythm at 58 beats per minute. Normal axis and
intervals. A 0.5-mm J-point elevation in leads V4 through V6
that were also seen on an old electrocardiogram. There were
no acute ST segment or T wave changes.
A chest x-ray demonstrated tall lung field, poor
visualization of the left retrocardiac area, and no pulmonary
edema.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL ISSUES: There was no further
gastrointestinal bleeding following admission. A colonoscopy
done on hospital day two demonstrated ulcerations in the
distal rectum but was otherwise normal to the hepatic flexure
with no blood or other bleeding site noted.
The patient was started on daily Anusol HC suppositories and
should treat his constipation with other techniques (such as
bisacodyl suppositories or MiraLax) to avoid rectal trauma.
2. CARDIOVASCULAR ISSUES: After aggressive resuscitation
with intravenous fluids, the patient's blood pressure
remained stable. Of note, he has a labile blood pressure at
baseline and typically runs in the 80s to 90s systolic.
He was initially started on broad spectrum antibiotics
(levofloxacin and metronidazole) out of concern for possible
septic shock, but these were discontinued once his blood
pressure stabilized, and he remained afebrile without
leukocytosis. His hematocrit stabilized at his baseline at
the time of discharge. All of his culture data were negative
at the time of discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be returned to the [**Hospital **] in [**Location 1268**], [**State 350**].
MEDICATIONS ON DISCHARGE:
1. Docusate 200 mg by mouth twice per day.
2. Bupropion 150 mg by mouth twice per day.
3. Gabapentin 100 mg by mouth three times per day.
4. Milk of Magnesia 30 cc by mouth at hour of sleep.
5. Senna two tablets by mouth at hour of sleep.
6. Baclofen 10 mg by mouth four times per day.
7. Combivent 1 to 2 puffs inhaled q.6h. as needed (for
wheezing).
8. Diazepam 5 mg by mouth q.6h. as needed (for anxiety).
9. Ensure one can by mouth three times per day.
10. Super Cereal by mouth every other day.
11. Hydromorphone 3 mg subcutaneously before dressing
changes.
12. Iron sulfate 325 mg by mouth once per day.
13. Multivitamin one tablet by mouth once per day.
14. Pantoprazole 40 mg by mouth once per day.
15. Anusol HC suppositories per rectum once per day.
16. Bisacodyl suppository 10 mg per rectum once per day.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Rectal ulceration.
3. Substance abuse.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The [**Hospital3 4262**] nurse practitioner was to see the
patient at his nursing home on the day following discharge.
2. The patient's primary care physician (Dr. [**First Name8 (NamePattern2) 402**]
[**Last Name (NamePattern1) 7461**]) was to make arrangements to follow up with the
patient next week.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 5838**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2140-9-17**] 17:02
T: [**2140-9-20**] 09:22
JOB#: [**Job Number 107409**]
|
[
"578.9",
"564.00",
"311",
"569.41",
"707.0",
"344.00",
"596.54",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
7342, 7421
|
6479, 7321
|
2112, 2893
|
7454, 8014
|
5209, 6286
|
6301, 6452
|
150, 180
|
209, 1403
|
1426, 2085
|
2910, 5175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,193
| 109,543
|
36553+58096
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-4-3**] Discharge Date: [**2152-4-6**]
Date of Birth: [**2103-9-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
transfer for ? portal-biliary fistula, obstructive jaundice,
pancreatitis w/ likely Klatskin tumor
Major Surgical or Invasive Procedure:
[**2152-4-3**]: PTC placement
[**2152-4-3**]: Hepatic angiogram
History of Present Illness:
The patient is a 48 year old Laotian man with a history of
chronic alcohol abuse who is transferred to [**Hospital1 18**] with a
possible
portal-biliary fistula, obstructive jaundice, and pancreatitis
s/p ERCP with stent [**2152-3-31**] to evaluate likely Klatskin tumor.
The patient presented to [**Hospital6 204**] on [**2152-3-28**] with
a 1 month history of epigastric pain and a 2 week history of
jaundice. He has a history of heavy alcohol use, but had
stopped
drinking over the previous 4 weeks because of associated
epigastric pain. He was admitted for further workup and a MRCP
was obtained, demonstrating intra-hepatic ductal dilatation with
a filling defect at the biliary confluence. This was concerning
for a Klatskin tumor and, given the patient's obstructive
biliary
picture, he was taken for ERCP on [**2152-3-31**]. At this time his R
and
L ducts were dilated, a sphincterotomy was performed, and a 15cm
10Fr stent was placed in the R ductal system (the L was unable
to
be stented due to tight stricture).
Post-procedurally, the patient developed abdominal pain and RUQ
tenderness. He was noted to have melanotic stools, and serial
laboratory studies demonstrated a drop in his hematocrit of ~10
points (from 40 to 29). Additionally, he was found to have
increasing serum bilirubin levels; at the time of transfer his
total bilirubin level was 9.2 (increased from 6 at the time of
admission to [**Hospital3 **]). His lipase was also significantly
elevated at 1100, and his amylase was 200. A CT scan performed
emergently on [**4-2**], demonstrated a possible fistula between the
stent and a portal venous vessel, and he was therefore
transferred to [**Hospital1 18**] for further care.
At the time of transfer, his INR was 1.5, his platelet count was
251, and his hematocrit was 29.6. He received 2U FFP and 1U
PRBC
prior to transfer, and he has been hemodynamically stable
without
tachycardia or hypotension.
Past Medical History:
PMH: ETOH abuse
PSH: None
Social History:
Soc Hx: married, not currently working, denies illicit drug use;
+ heavy EtOH use (stopped drinking approximately 4 weeks ago)
Family History:
N/C
Physical Exam:
- Temp 99.1 HR 76 BP 153/89 98% RA
- NAD, non-toxic appearing Laotian man
- + scleral icterus
- RRR, no murmurs
- lungs clear to auscultation
- Abdomen soft, tender to palpation in epigastrium and RUQ with
mild voluntary guarding; there is no rebound tenderness and no
peritoneal signs
- Rectal exam: good tone; + dark melanotic stool; strongly
guaiac
positive
Pertinent Results:
On Admission: [**2152-4-3**]
WBC-13.3* RBC-3.91* Hgb-11.4* Hct-32.9* MCV-84 MCH-29.2
MCHC-34.7 RDW-15.3 Plt Ct-273
PT-17.7* PTT-31.0 INR(PT)-1.6*
Glucose-105 UreaN-9 Creat-0.8 Na-137 K-3.9 Cl-101 HCO3-25
AnGap-15
ALT-53* AST-31 LD(LDH)-183 CK(CPK)-56 AlkPhos-144* Amylase-131*
TotBili-11.3* DirBili-7.7* IndBili-3.6
Albumin-3.8 Calcium-8.9 Phos-3.5 Mg-2.1 Iron-93
calTIBC-241* Ferritn-723* TRF-185*
HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HAV-NEGATIVE HCV Ab-NEGATIVE
HCG-<5, CEA-1.5, AFP-16.8* CA [**61**]-9 -Test 8
At Discharge: [**2152-4-6**]
WBC-11.5* RBC-3.65* Hgb-10.5* Hct-30.9* MCV-85 MCH-28.7
MCHC-33.9 RDW-15.8* Plt Ct-367
PT-13.4 PTT-28.5 INR(PT)-1.2*
Glucose-150* UreaN-11 Creat-0.8 Na-136 K-3.7 Cl-103 HCO3-25
AnGap-12
ALT-51* AST-33 AlkPhos-132* TotBili-9.4* Albumin-3.6
Calcium-8.6 Phos-2.9 Mg-2.2
Brief Hospital Course:
48 y/o male transferred to [**Hospital1 18**] from [**Hospital6 204**].
At the outpatient hospital he had undergone ERCP and post
procedurally he developed a post ERCP pancreatitis as well as a
10 point Hct drop with grossly melanotic stool with concern for
arterio-biliary fistula. He was noted to have active bleeding
into the biliary tree upon arrival at [**Hospital1 18**]. A stent had been
placed in the right biliary system but the left system remained
obstructed at the time of transfer.
On [**4-3**] he underwent a hepatic angiogram which showed no evidence
of arterial biliary fistula, but there is a small area of
contrast pooling seen on portal venogram in segment VII adjacent
to endoscopically placed biliary drain done the same day. He
also had successful embolization of segment VII portal vein
with Gelfoam and successful placement of external left biliary
drain.
His hematocrit then remained stable through the hospitalization.
He was treated with one day of Unasyn and Flagyl and was then
switched to PO Cipro for prophylaxis.
The PTC drain was opened to bag drainage and draining 100-200 cc
daily.
Interventional radiology was to attempt a second PTC drain on
[**4-5**] through the left side following stent removal by ERCP. The
patient, through the interpretive services and discussion with
his family and the hepatobiliary team has decided to forego
these procedures at this time.
He was noted to be hypertensive to the 160's systolic on the
morning of [**4-6**] and he was given one dose of IV lopressor and
then started on PO beta blockade.
Patient has requested transfer back to [**Hospital6 204**].
Medications on Admission:
Pepcid PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5-1 mg Injection
Q3H (every 3 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 204**] - [**Hospital1 189**]
Discharge Diagnosis:
probable Klatskins tumor
Discharge Condition:
Fair
Discharge Instructions:
Transfer to [**Hospital6 204**] (originating hospital for
transfer)
Drain and record PTC output. Teach patient drain care. Capping
drain at this time will likely produce fever and possible
infection, please leave open to bag draiange
Advance diet as tolerated
Continue PO Cipro
Followup Instructions:
If patient changes his mind about pursuing second PTC placement
and surgery, patient can contact Dr [**Name (NI) 4727**] office at
[**Telephone/Fax (1) 673**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2152-4-6**] Name: [**Known lastname 13232**],[**Known firstname 13233**] Unit No: [**Numeric Identifier 13234**]
Admission Date: [**2152-4-3**] Discharge Date: [**2152-4-6**]
Date of Birth: [**2103-9-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 48**]
Addendum:
Left PTC (percutaneous transhepatic cholangiography tube) MUST
stay in place to prevent jaundice.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 13235**] - [**Hospital1 1612**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2152-4-6**]
|
[
"577.0",
"155.1",
"998.11",
"E878.8",
"300.00",
"997.4",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.64",
"39.79",
"51.98",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
7418, 7642
|
3895, 5522
|
411, 476
|
6266, 6273
|
3063, 3063
|
6599, 7395
|
2657, 2662
|
5583, 6106
|
6218, 6245
|
5548, 5560
|
6297, 6576
|
2677, 3044
|
3589, 3872
|
271, 373
|
504, 2446
|
3077, 3575
|
2468, 2495
|
2511, 2641
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,764
| 179,551
|
36166
|
Discharge summary
|
report
|
Admission Date: [**2154-1-7**] Discharge Date: [**2154-1-17**]
Date of Birth: [**2090-2-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal cancer.
Major Surgical or Invasive Procedure:
[**2154-1-7**]: Transhiatal esophagectomy, placement of a jejunostomy
tube, pyloroplasty, umbilical hernia repair.
History of Present Illness:
The patient is a 63-year-old lady who presented with a
nine-month history of voice change. Despite her medical
history, she had an excellent performance status preoperatively.
Upon her daughter's request, she underwent an upper endoscopy
in [**2153-9-26**] that showed a nodule in the gastroesophageal
junction that was biopsied. Pathology of that specimen
indicated high-grade dysplasia. However, repeat pathologic
evaluation of the specimen that was obtained at [**Hospital1 24300**] Hospital confirmed presence of an intramucosal carcinoma
in the setting of high-grade dysplasia. Endoscopy, EUS and PET
scan were all performed suggesting T1a, N0, stage I esophageal
carcinoma. With this operative indication, the patient was
brought to the operating room for transhiatal esophagectomy.
Past Medical History:
Non-insulin dependent diabetes
Hypertension
Hypercholesterolemia
Rheumatic fever
Glaucoma
Diverticulosis
Roscea
PSH: lap chole [**2151**] right tigger finger [**Doctor First Name **] [**2152**], L rotator
cuff repair [**2149**], C4-6 laminectomy and foraminotomy [**2147**], facial
resurfacing [**2149**], b/l glaucoma [**Doctor First Name **], left LE vein striping
Social History:
Married, lives with family. Tobacco quit 34 years ago, ETOH
occasional
Family History:
Father- throat ca died 60yrs
[**Name (NI) 82040**] sister died [**Name2 (NI) 499**] ca [**2128**]
Physical Exam:
VS: T: 98.8 HR: 95-100 SR BP: 110-120/60-70 Sats: 96% RA
Wt: 77.1 kg
General: sitting up in chair in no apparent distress
Card: RRR
Resp: diminished breath sounds at bases otherwise clear
GI: bowel sounds positive, abdomen soft. J-tube in place site
clean no erythema
Extr: warm 1+ bilateral edema
Incision: neck incision clean, dry intact with steri-strips,
abdominal clean dry intact with staples
Neuro: non-focal
Pertinent Results:
[**2154-1-14**] WBC-6.3 RBC-3.07* Hgb-9.0* Hct-26.4* Plt Ct-304
[**2154-1-12**] WBC-7.5 RBC-2.79* Hgb-8.1* Hct-23.5* Plt Ct-254
[**2154-1-11**] WBC-7.2 RBC-2.78* Hgb-8.2* Hct-23.4* Plt Ct-217
[**2154-1-7**] WBC-5.6 RBC-3.51* Hgb-10.3*# Hct-28.9* Plt Ct-227
[**2154-1-17**] Glucose-250* UreaN-18 Creat-0.6 Na-135 K-4.9 Cl-94*
HCO3-33*
[**2154-1-16**] Glucose-244* UreaN-24* Creat-0.7 Na-134 K-3.9 Cl-97
HCO3-29
[**2154-1-15**] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103
HCO3-27
[**2154-1-15**] Glucose-235* UreaN-29* Creat-0.7 Na-139 K-4.2 Cl-103
HCO3-27
[**2154-1-14**] Glucose-257* UreaN-30* Creat-0.7 Na-141 K-4.0 Cl-107
HCO3-22
[**2154-1-13**] Glucose-139* UreaN-27* Creat-0.8 Na-143 K-3.4 Cl-110*
HCO3-23
[**2154-1-12**] Glucose-116* UreaN-21* Creat-0.7 Na-142 K-4.5 Cl-112*
HCO3-21*
[**2154-1-8**] Glucose-183* UreaN-8 Creat-0.6 Na-138 K-4.5 Cl-106
HCO3-24
[**2154-1-7**] Glucose-120* UreaN-11 Creat-0.7 Na-139 K-3.1* Cl-104
HCO3-25 AnGa
[**2154-1-9**] ALT-74* AST-69* LD(LDH)-257* AlkPhos-57 Amylase-41
TotBili-0.8
[**2154-1-15**] Calcium-8.8 Phos-2.4* Mg-1.8
Culture: Blood cultures [**2154-1-9**]: NO growth x2, Urine Culture
No growth
CXR:
[**2154-1-16**]:
There is significant interval improvement within right
subpulmonic effusion, which is now small in size. There is
persistent
bibasilar atelectasis. The lungs are otherwise clear with no
signs of
pneumonia or congestive heart failure. Cardiomediastinal
silhouette is stable with moderate cardiomegaly and tortuosity
of the aorta.
[**2154-1-13**]: 1. No pneumothorax following chest tube removal.
2. Slight worsening right lower lobe atelectasis with adjacent
pleural
effusion. No substantial change in left lower lobe atelectasis.
[**2154-1-10**]: There has been improvement of the left small
pleural effusion and atelectasis, however progression of the
small
right pleural effusion and atelectasis. Lines and tubes remain
in similar
position. The cardiomediastinal silhouette is stable with a tiny
amount of
mediastinal air consistent with post-esophagectomy changes
[**2154-1-7**]: Interval placement of ET tube, NG tube, left chest
tube, and
epidural catheter in appropriate positions. Interval left
pleural effusion
and bibasilar atelectasis.
Brief Hospital Course:
Mrs. [**Known lastname 4886**] was admitted on [**2154-1-7**] for Transhiatal
esophagectomy, placement of a
jejunostomy tube, pyloroplasty, umbilical hernia repair. She
was transferred to the ICU intubated in stable condition with a
left chest tube to suction, NGT to low-wall suction, foley, neck
JP, and a Bupivacaine/Dilaudid epidural for pain control. On
POD1 she was extubed. She was found to be hypotensive and the
epidural was titrated down and administered a fluid bolus with a
good result. On POD2 she was out bed to chair transferred to
the Floor but returned to the ICU for respiratory distress,
atelectasis and hypoxemia. She spiked a fever, pan cultured
which grew no organism. She was very sensitive to narcotics and
the epidural was removed. Her pain was managed with Tylenol and
Toradol. Beta-blockers were started for tachycardia. On POD3
her pain was under better control, she was gently diuresed and
pulmonary toileting was continued. On POD4 the chest film
showed a right lower lobe effusion/atelectasis. A right lower
lobe ultrasound showed minimal effusion. She was started on
trophic tube feeds. She continued to improve and transferred out
of the ICU on POD5. On POD6 The chest-tube and NGT were removed.
Her activity increased with increase in discomfor and was
started on Roxicet with good control. She was seen by physical
therapy who recommended STR. Her bowel function returned and
the tube feeds were increased. Nutrition was consulted who
recommended Fibersource HN Goal rate 55 cc/hr. On POD7 [**Hospital **]
clinic was consulted for better management of her diabetes. She
was started on insulin. A grape juice challenge was given with
no obvious anastomoses leak. She was started on a clear liquid
diet advanced to fulls. On POD8 the JP was removed. Her
insulin was titrated for elevated blood sugars. Her medications
were converted to PO meds. On POD 9 she required gentle
diuresing. Her electrolytes were replete. She continued to make
steady progress and was transferred to rehab. She will
follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Lisinopril 40mg qAM, Lipitor 20mg qHS, metformin 500mg [**Hospital1 **],
Avandia 4mg [**Hospital1 **], glyburide 5mg [**Hospital1 **], Aspirin 81mg daily, vitamin
2 AM, 2PM, Calcium 600mg +VitD 1 AM, 1PM, HCTZ 25mg qAM,
doxycycline 100mg [**Hospital1 **], omeprazole 20mg qAM, Lunigan
drop 1 drop each eye qHS
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Five (5) PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once
a day.
7. Nutren Pulmonary Full strength;
Tube Feeds via J-tube Cycle 70 ml/hr x 15 hrs or
8. Ibuprofen 100 mg/5 mL Suspension [**Last Name (STitle) **]: One (1) PO Q8H (every
8 hours) as needed.
9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1)
PO DAILY (Daily).
10. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) MMML PO Q4H
(every 4 hours) as needed for pain.
11. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ML PO every
six (6) hours as needed for pain.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: Three (3) ML
Inhalation Q6H (every 6 hours).
14. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Thirty Two (32)
Units Subcutaneous Dinner time.
15. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
please titrate as blood pressure tolerates. Home dose 20mg
daily.
16. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Regular Insulin Sliding Scale
71-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 2 Units 0 Units
141-160 mg/dL 4 Units 4 Units 4 Units 0 Units
161-180 mg/dL 6 Units 6 Units 6 Units 0 Units
181-200 mg/dL 8 Units 8 Units 8 Units 4 Units
201-220 mg/dL 10 Units 10 Units 10 Units 6 Units
221-240 mg/dL 12 Units 12 Units 12 Units 10 Units
241-260 mg/dL 14 Units 14 Units 14 Units 12 Units
261-280 mg/dL 16 Units 16 Units 16 Units 14 Units
281-300 mg/dL 18 Units 18 Units 18 Units 16 Units
301-320 mg/dL 20 Units 20 Units 20 Units 18 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] Healthcare Center
Discharge Diagnosis:
Non-insulin dependent diabetes
Hypertension
Hypercholesterolemia
Rheumatic fever
Glaucoma
Diverticulosis
Roscea
PSH: lap chole [**2151**] right tigger finger [**Doctor First Name **] [**2152**], L rotator
cuff repair [**2149**], C4-6 laminectomy and foraminotomy [**2147**], facial
resurfacing [**2149**], b/l glaucoma [**Doctor First Name **], left LE vein striping
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills.
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficulty or painful swallowing, abdominal pain, diarrhea
-Incision develops drainage
-HOB elevated 30 degree or more indefinitely
Feeding tube sutures become loose or break, please tape tube
securely and call the office [**Telephone/Fax (1) 4741**]. If your feeding tube
falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 4741**]. 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.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] [**1-31**] at 2:00 pm on the
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**]
Report to the [**Location (un) 861**] Radiology Department for a Barium
Swallow before your appointment.
Completed by:[**2154-1-17**]
|
[
"365.9",
"562.10",
"530.85",
"518.0",
"511.9",
"458.29",
"785.0",
"398.90",
"150.8",
"250.00",
"401.9",
"553.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"96.07",
"44.29",
"42.41"
] |
icd9pcs
|
[
[
[]
]
] |
9590, 9653
|
4535, 6649
|
290, 407
|
10064, 10073
|
2284, 4512
|
10932, 11268
|
1727, 1827
|
7010, 9567
|
9674, 10043
|
6675, 6987
|
10097, 10909
|
1842, 2265
|
231, 252
|
435, 1232
|
1254, 1623
|
1639, 1711
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,154
| 189,275
|
51903
|
Discharge summary
|
report
|
Admission Date: [**2135-10-25**] Discharge Date: [**2135-10-29**]
Service: MEDICINE
Allergies:
Codeine / Niacin
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement x 3 in right
coronary artery saphenous vein graft.
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female with medical history
significant for MI, with multiple catheterizations, s/p CABG in
[**2120**], unstable angina, and hyperlipidemia, presenting from her
nursing home with chest pain for the last 2-3 days. She says
her pain is [**5-2**] in severity, and radiates to the back. It was
relieved by sublingual nitroglycerin. She has had intermittent
diaphoresis, but denies nausea, diarrhea, abdominal pain. No
SOB. The pain is both at rest and with activity.
Past Medical History:
CAD, s/p CABG [**2120**]
s/p multiple MIs, LVEF 40% in [**2129**]
Unstable angina
Hyperlipidemia
Hypertension
Cataracts
Peripheral neuropathy, polyneuropathy; lower cervical bilateral
radiculopathy at multiple levels; bilateral R>L carpal tunnel
compression of the median nerve; and compression of the L ulnar
nerve at the wrist and elbow.
Alzheimer's Disease
Hypothyroidism
Mitral regurgitation
Urinary incontinence
Right shoulder osteoarthritis
Monoclonal gammopathy of unknown significance
Surgical history:
R hip replacement [**2114**]
Hysterectomy
Rectal polypectomy
Social History:
Lives at [**Hospital 100**] Rehab - lived alone until a few months ago.
Ambulates with a walker. She is independent with eating, but
needs assistance with other ADLs. She completed high school and
worked in retail sales. She denies smoking, etoh use, or IVDU.
Family History:
Family history of CAD.
Physical Exam:
VS: 97.6, 145/59, 63, 97% RA
Gen: Frail appearing caucasian female, lying in bed, appearing
comfortable. Conversational.
HEENT: moist MM.
Neck: No JVD.
Luns: Bibasilar crackles. No wheezes or rhonchi.
CVS: RR, normal rate, II-III/VI systolic murmur heard at RSB,
LLSB, with radiation to axilla. No rubs or gallops.
Abd: NABS, soft, NT/ND. No HSM.
Extr: Non-pitting edema of bilateral lower extremities, L > R.
No calf tenderness. No erythema.
Neuro: vision loss in her R eye, otherwise CN intact, strength
[**4-27**] upper and lower extremities bilaterally.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2135-10-29**] 11:10AM 5.0# 3.41*# 9.7* 29.8* 88 28.5 32.6 14.4
260#
[**2135-10-28**] 04:49PM 10.4 2.70* 8.5* 23.9* 88 31.5 35.6* 14.5
145*#
[**2135-10-28**] 02:47AM 7.1 3.47* 10.0* 30.0* 86 28.8 33.4 14.0
301
[**2135-10-27**] 06:30AM 6.0 3.76* 11.1* 32.3* 86 29.5 34.3 14.0
334
[**2135-10-26**] 06:40AM 6.2 3.86* 11.2* 32.7* 85 29.1 34.3 14.0
312
[**2135-10-25**] 02:00PM 7.7 3.75* 10.9* 31.8* 85 29.0 34.2 13.9
354
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2135-10-29**] 11:10AM 126* 23* 1.2* 133 3.1* 96 29
[**2135-10-28**] 02:47AM 111* 19 1.0 133 3.81 95* 29
[**2135-10-27**] 06:30AM 90 21* 1.0 135 4.0 100 25
[**2135-10-26**] 06:40AM 92 25* 1.1 136 4.3 101 26
[**2135-10-25**] 02:00PM 110* 23* 1.0 136 4.1 100 26
CK:
[**2135-10-29**] 11:10AM 130
[**2135-10-28**] 10:00AM 259
[**2135-10-28**] 02:47AM 140
[**2135-10-26**] 06:40AM 61
[**2135-10-25**] 09:56PM 75
[**2135-10-25**] 02:00PM 103
[**10-26**] trop < 0.01
[**10-25**] trop < 0.01
[**10-25**] trop < 0.01
Iron 29* TIBC 404, Vit B12 1273, Ferritin 40, TRF 311
Total cholesterol 159, TG 1001, HDL 72, Chol/HDL 2.2, LDL calc
67
CXR [**10-25**]: The cardiomediastinal silhouette is unchanged in the
interval. There are sternal wires and mediastinal clips
indicative of a prior CABG. The pulmonary vascularity is normal
in appearance without redistribution. There is linear
atelectasis in the left lower lung field, as well as left base
atelectasis with obscuration of the left hemidiaphragm.
IMPRESSION: No CHF. Left base atelectasis/consolidation.
CTA [**10-25**]: No dissection, no aneurysm, no pulmonary embolus.
Cardiomegaly. Coronary artery calcifications and stents.
Calcifications from aortic arch to distal decending aorta.
Bilateral pleural effusions, small, with associated bibasilar
atelectasis. No lymphadenopathy. Nodular densities in both
breasts - recommend mammogram.
CT abd [**10-25**]: Hyperdense cyst in R kidney. Otherwise normal.
No aneurysm or dilatation of aorta.
EKG [**10-25**]: Sinus rhythm. Left atrial abnormality. Lead V2 was
not obtained. Non-specific intraventricular conduction delay.
Modest diffuse non-specific ST-T wave
abnormalities. Clinical correlation is suggested. Since the
previous tracing
of [**2130-3-12**] ST-T wave changes appear slightly less prominent.
EKG [**10-25**]: Sinus rhythm. Left atrial abnormality. Modest
non-specific intraventricular conduction delay. Modest
non-specific ST-T wave changes. Clinical correlation is
suggested. Since the previous tracing earlier this date no
significant change.
EKG [**10-25**]: Sinus rhythm. Ventricular premature beat. Left atrial
abnormality. Modest
non-specific intraventricular conduction delay. Poor R wave
progression.
QS deflections in leads VI-V2 may be in part positional, but
clinical
correlation is suggested for prior anteroseptal myocardial
infarction. Modest
non-specific ST-T wave changes. Clinical correlation is
suggested. Since the
previous tracing earlier this date further poor R wave
progression is seen,
althought there may be no significant change.
P-MIBI [**10-26**]: No anginal symptoms or ECG changes from baseline.
Nuclear
report sent separately.
Nuclear: 1) Moderate to severe lateral and inferior portion of
the lateral
wall defect with partial reversibility, not significantly
changed from [**2129**]. 2)
Global hypokinesis with calculated ejection fraction of 43%.
ECHO [**10-26**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic
dysfunction with focal near akinesis of the inferior and
inferolateral walls.
[Intrinsic left ventricular systolic function may be more
depressed given the
severity of valvular regurgitation.] Right ventricular cavity
size is
moderately increased with free wall hypokinesis. The aortic root
and ascending
aorta are mildly dilated. The aortic valve leaflets are mildly
thickened.
There is no aortic stenosis. Moderate (2+) aortic regurgitation
is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation
is seen. The pulmonary artery systolic pressure could not be
estimated. There
is no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of
[**2134-5-21**], the severity of mitral regurgitation may be slightly
increased and
right ventricular cavity enlargement/free wall hypokinesis is
now seen. Left
ventricular systolic function and aortic regurgitation are
similar.
EKG [**10-26**]: Sinus rhythm. Atrial premature beat. Left atrial
abnormality. Modest
non-specific intraventricular conduction delay. Consider left
ventricular
hypertrophy. Poor R wave progression is non-specific. Modest
non-specific
ST-T wave abnormalities. Clinical correlation is suggested.
Since the previous
tracing of [**2135-10-25**] probably no significant change.
Cardiac Cath [**10-27**]:
1. Selective coronary angiography revealed severe three vessel
coronary artery disease with a patent LIMA-LAD, a known SVG-D
occlusion,
a diffusely diseased SVG-OM, and high grade SVG-RCA stenoses.
The LMCA
had a 30% lesion. The LAD had a totally occlusion proximally
with the
distal vessel filling via the LIMA. The LCX had a proximal
occlusion
with a large OM filling via a patent but diseased SVG-OM. The
RCA had a
total occlusion with the distal vessel filling by the SVG. The
SVG to OM
had severe diffuse disease and ectasia with 60% mid graft
stenosis,
non-laminar flow in the distal graft and a 50% lesion at the
anastomosis. The SVG to RCA had serial 90% stenoses in the mid
and
distal graft. The LIMA to LAD was widely patent.
2. Limited resting hemodynamics demonstrated elevated system
pressures.
3. Left ventriculography was deferred.
4. Successful PTCA and stenting of the SVG to the RCA with three
3.0
mm Cypher drug-eluting stents. Final angiography showed no
residual
stenosis, no dissection and normal flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the SVG-RCA.
EKG [**10-27**]: Atrial fibrillation
Premature ventricular contractions or aberrant ventricular
conduction
Nonspecific ST-T abnormalities
Since previous tracing of [**2135-10-26**], ventricular premature
complex seen
EKG [**10-28**]: Sinus rhythm
Poor R wave progression - probably due to LVH but consider
anterior infarct
Left ventricular hypertrophy
Nonspecific inferolateral ST-T wave changes
Since previous tracing, atrial fibrillation absent; QRs changes
in V4- ? lead
placement
L femoral US [**10-28**]: No evidence of pseudoaneurysm, AV fistula,
or hematoma.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female with significant cardiac
history, including multiple prior MIs, CABG in [**2120**], unstable
angina, who presented with a 2 day history of left sided chest
pain radiating to her back.
1) Chest Pain - Her pain persisted intermittently over the first
couple of days while in house. Cardiac enzymes were negative x
3. A CTA was obtained due to the patient's complaint of
radiation "between shoulder blades," which was negative for
aneurysm, dissection, pulmonary embolus, or hiatal hernia
(patient with history of hiatal hernia in the past). The pain
was always relieved by nitro, and she was always without EKG
changes. A P-MIBI showed reversible defects in the lateral
wall, and despite the lack of change when compared with the
P-MIBI in '[**29**], since the patient remained symptomatic we decided
to proceed to catheterization. She had cardiac catheterization
on [**10-27**] which revealed severe three vessel coronary artery
disease with a patent LIMA-LAD, a known SVG-D occlusion, a
diffusely diseased SVG-OM, and high grade SVG-RCA stenoses. She
had three 3 mm drug-eluting stents placed in the SVG-RCA on
[**10-27**]. During the procedure, after predilation of the vessel,
the patient developed severe angina and slow flow as well as
inferior ST-elevations. Dopamine was started transiently for
bradycardia. After the administration of IC Nipride the flow
improved significantly. The patient did not require any further
pressors, and the blood pressure came back up to 120s on its
own. She was trasferred to the CCU for one day post-cath for
monitoring, and her pressure remained normal. Her
anti-hypertensive medications were restarted and her course was
uneventful. A quiet L femoral bruit was noted post-cath, and
was evaluated with a femoral US which did not demonstrate any
pseudoaneurysm or hematoma formation. The patient did not have
any further episodes of chest pain. Her CK peaked on [**10-28**] at
259 post-cath and began to trend down.
2) Back Pain: On further questioning, it appears that the
patient mistakes the location of her pain, as she points to her
lumbar spine as the location (rather than "between the shoulder
blades"). This pain could have been referred, however could
also be from her osteoporosis, for which she takes calcium and
vitamin D supplementation. She did not complain of any back
pain after the catheterization. As above, there was no evidence
of dissection on CTA.
3) Anemia: The patient had a hct of 30-32 during the
hospitalization. Her stool was trace guaiac positive, and her
iron studies revealed iron deficiency anemia. She is already on
iron supplementation and this should be continued. The
possibility of colonoscopy can be considered as an outpatient.
4) HTN: We continued her metoprolol, losartan, and imdur. Her
blood pressure was usually between 120 and 140 systolic.
5) Breast nodularity: Bilateral nodularity of the breasts was
noted on CT scan on admission. On physical exam, these are not
palpated, however it is suggested that she have an outpatient
mammogram.
6) Hypothyroidism: We continued her levothyroxine. TSH was
within normal limits.
7) Osteoporosis: Continued vitamin D, calcium.
8) Dementia: Continue aricept.
9) PPx: We started protonix due to her history of hiatal hernia.
She was also given Docusate Sodium 200 mg PO DAILY.
10) Code: DNR/DNI
Medications on Admission:
Metoprolol 25 mg PO BID
Losartan Potassium 25 mg PO BID
Levothyroxine Sodium 162.5 mcg PO DAILY
Isosorbide Mononitrate 60 mg PO QAM
Ferrous Sulfate 325 mg PO DAILY
Donepezil 10 mg PO HS
Docusate Sodium 200 mg PO DAILY
Vitamin D 800 UNIT PO DAILY
Calcium Carbonate 500 mg PO TID
Aspirin EC 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Donepezil Hydrochloride 5 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Levothyroxine Sodium 25 mcg Tablet Sig: 0.5 Tablet PO once a
day: (Total levothyroxine dose should be 162.5 mg daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
12. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
14. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO
once for 1 doses: Should get 40 mEq of potassium total.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Coronary artery disease
Hypertension
Iron deficiency anemia
Hypothyroidism
Discharge Condition:
Good, stable. Patient eating, drinking, urinating, having bowel
movements.
Discharge Instructions:
Please return to the hospital if you experience chest pain or
shortness of breath.
Resume your usual medications.
We have added one medication: Plavix 75 mg once a day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2135-11-2**] 11:30
Provider: [**Name10 (NameIs) 6800**] CLINIC Where: [**Hospital6 29**] [**Hospital3 1935**]
CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2135-11-2**] 1:00
Please call to make an appointment with your primary care
doctor, Dr. [**Last Name (STitle) **]: [**Telephone/Fax (1) 10012**]. He should schedule you for a
mammogram as well.
|
[
"396.3",
"244.9",
"V45.82",
"273.1",
"414.01",
"414.02",
"280.9",
"272.4",
"733.00",
"356.9",
"331.0",
"412",
"294.10",
"401.9",
"427.31",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.07",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
14596, 14661
|
9250, 12674
|
236, 334
|
14779, 14856
|
2406, 8556
|
15076, 15633
|
1781, 1805
|
13030, 14573
|
14682, 14758
|
12700, 13007
|
8573, 9227
|
14880, 15053
|
1820, 2384
|
186, 198
|
362, 890
|
912, 1486
|
1502, 1765
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,801
| 155,566
|
8132
|
Discharge summary
|
report
|
Admission Date: [**2113-6-2**] Discharge Date: [**2113-6-7**]
Date of Birth: [**2043-2-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Lisinopril / Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe nodule
Major Surgical or Invasive Procedure:
VATS LLL wedge resection, LLL lobectomy, mediastinal lymph node
dissection
History of Present Illness:
Ms. [**Known lastname 28975**] is a 70 year old female who was found to have a LLL
nodule on an abdominal CT done on [**10-31**]. This was followed up
with a chest CT on [**2113-5-23**] which showed an increase in
size. When previous scans were reviewed, the nodule can be
found as early as [**2106**]. She does report some dyspnea with
exhertion, but denies cough, hemoptysis, sputum production, or
chest pain. A head MRI was negative for metastases, PFTs
revealed an FVC of 1.82 (66%), FEV1 1.42 (72%), and DLCO 12.52
(71%). She also underwent a PET/CT scan, which revealed FDG
avidity in the left lower lobe nodule with a max SUV of 3.4.
The left thyroid lobe had a nodule measuring 2.6 cm which showed
max SUV of 15.7. She presents today for resection of the
nodule.
Past Medical History:
? left sided pleurisy
Diverticulosis
HTN: Rx'ed with Norvasc and HCTZ
Endometriosis
Bladder CA, s/p resection
s/p CCY '[**07**]
s/p appendectomy
s/p TKR
C.diff in [**2106**]
PUD
Ischemic colitis [**2105**]
Social History:
X 25-50 pack year smoker, discontinued 20 years ago.
Occupation: Stitcher. Does not report any alcohol use and
denies any exposure history.
Family History:
Mother with hypertension. Father had [**Name2 (NI) 499**] andpossible lung
cancer.
Physical Exam:
VITAL SIGNS: Temperature 98.2, pulse 91, blood pressure 153/79,
respiratory rate 18, oxygen saturation 95% on room air and
weight
196.8 pounds.
GENERAL: Well-nourished, well-developed woman in no apparent
distress, alert and oriented x3.
HEENT: NC/AT, EOMI, PERRL, sclerae are anicteric. Oropharynx
and nasopharynx free of mucosal abnormality. Tongue is midline.
Palate elevates symmetrically. Trachea is midline.
NECK: Supple, nontender and without mass. Thyroid is of normal
size and contour.
RESPIRATORY: Clear to auscultation and percussion. Chest
excursion is symmetric and good. There is no tactile fremitus
or egophony.
BACK: There is no spine or CVA tenderness.
HEART: Regular rate and rhythm without murmur or gallop. There
is no JVD. Peripheral pulses are intact. PMI is in normal
position. There is no peripheral edema. There is no abdominal
or carotid bruit.
GASTROINTESTINAL: Abdomen soft, nontender, nondistended,
without mass or hepatosplenomegaly. There is no hernia.
SKIN: No rashes, lesions, ulcers, induration, nodules,
tightening.
NEUROLOGIC: Strength and sensation are intact and symmetric.
Reflexes are normal and there is no facial asymmetry. Cognition
is intact. Cranial nerves are intact.
LYMPH NODES: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy.
MUSCULOSKELETAL: No clubbing, cyanosis or edema. The gait is
normal. There is no tenderness to palpation. There is normal
tone, alignment and range of motion. There is normal palpation.
Nails are normal.
PSYCHIATRIC: There is normal judgment, insight, memory, mood
and affect.
Brief Hospital Course:
Ms. [**Known lastname 28975**] was admitted after her surgery on [**2113-6-2**]. For
details of the procedure please see the operative report.
Briefly, she underwent a wedge resection initially, on which
frozen sections revealed likely adenocarcinoma. Therefore, a
LLL lobectomy was completed thoracoscopically. Postoperatively
she was extubated and transferred to the PACU were she was noted
to be sedated, hypoxic, and hypertensive. The hypertension
resolved with a short duration of a nitro drip. She was give
albuterol nebs, atrovent nebs, and racemic epinephrine andthe
hypoxia slowly resolved as she recovered from the anesthetic. A
postop CXR showed left sided volume loss but no air leak was
noted from the chest tubes. They were therefore left to water
seal.
She was transferred to the floor later that day where pain
was controlled with toradol and a dilaudid PCA. She was still
noted to be hypoxic with an oxygen saturation of 90-92% on 4-5L
NC. A repeat CXR showed that the lung had further reexpanded
witha small left pleural effusion. An ABG the morning of POD1
was 7.40/46/79/30/2 and her oxygen saturdation remained stable.
She was continued on nebulizers, incentive spirometry, and chest
PT every 4 hours. She was out of bed to a chair on POD1. Her
diet was advanced and her foley catheter was removed.
However, she failed to void after the catheter was removed
and a bladder scan showed only 100cc of urine in the bladder
after 8 hours. A small fluid bolus was given over 2 hours and
her urine output improved.
In the AM of POD2 her lungs had increased crackles and she
was given 20cc of IV lasix. Her oxygen saturation did not
improve and she was requiring bipap. In addition she converted
into atrial fibrillation. She was moved to the ICU where she
was started in bipap, was started on an amiodarone drip, and
converted to sinus rhythm. She received more lasix and her
oxygen saturday improved. On POD3 a bronchoscopy was done
showing minimal secretions and she was saturating well on 3-4L.
Both of her chest tubes were removed with no worsening of her
pneumothorax. She was transfered back to the floor where she
did well. She was converted to oral amiodarone and placed back
on her home medications. She was evaluated by PT who
recommended discharge to home with oxygen therapy. She was
discharged home on POD 5 with home oxygen at 3L. She will
complete a 2 week course of amiodarone.
Medications on Admission:
Norvasc
[**Last Name (un) **] Pro
Caltrate
Aleve
Zantac
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: then decrease to once daily.
Disp:*20 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: start this smedication dose on [**2113-6-12**] then stop
when medication is complete .
Disp:*14 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
7. Ipratropium Bromide 0.02 % Solution Sig: [**12-27**] Inhalation Q6H
(every 6 hours).
Disp:*1 box* Refills:*1*
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**12-27**]
Inhalation Q6H (every 6 hours).
Disp:*1 box* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
flexible bronchoscopy, left lower lobectomy
Discharge Condition:
good-requires home PT and home oxygen
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever, chills, redness or drainage
from your incision site.
You may shower. After showering, place a clean bandaid over the
chest tube site daily until healed. No tub bathing or swimming
for 3-4 weeks.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a follow up
appointment
Completed by:[**2113-6-7**]
|
[
"162.5",
"934.9",
"401.9",
"V10.51",
"427.31",
"276.6",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.4",
"33.24",
"34.22",
"32.29",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6852, 6910
|
3367, 5809
|
351, 427
|
6998, 7038
|
7400, 7522
|
1639, 1725
|
5915, 6829
|
6931, 6977
|
5835, 5892
|
7062, 7377
|
1740, 3344
|
289, 313
|
455, 1234
|
1256, 1463
|
1479, 1623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,017
| 199,207
|
4917+55620
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-5-26**] Discharge Date: [**2149-6-3**]
Date of Birth: [**2075-9-21**] Sex: F
Service: MEDICINE
Allergies:
Influenza Virus Vaccines / Ace Inhibitors / Atenolol
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Humeral fracture
Major Surgical or Invasive Procedure:
Right ORIF repair on [**5-28**]
History of Present Illness:
73yo F with diabetes, hypertension, presents with fall,
subsequent right shoulder fracture and admitted to medicine for
pre-op workup. Patient was amnestic to event post fall and so
most of the history was obtained from the chart.
.
Patient lives at [**Location **] and saw her PCP this AM in the same
buidling. She was on her way to the lab when she tripped on a
lobby rug and fell. SHe reported to
CP/SOB/palpitation/dizziness/abdominal pain prior to the fall.
She has no recollection of the fall. Eye witness reported no
seizure, no LOC. The next thing that she remembered was that she
was on a wheelchair on her way to XR. XR show right shoulder
fracture and dislocation and she was then sent to the ED.
Patient c/o right shoulder and facial pain after the fall.
.
In ED, her vital signs were T 97.9 P104 BP126/78 R 14. She
recieved 3mg dilaudid. Orthopedics were consulted in the ED and
recommended that she should have repair of the right shoulder.
.
Currently, she only complains of right shoulder pain. She denies
chest pain, shortness of breath, abdominal pain, nausea,
diarrhea, dysuria, headache, facial pain. SHe has chronic cough
that has not changed in character. Patient is able to walk about
1 block without SOB, she is able to climb stair with several
stops, she is able to mop, sweep and do laundry all by herself.
Past Medical History:
PAST MEDICAL HISTORY:
- diabetes(FS range in 200-300 per {PCP note in [**1-20**])
- hypertension
- hyperlipidemia
- gastritis
- DJD
- stress incontinence
- COPD
- diverticulosis
- stroke(left occipital)
- alcohol abuse
Social History:
Patient lives in [**Location **] senior housing for the last 20 years.
She ambulates by herself and perforrms all ADLs by herself. She
smokes 1ppd for the last 62 years. She has not had ETOH for the
past 1 year.
Family History:
non contributory
Physical Exam:
97.8 BP110/62 P69 R22 92% on 3L FS 357
Gen- in C collar, complaining of thirst, no acute distress
otherwise
HEENT- right perioribital bruising, EOMI, PERRLA, no nasal
tenderness, mild right maxillary sinus tenderness, very dry
mucus membrane, neck in C collar
CV- rrr, no r/m/g
RESP- crackles bilateral bases, no wheezes, no accessory muscle
use, no distress
[**Last Name (un) **]- soft, nontender, nondistended, no hepatosplenomegaly
EXT- no pitting edema, 2+ DP on left LE, 1+ on right LE, right
UE in sling, right shoulder tender, right arm ROM deferred, left
arm ROM nml with no tenderness
neuro- A+O x3, CN II-XII intact(shoulder shrug not tested), [**3-21**]
muscle strength in all extemity( except right US, not tested),
sensation grossly intact(right arm not tested), gait deferred.
Pertinent Results:
[**2149-5-26**] 01:03PM GLUCOSE-285* UREA N-10 CREAT-0.5 SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2149-5-26**] 06:50PM CK-MB-NotDone cTropnT-<0.01
[**2149-5-26**] 06:50PM CK(CPK)-63
[**2149-5-26**] 01:03PM CK-MB-NotDone cTropnT-<0.01
[**2149-5-26**] 01:03PM WBC-30.5*# RBC-4.84 HGB-15.1 HCT-43.2 MCV-89
MCH-31.1 MCHC-34.8 RDW-12.6
[**2149-5-26**] 01:03PM NEUTS-75* BANDS-12* LYMPHS-7* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2149-5-26**] 01:03PM PLT COUNT-399
[**2149-5-26**] 10:26AM UREA N-8 CREAT-0.6 SODIUM-140 POTASSIUM-4.7
CHLORIDE-98 TOTAL CO2-29 ANION GAP-18
[**2149-5-27**] 06:38AM BLOOD WBC-17.8* RBC-3.41*# Hgb-10.9*#
Hct-30.5*# MCV-90 MCH-31.8 MCHC-35.6* RDW-12.7 Plt Ct-303
[**2149-6-3**] 09:15AM BLOOD WBC-10.4 RBC-2.94* Hgb-9.2* Hct-25.8*
MCV-88 MCH-31.4 MCHC-35.8* RDW-14.3 Plt Ct-323
[**2149-6-3**] 02:00AM BLOOD PT-32.5* PTT->150* INR(PT)-3.5*
[**2149-6-3**] 09:15AM BLOOD PT-45.1* PTT-150* INR(PT)-5.2*
[**2149-6-3**] 09:15AM BLOOD Plt Ct-323
[**2149-6-3**] 12:55PM BLOOD PT-40.5* PTT-28.0 INR(PT)-4.6*
[**2149-6-3**] 09:15AM BLOOD Glucose-298* UreaN-5* Creat-0.4 Na-136
K-3.9 Cl-102 HCO3-28 AnGap-10
Brief Hospital Course:
[**Doctor Last Name **] wards:
1. Humeral fracture: pt initially presented with right humeral
fracture here for repair. She was admitted for management of her
medical issues and for repair by orthopedics. Pt went to the OR
on [**5-28**]. Had surgical repair of complex humeral fracture. On
surgical eval, a large hematoma was found. PT received 1U PRBC
post op for hct 24. Ortho followed patient for remainder of
hospital course. On [**6-2**] insicion site was erythematous. Pt to
receive Keflex for 7 day course. Also had ultrasound of site
which showed superficial hematoma. Pain was controlled with
oxycodone PRN and tylenol TID.
.
2. Pulmonary Embolism: On [**5-29**] pt found to be increasingly
hypoxic. Tachycardia and shortness of breath also associated.
On evaluation by MICU team pt felt to have PE and was started on
Heparin. (SEE MICU course). CT showed left lingular PE. After
transfer from MICU, pt was started on Heparin drip. Then
coumadin was started originally at 5 mg dose. Pt INR, PTT
supratherapeutic on [**6-3**], coumadin/heparin was held and coumadin
to be started as outpatient to keep INR [**12-20**] for chronic therapy
after PE.
.
3. [**Name (NI) 3674**] Pt initially had large hct drop on admission
secondary to fluid administration and blood loss. Pt with low
hct for remainder of hospital stay despite 1 U prbc after
surgery. On day of admission, u/s performed to evaluate
hematoma at incision site. Hematoma found, but superficial.
Ortho consulted, they felt that there was no indication for
removal of hematoma.
--HCT should be checked daily until no longer dropping/ anemic.
IF HCT decreases, ultrasound should be done to verify if pt has
bleeding into humerus fx.
.
4. COPD: Pt with extensive smoking history. Pt has no 02
requirement at home, but required 2-3 L to keep sats high 90%.
Events on [**5-29**] (PE) were clouded with COPD exacerbation as her
hypoxia was responsive to albuterol and ipratroprium nebs. SEE
MICU course. After transfer out of the MICU, pt was continued on
02 and albuterol, advair. This should be continued as out
patient. Echo shows significant Pulm htn, CXR, CT show
extensive emphysema.
.
5. [**Name (NI) 20472**] Pt with Type II diabetes. Blood sugars controlled
with insulin sliding scale. [**Last Name (un) **] diabetic service was
consulted initially and continued to follow patient. They
recommended keeping pt off oral hypoglycemics while inpatient.
They discouraged sulfonylureas while outpatient given the risk
of hypoglycemia in this patient.
.
6. [**Name (NI) **] Pt initially on anti-hypertensive agents while
inpatient, but these were held after MICU stay. Pressures under
moderate control, but anti-hypertensives should be restarted
after d/c.
.
7. Code status- patient was made DNR/DNI after d/c from MICU.
.
MICU course:
While on the medicine floor on HD#4, the patient had three
episodes of desats. During the first episode the patient O2sats
fell to 85% on 40% FiO2. With nebulizer this improved to 94%.
She was also hypotensive to 88/40 and received 1L fluid bolus
with improvement to 108/50. The second trigger happened at 12pm.
The patient's vitals were as follows: BP 88/40, HR 104, RR30,
O2sats 88% on 40%FiO2. The patient become lethargic,
tacchycardic and tachypneic to the 30s. The patient received
12.5 mg of lopressor. The frequency of her nebs was increased to
Q4h, an EKG was done which showed 1mm ST depressions in the high
lateral leads and PACs, and a CXR was done which showed: recent
left humeral head repair and left lower lobe consolidation,
pleural effusion, which could be due to atelectasis and/or
infectious process. The patient triggered again at 3pm. Her
vitals were: T 99.3, HR 74, BP 104/48 O2sat 78-85 on 40%FiO2.
The patient was started on vanc/levo/flagyll. At that point the
team felt that the patient needed to come to the MICU for
further monitoring. On admission to the MICU, the pt was
continued on levo/flagyl for presumed PNA, but vanc was d/c'd.
Initially, the pt was too belligerant to obtain a chest CT, so
she was empirically started on heparin given concern for PE. She
was given nebulizer treatments, and her O2 sats improved to the
90's on 6L NC. She was able to undergo a chest CTA the
following day, which showed a L sided segmental PE, moderate
bilateral pleural effusions, and no consolidation. She was
continued on heparin and her Abx were stopped. Per her
daughter, the pt's mental status was more confused and combative
than usual, so a head CT was performed.
Medications on Admission:
AGGRENOX 25-200MG [**Hospital1 **]
BETAMETHASONE DIPROPIONATE 0.05%--Apply to rash every day
GLIPIZIDE 20MG [**Hospital1 **]
LASIX 20 mg QD
LIPITOR 20MG QD
METFORMIN HCL 1000MG [**Hospital1 **]
NIFEDIPINE ER 60MG QD
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-18**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of
breath or wheezing.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: Please check FS QACHS.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: Please see sliding scale.
15. Outpatient Occupational Therapy
16. Outpatient Lab Work
Please check INR (Goal is [**12-20**]). If INR is less than 3, please
restart coumadin at 1 mg QHS.
17. Outpatient Lab Work
PLease check Hematocrit. If the hematocrit is worsening please
check ultrasound of right shoulder for enlarging hematoma.
18. Lactulose 10 g Packet Sig: One (1) dose PO three times a day
as needed for constipation: Goal 1 bowel movement per day.
19. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
PLEASE CHECK INR before giving to patient. If INR less than 3
please restart medication. INR was 4.2 today.
Discharge Disposition:
Extended Care
Facility:
On [**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
Right Humerus fracture
Pulmonary Embolism
COPD
Discharge Condition:
Good able to ambulate and to feed herself.
Discharge Instructions:
Please participate in Occupational therapy.
Please take all medications as prescribed.
Please check INR (Goal [**12-20**]) tomorrow. If the INR is less than 3,
please start coumadin again at 1 mg daily. Check twice weekly
INR until.
Please check HCT every other day. If significantly worsening,
please check ultrasound of shoulder to make sure hematoma not
worsening.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Date/Time:[**2149-8-26**] 8:45
Please follow up with orthopedics, Dr. [**Last Name (STitle) 1005**] or Dr. [**Last Name (STitle) **]
in 2 weeks by calling [**Telephone/Fax (1) 1228**] to schedule an appointment.
Name: [**Known lastname **],[**Known firstname 3415**] Unit No: [**Numeric Identifier 3416**]
Admission Date: [**2149-5-26**] Discharge Date: [**2149-6-3**]
Date of Birth: [**2075-9-21**] Sex: F
Service: MEDICINE
Allergies:
Influenza Virus Vaccines / Ace Inhibitors / Atenolol
Attending:[**First Name3 (LF) 161**]
Addendum:
PT has maxillary fracture and should be followed by Plastic
surgery as outpatient. Please make f/u appt in [**11-18**] weeks by
calling [**Telephone/Fax (1) 3417**]
Discharge Disposition:
Extended Care
Facility:
On [**Location (un) **] - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]
Completed by:[**2149-6-3**]
|
[
"285.1",
"401.9",
"272.4",
"802.4",
"812.01",
"486",
"802.8",
"998.12",
"250.00",
"E885.9",
"415.11",
"V12.59",
"E878.8",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.81",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12635, 12862
|
4253, 8773
|
328, 361
|
11249, 11294
|
3059, 4230
|
11714, 12612
|
2213, 2231
|
9040, 11062
|
11179, 11228
|
8799, 9017
|
11318, 11691
|
2247, 3040
|
272, 290
|
389, 1725
|
1769, 1968
|
1984, 2197
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,269
| 193,559
|
1825
|
Discharge summary
|
report
|
Admission Date: [**2156-1-6**] Discharge Date: [**2156-1-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Respiratory distress; found down
Major Surgical or Invasive Procedure:
Mechanical ventilation.
Pressors.
Central line access.
History of Present Illness:
[**Age over 90 **] yo F w/ h/o ischemic CM, EF40%, PAFm CAD, CRF (Cr 2.1) who
was found down at home, minimally responsive and in resp
failure. Per family, she c/o some nausea in AM and no other
localizing sxs. She had progressively labored breathing
throughout the day. Home health aid was concerned and contact[**Name (NI) **]
PCP, [**Name10 (NameIs) 1023**] recommended calling EMS.
.
On their arrival she was foud on the floor, struggling to
breath. She was given lasix, NTG SL and was transported to
[**Hospital1 18**]. In ED, she initially was on NRB w/ O2 sat of 96% but was
intubated d/t work of breathing. BP 184/82, AFib at 114.
.
SBP was in 60s post-intubation and she received 1L NS and was
started on Levophed. Also got CTX and Azithro. CXR showed
question of RUL infiltrate vs asymmetric pulm edema.
.
ECG showed AFIB w/ RVR at 120s (old LBBB); neg CE's. Initial
lactate was 4.8 and she was started on the MUST protocol for
sepsis (MVo2 70).
Past Medical History:
1. CAD
EF 40%; 2+ AR; 2+MR [**First Name (Titles) **] [**Last Name (Titles) **] [**6-10**]
Admit for CHF (intubation) in [**2153**]. cath in [**2153**] w/ PCWP 17, CI
2.1; 2VD w/ L dom system, s/p PCI to mid LCX (705) and L-PDA
(80%); also has 50 %RCA
2. pAF on coumadin
3. asthma
4. h/o thyroid [**Doctor First Name **]; on replacement
5. diverticulosis
6. hyperchol
7. r hip fx
8. h/o M-W tear
Social History:
Lives alone; home health aide daily to help with ADL's
-Tob: quit [**2109**]
-EtOH: rare
Family History:
NC
Physical Exam:
T102 BP 95/68 P 115 RR 21
SaO2 100% on AC 500ccxRR 15 on PEEP 5 and 100% FiO2
ABG 7.27/47/276
Obese, intubated female, skin mottled, pink-frothy material in
ETT.
Surgical pupils, ractive to light, MMM.
Faint irreg S1/S2.
Caorse BS with rales bilaterally.
Softly disteded abdomen, decreased breath sounds, obese.
Cool hands and feet.
Pertinent Results:
[**2156-1-6**] 05:00PM WBC-12.5*# RBC-4.63 HGB-13.4 HCT-43.2 MCV-93
MCH-29.0 MCHC-31.0 RDW-13.6
[**2156-1-6**] 05:00PM NEUTS-68.6 LYMPHS-27.9 MONOS-2.5 EOS-0.9
BASOS-0.1
[**2156-1-6**] 05:00PM HYPOCHROM-1+
[**2156-1-6**] 05:00PM PLT COUNT-285
.
[**2156-1-6**] 05:00PM PT-13.0 PTT-25.3 INR(PT)-1.1
.
[**2156-1-6**] 05:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-1-6**] 05:00PM URINE RBC-[**3-13**]* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2156-1-6**] 05:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
.
[**2156-1-6**] 05:00PM GLUCOSE-286* UREA N-40* CREAT-2.1* SODIUM-139
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-24 ANION GAP-21*[**2156-1-6**]
05:00PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-6.6*# MAGNESIUM-2.4
.
[**2156-1-6**] 05:00PM ALT(SGPT)-21 AST(SGOT)-31 LD(LDH)-230
CK(CPK)-101 ALK PHOS-163* AMYLASE-180* TOT BILI-0.3 LIPASE-188*
.
[**2156-1-6**] 05:00PM CK(CPK)-112
[**2156-1-6**] 05:00PM CK-MB-3 cTropnT-0.02*
.
[**2156-1-6**] 05:00PM CORTISOL-52.7*
[**2156-1-6**] 05:00PM CRP-6.77*
.
[**2156-1-6**] 05:21PM LACTATE-4.8*
[**2156-1-6**] 05:57PM LACTATE-4.0*
[**2156-1-6**] 07:05PM LACTATE-2.0
[**2156-1-6**] 08:14PM LACTATE-1.3
Brief Hospital Course:
.
[**Age over 90 **] F with CMY (EF 40%), PAF, asthma, who despite influenza
vaccination was found down and developed influenza A and
retrocardiac infiltrate and required mechanical ventilation,
volume repletion, and management of anxiety to prevent paroxysms
of severe hypertension/flash pulmonary edema.
.
ICU COURSE:
.
1. Sepsis: Secondary to CAP vs UTI in setting of Influenza A
-Managed with IVF (500cc boluses), following urine output/MVO2.
Eventually required levophed and vasopressin which were weaned
over time with volume repletion.
- Started in MICU on zosyn and levofloxacin, but zosyn d/c'd on
day 4 after negative cultures and presumed CAP.
- Negative [**Last Name (un) 104**] stim response; started on empiric dexamethasone.
- Required vasopressin/levophed initially and weaned off on
[**1-7**].
- Held BP meds initially in context of sepsis.
.
2. Resp failure: Felt to be secondary to PNA, although PNA was
never confirmed by CXR (bact CAP vs influenza vs aspiration
PNA). Influenza DFA was positive.
-Abx as above. Since no gram + sputum, did not add Vanco.
-Lung protective ventillation, AC ventilation. Struggled with
pressure support transition and had number of good spontaneous
breathing trials but became anxious after too long on trials.
Eventually, had direct extubation, which was successful except
for marked anxiety causing hypertension, flash pulmonary edema
and requiring BiPAP briefly. She benefitted from haldol and then
zyprexa for anti-anxiety. She has been stable on zyprexa 5 mg
tid.
.
3. AFIB: DC CV was considered for PAF which developed during
period of ventilation because the patient was persistently
hypotensive. Amiodarone, her outpatient regimen, was continued.
There was no evidence of ischemia. Afib was likely sec to high
catecholamine state in sepsis. Heparin gtt was avoided because
of hx of falls. The HR improved with IVF and treatment of
sepsis. Dig loaded but then d/c'd because was stable from
respiratory standpoint to add metoprolol(stable without
brochospasm on outpatient 12.5 po tid), which she tolerated
well.
.
4. Ischemic CM: has mild CHF. Trop leak of 0.12. On asa,
lipitor. Initially held beta blocker for hypotension but
eventually was able to add back. Old [**Month/Year (2) **] shows WMA, but this
event thought to be demand ischemia in setting of sepsis and so
cath was deferred. Repeat [**Month/Year (2) **] showed EF of 55%. Anxiety and
panic attacks frequently caused hypertension above SBP 220 and
flash pulmonary edema on the substrate of the patient's CM. NTG
drip and hydralazine were important for afterload reduction
.
5. Metab acidosis: Sec to sepsis; improved with IVF, abx.
.
6. FEN: Tubefeeds started on [**1-7**]. Had some abd bloating,
treated with enemas and lactulose with success.
Post-intubation, speech pathology recommended ground thick
nectar liquids, soft ground solids, meds crushed with
applesauce. D5W 80cc/hr running for hypernatremia in setting of
diuresis (often needed for anxiety-induced flash pulmonary
edema).
.
6. CRF: Cr at baseline after volume repletion, but eventually
diuresed causing some prerenal physiology (FeUrea <30).
.
7. Proph: SQ hep; PPI. On Lactulose for FOS on KUB.
.
FLOOR COURSE:
.
In summary, on presentation to the floor, the patient is a [**Age over 90 **]
year old female with multiple medical problems, including
ischemic cardiomyopathy (EF 40%), paroxysmal atrial
fibrillation, CRI (Cr 2.1), and asthma, who was brought to the
ED at [**Hospital1 18**] on [**2155-12-7**] after being found minimally responsive
at home. She was admitted to the MICU with respiratory failure
and shock. She was intubated and initiated on the MUST
protocol. She was initially treated with Zosyn and Levofloxacin
for likely community acquired pneumonia. She was placed on
steroids for treatment of asthma exacerbation. On [**1-7**], she
was found to have influenza A, and she was started on
amantadine. On [**1-7**], her Zosyn was discontinued, and she was
off pressors. On [**1-14**], the patient was extubated. Per the MICU
team, she has had numerous episodes of anxiety-related
hypertension with SBP>220. These episodes have resolved with
administration of Lasix, Hydralazine, Zyprexa, and nitrates.
.
1. Influenza A/Pneumonia: DFA POS for Influenza A. Pt had
completed a seven day course of Levofloxacin.
-Continued supplemental O2. O2 sat at baseline on the floor was
initially around 94% on 4L, weaned down to 93-96% on 2L. At
discharge, her RA O2 sats ranged btw 90-94%RA.
-Bronchodilators were continued as needed. Pt was often
appreciated to have wheezes on physical exam and benefited from
inhalers and frequent nebulizer treatments.
-Aspiration precautions.
.
2. Asthma exacerbation:
-Continue bronchodilators freqently, as above.
-On admission to the floor on [**1-17**], the pt was placed on a 12 day
course of prednisone starting at 60mg and progressing to 5mg. At
the time of discharge, the pt has 2 days left of prednisone 20mg
qd, to be followed by 3 days of 5mg qd.
.
3. Upper respiratory congestion:
.
The patient had no SOB on the floor until [**1-21**], when she had two
transient episodes of SOB without decrease in O2 sat. The first
episode seemed to have begun as a result of anxiety related to
sitting in her chair too long. RA sat was 90% and 97% on 2L
(baseline), SBP 120. Exam was notable for a productive cough and
rhonchi on lung exam, but no crackles or wheezes. Portable CXR
showed no failure. The pt was given 40mg IV lasix and 2.5mg
zyprexa, and the episode resolved within minutes.
Two hours later, the pt again had SOB without decrease in O2 sat
and with maintained ability to speak in full sentences without
dyspnea. Lung exam showed diffuse wheezes (not atypical for this
pt) and she was given a nebulizer. Pt felt less SOB lying down
than sitting up.
The episodes were attributed to anxiety related to upper airway
congestion, given no failure on exam or on portable CXR, no
infiltrate, WBC, or fever (afebrile during the entire time on
the floor), and the episodes' response within minutes to calming
and deep breathing. She was started on sudafed, guifenasen, and
chest PT as needed. There were no further episodes.
.
A repeat CXR on [**1-22**] showed mild CHF, small bilateral pleural
effusions, and atelectasis. The patient was clinically much
improved on [**1-22**], with no distress.
.
3. Anxiety:
-Continued Zyprexa/Seroquel.
.
4. Neuro:
-On [**1-19**], the pt had an episode of "bluish glass" obstructing
vision which came on suddenly and resolved suddenly after 2.5
hours. As noted below, the pt has been off coumadin since a fall
leading to hip fracture in [**6-12**]. ([**Name6 (MD) **] [**Name8 (MD) **] NP[**MD Number(3) 10222**]'s office, she
has had other smaller falls, including one in [**10-12**] when she
dropped her remote control, leaned over to pick it up, then
fell. She then dragged herself to the bathroom where she could
pull herself up, as she did not want to active the healthalert
system.) Neurology consult felt that sx were likely c/w
amaurosis fugax from a TIA.
-A carotid US showed less than 40% stenosis in both ICA's were
normal vertebral arteries. The pt's neurological symptoms were
discussed with pt and pt's daughter in relation to pt's need for
anticoagulation. Pt and daughter were both aware of risks and
benefits of being on coumdin, especially now with stroke risk
being more real given recent TIA event. They will discuss these
issues with each other and with the pt's PCP.
.
5. PAF: Tele on the floor showed the pt in NSR. Rate was
well-controlled.
-Continued beta-blocker.
-Continued Amiodarone.
-As above, pt is not on coumadin given fall risk, but
this may be reconsidered given recent TIA.
.
6. Ischemic cardiomyopathy: EF 40%.
-Continued ASA/statin/BB.
-Pt can consider adding ACE I for afterload reduction as
outpatient.
.
7. CRI:
-Patient??????s baseline Cr=2.1 -- remained at baseline while
on floor. Had held lasix initially given ARF in setting of
likely ATN in MICU, but restarted lasix [**1-10**] consider adding ACE I as an outpatient, given that
Cr is at baseline.
.
8. Hypernatremia from water deficit: The pt received D5W at
80cc/hr for several days to correct her free water deficit.
Sodium had corrected by the time of discharge. Also encourage pt
to drink liquids (doesn't like drinking the thickened fluids).
.
9. Endo: Patient has been on regular sliding scale insulin qid
in the setting of steroids. SF usually within low-mid 100's.
- Should continue RISS in rehab and reevaluate patient for
potential need for oral hypoglycemic, once she is off the
prednisone taper.
.
10. FEN:
Per swallow evaluation, pt may have nectar thick liquids and
ground/soft solids.
-Assist with meals.
-Aspiration precautions.
.
11. Hypothyroidism:
-Continued Levothyroxine.
.
12. Access: PIV
.
13. Prophylaxis: Mainted on SC heparin. On PPI (home med).
Rec'd pneumovax [**2156-1-19**].
.
14. Dispo: Seen by PT and OT, who recommended acute rehab.
.
15. FULL CODE.
Medications on Admission:
lasix 40 mg [**Hospital1 **]
amio 100 mg once daily.
lipitor 20mg once daily.
detrol 5 mg once daily
advair diskus
colace 100 mg [**Hospital1 **]
protonix 40 mg once daily
synthroid 75 mcg once daily.
lopressor 12.5 mg [**Hospital1 **].
hydralazine 10 mg tid
Allergies to fresh salmon.
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB INH
Inhalation Q6H (every 6 hours) as needed.
3. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Erythromycin 5 mg/g Ointment Sig: One (1) in OU Ophthalmic
TID (3 times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) U Injection TID (3 times a day).
9. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day).
12. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
13. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Eight
(8) Puff Inhalation [**Hospital1 **] (2 times a day).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
15. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] PRN
() as needed for hemorroidal pain.
16. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 3
days: To be started [**2156-1-25**].
20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: (Pt to start on 3 days of prednisone at 5mg qd on
[**2155-1-24**], i.e. once these 2 days are over.).
21. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): Per attached sliding scale. The
need for this medication can be reevaluated after pt is off
steroids.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Principal:
1. Influenza Pneumonia.
2. Resiratory Failure.
3. Malignant Hypertension.
4. Hypernatremia.
5. Transient change in vision right eye, ? Amaurosis Fugax.
Secondary:
4. Paroxysmal Atrial Fibrillation.
5. Asthma.
6. Diverticulitis.
7. Hypercholesteremia.
8. Chronic Renal Insufficiency.
9. Systolic Heart Failure.
10. Mitral and Aortic Insufficiency.
11. S/P Left Hip Fracture.
12. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear.
13. Hypothyroidism.
14. Left Bundle Branch Block.
15. Two vessel coronary artery disease s/p stenting of the mid
LCX and origin LPDA.
Discharge Condition:
Stable and improved
Discharge Instructions:
Please call your doctor or return to the ER if you have any
fevers, chills, difficulty breathing, or chest pain.
.
Please take all your medications as directed.
Followup Instructions:
Dr. [**Last Name (STitle) **] is aware that you are going to [**Hospital3 **], and
when he receives the discharge paperwork, he will call you to
set up an appointment within a week.
|
[
"300.00",
"276.0",
"785.52",
"428.0",
"995.92",
"427.31",
"424.0",
"038.9",
"493.92",
"433.10",
"403.91",
"487.0",
"428.20",
"276.2",
"518.81",
"362.34",
"584.9",
"244.0",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.04",
"96.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14990, 15060
|
3532, 12575
|
293, 349
|
15699, 15720
|
2248, 3509
|
15929, 16114
|
1876, 1880
|
12912, 14967
|
15081, 15678
|
12601, 12889
|
15744, 15906
|
1895, 2229
|
220, 255
|
377, 1334
|
1356, 1754
|
1770, 1860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,973
| 147,319
|
27684
|
Discharge summary
|
report
|
Admission Date: [**2127-5-28**] Discharge Date: [**2127-5-31**]
Date of Birth: [**2080-2-23**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Demerol / Dilaudid
Attending:[**First Name3 (LF) 45556**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 47 yo female with h/o breast ca, thyroid ca, and
metastatic melanoma who is a code sepsis. Pt was in [**Hospital 478**]
clinic and noted to have a BP of 72/50 with a HR of 130, O2 sat
97 RA. Received 1 L NS in clinic. She was transferred to ED for
further w/u. In the ED VS on arrival were: BP: 84/p; HR: 120
.
She was given an additional 4 L NS and remained hypotensive to
the 90s systolic, and T was 101 rectally. She was started on
code sepsis and a central line (RIJ) was placed. She was given
1 gram of vancomycin IV, 1 g of ceftazadime IV, dexamethasone 4
mg IV, and one amp of D50 for glucose of 36-->135. She was given
an additional 3 L NS. Also given 1 amp calcium gluconate for a
calcium of 6.6.
.
Per pt, she says that up until three weeks ago she was feeling
quite well. She was admitted [**Date range (3) 67609**] for "chemo" unknown
type (DTFC). She has been feeling lightheaded and fatigued
since that time. No F/C/N/V. +decreased appetite and poor po
intake past 2-3 weeks. +wt loss 20 lbs over past 1-2 months. No
sore throat. No open sores. No BRBPR. No dysuria/cough. Per
husband, pt has been confused at times for the past few weeks.
Sometimes she will be with it, other times, will not know what
day of the week it is. No sick contacts.
Past Medical History:
1. Breast cancer- as above
2. Thyroid cancer- as above
3. Metastatic melanoma- as above
4. Hypothyroidism s/p thyroidectomy
Oncologic history: In [**2114**], pt was diagnosed with right breast
ductal carcinoma in situ. She is s/p a right mastectomy and
right axillary lymphadenectomy ([**Hospital **] Hospital). The lymph
nodes were negative per Dr. [**Last Name (STitle) 67610**] [**Name (STitle) **] note and tumor was HR
positive. She started tamoxifen in [**2118**]. In [**2122**], nodule on left
breast was present, bxd and consistent with recurrence of breast
ca. She had adriamycin/cytoxan, taxol, and then radiation
treatment and was on arimidex post-trt.
.
As part of her workup, she had a PET scan and she had uptake in
thyroid. She was eventually dxd with thyroid ca and is s/p
thyroidectomy and radioactive iodine.
.
Early [**2125**], mole on right upper back was noted to change in
color, size. In [**10-21**] she underwent biopsy which per notes was
c/w melanoma. She had local wide excision and sentinel lymph
node biopsy (negative). In [**1-20**], pt felt left axillary mammary
mass and subcutaneous nodule near former wide local excision. In
[**2-20**] PET scan showed uptake in mass in tissues along medial
border of right scapula, left and right axillae, and axillary
skeleton. A biopsy at [**Company 2860**] of left axillary mass in [**3-22**] c/w
metastatic melanoma. She also had a bone marrow biopsy [**12-19**] WBC
~100,000 which showed a leukomoid reaction.
Social History:
Married. Has two children, 2 children [**Doctor First Name **] 21 and [**Doctor First Name **] 19. No
smoking, drinking. Lives on [**Hospital3 **].
Family History:
F: stomach/throat cancer. Maternal cousins: 2 with breast
cancer. Of Irish Decent.
Physical Exam:
VS: T: 100.0; BP: 106/64; HR: 122; RR: 21; O2: 93 RA CVP 6
Gen: speaking slowly, hoarse voice in full sentences in mild
distress
HEENT: PERRLA 5-->4 left slightly bigger than right; dry MM;
conjunctiva pale; sclera anicteric. OP without sores, ? white
plaques
Neck: No LAD. JVD flat
CV: Tachycardic. S1S2. No M/R/G
Lungs: CTA b/l
Chest/BACK: Left axillary: protruding hard mass 8-10 cm
anteriorly extending to left upper back/scapula. +pain upon
palpation. Erythematous, only slightly warm. Limited ROM at left
shoulder. +scar left scapula ~7 cm.
Abd: NABS. Soft, NT, ND. No hepatomegaly. Midline scar from
pubis--> umbilicus.
Ext: No edema. DP 2+
Neuro: CN II-XII tested and intact. Thought it was "[**2116**]" and
"the 19th". Did not know where she was, though knew details
about family, diagnosis. Alert, conversational, goal directed.
Skin: extremely pale.
Pertinent Results:
[**2127-5-28**] 11:24PM TYPE-MIX PH-7.39
[**2127-5-28**] 11:24PM LACTATE-1.8
[**2127-5-28**] 11:24PM O2 SAT-73
[**2127-5-28**] 11:24PM freeCa-1.04*
[**2127-5-28**] 11:00PM GLUCOSE-70 UREA N-12 CREAT-1.0 SODIUM-139
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-22 ANION GAP-13
[**2127-5-28**] 11:00PM ALT(SGPT)-21 AST(SGOT)-37 LD(LDH)-485* ALK
PHOS-252* AMYLASE-14 TOT BILI-0.2
[**2127-5-28**] 11:00PM LIPASE-10
[**2127-5-28**] 11:00PM ALBUMIN-1.8* CALCIUM-6.7* PHOSPHATE-2.7
MAGNESIUM-1.5*
[**2127-5-28**] 11:00PM WBC-56.5* RBC-3.07*# HGB-9.4*# HCT-29.3*#
MCV-96 MCH-30.5 MCHC-32.0 RDW-14.9
[**2127-5-28**] 11:00PM PLT COUNT-184
[**2127-5-28**] 09:42PM COMMENTS-GREEN TOP
[**2127-5-28**] 09:42PM LACTATE-2.9*
[**2127-5-28**] 08:39PM COMMENTS-GREEN TOP
[**2127-5-28**] 08:39PM GLUCOSE-111* LACTATE-2.7*
[**2127-5-28**] 08:39PM O2 SAT-96
[**5-28**] CXR: No evidence of pneumonia.
.
[**2127-5-28**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2127-5-28**] 08:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2127-5-28**] 07:40PM CORTISOL-13.4
[**2127-5-28**] 07:28PM TYPE-[**Last Name (un) **] PO2-65* PCO2-41 PH-7.38 TOTAL CO2-25
BASE XS-0 COMMENTS-GREEN TOP
[**2127-5-28**] 07:28PM LACTATE-2.6*
[**2127-5-28**] 07:28PM HGB-7.9* calcHCT-24 O2 SAT-92
[**2127-5-28**] 06:23PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2127-5-28**] 06:23PM LACTATE-3.9*
[**2127-5-28**] 06:00PM GLUCOSE-37* UREA N-15 CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18
[**2127-5-28**] 06:00PM CALCIUM-6.4* PHOSPHATE-2.8 MAGNESIUM-1.6
[**2127-5-28**] 06:00PM WBC-66.5* RBC-2.39* HGB-7.4* HCT-22.5* MCV-95
MCH-30.9 MCHC-32.7 RDW-14.6
[**2127-5-28**] 06:00PM NEUTS-88* BANDS-8* LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2127-5-28**] 02:00PM PLT SMR-NORMAL PLT COUNT-264
[**2127-5-28**] 02:00PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-1+
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
[**2127-5-28**] 02:00PM NEUTS-93* BANDS-1 LYMPHS-2* MONOS-1* EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 PROMYELO-1*
[**2127-5-28**] 02:00PM WBC-90.2* RBC-3.03* HGB-8.9* HCT-27.0* MCV-89
MCH-29.4 MCHC-33.1 RDW-14.9
[**2127-5-28**] 02:00PM LD(LDH)-443*
[**2127-5-28**] 06:00PM PLT COUNT-218
Brief Hospital Course:
Ms. [**Known lastname **] is a 47 yo female with breast cancer, thyroid cancer,
and metastatic melanoma who presents to the ED hypotensive and
febrile.
.
Sepsis/hypotension: Ms. [**Known lastname **] came to a clinic appointment on
[**5-28**] and was found to have a BP of 72/50. She was given 1L of
fluid in the clinic and transferred to the ED. In the ED she
was given an additional 4L with minimal response in BP and was
found to be febrile to 101 rectally. A central line was placed
and she was started on a code sepsis. She was started
empirically on Cefepime and Vancomycin and given an additional
3L of NS. She was admitted to the MICU for monitoring and
sepsis workup. While in the unit she was afebrile and her blood
pressures remained stable (110s/60s). The source for the fever
remained unknown. A UA and CXR were negative and it was felt
that the likely etiology of her fever was an infectious process
around her left axillary mass. She was stable in the MICU and
was transferred to the floor for further evaluation. While on
the floor, antibiotics were changed to PO dicloxicillin to treat
skin flora. Her foley was d/c'd as she had good urine output
and her IJ was d/c'd to prevent infection. Blood and urine
cultures have remained negative during her hospitalization. She
has remained afebrile with stable BPs since transfer to the
floor.
.
Constipation: During her hospitalization, Ms. [**Known lastname **] noted that
it had been 2 weeks since her last bowel movement. She was
extrememely uncomfortable and was given a bowel regimen and
eventually a Fleet enema when the bowel regimen did not work.
This resulted in multiple loose stools with much relief to the
patient. Of note, on her way to the bathroom, she fell on her
bottom. She did not hit her head. PT evaluated the patient
before discharge.
.
Adrenal insufficiency: Ms. [**Known lastname **] had a history of hypotension
which responed to fluids, but would drop eventually again. A
cortisol stim test done in the MICU showed inadequate response
(13.4 to 19.5). She was started on hydrocortisone, 50 mg q6
hours and fludrocortisone, 0.5 mg daily. Adrenal insufficiency
may also have been the etiology of her hypoglycemia in the ED to
36 in the setting of decreased PO intake. BS improved throughout
the hospitalization. The patient will be discharged with
Hydrocortisone 30mg po q 8hours without Fludricortisone. The
patient has been instructed to continue replacement at the
current dose with taper to VNA by the patient's primary
oncologist. VNA services have been instructed to contact the
patient's Oncologist for these instructions.
.
Anemia: Ms. [**Known lastname 54886**] baseline hct at [**Hospital1 18**] had been in the mid
to upper 20s. She required 3 units pRBC in past and was mildly
guaiac positive per ED. During this admission she was
transfused one unit pRBC with a good response (up to 25.3 from
22.5). The patient's hematocrit has remained stable since that
time and no additional transfusions were needed.
.
Pain control: She was maintained on fentanyl patch for
comfort/pain despite the fact that it can lead to lower BPs, as
well as methadone per outpatient doses. She was hesitant to try
morphine during the hospitalization as this medication has led
to nausea/vomiting in past. Also, once transferred to the floor
she began to have more pain in her axilla. She was restarted on
outpatient tramadol with good response. She may require an
increased dose of fentanyl patch (from 25 to 50) or adding
fentanyl PRNs (or other med for breakthrough pain) as disease
progresses. Upon discharge, she noted that her pain was well
controlled on her outpatient regimen.
.
Breast cancer: Ms. [**Known lastname **] was taking aramedix as an outpatient.
This was held while in the hospital.
.
Hypothyroid: Hypothyroidism has remained stable. She was
continued on levoxyl per her outpatient dose.
.
Leukocytosis: The patient has had an elevated WBC 70-90K since
mid-[**Month (only) **]. She had a bone marrow biopsy to work this up in the
past which showed a leukemoid reaction.
.
Code Status: DNR/DNI. Code status was discussed with pt who is
clear that she would not want intubation/CPR/or shocks. Also
discussed with her husband who is in agreement.
Medications on Admission:
Arimidex
Levoxyl 137 mcg qday
Fentanyl patch 25 mcg
Methadone 2.5-5 mg q6 hr prn
Tramadol 50-100 mg prn
Ativan 0.5-1 mg prn
Discharge Medications:
1. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Methadone 5 mg Tablet Sig: 0.5-1 Tablet PO QID (4 times a
day) as needed for pain.
Disp:*120 Tablet(s)* Refills:*2*
3. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
4. Hydrocortisone 20 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours): Please take as prescribed until instructed to decrease
dose.
Disp:*135 Tablet(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*180 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*180 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for diarrhea.
Disp:*30 Tablet(s)* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary: Metastatic melanoma
Secondary:
Breast cancer
Thyroid cancer
Hypothyroidism s/p thyroidectomy
Discharge Condition:
Stable, patient going home with VNA bridge to hospice as
previously planned
Discharge Instructions:
Please take all medications as instructed.
Please make any outpatient appointments with your providers as
needed or desired. Please call your oncologist Dr. [**Last Name (STitle) **], at
([**Telephone/Fax (1) 67611**], to discuss any additionally needed follow up as
well as your hydrocortisone taper.
If you begin to experience increasing pain, shortness of breath
or any other concerning symptoms, please call Dr. [**Last Name (STitle) **] as
needed.
Followup Instructions:
Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 67611**] to
discuss any additionally needed follow up as well as plans for
hydrocortisone taper.
If you would like to set up an appointment with Dr. [**Last Name (STitle) 8448**],
please call [**Telephone/Fax (1) 30738**].
|
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icd9cm
|
[
[
[]
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[
"38.93"
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,333
| 155,027
|
30940
|
Discharge summary
|
report
|
Admission Date: [**2124-6-29**] Discharge Date: [**2124-7-28**]
Date of Birth: [**2047-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Weakness and Respiratory distress, OSH transfer for
[**Last Name (un) 4584**]-[**Location (un) **]-Syndrome
Major Surgical or Invasive Procedure:
Intubation
Abdominal Surgery with Colostoma and Hartmans pouch
PICC line
History of Present Illness:
Patient is a 76 M with history significant for HTN and colon CA
s/p resection 1 year ago, presented to OSH on [**6-22**] and was
transferred to [**Hospital1 18**] on [**2124-6-29**], intubated with a diagnosis of
[**First Name9 (NamePattern2) 30065**] [**Location (un) **] syndrome and has had a complicated hospital
course. He initially presented to the OSH on [**6-21**], after a fall
in the bathroom after which he noted bilateral lower and upper
extremity weakness and tingling. LP showed albuminocytologic
dissociation. EMG was consistent with polyneuropathy. He
received IVIG 30 mg x 4 (on [**5-31**], [**6-26**] and [**6-28**]) with
solumedrol 40mg IV premedication.
Past Medical History:
HTN
hyperlipidemia
colon ca s/p resection 1 year ago. No chemo/radiation.
s/p L total knee replacement
s/p R total hip replacement
Social History:
retired. lives with wife. formerly worked in paper processing.
No smoking, occasional alcohol, no drug use.
Family History:
non-contributory
Physical Exam:
Physical exam on admission:
VS: Temp: 99.8 BP: 177/86 HR:86 RR:16 O2sat 99%
AC 500x16, 40%, PEEp 5
general: intubated, alert, comfortable, NAD
HEENT: OG tube in place. PERLLA, EOMI, anicteric, no scleral
icterus, no sinus tenderness, MMM, no supraclavicular or
cervical lymphadenopathy, no jvd, no carotid bruits, no
thyromegaly or thyroid nodules
lungs: CTA b/l anteriorly
heart: heart sounds disatnt. RR, S1 and S2 wnl, no murmurs, rubs
or gallops appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema. L PICC in place
with out edema,
skin/nails: no rashes/no jaundice/no splinters
neuro: Alert. Intubated. Strength: UE: 3-4/5 b/l, LE: [**3-6**] b/l.
IN MICU:
Physical Exam:
VS: Temp: 103.1 Tc 100.6 BP: 107/47 HR:83 RR:26 O2sat 985 40%
trach collar.
general: resting in bed, awake, alert, with trach collar,
mouthing words, following commands.
HEENT: perrl, eomi, mmm
lungs: diffuse rhonchi b/l, good air movement throughout.
heart: rrr, no m/r/g
abdomen: soft, diffuse mild TTP, midline scar with staples
superiorly, roughly 5 cm open wound below umbilicus with packed
gauze.
skin/nails: no rashes/no jaundice/no splinters
neuro: Alert. Strength: UE: 3-4/5 b/l, LE: can barely wiggle
legs.
Pertinent Results:
LABS on admission:
WBC-7.5 HCT-40.4 MCV-93 RDW-14.1
NEUTS-82* BANDS-2 LYMPHS-4* MONOS-10 EOS-0 BASOS-1 ATYPS-1*
METAS-0
PT-13.4* PTT-45.9* INR(PT)-1.2*
Na 133, K 3.6, Cl 103, HCO3 21, BUN 19, Cr 0.7, Glu 108
CALCIUM-7.7* PHOSPHATE-2.1* MAGNESIUM-2.8*
LIPASE-101*
ALT(SGPT)-50* AST(SGOT)-41* LD(LDH)-169 ALK PHOS-55 AMYLASE-89
TOT BILI-0.5
.
LABS on discharge:
WBC-3.9* Hct-26.7* MCV-91 Plt Ct-247
Glucose-131* UreaN-7 Creat-0.5 Na-135 K-3.0* Cl-102 HCO3-27
AnGap-9
ALT-105* AST-85*
.
MICRO:
[**2124-7-20**] SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2124-7-20**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2124-7-23**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MRSA.
KLEBSIELLA PNEUMONIAE. PANSENSITIVE.
Radiology:
[**2124-7-26**] VIDEO OROPHARYNGEAL SWALLOW
Reason: please eval for aspiration
Final Report
INDICATION: 76-year-old man with difficulty swallowing, please
evaluate for
aspiration. No comparison is available.
TECHNIQUE: Fluoroscopic guidance was provided to the speech and
swallow
department. The patient was given various consistency of the
barium.
IMPRESSION: Post-swallowing, aspiration and penetration of thin
liquid that
responded to chin tuck movement.
Speach and swallow:
Date: [**2124-7-26**]
Signed by [**Last Name (NamePattern4) 57715**] [**Last Name (NamePattern1) 15102**], CCC-SLP on [**2124-7-26**]
Affiliation: [**Hospital1 18**]
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Thin liquid,
Nectar-thick
liquid, pureed consistency barium, one-half of a cookie coated
with barium and one barium pill were administered. Results
follow:
NOTE: THE EXAM WAS COMPLETED WITH THE PASSY MUIR SPEAKING VALVE
IN PLACE.
ORAL PHASE:
The oral phase was noted for mild-moderate deficits,
specifically
with regards to weakened base of tongue retraction via the
posterior pharyngeal wall during the swallow. This contributed
to
the vallecular residue appreciated and tongue pumping and
piecemeal behavior was noted. Additionally, mastication was
prolonged with the cookie and there was mild oral residue with
solids on the tongue. The pt cleared this with repeat swallows.
Otherwise bolus control, formation and oral transit were judged
to within functional limits.
PHARYNGEAL PHASE:
The pharyngeal phase was noted for mild-moderately reduced
hyolaryngeal excursion with mildly incomplete epiglottic
deflection. As a result, there was mild-moderate vallecular
residue for both solids and liquids.
The pharyngeal phase was otherwise judged to be within
functional
limits for a timely swallow initiation with adequate velar
elevation, laryngeal valve closure, pharyngeal transit time,
bolus propulsion, and pharyngoesophageal sphincter. The 13 mm
barium tablet did pass freely through the pharynx, esophagus and
to the stomach.
ASPIRATION/PENETRATION:
There was mild penetration after the swallow with thin liquids
due to spillover of residue into the laryngeal vestibule. This
was cleared with a cued cough.
There was mild/trace silent aspiration after the swallow with
thin liquids and nectar thick liquids due to spillover of
residue
into the airway. No reflexive cough was present, however cued
coughs were effective at eliminating subglottic aspirate
material.
TREATMENT TECHNIQUES:
A chin tuck maneuver was effective at eliminating aspiration by
significantly decreasing pharyngeal residue. The pt only
required
two swallows to clear residue from sips or bites vs [**5-5**] swallows
just for a teaspoon of liquid.
SUMMARY:
Mr. [**Known lastname 73145**] presents with a mild-moderate oropharyngeal
dysphagia primarily characterized by decreased tongue propulsion
and hyolaryngeal excursion which contributed to pharyngeal
residue and trace silent aspiration after the swallow with thin
and thick liquids. However, aspiration was prevented with the
use
of a chin tuck maneuver combined with double swallows for bites
and sips. The pt was able to swallow the pill whole for today's
examination, but it was difficult for him to combine this with
the chin tuck maneuver. As such, I would recommend the pt be
advanced to a ground solid, thin liquid po diet texture with
aspiration precautions. Additionally, pills should be given
whole
with puree textures, using the chin tuck. Aspiration precautions
and 1:1 assistance will be required at all meals.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4.
RECOMMENDATIONS:
1. Advance to a po diet texture of ground solids, thin liquids
with aspiration precautions. Additionally, pills should be given
whole with puree textures, using the chin tuck.
2. Pt will need to perform a chin tuck and swallow twice for
every bite and sip.
3. Aspiration precautions and 1:1 assistance will be required
at
all meals.
These recommendations were shared with the patient, the nurse
and
the medical team.
Brief Hospital Course:
[**Last Name (un) 4584**] [**Location (un) **] complicated by respiratory failure, s/p
tracheostomy: He completed a course of IVIG prior to transfer to
[**Hospital1 18**]. Despite the use of IVIG, his NIF continued to decline and
he required intubation. Given his progressive decline, he was
transferred to [**Hospital1 18**] for further evaluation. Neurology has
followed him throughout his hospitalization. He was initially on
the [**Hospital Unit Name 153**] service from [**2124-6-29**] until [**2124-7-9**]. Multiple attempts
were made to liberate him from the ventilator, however he
continued to have respiratory muscle weakness and was unable to
pass RSBI/SBT. He remained intubated so underwent trach
placement on [**7-11**]. He also underwent bronch on [**7-11**] which
revealed a large mucous plug in the R mainstem. The patient has
improving muscle strength and respiratory efforts. He was
successfully weaned to trach collar on [**7-20**]. He was transfered
from MICU to the inpatient medical service on [**2124-7-22**]. On the
floor he remained on trach mask (with intermittent trials of
breathing on RA). Patient's paralysis has continued to improve
although patient has not recovered fully yet. Pt received
physical therapy throughout his hospitalization.
Pneumonia, aspiration and ventilator-associated pneumonia,
Klebsiella and MRSA: He then developed increased secretions and
either aspiration vs. ventilator-associated pneumonia and was
treated with ceftriaxone and vancomycin. Pt's PNA is currently
being treated with Vancomycin and Ceftriaxone (started on
[**2124-7-22**]) through his PICC line which was placed on [**2124-7-27**]. At
the time of discharge, his secretions had turned from green to
white, they thinned, and his oxygenation needs remained stable.
Intestinal perforation: On [**2124-7-9**], he developed an acute
abdomen with free air under the diaphragm and was taken for
ex-lap by the surgery team. At the time of surgery, he was found
to have a perforation at the site of previous colonic
anastomosis. It was repaired with sigmoid resection and
formation of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pouch. He was subsequently managed by the
SICU team. He continued on antibiotics post-op and did well.
HTN: His hypertension was stable over the course of his stay.
Transaminitis, gall bladder edema: His liver function tests were
elevated throughout most of his hospital course and it was felt
to likely be due to GBS. His statin was stopped as a result and
it can be restarted as an outpatient.
Medications on Admission:
Medications on transfer:
Atorvastatin 40
Captopril 25 TID
Toprol 25
Solumedrol 40 mg w/ IVIG
IVIG 30 mg x 4
Naprosyn 500 [**Hospital1 **]
Lovenox 40 SC qday
protonix 40 IV qday
procel 3 scoops daily
Vancomycin 1000 [**Hospital1 **] (started [**6-27**])
Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 7 days.
2. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 7 days.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP <90, HR <55.
4. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
Q24H (every 24 hours).
5. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
treatment Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
19. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q8H (every 8 hours).
20. Insulin Lispro (Human) 100 unit/mL Solution Sig: variable
units Subcutaneous ASDIR (AS DIRECTED): As per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Primary diagnosis:
[**First Name9 (NamePattern2) 30065**] [**Location (un) **] syndrome
UTI
Pneumonia
Bowel perforation
Peritonitis
Wound dehiscence
Transaminitis
.
Secondary diagnosis:
HTN
Hypercholesterolemia
Discharge Condition:
Stable. O2 sats stable on 40% TM. Afebrile.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for further management of [**First Name9 (NamePattern2) 30065**]
[**Location (un) **] syndrome. You were intubated and eventually needed
tracheostomy due to inability to wean from the ventilator. You
also developed a bowel perforation and underwent surgery for
repair of the perforation. Your sigmoid colon was resected and
an end colostomy was formed, with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pouch. You had a
wound dehiscence which is now stable. You were treated with
antibiotics for a UTI, pneumonia and peritonitis. You will
remain on antibiotics for another 7 days.
.
Please take all your medications as prescribed.
.
Please keep all of your follow-up appointments.
.
Please call your PCP or go to the nearest ER if you have any of
the following symptoms: fever, chills, shortness of breath,
difficulty breathing, worsening secretions, nausea, vomiting,
diarrhea, abdominal pain, distension, swelling in your legs,
urinary symptoms, worsening weakness or any other worrisome
symptoms.
Followup Instructions:
Please call Neurology for a follow up appointment in 10 weeks.
You can make an appointment with either Dr. [**First Name (STitle) **] or Dr.
[**Last Name (STitle) 575**]. The number for the [**Hospital 878**] Clinic is [**Telephone/Fax (1) 29128**].
.
Please follow up with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] (surgery) on [**2124-8-10**] at
2:30pm. Dr.[**Name (NI) 15146**] office is in [**Last Name (NamePattern1) **]., [**Hospital Unit Name 3269**], [**Hospital Unit Name **] at [**Hospital1 69**].
Please call his office at ([**Telephone/Fax (1) 2537**] if you have any
questions or need to reschedule.
.
Please follow up with your PCP 2-4 weeks after discharge from
rehab.
|
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icd9cm
|
[
[
[]
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[
"96.6",
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"99.04",
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icd9pcs
|
[
[
[]
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12818, 12870
|
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|
424, 498
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1500, 1518
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526, 1204
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12910, 13056
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2832, 3154
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10532, 10762
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1226, 1359
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1375, 1484
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,845
| 137,592
|
49921
|
Discharge summary
|
report
|
Admission Date: [**2128-7-8**] Discharge Date: [**2128-7-17**]
Date of Birth: [**2052-7-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ace Inhibitors
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Angioedema
Major Surgical or Invasive Procedure:
Nasogastric intubation
Mechanical Ventilation
PICC line placed
History of Present Illness:
Ms [**Known lastname 805**] is a 75 year old woman with past medical history
significant for hypertension, rheumatoid arthritis, lupus,
diabetes, presenting with sudden onset of tongue swelling.
.
Per report, patient was sleeping and woke up noticing her tongue
was very swollen. Patient was brought to ED for evaluation.
On arrival, 97.8, BP 210/palp, HR 88, RR 20, 100% RA. Patient
received diphenhydramine 50mg IV, solumedrol 125mg IV, and
famotidine 20mg IV. 2 units of FFP were also ordered but not
given as patient did not respond to above and required emergent
nasal intubation in the OR with surgical backup.
Anethesia was able to intubate nasally under fiberoptic
guidance. Patient was sedated with Ketamine 40mg, Propofol 100mg
and Midazolam 2mg. She also received 10mg IV Labetalol. Blood
pressure at beggining of the case was 220/136. Per their notes
significant edema aroudn cords and posterior oropharinx was
noted.
.
Review of systems:
Can not be obtained as patient is intubated
Past Medical History:
#. DM2- diagnosed [**2118**]
#. Rheumatoid arthritis - diagnosed at age 50; [**Doctor First Name **] 1:1280 -
followed by Dr. [**Last Name (STitle) 6426**]; on chronic steroids
#. Osteoarthritis
#. Possible SLE, discoid lupus since [**2121**] with a positive right
sided lymph node biopsy recently
#. Left renal mass detected in [**2121-8-4**] - pt doesn't want
further w/u
#. Anemia - Normocytic in past
#. Asthma
#. Hypertension - TTE [**6-10**] - EF >60%. Mild AR
#. History of low back pain
#. C. diff colitis with recurrence 8 and [**10-9**]
#. Hypothyroidism
#. ?Cecal Mass on CT - [**Last Name (un) **] [**6-10**] negative. CEA 5.7
Social History:
Drugs: None
Tobacco: None
Alcohol: None
Other: The patient currently lives at home with her daughter
[**Name (NI) 104271**] [**Name (NI) 805**] ([**Telephone/Fax (1) 104272**]), also HCP. The patient at
baseline walks with a cane or a walker. She feeds herself but
has meals prepared, requires assistance with dressing and
bathing
Family History:
No history of angioedema
Father had DM, CAD, HTN.
No cancer or stroke in family.
Physical Exam:
ADMISSION PHYSICAL:
General Appearance: Well nourished, sedated
Eyes / Conjunctiva: Very large protruding tongue
Head, Ears, Nose, Throat: Endotracheal tube
Lymphatic: Cervical WNL
Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (Murmur:
Systolic, Diastolic), II/VI systolic murmur at left base, II/VI
diastolic murmur at RUSB to apex
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: ), Transmitted upper airway sounds
Abdominal: Soft, Bowel sounds present
Extremities: Right: 2+, Left: 2+
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
DISCHARGE PHYSICAL:
HEENT: normal appearing tongue
Pertinent Results:
[**2128-7-8**] 03:26AM WBC-5.9 RBC-3.66*# HGB-10.5*# HCT-33.1*#
MCV-90# MCH-28.8 MCHC-31.9 RDW-16.8*
[**2128-7-8**] 03:26AM NEUTS-45.9* LYMPHS-45.3* MONOS-7.0 EOS-1.3
BASOS-0.5
[**2128-7-8**] 03:26AM PLT COUNT-185
[**2128-7-8**] 03:26AM PT-14.0* PTT-26.4 INR(PT)-1.2*
[**2128-7-8**] 03:26AM GLUCOSE-81 UREA N-45* CREAT-2.3* SODIUM-141
POTASSIUM-3.9 CHLORIDE-113* TOTAL CO2-19* ANION GAP-13
.
Labs during hospitalization:
[**2128-7-9**] 02:44AM BLOOD ESR-70*
[**2128-7-9**] 02:44AM BLOOD TSH-0.27
[**2128-7-9**] 02:44AM BLOOD C3-70* C4-13
[**2128-7-16**] 05:57AM BLOOD Vanco-20.4*
.
Labs on discharge:
[**2128-7-17**] 05:30AM BLOOD WBC-9.6 RBC-2.88* Hgb-8.2* Hct-26.2*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.2* Plt Ct-128*
[**2128-7-17**] 05:30AM BLOOD Glucose-100 UreaN-47* Creat-1.8* Na-142
K-3.9 Cl-110* HCO3-23 AnGap-13
[**2128-7-17**] 05:30AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.0
.
Micro:
[**2128-7-10**] enterococcus UTI sensitive to vancomycin
[**2128-7-11**] enterococcus UTI
[**2128-7-12**], [**2128-7-14**], [**2128-7-16**] Ucx negative
.
Blood cx [**2128-7-12**] and [**2128-7-13**] No growth.
.
[**2128-7-10**] 11:35 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2128-7-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
CONSISTENT WITH HAEMOPHILUS SPECIES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SUGGESTING HEMOPHILUS. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
__________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2128-7-10**] 2:15 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2128-7-16**]):
STAPH AUREUS COAG +.
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2128-7-12**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2128-7-9**] 02:44AM BLOOD C3-70* C4-13
.
[**2128-7-9**] 11:25PM BLOOD C3D CIRCULATING IMMUNE COMPLEXES-Test
Test Result Reference
Range/Units
C3D IMMUNE COMPLEX 18 H 0-8 NEGATIVE
MCG/ML
.
[**2128-7-9**] 02:44AM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-Test
Test Result Reference
Range/Units
C1 INHIBITOR, FUNCTIONAL >100 %
REFERENCE RANGE:
>=68 NORMAL
41-67 EQUIVOCAL
<=40 ABNORMAL
LESS THAN 40% OF THE REFERENCE FUNCTIONAL ACTIVITY INDICATES
A LIKELY DIAGNOSIS OF HEREDITARY ANGIOEDEMA OR ACQUIRED C1
INHIBITOR DEFICIENCY.
.
[**2128-7-9**] 02:44AM BLOOD
THYROTROPIN-BINDING INHIBITORY IMMUNOGLOBULIN (TBII)
Test Result Reference
Range/Units
TBII <6.0 <=16.0 %
REFERENCE RANGE: <=16% INHIBITION
.
[**2128-7-9**] 02:44AM BLOOD RAST-Allergen
RAST
Allergen, Ige %ASM [**Doctor Last Name **]/L
Specific IgE
Allergen for Wheat 32 <.35
Undetectable
Allergen for Peanut 9 <.35
Undetectable
Allergen for Chicken 13 <.35
Undetectable
.
CXR [**2128-7-8**]
SINGLE SEMI-ERECT PORTABLE CHEST RADIOGRAPH: An endotracheal
tube has been
inserted with tip 3.6 cm from the carina. The heart is again
enlarged.
Mediastinal and hilar contours are unchanged. There is no focal
consolidation, large effusion or pneumothorax. Pulmonary
vasculature is
grossly normal. Again seen is S-shaped scoliosis.
IMPRESSION: Endotracheal tube in standard position.
.
CXR [**2128-7-11**]
REASON FOR EXAMINATION: Followup of a patient with angioedema.
Portable AP chest radiograph was compared to prior study
obtained on [**2128-7-10**].
The ET tube tip is 5.2 cm above the carina. The right internal
jugular line
tip is at the low SVC/cavoatrial junction. The cardiomediastinal
silhouette
is stable. Minimal increase in left basal opacity is noted that
might be
consistent with atelectasis/aspiration, although developing
infectious process cannot be excluded. Attention to this area on
the subsequent radiographs is recommended.
.
CXR [**2128-7-12**]
FINDINGS: As compared to the previous radiograph, the
nasogastric tube has
been removed. The endotracheal tube and the right-sided central
venous access line are unchanged. The pre-existing blunting of
the left costophrenic angle is now resolved, unchanged extent of
the retrocardiac atelectasis. Unchanged moderate cardiomegaly
without signs of overhydration. Marked asymmetry caused by
scoliosis of the thoracic spine.
.
CXR [**2128-7-13**]:
REASON FOR EXAM: Assess left PICC.
Left PICC tip is in the upper SVC. Right IJ catheter tip remains
in place. Cardiomegaly is stable. The lungs are clear. There is
no pneumothorax or enlarging pleural effusions.
.
CXR [**2128-7-16**]:
IMPRESSION: AP chest compared to [**7-13**]:
Severe cardiomegaly is chronic. Small right pleural effusion has
increased
since [**7-13**] and pulmonary vasculature is mildly engorged but
there is no
pulmonary edema.
Brief Hospital Course:
Hospital course:
1) Angioedema: Pt arrived with angioedema. She was intubated via
nasopharyngeal intubation in the OR on arrival. In the MICU,
she was kept on mechanical ventilation until upper airway edema
decreased and vocal cords could be visualized. Allergy was
consulted and recommended IV steroids, IV famotidine, and IV
diphenhydramine. Also, several allergy labs were sent, including
RAST to foods, C1 esterase, C3/C4, and TBII (see results section
for details). Her angioedema improved, and she was successfully
extubated on [**2128-7-12**]. Speech and Swallow consult was completed
and patient able to tolerate foods however the patient preferred
to stay on a soft dysphagia diet. Her prednisone was tapered q3
days down from prednisone 60mg daily. She received prednisone
40mg daily the day of discharge. She need to receive prednisone
20 mg daily x3 days in rehab and then she should be maintained
on prednisone 10mg daily which is her home dose for her RA. She
should avoid [**Last Name (un) **]/ACE-I in the future given possibility of
contribution to angioedema. Her meloxicam was also discontinued
in case it can cause angioedema. Her tongue was not swollen at
discharge. She was tolerating aspirin while in the hospital.
She should follow up with allergy as an outpatient.
2) Hypertension: Hypertensive on arrival to MICU. In the MICU
her HTN was controlled with IV labetalol and hydralazine
alternating. Once patient able to start po after extubation,
she was restarted on her home beta blocker and CCB. Her
nifedipine CR was titrated up to 120mg daily. We tried to
increase her metoprolol to 50XL daily but this caused increased
wheezing so she was decreased back to metoprolol 25XL daily. She
should avoid [**Last Name (un) **]/ACE-I in the future given possibility of
contribution to angioedema. Her blood pressure should be
closely monitored at rehab.
3) Urinary Tract Infection: UCx with vancomycin susceptible
enterococcus. Treatment was with vancomycin.
4) Ventilator Associated Pneumonia: While on ventilator, she
developed leukocytosis, infiltrate on CXR and sputum 4+ for GPC
in pairs and clusters which ultimately grew MSSA and 2+ GNR
consistent with haemophilus. She was started vancomycin and
levofloxacin (allergic to PCN). Her last dose of levofloxacin is
[**2128-7-22**] and her last dose of vancomycin is [**2128-7-23**]. When these
antibiotics are completed she should have her CBC, chem 7, and
LFTs checked.
5) 1/4 bottles GPC: She should complete a 14 day course of
vancomcyin with last dose on [**2128-7-23**]. She had a PICC line
placed.
6) Rheumatoid arthritis/lupus: On chronic prednisone 10mg po
daily at baseline which was held while on high dose IV
solumedrol. She will need to receive prednisone 20 mg daily x3
days in rehab for her angioedema and then she should be
maintained on prednisone 10mg daily which is her home dose for
her RA. Her meloxicam was discontinued since it could cause
angioedema. She was started on tylenol for RA pain. Her
angioedema was not felt to be related to her lupus. She should
follow up with rheumatology.
7) OA: calcium/vit D was held while patient is on levofloxacin
and should be restarted when levofloxacin is completed.
8) Diabetes: Continue SSI.
9) Code: Full confirmed with patient
10) Dispo: to rehab for PT
Medications on Admission:
1. Aspirin 81 mg Tablet daily
2. Acetaminophen 325 mg PRN
3. Metoprolol Succinate 25 mg Tablet daily
4. Losartan 100 mg daily
5. Clonidine 0.2 mg/24 hr Patch every Tuesday
6. Nifedipine 60 mg daily
7. Simvastatin 10 mg daily
8. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit Capsule
9. Senna 8.6 mg Tablet at bedtime
10. Levothyroxine 50 mcg
11. Prednisone 10 mg Tablet
12. Docusate Sodium 100 mg Capsule
13. Pantoprazole 40 mg Tablet daily
14. Potassium Chloride 20 mEq Tab
15. Meloxicam 7.5 mg Tablet Sig: 1-2 Tablets PO once a day
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stool.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime: hold
for loose stool.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing/sob.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
9. 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.
10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day: can stop once patient is ambulating
regularly.
12. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 5 days: last day [**2128-7-22**].
13. insulin
as per attached sliding scale, check finger sticks qachs
14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for
3 days: starting [**2128-7-18**].
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**7-21**].
16. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
17. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
19. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 6 days: last dose [**2128-7-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
-Angioedema
-Enterococcus urinary tract infection
-MSSA pneumonia
.
Secondary diagnosis:
-DM2
-Rheumatoid arthritis
-Osteoarthritis
-Possible SLE, discoid lupus since [**2121**] with a positive right
sided lymph node biopsy recently
-Left renal mass detected in [**2121-8-4**]
-Anemia
-Asthma
-Hypertension - TTE [**6-10**] - EF >60%. Mild AR
-History of low back pain
-C. diff colitis with recurrence 8 and [**10-9**]
-Hypothyroidism
-Cecal Mass on CT - [**Last Name (un) **] [**6-10**] negative. CEA 5.7
.
Please tell the doctors at rehab if you develop swelling of the
tongue, difficulty swallowing, chest pain, headache, diarrhea,
blood in the stool, shortness of breath, wheezing, or any new
concerning symptom.
Discharge Condition:
Stable satting fine on room air.
Discharge Instructions:
You were admitted with a swollen tongue (a condition called
angioedema) and you required intubation. You were given high
dose steroids and are slowly being tapered off the steroids to
your original home steroid dose. You should no longer take
valsartan as this could have caused your tongue to swell. You
also developed pneumonia and a urinary tract infection and are
on vancomycin and levfloxacin to treat those infections. It is
very important that you complete your course of steroids and
antibiotics.
.
Please take all medications as detailed on the attached sheet.
.
The following medications were discontinued:
-losartan- should not be restarted as it could lead to
angioedema (tongue swelling)
-meloxicam was stopped in case it could be related to your
angioedema
-calcium and vitamin D combo pill were held because you are on
levofloxacin this can be restarted after you are done with
levofloxacin
.
The following medications were started:
-you were changed from pantoprazole to famotidine
-levofloxacin for pneumonia
-vancomycin for pneumonia and urinary tract infection
-insulin sliding scale while on increased prednisone dose
.
The following medications were increased:
-prednisone increased dose for 3 more days
-nifedipine increased since we stopped losartan
-acetaminophen increased for pain
Followup Instructions:
Neurology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2128-7-29**] 12:30
Allergy: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2128-8-2**]
10:30
Completed by:[**2128-8-2**]
|
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"599.0",
"714.0",
"493.90",
"707.22",
"041.11",
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"707.03",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"31.42",
"96.72"
] |
icd9pcs
|
[
[
[]
]
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14920, 14990
|
9020, 9020
|
321, 385
|
15770, 15805
|
3369, 3961
|
17162, 17478
|
2437, 2520
|
12933, 14897
|
15011, 15011
|
12366, 12910
|
9038, 12340
|
15829, 17139
|
2535, 3350
|
4854, 8997
|
1364, 1409
|
271, 283
|
3980, 4819
|
413, 1345
|
15119, 15749
|
15030, 15098
|
1431, 2072
|
2088, 2421
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,606
| 108,638
|
1537
|
Discharge summary
|
report
|
Admission Date: [**2151-11-13**] Discharge Date: [**2151-11-25**]
Date of Birth: [**2072-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 9006**] is a 79yo Cantonese man (nonverbal at baseline) with
h/o severe dementia, several aspiration pnas, frequent UTIs who
was recently discharged from our hospital in [**Month (only) 359**] during
which time he was treated for Cdiff, UTI with yeast, and
aspiration pna with Zosyn. He presents today from his nursing
home with shortness of breath and dark urine. According to the
patient's grandson, who saw him yesterday, he looks much worse
today than he did at that time. He just finished treatment for
Cdiff with flagyl and po vanco, which was just stopped and by
report diarrhea worsened after discontinuing. It is also unclear
by his records whether he remains on or has just stopped zosyn
and vanco iv for aspiration pna. Culture data in our computer is
unrevealing except for urine repeatedly positive for yeast.
.
On arrival to our ER he was found to have new hypernatremia to
159 and to be tachycardic between 114-150 (last d/c summary
shows pt was tachycardic from 90s-110s throughout entire last
admission). He had O2 sat 81% on RA and required nonrebreather
mask in the ER for O2 sat 100%. His white count was 20, which is
stable from his last admission. He was given vancomycin 1g iv,
levofloxacin 500mg and flagyl 500mg. He was started on D5 1/2NS
at 150cc/hr. Blood and urine cultures were sent.
.
After a long discussion with his family (by the ER resident, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) they decided to continue his DNR/DNI status but
otherwise want him treated as needed. They will revisit this
after seeing if he stabilizes in a few days (versus possible
change to CMO). He was admitted to the ICU for increased nursing
needs.
Past Medical History:
- severe dementia, nonverbal at baseline
- subdural hematoma
- HTN
- chronic indwelling foley, s/p frequent UTIs
- Gtube, s/p several asp pnas
- BPH
- stage IV sacral decub
- MRSA wound infection
- osteoarthrosis
- dysphagia
- DM2
- PUD
Social History:
lives in nursing home. has 2 sisters, son-in-law, grandson who
are very involved. no etoh or tobacco. wife and several
children, most of whom are Cantonese-speaking only.
Family History:
noncontributory
Physical Exam:
109, 105/80, RR 24, 100% on NRB
gen: minimally responsive, opens eyes to shouting, cachectic
HEENT: PERRL, MM dry, mouth breathing, eyes and cheeks sunken
Neck: JVP 3-4cm, no LAD
Cor: s1s2, tachy, regular rhythm, no r/g/m
Pulm: CTAB, dcreased BS on R compared to L
Abd: soft, cachectic, NT, +bs, Gtube in place
guaiac neg in ER
Ext: no c/c/e, w/w/p
Skin: notable breakdown on medial surfaces of both knees, at top
of R ear, large sacral decub stage 4
Pertinent Results:
CHEST (PORTABLE AP) [**2151-11-13**] 7:13 PM
AP UPRIGHT CHEST: Tip of a right PICC terminates in the distal
SVC. Heart, mediastinal structures are unremarkable and stable.
Nodular density previously noted in the right mid lung not well
appreciated. Basilar consolidations, right greater than left,
improved in comparison to the prior study. There is persistent
prominence of the pulmonary central vasculature representing
volume overload. No pneumothorax is identified.
Improving bibasilar consolidations. Mild pulmonary interstitial
edema.
.
CHEST (PORTABLE AP) [**2151-11-14**] 5:49 AM
There has been improvement in the right-sided aspiration
pneumonia. Changes in the left chest remain unaltered.
IMPRESSION: Some improvement in right lower lobe pneumonia.
.
CHEST (PORTABLE AP) [**2151-11-17**] 12:32 AM
Bilateral pulmonary opacities markedly asymmetric with left
predominance could represent either widespread pneumonia or
asymmetric pulmonary edema. Clinical correlation is needed.
.
CHEST XR: [**2151-11-23**]
There are bilateral effusions with a left lower lobe opacity,
which may represent atelectasis or pneumonia. There are also
similar bilateral diffuse parenchymal opacities, which are
predominantly basilar. There is no cardiac enlargement or upper
zone redistribution of the pulmonary vessels. There is also a
more nodular density seen in the left upper lung zone as well,
perhaps an early consolidation
.
CHEST CT: [**2151-11-24**]
Bilateral smoothly layering fluid density pleural effusions,
without evidence of loculation, but with compressive
atelectasis.
2. Centrilobular emphysema.
3. Low-density lesion within the liver dome, likely represents a
simple cyst. A left well-characterized lesion in the pancreatic
head is also seen. MRI or multiphasic CT is recommended for
further evaluation if indicated
.
EKG: [**11-24**]
Sinus tachycardia. Non-specific ST-T wave changes. Compared to
the previous tracing lateral T wave inversion is new
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-11-25**] 06:48AM 23.9*
[**2151-11-24**] 03:54PM 11.5* 2.32* 7.6* 22.5* 97 32.7* 33.6
18.8* 3851
1 VERIFIED BY SMEAR
SOME LARGE PLATELETS NOTED ON SMEAR
[**2151-11-24**] 05:12AM 23.9*
[**2151-11-24**] 02:11AM 25.0*
[**2151-11-21**] 06:07AM 10.8 2.65* 8.3* 25.6* 97 31.4 32.5 18.4*
539*
[**2151-11-20**] 06:07AM 10.2 2.55* 8.2* 24.5* 96 32.2* 33.5 18.0*
570*
[**2151-11-18**] 05:02AM 9.4 2.39* 7.7* 22.7* 95 32.0 33.8 17.7*
577*
RECEIVED THE SPECIMENS IN THE ROUTINE BAG NOW.
[**2151-11-17**] 08:40AM 9.8 2.59* 8.3* 24.3* 94 32.0 34.1 17.4*
543*
[**2151-11-16**] 02:49AM 9.9 2.51* 7.9* 23.0* 92 31.6 34.3 17.3*
546*
[**2151-11-15**] 03:44PM 22.0*
[**2151-11-15**] 04:27AM 10.9 2.44*# 7.4*# 23.0* 94 30.3 32.1
17.5* 517*
[**2151-11-15**] 02:35AM 21.8*
[**2151-11-14**] 02:04PM 20.8*
[**2151-11-14**] 03:30AM 13.1* 1.73* 5.4* 17.2* 100* 31.0 31.2
17.1* 527*
[**2151-11-13**] 06:35PM 20.3* 2.13* 6.6* 21.2*1 100* 31.0 31.1
17.0* 674*
1 CRITICAL RESULT CALLED TO DR. [**Last Name (STitle) 96**] IN EW AT [**2090**]
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2151-11-17**] 08:40AM 76.6* 20.1 2.4 0.8 0.1
[**2151-11-16**] 02:49AM 86.5* 0 11.3* 1.7* 0.5 0.1
[**2151-11-13**] 06:35PM 76.9* 20.4 1.7* 0.5 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Macrocy
[**2151-11-17**] 08:40AM 1+ 1+
[**2151-11-13**] 06:35PM 3+ 1+ 2+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2151-11-24**] 03:54PM 3851
1 VERIFIED BY SMEAR
SOME LARGE PLATELETS NOTED ON SMEAR
[**2151-11-21**] 06:07AM 539*
[**2151-11-20**] 06:07AM 570*
[**2151-11-18**] 05:02AM 577*
RECEIVED THE SPECIMENS IN THE ROUTINE BAG NOW.
[**2151-11-17**] 08:40AM 543*
[**2151-11-17**] 08:40AM 13.6* 28.5 1.2*
[**2151-11-16**] 02:49AM 546*
[**2151-11-15**] 04:27AM 517*
[**2151-11-14**] 03:30AM 527*
[**2151-11-13**] 06:35PM 674*
[**2151-11-13**] 06:35PM 13.3* 27.0 1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-11-25**] 06:48AM 126* 28* 0.8 141 3.9 108 26 11
[**2151-11-24**] 05:12AM 129* 30* 0.8 142 4.0 108 25 13
[**2151-11-23**] 08:59AM 122* 32* 0.9 144 3.7 111* 31 6*
[**2151-11-22**] 07:10AM 123* 30* 0.8 144 3.8 111* 26 11
[**2151-11-21**] 06:07AM 128* 31* 0.9 147* 3.6 113* 25 13
[**2151-11-20**] 06:07AM 123* 30* 0.9 147* 3.7 115* 25 11
[**2151-11-18**] 05:02AM 111* 29* 0.9 144 3.8 112* 24 12
RECEIVED THE SPECIMENS IN THE ROUTINE BAG NOW.
[**2151-11-17**] 08:40AM 114* 29* 0.9 144 4.21 115* 20* 13
SLIGHTLY HEMOLYZED
1 HEMOLYSIS FALSELY ELEVATES K
[**2151-11-16**] 02:49AM 105 33* 0.9 139 3.5 109* 22 12
[**2151-11-15**] 03:44PM 141
[**2151-11-15**] 04:27AM 128* 39* 1.0 146* 4.0 114* 22 14
[**2151-11-15**] 02:35AM 147*
[**2151-11-14**] 02:04PM 115* 48* 0.9 150* 3.7 119* 23 12
[**2151-11-14**] 03:30AM 120* 55* 1.0 157*1 4.0 124*1 24 13
1 VERIFIED BY REPLICATE ANALYSIS
NOTIFIED [**Doctor First Name **] AT 0500 [**2151-11-14**]
[**2151-11-13**] 06:35PM 137* 63* 1.2 159*1 4.8 124*1 27 13
1 VERIFIED BY REPLICATE ANALYSIS
NOTIFIED A.[**Doctor Last Name **],11.18.06,7.45P
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2151-11-23**] 08:59AM Using this1
1 Using this patient's age, gender, and serum creatinine value
of 0.9,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2151-11-23**] 08:59AM 8.0* 3.3 1.9
HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF
[**2151-11-14**] 03:30AM 68* 698 17.3 1678* 52*
LAB USE ONLY RedHold
[**2151-11-13**] 06:35PM HOLD
Blood Gas
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2151-11-13**] 06:56PM 1.2
Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2151-11-23**] 05:30PM Straw Hazy >=1.035
[**2151-11-18**] 07:26PM Yellow Clear 1.012
[**2151-11-13**] 06:55PM Yellow Hazy 1.018
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2151-11-23**] 05:30PM LG NEG NEG NEG NEG NEG NEG 6.5 TR
[**2151-11-18**] 07:26PM LG NEG NEG NEG NEG NEG NEG 5.0 TR
[**2151-11-13**] 06:55PM LG POS 30 NEG TR NEG NEG 5.0 MOD
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2151-11-23**] 05:30PM 21-50*1 0-2 OCC NONE 0
1 CORRECTED RESULT, PREVIOUSLY REPORTED AS 0-2
NOTIFIED [**Name8 (MD) **], RN AND [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] AT 8PM [**2151-11-23**]
[**2151-11-18**] 07:26PM 21-50* [**6-5**]* FEW NONE 0
[**2151-11-13**] 06:55PM [**11-15**]* [**6-5**]* MOD MANY 0-2
URINE CASTS CastGr
[**2151-11-13**] 06:55PM 0-2 COARSE GRANULAR CASTS
Chemistry
URINE CHEMISTRY Hours Creat Na
[**2151-11-13**] 09:00PM RANDOM 41 50
CATHETER
[**2151-11-13**] 09:00PM RANDOM
CATHETER
OTHER URINE CHEMISTRY Osmolal
[**2151-11-13**] 09:00PM 464
CATHETER
LAB USE ONLY, URINE Uhold
[**2151-11-13**] 09:00PM HOLD
.
Urine [**11-13**]: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
2ND ISOLATE. <10,000 organisms/ml
Urine [**11-25**]: No growth
.
Blood culture [**11-13**] x2: No growth
Blood Culture [**11-23**] x2: Pending
.
Stool culture (C.diff screen) [**11-14**], [**11-15**], [**11-16**]: C.diff toxin
negative
.
MRSA screen [**11-15**]: (+)MRSA, (+)VRE
.
Brief Hospital Course:
79yo man male with recurrent Urinary tract infections,
aspiration pnas to ICU with SOB, hypernatremia and anemia. In
the MICU maintained on vanc zosyn flagyl. urine culture + for
pseudomonas. Loose brown stools. Periodically alert. Sating
well. Transferred to floor, aphasic, cachectic. DNR/DNI, pending
further follow up of infection and placement. To floor on Zosyn,
oral vanc and flagyl for c-diff and UTI.
.
# SOB: unclear etiology. Chronic aspirator, but with no evidence
of pneumonia. Patient put on aspiration precautions. Pt put on
zosyn and flagyl, providing adequate coverage for patient if
aspirating. Continued to monitor for signs of ensuing infection.
Pt tachypneic to 40, unclear etiology but saturating fine.
Repeat CXR with worsening pneumonia vs increasing pulmonary
edema. Chest CT was performed and pulmonary was consulted to r/o
infectious event including empyema. CT showed b/l pleural
effusions w/ underlying atelectasis but felt by medicine and
pulm that not parapneumonic given Pt is afebrile and more
suggestive of some CHF component. Considered ECHO but no
apparent breathing distress and sating at 100%RA and diuresing
but BP borderline. Pt d/c'd sating at 100% on RA with no
apparent dyspnea.
.
# fever: Pt w/ one episode of 101.1 temp. BCX, UCX sent, foley
replaced, PICC line and PEG tube checked w/ no signs of
infection. Sacral decub also checked w/ no clincial signs of
infection. Repeat EKG w/ no new changes. Repeat CXR showing no
acute cardiac issues but ? increase in b/l basilar effusion w/
LLL opacity, ? infectious- see above. (+) rhonchi on exam, no
apparent trouble breathing, mild productive cough. UCX w/ no
growth, BCX pending. Fever resolved w/ tylenol and remained
afebrile for rest of stay
.
# Urinary tract infection: pt was started on fluconazole for
urine with yeast on [**10-25**] for 2 weeks. Pt started on Zosyn for
UTI currently, given pseudomonas in culture and bacteria
sensitive to zosyn. Considered total 10 day course of Abx for
UTI and aspiration pneumonia.
.
# C-diff-pt was diagnosed during last hospitalization in [**Month (only) 359**]
and was treated from [**10-26**] with oral vanco and flagyl for
planned total 3 weeks. Unsure date of stopping medication but as
report diarrhea recurred once stopping. c-diff toxin (-) x 3.
Had been treated with PO vancomycin, but with neg c-diff x 3,
[**11-18**] DC'd po vanc. Continued IV flagyl for aspiration pneumonia
.
# sacral decub: No signs of infection, clinical signs of
infection so will not cover for skin flora at this time.
Attempted to control incontinence to avoid fecal material
contaminating wounds, by placing a rectal bag. Dressed wound
with following wound care recs.
.
# ARF: On admission which appeared pre-renal, baseline 1.5,
currently at 0.9.
Likely hypovolemia for renal failure resolved with hydration,
though also UTI. FENA prerenal picture.
.
# anemia: Crit to 24 on admission to ICU. Iron studies with
anemia of chronic disease. guaiac neg in ER. Transfused 1 unit
in the MICU. Continued to guaiac stools. HCT remaining stable at
23-25 while in house and discharged at 23.9.
.
#hematuria: Foley changed as result of fever 101.1. Soon after
Pt removed w/ balloon inflated resulting in bleeding and
subsequent clots. 3 way foley placed w/ frequent flushing.
Hematuria resolved upon discharge.
.
# FEN: NPO, tube feeds by Gtube (probalance 40cc/hr).
Hypovolemic hypernatremia treated with D5 1/2NS and free water
boluses in Gtube. Free water deficit of 3L on admission to the
ICU. Monitored fluid status. [**11-20**] increased free water bolus to
125 q 4 but net +, [**11-21**] increased free fluid bolus given
hypernatremia to 150 Q4, though appears to be overloaded on CXR,
so considered possible lasix - see above.
.
# contact: grandson [**Name (NI) **] [**Telephone/Fax (1) 9007**]; [**Name2 (NI) **]er (HCP) yuping
[**Telephone/Fax (1) 9008**]; son-in-law [**Doctor Last Name **] [**Telephone/Fax (1) 9009**]
Medications on Admission:
iv vancomycin ?d/ced [**11-4**]
fluconazole
?zosyn
ativan
lansoprazole 30mg gtube qday
keppra 500mg gtube [**Hospital1 **]
zantac
vicodin 2 tabs [**Hospital1 **]
heparin sq
flagyl
PO vancomycin
sertraline
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. 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.
3. 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.
4. Piperacillin-Tazobactam 4.5 g Recon Soln [**Hospital1 **]: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 1 days: Please d/c
after one more day to complete day [**10-5**] for UTI.
Disp:*3 Recon Soln(s)* Refills:*0*
5. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Month/Year (2) **]:
One (1) Intravenous Q8H (every 8 hours) for 1 days: Please d/c
after one more day. Flagyl was given as prophylactic while in
other antibiotic.
Disp:*3 qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Severe dementia
hypernatremia
urinary tract infection
c-diff colitis
recurrent aspiration pneumonia
Discharge Condition:
at baseline; Patient is non verbal, bed ridden has a PEG and a
PICC line for IV antibiotics. Is afebrile
Pt is very tachycardic at baseline
Discharge Instructions:
You were admitted for dehydration, urinary tract infection, and
aspiration pneumonia. You were treated with antibiotics.
-Please take all medications as prescribed to you
-Please maintain all appointments
Followup Instructions:
Please follow up your primary care doctor
Completed by:[**2151-11-25**]
|
[
"428.0",
"584.9",
"438.11",
"518.81",
"250.00",
"276.52",
"707.03",
"041.7",
"294.8",
"585.9",
"285.29",
"401.9",
"276.0",
"008.45",
"507.0",
"600.00",
"599.0",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15889, 15960
|
10722, 14674
|
338, 345
|
16104, 16247
|
3056, 10699
|
16501, 16575
|
2552, 2569
|
14930, 15866
|
15981, 16083
|
14700, 14907
|
16271, 16478
|
2584, 3037
|
278, 300
|
373, 2087
|
2109, 2348
|
2364, 2536
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,487
| 113,479
|
51045
|
Discharge summary
|
report
|
Admission Date: [**2143-6-28**] Discharge Date: [**2143-7-4**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 14961**]
Chief Complaint:
CC - MS changes
Major Surgical or Invasive Procedure:
Intubation [**2143-6-28**], extubation [**2143-6-29**]
History of Present Illness:
HPI - This is a 89 y/o male with h/o demetia, depression, SI in
past requiring inpt psych hospitalization 2 months ago, CAD, HL,
orthostatic hypotension, ITP, p/w MS changes on [**2143-6-28**]. Per pt's
wife, pt found around 12:30 am at home on [**2143-6-28**] sitting, but
unresponsive and unable to speak. Pt taken to ED, code stroke
was called. Pt was admitted to the Neuro ICU, and MRI depicted
two small foci likely representing small infarcts in right
periventricular matter. During this time the pt was intubated
for airway protection as he had been vomiting; extubated
successfully this AM. However, it was felt by the Neuro team
that these small changes were unlikely to cause his MS changes.
A metabolic w/u showed elevated LFTs and a serum tylenol level
of 165 on [**2143-6-28**] at 2pm, drawn approximately 12-16 hrs after
presentation. Pt was not given any NAC until [**2143-6-29**] at 3pm (24
hrs after level was drawn). Upon further questioning with pt, he
confessed to taking to tylenol for a suicide attempt and did not
want his family to know. Upon detailed coversation with his
family and HCP, we were told the patient has done this in the
past requiring inpt psychiatric hospitalization 2-3 months ago.
Per his son, he has not seemed more depressed or expressed any
suicidal ideations.
.
Currently, pt has no complaints except for the bruising on his
arms. Patient does have active SI and says "I didn't take enough
tylenol"
Past Medical History:
1. Dementia - sees Dr. [**Last Name (STitle) **]
2. Depression, ?prior SI/attempts - sees Dr. [**Last Name (STitle) **]
3. s/p MVA earlier this year
4. CAD s/p CABG x 3v
5. HL
6. Orthostatic hypotension
7. h/o ARF resulting in MS changes
8. thrombocytopenia, h/o ITP - sees Dr. [**First Name (STitle) **]
Social History:
SH - Lives at home with his wife. [**Name (NI) **], [**Name (NI) **] [**Name (NI) 17931**], is HCP
([**Telephone/Fax (1) 106034**]). Former tobacco h/o (>130 pk/yr), no EtOH or
illicits.
Family History:
FH - Sister died of cancer. Father had GI cancer.
Physical Exam:
VS - T 96.5, BP 135/95, HR 78, RR 20, SaO2 100%/2LNC, I/O =
1475/950
General - Pleasant, AO x 3 though conversation rambling. In NAD.
HEENT - NC/AT, PERRL/EOMI. MM dry, OP clear.
Neck - supple, no JVD
Chest - bibasilar crackles, otherwise clear
CV - RRR s1 s2 nl, 2/6 SEM at LSB
Abd - soft, NT/ND, NABS
Ext - no c/c/e, pulses 2+ b/l
Neuro - AO x 3, conversant though rambling. Moving all four
extremities equally. CN II-XII intact grossly
Psych - +SI
Pertinent Results:
[**2143-7-1**] 05:45AM BLOOD Plt Ct-48*
[**2143-7-1**] 11:00AM BLOOD Plt Ct-37*
[**2143-7-2**] 05:55AM BLOOD PT-15.6* PTT-26.0 INR(PT)-1.4*
[**2143-7-2**] 05:55AM BLOOD Plt Ct-49*
[**2143-7-3**] 06:55AM BLOOD PT-13.0 PTT-24.6 INR(PT)-1.1
[**2143-7-3**] 06:55AM BLOOD Plt Ct-36*
[**2143-6-29**] 02:45AM BLOOD ALT-237* AST-292* AlkPhos-56 TotBili-0.6
[**2143-6-29**] 02:14PM BLOOD ALT-1156* AST-1416* AlkPhos-62
TotBili-1.0
[**2143-6-30**] 04:33AM BLOOD ALT-[**2105**]* AST-[**2153**]* LD(LDH)-1131*
AlkPhos-61 TotBili-1.1
[**2143-7-1**] 05:45AM BLOOD ALT-2651* AST-2197* LD(LDH)-1093*
AlkPhos-67 TotBili-1.0
[**2143-7-2**] 05:55AM BLOOD ALT-1621* AST-706* LD(LDH)-295*
CK(CPK)-135 AlkPhos-68 TotBili-1.5
[**2143-7-3**] 06:55AM BLOOD ALT-1106* AST-278* LD(LDH)-256*
AlkPhos-79 TotBili-0.9
[**2143-6-28**] 02:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-165.5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2143-6-29**] 02:14PM BLOOD Acetmnp-11.9
TTE [**6-28**] -
The left atrium is normal in size. No atrial septal defect or
patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 60-70%).
Tissue velocity imaging demonstrates an e' of <0.08m/s c/w an
elevated left
ventricular filling pressure (>12mmHg). No masses or thrombi are
seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
EEG [**6-28**] - IMPRESSION: This is an abnormal portable EEG due to
the presence of
slow and disorganized background rhythms with superimposed fast
activity. This finding suggests an encephalopathy. Medications,
infection, or metabolic disturbances are among the most common
causes.
There were no clear focal abnormalities recorded.
CT head [**6-28**] - IMPRESSION: Limited study due to motion. No
evidence of hemorrhage. If there is a further concern for
stroke, please perform further evaluation by MRI. The
information was discussed with the referring physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
in person at the completion of the study.
MRI/MRA of head [**6-28**] - IMPRESSION: Small foci of restricted
diffusion seen in the left frontal and right frontal lobes,
likely representing small distal infarcts.
MRA: Major branches of the Circle of [**Location (un) 431**] appear patent. There
is no evidence of significant stenosis. The vertebral arteries
and basilar artery appear unremarkable with normal appearing
flow. Incidentally noted is a 3mm right carotid cavernous
aneurysm.
IMPRESSION: Vertebral arteries and basilar arteries appear
unremarkable. Incidental note of a 2 mm right carotid cavernous
aneurysm.
Brief Hospital Course:
This is an 89 y/o male with depression, h/o SI, CAD, dementia,
ITP, who initially presented with mental status changes,
initially thought to be [**2-28**] CVA and admitted to the Neuro ICU
service. He was intubated on arrival for airway protection as he
was vomiting and to be able to accurate scans. An MRI/MRA of the
head demonstrated two small ischemic foci in the right and left
frontal lobes, likely [**2-28**] old infarcts. Based on these findings,
it was felt that the etiology of the MS changes was not
secondary to an acute CVA. He had a stroke w/u, including a TTE
and carotid u/s which was unremarkable. He was not started on
any anti-platelet regimen due to his thrombocytopenia [**2-28**] ITP.
An EEG showed diffuse slowing c/w toxic/metabolic process.
During the w/u, the patient was noted to have elevated LFTs
(transaminases in the 200-300's) on [**2143-6-28**]. A serum tylenol
level was checked approximately 12-16 hrs after admission and
was elevated in the hepatotoxic range of 165 on [**2143-6-28**]. Once the
patient was extubated, it was elicited from the patient that he
had taken too much tylenol to "call it quits." It was also
further elicited from the patient's family that the patient has
a history of suicidal attempts, requiring a recent inpt
psychiatric hospitalization 2-3 months ago in [**Hospital 17065**]
hospital. The patient was transferred to the Medicine service
for further management on [**2143-6-29**]. Psychiatry and Hematology were
involved during his course.
.
1. Tylenol toxicity - Toxic/metabolic w/u revealed elevated LFTs
and a serum tylenol level of 165 on [**6-28**] (12-16 hrs after pt
presented, no level checked on admission). Pt not given any
mucomyst (NAC) until [**6-29**] for unclear reasons and was started on
NAC continuous gtt 18 mg/kg/hr per in-house toxicologist. The
patient's LFTs continued to trend upward as well as his INR
(indicative of synthetic function) and finally peaked on [**2143-7-1**].
His enzymes then began trending down, with return of his INR to
1.1 (normal) on [**2143-7-3**]. The NAC gtt was d/c'd on [**2143-7-2**] as it
was clear the patient's liver was recovering - this was
confirmed with in-house toxicology. During his course, he did
not demonstrate any signs of encephalopathy or other end-organ
damage. Medications metabolized through the liver, including
aricept, risperdal, zocor, and effexor were held during the
active hepatitis. They may be restarted once his LFTs are back
to baseline. LFTs should be checked every day or every other day
until they normalize. His synthetic function is preserved,
indicated by his INR of 1.1 (normal). Given this was a suicide
attempt, 1:1 sitter was always present and psych was consulted
(see below).
.
2. Dementia - per family, pt at baseline. Aricept was held given
acute hepatic injury, could be restarted once LFTs completely
back to baseline.
.
3. Depression, NOS - follows with psych as outpt, h/o
SI/attempts in past. Psych was consulted during this admission
and recommended geriatric psych placement given patient is not
safe at home. Family was agreeable to this plan. His risperdal
and effexor was d/c'd during this course given acute hepatic
injury - may be restarted once LFTs back to baseline and
depending on psych's preferences. Patient is a section 12 and
continues to be actively suicidal. He has not been agitated at
all and not required any prn anti-psychotics.
.
4. Thrombocytopenia - pt w/history of ITP, unresponsive to
steroids but given Rhogam in past for plts<40 (last dose per OMR
[**3-31**]). Likely his thrombocytopenia is [**2-28**] ITP, although
risperdal is associated with thrombocytopenia and was recently
started in [**6-1**]. Another concern is his thrombocytopenia could
have been worsened acutely from hepatic injury. Hematology was
consulted in-house and recommened one dose of Rhogam (250
units/kg) for plts<40 as patient was having an episode of nose
bleed. This was given w/o complication on [**2143-7-1**]. Rhogam works
to hemolyze the RBCs through the spleen, saving the platelets
from being destroyed instead. His platelets are currently stable
and there are no signs of bleeding. If patient becomes more
thrombocytopenic or begins to bleed, hematology should be
consulted as the patient may need additional doses of Rhogam. To
monitor his platelets, his Hct, platelets, and coags need to be
checked weekly to ensure stability.
.
5. Orthostatic hypotension - continue fludrocort and midodrine
.
6. HL - held zocor given hepatic injury, may be restarted once
LFTs back to baseline
.
7. F/E/N - regular diet, IVF
.
8. PPx - PPI, pneumoboots
.
9. Code - FULL (confirm each situation w/HCP son [**Name (NI) **] [**Name (NI) 17931**]
[**Telephone/Fax (1) 106034**]; h [**Telephone/Fax (1) 106035**])
.
10. Dispo - medically stable to be transferred to [**Female First Name (un) **]-psych
facility. Liver function has returned to [**Location 213**] and
thrombocytopenia has stabilized.
Medications on Admission:
MEDS (home) -
1. Aricept 5 mg qd
2. Effexor SR 75 mg q24
3. Fludrocort 0.1 mg [**Hospital1 **]
4. Midodrine 10 mg tid
5. Zocor 40 mg qd
6. Risperdal 0.5 mg qd
Discharge Medications:
1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary - hepatotoxicity [**2-28**] tylenol overdose
Secondary - depression, suicidal ideations, dementia, ITP, HL,
orthostatic hypotension
Discharge Condition:
Medically stable, liver synthetic function at baseline
Discharge Instructions:
-continue medications as prescribed
-anti-depressants and anti-psychotic medications were stopped
given pt's hepatotoxicity; once liver enzymes return to baseline
can likely restart medications
-please follow-up with appts below
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2143-7-31**]
12:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2143-8-8**]
10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2143-8-27**] 11:30
Completed by:[**2143-7-4**]
|
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"414.00",
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"272.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"96.71",
"96.04",
"99.29"
] |
icd9pcs
|
[
[
[]
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11620, 11665
|
6061, 11021
|
231, 288
|
11850, 11907
|
2856, 6038
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|
176, 193
|
317, 1764
|
1787, 2094
|
2111, 2300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,122
| 160,937
|
43934+58669
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-3-27**] Discharge Date: [**2192-4-11**]
Date of Birth: [**2127-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Motrin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
STEMI after penile prosthesis replacement
Major Surgical or Invasive Procedure:
[**2192-3-27**] Removal and replacement of penile prosthesis with
extensive irrigation.
[**2192-3-29**] coronary artery bypass grafts x4
(LIMA-LAD,SVG-OM,SVG-RCA sequenced to PDA)
left heart catheterization, coronary angiogram
History of Present Illness:
Mr. [**Known lastname **] is a 64 year old black male who was admitted on
[**2191-3-28**] for replacement of non-functioning penile implant. The
patient underwent uncomplicated penile implant removal and
replacement with urology on [**3-27**]. On the evening of [**3-27**], he
developed severe chest burning and discomfort. He reported that
his chest was "on fire", and has never had such severe symptoms
before. He denied SOB or nausea with this pain. His pain never
truly went away. He was given aspirin and cardiac enzymes were
negative at the time. EKG was reportedly "normal", however, upon
re-evaluation there were noted to be ST elevations inferiorly.
Cardiology was consulted. An EKG the next morning showed
continued elevation inferiorly with positive enzymes.
He underwent immediate cardiac cath which showed 3VD with 70%
mid LAD, 90% D2, 80% OM, 70% r-PDA, and 90% RCA lesion. No
interventions were performed. No Plavix was given. A Heparin
infusion without bolus was started and the patient was
transferred to the CCU. On arrival to CCU, Integrillin was
started. He initially required a nitro infusion, which was
discontinued with him remaining chest pain free.
Past Medical History:
acute myocardial infarction
coronary artery disease
s/p coronary artery bypass grafts x4
Failed penile prosthesis implant.
insulin dependent diabetes mellitus
Dyslipidemia
Hypertension
Ulcerative proctitis [**2173**]
Gastroesophageal reflux - H.pylori positive
Right shoulder pain
Cervical radiculitis --> surgery x2
Left sciatic pain
Back pain
Quadriceps rupture [**2181**]
Left ruptured tm [**2173**]
Erectile dysfunction
Depression
Gun shot wound - to right calf many years ago
C3-C6 laminectomy and C3/C7 foraminotmies and a posterior fusion
cervical myelopathy
Vertigo
Past Surgical History:
Cervical radiculitis --> surgery x4
[**2192-3-27**] Removal and replacement of penile prosthesis with
extensive irrigation
s/p repair of ruptured quadriceps
Social History:
- Tobacco history: quit smoking in [**2160**]; prior 10 year 1 ppd
smoking history
- ETOH: 1 bottle of red wine per week
- Illicit drugs: denies
Occupation: Works as a culinary instructor
Family History:
Mother - HTN
Father - DM
siblings - healthy
daughter with an immunodeficiency syndrome
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8, 112/75, 83, 22, 100% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, L sided crackles
clear with coughing, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
GU: Incision at supropubic area c/d/i. Hemiscrotum Incision
c/d/i w/out evidence hematoma or infection. Circumcised. No
Ecchymosis at penile shaft/scrotum noted and no induration.
NEURO: AAOx3, CNII-XII intact, [**6-9**] symmetric strength UE and LE.
PULSES: 2+ carotid/femoral/popliteal/DP/PT bilaterally
Pertinent Results:
[**2192-3-27**] 10:41PM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-3-28**] 05:55AM BLOOD CK-MB-56* MB Indx-7.7* cTropnT-0.50*
[**2192-3-28**] 01:40PM BLOOD CK-MB-103* MB Indx-7.8* cTropnT-1.77*
[**2192-3-28**] 10:07PM BLOOD CK-MB-111* MB Indx-6.2* cTropnT-4.45*
[**2192-3-29**] 04:00AM BLOOD CK-MB-66* MB Indx-4.7 cTropnT-3.96*
.
CARDIAC CATH ([**2192-3-28**]):
1. Coronary angiography in this right dominant system
demonstrated
triple vessel disease. The LMCA was patent. The LAD had mild
proximal
disease then a 70% tubular lesion at the take off of the 2nd
diagnol and
a 90% tubular lesion at the take off and involving the D3. THe
LAD
gives rigorous to the distal RCA via its septal branches. The
Lcx had
diffuse moderate serial lesions proximally. There was an
atretic AV
groove LCx. The OM is a large bifurcating with long smooth 80%
mid-distal(starts proximal to the upper pole and goes all the
way down
to the mid and lower pole. The RCA had a very long diseased
segment
involving the whole mid vessel (vertical segment) with serial
lesions
tapering to 90% in 3 spots. THe lumen of the rest of the
segment is 60%
diseased. THe r-PDA had a 70% mid lesion.
2. Limited resting hemodynamics revealed systemic normotension
with
elevated left sided filling pressures and an LVEDP of 20mm HG.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
.
TEE [**2192-3-29**]:Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate regional left ventricular systolic
dysfunction with basal inferior wall dyskinesis, akinesis of the
mid to distal inferior wall and apex, akinesis of the distal
septum, and hypokinesis of the basal to mid inferoseptal wall,
basal to mid inferolateral wall, mid anteroseptal wall, and
distal anterior wall. Overall left ventricular systolic function
is moderately depressed (LVEF= 30-35 %). Right ventricular
chamber size is normal, with mild global free wall hypokinesis.
There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results at time of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on
an epinephrine infusion. Left ventricular function appears
improved (LVEF 35-40%). The inferior wall which was previously
akinetic is now hypokinetic. Right ventricular function is
slightly improved. Mitral regurgitation is unchanged. The aorta
is intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting
physician
[**2192-4-10**] 04:45AM BLOOD WBC-10.9 RBC-3.23* Hgb-9.5* Hct-27.3*
MCV-85 MCH-29.3 MCHC-34.6 RDW-13.2 Plt Ct-636*
[**2192-4-10**] 04:45AM BLOOD Plt Ct-636*
[**2192-4-10**] 04:45AM BLOOD Glucose-152* UreaN-19 Creat-1.3* Na-135
K-4.5 Cl-100 HCO3-27 AnGap-13
[**2192-4-10**] 04:45AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2
[**2192-4-5**] PA&LAt CXR:
bilateral pleural effusions. The cardiac and mediastinal
contours are
unchanged. Multiple intact sternal wires are again seen.
Posterior and
anterior cervical fusion hardware is unchanged in orientation.
Mild-to-moderate adjacent atelectasis at the lung bases is
stable, slightly
worse at the left. There is no pneumothorax.
IMPRESSION: Minimally changed moderate bilateral pleural
effusions with
adjacent atelectasis. No pulmonary edema.
Brief Hospital Course:
The patient was brought to the Operating Room on [**3-29**] and
underwent revascularization(LIMA-LAD, SVG-RCA and PDA, SVG-OM).
The surgery was performed by Dr. [**Last Name (STitle) **], please see intraop notes
for further details.
He was transferred to the CVICU in stable condition, intubated
and sedated on an Epinephrine infusion. The EKG was questionable
for a-flutter in the 140's and cardioversion was attempted but
failed and he was started in Amiodarone. He returned to SR. He
continued to have a low EF and the Epinephrine was weaned off
and he was started on Milrinone and NeoSynsphrine. He was slow
to clear anesthesia and remained intubated until POD#2, when he
weaned and extubated without incident. Milrinone and Neo were
weaned off by POD#3.
Chest tubes were removed and he was transferred to the floor on
POD #4. Low dose beta blockers were started and wires were
removed without incident. He continued to progress well. His
Foley was removed without incident. His Cipro was continued for
the recent urological proceedure. Postopertaively his was
restarted on his Lantus and was seen by [**Last Name (un) **] for diabetic
management. He was initially hyperglycemic and then hypoglycemic
and his evening lantus was adjusted. He will need to follow up
with [**Last Name (un) **] as an out patient. The patient was evaluated by the
Physical Therapy service for assistance with strength and
mobility.
He developed drainage from the lower third of the sternal wound
(serosanguinous0 and there was some skin over riding edge. he
had a low grade fever (100.7) and some necrotic fat. When a
leukocytosis to 15K developed, Levoquin was begun. It was
incised and drained at the bedside. A wound vac was placed for
further healing. The vein site at the left knee dehisced and
this was packed. Levaquin will be continued for a 7 day course.
He will return after some wound healing and the visible wire at
the base of the sternal wound willbe removed.
By the time of discharge on [**4-11**] he was ambulating freely and
pain was controlled with oral analgesics. The patient was
discharged to The [**Hospital1 **] in good condition with appropriate
follow up instructions.
Medications on Admission:
DIAZEPAM [VALIUM] - 2 mg Tablet - 1 to 2 Tablet(s) by mouth
every eight (8) hours dizziness (*only takes at night*)
GABAPENTIN - 100 mg Capsule - 3 Capsule(s) by mouth three times
daily. Start with one capsule three times daily for week, then
increase to 2 capsules three times daily and then 3 capsules
three times daily
HYDROCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 2 Tablet(s) by
mouth at hs, and may take one additional tablet during the day
as needed for pain (*not taking*)
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 16 units [**Hospital1 **]
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth daily
MOM[**Name (NI) **] [NASONEX] - (Not Taking as Prescribed) - 50 mcg
Spray, Non-Aerosol - 2 puffs(s) nostrile once a day
OXYCODONE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 5 mg
Tablet - 1 Tablet(s) by mouth every four (4) - six (6) hours as
needed for pain (*not taking*)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day
SIMVASTATIN - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day take in the evening
SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth four times a
day (*pt denies taking*)
TERAZOSIN - 5 mg Capsule - 1 Capsule(s) by mouth bedtime
TIMOLOL MALEATE [ISTALOL] - (Prescribed by Other Provider:
[**Name Initial (NameIs) **]) - 0.5 % Drops, Once Daily - 1 (One) drop in each eye
once a day
TIZANIDINE - 2 mg Tablet - 3 Tablet(s) by mouth three times a
day as needed for muscle spasm
.
Medications - OTC
ASPIRIN - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by mouth
once a day
BIFIDOBACTERIUM INFANTIS [ALIGN] - 4 mg (1 billion cell) Capsule
- 1 Capsule(s) by mouth once a day
OXYMETAZOLINE - 0.05 % Aerosol, Spray - one to two sprays nasal
twice a day
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever>99.
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for dizziness.
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain >[**5-15**].
Disp:*40 Tablet(s)* Refills:*0*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
14. amiodarone 200 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): 400ng(2 tablets) twice daily for two weeks then 200mg
(one tablet( twice daily for two weeks, then 200mg(one tablet)
daily until directed to stop.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
doses.
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 doses.
17. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
18. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
(20) units Subcutaneous Q AM.
19. insulin regular human 100 unit/mL Solution Sig: as directed
Injection four times a day: 120-160:2units SQ ac,Ohs;
161-200:4units ac,2units HS;201-240:6units ac,4units
HS;241-280:8units ac,6units HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
acute myocardial infarction
coronary artery disease
s/p coronary artery bypass grafts x4
Failed penile prosthesis implant.
insulin dependent diabetes mellitus
Dyslipidemia
Hypertension
Ulcerative proctitis [**2173**]
Gastroesophageal reflux - H.pylori positive
sternal wound infection- superficial
Right shoulder pain
Cervical radiculitis --> surgery x2
Left sciatic pain
Back pain
Quadriceps rupture [**2181**]
Left ruptured tm [**2173**]
Erectile dysfunction
Depression
Gun shot wound - to right calf many years ago
C3-C6 laminectomy and C3/C7 foraminotmies and a posterior fusion
cervical myelopathy
Vertigo
extensive irrigation
s/p repair of ruptured quadriceps
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - lower end of sternal wound open with wound vac in
place
Leg Left - SVH site at knee one inch wound approx [**2-6**] inch deep
open with wet to dry dressing in place .
Edema: +1 left lower extremity
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**
-Do NOT pull down on implanted bulbs in scrotum.
-Please also refer to the instructions provided to you by the
manufacturer
-Please keep your phallus at midline, pointed toward your
umbilicus, taped in place with protective gauze if necessary for
the next week. Of course you may point it downward for voiding.
-over the next several days you may experience some increased
swelling of your phallus and scrotum resembling a semi-rigid
phalus (semi-erect); this is normal. This may be accompanied by
discoloration (ecchymosis) involving the phallus and the
scrotum; this too is normal and will gradually resolve.
-Please remove the surgical dressing over penis and/or under
scrotum on post-operative day two: no further wound care is
needed and you may leave the wound open to air. Wear
comfortable, loose fitting briefs or boxer-briefs for
support--they should be cotton and/or breathable
-Do NOT use prosthesis for 6 weeks and until explicitly advised
by your urologist
-You may shower, but do not bathe, swim or otherwise immerse
your incision. NO sexual activity until cleared by urologist.
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2192-5-3**] at 1:15pm
Cardiologist:Dr. [**First Name (STitle) **] [**2192-4-26**] at 1:00p
Wound check [**Hospital Ward Name **] 2A [**2192-4-10**] at 10:45a
Please schedule appt with PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] ([**Telephone/Fax (1) 250**]in [**4-8**]
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*
Please call to arrange your follow-up appointment AND if you
have any urological questions.
[**Last Name (LF) 3330**], [**Name8 (MD) **], MD UROLOGY [**Telephone/Fax (1) 3331**]
You have other pre-arranged appointments listed here:
Provider: [**Name Initial (NameIs) 2169**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2192-4-12**] 2:00
Completed by:[**2192-4-11**] Name: [**Known lastname **],[**Known firstname 14923**] D Unit No: [**Numeric Identifier 14924**]
Admission Date: [**2192-3-27**] Discharge Date: [**2192-4-11**]
Date of Birth: [**2127-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Motrin
Attending:[**First Name3 (LF) 135**]
Addendum:
F/U with Dr [**Last Name (STitle) **] is changed to [**2192-4-19**] at 1:30pm
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2192-4-11**]
|
[
"401.9",
"E878.2",
"607.84",
"V58.67",
"428.32",
"E878.8",
"272.4",
"428.0",
"530.81",
"250.00",
"518.0",
"410.41",
"414.01",
"998.59",
"997.1",
"996.39",
"998.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"64.97",
"88.56",
"37.22",
"00.59",
"88.53",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
18630, 18860
|
7979, 10170
|
328, 557
|
14867, 15193
|
3962, 5257
|
17132, 18607
|
2763, 2852
|
12096, 14060
|
14177, 14846
|
10196, 12073
|
5274, 7956
|
15217, 17109
|
2383, 2541
|
2892, 3943
|
247, 290
|
585, 1763
|
1785, 2360
|
2557, 2747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,286
| 109,698
|
1135+55263
|
Discharge summary
|
report+addendum
|
Admission Date: [**2193-10-15**] Discharge Date: [**2193-10-20**]
Date of Birth: [**2110-4-2**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending:[**First Name3 (LF) 7303**]
Chief Complaint:
83 year old female with post-traumatic left hip OA
Major Surgical or Invasive Procedure:
[**2193-10-15**] Left hip hardware removal, total hip arthroplasty
History of Present Illness:
83 year old female with post-traumatic left hip OA
Past Medical History:
Atrial fibrillation, hypertension, hypothyroidism, osteoporosis
Social History:
NC
Family History:
NC
Physical Exam:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
Pertinent Results:
Labs on admission:
[**2193-10-16**] 01:13AM BLOOD WBC-14.2*# RBC-3.24* Hgb-9.8* Hct-29.3*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.7 Plt Ct-144*
[**2193-10-16**] 01:13AM BLOOD PT-13.2 PTT-25.4 INR(PT)-1.1
[**2193-10-16**] 01:13AM BLOOD Glucose-101 UreaN-22* Creat-1.3* Na-139
K-5.5* Cl-106 HCO3-19* AnGap-20
[**2193-10-16**] 01:13AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.5* Iron-61
[**2193-10-16**] 01:13AM BLOOD calTIBC-208* Ferritn-143 TRF-160*
Cardiac enzymes:
[**2193-10-16**] 05:06AM BLOOD CK-MB-7 cTropnT-0.02*
[**2193-10-16**] 04:38PM BLOOD CK-MB-9 cTropnT-0.02*
[**2193-10-17**] 04:20AM BLOOD CK-MB-8 cTropnT-0.02*
[**2193-10-17**] 10:40AM BLOOD CK-MB-7 cTropnT-0.01
Labs prior to discharge:
Brief Hospital Course:
The patient was admitted on [**2193-10-15**] and, later that day, was
taken to the operating room by Dr. [**Last Name (STitle) 5322**] for left hip DHS
removal and primary total hip arthroplasty without complication.
Please see operative report for details. Postoperatively the
patient did well. The patient was initially treated with a PCA
followed by PO pain medications on POD#1. The patient received
IV antibiotics for 24 hours postoperatively, as well as lovenox
for DVT prophylaxis starting on the morning of POD#1. The drain
was removed without incident on POD#1. The Foley catheter was
removed without incident. The surgical dressing was removed on
POD#2 and the surgical incision was found to be clean, dry, and
intact without erythema or purulent drainage.
While in the hospital, the patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
stable, and the patient's pain was adequately controlled on a PO
regimen. The operative extremity was neurovascularly intact and
the wound was benign. The patient was discharged to home with
services or rehabilitation in a stable condition. The patient's
weight-bearing status was WBAT LLE with posterior precautions.
[**Hospital 153**] Hospital Course:
Ms. [**Known lastname 1968**] is an 83 yo F with PMH atrial fibrillation, s/p left
hip replacement admitted to the MICU for respiratory depression
s/p getting morphine for pain and agitation in the PACU.
.
#Respiratory depression: was most likely [**3-11**] morphine given
postoperatively in the setting of baseline renal insufficiency.
On arrival to the ICU she is maintaining her respiratory rate
and ABG with normal CO2. CXR showed no edema, pleural
effusions, vascular congestion.
.
#Hypotension: she has borderline hypotension on arrival to the
ICU (recent bp in clinic 90/60), likely 2/2 blood loss in the
OR, volume depletion and afib with rvr.
Pt received 2U PRBC for post op anemia and then another 2U the
day after for a drop in Hct. Hypotension resolved following
appropriate volume resuscitation.
.
#Afib wit RVR: likely [**3-11**] operative stress/medication, new
anemia. Pt was monitored on the tele. Pt was relateively
rate-controlled on Metoprolol Tartrate 37.5mg PO QID.
Pt placed on lovenox for anticoagulation and bridged to
Coumadin. Patient therapeutic at the time of discharge. TTE
was unremarkable. She needs to be on propanolol 80mg [**Hospital1 **] per
[**Female First Name (un) 1634**] Med not metoprolol when she goes to rehab.
.
#s/p left hip replacement: was doing well post op. On Tylenol,
Lidocaine patch, and low dose oxycodone for pain control. xrays
showed good component position.
.
#agitation: was given Haldol PRN, standing seroquel. Geriatrics
service was consulted who raised the consideration that she also
might be suffering from mild etoh withdrawal. This cold also
explain her tachycardia. She was therefore started on low dose
ativan.
.
#chest pain: brief, fleeting. No EKGs changes. troponins flat.
Medications on Admission:
Aspirin, calcium, felodipine, levothyroxine, propranolol,
raloxifene, Coumadin, and valsartan
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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) as needed for
Constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR [**3-12**].
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
12. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for distress.
15. Lorazepam 0.25 mg IV BID:PRN distress
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left hip post traumatic OA
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by Dr. [**Last Name (STitle) 5322**] 2 weeks after your
surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue coumadin.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by Dr. [**Last Name (STitle) 5322**] at 2 weeks post op.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment.
Physical Therapy:
WBAT LLE with posterior precautions
Treatments Frequency:
Dry sterile dressing to incision daily. Staples out by Dr.
[**Last Name (STitle) 5322**] at 2 week post op visit. Coumadin daily for INR [**3-12**]
Followup Instructions:
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2193-10-30**] 10:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7304**], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2193-12-6**] 9:00
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**]
Completed by:[**2193-10-19**] Name: [**Known lastname 447**],[**Known firstname **] [**Last Name (NamePattern1) 940**] Unit No: [**Numeric Identifier 941**]
Admission Date: [**2193-10-15**] Discharge Date: [**2193-10-20**]
Date of Birth: [**2110-4-2**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending:[**First Name3 (LF) 942**]
Addendum:
Please note that patient was discharged on metoprolol 50mg QID
and not her home dose of propanolol. Patient also given 1 unit
pRBCs on [**10-19**] for hct of 27.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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) as needed for
Constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR [**3-12**].
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
12. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
13. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for distress.
14. Lorazepam 0.25 mg IV BID:PRN distress
15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
Left hip post traumatic OA
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS
1. Please return to the emergency department or notify MD if you
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by Dr. [**Last Name (STitle) **] 2 weeks after your
surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue coumadin.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by Dr. [**Last Name (STitle) **] at 2 weeks post op.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment.
Physical Therapy:
WBAT LLE with posterior precautions
Treatments Frequency:
Dry sterile dressing to incision daily. Staples out by Dr.
[**Last Name (STitle) **] at 2 week post op visit. Coumadin daily for INR [**3-12**]
Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 809**] Date/Time:[**2193-10-30**] 10:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 943**], MD Phone:[**Telephone/Fax (1) 944**] Date/Time:[**2193-12-6**] 9:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 945**]
Completed by:[**2193-10-20**]
|
[
"E935.2",
"427.31",
"276.8",
"786.03",
"244.9",
"293.0",
"401.9",
"348.8",
"285.1",
"458.29",
"716.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"99.04",
"78.69"
] |
icd9pcs
|
[
[
[]
]
] |
11075, 11145
|
1474, 2896
|
325, 395
|
11216, 11225
|
759, 764
|
13692, 14123
|
599, 603
|
9723, 11052
|
11166, 11195
|
4690, 4786
|
2913, 4664
|
11249, 12786
|
618, 740
|
13464, 13500
|
13522, 13669
|
1212, 1451
|
235, 287
|
12798, 13446
|
423, 475
|
778, 1195
|
497, 563
|
579, 583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,469
| 104,202
|
32847
|
Discharge summary
|
report
|
Admission Date: [**2173-1-25**] Discharge Date: [**2173-1-25**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
left lower extremity ishemia
Major Surgical or Invasive Procedure:
left lower extremity above knee amputation
History of Present Illness:
This patient is an 85 year old male who was transferred from an
outside hospital for acute left lower extremity ischemia.
Past Medical History:
PMH: TIAs, cardiomyopathy, CAD, CHF, PVD, BPH, CRI (2.0),
hypothyroid, paraoxysmal A-fib,MI '[**70**], demntia
PSH: CABG '[**39**] and '[**51**], ? LLE BPG
Social History:
n/c
Family History:
n/c
Physical Exam:
This patient arrived on the floor in ventricular tachycardia,
unresponsive. Lungs were clear. Abdomen was soft. Left lower
extremity was mottled and blue.
Pertinent Results:
[**2173-1-25**] 07:01AM BLOOD WBC-3.1* RBC-3.08* Hgb-9.8* Hct-29.3*
MCV-95 MCH-31.7 MCHC-33.3 RDW-13.7 Plt Ct-107*
[**2173-1-25**] 07:01AM BLOOD PT-20.5* PTT-59.4* INR(PT)-1.9*
[**2173-1-25**] 04:03PM BLOOD PT-25.1* PTT->150 INR(PT)-2.5*
[**2173-1-25**] 07:01AM BLOOD ALT-136* AST-294* LD(LDH)-412*
CK(CPK)-6636* AlkPhos-23* Amylase-28 TotBili-0.5
[**2173-1-25**] 02:11PM BLOOD ALT-330* AST-909* LD(LDH)-857*
CK(CPK)-[**Numeric Identifier 18897**]* AlkPhos-20* Amylase-51 TotBili-1.0
[**2173-1-25**] 04:03PM BLOOD Glucose-158* UreaN-52* Creat-2.0* Na-152*
K-3.6 Cl-112* HCO3-19* AnGap-25*
[**2173-1-25**] 04:03PM BLOOD Calcium-7.2* Phos-6.3* Mg-1.8
[**2173-1-25**] 07:01AM BLOOD CK-MB-33* MB Indx-0.5 cTropnT-0.68*
[**2173-1-25**] 08:01AM BLOOD Type-ART pO2-423* pCO2-36 pH-7.11*
calTCO2-12* Base XS--17
[**2173-1-25**] 08:48AM BLOOD Type-ART pO2-177* pCO2-44 pH-7.37
calTCO2-26 Base XS-0
[**2173-1-25**] 01:17PM BLOOD Type-ART pO2-82* pCO2-35 pH-7.30*
calTCO2-18* Base XS--7
[**2173-1-25**] 05:06PM BLOOD Type-ART pO2-61* pCO2-38 pH-7.25*
calTCO2-17* Base XS--9
Brief Hospital Course:
This patient arrived at [**Hospital1 18**] in ventricular tachycardia and was
unresponsive. He was quickly asessed by the surgical team and
intubated and transferred to the ICU. He spontaneously
converted to sinus rhythum after a liter or so of IV fluids. A
central venous line and an A-line was placed. The patient
became progressively acidotic and hypotensive. He was started
on Levophed and Vasopressin and eventually Neosynepherine. He
was maxed out on these drugs. The decision was made to go
through with a bedside above the knee amputation with a gigli
saw. This was thought to be his only hope of survival beacause
this was thought to be the cause of his sepsis. His condition
continued to get worse however. He was made CMO by his family
later that day and he died shortly therafter.
Medications on Admission:
amlodipine 5', amio 200', asa 81', celexa 20', flomax 0.4',
isosorbide 20', synthroid 0.075', zocor 80', ativan 0.5',
lopressor 25', plavix 75', quinapril 20', salasate 750',
metamucil, tylenol, colace, MOM, dulcolax, melatonin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
left lower extremity ischemia, sepsis, septic shock
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2173-1-28**]
|
[
"427.31",
"V66.7",
"V45.81",
"995.92",
"412",
"038.9",
"996.74",
"437.0",
"425.4",
"427.1",
"290.40",
"785.52",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.07",
"96.71",
"96.04",
"84.17",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3098, 3107
|
1987, 2791
|
290, 334
|
3202, 3209
|
900, 1964
|
3262, 3297
|
702, 707
|
3069, 3075
|
3128, 3181
|
2817, 3046
|
3233, 3239
|
722, 881
|
222, 252
|
362, 486
|
508, 665
|
681, 686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,853
| 100,010
|
40054
|
Discharge summary
|
report
|
Admission Date: [**2109-12-10**] Discharge Date: [**2109-12-14**]
Date of Birth: [**2055-6-3**] Sex: F
Service: UROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Gross hematuria, 50-pound weight loss
Major Surgical or Invasive Procedure:
Open left radical nephrectomy
History of Present Illness:
54 y/o female w/Large left renal mass, s/p mediastinoscopy
showing metastatic RCC. [**Known firstname **] is a previously healthy
patientn who, two years ago, noted one episode of gross
hematuria, which quickly resolved. More recently, she has had a
50-pound weight loss from 210 to 160 pounds over the past six
months. She has noted some
fullness in the left upper quadrant, but no actual pain and only
requires very occasional Tylenol for this. Imaging was
performed, which revealed a very large left renal mass
consistent with renal cell carcinoma. On [**2109-11-6**], she
underwent a mediastinoscopy with lymph node biopsy, which was
consistent with metastatic carcinoma. She has noted severe
fatigue and although she can walk at least 10 minutes, her
performance status is lower than normal for her, probably ECOG
1. No gross hematuria. No urinary infections or other urinary
symptoms. She has occasional night sweats, no fever, occasional
cough, no hemoptysis.
Past Medical History:
PMH/PSH: Mediastinoscopy [**2108**], Ectopic pregnancies, right knee
surgery, [**2104**], laparoscopy to evaluate for multiple
miscarriages, GERD.
Social History:
A 40-pack-year smoking history, quit in [**2088**]. No alcohol. She
is a housewife. They have a 12-year-old daughter.
Family History:
Family history is unremarkable.
Physical Exam:
NAD, A&Ox3
No respiratory distress
Abd: soft, NT, ND, Left flank incision: C/D/I, CT site: C/DI
Ext: No c/c/e
Pertinent Results:
[**2109-12-13**] 06:56AM BLOOD WBC-7.4 RBC-3.54* Hgb-9.2* Hct-28.1*
MCV-79* MCH-26.1* MCHC-32.9 RDW-16.5* Plt Ct-281
[**2109-12-13**] 06:56AM BLOOD Glucose-110* UreaN-11 Creat-1.3* Na-136
K-4.4 Cl-104 HCO3-27 AnGap-9
Brief Hospital Course:
Patient was admitted to Urology after undergoing an open left
radical nephrectomy. No concerning intraoperative events
occurred; please see dictated operative note for details. The
patient received perioperative antibiotic prophylaxis. The
patient was transferred to the SICU from the PACU due to
hypotension. On the evening of POD 0, Hct was 25. She was
transfused 1 unit overnight and was on pressors to keep SBP>90.
Her Epidural was lowered and changed to plain bupivicaine and
dilaudid PCA, and her BP improved by POD 1. On POD 1, pain was
well controlled on PCA and Epidural, hydrated for urine output
>30cc/hour, provided with pneumoboots and incentive spirometry
for prophylaxis, and she ambulated once. On POD 1, pressors
were also weaned off, and chest tube was removed with no
complications. CXR showed no pneumothorax. On POD2, she was
transferred to the floor and diet was advanced. On POD3,
epidural and foley was removed and she was transitioned to oral
pain meds. The remainder of the hospital course was relatively
unremarkable. The patient was discharged in stable condition on
POD 4, eating well, ambulating independently, voiding without
difficulty, and with pain control on oral analgesics. On exam,
incision was clean, dry, and intact, with no evidence of
hematoma collection or infection. The patient was given explicit
instructions to follow-up in clinic with Dr.[**Last Name (STitle) 3748**].
Medications on Admission:
Tylenol PRN
Pepcid PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours) as needed for heartburn.
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for fever, pain.
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic RCC/Left renal mass s/p open left radical nephrectomy
Discharge Condition:
Stable
Alert and oriented
Ambulatory
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, except hold aspirin until
you see your urologist in follow-up
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids
Followup Instructions:
Schedule an appointment with your primary care physician to have
your staples removed on [**2109-12-20**].
Call Dr.[**Name (NI) 11306**] office ([**Telephone/Fax (1) 8791**];for follow-up AND if you
have any questions (page Dr. [**Last Name (STitle) 3748**] at [**Telephone/Fax (1) 2756**]).
Completed by:[**2109-12-14**]
|
[
"197.6",
"196.1",
"276.52",
"198.7",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.0",
"40.3",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
4130, 4136
|
2093, 3518
|
311, 343
|
4245, 4284
|
1852, 2070
|
5337, 5662
|
1673, 1706
|
3591, 4107
|
4157, 4224
|
3544, 3568
|
4308, 5314
|
1721, 1833
|
234, 273
|
371, 1347
|
1369, 1519
|
1535, 1657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,970
| 155,947
|
40885
|
Discharge summary
|
report
|
Admission Date: [**2149-9-16**] Discharge Date: [**2149-9-18**]
Date of Birth: [**2067-2-28**] Sex: F
Service: MEDICINE
Allergies:
Terbutaline / Dicloxacillin / Advair Diskus / Codeine /
Penicillins / Zantac / Fosamax / Heparin Agents / Ativan /
Percocet / Vancomycin / Glucocorticoids (Corticosteroids) / Ace
Inhibitors / Amoxicillin / alendronate sodium / NSAIDS
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
Right-sided Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yo F w/ PMH pulmonary hypertension on 3-4L O2 at home, CAD
s/p MI with stent placement in RCA/LAD in [**2140**] and LMCA and LAD
in [**4-23**], HTN, dyslipidemia, PVD, CKD (baseline 2.5-2.9), COPD
who p/w acute onset of back pain. She explains that at 4pm in
the afternoon, she had sudden onset of pain at her R waist that
started at her back and traveled to her side. She describes it
as a "deep" pain, [**9-22**], that was not worse w/ movement or
breathing and did not radiate. It subsided after 3 hrs, though
she relates no specific alleviating factors. She had associated
dyspnea and turned her oxygen from up from 3L to 4L with
subsequent relief. She also reported slight nausea at the
beginning of the episode that relieved. She denies other
associated symptoms such as fevers/chills, chest pain,
diaphoresis, abd pain, lightheadedness, or dizziness. She denies
any increased swelling in her extremities and reports a 5 pound
weight loss over the last month. She explains that she has not
been eating well due to not feeling well secondary to her PVD.
.
Initial vitals in the ED were HR 89 BP 108/73 R 25 O294% 4L NC.
She had elevated BNP (30,000) and troponin (0.09 - higher than
baseline). Bedside echo showed large RA, RV concerning for
worsening pulm HTN which may be the cause of her elevated BNP.
Got 20mg IV lasix with BP down to 80s/60s with 86% on 5L NC, but
improved with stimulation and NRB. Then was 94% on NRB, BP up
to 102/70s which is where she has been. She was given fentanyl
for the back pain with subsequent hypotension. EKG showed sinus
with RAD, RBBB but nothing new, questionable ST depressions in
lateral leads. Upon transfer, vitals were 78, 96% NRB, 16,
116/64. She was put on 4L NC with O2 sats ###. She is currently
feeling comfortable with no dyspnea and is pain-free. She has no
other acute symptoms.
.
Pt last saw her Cardiologist, Dr. [**Last Name (STitle) 2257**], on [**2149-9-15**], where
she appeared cardiovascularly stable and will see him again as
needed.
.
On review of systems, s/he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
cough, hemoptysis, black stools or red stools. S/he denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC HISTORY: +Hypertension +Dyslipidemia -Diabetes
-Coronary Artery Disease s/p MI in [**2117**]
-CABG: None (Declined [**3-24**])
-PERCUTANEOUS CORONARY INTERVENTIONS: RCA/LAD stents in [**2140**] by
Dr. [**Last Name (STitle) 2257**] ([**Hospital1 3494**]); and LMCA and LAD DES [**2149-4-23**] at [**Hospital1 18**]
-PACING/ICD: None
2. OTHER PAST MEDICAL HISTORY:
- PERIPHERAL VASCULAR DISEASE
- HISTORY TOBACCO USE
- ? History of HIT
- Rectal Cancer
- COPD (02 dependent, 4 L/min at home)
- CKD (Baseline Cr 2.5-2.9) secondary to renal hypoplasia
- History of pulmonary embolism
-Thyroid disease
-Iron deficiency anemia
-PULMONARY HYPERTENSION (PA systolic pressure estimated by ECHO
[**9-22**] calculated from peak TR velocity is 45 to 75), PASP of
68mmHg with moderate improvement with Nitric Oxide to 49mmHg.
s/p b/l pulmonary vascular surgery in [**2142**]
-Abdominal Aortic Aneurysm s/p repair in [**7-18**]
-s/p CAROTID ENDARTERECTOMY
-DEPRESSIVE DISORDER
Social History:
Lives alone at [**Hospital3 **] facility in [**Location (un) 1514**], MA. Most
recently in cardiopulmonary rehab.
-Tobacco history: quit smoking in [**2128**], 30 pack-years
-ETOH: Denies usage
-Illicit drugs: none
Family History:
Strong family history of CAD and cardiac death before age 50
(brothers, sisters, [**Name2 (NI) **], daughter). Father died from MI at
age 45.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.2 BP= 89/49 (89-113/49-60) HR= 67 (67-76) RR= 15
(15-21) O2 sat= 91 (91-94) 4L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP up to the ear. Positive hepatojugular
reflex.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, slightly loud S2. No m/r/g. No parasternal
heave. 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, ND. Voluntary guarding in RUQ with slight TTP in
the area. Umbilical hernia noted, easily reduced. Abd scar noted
from previous surgery. No HSM or tenderness. Abd aorta not
palpable. No abdominial bruits.
EXTREMITIES: No clubbing, cyanosis. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP and PT dopplerable
Left: Carotid 2+ Radial 2+ DP and PT dopplerable
.
DISCHARGE PHYSICAL EXAM
Vitals - Tm/Tc: 97.4/97.4 HR:68-78 BP:78-98/ RR: [**11-30**] 02 sat:
94% RA
Tele: Sr, no VEA
.
GENERAL: 82 yo F in no acute distress during exam
HEENT: mucous membs dry, no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, tender to palpation at RUQ, non-distended, BS
normoactive. No rebound or guarding.
EXT: wwp, no edema.
NEURO: CNs II-XII intact. 3/5 strength in U/L extremities.
SKIN: no rash
PSYCH: appears tired, c/o no appetite or energy.
Pertinent Results:
ADMISSION LABS
[**2149-9-16**] 07:15PM BLOOD WBC-9.8# RBC-4.16* Hgb-11.8* Hct-34.3*
MCV-82 MCH-28.4 MCHC-34.4 RDW-18.3* Plt Ct-242
[**2149-9-16**] 07:15PM BLOOD Neuts-88* Bands-0 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2149-9-16**] 07:15PM BLOOD PT-28.7* PTT-40.0* INR(PT)-2.8*
[**2149-9-16**] 07:15PM BLOOD Glucose-163* UreaN-51* Creat-3.1* Na-137
K-4.4 Cl-101 HCO3-16* AnGap-24*
[**2149-9-16**] 07:15PM BLOOD CK(CPK)-48
.
DISCHARGE LABS
[**2149-9-18**] 01:25PM BLOOD WBC-8.1# RBC-4.41 Hgb-12.5 Hct-41.7
MCV-95 MCH-28.3 MCHC-29.9* RDW-18.0* Plt Ct-191
[**2149-9-18**] 06:05AM BLOOD PT-31.1* PTT-41.5* INR(PT)-3.1*
[**2149-9-18**] 01:25PM BLOOD Glucose-122* UreaN-52* Creat-3.6* Na-135
K-5.4* Cl-105 HCO3-14* AnGap-21*
[**2149-9-18**] 01:25PM BLOOD CK(CPK)-55
[**2149-9-17**] 07:45AM BLOOD ALT-19 AST-37 LD(LDH)-263* AlkPhos-90
TotBili-0.3
[**2149-9-16**] 07:15PM BLOOD CK-MB-2 proBNP-[**Numeric Identifier 89289**]*
[**2149-9-16**] 07:15PM BLOOD cTropnT-0.09*
[**2149-9-17**] 07:45AM BLOOD cTropnT-0.09*
[**2149-9-18**] 01:25PM BLOOD Calcium-9.0 Phos-5.9* Mg-2.3
.
MICROBIOLOGY
[**2149-9-16**] Urine Cx (final): NO GROWTH
[**2149-9-16**] Blood Cx: pending
.
IMAGING
[**2149-9-16**] ECG: RBBB, TWI II, III, aVF and ST depressions V4 and V5
and PVCs (unchanged from prior)
.
[**2149-9-16**] CHEST (PORTABLE AP): Mild pulmonary edema, perhaps
minimally worse compared to the prior study, with small
bilateral pleural effusions. Hyperinflation of the lungs
compatible with underlying emphysema.
.
[**2149-9-16**] CT ABD & PELVIS W/O CONTRAST: The spleen, pancreas,
adrenal glands, and liver are unremarkable within the
constraints of this non-contrast study. The patient is status
post cholecystectomy. Note is made of renal hypodensities in the
left kidney, which are unchanged and in keeping with simple
cysts. The right kidney is atrophic. Regional vascular
structures are notable for extensive atherosclerotic
calcification of the aorta. The patient is status post
aortobifemoral bypass graft, which appears unchanged. There is
no evidence of expanding abdominal aortic aneurysm. There is a
large duodenal diverticulum. There is a ventral wall hernia,
containing loops of bowel without evidence of obstruction. There
is no free gas or fluid in the upper abdomen. There is a small
right spigelian hernia, containing a loop of bowel, though with
no obstruction. The urinary bladder and distal ureters are
normal. The uterus is normal and note is made of calcification
of the arcuate arteries. The adnexa are unremarkable. There is a
large amount of stool seen at the rectum, and rectal anastomotic
sutures are unchanged. There is no free gas or fluid in the
pelvis. There is no pelvic sidewall or inguinal lymphadenopathy.
OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic
lesion. Note is made of degenerative changes in the lower lumbar
spine.
.
[**2149-9-16**] CT CHEST W/O CONTRAST: The aorta is normal in caliber.
There is no
evidence of medialized atherosclerotic plaque to suggest
dissection, though assessment is limited without contrast. Note
is made of extensive coronary arterial calcification as well as
coronary arterial stents. There is trace pericardial fluid.
There is a small left pleural effusion and no right pleural
effusion. There are scattered mediastinal and hilar lymph nodes,
none of which appear enlarged by size criteria. There is no
axillary lymphadenopathy. Evaluation of the lungs is slightly
limited secondary to respiratory motion. Note is made of
biapical pleural parenchymal scarring. Additionally, there is
mild pulmonary edema. A poorly delineated nodule is visualized
in the right lower lobe (2:27), not clearly seen on comparison
studies, likely representing an area of inflammation or pleural
thickening.
Brief Hospital Course:
82 yo F w/ PMH pulmonary hypertension and COPD on 3-4L O2 at
home, CAD s/p MI with stent placement in RCA/LAD in [**2140**] and
LMCA and LAD in [**4-23**], HTN, dyslipidemia, PVD, CKD (baseline
2.5-2.9), COPD who p/w acute onset of intermittent back pain,
thought to be musculoskeletal in nature and transient hypoxia.
.
ACUTE
# Arrest - Pt's had left lower back pain, right neck pain and
bilateral shoulder pain on HD #3. She previously had been having
transient right-sided back pain, intermittently reproducible
upon palpation that was thought to be musculoskeletal in nature.
For this episode of pain on HD #3, she received flexeril for the
pain and zofran for associated nausea. However, she became
hypotensive during this episode, with SBP in the 60s. The pt was
having agonal breaths, but had a pulse. She was then ventilated
with a bag-mask. She became bradycardic and was given 1 amp of
atropine but this blew out her IV line. As a femoral line was
about to be placed, it was noted that the pt was not taking any
breaths of her own at all, and as she was DNI, interventions
were stopped and the patient passed.
.
# Back pain - Patient presented with acute onset right-sided
back pain that had lasted for 3 hours. Pt's pain resolved while
she was in the ED, but returned once she was transferred from
the CCU to the medical floor. Thoughts about the etiology of the
pain included muscle spasm as the pain was transient and
reproducible upon palpation in the ED or early zoster as it is
common for the pain to precede the rash, though no rash had been
noted as of yet. Pt's pain returned on HD#2, and she received
tylenol and a lidocaine patch.
.
# Hypoxia - Pt was on 3-4L 02 at home with baseline sats in
low-mid 90s. Pt transiently on NRB in the ED and was quickly
transitioned to 4L NC upon transfer to CCU with 02 sats in the
low 90s. Appeared back to her baseline. Unclear etiology of
transient hypoxia but could have been due to decreased
oxygenation secondary to tachypnea as a result of her pain.
.
CHRONIC
# Pulmonary Hypertension: Most recently shown to have PASP of
68mmHg with moderate improvement with Nitric Oxide to 49mmHg on
cardiac catheterization in [**5-24**]. Had trial of sildenafil with
minimal improvement in pulmonary vascular resistance. Etiology
could be due to chronic thromboembolic disease as pt has hx of
PE, with contribution from her COPD. Does not appear to be in
acute right heart failure though she could be slightly fluid
overloaded. She was continued on her home torsemide and warfarin
until HD #3 when her INR was 3.1 and her warfarin was
discontinued.
.
# CAD s/p MI and 4 stent placement: Pt is s/p MI in [**2117**] w/
RCA/LAD stents in [**2140**] by Dr. [**Last Name (STitle) 2257**] ([**Hospital1 3494**]) and LMCA and
LAD DES [**2149-4-23**] at [**Hospital1 18**]. Pt was chest-pain free. EKG showed no
acute changes and no STE. She was continued on her home aspirin,
plavix, metoprolol, isosorbide mononitrate.
.
# COPD: Pt w/ hx of COPD and hyperinflation on CXR consistent
with emphysema. Likely attributing to her 02 requirements at
baseline. Currently stable. She was continued on her home
tiotropium bromide daily and levalbuterol prn sob/wheezing
.
# CKD - baseline Cr 2.5-2.9 secondary to renal hypoplasia
(atrophic right kidney). Pt had slightly elevated Cr (3.1) on
day of admission, that decreased to her baseline (2.9) by HD#2,
but Cr peaked at 3.6 on HD#3. She was continued on her home iron
and calcium supplementation.
.
# PVD - Her ABI was 0.79 on the left and 0.66 on the right per
her last office visit with Dr. [**Last Name (STitle) **], and her pulse volume
tracings suggest bilateral superficial femoral artery
occlusions, though she is not a surgical candidate due to her
multiple comorbidities. She was encouraged to continue walking
despite the pain because otherwise she may lose the ability to
walk secondary to severe PVD. She is unable to take Cilostazol
due to her history of congestive heart failure.
Medications on Admission:
aspirin 325 mg Tablet Sig: 1 Tablet Daily
clopidogrel 75 mg Tablet Sig: 1 Tablet Daily
pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: 1 Tablet,
Delayed Release (E.C.) every 24 hours
folic acid 1 mg Tablet Sig: 1 Tablet Daily
tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: 1
Cap Inhalation Daily
levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
1 neb Inhalation q6-8 hours prn dyspnea or wheezing
torsemide 5 mg Tablet Sig: 2 Tablet Daily
metoprolol succinate 50 mg PO daily
latanoprost 0.005 % Drops Sig: 1 Drop Ophthalmic HS
warfarin 1 mg Tablet PO Daily at 4 PM.
acetaminophen 325 mg Tablet, 2 Tablet PO Q6H prn pain.
ferrous sulfate 300 mg (60 mg iron), 1 Tablet PO Daily
multivitamin 1 Tablet PO Daily
nitroglycerin 0.4 mg Tablet, Sublingual, 1 tab PRN chest pain
isosorbide mononitrate 30 mg Tablet Extended Release 1 Tablet
daily
calcitriol 0.25 mcg Capsule, 1 Capsule PO Monday
-Wednesday-Friday
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
Completed by:[**2149-9-19**]
|
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"790.92",
"V49.86",
"440.20",
"458.29",
"724.8",
"E934.2",
"585.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14869, 14878
|
9866, 13850
|
516, 522
|
14929, 14938
|
6069, 9843
|
14994, 15143
|
4203, 4347
|
14837, 14846
|
14899, 14908
|
13876, 14814
|
14962, 14971
|
4387, 6050
|
455, 478
|
550, 2957
|
3354, 3954
|
3970, 4187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,418
| 118,975
|
4356
|
Discharge summary
|
report
|
Admission Date: [**2132-2-25**] Discharge Date: [**2132-2-28**]
Date of Birth: [**2084-1-21**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Zetia
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 18801**] is a 48 yo M with a history DM, IGA nephropathy,
hypertension who presented with chest pain and orthopnea. The
patient reports that over the last 1 week he has been feeling
unwell with decreased appetite and general malaise. He then
reported that on friday he began to feel more frustrated about
his illness and having to take medicaitons and decided to stop
taking them. At this time he did not have any suicidal thoughts,
just did not feel like taking his medications. However, he did
express feeling depressed about his medical condtion.
.
Within approximately 24 hours of stopping his meds he began to
have symptoms of chest pain (pleuritic, positional, pressure in
chest), dry cough, dyspnea at rest, orthopnea, blurry vision and
right-sided, throbbing headaches. He decided to get medical care
today for these symptoms. He reported nausea with emesis x 1.
Also had palpiations.
.
In the ED he got SL NTG, nitro gel with improvement of his sx,
but unchanged BP. He then was started on a nitro gtt and given
80 mg IV lasix, diltiazem SR 360 mg x 1, hydralazine 100 mg
once. ED resident spoke with cards who recommended giving the
home meds. No ECG changes per ED with exception of TWI. BPs
initially 241/114, HR 90 02 sat 99 % RA . Not yet on dialysis,
renal consult fellow notified.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: cath in [**5-11**] with no
interventions needed
3. OTHER PAST MEDICAL HISTORY:
-Diabetes mellitus for over 20 years. History of retinopathy and
laser
treatment as well as neuropathy. He also has a history of
peripheral vascular disease
-Hypertension.
-Hyperlipidemia: He had been on atorvastatin for at least three
years before discontinuing this and Zetia due to elevated CK.
-Chronic kidney disease due to IgA nephropathy. Stage 5.
-Status-post left great toe amputation, right knee surgery, and
right wrist surgery (the latter two for injuries sustained from
falls).
Social History:
He lives alone. He worked previously as a cook.
He stopped when he went on disability about three years ago. He
smoked [**2-8**] to 1 ppd since a teenager, but quit 6 weeks ago. He
rarely drinks alcohol. He smokes marijuana occasionally.
Family History:
His mother died of breast cancer at 59, had DM and HTN. His
father is 68 and has HTN. He has two siblings, one sister
with diabetes and one brother with hypertension. He has a
healthy 20-year-old son.
Physical Exam:
VS: T=98.3 BP=167/87 HR=94 RR=18 O2 sat= 98%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate. AA male
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 14 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or slight right-sided tenderness. No
abdominial bruits.
EXTREMITIES: No c/c/e. missing great big toe on left
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
LABS ON ADMISSION:
.
[**2132-2-25**] 06:45PM WBC-7.2 RBC-2.98* HGB-8.8* HCT-25.6* MCV-86
MCH-29.6 MCHC-34.4 RDW-15.0
[**2132-2-25**] 06:45PM NEUTS-68.7 LYMPHS-23.2 MONOS-4.0 EOS-3.2
BASOS-0.9
[**2132-2-25**] 06:45PM GLUCOSE-96 UREA N-69* CREAT-9.9*# SODIUM-145
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-20* ANION GAP-20
[**2132-2-25**] 06:45PM CALCIUM-6.8* PHOSPHATE-8.1* MAGNESIUM-2.3
[**2132-2-25**] 06:45PM CK(CPK)-5999*
[**2132-2-25**] 06:45PM CK-MB-23* MB INDX-0.4 cTropnT-0.51*
proBNP-[**Numeric Identifier 18802**]*
.
RADIOLOGY:
CXR ([**2-25**]):
IMPRESSION: The patient is not in failure by radiograph. There
is a
moderate-sized left pleural effusion with adjacent patchy
opacity. While this may be due to adjacent relaxation
atelectasis, an early developing infiltrate with a corresponding
parapneumonic effusion cannot be excluded.
VENOUS MAPPING: IMPRESSION: No evidence of central venous
stenosis. Normal arterial waveforms in bilateral brachial
arteries. Small upper extremity veins with the exception of the
left basilic vein which would be appropriate for AV fistula.
Brief Hospital Course:
HYPERTENSIVE EMERGENCY:
He was admitted to the CCU and started on a NTG gtt. He was
restarted on home meds including lisinopril but excluding
valsartan. NTG was weaned on [**2-26**]. Je was restarted on his
home regimen and his blood pressures normalized.
- Outpatient optho eval given vision changes. Scheduled for Wed,
[**3-12**] 2:00PM.
.
RENAL FAILURE: Patient had a significantly elevated creatinine
on admission likely related to acute kidney injury from
hypertension in the setting of chromic renal insufficiency.
Renal was consulted and monitored daily to evaluate for the
possibility of needing dialysis. His creatinine stabilized and
he was able to avoid dialysis with this admission. He had
venous mapping done for potential AV fistula placement. He was
discharged with a plan for lab draws to be followed by renal.
.
CK ELEVATION: He was also noted to have CK elevations out of
proportion to CK-MB. Baseline CK around 1000, peaked around
5000. This elevation may have been related to acute renal
failure or myocardial demand. He has had chronic CK elevations
with unclear diagnosis in spite of extensive evaluation. These
findings were discussed with his outpatient rheumatologist and
he was seen by his outpatient neurologist. No further testing
was indicated and he will continue to follow up this outpatient
workup.
.
ANEMIA: Hematocrit 22 from baseline in 30s. Patient has
microcytic, hypochromic anemia with low iron and is likely iron
deficient. Also may be anemic from renal failure or hemolysis
from hypertension, but does not have elevated TIBC or low
haptoglobin. He has no evidence of active bleeding. Transfussed
one unit.
.
CHEST PAIN and TROPONIN ELEVATIONS: Improved with nitroglycerin,
no significant ECG changes. Likely secondary to hypertensive
emergency. Additionally, patient did have negative stress test
last month without signs of coronary ischemia. He was continued
on ASA, BB, ACE.
.
DIABETES: Patient was mildly hypoglycemic at times. HbA1c 5.7 %
suggesting excellent control. His lantus dose was decreased from
20 to 17 units.
.
DEPRESSION: Patient denies feeling depressed or that his mood
has affected his medication compliance. Social work was
consulted to discuss patient coping.
Medications on Admission:
DILTIAZEM HCL - 360 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
FUROSEMIDE - 80 mg Tablet - one Tablet(s) by mouth two tablets
in
the AM and one in the afternoon
HYDRALAZINE - 50 mg Tablet - two Tablet(s) by mouth three times
a
day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - take 20 units
daily
INSULIN LISPRO [HUMALOG] - (Dose adjustment - no new Rx) - 100
unit/mL Solution - Per sliding scale with meals
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - one
Tab(s) by mouth daily
PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 50 mg
Capsule - 1 Capsule(s) by mouth three times a day
VALSARTAN [DIOVAN] - 320 mg Tablet - one Tablet(s) by mouth
daily
at night
ASA 325mg QDAY
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
2. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
8. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for at night: take in the evening.
9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
10. Insulin Glargine 100 unit/mL Cartridge Sig: Seventeen (17)
units Subcutaneous at bedtime.
11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Insulin Lispro 100 unit/mL Solution Sig: 1-10 units
Subcutaneous three times a day: as directed per sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertensive emergency, myocardial infarction due to
demand ischemia, acute renal failure, chronic kidney disease
Secondary: Anemia, chronic hypertension, medicatio
noncompliance, diabetes
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted with chest pain and difficulty breathing after
stopping your blood pressure medications. Your high blood
pressure resulted in kidney damage and poor blood flow to your
heart causing heart damage. You were treated for the high blood
pressure and all your medications were restarted. Once
improved, you were discharged home for further recovery.
Your blood levels were low and you received a blood transfusion
for this.
Take all medications as prescribed, including all of your blood
pressure medicaitons. You should not stop these medicaitons
unless instructed by your doctor.
Please keep all outpatient appointments.
Seek medical advice if you notice fever > 101, chills,
difficulty breathing, chest pain, difficulty with urinating or
any other symptom which is very concerning to you.
Followup Instructions:
In addition to the following appointments, your renal doctor
(Dr. [**Last Name (STitle) 118**] will call to schedule an appointment. If you do
not hear from them in the next two days, please call
[**Telephone/Fax (1) 60**].
[**2132-5-2**] 12:00p [**Doctor Last Name **],[**Doctor Last Name **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] NEUROLOGY UNIT CC8 (SB)
[**2132-4-9**] 08:30a [**Last Name (LF) 2540**],[**First Name3 (LF) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] RENAL DIV-CC7 (SB)
[**2132-4-8**] 01:00p [**Last Name (LF) 2106**],[**First Name3 (LF) 2105**]
LM [**Hospital Unit Name **], [**Location (un) **] TRANSPLANT MEDICINE (NHB)
[**2132-3-26**] 01:30p [**Last Name (LF) **],[**First Name3 (LF) **] (RHEUM LMOB)
LM [**Hospital Unit Name **], [**Location (un) **] RHEUMATOLOGY LMOB WEST (SB)
[**2132-3-20**] 02:20p [**Last Name (LF) **],[**First Name3 (LF) **] (TRANSPLANT)
LM [**Hospital Unit Name **], [**Location (un) **] TRANSPLANT CENTER (NHB)
[**2132-3-12**] 11:00a [**Last Name (LF) 14290**],[**First Name3 (LF) **] G.
[**Hospital6 29**], [**Location (un) **] OPTOMETRY
[**2132-3-7**] 02:50p [**Last Name (LF) **],[**First Name3 (LF) **] (TRANSPLANT)
LM [**Hospital Unit Name **], [**Location (un) **] TRANSPLANT CENTER (NHB)
[**2132-3-5**] 08:30a PODIATRY,[**Location (un) 542**]
BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] [**Hospital 1947**] CLINIC
(SB)
Completed by:[**2132-3-8**]
|
[
"584.9",
"250.40",
"585.6",
"285.9",
"403.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9297, 9303
|
5140, 7375
|
286, 292
|
9546, 9585
|
4023, 4028
|
10445, 11983
|
2987, 3190
|
8214, 9274
|
9324, 9525
|
7401, 8191
|
9609, 10422
|
3205, 4004
|
2101, 2187
|
236, 248
|
320, 1996
|
4042, 5117
|
2218, 2714
|
2018, 2081
|
2730, 2971
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,856
| 134,189
|
24623
|
Discharge summary
|
report
|
Admission Date: [**2171-8-6**] Discharge Date: [**2171-9-3**]
Date of Birth: [**2117-2-27**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Levaquin
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Anasarca, SOB x 1 week
Major Surgical or Invasive Procedure:
Thoracentesis [**2171-8-7**], [**2171-8-14**], [**2171-9-3**]
Transesophageal echocardiogram [**2171-8-26**]
Placement of Central intravenous catheter [**2171-8-23**]
PICC line placement [**2171-8-27**]
TIPS evaluation [**2171-8-27**]
History of Present Illness:
Patient is a 54 y/o female with IDDM, traumatic brain injury
[**2167**] (memory impairment), HCV cirrhosis, esophogeal varices, hx
of R hydropneuomothorax, HCC s/p radio freq ablation in [**Month (only) **]
[**2170**] s/p TIPS two weeks ago, admitted for worsening anasarca x 1
week and worsening SOB and nonproductive cough x 4 days.
Direct admit from clinic, multiple paracentesies, thoracentesies
and SBP over the past two years.
Patient states that most questions have to be deferred to her
daughter [**Name (NI) **], because patient has memory problems since [**Name (NI) 8751**] in
[**2167**].
Patient admits to increase in lower ext swelling, abdominal
swelling, upper arm swelling, and facial edema x 1 week. She
reports her weight to be 149 lbs. Admits to continual chills,
but no fevers or rigors. Admits to chronic diarrhea, but no
bloody or melanotic stools. No vomiting.
Of note, patient does not have any lasix or spironolactone
listed on her personal med list. She was also not discharged on
any lasix or spironolactone on her last discharge from [**Hospital1 18**] on
[**7-24**].
ROS: Patient denies CP, dysuria, hemoptysis, hematemesis,
ALLERGIES: levaquin/flagyl
Past Medical History:
Hepatitis C cirrhosis
HCC s/p RFA in [**2171-5-3**]
Chronic kidney disease, most likely due to diabetes (nephrology
consulted last admission)
s/p MVC -> brain injury with cognitive impairment and paralyzed
vocal cords
s/p multiple pericenteces
s/p multiple thoracenteces for R pleural effusions
h/o 2 episodes SBP in past year
HCC s/p RFA in [**2171-5-3**]
Type 2 Diabetes mellitus x 17 years, on insulin
Hypertension
s/p motorcyle accident [**2167**]
-traumatic brain injury, coma x 8 weeks
-s/p failed trial of IFN 17 yrs ago
Social History:
Home: Lives with sister in [**Name (NI) 47**]
Remote history of tobacco, questionable drug/alcohol use/abuse
Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62169**] Healthcare proxy, [**Name (NI) **] home
[**Numeric Identifier 62172**]. Cell[**Telephone/Fax (1) **]. Pt does not recall if she used IV
drugs in the past. Denies current etoh use.
Family History:
No family history of liver disease
Sister with non-[**Name (NI) 29512**] lymphoma and lung cancer. Other sister
with [**Name2 (NI) 499**] cancer (age 58). Several family members with DM2.
[**Name2 (NI) 6961**] both died age 60s or 70s of myocardial infarctions.
Physical Exam:
VS: 188/70 HR 68 Resp 28 RA 90-94%
GEN: Appears much older than stated age, NAD, AAOx3
HEENT: constricted pupils but still reactive, sclera anicteric,
eomi, no nystagmus, no lad, OP clear, upper dentures, some
facial swelling.
NECK: CVP 17cm, no bruits
CV: RRR Sys murmur [**1-8**] best heard at RUSB rads to LUSB., nl PMI,
no heaves
LUNGS: dullness to percussion, decreased BS, and egophony R i/2
post lung field.
L lung field clear
ABD: Shifting dullness to percussion, fluid wave+, nontender, bs
present
EXT: good pulses in ext, edema 3+ bilat lower ext up to sacrum.
2+ bilat edema in hand arms up to shoulders.
NEURO: CN2-12 intact, motor intact, nl symmetric reflexes,
strength 5/5 intact.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2171-9-1**] 04:00AM 12.4* 2.69* 7.4* 22.9* 85 27.4 32.1
17.4* 595*
[**2171-8-30**] 04:23AM 12.0* 2.90* 8.1* 25.3* 87 28.0 32.0
17.4* 553*
[**2171-8-8**] 05:02AM 12.2* 2.76* 8.0* 24.0* 87 29.1 33.5
17.0* 405
[**2171-8-7**] 03:30PM 14.0* 4.01* 11.5* 33.9* 84 28.8 34.1
16.9* 407
[**2171-8-6**] 11:35PM 13.6* 4.09* 11.5* 34.7* 85 28.1 33.2
16.8* 411
.
BASIC COAGULATION PT PTT INR(PT)
[**2171-9-1**] 04:00AM 16.1* 39.0* 1.5*
[**2171-8-22**] 04:44AM 13.3* 36.7* 1.2*
[**2171-8-6**] 11:35PM 13.2* 90.1* 1.2*
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2171-9-1**] 04:00AM 116* 34* 3.4* 137 4.2 108 21*
[**2171-8-28**] 09:19AM 86 40* 3.4* 134 4.2 106 20*
[**2171-8-27**] 04:21AM 79 40* 2.8* 139 4.6 110* 20*
.
[**2171-8-20**] 04:23AM 109* 50* 3.3* 142 3.9 112* 21*
[**2171-8-18**] 04:17AM 165* 53* 3.7* 140 3.8 108 23
.
[**2171-8-8**] 05:02AM 51* 52* 2.9* 145 4.5 118* 18*
[**2171-8-6**] 11:35PM 201* 49* 2.8* 142 4.3 116* 15*
.
ENZYMES & BILIRUBIN ALT AST LDH AlkPhos TotBili
[**2171-8-28**] 03:15PM 8 19 85 0.3
[**2171-8-15**] 04:40AM 9 21 257* 112 0.4
[**2171-8-6**] 11:35PM 15 30 320* 206* 0.3 Amylase
40
.
.
[**2171-8-6**] ABDOMEN US: IMPRESSION:
1. Large right pleural effusion. Spot marked for thoracentesis.
2. Small ascites. No mark made for bedside paracentesis.
3. Patent TIPS with wall-to-wall flows, velocities ranging from
one
110.0 to 140.0 cm/sec.
4. Status post two RF ablation lesions in the right hepatic
lobe.
5. Cirrhosis
.
[**2171-8-10**] LUNG SCAN: Indeterminate probability of pulmonary
embolism with a matched defect in the right mid and lower lobe
and associated effusion seen on Xray.
.
[**2171-8-20**] LUNG SCAN: Low probability of pulmonary embolism.
.
BILAT LOWER EXT VEINS [**2171-8-10**]: No evidence of DVT
.
[**2171-8-12**] Echo: Nml left ventricular wall thickness, cavity size
and regional/global systolic function (LVEF >55%) The right
ventricular cavity is mildly dilated. No AS or AR. Physiologic
mitral regurgitation is seen (within normal limits). Moderate
[2+] TR. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. Compared to [**2171-6-20**] images, RV cavity increased with
pulm artery HTN no present & TR increased.
.
[**2171-8-26**] Transesophageal echo
Mild mitral regurgitation with normal valve morphology. No 2D
echocardiographic evidence for endocarditis. No evidence of
atrial septal
defect or significant intrapulmonary shunt with agitated saline
contrast with maneuvers. Complex, non-mobile atheromas in
descending thoracic aorta
Brief Hospital Course:
ASSESSEMENT/PLAN: 54 y/o F w/ HCV cirrhosis s/p TIPS [**7-/2171**],
HCV s/p radiofrequency [**5-/2171**] initially admitted for SOB &
anasarca, complicated by MICU stay for resp. distress and
subsequently developing GNR bacteremia as well as acute on
chronic renal failure.
.
# Anasarca and volume overload: Etiology was felt to be
secondary to a combination of liver disease, nephrotic syndrome
([**1-4**] chronic kidney disease), and albumin 1.9 on admission.
Initially there was concern for TIPS failure but [**8-7**] ultrasound
showed a widely patent TIPS. Pt received aggressive albumin
replacement and diuresis with moderate urine output. Diuresis
had to be discontinued due to worsening renal failure. Pt was
not restarted on diuresis at discharge but was instructed to
weigh herself daily and report wts. greater than 3lbs daily to
her PCP.
.
# Pleural effusion: Pt admitted with R pleural effusion worse
than previously. Appeared to be hydrothorax consistent with
portal hypertension and cirrhosis. Therapeutic thoracentesis
were performed, however with rapid reaccumulation of the fluid R
> L. Developed respiratory distress requiring transfer to the
MICU. Pleurodesis was considered but discarded, the decision was
made not to place a pleurex catheter as longterm, because would
continue to drain given portal hypertension and have potential
for infection. A thoracentesis was done on the day of discharge
without complications ~2L was removed. Pt's O2sats were 96% on
RA.
.
# Respiratory Distress: Pt admitted with increased O2
requirement however worsened and required stay in MICU. Did not
require intubation during this stay. Resp. distress was thought
to be related to hydrothorax secondary to cirrhosis, however
there was the possibility of PE, hence was empirically treated
with heparin infusion. However, repeat V/Q scan showed low
probability. She was also aggressively diuresis, at one point on
a lasix drip. She underwent multiple thoracentesis as above for
R>L pleural effusions.
.
# HCV Cirrhosis: Most likely to be etiology of
hydrothorax/bilateral pleural effusion. MELD 18, HCV viral load
2.1 million during this admission. Pt not felt to be good
candidate for interferon treatment as unable to tolerate 17yrs
ago. Also felt to be transplant candidate due to poor mental
capacity. TIPS noted to be patent on ultrasound, however TIPS
revision indicated no significant gradient & hence no further
dilation was necessary. However, pt still with large R pleural
effusion.
Grade I esophageal varices; had no evidence of bleeding. Pt was
continued on lacutlose, ursodiol and propanolol.
.
# Nephrotic syndrome: Admitted with anasarca also, found to have
nephrotic syndrome. Appeared to be more consistent with
longstanding diabetes rather than HCV glomerulonephritis as spep
normal, [**Doctor First Name **] neg, c3,c4 normal and cryoglobulins neg. Renal
biopsy did not occur as felt to not significantly change
management. Initially treated with valsartan, however eventually
discontinued with worsening creatinine level. The renal service
was involved in the care of the patient.
.
# Pulmonary HTN: Discovered on echocardiogram in the w/u for
dyspnea in this pt. No evidence of pulmonary emboli, no clear
etiology at this point. Pulmonary was involved in the care of
this patient. Strongyloidis antibody negative. Pt considered not
to be a good candidate for right heart catheterization to
evaluate possible etiology. Pt with peripheral eosinophilia,
pulm: no evidence for pulmonary pneumonitis. Negative bubble
study per TEE to evaluate for septal defect: shunt as potential
cause of pulm. HTN.
.
# Acute on chronic renal failure: Pt with known chronic kidney
disease secondary to hypertension and diabetes. Started on
calcitriol, calcium acetate. Initially worsened in the setting
of aggressive diuresis while in the MICU. This improved with
decrease in diuresis. However, sudden worsening of creatinine
after initiation of Nafcillin. Finding appeared consistent with
AIN with urine eos and improvement of Cr. after cessation of the
drug. She continued to have good urine output during this
period. Cr. was ~3.6 at discharge, labs to be drawn per home
nursing services and monitored by Dr. [**Last Name (STitle) 497**] and nephrology.
.
# Anemia: Lab values consistent with anemia of chronic disease.
Required a few units of PRBC during this admission. Also started
on iron to aid in treatment of chronic kidney disease. Although
known guaiac positive stool during admission as well as
esophageal varices, no evidence of active bleeding.
.
# Diabetes Mellitus: Pt with long standing diabetes, received
glargine daily with sliding scale insulin. However, had
hypoglycemic episode in the setting of poor po intake. Hence
long acting stopped, pt's sugars well controlled on only sliding
scale insulin.
.
# Hypothyroidism: Pt was continued on synthyroid, however dose
was doubled during admission due to elevated TSH of 11. She was
discharged on Levothyroxine 50mg daily.
.
# HTN: Poorly controlled hypertension prior to admission, BP
continued to remain elevated during admission despite aggressive
BP therapy. The renal service contributed that some level of
hypertension should be allowed for adequate renal perfusion
given chronic hypertension and diabetic nephropathy. She was
discharged home on home regimen of propanolol 20mg TID as well
as amilodipine daily.
.
# Traumatic brain injury [**Last Name (STitle) 8751**] [**2167**]. Short term and long term
memory loss, appears stable based off prior notes.
.
# Bacteremia: Pt found to have MSSA in [**1-6**] bottles as well as
coag negative staph. She was initially treated with Vancomycin
then continued on augmentin for combined treatment of MSSA and
enterococcus UTI. However, pt developed fevers despite treatment
and had to be restarted on Vancomycin. Naficillin was added to
the regimen, however developed symptoms consistent with AIN,
thus had to be stopped. Vancomycin levels were 47, hence stopped
and levels monitored. She did not require additional dosing of
vancomycin. ID was involved in the care of this patient.
.
# UTI: Initially found to have UTI with enterococcus sensitive
to ampicillin. Was treated with augmentin. Repeat culture was
dirty, started empirically on ceftriaxone, this was discontinued
as repeat UA & cultures were bland.
.
Pt was discharged home with home O2 and PICC line in place. She
is to be closely monitored with labs as well as follow up with
her primary care physician.
Medications on Admission:
Levothyroxine 25mcg daily
trazodone 200mg qhs
norvasc 10mg qam
ursodiol 300mg tid
atarax 25mg [**Hospital1 **]
prilosec 20mg daily
propranolol 20mg TID
lactulose 1 tsp daily
Glargine 20 units Q 12hr
Regular insulin sliding scale
Discharge Medications:
1. home oxygen
Patient should receive home oxygen at 2-6L per minute by nasal
canula as needed to maintain O2sat > 94%.
If O2 sat decreases below 94% or if O2 requirement suddenly
increases, please contact MD.
2. PICC LINE CARE
Please perform PICC line care per protocol
3. Trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed: Insomnia.
Disp:*40 Tablet(s)* Refills:*0*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1800 ML(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
Disp:*15 Capsule(s)* Refills:*2*
12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
13. Oxycodone 5 mg Tablet Sig: 0.5 - 1 Tablet PO Q4-6H () as
needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please use attached sliding scale
4 times daily.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Recurrent pleural effusions
Bacteremia
Urinary tract infection
Acute on chronic renal failure
Hepatitis C cirrhosis
Hepatocellular carcinoma s/p RFA
Discharge Condition:
Stable. O2sats 93% on 2L; 96% on RA after thoracentesis.
Discharge wt. 60.2kg
Discharge Instructions:
You were admitted with shortness of breath related to fluid
collection around your lungs. We drained the fluid however
because of your liver failure, the fluid will reaccumulate.
.
You also developed an infection in your blood and bladder. You
received treatment for this.
.
We have made some changes to your medications. Please see the
medication list for medications you should be on. These are the
changes made.
- You have been started on home O2 at 2 liters.
- Please do not take glargine insulin(long acting). You may use
the
regular insulin at meal times. You'll need to check your
sugars
before each meal and at bedtime. We've provided a sliding
scale.
- Take 2 tablespoons of Lactulose twice daily
- Take Iron pills three times a day
- Increased your levothyroxine from 0.25mcg to 0.5mcg
- Calcium acetate 1334mg by mouth three times daily
- Calcitriol 0.25mg by mouth every OTHER day
.
Please call Dr[**Last Name (STitle) **] office to schedule an appointment. You
have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] (Kidney doctor) on
[**2171-9-26**].
.
Weigh yourself daily.
.
Please come to the emergency room or call your doctor if you
develop fevers, decreased urine, shortness of breath, increase
in weight or size of abdomen or any other worrisome symptoms.
Followup Instructions:
Please call Dr.[**Name (NI) 948**] office and make an appointment to see
him within 1-2weeks of discharge from the hospital.([**Telephone/Fax (1) 10248**]
.
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2171-9-26**] 9:00
.
RENAL: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2171-9-26**] 1:00
|
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"572.3",
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"518.81",
"571.5",
"250.40",
"584.9",
"403.90",
"511.8",
"790.7",
"416.0",
"511.9",
"041.4",
"070.54",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
15180, 15229
|
6542, 13032
|
298, 535
|
15422, 15502
|
3705, 6519
|
16875, 17341
|
2711, 2974
|
13312, 15157
|
15250, 15401
|
13058, 13289
|
15526, 16852
|
2989, 3686
|
236, 260
|
563, 1755
|
1777, 2307
|
2323, 2695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,449
| 133,796
|
39779
|
Discharge summary
|
report
|
Admission Date: [**2103-8-2**] Discharge Date: [**2103-8-14**]
Date of Birth: [**2046-12-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Transfer from OSH with SAH
Major Surgical or Invasive Procedure:
[**2103-8-1**]: Cerebral Angiogram- Diagnostic
History of Present Illness:
56 yo female with PMH of HLP and spontaneous pneumothorax
presents with new onset headache and neck stiffness. Patient
states that she woke up this morning at 3:30 am was speaking to
her son when she developed a sudden onset of a [**8-26**] headache.
Pain was located along the bifrontal region of the head and was
associated with neck stiffness and some blurry vision. NO
diplopia, nausea, vomiting, dsyarthria, or dysphagia.
Past Medical History:
Spontaneous pneumothorax [**2068**] s/p chest tube
Social History:
social EtOH. Ex smoker 20 years ago. No illicit drug
use. Not sexually active.
Family History:
Stroke - father in his 50s
Physical Exam:
PHYSICAL EXAM:
O: T:98.9 BP: 121/58 HR:59 R 14 O2Sats 99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERRL EOMI
Neck: Supple. negative kernig sign
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-17**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-21**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
DISCHARGE EXAM:
Intact
Pertinent Results:
[**2103-8-2**] 04:07PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2103-8-2**] 04:07PM PT-12.0 PTT-24.3 INR(PT)-1.0
[**2103-8-2**] 04:07PM PLT COUNT-268
[**2103-8-2**] 04:07PM WBC-7.5 RBC-4.35 HGB-12.8 HCT-37.4 MCV-86
MCH-29.3 MCHC-34.2 RDW-12.8
[**2103-8-2**] CT head
SAH with question of small R posterior AVM
[**2103-8-2**] Angiogram: IMPRESSION: Fetal configuration of the right
PCA, which supplies the vascular malformation in the right
posterior parietal lobe. This is consistent with an AV fistula
which has a single dilated vein which has significant stenosis
distally.
Ultrasound:
Acute thrombus seen in distal left cephalic vein in the region
of the antecubital fossa, without extension proximally into the
mid-to-upper portion of the cephalic vein, nor into the deep
veins of the right arm.
Brief Hospital Course:
[**8-2**] Pt admitted to neurosurgery service and underwent emergent
diagnostic cerebral angiogram to evaluate for AVM or aneurysm.
She was transferred to the ICU for q1 neurochecks and strict
blood pressure control less than 140. Upon post op examination
she was doing well. Her groin site was clean and dry with no
hematoma and she had good distal pulses. She remained
neurologically intact with full strength and orientation. She
was kept on flat bed rest for 4 hours after sheath removal and
her diet was advanced.
[**8-3**] -[**8-5**] She remained neurologically intact and was closely
monitored hemodynamically. Pain was controlled and planning was
initiated for treatment.
On [**8-6**] She was cleared for transfer to the stepdown. Dr [**First Name (STitle) **]
requested a second opinion from a physician at [**Name9 (PRE) 2025**] per the
patient's request.
On [**8-7**] the patient was pre-op'd for angiogram and embolization.
ON [**8-8**] patient went to Angio with Dr. [**First Name (STitle) **] for attempted
embolization of her AVM, but the angiogram did not reveal a
draining vein in the complex and hence embolization was not
possible, patient was transferred back to the floor.
On [**8-10**] patient developed a fever of 101.6 and as part of the
fever work up a Chest Xray and UA was ordered. Upon examination
on [**8-11**] we noted a tender right upper extremity with a cord like
vein in the right anti cubital fossa from an old IV. A right
upper extremity Ultrasound was obtained. Patient is refusing a
CXR at this time. Right upper extremity US revealed a
superficial cephalic vein thrombosis which does not require
anticoagulation; she has been advised to use warm compresses and
NSAIDs for treatment.
After review of her case and images with Dr. [**Last Name (STitle) 87594**] from [**Hospital1 2025**],
Dr. [**First Name (STitle) **] offered the patient a coiling on [**8-13**] and the patient
opted to seek a second open ion and think over the procedure.
The patient is afebrile and is being taken off of her Keppra
since she has been seizure free and discharged home with follow
up appointments.
Medications on Admission:
MVI
1 gram of fish oil PO daily
Vit D [**2092**] units q day
co enzyme q 10
gingko
Discharge Medications:
.
1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for Headaches.
Disp:*30 Tablet(s)* Refills:*0*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SAH, Arteriovenous malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram
?????? 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:
?????? When you go home, 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
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
> You were taking Keppra for siezure propholaxis during your
hospitalization since you had no seizures after your initial
hemorrhage you will not need to continue to take this
medication. Given your the Short duration which you were on this
medication you do not require a taper. you can just stop this
medication.
Followup Instructions:
Follow-Up Appointment Instructions
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] on [**8-17**] at 9am. Location:
[**Hospital Ward Name 332**] Basement ( Radiation Specialist)
You are scheduled to see Dr. [**Last Name (STitle) 1132**] on [**8-17**] at 3pm. You need
to arrive at [**State 83674**], Proger building.
Registration is located on the [**Location (un) 448**] on the Proger
Building. Once you are finished, proceed to the [**Hospital 4695**]
clinic which is located on the [**Location (un) 436**].
Your images have been uploaded to a disk. Once you are
discharged, you need to pick up the cds at West Clinical Ctr,
[**Location (un) 470**], film library (across from radiology dept).
Please return our office to see Dr. [**First Name (STitle) **] on in 2 weeks. Call
[**Telephone/Fax (1) 1669**]
Completed by:[**2103-8-14**]
|
[
"780.60",
"453.81",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6191, 6197
|
3292, 5418
|
301, 350
|
6273, 6273
|
2442, 3269
|
7673, 8552
|
999, 1028
|
5552, 6168
|
6218, 6252
|
5444, 5529
|
6424, 7650
|
1058, 1294
|
2415, 2423
|
235, 263
|
378, 809
|
1587, 2399
|
6288, 6400
|
831, 884
|
900, 983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,182
| 115,566
|
33857
|
Discharge summary
|
report
|
Admission Date: [**2116-6-1**] Discharge Date: [**2116-6-7**]
Date of Birth: [**2049-10-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lovastatin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
CP & SOB
Major Surgical or Invasive Procedure:
CABG X 3, pericardial stripping on [**2116-6-3**]
History of Present Illness:
66 y/o male s/p cardiac cath, presented to ED w/CP. Workup
revealed possible constrictive pericarditis (and know CAD from
cath). He was transferred to [**Hospital1 18**] for surgery.
Past Medical History:
HTN
Gallstones
Chronic sinusitis
hypothyroid
s/p melanoma excision
prostate ca s/p surgery
Social History:
retired
ETOH: few per week
Denies tobacco
Family History:
father w/CAD
Physical Exam:
Unremarkable upon admission
Pertinent Results:
[**2116-6-4**] 02:31AM BLOOD WBC-10.9 RBC-3.97* Hgb-11.8* Hct-34.4*
MCV-87 MCH-29.7 MCHC-34.4 RDW-13.3 Plt Ct-183
[**2116-6-4**] 02:31AM BLOOD PT-12.3 PTT-26.6 INR(PT)-1.0
[**2116-6-4**] 11:55PM BLOOD Glucose-125* UreaN-20 Creat-1.4* Na-141
K-4.4 Cl-104 HCO3-29 AnGap-12
[**Last Name (LF) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2049-10-12**]
Age (years): 66 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2116-6-3**] at 11:58 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW3-: Machine: aw3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-5**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is mildly
depressed (LVEF= 40 - 45%). with mild global free wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-5**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post- CPB: Patient is AV paced on no pressors or inotropes.
Good biventricular systolic fxn. EF now 50 - 55%. AI unchanged.
MR remains 1 - 2+. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2116-6-3**] 13:55
Brief Hospital Course:
Transferred to [**Hospital1 18**] from outside hospital. Underwent echo,
cardiac MRI, and routine pre-operative evaluation. He was taken
to the OR on [**2116-6-3**], and underwent CABG X 3, and pericardial
stripping (please see operative report for details of
procedure). Post-operatively, he was taken to the ICU on IV NTG
gtt. He was extubated the evening of surgery, weaned off NTG,
and was transferred to the telemetry floor on POD # 1. On POD #
2, his chest tubes and epicardial pacing wires were removed, and
he began to progress with ambulation. POD # 3 Pt stable - could
not move bowels, bowel regime given. Moved Bowels. POD # 4 pt
stable for DC.
Medications on Admission:
ASA 81'
Verapamil 240'
Synthroid 0.1'
Lasix 20'
Claritin
Viagra
Lovenox
NTG
Ambien
Discharge Medications:
1. 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.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] care
Discharge Diagnosis:
CAD
constrictive pericarditis
HTN
hyperlipidemia
nephrolithiasis
Discharge Condition:
good
Discharge Instructions:
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
shower daily, no swimming or bathing for 1 month
no driving for 1 month
Followup Instructions:
With Dr. [**Last Name (STitle) 78249**] in [**3-8**] weeks
With Dr. [**Last Name (STitle) 78250**] in [**3-8**] weeks
With Dr. [**Last Name (STitle) 914**] in 4 weeks
Completed by:[**2116-6-7**]
|
[
"414.01",
"244.9",
"V10.83",
"272.4",
"411.1",
"423.2",
"401.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.31",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
6013, 6065
|
4083, 4744
|
298, 350
|
6174, 6181
|
831, 4060
|
6378, 6575
|
754, 768
|
4877, 5990
|
6086, 6153
|
4770, 4854
|
6205, 6355
|
783, 812
|
250, 260
|
378, 564
|
586, 679
|
695, 738
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,462
| 194,869
|
32662
|
Discharge summary
|
report
|
Admission Date: [**2142-11-27**] Discharge Date: [**2142-12-20**]
Date of Birth: [**2081-7-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
Right-sided thoracentesis
CT-guided biopsy of a lung nodule
cardiac catheterization
History of Present Illness:
The patient is a 61 year old Hatian-Creole speaking female who
presented on [**2142-11-27**] with shortness of [**Date Range 1440**]. History taken
via interpreter. The patient reports intermittent SOB over the
past year. She was admitted for an extended period of time to
[**Hospital 8**] hospital in [**Month (only) 116**] of this year and had an extensive
workup which included the diagnosis of severe dilated
cardiomyopathy. She reports that she returned from a trip to
[**Country 2045**] approximately three weeks ago. Immediately following her
return she started experiencing worsening of her shortness of
[**Country 1440**]. She also was experiencing pain in legs bilaterally as
well as lower extremity swelling. On presentation she endorsed
paroxysmal nocturnal dyspnea and orthopnea also endorsed a cough
productive of white sputum. At baseline she is able to walk [**1-23**]
blocks without shortness of [**Month/Day (2) 1440**] but on presentation had
dyspnea with one or two steps. She also reported an itchy rash
on her chest, back and feet which has only been present "while
she has been sick." Finally in the ER she was noted to have
"vulvar masses."
.
In the ER she was found to be hypertensive with SBP in the 170s
for which she was started on a nitroglycerin drip. She also
required BiPAP for two hours. She received Lasix 40 mg IV x1,
levofloxacin 750 mg IV x1, aspirin 325 mg x1 and Zofran 4 mg IV
x 1. CXR showed a R. sided pleural effusion and a CT torso
revealed multiple filling defects which were felt to represent
chronic pulmonary emboli and not an acute process. She was
started on lovenox and transfered to the medicine service.
.
Review of systems: Denies fevers/chills, headache, chest pain or
pressure, and abdominal pain. Has noted a decrease in her
appetite for a while, with some weight loss (unable to
quantify), but recently this is improved. Denies N/V, abdominal
pain, diarrhea, constipation, BRBPR.
Past Medical History:
CHF - EF 15-20% global hypokinesis
h/o + PPD (15 mm) in [**5-28**] at [**Hospital1 8**], AFB neg x 3, untreated
Chronic PE and R. DVT
Pulmonary nodules on CT of unclear etiology
Valvular disease: 3+ TR, 3+ MR, significant PR
? liver problem diagnosed in [**Country 2045**] (records not available)
Social History:
She currently is living wither her daughter. She came from
[**Country 2045**] one year ago and her husband is still there. She does not
smoke or drink. She denies illicit drug use.
Family History:
Both her mother and her father died suddenly. She does not know
how old they were when they died. She ahs one brother and 3
sisters who are all healthy to her knowledge. She has nine
children and 18 grandchildren who are also healthy. No known
family history of heart disease.
Physical Exam:
Admission Physical Exam:
VS-T96.8 BP108/90 P85 RR18 100%O2 on 4L
Gen- older dark-skinned woman lying in bed sleeping, breathing
only slightly labored on supplemental O2 by nasal cannula
HEENT- sclerae anicteric, PERRL, EOMs full
Neck- supple, without lymphadenopathy. No JVD seen at 30
degrees.
Lungs- good [**Country 1440**] sounds in upper and mid lung fields. Reduced
[**Country 1440**] sounds over R base, with dullness to percussion there.
Some minor crackles in L base.
Heart- regular rhythm, no m/r/g
Abd- soft, ?somewhat distended abdomen (unknown baseline),
without tenderness. Liver edge palpable ~1-1.5in below rib
margin, nontender and with no palpable nodularity. +BS
Ext- no pretibial edema bilat. Trace edema at ankles. Good DP
pulses.
Guaiac negative per ED (not repeated here)
.
Discharge Physical Exam:
Vitals: T: 98.8 BP: 84/63 P: 88 R: 20 O2: 97% on RA
.
General: Thin appearing elderly woman, sitting up in bed in no
acute distress
HEENT: PERRL, EOMI, oropharynx clear
Neck: supple, no LAD, JVP not elevated
Breast: no masses noted on my exam, no nipple discharge, no
adenopathy
CV: RRR, S1 + S2, II/VI HSM heard best at apex radiating to
axilla
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: non-tender, non-distended, bowel sounds present
Ext: WWP, 2+ pulses, no c/c/e
Skin: rash on her back, chest and the soles of her feet. Her
palms are not involved. The rash on her feet is hyperpigmented
discrete macules. On her back and chest she also has irregular
shaped hyperpigmented, slightly raised lesions.
GU: 2 cm round, soft mass within left labia minora, non-tender
Lymph: No cervical, axillary, or inguinal LAD
Pertinent Results:
ADMISSION LABORATORIES:
==========================================
Hematology:
[**2142-11-27**] 09:25PM WBC-4.0 RBC-4.13* HGB-12.0 HCT-37.4 MCV-90
MCH-28.9 MCHC-32.0 RDW-17.9*
[**2142-11-27**] 09:25PM NEUTS-31* BANDS-0 LYMPHS-60* MONOS-5 EOS-2
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2142-11-27**] 09:25PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2142-11-27**] 09:25PM PLT SMR-NORMAL PLT COUNT-202
[**2142-11-27**] 09:25PM PT-15.8* PTT-38.5* INR(PT)-1.4*
Plts 172-225
.
Chemistries:
[**2142-11-27**] 09:25PM GLUCOSE-100 UREA N-14 CREAT-1.0 SODIUM-145
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-24 ANION GAP-15
[**2142-11-27**] 09:25PM ALT(SGPT)-19 AST(SGOT)-33 LD(LDH)-298* ALK
PHOS-202* AMYLASE-117* TOT BILI-1.8*
[**2142-11-27**] 09:25PM LIPASE-32
[**2142-11-27**] 09:25PM ALBUMIN-3.1* CALCIUM-9.0 PHOSPHATE-3.7
MAGNESIUM-1.8
[**2142-11-27**] D-Dimer-4878*
.
Other Admission Labs:
[**2142-11-27**] proBNP-7535*
[**2142-11-27**] Toxicology ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2142-11-27**] 03:26AM Lactate-4.2*
[**2142-11-27**] 09:31PM Lactate-2.0
[**2142-11-27**] 02:00AM D-DIMER-4878*
[**2142-11-27**] 05:00AM Urinalysis - negative
.
Cardiac enzymes:
[**2142-11-27**] 02:00AM CK(CPK)-101 CK-MB-3 cTropnT-0.02*
[**2142-11-27**] 08:30AM CK(CPK)-56 CK-MB-NotDone cTropnT-0.01
[**2142-11-27**] 03:45PM CK(CPK)-47 CK-MB-NotDone cTropnT-0.01
[**2142-12-1**] 05:00PM CK(CPK)-62 CK-MB-NotDone cTropnT-<0.01
.
OTHER LABORATORIES:
================================================
Iron studies:
[**2142-11-29**] Iron-28* calTIBC-350 Ferritn-78 TRF-269
.
Lipid panel:
[**2142-12-6**] Triglyc-123 HDL-30 CHOL/HD-4.5 LDLcalc-79 Cholest-134
.
Hepatitis panel:
[**2142-11-28**] HBsAg-NEGATIVE HBsAb-NEGATIVE HCV Ab-NEGATIVE
[**2142-11-29**] HIV Ab-NEGATIVE
[**2142-12-5**] ANCA-NEGATIVE B
.
Thyroid:
[**2142-11-29**] TSH-2.2
.
RPR:
[**2142-12-15**] Non-reactive
.
Induced Sputum Samples:
[**2142-12-13**]: negative AFB
[**2142-12-12**]: negative AFB
[**2142-12-11**]: negative AFB
.
Pleural fluid cytology- NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells, histiocytes and lymphocytes
.
Flow Cytometry, peripheral blood-
INTERPRETATION: Non-specific T-cell dominant lymphoid profile;
diagnostic immunophenotypic features of involvement by
non-Hodgkin's B-cell lymphoma are not seen in specimen.
Correlation with clinical findings is recommended. Flow
cytometry immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
.
DISCHARGE LABORATORIES:
==================================================
Hematology:
CBC: WBC: 3.4 Hgb: 10.8 Hct: 34.3 Plts 213
Coags: PT: 23.4 PTT: 64.0 INR: 2.3
.
Chemistries:
Na: 140 K: 5.1 Cl: 105 HCO3: 26 BUN: 25 Cre: 1.0 Glu: 88
Ca: 10.1 Mg: 2.1 P: 5.3
ALT: 13 AST: 24 LDH: 269* AP: 114 Total Bili: 1.0 GGT: 222
.
STUDIES:
====================================================
ECG, [**2142-11-27**]- NSST changes laterally
.
CXR, portable, [**2142-11-27**]- Right pleural effusion with associated
consolidation, likely atelectasis. However, pneumonic
consolidation cannot be excluded and clinical correlation is
recommended
.
CTA & CT ABD/PELVIS, [**2142-11-27**]-
1. Multiple eccentrically located filling defects and linear
webs in the branches of the pulmonary arteries as described
above, concerning for chronic pulmonary emboli. No defintite
acute PE is identified.
2. Multiple nodular opacities measuring up to 9 mm in diameter.
Followup CT exam within three months is recommended.
3. Gallbladder wall thickening and edema with calcified
gallstones suggestive of acute cholecystitis. Correlate
clinically.
.
BILAT LE US, [**2142-11-28**]-
1. Extensive occlusive DVT of the right distal femoral,
popliteal and posterior tibial veins with more acute clot
distally and a more chronic appearance proximally.
2. Chronic DVT with recanalization of the right superficial
femoral vein.
3. No definitive evidence of left-sided acute or chronic
thrombus, however, some wall irregularity is noted.
.
ECHO (TTE), [**2142-11-28**]-
Conclusions: The left atrium is markedly dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The left ventricular cavity is moderately
dilated. There is an inferobasal left ventricular aneurysm.
There is severe global left ventricular hypokinesis (LVEF =
15-20%). The distal anterior, distal lateral and apical segments
have relatively preserved function. The right ventricular cavity
is markedly dilated. 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 stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, posteriorly directed jet of moderate to
severe (3+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Severe biventricular hypokinesis/akinesis. Moderate
to severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. Right ventricular pressure/volume overload.
The estimated pulmonary artery systolic pressure is likely
UNDERestimated due to elevated right atrial pressures.
.
CXR, portable, [**2142-11-29**]-
Reason: evaluate for PTX s/p R thoracentesis
In comparison with the study of [**11-27**], there has been removal of
a substantial amount of fluid from the right pleural space. No
convincing evidence of pneumothorax.
.
REST THALLIUM, VIABILITY SCAN, [**2142-11-30**]-
1. Normal myocardial perfusion, viable myocardium.
2. Increased left ventricular cavity size.
.
CXR, PA & LAT, [**2142-12-1**] 12:03pm-
Reason: Questionable reaccumulation of right pleural effusion.
There is interval increase in right pleural effusion [since [**11-29**]], which appears to be partially loculated with predominantly
increased anterolateral rather than posterior component of
pleural fluid. The cardiomegaly is moderate-to-severe and
unchanged. The lungs are clear except for unchanged opacity in
the right mid lung consistent with area of atelectasis
demonstrated on a torso CT from [**2142-11-27**].
.
CXR, portable, [**2142-12-1**] 4:19pm-
Reason: Evaluate acute pulmonary edema, patient with acute
shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] 15%.
Comparison is made with prior study performed four hours
earlier.
There have been no acute interval changes. Marked cardiomegaly,
right pleural effusion are unchanged. There is no pneumothorax
and overt CHF.
.
EKG, [**2142-12-1**]-
Sinus rhythm with premature ventricular beat. Left atrial
abnormality.
Probable left ventricular hypertrophy. Compared to prior tracing
of [**2142-11-27**]. Q-T interval is slightly shorter. Otherwise, no
major change is evident.
.
CT CHEST W/O CONTRAST, [**2142-12-4**]-
Reason: Please assess pulmonary "nodules" noted in [**2142-11-27**] CTA
for round atelectasis [**2-23**] CHF vs. masses, suspicious for
malignancy.
Impression: One-week stability of multiple roughly nodular
subpleural lesions in the lower lungs argues against bacterial
infection, such as septic emboli, and could be due instead to
more indolent pathogens such as Nocardia or even fungus.
Involution of the thymus also argues for an infection, but more
likely is vasculitis, including Wegener or Churg-[**Doctor Last Name 3532**], and
lymphoma, including lymphomatoid granulomatosis.
.
EKG, [**2142-12-4**]-
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy.
Diffuse ST-T wave changes - could be due in part to left
ventricular
hypertrophy. Clinical correlation is suggested. Since previous
tracing of [**2142-12-1**], further ST-T wave changes seen.
.
CT-GUIDED NEEDLE BIOPSY, [**2142-12-7**]-
Successful right lower lobe lung nodule biopsy. The patient
tolerated the procedure well without any immediate
post-procedure complications. Pathology results on tissue
sample pending.
.
CXR, portable, [**2142-12-7**]-
Reason: post lung biopsy
Comparison: Chest radiographs of [**2142-12-1**], CT of the chest from
[**2142-12-4**], as well as screen capture images from CT-guided lung
biopsy performed earlier on the same day.
Impression: No increase in small right pleural effusion, no
pneumothorax and no new parenchymal opacity are present after
CT-guided lung biopsy. Multiple lung lesions are better
evaluated on the CT scan of three days prior. Moderate-to-severe
cardiac enlargement with prominence of the left ventricle is
unchanged. No new pulmonary lesions are identified.
.
Cardiac Catheterization [**2142-12-10**]:
1. Coronary angiography in this right dominant system
demonstrated an LMCA, LAD, LCX and RCA all without
angiographically
significant disease.
2. Limited resting hemodynamics revealed severely depressed
cardiac
index of 1.3 L/min/sq meter. Pulmonary artery pressures were
markedly
elevated, as were biventricular filling pressures.
3. IV lasix was given in the lab and milrinone was initiated.
The
patient tolerated milrinone load well and was transferred to the
CCU
with stable blood pressure for further care of her heart
failure.
Brief Hospital Course:
61 yo Haitian-Creole-speaking female who presented with
shortness of [**Month/Day/Year 1440**] and unclear past medical history, revealed
to have R pleural effusion, EF 15-20% on Echo, chronic PEs and R
DVT, and pulmonary nodules on CT of unclear etiology
.
Systolic Congestive Heart Failure: On admission the patient was
complaining of shortness of [**Month/Day/Year 1440**] and was found to have a BNP
in the 7535. She was found on echocardiogram to have severe
global hypokinesis, with etiology unclear and no focal
abnormality. Prior to this admission she was not taking any
medications for her congestive heart failure despite being
diagnosed with heart failure at [**Hospital 8**] hospital in [**Month (only) 116**] of
this year and was found to have an ejection fraction of 24%.
During this admission, the patient was informed of her [**Last Name **]
problem and the importance of outpatient follow up and chronic
medication adherence was emphasized. Diuresis was performed
with IV Lasix, with good response and she was ultimately
transitioned to an oral regimen. She lost a total of 6kg during
this diuresis. Additional cardiac medications were gradually
added during the admission, and her SBP held in the 80s-100s.
This medication regimen included Lasix 10 mg PO daily,
lisinopril 5 mg PO daily, and Toprol XL 25 mg PO daily. She was
followed by the congestive heart failure service throughout this
admission who adjusted this regimen to optimize her function and
symptoms. She was observed on telemetry throughout her stay
with baseline normal sinus rhythm with frequent premature
ventricular contractions. A cardiac catheterization on [**12-10**]
was significant for no angiographically apparent disease in all
vessels, a CI of 1.3, SVR 3015, and elevated biventricular
filling pressures as well as PA pressures. She briefly was
transferred to the CCI to allow for her to receive milrinone and
IV lasix for more aggressive diuresis. On the floor, she
tolerated the above medication regimen well. Her baseline SBP
was 80s-90s, but she was asymptomatic without lightheadedness,
dizziness, chest pain or shortness of [**Month/Year (2) 1440**]. She was
oxygenating well on room air. She will be following up with Dr.
[**Last Name (STitle) **] in the [**Hospital 1902**] clinic.
.
Pulmonary Nodules: Patient was noted to have multiple nodular
opacities on admission CT scan. Of note she also had a CT scan
during her admission to [**Hospital 8**] hospital in [**Month (only) 116**] of this year
at which time she was also noted to have "ground glass
opacities, peribronchial thickening and mediastinal and hilar
lymphadenopathy as well as a small right pleural effusion." She
underwent bronchoscopy and biopsy at [**Hospital 8**] hospital which
was negative in [**Month (only) 116**] but was not directed. She underwent CT
guided biopsy of a nodule during this hospitalization which was
negative for malignancy but showed reactive cells. She underwent
three induced sputum samples which were AFB stain negative for
tuberculosis. She will follow up in the pulmonary clinic here
at [**Hospital3 **] for further management. She will likely need a
VATS biopsy as an outpatient for further investigation of these
nodules.
.
Pulmonary Embolism: Patient diagnosed with subacute pulmonary
embolisms on admission. She had an elevated D-dimer at 4878.
She was also diagnosed with chronic right sided DVT. It is
unclear why the patient is so coagulopathic. Given the
patient's prolonged illness and weight loss there was concern
for malignancy. The patient was also experiencing hemoptysis
and vaginal bleeding. Per her records from [**Hospital 8**] hospital
it appears that the vaginal bleeding is chronic and was worked
up with a transvaginal ultrasound in [**2142-5-22**] which revealed
a 5 mm endometrial stripe. The hemoptysis was new on this
admission. It began upon initiation of anticoagulation. She had
three negative induced sputum samples for tuberculosis. She had
a CT guided biopsy of her pulmonary nodules which was negative
for malignancy. She was seen by the pulmonary service who
recommended that there was no contraindication to her
anticoagulation given that her degree of hemoptysis was slight.
For the majority of her hospitalization she was anticoagulated
with a heparin drip and ultimately transitioned to warfarin for
chronic anticoagulation. On discharge her INR was 2.3. She
will follow up in coumadin clinic at [**Hospital6 12736**].
.
Abnormal CBC: On admission the patient was noted to have a
lymphocytosis on differential with a normal WBC. Of note this
was also present on differential from her [**Hospital 8**] hospital
admission. Differential diagnosis for a lymphocytosis is
extremely broad and includes infectious, autoimmune,
hypersensitivity, malignant and pre-malignant states. Flow
cytometry revealed non-specific T-cell dominant lymphoid
profile; diagnostic immunophenotypic features of involvement by
non-Hodgkin's B-cell lymphoma were not seen in specimen. No
etiology was found for her abnormal differential. Outpatient
hematology follow up may be warranted.
.
Abnormal Liver Enzymes: On admission the patient was noted to
have a midly elevated LDH and alkaline phosphatase. She also
was found to have an elevated GGT. On admission she had a CT
scan which was consistent with acute cholecystitis. At no time
during this hospitalization did she complain of right upper
quadrant pain. Her enzyme abnormalities were attributed to
congestive heart failure leading to hepatic congestion. They
improved over the course of her hospitalization. Given her lack
of symptoms this was deferred to outpatient management.
.
Vulvar Swelling: On admission ER physical exam the patient was
noted to have "multiple vulvar lesions." On my initial physical
exam she pointed out a 1x1 cm firm nodule in labia minora which
she says has been present since she gave birth to her children.
It is non-painful. The location is consistent with a
Bartholin's gland cyst. It does not appear infectious. She had
a negative RPR during this admission. She may consider
gynecology follow up as an outpatient.
.
Breast Lumps: On admission physical exam the patient was noted
to have a "soft, mobile, non-tender 1.5-2cm lump at the 2:00
position on the right breast and a small, firm, non-tender lump
in the 10:00 position on her right breast (exam on [**2142-11-28**])." I
was not able to appreciate any abnormalities on my exam. The
patient reports that she has never had a mammogram. This may be
considered as an outpatient.
.
Vaginal Bleeding: Patient with noted vaginal bleeding since
initiation of anticoagulation for her pulmonary embolism. She
describes having blood on the toilet paper when she urinates.
In records from her previous hospitalization at [**Hospital 8**]
hospital she was also noted to have vaginal bleeding and
underwent transvaginal ultrasound which revealed a 5 mm
endometrial strip no specific abnormalities. She did have a
pelvic exam during this hospitalization which revealed scant
blood in the vaginal canal. On discharge she reported that the
bleeding persisted. [**Month (only) 116**] need to consider repeat ultrasound and
endometrial biopsy as an outpatient.
.
Hemoptysis: The patient began to experience hemoptysis after
initiation of anticoagulation. On presentation she had a
chronic, non-productive cough. Patient did have a positive PPD
during this hospitalization and currently has three negative
induced sputums on acid fast stain. Patient does have a number
of pulmonary nodules and underwent CT guided biopsy which was
negative for malignant cells and showed reactive cells. At no
time was the hemoptysis hemodynamically significant. She will
follow up in pulmonary clinic as an outpatient.
.
Positive PPD: The patient was noted to have a 15 mm PPD at
[**Hospital 8**] hospital in [**2142-5-22**]. While on a heparin gtt for her
PE/DVTs as above, she was noted to have several episodes of
hemoptysis. This was discussed with infection control, who
recommended placing the patient on TB precautions and ruling her
out for tuberculosis with three induced sputum samples for acid
fast stain. This was done successfully. The patient will need
9 months of INH therapy as an outpatient. This can be
coordinated by her primary care physician or her new outpatient
pulmonologist.
.
Rash: Patient reported a pruritic rash on presentation. On exam
she has a rash on her back, chest and the soles of her feet.
Her palms were not involved. The rash on her feet is
hyperpigmented discrete macules. On her back and chest she also
has irregular shaped hyperpigmented, slightly raised lesions.
Differential for rashes that involve the soles of the feet is
not particularly long. Includes secondary syphilis, rickettsial
infections, RMSF, guttate psoriasis, hand-foot-mouth disease.
She had a negative RPR during this admission. The other above
etiologies did not appear consistent with her presentation. She
received symptomatic treatment with sarna lotion.
.
Prophylaxis: Given her known history of blood clots she was
anticoagulated with heparin with a bridge to coumadin.
.
Code: Full Code
.
Disposition: To home with follow up with her new primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (un) 76110**] at [**Hospital6 12736**].
Medications on Admission:
none x1yr. Says at one time she was took 2 medications in [**Country 2045**]
prescribed by two different doctors. Unable to give more details
(?for a liver problem).
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Idiopathic dilated cardiomyopathy
2. Congestive heart failure
3. Bilateral pulmonary embolism
4. Right deep venous thrombosis
5. Hemoptysis
6. Positive PPD
7. Vaginal bleeding
8. Pulmonary nodules
9. Mitral regurgitation
10. Tricuspid regurgitation
11. Abnormal liver function tests
12. Vulvar lesions
13. Breast masses
14. Rash
Discharge Condition:
Stable. On Room air.
Discharge Instructions:
You were admitted with shortness of [**Country 1440**] on [**2142-11-27**]. During
this hospitalization you were found to have an enlarged and
poorly functioning heart. You were also found to have blood
clots in your lungs and in your right leg. You underwent
CT-guided biopsy of a pulmonary nodule, which was negative for
malignancy. It will be important for you to follow up with
cardiology, pulmonary, the coumadin clinic and your new PCP in
order to continue to manage these conditions. These
appointments with an interpreter have been set up.
.
Please call 911 or your doctor if you develop lightheadness,
dizziness, chest pain, worse shortness of [**Date Range 1440**], bleeding that
will not stop or any other concerning symptom.
.
You are being discharged on several new medications. It is
important to take these medications as prescribed. If you
develop lightheadedness or dizziness, please call your doctor.
Followup Instructions:
1. PCP: [**Last Name (NamePattern4) **]. [**Last Name (un) 76110**], [**12-21**] at 2:30 PM at
[**Location (un) 15953**] Health Clinic through the [**Hospital6 12736**].
You will need to come in 15 minutes early (2:15) to fill out
paperwork. The clinic is located at [**Street Address(2) 76111**],
[**Hospital1 8**], MA. The phone number is [**Telephone/Fax (1) 49950**].
.
2. Coumadin management: Your coumadin will also be managed by
[**Location (un) 15953**] Health Clinic. Dr. [**Last Name (un) 76110**] will help you to
coordinate this.
.
3. Cardiology: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], Phone:[**Telephone/Fax (1) 3512**], [**2142-12-24**]
9:00. [**Hospital Ward Name 23**] 7.
.
4. Pulmonology: PULMONARY BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2143-1-14**] 10:30, DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2143-1-14**] 11:00.
.
5. You should also see an OB/Gyn doctor as an outpatient
regarding your episode of vaginal bleeding and the mass you have
noticed at your vulva. This can be coordinated with Dr.
[**Last Name (un) 76110**].
|
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"285.9",
"401.9",
"511.9",
"518.89",
"453.8",
"795.5",
"288.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.23",
"33.26",
"93.90",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
24338, 24344
|
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|
355, 441
|
24720, 24743
|
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|
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|
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|
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|
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|
275, 317
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|
5902, 6193
|
2445, 2744
|
2760, 2946
|
4081, 4933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,900
| 187,271
|
29230
|
Discharge summary
|
report
|
Admission Date: [**2172-10-3**] Discharge Date: [**2172-10-19**]
Date of Birth: [**2122-6-10**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Bacitracin / Morphine / Percocet / Oxycodone
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Altered MS
Major Surgical or Invasive Procedure:
PICC line placement (10.11)
Tunneled Hemodialysis Line Placement (10.11)
Right Femoral Line placement and removal
Right iliac arterial line placement and removal
History of Present Illness:
HPI: 50 year old male s/p kidney transplant and CRI, HTN,
restrictive lung disease, metastatic calcipholaxis, who presents
from [**Hospital 100**] Rehab with altered mental status and fevers. He was
recently discharged from [**Hospital1 18**] after prolonged hospital course
([**8-24**] - [**10-2**]). Patient sent from rehab for fevers and
hypotension.
.
In the ambulance, found to be hypotensive, hypoxic to 80s and
febrile. Given narcan with some improvement of MS. [**First Name (Titles) **] [**Last Name (Titles) **] A&Ox1
(unknown baseline) hypotensive and febrile (103.8R). He was
given a dose of cefriaxone and vancomycin. He had a failed L IJ
attempt, so a L fem line placed. UA was found to be grossly
positive. He received a total of 2.5L NS and BP improved to
110/62. His oxygenation improved to 99-100% on a NRB. A CT head
showed was negative for an acute bleed. Also of note, his EKG
showed diffuse twave inversions v2-v6. He received a dose of
aspirin. Cardiology was called and felt there was no
intervention needed at this time. Initial hct in the ED was 22
and a repeat was 20. He did not receive blood in the ED.
.
Past Medical History:
1. L cadavaric kidney transplant ([**2152**]) for renal failure [**1-31**]
presumed chronic glomerulonephritis
2. ESRD, baseline Cr 1.5 in [**5-3**]
3. DM
4. Restrictive lung disease
5. HTN
6. Interstitial pulmonary fibrosis
7. s/p L AV fistula
8. hypercholesterolemia
9. Gout
10. Metastatic Calciphylaxsis
Social History:
lives by himself, divorced; no EtOH or tobacco. Arrived from
rehab
Family History:
diabetes mellitus
Physical Exam:
PEX on day of discharge:
V: HR 70 BP 112/50 RR 14 O2 99% RA
Gen: NAD, lying in bed, comfortable, conversant
HEENT: O/P clear
Neck: supple
CV: RRR, III/VI systolic murmur at apex
Pulm: clear anteriorally
Abd: soft, NT.ND
Ext: left BKA, necrotic toes of right. Multiple areas of
necrosis on extremities
Pertinent Results:
on discharge: WBC 18.3 (16 yesterday), HCT stable at 27.4, Plt
434
sodium 143, K 3.9, Chloride 110, bicharb 26, Bun 13, Cr 2.6 Gluc
58, Cal 5.9, ionized calcium 0.99, magnesium 2, phos 3.
.
MICRO: all blood cultures no growth to date. Cdiff x1 negative.
Urine cultures all negative. 1/4 bottles of blood cultures from
[**2172-10-16**] showed coag neg staph
.
Head CT [**10-3**]:
1. No evidence of acute intracranial hemorrhage. MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is most sensitive for evaluation of
acute ischemia.
2. Persistent opacification of the mastoid air cells on the
left.
3. Extensive vascular calcifications.
.
CT abd/pelvis [**10-6**]:
1. Progression of induration along the collecting system of the
left lower quadrant transplant kidney of unclear etiology. While
this may represent progression of postoperative change (i.e.
secondary to lymphatic obstruction), a low-grade liposarcoma
with prominence of the renal sinus fat cannot be completely
excluded. No hydronephrosis.
2. Anasarca with increased moderate bilateral pleural effusions
and small amount of ascites.
3. Cholelithiasis.
4. Focus of hypoenhancement within a prominent spleen as noted
on prior which may be secondary to prior infarction/infection.
.
CXR 10.14:
Bilateral pleural effusions and pulmonary airspace opacities,
similar in appearance. The findings represent CHF.
Brief Hospital Course:
50 yo M with metastatic calciphylaxis and ESRD s/p kidney
transplant on chronic immunosuppressive therapy admitted with
fevers and hypotension.
.
# Fever.
Initially admitted to the MICU with fever & hypotension
concerning for bacterial sepsis. Was placed on broad spectrum
Abx including Vancomycin/Meropenem/Fluconazole to cover both
bacterial and fungal sources. ID was consulted who agreed with
the Abx coverage. When his fevers persisted into HD#2,
fluconazole was changed to Caspofungin. His fevers regressed
and his Abx were sequentially discontinued. No bacterial source
was ever isolated despite multiple urine, sputum and blood
cultures. His Meropenem was d/c'ed on [**10-11**] and then Vancomycin
was removed on [**10-14**]. His fluconazole was to continue for a 2
week course to end on [**2172-10-22**]
.
# Altered mental status.
On evaluation, found to be quite altered and delirious. Thought
secondary to his narcotics given that Morphine/Oxycodone are
renally cleared. He was monitored off narcotics and his MS
slowly improved back to his baseline. He is NOT to receive any
narcotics except for Dilaudid as all other medications
(oxycodone, morphine, oxycontin, etc) will make him altered once
more given his renal failure. He was continued on Dilaudid,
Neurontin, and Ibuprofen only for pain control. Please give
doses as specified in his medication planning as these prevent
profound hypotension.
He was also evaluated by psychiatry on [**10-14**] and found not to
have capacity to make his own medical decisions. The psychiatry
team asked for further evaluation as needed in regards to future
medical decisions along with working with his HCP.
.
# Dyspnea.
Possible etiologies included volume overload, reactive airways
(wheezes on exam). He was found to be volume overloaded given
his need for IVF resuscitation with his hypotension. He was
progressively dialyzed and this fluid was removed. His dialysis
should be continued as per nephrology recommendations.
.
# Hypotension
He has been intermittently hypotensive throughout his ICU stay
mainly due to over-aggressive dialysis or narcotic medication
administration. His BP is difficult to measure with
non-interventional means (ie BP cuff) as they are not accurate
compared to when arterial line was in place. Please monitor
clinically as even when his BP read 50s on his BP cuff he was
awake and alert. Please take BP from on top of his AV fistual as
this may be more accurate. (this fistula is non-functional.)
Please follow him clinically.
.
# Pain.
Significant pain secondary to necrotic soft tissue and his
metastatic calciphylaxsis. He was given Dilaudid, Narcotics,
and Ibuprofen only as all other narcotics lead to excessive
sedation. Please allow Dilaudid only as narcotic medications.
Please follow medication recommendations as these were titrated
for maximal effect without excessive sedation/hypotension.
Please hold dilaudid on the mornings of dialysis so that his
blood pressure is not too low. He should be given a dose of
dilaudid right after dialysis.
.
# Metastatic calciphylaxis.
Poor prognosis as no known curative treatment. Renal was
involved who recommended trying IV pamidronate for experamental
tx without much improvement in his symptoms. They recommended to
keep his calcium level as low as possible with goal corrected
calcium of 8.0 and an ionized Calcium level of 0.8 to 0.9.
Please continue to check calcium levels daily (and ionized
calcium level if this is available). Please discuss with
nephrology regarding further recommendations to keep his calcium
level low. An oral daily bisphophonate etidronate was initiated
and is to be continued under renal recommendations.
.
# CV.
No acute issues currently. Episodes of a fib noted on tele
during his stay. He was on metoprolol for rate control, but
given his hypotension, this was discontinued (he also had no
more episodes of afib). His daily ASA was continued.
.
# Renal Failure.
S/p failed renal transplant. On chronic immunosuppressive
therapy and ESRD. Initially placed on CVVH when his BP would
not tolerate intermittent HD. When his BP stabilized, he was
transitioned to HD with intermittent ultrafiltration to remove
excess volume. He was continued on prednisone 5mg daily,
cinacalcet and renagel per renal recommendations.
.
# Diabetes. Continued fixed dose and sliding scale insulin.
.
# FEN. Diabetic, Renal diet with shake supplements for nutrition
# PPX. No DVT ppx given poor skin (avoid Hep SC and
pneumoboots), PPI. No flu shot given for concern of initiating
calciphylaxis.
# ACCESS: Right PICC ([**2172-10-8**]), Right SC HD line([**2172-10-8**])
# Communication: HCP [**Name (NI) 56926**] [**Name (NI) 70290**] [**Telephone/Fax (1) 70291**]; other, [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 70292**] [**Telephone/Fax (1) 70293**]
# CODE: FULL CODE.
.
DISPO - To HebReb MACU for further outpatient stabilization
Medications on Admission:
1. Pantoprazole 40 mg Q24H
2. Allopurinol 100 mg HD
3. B Complex-Vitamin C-Folic Acid 1 mg daily
4. Aspirin 81 mg Daily
5. Acetaminophen 325 mg PRN
6. Lidocaine HCl 2 % Gel PRN
7. Diphenhydramine HCl 25 mg PRN
8. Simvastatin 40 mg daily
9. Cinacalcet 30 mg QOD
10. Sevelamer 800 mg TID with meals
11. Metoprolol Tartrate 25 mg [**Hospital1 **]
12. Digoxin 125 mcg PO Q MONDAY AND FRIDAY
13. Senna 8.6 mg [**Hospital1 **]
14. Docusate Sodium 100 mg [**Hospital1 **]
15. Gabapentin 300 mg daily
16. Hydromorphone 4 mg Tablet 1-2 Tabs PO Q3H
17. Morphine 30 mg Tablet SR q12
18. Meropenem 500 mg IV Q24H end date [**2172-10-15**]
19. Vancomycin 1000 mg IV HD PROTOCOL end date [**2172-10-15**]
20. Dilaudid IV PRN
Discharge Medications:
1. Etidronate Disodium 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Day/Year **]: One (1) Cap
PO DAILY (Daily).
4. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
6. Cinacalcet 30 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QOD ().
7. Allopurinol 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday): Please dose with dialysis.
8. Prednisone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day/Year **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
11. Trazodone 50 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Fluconazole 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q24H (every
24 hours) for 3 days: Please continue until [**2172-10-22**].
13. Ibuprofen 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8
hours).
14. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID
(2 times a day) as needed.
15. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q6H
(every 6 hours).
16. Gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY
(Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day/Year **]: One (1)
Injection Q8H (every 8 hours) as needed.
19. Hydromorphone 2 mg/mL Syringe [**Month/Day/Year **]: 0.5 mg Injection Q3H
(every 3 hours) as needed: hold for oversedation.
20. Dilaudid 2 mg/mL Solution [**Month/Day/Year **]: One (1) mg Injection q3hrs:
Hold for sedation and please hold prior to HD to avoid
hypotension .
21. Dilaudid 2 mg/mL Solution [**Month/Day/Year **]: 0.5 mg Injection after
hemodialydid: Hold for sedation .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
Altered MS/confusion due to iatrogenic narcotic overdose
Fever/Hypotension
Dyspnea due to volume overload
ESRD on CRRT/HD
Necrotic skin wounds
Secondary Diagnoses:
Hypotension
ESRD on HD
Metastatic Calciphylaxsis
Discharge Condition:
Stable to be discharged to rehab
Discharge Instructions:
Please follow up with his nephrologist after you are discharged
from the hospital.
Please check calcium and corrected calcium levels (adjusted for
albumin) daily - goal Corrected Calcium level 8.0. Goal ionized
Calcium levels are 0.8 to 0.9.
Do NOT give any opioid pain medications that are renally cleared
(morphine, Oxydodone, percocet, vicodin, Oxycontin) as these
made him quite confused. You may use Dilaudid only for pain
control (and acetaminophen and ibuprofen).
Please hold dilaudid on the mornings of dialysis so that his
blood pressure is not too low. He can be given acetaminophen and
ibuprofen on those mornings. He should be given a dose of
dilaudid right after dialysis.
He should NOT receive any skin biopsies, suturing, or
subcutaneous injections of any kind (including Heparin SQ) as
these make his calciphylaxsis worsen.
His foley catheter should NOT be removed for concern over his
necrotic skin. He should see a urologist to have this changed if
necessary.
His blood pressure runs low - SBP 80-100. This can decrease
with narcotic medications - please monitor his mental status
rather than just the BP as it measures inappropriately low in
his arm. (Palpated pulse pressure is around 120.) Also consider
checking the BP above the AV fistual (non-functional fistula)
for better readings.
Followup Instructions:
Please follow up with your nephrologist Dr. [**Last Name (STitle) 7473**] after
discharge. ([**Telephone/Fax (1) 773**]
Primary care provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2172-11-17**] 2:30
Completed by:[**2172-10-19**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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11886, 11952
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2447, 2447
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1678, 1987
|
2003, 2073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,778
| 188,885
|
44109
|
Discharge summary
|
report
|
Admission Date: [**2131-8-2**] Discharge Date: [**2131-8-8**]
Date of Birth: [**2051-10-9**] Sex: M
Service: MEDICINE
Allergies:
Tetanus,Diphther Toxoid Adult / Aggrenox
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Altered Mental Status
Hyperthermia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 79 year-old male with a history of diabetes,
peripheral [**First Name3 (LF) 1106**] disease, stroke, CAD, chronic renal failure
who presents with hyperthermia and lethargy. Patient was found
by his wife to be minimally responsive and EMS was called. Per
report, he has a history of similar episodes in the past.
Patient lives on the [**Location (un) 442**] of apartment building, and does
not normally open windows or turn on air conditioning. EMS found
patient minimally responsive and reported that the patient's
home was extremely warm. He was BIBA for further evaluation and
management. He does not remember currently what happened prior
to coming to the hospital, but understands what has happened
since he has been here.
.
In the ED, vital signs were T:104.9 BP:181/80 HR:74 RR:24 O2Sat
100% on RA. He received Demerol. Groin and axilla were packed
with ice and cooling blanket was placed on patient. As
temperature improved to 102 degrees, patient's mental status
improved, temperature was brought down to 98.6 degrees prior to
transfer. Due to concern for sepsis, he received 2 litres IV
fluid and was given 1 dose ceftriaxone. Chest x-ray demonstrated
fluid overload and patient had increased respiratory rate,
therefore he received furosemide 80mg IV, and was also
temporarily started on NIPPV. ABG was done 7.34/39/141.
Non-contrast CT Torso was done to assess for infection and
appeared negative. For refractory hypertension and fluid
overload on chest x-ray, he was started on nitroglycerin gtt,
which was turned off after blood pressure improved. For
hyperkalemia, ECG was unchanged and he received calcium
gluconate 1 gram and Kayexalate 30gm PO. CT head was also
performed and showed no acute process.
Past Medical History:
*Gout
* MRSA/Enterococcal (not VRE) UTI [**7-9**]
* DM type 2 complicated by neuropathy & retinopathy, Hgb A1c
6.8% in [**9-9**]
* CAD s/p 4v CABG ([**2119**])
* PVD s/p bypass grafting (s/p L popliteal to DP bypass w/ R arm
vein ([**8-4**]) ; failed - s/p revision ([**3-5**]); RLE claudication -
s/p R SFA to DP saphenous vein bypass ([**5-6**]) ; stenosed distal
graft - s/p atherectomy ([**9-6**]))
* 2nd & 3rd degree AV block s/p pacemaker in [**2123**]
* hypertension
* s/p L carotid endarterectomy in [**2128**]
* hyperlipidemia
* known infrarenal aortic aneurysm s/p graft repair ([**12/2119**])
* anxiety/depression
* osteoarthritis
* chronic back pain
* cataracts
* chronic renal insufficiency (recent creatinine values 1.3-2.1)
* H/o intermittent slurred speech with CVA diagnosed in [**9-/2129**]
* H/o vertigo, uses meclizine occasionally as outpatient
Social History:
Patient is a retired carpenter who lives with his wife. [**Name (NI) **] has a
30-pack-year smoking history, but quit about 30 years ago. He
does not drink alcohol. He denies h/o illicit drug use. He uses
a walker to ambulate due to leg pain. He receives home VNA.
Family History:
Mother with CAD,HTN and stroke. 2 brothers with CAD s/p CABG.
Physical Exam:
Physical Exam:
Vitals: T: 98.6 BP: 181/58 HR: 72 RR: 20 O2Sat: 94%
Gen: alert and oriented, NAD
Cardiac: RRR, no murmurs
Lungs: CTAB
Abd: soft, NT, +BS
Ext: 2+ oedema BL
Pertinent Results:
Laboratories: Notable for Creatinine of 2.7 (baseline 1.7-2.0),
potassium 6.3, lactate 2.1, UA negative for Leukocyte esterase
or nitrites, WBC 18.5 with 85% PMN and 1% Bands, Hct 30.7
(baseline 34-36), normal liver enzymes. See below for rest.
.
ECG: Sinus rhythm at 76 bpm, left-atrial abnormality, normal
axis, first degree AV conduction delay, normal QT intervals,
poor R-wave progress, no specific ST or T-wave changes, Q-waves
in III and aVF, consistent with prior inferior MI. Patient had
left-bundle morphology IVCD in prior tracing, but QRS width is
124, so now complete LBBB.
.
Imaging:
CXR: Demonstrates cardiomegaly, poor inspiratory effort, hilar
prominence with increased [**Name (NI) 1106**] markings bilaterally, PPM.
.
CT Torso on [**2131-8-2**]: IMPRESSION: 1. No source of infection is
identified on this non-contrast CT. 2. Stable perinephric low
density lesion, likely an exophytic simple renal cyst. 3. New
linear metal density wires within the urinary bladder. Please
correlate with patient's surgical history.
4. Extensive [**Year (4 digits) 1106**] calcifications. 5. L5 spondylolysis
without spondylolisthesis. 6. Stable, nonspecific stranding
around the kidneys bilaterally. 7. Cholelithiasis.
.
CT Head on [**2131-8-2**]: IMPRESSION:
1. No evidence of acute intracranial process.
2. Encephalomalacia of the right occipital lobe, consistent with
the
patient's history of right posterior cerebral artery infarct.
3. Stable, subtle, asymmetric low attenuation of the left
temporal lobe, most likely representing chronic small vessel
disease.
.
TTE on [**2131-8-6**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2130-9-27**],
mild mitral regurgitation is now seen (may be no difference as
image quality is better on the current study).
Brief Hospital Course:
This is a 79 year-old male with a history of diabetes,
peripheral [**Year (4 digits) 1106**] disease, stroke, CAD, chronic renal failure
who presents with hyperthermia.
<br>HOSPITAL COURSE BY PROBLEM:
<br>Fevers - Patient presented with fever to 104, which came
down with cooling blankets and ice. Initially fever was
believed to be hyperthermia (being in a hot room with no A/C in
the summer), but patient re-spiked after cooling which increased
concern about infectious etiology, likely exacerbated by high
room temperatures at home. Temperature did not qualify for heat
stroke (core body temperature did not reach 40.5 centigrade).
His second UA was dirty and CT torso showed foreign body in
bladder, which upon cystoscopy by urology proved to be a copper
wire (the reason it was in his bladder remains unknown). He was
treated with vancomycin and ceftriaxone for possible
complicated/MRSA UTI. He had one blood culture on [**8-2**] positive
for coag-negative staph in one bottle but this was ultimately
thought to be a contaminant and ceftriaxone was D/Ced at this
point. The copper wire grew out coag-positive staph which was
speciated as MRSA and was the reason he was initially put on
vancomycin, and this was continued until [**2131-8-8**]. At this point
the vancomycin was D/Ced and switched to bactrim becasue the
copper wire cultures showed the staph was also sensitive to
bactrim. He also received IV fluid hydration. He was initially
admitted to the ICU at presentation, and once he had defervesced
and was hemodynamically stable he was transferred to the floor.
On the floor, he remained afebrile for the rest of his hospital
course.
<br>Acute on chronic renal failure - Patient presented with
hyperkalemia likely secondary to renal failure. Acute renal
failure was felt to be likely secondary to dehydration and
possibly a component of ATN. FeUrea was >30. Baseline creatinine
seems to be about 1.2 and he is followed in renal clinic as an
outpatient. He peaked at a creatinine of 2.7 and with
resuscitation trended down to 1.5.
<br>Bladder Foreign Body: CT scan showed foreign body in the
bladder which was new since last CT scan in [**2131-4-3**]. Urology
removed a long copper wire from the patient's bladder. Unclear
how this occurred, patient denied placing it there. This may
have been a source of infection contributing to patient's
fevers. Vancomycin and then bactrim were given as per above.
<br>Leukocytosis: Likely secondary to infectious source,
presumably UTI in the setting of bladder foreign body. No growth
on urine culture, but patient was nevertheless treated
empirically with ceftriaxone for complicated UTI as well as with
vancomycin and then bactrim for MRSA on copper wire as per
above.
<br>Mental Status: Patient presented with altered mental status.
This improved with resolution of fevers. Likely toxic-metabolic
encephalopathy. His mental status continued to remain at his
baseline throughout his hospital stay.
<br>Acute on chronic hypertension: Patient became very
hypertensive with fever spikes, requiring nitro gtt in the ED,
and then again briefly in the ICU for about 1 hour. Home
anti-hypertensives were restarted, and he remained fairly well
controlled for the rest of his hospital stay. He did have some
intermittent spikes to the 180s-200s but overall his blood
pressure was in the 160s.
<br>Chronic pain - continued gabapentin
<br>CAD - Continued clopidogrel, aspirin, simvastatin,
metoprolol,
<br>Gout - continued allopurinol, tramodol
<br>Diabetes - Insulin 40 Units in AM, 30 Units in PM per home
regimen, and sliding scale
<br>FEN: Low-sodium, heart-healthy diabetic diet, IV fluids as
above.
<br>Access: Right subclavian CVL was inserted.
<br>PPx: Heparin SC
<br>Code: Full code
<br>Comm: With patient and wife
Medications on Admission:
#. Metoprolol succinate 100mg daily
#. Valsartan 320mg daily
#. Furosemide 60mg daily
#. Clopidogrel 75mg daily
#. Insulin 40 Units in AM, 30 Units in PM
#. Aspirin 81mg daily
#. Allopurinol 200mg daily
#. Darbepoetin 60mcg q2 weeks
#. Doxercalciferol 2.5 mcg qOD
#. Gabapentin 600mg TID
#. Nitroglycerin SL PRN
#. Simvastatin 80mg daily
#. Tramadol 50mg daily
#. Trazodone 50mg daily
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day in
the morning.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day in
the evening.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: ASDIR
Subcutaneous ASDIR: please take 40 units with breakfast and 30
units with dinner every day.
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
11. Darbepoetin Alfa In Polysorbat 60 mcg/0.3 mL Pen Injector
Sig: One (1) Subcutaneous Every other week.
12. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO
every other day.
13. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times
a day.
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for chest pain.
15. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day.
17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Foreign body in bladder colonized with MRSA
Acute on chronic renal failure
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a high temperature and
increased white blood cells. Your blood grew a small amount of
bacteria but this was likely a contaminant and not a true blood
infection. you were also found to have a copper wire in your
bladder which had some infection, but your urine itself did not
seem to be infected. You were briefly in the ICU and your fever
resolved and after you were transferred to the medical floor you
were stable with no further signs of infection. You received
some antibiotics to treat any possible infection of the blood or
urine.
Please take all your medications as directed. If you have high
fever, urinary burning or discomfort, or shortness of breath,
chest pain, fever or other symptoms which are concerning to you,
please call your PCP or if your PCP is not available please go
to the nearest emergency room.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2131-8-16**]
|
[
"362.01",
"939.0",
"250.60",
"428.30",
"E915",
"276.7",
"428.0",
"285.9",
"357.2",
"250.50",
"584.5",
"V02.59",
"585.9",
"276.51",
"349.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.32",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11759, 11816
|
5974, 6148
|
333, 339
|
11935, 11944
|
3557, 5951
|
12859, 13084
|
3286, 3350
|
10206, 11736
|
11837, 11914
|
9796, 10183
|
11968, 12836
|
3380, 3537
|
259, 295
|
6176, 8715
|
367, 2097
|
8730, 9770
|
2119, 2986
|
3002, 3270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,781
| 145,756
|
38752
|
Discharge summary
|
report
|
Admission Date: [**2120-12-8**] Discharge Date: [**2120-12-13**]
Date of Birth: [**2053-8-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Hydromorphone
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
4-5 days of headache, nausea, emesis
Major Surgical or Invasive Procedure:
Stereotactic aspiration and biopsy of left cerebellar cyst
History of Present Illness:
Ms. [**Known lastname **] is a 67 year old woman with a history of Stage 1V
ovarian cancer diagnosed this year. She has been treated with
surgery and chemotherapy and has had a good response.
She has been reporting gait disturbance without falls for 4-5
days, headaches for 4 days, nausea, dizziness and emesis
overnight. CT head showed a large left cerebellar lesion. She
has
had no prior brain imaging.
Her oncologist, Dr. [**Last Name (STitle) 4149**], was called and she reports that while
lung and brain metastases are not common locations, the lung
nodules responded well to the chemotherapy treatment for the
ovarian cancer.
Past Medical History:
- history of transient ischemic attack
- hypertension
- [**Last Name (STitle) 499**] polyps
- asthma
- depression
Social History:
- denies tobacco and recreational drug use
- rare alcohol use
Family History:
- father with [**Name2 (NI) 499**] cancer, deceased at 49
- brother with prostate cancer
Physical Exam:
O: 97.2 81 143/73 18 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs intact.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light. Visual fields
are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-8**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger, heel to shin, and
rapid alternating movements.
On Discharge: 30% vision loss in right eye which is chronic, o.w
nonfocal
Pertinent Results:
CT HEAD [**12-8**]
Cystic mass within the left cerebellar hemisphere which exerts
some mass effect on the fourth ventricle. Findings may represent
a cystic
metastasis or primary brain neoplasm and further evaluation with
MRI is
recommended.
MRI Brain [**12-8**]
Cystic left cerebrellar hemispheric lesion (4.0x3.6x2.1cm) with
mild
surrounding flair abnormality, a thin rim of enhancement without
mural
nodularity, and no diffusion restriction. Compatible with
ovarian metastasis.
There is mass effect on the 4th ventricle without evidence of
upward or
downward cerebeller herniation.
CT Head [**12-11**]:
Postoperative drainage of a left cerebellar cyst with
pneumocephalus as described. No evidence for herniation. No
hemorrhage
Brief Hospital Course:
Patient presented to [**Hospital1 18**] with 4-5 days of headache, nausea,
and emesis and was found to have a large left cerebellar cystic
mass. She was admitted to the ICU for observation and had an
MRI. The MRI showed the cystic mass in the left cerebellum. On
the morning of [**12-9**] she was evaluated on rounds and her exam was
nonfocal with the exception of headache. Dr. [**Last Name (STitle) **] took over
her care with plans to do a stereotactic biopsy of the lesion on
[**12-10**]. She remained stable in the unit awaiting her procedure and
on [**12-11**] she underwent a stereotactic aspiration of cyst, biopsy,
and rickham catheter placement. She tolerated the procedure well
was extubated in the OR and trasnfered to the ICU for post-op
care. She remained stable overnight on [**12-11**] and on [**12-12**]
transfer orders were written for her to be trasnferred to the
floor.
She was ambulating in the hallways independently on [**12-13**], and
was seen by PT who determined that she was safe to go home. She
was discharged to home on [**2120-12-13**].
Medications on Admission:
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg
Capsule - 2 Capsule(s) by mouth DAILY (Daily)
IBUPROFEN - (Dose adjustment - no new Rx) - 600 mg Tablet - 1
Tablet(s) by mouth three times a day as needed for pain
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime and as
needed
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth DAILY (Daily)
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth q8hr as
needed for nausea, vomiting
OXYCODONE - 5 mg Tablet - [**1-6**] Tablet(s) by mouth q4hr as needed
for pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1/2-1 Tablet(s) by
mouth q6hr as needed for nausea, vomiting
SCALP PROSTHESIS - - apply to head
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 2
Tablet(s) by mouth DAILY (Daily)
VERAPAMIL - (Prescribed by Other Provider) - 240 mg Tablet
Sustained Release - 1 Tablet(s) by mouth every twenty-four(24)
hours
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/ha.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. verapamil 120 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q24H (every 24 hours).
8. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-6**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for GERD.
10. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
Disp:*60 Tablet(s)* Refills:*0*
13. dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q6 () for 1
days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left cerebellar cystic lesion
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:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**7-13**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic with Dr.
[**Last Name (STitle) 3929**] at 1300. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) 442**]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain
Completed by:[**2120-12-13**]
|
[
"276.1",
"V12.72",
"V10.43",
"623.8",
"197.0",
"272.4",
"198.3",
"401.9",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
6736, 6742
|
3275, 4350
|
316, 377
|
6816, 6816
|
2518, 3252
|
8909, 9785
|
1273, 1364
|
5484, 6713
|
6763, 6795
|
4376, 5461
|
6999, 8886
|
1379, 1481
|
2438, 2499
|
240, 278
|
405, 1040
|
1733, 2424
|
6831, 6975
|
1062, 1177
|
1193, 1257
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,174
| 129,101
|
43487
|
Discharge summary
|
report
|
Admission Date: [**2175-7-15**] Discharge Date: [**2175-7-19**]
Date of Birth: [**2116-6-23**] Sex: M
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
fever, dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 yo endstage multiple myeloma s/p auto BMT ('[**71**]), failed VAD
chemothx x 4, thalidomide, velcaide (most recently in [**3-26**]),
recently hospitalized (d/c [**7-13**]) for pneumonia now presenting
with fever and dehydration.
Past Medical History:
1. multiple myeloma. Not yet ready for hospice but has
preferred supportive management.
2. fracture of spine in [**2168**], did not receive fixation.
3. s/p knee arthroscopy.
4. skin lesions (ak vs. sq. cell). Bx??????d postponed by derm b/c
neutropenia
Social History:
Lives with wife in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**]. Former mechanic for [**Location (un) **].
Son is police offier in [**Location (un) **]. No EtOH. No IVDU.
Family History:
non contributory
Physical Exam:
VS 102.2 118 24-28 94% on NC+partial mask
Pupils constricted but reactive b/l. No LAD. No oral lesions.
Chest with loud rhonchi and wheezing throughout all lung fields.
Heart regular with
pansystolic murmur radiating to axilla. No peripheral edema.
Abdomen soft nt nd with splenomegaly. No CVA, paraspinal,
spinal tenderness. Extremities warm and well perfused.
Pertinent Results:
CT CHEST
Interval development of multiple predominantly upper lobe,
poorly defined
nodules, some of which demonstrate central lucency, possibly
reflecting
cavitation or a bronchogram given motion artifact. The
differential diagnosis
includes invasive Aspergillus, nocardia, and septic emboli.
Striking, diffuse, bilateral dependent areas of ground glass
opacity which
spare the anterior/nondependent portions of the lungs and are
associated with
bronchial dilation. The distribution is suggestive of ARDS,
which may
complicate infection. Diffuse atypical infection and drug
toxicity are also in
the differential diagnosis.
Brief Hospital Course:
Pt was treated in the ICU for difficulty maintaining adequate
oxygen saturation. Pt's family chose to make patient DNR/DNI
but to continue antibiotic treatment of pneumonia and blood
product support. He was transferred to BMT service where his
discomfort with breathing was treated with morphine for comfort,
antibiotics were continued and blood product support was
continued. Patient expired while on BMT service with family by
his side.
Medications on Admission:
MEDICATIONS CONTINUED ON DISCHARGE FROM HOME
1. Decadron 40mg biw
2. procrit q thurs
3. zometa q thurs
4. fentanyl patch 75mcg to be changed tonight.
5. nystatin s&s
6. vit b12 x 2 qd
7. tums 1 [**Hospital1 **]
8. compazine prn nausea
9. Tylenol prn fever
10. Levofloxacin 500 mg Tablet
11. Metronidazole 500 mg Tablet
Discharge Medications:
n/a
Discharge Disposition:
Home
Discharge Diagnosis:
respiratory failure secondary to pneumonia secondary to multiple
myeloma
Discharge Condition:
n/a
Completed by:[**2175-7-23**]
|
[
"518.81",
"415.19",
"785.0",
"996.85",
"203.00",
"486",
"E878.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
3022, 3028
|
2174, 2616
|
330, 336
|
3144, 3178
|
1526, 2151
|
1105, 1123
|
2994, 2999
|
3049, 3123
|
2642, 2971
|
1138, 1507
|
272, 292
|
364, 599
|
621, 878
|
894, 1089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,294
| 172,209
|
43128
|
Discharge summary
|
report
|
Admission Date: [**2193-11-9**] Discharge Date: [**2193-11-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with balloon angioplasty of 2 poles of
D1
History of Present Illness:
86yo man with PMH significant for CAD w/ known two vessel
disease including LAD lesion, HTN, aortic stenosis with [**Location (un) 109**] 1.1,
presented with 2-3 hrs substernal chest pain with radiation to
RUE, not associated with dyspnea, diaphoresis, nausea, vomiting,
lightheadedness, diaphoresis, or any other symptoms. He notes
this pain is similar to his usual angina. He took 3 sublingual
nitros without improvement, which is unusual for him. Pain was
the worst it has been and has not resolved since admission
(though it has improved to [**4-18**]).
Received ASA in the ambulance. In the ED, received O2, lasix,
lopressor, NTG gtt, heparin gtt, integrilin, plavix.
Cath lab showed chronic occlusion of LAD, occluded D1, 20%
stenosis of LMCA, occluded OM1 30% proximal. LVEDP 20, PCWP 35.
Balloon angioplasty of 2 poles of D1. No stents placed.
Cath in [**7-12**] revealed 2 vessel disease (LMCA w/ 20% distal
lesion, LAD w/ total occlusion after first septal and diagonal
branch, LCx w/ luminal irregularities w/ large third obtuse
marginal occlusion), severe aortic stenosis, severe left
ventricular diastolic dysfunction, mild pulmonary hypertension.
Past Medical History:
CAD (known LAD lesion occluded)
congestive heart failure
angina
HTN
aortic stenosis ([**Location (un) 109**] 1.1)
edema
hyperlipidemia
chronic renal insufficiency
gout
hyperkalemia
B12 deficiency
chronic leukocytosis (BL [**1-28**])
chronic thrombocytosis (400s)
GERD
polycythemia [**Doctor First Name **]/MPS
Social History:
lives alone, retired clothing salesman. H/o tobacco use, quit
22yrs ago, 45pack-year history. Denies alcohol, drug use.
Family History:
Mother and father who had MIs in mid-50s, sister w/ MI in 70s.
?CVA in mother. Denies DM.
Physical Exam:
VS: T 98.6, HR 60, ABP 137/54 (83), RR 20s, SaO2 97%/4L NC
CVP 9, PAP 42/18, mean 26, CO 5.1, CI 2.66, SVR 1129
dobutamine 2.5, integrelin 1.0, nitro 0.78 (mcg/kg/min)
Genl: elderly man lying still in bed, appears tired
HEENT: NCAT, PERRL, OP clear, dry mucous membranes
Neck: JVP not appreciated
CV: RRR, nl S1, S2, ?systolic murmur, no rubs/gallops
Pulm: +rales in dependent location, +wheezes anteriorly and
superiorly, tachypnea
Abd: soft, nondistended, nontender, BS+
GU: arterial sheath in place, dressing C/D/I, no hematoma
Ext: warm, dry, PP 2+ in bilateral PT and DP
Neuro: grossly normal, face symmetric, strength 5/5 in BUE, able
to move bilateral toes
Pertinent Results:
Admission labs:
CBC: WBC-15.0* RBC-3.41* Hgb-11.6* Hct-36.7* Plt Ct-477*
Diff: Neuts-81.3* Bands-0 Lymphs-15.3* Monos-3.1 Eos-0.3
Baso-0.1
Coags: PT-13.9* PTT-34.8 INR(PT)-1.3
Chem 10: Glucose-163* UreaN-57* Creat-2.4* Na-135 K-6.1* Cl-103
HCO3-21*
Calcium-8.0* Phos-3.8 Mg-1.7
ABG: Type-ART O2 Flow-2 pO2-60* pCO2-40 pH-7.33* calHCO3-22 Base
XS--4
Discharge labs:
CBC: WBC-10.3 RBC-2.67* Hgb-9.6* Hct-28.6* Plt-356
Chem 7: Glucose-105 UreaN-57* Creat-2.6* Na-140 K-5.2* Cl-106
HCO3-24
Cardiac enzs:
[**2193-11-8**] 10:40PM BLOOD CK(CPK)-141
[**2193-11-9**] 06:31AM BLOOD CK(CPK)-[**2170**]*
[**2193-11-9**] 01:48PM BLOOD CK(CPK)-1491*
[**2193-11-9**] 10:08PM BLOOD CK(CPK)-845*
[**2193-11-10**] 05:53AM BLOOD CK(CPK)-619*
[**2193-11-8**] 10:40PM BLOOD CK-MB-6 cTropnT-0.05*
[**2193-11-9**] 06:31AM BLOOD CK-MB-229* MB Indx-11.6*
[**2193-11-9**] 01:48PM BLOOD CK-MB-169* MB Indx-11.3*
[**2193-11-9**] 10:08PM BLOOD CK-MB-82* MB Indx-9.7* cTropnT-10.14*
[**2193-11-10**] 05:53AM BLOOD CK-MB-58* MB Indx-9.4* cTropnT-9.17*
Other:
[**2193-11-9**] TSH-1.7
[**2193-11-9**] Free T4-1.2
------------
EKG on admission: NSR at 70bpm, axis in nl quadrant, 1st degree
AVB with PR interval approx 500ms. ST depressions in V2-V5, II,
III, avF; ST elevations in aVL, ?I.
...
Cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The LMCA had 20% stenosis.
The LAD
had 40% proximal and 100% total chronic mid occlusion. The D1
had upper
and lower poles that were both acutely occluded. The LCX had
moderate
disease with occluded OM1. The RCA had proximal 30% stenosis.
2. Resting hemodynamics demonstrated severely elevated right
sided
pressures (mean RA pressure was 12 mmHg, mean PCWP was 45 mmHg).
There
was evidence of moderate pulmonary hypertension with mean PA
pressure of
43 mmHg. The cardiac index was severely depressed at 1.6
L/min/m2.
3. Successful balloon angioplasty of the D1 upper and lower
poles with a
2.0 mm balloon. Final angiography demonstrated a minimal
residual
stenosis, no angiographically apparent dissection, and normal
flow (See
PTCA Comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Acute occlusion of upper and lower D1 poles. Chronic mid LAD
occlusion.
3. Markedly depressed cardiac index.
4. Successful balloon angioplasty of the upper and
lower D1 poles
...
CXR ([**11-9**]): Findings consistent with CHF.
CXR ([**11-10**]): The heart size is enlarged. No pleural effusions or
focal consolidations demonstrated. There is prominence of the
central pulmonary vasculature and increased vascular markings
towards the upper lobe consistent with some underlying cardiac
failure, but mildly improved compared to the most recent chest
x- ray with resolution of interstitial edema.
...
ECHO ([**9-11**]): mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mild LV systolic dysfunction,
40-45%. [**Location (un) 109**] 1.1. Inferior and inferolateral
akinesis/hypokinesis. RV nl. Moderate AS, mild AR, mild MR,
moderate PA HTN.
.
ECHO ([**11-9**]): There is symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is
moderately-to-severely depressed (ejection fraction 30 percent)
secondary to severe hypokinesis of the inferior and posterior
walls, and moderate hypokinesis of the anterior and lateral
walls; the apex also appears hypokinetic. At least mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. At least
mild (1+) mitral regurgitation is seen. There is no pericardial
effusion.
...
Scrotal u/s: 1. Large left inguinal hernia with multiple bowel
loops and fluid within the scrotum.
2. Single testis and epididymis are identified and appear
normal. Soft tissue adjacent to scotal wall which is of
uncertain etiology, but may represent an atrophic testis.
Correlation with the patient's history is suggested.
3. Hydrocele.
Brief Hospital Course:
Assessment: 86yo man w/ known CAD and LAD occlusion, CHF, HTN,
hyperlipidemia, aortic stenosis, CRI, presenting with SSCP and
STEMI, taken to cardiac cath, where he had balloon angioplasty
of D1 upper and lower poles, admitted in CHF.
Hospital course is reviewed below by problem:
1. CAD - Mr. [**Known lastname 92971**] was admitted with an ST elevation MI. He has
a known history of LAD occlusion and was found to have occlusion
of the upper and lower poles of his first diagonal branch. The
lesions of the first diagonal were opened with balloon
angioplasty, the LAD lesion was treated medically as before. He
was treated with dobutamine post-catheterization, but this was
quickly weaned off without difficulty. During his
hospitalization, he had multiple episodes of angina with pain in
his right shoulder or chest. The pain was not associated with
dyspnea, diaphoresis, nausea, vomiting, lightheadedness,
dizziness, or other symptoms. They were relieved with one
sublingual nitro, tylenol, or spontaneously resolved after
several minutes. This was likely his stable angina and was not
associated with new EKG changes. He was treated with a nitro
drip in the CCU and was changed to a long acting po nitrate on
the floor, which was titrated up for chest pain as his blood
pressure tolerated. He was on Imdur 90mg on discharge. He was
also restarted on his norvasc prior to discharge for angina. He
was not given a beta-blocker due to his AV block (see below) and
bradycardia. This decision was deferred to his primary
cardiologist. On discharge, he was able to ambulate without
desaturation or pain.
2. AV block - He was noted to have first degree AV block and 2nd
degree AV block, initially with 2:1 block. His PR interval was
also increased with change in positioning, thought to be
secondary to increased intraabdominal pressure from his hernia
(see below). His primary cardiologist was contact[**Name (NI) **] and a prior
history of 1st degree AV block and Weinckebach was confirmed. He
was not treated with a beta blocker given his AV block and
intermittent bradycardia to the high 50's.
3. Heart failure - The patient was admitted with clinical
symptoms and and CXR signs of heart failure, and a LVEDP 20,
with PCWP 35. An ECHO here showed LVEF of 30%, down from 40-45%
in [**9-11**]. His heart failure was likely both systolic and
diastolic in nature, with the dyastolic dysfunction likely
secondary to HTN and aortic stenosis. The patient was allowed to
self-diurese with initial net fluid goals of -1L. He diuresed
well with net fluid output greater than intake until the last
several days, when he was clinically stable with clear lungs and
no signs of heart failure.
4. Inguinal hernia - per ultrasound. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], chief of
minimally invasive surgery, was informed and a resident saw the
patient and discussed him with Dr. [**Last Name (STitle) **]. They recommended
making an outpatient follow-up appointment ([**Telephone/Fax (1) 2723**]) to
discuss repair as an outpatient. The initial concern was that
pressure on his hernia was increasing intraabdominal pressure
and causing increased vagal tone. The surgeons, however, noted
that correcting the hernia surgically would likely increase
intraabdominal pressure to a greater extent. They recommended
waiting until the proper post-MI period. The patient was given
the number to call to make the follow-up appointment.
5. Renal failure - On admission, his creatinine was 2.4, which
is at his baseline of 2.0-2.4. During the hospitalization, his
creatinine increased to 2.7, likely secondary to dye load &
diuresis. He was treated with mucomyst pre- and
post-catheterization. His electrolytes remained stable. ACEI/[**Last Name (un) **]
were held given his renal function.
6. MPS - His home regimen of hydroxyurea was continued without
difficulty.
7. Gout - His allopurinol was renally dosed at 100qd during the
hospitalization.
8. Dispo - He was discharged to a short term facility for
rehabilitation.
9. Code status - Full.
Medications on Admission:
Meds (per pt's report, which is unsure, and OMR, which is
outdated):
nitroglycerin sl
isosorbide mononitrate CR 30mg qd
allopurinol 100mg qd
cozaar 50mg qd
(zantac)
norvasc
hydroxyurea 500mg qd
(ativan)
atenolol 100mg qd
(lasix 40mg qd)
ecASA 81mg qd
lipitor
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Dissolve one tablet under your tongue for chest pain. If the
pain does not go away, you may repeat this twice. If you still
have pain after 3 tablets, call 911 and go to the hospital.
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Zantac 75 75 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for heartburn: Take one tablet 30-60 minutes prior to
eating foods which cause heartburn, maximum 2 tablets in 24hrs.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
1. ST elevation myocardial infarct, occlusion of both poles of
the first diagonal branch.
2. Heart failure, diastolic and systolic, ejection fraction 30%
Secondary:
1. First degree AV block
2. Second degree AV block, type I
3. Inguinal hernia
4. Chronic renal insufficiency
Discharge Condition:
Stable; he is still having angina - chest pain and right
shoulder pain - which he had prior to admission, it resolves
with sublingual nitroglycerin. He is able to ambulate without
desaturation or angina.
Discharge Instructions:
Take all medications as prescribed.
Continue to take your nitroglycerin tablets as you were - if you
have chest pain or shoulder pain, put one tablet under your
tongue. If this does not cause the pain to stop, you may repeat
this twice. If you have taken three tablets and you still have
pain, call 911 and go to the hospital.
Call your doctor if you have any chest pain, shortness of
breath, nausea, vomiting, lightheadedness, dizziness, sweating,
arm or jaw pain, or any other concerning symptom.
Go to your scheduled follow-up appointments with Dr. [**First Name (STitle) 216**] and
Dr. [**Last Name (STitle) **]. Please call the number listed below to make a
follow-up appointment with Dr. [**Last Name (STitle) **] to address your hernia.
Followup Instructions:
You have a follow-up appointment with Dr. [**First Name (STitle) 216**] ([**Telephone/Fax (1) 250**])
on Tuesday, [**11-19**], 3:30pm.
You have a follow-up appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 34506**])
on [**2200-12-3**]:45pm.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], minimally invasive surgery, at
[**Telephone/Fax (1) 2723**], to schedule an outpatient appointment for your
hernia.
|
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"414.01",
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"402.91",
"530.81",
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"410.51",
"424.1",
"428.43",
"550.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.66",
"88.52",
"88.56",
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] |
icd9pcs
|
[
[
[]
]
] |
12644, 12729
|
6789, 10850
|
273, 340
|
13057, 13263
|
2811, 2811
|
14058, 14522
|
2020, 2111
|
11159, 12621
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12750, 13036
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10876, 11136
|
4964, 6766
|
13287, 14035
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3177, 3911
|
2126, 2792
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223, 235
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368, 1533
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2827, 3161
|
3925, 4947
|
1555, 1867
|
1883, 2004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,473
| 154,119
|
39897
|
Discharge summary
|
report
|
Admission Date: [**2134-12-18**] Discharge Date: [**2135-1-6**]
Date of Birth: [**2080-8-20**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Codeine / Nafcillin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Myalgias, fever, rash
Major Surgical or Invasive Procedure:
Transesophageal echocardiography x 2
Arthrocentesis of right shoulder
History of Present Illness:
This is a 54 yo male who presented to [**Hospital1 2436**] with 4-5 days
of malaise and chills, painful nodes starting on
fingers/toes/skin, transferred to [**Hospital1 18**] ICU given concern for
endocarditis and for closer monitoring. Pt stated that starting
on [**12-13**] days prior to admission, he was sore all over, had
fever, chills, sweats and shakes. His highest recorded temp was
100. He endorsed myalgias, arthralgias, that initiated in his
right knee, and then became worse in his left wrist and left
shoulder. He has also had a rash on his forehead for several
days, non-pruritic. He denied any SOB, cough, HA, CP, urinary
syx, abdominal pain, diarrhea, bloody or black stools. He also
reported blurred vision for the few days prior to admission.
Additionally, he had some visual hallucinations first noticed a
couple of days prior to admission seeing columns and "weird
lines" in his visual field. His wife also reported that he was
responding to auditory stimuli, but pt does not recall this. He
denied any sick contacts, though his wife has been in and out of
the hospital for RA flares requiring admission for solumedrol
infusions. His recent travel includes visiting his sons in [**Name2 (NI) **],
and he does work outside, but regularly checks for ticks but
denies any recent bites. He denied any recent dental work. He
was seen by his PCP 1 day prior to admission and was started on
cephalexin for a skin infection on forehead. He did not improve,
and presented to [**Hospital1 2436**] ED this on [**12-18**] because of "not
being able to get out of his chair" because of weakness. When
seen at [**Hospital1 2436**] ED, initial BP 78/51, was felt to have
endocarditis with septic emboli, with new murmur and
thrombocytopenia. Bedside Echo showed mild MR but no vegetations
but hypokinesis. He was given ceftriaxone and vancomycin. CT
head was negative. Found to have SBP in 70s. Outside labs
notable for platlets 40, trop 0.5, elevated BUN/Cr 46/1.9, WBC
9.5 with 23% bands, lactate 2.9, no hemolysis.
In the ED, initial VS were: 96 113/76 16 99%. Neurologic status
was intact but reported recent episodes of confusion. Peripheral
stigmata c/w endocarditis. EKG showed SR with nonspecific ST-T
changes. Blood cultures drawn, and he was given one dose of
Gentamicin. CXR and L shoulder film (has shoulder pain) pending.
Current VS: 98.2 97 100/70 100RA. Access is 2 PIV >= 18g.
In the ICU, his main complaint is diffuse weakness and pain.
Otherwise, his VSS were stable.
Review of systems:
(+) Per HPI, + for constipation
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations. Denies nausea, vomiting,
diarrhea, abdominal pain. Denies dysuria, frequency, or
urgency.
Past Medical History:
HTN
Seasonal allergies
Squamous cell carcinoma of tongue ([**2124**])
Ocular migraines
Social History:
He is employed as a podiatrist. He currently lives with his wife
at home. He has two sons currently in college in [**Name (NI) 5622**]
and [**Location (un) 5169**], [**State 350**]. He is sexually active with his wife,
they are monogamous, with no history of STD's.
- Tobacco: none now, briefly as a teenager
- Alcohol: 1-2 beers/night + [**3-25**] shots of Bourbon
- Illicits: none
Family History:
Father - HTN, [**Name (NI) 2320**], A. fib
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 97.9 BP: 94/66 P: 93 R: 16 O2: 95% RA
General: Alert, oriented, lying down in bed, no acute distress
Skin: erythematous maculopapular rash on forehead, 0.5cm black
lesion on forehead, splinter hemorrhages on left 2nd and 3rd
nails, several purpuric circular lesions on index fingers,
painful lesion on L index finger, scattered purpuric sub-cm
lesions on feet bilaterally, erythematous papules distributed
over chest and arms, petechiae scattered throughout extremities
HEENT: Sclera anicteric, PERRL, EOMI, dry MM, oropharynx clear
without exudate, no conjunctival hemorrhage
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema, tenderness to
palpation of lateral aspect of left shoulder, no erythema or
apparent effusion
Neuro: A&Ox3, responding to questions appropriately, CN II-XII
intact, slight left eyelid droop, weak grip bilaterally, 2+
DTR's in biceps and brachioradialis, unable to elicit patellar
DTR's bilaterally, toes downgoing
Psych: answering questions appropriately, no auditory or visual
hallucinations, does not appear to be responding to internal
stimuli, good eye contact, appropriate
DISCHARGE PHYSICAL:
General: Alert, oriented, no acute distress, appears comfortable
HEENT: PERRL, EOMI, visual fields intact, sclera anicteric, no
conjunctival lesions or erythema, MMM, oropharynx clear with no
lesions noted on buccal or perioral membrane, no desquamation of
tongue or palate.
Neck: supple, no LAD in cervical or supraclavicular area
Chest: mild asymmetry of chest with sternoclavicular joint on
right slightly more pronounced, but much improved since initial
presentation
Lungs: rales present bilaterally at bases, good respiratory
expansion.
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops;
II/VI SEM best heard at LUSB, and II/VI apical murmur, no
diastolic murmur appreciated on exam
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no hepatosplenomegaly, no
masses to palpation
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema in [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 6816**] up to knees, 3+ pitting edema in LUE, 2+ in RUE,
left arm larger than right with associated erythema. Left and
right lower legs are symmetric in diameter.
MSk: No pain to palpation of spinous processes in back. No
flank tenderness, no CVA tenderness. Mild tenderness to
palpation of quadriceps tendon insertion site on the right knee,
mild effusion noted. ROM improved as patient can now abduct
both arms to >90 degrees and flex both shoulders to >90 degrees
with less pain than previous. Some pain with flexion of left
arm. Intact passive and active ROM of hips and knees
bilaterally. No tenderness to palpation of lower gastrocnemius
muscle and Achilles tendon bilaterally; no pain on flexion or
extension of right foot, no areas of erythema, swelling, no
palpable cords on either leg.
Skin:
Erythema of skin much improved, with most noticed peripherally
in the extremities at this point, rash continues to desquamate,
not present on palms or soles. Mild erythema on dorsum of feet
and anterior shins bilaterally, non-tender, blanching with
underlying petechiae. 3 2x1cm papules w/ black eschars over
forehead without surrounding erythema, resolving. 2 are on the
anterior forehead, and one is more posterior.
LUE: no new lesions.
RUE: no new lesions. PICC site c/d/i with no exudate or
erythema.
LLE: no new lesions.
RLE: no new lesions.
Neuro: CNs II-XII intact, left tongue deviation likely due to
previous surgery. 2+ reflexes in upper and lower extremities,
downgoing toes bilaterally, mild weakness in all extremities
(prox>distal, UE>LE) but continues to improve, normal sensation
in all extremities. Normal grip strength in hands bilaterally,
symmetric.
Skin findings were as follows during admission:
LUE: splinter hemorrhages on 1st and 2nd nailbed, dark palpable
lesions on pads of 1st (new), 2nd and 3rd digits, non-painful;
[**Last Name (un) 1003**] lesions on palm (non-painful), no new lesions.
RUE: dark erythematous papules on PIP of 2nd and 4th digits,
splinter hemorrhage under nail of 3rd digit, palpable lesions on
all fingerpads; no new lesions.
LLE: palpable purple lesions on toe pads of 1st and 5th digit.
Erythema over the lateral dorsum of left foot, warm to touch but
non-tender, more widespread than yesterday involving most of
lateral aspect of the foot and anterior shin, non-tender to
palpation. Splinter hemorrhage under nail of great toe.
Petechiae present over knee with some surrounding erythema.
RLE: palpable purple lesions on great toe with surrounding
erythema, red macule on pad of 5th digit. Red papules over
lower leg, improved. Erythema over lateral dorsum of foot, more
widespread than yesterday, mildly warm, no tenderness to
palpation. Petechiae present over knee with some surrounding
erythema.
Pertinent Results:
ADMISSION LABS:
================
[**2134-12-18**] 02:50PM BLOOD WBC-8.7 RBC-4.19* Hgb-13.6* Hct-36.9*
MCV-88 MCH-32.4* MCHC-36.8* RDW-13.5 Plt Ct-42*
[**2134-12-18**] 02:50PM BLOOD Neuts-82* Bands-8* Lymphs-5* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2134-12-18**] 02:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-1+
[**2134-12-18**] 02:50PM BLOOD PT-11.8 PTT-24.4 INR(PT)-1.0
[**2134-12-18**] 02:50PM BLOOD ESR-20*
[**2134-12-18**] 02:50PM BLOOD Glucose-140* UreaN-42* Creat-1.5* Na-131*
K-3.4 Cl-98 HCO3-21* AnGap-15
[**2134-12-18**] 02:50PM BLOOD ALT-103* AST-116* LD(LDH)-288*
CK(CPK)-503* AlkPhos-47 TotBili-1.0
[**2134-12-18**] 02:50PM BLOOD CK-MB-15* MB Indx-3.0
[**2134-12-18**] 02:50PM BLOOD cTropnT-0.14*
[**2134-12-18**] 02:50PM BLOOD Albumin-3.1* Calcium-7.9* Phos-2.7 Mg-2.5
[**2134-12-18**] 02:50PM BLOOD Hapto-366*
[**2134-12-18**] 08:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2134-12-18**] 08:50PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2134-12-18**] 08:50PM URINE RBC-0-2 WBC-[**3-26**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2134-12-18**] 08:50PM URINE CastHy-0-2
[**2134-12-18**] 10:30PM URINE Hours-RANDOM UreaN-690 Creat-50 Na-46
K-20 Cl-38
[**2134-12-18**] 10:30PM URINE Osmolal-423
DISCHARGE LABS:
===============
White Blood Cells 11.6
Red Blood Cells 2.53
Hemoglobin 7.8
Hematocrit 23.0
MCV 91
MCH 30.7
MCHC 33.7
RDW 14.0
DIFFERENTIAL
Neutrophils 77.4
Lymphocytes 11.9
Monocytes 5.8
Eosinophils 4.2
Basophils 0.6
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 405
Sedimentation Rate 75
Glucose 98
Urea Nitrogen 11
Creatinine 1.4
Sodium 137
Potassium 4.1
Chloride 104
Bicarbonate 27
Anion Gap 10
IMMUNOLOGY
C-Reactive Protein 73.9
MICRO:
BCX [**12-18**]: PENDING
UCX [**12-18**]: PENDING
LYME [**12-18**]: negative
RMSF: negative
Ehrlichia: negative
ASO TITER: negative
RPR: non-reactive
HIV: negative
IMAGING:
===========
CXR [**2134-12-18**]:
Heart size is normal. Mediastinum is normal. There is mild
degree of
interstitial pulmonary edema, but no focal consolidation to
suggest septic
emboli or [**Month/Day/Year 1083**] process in the lung. No appreciable pleural
effusion or pneumothorax has been demonstrated.
SHOULDER XRAY [**2134-12-18**]:
Three views of the left shoulder were reviewed. There is no
evidence of
fracture, dislocation, lytic or sclerotic lesion seen.
TTE [**12-20**]:
Mild-moderate mitral regurgitation with normal valve morphology.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild pulmonary artery
systolic hypertension. If clinically indicated, a TEE would be
better able to assess the mitral valve for a possible
vegetation/endocarditis as the cause of the pathologic
regurgitation.
TTE [**12-21**]:
Probable small mitral valve vegetation with mild to moderate
mitral regurgitation. No abscess. Normal biventricular systolic
function.
RUQ U/S [**12-21**]:
1. No evidence of fluid collection.
2. Normal hepatic echotexture, however, mild splenomegaly which
may be due to underlying liver disease.
3. Cholelithiasis without evidence of cholecystitis.
4. Right pleural effusion.
MRI Right shoulder [**2134-12-23**]:
1. Findings in keeping with myositis, with affecting
supraspinatus,
infraspinatus, trapezium and pectoralis major muscles. The
differential
diagnosis is broad and includes polymyositis, viral myositis,
medication
associated myopathy. However, the clinical presentation of
sepsis and finding of multifocal punctate areas focal signal
intensity abnormalities raises concern for pyomyositis with
microabscesses.
2. Trace fluid in the right sternoclavicular joint with
periarticular edema. Differential includes infection and other
inflammatory arthropathy.
CT torso [**2134-12-23**]:
1. Findings are consistent with acute pyelonephritis.
2. Small bilateral pleural effusion and associated atelectasis.
3. Multiple gallstones without cholecystitis.
MRI Spine [**2134-12-28**]:
1. No evidence of discitis, osteomyelitis, epidural collection
or
paravertebral collection in the cervical, thoracic, or lumbar
spine.
2. Multilevel cervical spondylosis with moderate spinal canal
stenosis at
C5-6 and C6-7.
3. L5-S1 spondylosis and facet arthropathy, with lateral recess
narrowing and mild-to-moderate bilateral neural foraminal
narrowing.
CXR [**2134-12-30**]:
Mild degree of bilateral pleural fluids that have developed
during the latest two weeks' examination interval. No new
parenchymal abnormalities.
TEE [**2134-12-31**]:
IMPRESSION: No vegetations or abscesses seen.
CT head non-contrast [**2135-1-3**]:
IMPRESSION: No acute abnormality.
Left upper extremity ultrasound [**2135-1-3**]:
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
Chest X-ray [**2135-1-3**] portable:
1. Right PICC projects over low SVC.
2. Bibasilar opacities, which may be atelectasis but can be
pneumonia in the appropriate clinical setting.
Chest X-ray [**2135-1-6**] portable:
Right PICC projects over mid SVC.
Brief Hospital Course:
This is a 54 yo male who presented to [**Hospital1 2436**] with 4-5 days
of malaise and chills, painful nodes starting on
fingers/toes/skin, with significant bandemia, thrombocytopenia
and acute renal failure.
# Fever/septicemia/MSSA endocarditis: Differential diagnosis was
broad including bacterial or viral illness, endocarditis, or
arthropod illness, in addition to vasculitis. Patient was
afebrile on admission, but with significant bandemia of 8% (23%
at OSH). ID was consulted, and recommended coverage for gram
positive cocci and pseudomonas given rash on forehead and
concern for cellulitis, and vancomycin and cefepime was started.
Erythematous rash was also concerning for TSS, and the patient
was started on Clindamycin. Also, given that the patient spends
time outside, the patient was covered for tick-borne illnesses
such as Erlichiosis with doxycycline. Outside hospital records
noted the growth of MSSA from 3/3 bottles. Later MIC testing
showed pan-sensitivity of the isolate. Endocarditis was
considered likely given petechiae and purpuric lesions possibly
consistent with embolic phenomena. A repeat TTE showed no
vegetation, but subsequent TEE showed a mitral vegetation with
no associated abscess. A vasculitic process such as TTP/HUS was
also considered given fever, acute kidney injury, altered mental
status, thrombocytopenia and vasculitic-appearing lesions on the
patient's extremities. However, hemolysis labs were negative and
no schistocytes were seen on peripheral smear. Hematology was
consulted, and thought that no hemolysis or TTP was occurring,
and that thrombocytopenia might be due to the patient's
underlying illness and/or sequestration. Initial lactate was
2.5, and downtrended to 2.3 during the patient's early
hospitalization. The patient remained hemodynamically stable
and was transferred to the medical floor. Blood cultures and
urine cultures were sent, which showed no growth. Lyme
serologies, RMSF, blood smear for babesia were non-revealing.
HIV with viral load, RPR, ASO titer, throat culture were sent
and were also non-revealing. The patient's antibiotic regimen
was narrowed to IV nafcillin, which was stopped on [**12-25**] due to
the appearance of a morbilliform rash on the patient's back that
was noted. Vancomycin was restarted and dosing was adjusted
according to renal function and trough values. Due to
persistent fevers, MRI of the spine, as well as a non-contrast
head CT was ordered to search for any underlying areas of
infection, both of which were negative. CT torso was also
performed and showed some features suggestive of septic emboli
in the kidney. Surveillance blood cultures did not grow
bacteria while the patient was hospitalized at [**Hospital1 18**], with two
blood cultures pending at discharge. Due to continuous fevers,
a repeat TEE was performed ten days after the initial test which
showed no evidence of vegetations or abscess. A repeat ECG
was performed and showed no change. The patient will be
following up with [**Hospital1 **] Disease at two and four weeks after
discharge for follow-up of antibiotic therapy and clinical
status. He was discharged on vancomycin 1000 mg [**Hospital1 **]. Weekly
labs, including CBC, Chem7, ESR, CRP, vancomycin troughs and
liver function tests will be performed weekly after discharge
for VNA services. Patient is being discharged with a
prescription for acetaminophen for fevers and joint pains, and
has been asked to hold on taking ibuprofen for now given his
recovering renal function. He was also prescribed a limited
prescription of oxycodone for pain. He knows to report any
change in symptomatology to his PCP or the [**Hospital1 **] Disease
department. He has also been advised to seek medical care for a
fever > 102F.
# Thrombocytopenia: Differential diagnosis included decreased
production processes due to alcohol or other bone marrow process
vs. increased destruction secondary to immune-mediated process
such as ITP, medication, or non-immune mediated such as TTP/HUS
or DIC. Hemolysis labs were negative, and peripheral smear
showed Burr cells and Helmet cells, but no schistocytes.
Hematology felt that the thrombocytopenia may have been due to
the patient's underlying illness and possibly splenic
sequestration. The platelet count normalized over the few days
after admission to a normal level. Platelet count actually
increased during the patient's later admission, likely due to
ongoing inflammation.
#. Right shoulder pain: the patient complained of right shoulder
pain during his illness, and there was noted to be warmth to the
right deltoid as well as swelling, erythema and pain to
palpation of the right sternoclavicular joint. Orthopedics was
consulted and recommended MRI of the shoulder, which revealed
possible microabscesses of the shoulder musculature and a small
fluid collection around the sternoclavicular joint. Symptoms
resolved over the course of the patient's hospitalization, and
near full range of motion was noted at discharge.
#. Left shoulder pain: the patient complained of left shoulder
pain during his admission, for which orthopedics was consulted.
They thought that the pain was likely to due to myalgias from
his ongoing illness, and less likely to be septic arthritis.
Joint tap was attempted, but elicited no fluid. The shoulder
exam was monitored throughout the hospital stay, and improvement
in symptoms was observed.
# Radiologic kidney finding: CT torso was performed during
hospitalization, and had findings suggestive of pyelonephritis.
Urine cultures showed no growth of organisms. It was thought
that the noted lesions may represent septic emboli of the kidney
from the patient's endocarditis.
#. Diffuse weakness: Dr. [**Known lastname 4640**] had diffuse weakness during his
admission, for which he had trouble moving both his arms and
legs, worse in the upper extremities, and in a more proximal
distribution. Etiology was thought to be due to bacteremia, or
perhaps an element of ICU neuropathy. Patient was monitored for
focal neurologic and musculoskeletal findings. Exam improved
steadily over the course of the patient's admission. MRI found
evidence of microabscesses in the right shoulder, which may
serve to explain some of the upper extremity symptoms.
Antibiotic therapy was continued as mentioned above. His
weakness progressively improved over the course of his
hospitalization. He will be participating in physical therapy
as an outpatient to facilitate further recovery.
#. Drug Rash: the patient developed a morbilliform rash on his
back on [**2134-12-25**], which eventually spread over his entire body.
The rash, evaluated by Dermatology, was thought to be due to
nafcillin, and the antibiotic regimen was switched to IV
vancomycin. The rash eventually evolved from a papular eruption
to a diffuse erythema with subsequent desquamation. The patient
was provided steroid creams and hydroxyzine for relief of
pruritus and Aquaphor for moisturization. The rash was largely
resolved by the time of discharge, with some residual
desquamation occurring.
# Acute kidney injury (Prerenal and acute tubular necrosis):
There was no previous creatinine to compare to prior to
admission, but per patient report, he had no previous renal
insufficiency. Differential diagnosis included pre-renal
etiology given that he appeared hypovolemic initially, with
improvement of creatinine from 1.9 to 1.5 on the same day after
fluids. FeNa was 1%, with urine Na 46. Intra-renal etiology was
thought to be possible given elevated urine sodium. Urinalysis
and urine cultures showed few red and white blood cells. He was
given IV fluids, and his creatinine trended back to normal.
Later on in the [**Hospital 228**] hospital course, creatinine again
began to rise, peaking around 2.0. Urine sediment was examined
and showed granular and muddy brown casts, consistent with acute
tubular necrosis. The etiology was thought to be due to
dehydration, especially with extensive third spacing and
insensible losses, or possibly vancomycin toxicity, due to high
trough levels. Patient's creatinine slowly improved with
continuous hydration. At the time of discharge, his creatinine
was 1.4, and was improving with PO hydration. His creatinine
will be followed up upon discharge, as well as vancomycin trough
levels upon discharge.
# Left upper extremity swelling: near the end of the [**Hospital 228**]
hospital course, his left arm was noted as more swollen than the
right. Ultrasound was performed and showed no evidence of clot.
The area was monitored an no worsening of the swelling was
noted. His symptoms will be monitored on follow-up with his
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] Diseases.
# Visual hallucinations: Patient was speaking nonsensically
during initial presentation and concern for visual
hallucinations though never clear. Differential diagnosis
included acute intracranial process such as embolic phenomena,
though negative CT head at outside hospital vs. alcoholic
hallucinosis. There were no focal neurologic findings on exam.
He was placed on a CIWA until he was out of the window period
from his last drink. Hallucinations did not recur during his
time hospitalized at [**Hospital1 18**]. Repeat non-contrast head CT showed
no structural findings or evidence of infection.
# Transaminitis: Differential diagnosis included acute viral
process vs. alcoholic hepatitis vs. shock liver given
hypotension at OSH vs. acute febrile illness as above. AST and
ALT were similarly elevated with normal alkaline phosphatase and
total bilirubin. Enzymes were trended and showed a likely
hepatocellular process. Levels of bilirubin trended down over
the course of hospitalization. His transaminases remained
elevated throughout his hospital course, but were stable. The
levels of liver function tests will be followed weekly upon
discharge.
# Hypertension: patient's home antihypertensive regimen was held
during hospitalization, due to the hypotensive illness the
patient experienced while hospitalized. He should resume his
amlodipine upon discharge.
# GERD: patient was not taking a PPI at the time of admission,
since he was symptom-free at that time. He was not provided
therapy during admission. He should resume PPI therapy as
needed in the future for symptomatic GERD.
# Follow-up: Patient will have weekly lab draws consistent of
CBC, Chem7, ESR, CRP, LFTs and vancomycin troughs to be
performed by VNA services. He will also have a vancomycin
trough drawn on the day after discharge, with results faxed to
the [**Hospital1 18**] [**Hospital1 **] Disease department. Follow-up on pending
blood cultures will need to be performed. He will be following
up with [**Hospital1 **] Disease at two and four weeks after
discharge. He also has an appointment with his PCP [**Last Name (NamePattern4) **] [**2135-1-12**].
Medications on Admission:
Omeprazole 20mg daily, sporadically takes it
Amlodopine 5mg daily
ASA 81mg, takes it [**3-25**] out of 7 days per week
Fish oil supplement
MVI daily
Discharge Medications:
1. petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day).
Disp:*1 bottle* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Please do not drive, operate heavy
machinery or drink alcohol while taking this medication.
Disp:*36 Tablet(s)* Refills:*0*
3. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
injection Intravenous Q 12H (Every 12 Hours).
Disp:*60 injection* Refills:*0*
4. Outpatient Physical Therapy
Please perform physical therapy for strength training
5. Lab work
Please perform a weekly CBC, Chem7, ESR, CRP, LFTs, and
vancomycin trough and fax results to the [**Hospital1 18**] [**Hospital1 **]
[**Hospital 2228**] clinic at [**Telephone/Fax (1) **]. If there are any questions,
you can call the clinic directly at [**Telephone/Fax (1) **].
6. Lab work
Please perform vancomycin trough on [**2135-1-7**] and fax results to
the [**Hospital1 18**] [**Hospital1 **] [**Hospital 2228**] clinic at [**Telephone/Fax (1) **]. If there
are any questions, you can call the clinic directly at
[**Telephone/Fax (1) **].
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Fish Oil Oral
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnoses:
Methicillin-sensitive stapylococcus aureus endocarditis
Nafcillin-associated rash
Bilateral shoulder pain
Acute kidney injury due to acute tubular necrosis
Transaminitis
Secondary diagnosis:
Hypertension
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 4640**],
It was truly a pleasure to take care of you at the [**Hospital1 18**]. You
came for further evaluation of fever, chills and generalized
body aches. Further evaluation showed that you have an
infection of your heart valve that is now being treated with
antibiotics. You will require close follow-up with [**Hospital1 **]
Diseases at two and four weeks after discharge then moving
forward per their recommendations. You will also need
laboratory follow-up on a weekly basis that will be drawn by
your VNA and sent to the [**Hospital1 **] [**Hospital 2228**] clinic. Please do
not hesitate to report any new symptoms or problems to the
[**Hospital **] Disease doctors [**Name5 (PTitle) **] your primary care doctor. If you
experience a fever > 102F, please seek medical attention with
your PCP or at the emergency department. Please also abstain
from alcohol.
The following changes have been made to your medications:
We ADDED vancomycin, an antibiotic, for treatment of your
infection.
We ADDED oxycodone for control of pains you may have.
We ADDED petrolatum ointment for your skin dryness.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] I
Address: [**Location (un) 82799**], [**Location (un) **],[**Numeric Identifier 82800**]
Phone: [**Telephone/Fax (1) 77864**]
When: [**Telephone/Fax (1) 20212**], [**1-12**], 1:45PM
*Your appointment on the 23rd has been canceled. Please see the
doctor [**First Name (Titles) **] [**Last Name (Titles) 20212**] at the time above.
Department: [**Last Name (Titles) **] DISEASE
When: THURSDAY [**2135-1-20**] at 2:50 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name **] DISEASE
When: FRIDAY [**2135-2-11**] at 8:30 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
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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icd9cm
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[
[
[]
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icd9pcs
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[
[
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14137, 25061
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311, 383
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26934, 26934
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9004, 9004
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27085, 28222
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2924, 3210
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411, 2905
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26866, 26913
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26949, 27061
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3232, 3320
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3336, 3723
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,144
| 154,402
|
30938
|
Discharge summary
|
report
|
Admission Date: [**2172-5-28**] Discharge Date: [**2172-6-3**]
Date of Birth: [**2106-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2172-5-29**] - CABGx3 (Internal mammary to the left anterior
descending, vein to diagonal artery and vein to obtuse marginal
artery)
History of Present Illness:
Mr. [**Known lastname **] is a 66 y/o gentleman with a known history of coronary
artery disease. He developed crescendo anginaover the past week
and presented to MWMC for evaluation. He ruled in for an
STEMIand cardiac catheterization revealed three vessel disease.
He was subsequently transferred to the [**Hospital1 18**] for surgical
management.
Past Medical History:
HTN
DVT
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Tear - Gastrectomy performed
Osteoarthritis
Splenectomy [**2161**]
MI
Social History:
Lives alone. Does not smoke or drink.
Family History:
No family history
Physical Exam:
64 sr 143/63
GEN: NAD
NEURO: A+Ox3, nonfocal exam
HEENT: PERRL, Anicteric sclera, OP benign, no carotid bruit
PULM: CTA
CV: RRR, normal S1-S2, no murmur
ABD: Soft, NT/ND/NABS
EXT: Warm, + Varicosities, paplable pulses
Pertinent Results:
[**2172-5-28**] 05:53PM ALT(SGPT)-17 AST(SGOT)-31 LD(LDH)-174 ALK
PHOS-64 TOT BILI-0.6
[**2172-5-28**] 05:53PM WBC-9.5 RBC-3.77* HGB-12.8* HCT-36.4* MCV-97
MCH-33.9* MCHC-35.1* RDW-13.2
[**2172-5-28**] 05:53PM PT-18.6* PTT-28.6 INR(PT)-1.7*
[**2172-5-28**] 05:53PM PLT COUNT-278
[**2172-5-28**] 05:53PM GLUCOSE-92 UREA N-8 CREAT-0.7 SODIUM-142
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-12
[**2172-6-1**] 06:50AM BLOOD WBC-11.7* RBC-2.80* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.1* MCHC-34.2 RDW-13.7 Plt Ct-175
[**2172-6-1**] 06:50AM BLOOD Plt Ct-175
[**2172-6-1**] 06:50AM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-140
K-4.0 Cl-104 HCO3-30 AnGap-10
[**2172-5-28**] 05:53PM BLOOD %HbA1c-6.2*
[**2172-5-30**] CXR
Greater consolidation and volume loss at the lung bases suggests
appreciable atelectasis though pneumonia cannot be excluded.
Moderate cardiomegaly unchanged. Low lung volumes may reflect
tracheal extubation. Upper lungs clear. Right jugular line tip
projects over the SVC. Relative elevation of the left
hemidiaphragm is longstanding.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2172-5-28**] via transfer from
[**Hospital6 **] for surgical management of his coronary
artery disease. He was worked-up in the usual preoperative
manner. On [**2172-5-29**], Mr. [**Known lastname **] was taken to the operating room
where he underwent coronary artery bypass grafting to three
vessels. Postoperatively he was taken to the intensive care unit
for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Coumadin was resumed
for his recent deep vein thrombosis. On postoperative day two,
he was transferred to the step down unit for further recovery.
He was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. Beta blockade, Minipress,
Norvasc, ACE-I, aspirin and a statin were resumed. By
post-operative day five he was ready for discharge to a
rehabilitation facilty.
Medications on Admission:
Atenolol
Norvasc
Minipress
Coumadin
Lisinopril
Diltiazem
Actonel
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: titrate daily for an INR goal of [**1-31**].5.
Disp:*1 Tablet(s)* Refills:*0*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. Prazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
Disp:*120 Capsule(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
CAD s/p CABG
HTN
DVT
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Tear
Osteoarthritis
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 27772**] in [**2-2**] weeks. ([**Telephone/Fax (1) 71278**]
Follow-up with Dr. [**Last Name (STitle) 5874**] in 2 weeks.
Please call all providers for appointments.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2172-6-3**]
|
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icd9cm
|
[
[
[]
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[
"99.07",
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icd9pcs
|
[
[
[]
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5041, 5124
|
2441, 3478
|
330, 468
|
5275, 5284
|
1357, 2418
|
5998, 6413
|
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|
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|
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|
3504, 3570
|
5308, 5975
|
1118, 1338
|
280, 292
|
496, 846
|
868, 1013
|
1029, 1068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,305
| 192,925
|
33893+33894+57884
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2143-1-8**] Discharge Date: [**2143-1-9**]
Date of Birth: [**2117-2-6**] Sex: F
Service: MEDICINE
Allergies:
Magnesium / Latex / Salicylate / Benzocaine
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
vistaril overdose
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 1637**] is a 25 yo F with HX of bipolar disorder, anxiety,
severe persistent asthma with multiple prior intubations, IVDA,
septic arthritis
presenting with drug overdose.She came from [**Hospital3 **]
where she had presented for her 5th detox from IV heroine on
[**1-7**], endorsing depression at which point she had a positive
tox screen for benzodiazepines, tricyclics and opiates. She was
receiving vistaril as part of detox, but also had own supply.
She stated on presentation to [**Hospital1 18**] ED that she had been taking
extra visteril as was not getting seroquel, doxepin for anxiety.
She had received 35mg methadone this am for detox. She was
estimated to have taken over 76 visteril in 48 hours she was
noted to have become progressively sedated with waxing and
[**Doctor Last Name 688**] mental status.
.
In the ED her VS were: T:97 HR: 122 BP 121/62 RR:14 sating 94%
on RA.
She was not noted to be agitated, but would climb out of bed
thus restraints were placed. She was noted to have roving eye
motions, and sinus tachycardia on EKG although she has a history
of this. She was without clonus, agitation, fever, dryness. A
urine/serum tox screen was positive for methadone. She was seen
by the toxicology team in the ED who felt that her presentation
was consistent with central anticholinergic. She was also noted
to have wheezing on respiratory exam. On CXR, she was noted to
have a RLL infiltrate with leukocytosis to 12.5.She received
levofloxain for PNA.
She was last discharged [**2142-10-11**] for septic arthritis with group
A bacteremia and resultant septic shock, with left knee
replacement.
.
On arrival to the floor her vital signs were stable and she
complained of [**9-3**] pain L knee pain.
.
Past Medical History:
Severe persistent asthma - multiple intubations
chronic sinusitis
opiod dependence
s/p bilateral knee replacements for osteonecrosis [**2-26**] long term
prednisione use (R knee [**9-1**], left knee [**1-1**])
hypogammaglobulinemia
hepatitis c
tobacco abuse
-spontaneous PTX in [**5-2**]
-s/p R VATS/bleb resection and pleurectomy at [**Hospital 8**] Hospital
in [**2141-6-25**]
osteopenia by xray
Social History:
She endorses recent injection of heroin in the past week and
reports that prior to this she had been clean for about two
years. She does have history of injection drug use and cocaine
use in the past.
Tobacco: She endorses smoking [**1-26**] PPD currently and has been
smoking for the past 10 years.
Family History:
Mother - breast cancer
[**Name (NI) **] - asthma and hyperthyroidism
Physical Exam:
Vitals: T: 95.6 BP: 104/52 P: 118 R:16 O2:97% 2L
General: waxes and wanes, arousable.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear.
Bilateral eccymoses below eyelids.
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral expiratory wheezes
CV: sinus tachycardic(before nebs), normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: left knee with surgical scar. No erythema, no TTP, no
effusion.
CXR: Wet read:
Multifocal areas of opacity at R lung base and perihilar diffuse
opacity. Could be infection, drug reaction, versus cardiogenic
in nature.
Labs: see below.
Pertinent Results:
[**2143-1-8**] 11:30PM POTASSIUM-4.3
[**2143-1-8**] 05:35PM LACTATE-1.4
[**2143-1-8**] 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2143-1-8**] 05:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2143-1-8**] 05:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2143-1-8**] 05:20PM URINE RBC-[**3-29**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2143-1-8**] 04:35PM GLUCOSE-124* UREA N-11 CREAT-0.7 SODIUM-136
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2143-1-8**] 04:35PM CK(CPK)-88
[**2143-1-8**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-1-8**] 04:35PM WBC-21.5*# RBC-4.67 HGB-11.8* HCT-35.4*
MCV-76* MCH-25.3* MCHC-33.4 RDW-18.4*
[**2143-1-8**] 04:35PM NEUTS-76.3* LYMPHS-15.9* MONOS-2.8 EOS-4.3*
BASOS-0.7
[**2143-1-8**] 04:35PM PLT COUNT-499*
[**2143-1-9**] 06:22AM BLOOD WBC-13.0* RBC-4.11* Hgb-10.1* Hct-32.5*
MCV-79* MCH-24.6* MCHC-31.1 RDW-17.7* Plt Ct-388
[**2143-1-9**] 06:22AM BLOOD Neuts-67.6 Lymphs-23.3 Monos-3.4 Eos-5.3*
Baso-0.4
[**2143-1-9**] 06:22AM BLOOD Plt Ct-388
.
CXR [**2143-1-8**]
COMPARISON: [**2142-10-6**].
SINGLE UPRIGHT VIEW OF THE CHEST AT 1705: Lung volumes are
somewhat low. A
right-sided central venous catheter has been removed. Surgical
material in
the right apex is consistent with prior right upper lobe
resection.
There is a focus of increased opacity in the right lung base,
concerning for
developing consolidation. Additionally, there is perihilar
opacity
bilaterally, with bronchiectasis. The heart size is normal.
There is no
mediastinal enlargement. Blunting of the right costophrenic
angle is
unchanged. There is no large pleural effusion. There is no
pneumothorax.
Bilaterally, old, remodeled rib fractures are present.
IMPRESSION: Perihilar ground-glass opacities with
bronchiectasis, and a more focal area of opacification in the
right lower lobe. Findings could reflect multifocal infection,
or drug reaction, combined with non-cardiogenic pulmonary edema.
Brief Hospital Course:
25 year old woman with hx severe persistent asthma with multiple
prior intubations, IVDA, septic arthritis s/p L knee replacement
presenting with drug overdose.
1. POLYSUBSTANCE ABUSE: Pt with known overdose on vistaril.
Urine/serum screen positive only for methadone. Pt known to be
in process of detoxing. Patient was drowsy on arrival, but did
not have other signs of cholinergic overdose. She was seen by
toxicology with a plan made for supportive therapy. She was very
alert on her second hospital day. She had some borderline QTC
prolongation on one EKG, which was improved on subsequent EKGs
and there was no clinical correlation. She was cleared from a
medical standpoint by the general medicine and toxicology teams.
2. Pneumonia: a CXR revealed what appeared to be a multifocal
pneumonia. Given Her history of prior overdose, there was a
concern that her CXR findings may represent a drug reaction,
such as occurs following cocaine use, however on further review
of the films with radiology, it was felt that her CXR was
consistent with a multifocal PNA. She was discharged on
levofloxacin, for a total 7 day course of antibiotic therapy.
Upon discharge, she was stable on room air.
3. ASTHMA: Pt noted to have wheezing on exam, with hx of non
compliance/ severe persistent asthma with multiple (> 20)
intubations in the past. Last seen by her pulmonologist Dr
[**Last Name (STitle) **] in [**4-2**], with multiple telephone communications
since. Her wheezing did improved with nebulizer treatment, and
it was felt that steroids were not indicated. A plan was made
for continued nebulizer treatments as an outpatient with follow
up with her PCP.
4. L knee septic arthritis s/p knee replacement: Pt received 6
week course of IV vancomycin at rehab. Pt has not attended
follow up I.D appointments despite numerous attempts by I.D to
contact. During this hospitalization, her right knee did not
appear inflammed or currently infected. She continued to
experience some mild pain managed with ibuprofen and tramadol.
5. Sinus tachycardia: She has a history of tachycardia, which
worsens following nebulizer treatments and with agitation. There
may also have been some contribution to her tachycardia from her
anticholinergic overdose with vistaril. Her tachycardia was
confirmed sinus with serial EKGs. Her tachycardia improved as
she become less agitated, and she was cleared from a medical
perspective by the medicine and toxicology teams.
Medications on Admission:
Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **]
2. Montelukast 10 mg Tablet once daily
3. Omeprazole 20mg E.R once daily.
4. Nystatin Five (5) ML PO QID PRN mouth pain.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) q4hr prn
6. Tiotropium Bromide 18 mcg Capsule once daily
7. Quetiapine 100 mg Tablet qHS.
8. Ferrous Sulfate 325 mg daily
9. Senna 8.6 mg Tablet [**Hospital1 **]
10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain: should be weaned over 6 weeks.
12. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: Four
(4) Million units Injection Q4H (every 4 hours) for 5 weeks: do
not stop medication until instructed by [**Hospital **] clinic at [**Hospital1 18**].
13. Clonazepam 0.5 mg Tablet Sig [**Hospital1 **] PRN anxiety.
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain .
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain .
10. Methadone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Vistaril Overdose
.
Secondary
Asthma
Knee joint infection s/p knee replacement
Discharge Condition:
stable, good, baseline ambulatory and mental status.
Discharge Instructions:
You were admitted to the hospital because you had overdosed on
vistaril. You were very lethargic because of this. You were also
found to have a pneumonia. You are being treated with
antibiotics for this.
The following changes were made to your medications.
Levofloxacin 750mg daily for 8 days.
.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2143-1-23**] 4:00
Admission Date: [**2143-1-9**] Discharge Date: [**2143-1-13**]
Date of Birth: [**2117-2-6**] Sex: F
Service: MEDICINE
Allergies:
Magnesium / Latex / Salicylate / Benzocaine
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Hypoxia and Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
25 yo female with past medical history of asthma complicated by
multiple intubation and IV drug abuse complicated by septic
shock and septic arthritis. Patient was sent from [**Hospital1 **] for
ED evaluation of pneumonia after her oxygen saturation was noted
to be low. She was discharged from [**Hospital1 18**] earlier today
([**2143-1-9**]) after a two day stay for toxic ingestion of
hydroxyzine. Was discharged back to [**Hospital1 **] after note of CXR
showing multifocal pneumonia and was subsequently started on
levofloxacin 750 mg PO for a planned 7 day course. Had fevers at
[**Hospital **] rehab today and report of decreased oxygen
saturation. Patient notes a cough which is now productive,
though she is unable to clarify whether cough is different from
her chronic cough.
In the emergency department, initial vitals were: T 101.8, HR
146, BP 129/107, RR 26, 85% RA. Was persistently tachycardic in
ED (sinus per EKG). Received levofloxacin at [**Hospital1 **]. In the
ED received vancomycin and ceftriaxone. Additionally, was given
lorazepam 2 mg IV x 1. Report by word of mouth through nursing
staff was that patient had acute mental status change after a
trip to bathroom in the ED. Prior to transfer to the ICU vitals
were: HR 120s, BP 117/97, RR 25, O2Sat 97% 4L NC.
REVIEW OF SYSTEMS:
(+)ve: fever, cough, sputum production, wheezing, dyspnea,
fatigue, rhinorrhea, nasal congestion, arthralgias
(-)ve: chills, night sweats, loss of appetite, chest pain,
palpitations, hemoptysis, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia,
melena, dysuria, urinary frequency, urinary urgency, focal
numbness, focal weakness, myalgias
Past Medical History:
1) Severe persistent asthma - multiple intubations (reports >
20)
2) Intravenous drug abuse - multiple detox from heroin
3) Hepatitis C
4) Septic shock from septic arthritis ([**9-/2142**]) - s/p left total
knee
replacement with washout and revision ([**2142-10-3**])
5) Opioid dependence
6) Chronic sinusitis
7) s/p bilateral knee replacements for osteonecrosis [**2-26**] long
term
prednisone use (right knee [**8-/2141**], left knee [**12/2141**])
8) Hypogammaglobulinemia
9) Tobacco abuse
10) Spontaneous pneumothorax in [**4-/2141**] -s/p R VATS/bleb
resection and pleurectomy at [**Hospital 8**] Hospital in [**2141-6-25**]
11) Osteopenia by xray
Social History:
Patient currently at [**Hospital1 **] for mandatory detox due to
possession charge. Prior to that was living with her mother.
Reports that she has a good relationship with her mother when
patient is sober.
Tobacco: Current [**1-26**] PPD use, overall smoking for last 10 years.
EtOH: Rare
Illicits: Recent injection of heroin (4 days prior to
presentation) and reports that prior to this she had been clean
for about two years. Additionally, history of cocaine use (IV
route), though patient denies use in last few months. Occasional
marijuana use.
Family History:
Mother - breast cancer
[**Name (NI) **] - asthma and hyperthyroidism
Physical Exam:
VS: T 98.4, HR 116, BP 111/83, RR 26, O2Sat 92% 4L NC
GEN: NAD, somnolent
HEENT: left periorbital ecchymosis, PERRL, EOMI, oral mucosa
moist, oropharynx benign, right scalp abrasion
NECK: Supple, no [**Doctor First Name **], no thyromegaly
PULM: tachypneic, inspiratory and expiratory wheezing with good
air movement, diffuse rhonchi, bibasilar crackles, no accessory
muscle use, loose-sounding cough
CARD: Tachy, nl S1, nl S2, no M/R/G
ABD: Tattoo across abdomen, BS+, soft, non-tender, non-distended
EXT: No cyanosis, clubbing, or edema
SKIN: Multiple ecchymoses, excoriations, and scabs (which she
picks and removes through the exam)
NEURO: Oriented x 3, intermittently somnolent to point where she
nods off during middle of conversation, CN II-XII intact, motor
grossly intact
PSYCH: Patient with good range of affect, is somewhat
confrontational, though appropriately frustrated with clinical
situation
Pertinent Results:
Admission Labs:
[**2143-1-8**] 04:35PM WBC-21.5*# RBC-4.67 HGB-11.8* HCT-35.4*
MCV-76* MCH-25.3* MCHC-33.4 RDW-18.4*
[**2143-1-8**] 04:35PM PLT COUNT-499*
[**2143-1-8**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-1-8**] 04:35PM CK(CPK)-88
[**2143-1-8**] 04:35PM GLUCOSE-124* UREA N-11 CREAT-0.7 SODIUM-136
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2143-1-8**] 05:35PM LACTATE-1.4
[**2143-1-9**] 06:22AM CALCIUM-8.7 PHOSPHATE-5.5*# MAGNESIUM-1.8
Other labs:
TSH.34
CRP106.4
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl neg for all [**1-9**] and [**1-10**]
serum positive only for methadone
Micro:
cdiff negative [**1-12**]
joint fluid [**1-11**] pending
urine [**1-10**], 18 pending
blood 12/16 pending
Studies:
CHEST (PORTABLE AP) Study Date of [**2143-1-8**]:
IMPRESSION: Perihilar ground-glass opacities with
bronchiectasis, and a more focal area of opacification in the
right lower lobe. Findings could reflect multifocal infection,
or drug reaction, combined with non-cardiogenic pulmonary edema.
ECG [**2143-1-7**]:
Sinus tachycardia. Modest ST-T wave changes are non-specific.
Since the
previous tracing of [**2142-10-5**] sinus tachycardia rate is faster and
modest
ST-T wave changes are present.
Chest Xray [**2143-1-9**]:
Single AP portable view of the chest is obtained. There is
persistent bilateral lung opacities worrisome for pneumonia.
There is no significant change from prior study. There is a
small right pleural effusion. Heart size cannot be assessed.
Mediastinal contour is grossly stable. There is no pneumothorax.
Right posterior upper rib fractures are again noted.
CT chest:
1. Bilateral ground-glass opacities, new pneumatoceles, focal
areas of
atelectais-consolidation, Chronic mild upper lobe
bronchiectasis, and focal air trapping as described above.
Differential diagnosis is broad and includes infectious causes
such as atypical viral/bacterial pneumonia including PCP,
[**Name10 (NameIs) **] edema secondary to drug reaction, chronic changes
secondary to patient's known hypogammaglobulinemia, or collagen
vascular disease such as goodpasture's syndrome. Exposure to
recreational drugs might be considered as well. Overall the
findings have progressed since the prior study obtained in
[**2141-8-25**].
2. Chronic mild upper lobe bronchiectasis and bronchial wall
thickening may be secondary to asthma or patient's known
hypogammaglobulinemia.
3. New pneumatoceles may be sequale of prior infection or active
infection
such as PCP.
4. Marked osteopenia with multiple stable vertebral body
compression fractures and old rib fractures.
Discharge labs:
Brief Hospital Course:
25 year old female with past medical history of asthma
complicated by multiple intubations and IV drug abuse
complicated by septic shock and septic arthritis. She was sent
from [**Hospital1 **] for ED evaluation of pneumonia after her oxygen
saturation was noted to be low.
#. Hypoxia, fevers: She was found to have possible multifocal
pneumonia on CXR, she was initially treated broadly with
Vancomycin, Zosyn, and Azithromycin, which was then narrowed to
Levofloxacin and Ceftriaxone and changed to Levofloxacin and
Cefpodoxime before dischage (planned last day [**1-15**]). Blood
cultures were sent and are pending. Sputum culture was
negative. She had a CT chest which showed ground glass
opacities bilaterally possibly reflecting infection vs
drug-induced lung injury. She was treated with nebulizer
treatments and a short course of prednisone for possible
contribution of her underlying asthma. Patient was originally
started on Tamiflu but then tested negative for influenza and
her tamiflu was stopped. Attempted ICU consent with patient
over course of stay however too somnolent at first and then
refused to discuss because she wanted to eat. It was eventually
signed as she was leaving and at that time full code status was
confirmed.
#. Somnolence: She had somnolence initially on presentation
that was thought to be related to a toxic ingestion given her
past history of drug abuse in conjunction with verbal report
from ED that patient went to restroom and came back to ED room
much more somnolent. Serum and urine tox screen were
unrevealing, and she had no further episodes.
#. Asthma: Patient had suboptimal air movement at presentation
to the ICU with inspiratory and expiratory wheezing and some
slight tachypnea. She was treated with standing albuterol and
ipratropium nebs, her home regimen of monteleukast and advair.
She was also treated with a prednisone taper. It seemed that
the patient's chronic respiratory sxs might not be due to asthma
(overall low lung volumes and does not require chronic steroids
like she has as a child) but to other chronic lung disease. The
patient was presented at the pulmonary conference and she will
need outpatient pulmonary follow-up. She was given the phone
number to schedule an appointment.
#. Knee pain: Patient had a left knee arthrocentesis on [**1-11**]
which showed 175/uL WBCs with 95%PMNs. Gram stain had no PMS and
no organisms. Culture was preliminarily negative. She had no
warmth and tenderness on exam. However, in the setting of joint
prosthesis, she will need cautious monitoring off of antibiotic
therapy. She was ambulatory at time of discharge and was given
the number of infectious disease to schedule a follow-up
appointment.
#. Opiate addiction: She was continued on a methadone taper.
The last day was 5mg on [**1-12**].
#. Psychiatric disease: She was very demanding during this
admission and psychiatry was consulted regarding her erratic
behavior. She was noted to be aggravated easily and the psych
team felt she should have a 1:1 sitter. She had a Code Purple
called for aggressive and agitated behavior and was given Ativan
and Seroquel with good effect.
Medications on Admission:
*per discharge summary earlier today*
1) Ipratropium Bromide 0.02 % Q4H:PRN shortness of breath or
wheezing
2) Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
3) Montelukast 10 mg PO QHS
4) Folic Acid 1 mg PO DAILY
5) Ibuprofen 400 mg PO Q8H:PRN pain
6) Thiamine HCl 100 mg PO DAILY
7) Multivitamin PO DAILY
8) Gabapentin 800 mg PO Q8H
9) Tramadol 50 mg PO Q8H:PRN pain
10) Methadone 15 mg PO DAILY
11) Levofloxacin 750 mg PO once a day for 7 days (Day 1 =
[**2143-1-9**])
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*qs 1 months supply* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours): Hold for sedation.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days: Please take this medication daily through
[**2143-1-15**].
Disp:*2 Tablet(s)* Refills:*0*
10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 doses: Take 60mg by mouth daily through [**2143-1-14**].
Disp:*3 Tablet(s)* Refills:*0*
11. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Inhalation Q2H (every 2
hours) as needed for dyspnea or wheezing.
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnosis:
Asthma
Hypoxia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Oxygen saturation 96% room air
Discharge Instructions:
You were admitted to the hospital because your oxygen level was
low in your blood. You were given nebulizer treatments,
antibiotics, and were treated with prednisone to help your
breathing.
Changes to your medications:
INCREASED Tramadol to 50mg by mouth every 6 hours as needed for
pain
DECREASED methadone to 5mg by mouth once on [**1-12**] and [**1-13**],
then stop this medication
ADDED Seroquel 50mg by mouth twice daily and 100mg by mouth at
night
ADDED Ativan 1mg by mouth three times daily as needed for
anxiety
Followup Instructions:
You have the following appointments scheduled:
[**Month/Year (2) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Phone: [**Telephone/Fax (1) 11262**]
Date/Time: [**2143-1-23**] 4:00pm
[**Hospital6 **] (PRIMARY CARE)
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2143-1-28**] 3:45pm
You should also follow-up with the infectious disease team.
Please call Dr. [**Last Name (STitle) 13895**] to set up an appointment at
[**Telephone/Fax (1) 457**]. You should see him within a month.
You should also follow-up with your pulmonary doctor. Please
call Dr. [**Last Name (STitle) 78324**] office at ([**Telephone/Fax (1) 513**] to schedule an
appointment.
Name: [**Known lastname 5990**],[**Known firstname 12637**] M. Unit No: [**Numeric Identifier 12638**]
Admission Date: [**2143-1-8**] Discharge Date: [**2143-1-9**]
Date of Birth: [**2117-2-6**] Sex: F
Service: MEDICINE
Allergies:
Magnesium / Latex / Salicylate / Benzocaine
Attending:[**Last Name (NamePattern1) 101**]
Addendum:
Pre-admission medications also included:
Methadone 15 mg PO on day 2 of detoxification ([**2143-1-8**])
Gabapentin 800 mg PO every 8 hours
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12639**] - [**Location (un) 382**]
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 103**]
Completed by:[**2143-1-9**]
|
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
25818, 26075
|
18086, 21251
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|
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15891, 18045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,488
| 125,138
|
10379
|
Discharge summary
|
report
|
Admission Date: [**2108-4-30**] Discharge Date: [**2108-5-8**]
Date of Birth: [**2033-9-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Caffeine / Quinine / Ampicillin
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
femoral line placement
PICC line placed by IR
port removal by general surgery
History of Present Illness:
this is a 74yo F w/ metatstatic sarcamatoid kidney cancer to L1,
T9, pelvic bone, liver, lung, skull currently undergoing
chemotherapy, Addison's on prednisone and recent hospitalization
for hypotension and fever, now admitted for fever to 102 in last
24hrs. 2 days prior to admission, she reports that she felt well
and had been afebrile but then progressively became more
confused w/ increased tenderness near her port site. She denies
any cough, SOB, CP, N/V, diarrhea, HA or sick contacts. [**Name (NI) **]
called ambulance yesterday when he noticed change in pt's MS.
.
Since admission, she was found to have elevated lactate levels,
and port site noted to have purulent drainage. This was removed,
and empiric abx were started - given cefepime, vanc, and flagyl.
Fem line was placed as pt has difficult access. Pt's blood cx
has grown out GPCPC, and she was continued on vancomycin. She
defervesced quickly, and has remained afebrile for 24hrs. She
has remained hemodynamically stable, and she is being
transferred to the floor for further management.
Past Medical History:
1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney
function, which allowed her to enter the chemotherapy trial.
3. Hypotension.
4. Chronic renal insufficiency.
5. COPD.
6. Peripheral vascular disease with bilateral carotid stenoses
status post TIA. In [**8-/2103**], the patient had left upper
extremity weakness and slurred speech with complete resolution
in
less than 24 hours.
7. Coronary artery disease (1 vessel). The first cardiac cath
in [**8-/2103**] showed total occlusion of right coronary artery. PCI
failed at that time. However, there were significant
left-to-right collaterals. Second cardiac cath in [**12/2107**] showed
no progression of her coronary artery disease. 60% diag, 40%lad
8. Preserved EF in past--echo [**2103**]-50%, cath showed normal index
in [**2107**] and RVG [**2108-3-28**] recently with ef of 72%
9. Osteoporosis, on Fosamax for 2 years and then on Forteo for 2
months, which she stopped at the end of [**Month (only) 359**]. Status post
undisplaced pathological fracture of her right pelvis, both
inferior and superior rami in 09/[**2107**].
10. Metastatic sarcomatoid kidney cancer.
11. Right ear deafness.
12. RAD
Social History:
The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job.
Family History:
One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.
Physical Exam:
VS: Temp: 99.7 BP: 93 /44 HR:75 RR: 16 100% 4l ncO2sat-->91%
room air
.
general: ill-appearing, pleasant, uncomfortable secondary to
pain
HEENT: PERLLA, EOMI, anicteric, posterior skull with multiple
raised areas, no sinus tenderness, MMdry , op without lesions,
no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site--site is
erythematous, warm and tender
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: chest skin as above--otherwise no rashes or lesions.
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
*** CULTURE DATA ***
[**2108-5-7**]: blood cx X 2 pending
[**2108-5-6**]: blood cx X 4 pending
[**2108-5-6**]: Cdiff pending
[**2108-5-6**]: Urine cx pending
[**2108-5-6**]: Cdiff negative
[**2108-5-3**]: blood cx pending X 2
[**2108-5-1**]: blood cx X 2 pending
[**2108-5-1**]: blood cx X 4 negative
[**2108-4-30**]: blood cx X 2 negative
[**2108-4-30**]: cath tip coag pos S.aureus, ox sensitive
[**2108-4-30**]: abscess: 2+ PMN, 3+ GPC in prs and clusters. Ox
sensitive coag pos S. aureus
[**2108-4-30**]: Stool Cdiff negative
[**2108-4-30**]: urine cx no growth
[**2108-4-30**]: blood cx: S. aureus, ox sensitive.
.
EKG: NSR at 75, nl axis, nl intervals, no st changes.
.
Radiologic: CXR:
INDICATION: Addison's disease and metastatic sarcomatoid kidney
cancer, now with fever.
COMPARISON: Four previous chest radiographs including [**4-10**], [**2108**] and
[**2108-4-16**].
FINDINGS: There is a new right central line, the tip overlying
the distal SVC. No pneumothorax is seen. The heart size and
mediastinal contours are stable. There are bilateral linear
interstitial markings consistent with CHF on a background of
emphysema. Left upper lung mass is partially obscured by the
scapular shadow, but persists. Cholecystectomy clips and left
upper abdominal curvilinear calcifications are better seen on
today's exam.
IMPRESSION: CHF on a background of emphysema.
.
ECHO [**2108-5-4**]: EF 60-65%, 1+ MR, mod pulm artery HTN, no valvular
vegetations.
Brief Hospital Course:
Assessment and Plan: 74 year-old woman with metastatic
sarcamatoid kidney cancer, Addison's disease, admitted with
fever and hypotension likely from port infection. Port removed
by general surgery on admission - blood cx from admission
growing MSSA, with last positive blood culture [**2108-4-30**]. Port
cath tip growing MSSA.
.
# GPC/MSSA sepsis: Port is likely source of infxn given
purulence when it was examined in ED; was improving initially
after starting on vancomycin. Transitioned to PO prednisone from
stress-dose steroids on admission. MSSA organism initially
treated with vancomycin, now transitioned to IV Cefazolin 2g
q12h per Infectious Disease consultant recommendation (increased
from 1g IV). TTE to eval for vegetation in setting of gram
positive sepsis was negative; TEE was performed also confirming
no endocarditis. The pt will continue IV cefazolin 2g IV q12h
until seen by ID ([**2108-6-6**]) by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She is to have
weekly CBC with diff, LFTs drawn and faxed to Dr. [**First Name (STitle) **] (see
prescription for outpt lab work). She is to continue prednisone
5mg po bid until seen by her oncologist (see follow up appt).
She remains afebrile, with port site without erythema,
induration or drainage. The site is non-painful and appears to
be healing well. Her stress dose steroids were tapered to po
prednisone, and she will continue with 5mg po bid on discharge.
.
# Elevated WBC ct, persistent during admission: No clear source.
Last positive blood culture was [**2108-4-30**]. UA negative with neg
Urine cx. Stool is Cdiff negative X 2. TEE was negative for
valvular lesions. Pt continues to be afebrile. VSS. A RUQ
ultrasound was ordered to assess for RUE DVT, and was negative.
Blood cultures were checked qd and her last positive blood cx
was [**2108-4-30**]. She will continue IV Cefazolin until seen by
Infectious Disease as an outpt.
.
# Hypotension, resolved: At baseline, BP fluctuates given hx of
Addison's. However, considered other etiologies for hypotension
- sepsis, adrenal insufficiency (s/p IV steroids tapered to po
prednisone), cardiogenic given cad history (unlikely),
hypovolemia/bleeding - hematocrit drop likely secondary to
fluids. BP increased during her admission so pt restarted on
outpt BP regimen (ACEI, BB, [**Last Name (un) **]). At discharge, her blood
pressure was within the normal range on her antihypertensive
regimen (atenolol, lisinopril and valsartan). Her IV Cefazolin
should be continued. We continued her steroids, tapered down to
5mg po bid, and she will see her PCP or endocrinologist as an
outpatient, where further steroid taper can be addressed.
.
# COPD: Uses oxygen intermittently at home. She is stable at 99%
on RA. She continued albuterol prn, cont steroids.
.
# Addison's: Was receiving hydrocort in ICU; transitioned to PO
steroids. Appears stable w/ prednisone 5mg [**Hospital1 **]. She just
transferred endocrine care to [**Hospital1 18**] and will f/u with them as
needed. We continued to taper her prednisone dose while she was
admitted. She will be discharged on 5mg po bid. She should f/u
with her PCP or endocrinologist for further tapering.
.
# Acute on chronic renal failure: Baseline Cr near 1.5; may have
had failure from prerenal etiology. Now improving w/ IVF and
renally dosing meds. restarted ACEI as she is hypertensive and
renal fxn back to baseline. At discharge, her Cr was better than
her baseline creatinine.
.
# Anemia/ thrombocytopenia: likely secondary to chronic disease,
renal disease, chemotherapy. Will need to monitor plts closely
as she is trending down - send HIT ab in this situation
- tx pRBC for goal Hct >24 and plts >10
.
# CAD: has hx 1 vessel dx w/ no interventions
- continue aspirin, beta blocker, ACEI
.
# PVD/TIA-- continue aspirin
.
# PPX: heparin sc, protonix with steroids, ISS
.
# Pain: both at port-a-cath site and due to bone mets; on
tylenol #3 at home, pain is now well controlled with Tylenol
III's.
.
# IV access: double lumen PICC and PIV
.
# DNR/DNI
.
# Communication: daughter [**Telephone/Fax (1) 34406**] [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 34407**]
.
Medications on Admission:
atenolol 25 mg daily
valsartan 160 mg daily
isosorbide mononitrate 30 mg daily
lisinopril 40 mg daily
prednisone 10 mg twice daily
docusate 100 mg twice daily
senna 1 tablet twice daily
potassium and sodium phosphate 2 packets daily
ranitidine 150 mg daily
magnesium hydroxide 30 mL every 6 hours as needed
albuterol 2-4 puffs every 6 hours as needed
simethicone as needed
aspirin 325 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Cefazolin 2 gm IV Q12H
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
Disp:*60 Tablet(s)* Refills:*0*
11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
12. Outpatient Lab Work
Please check weekly CBC with differential, BUN, Cr, ALT, AST,
alk phos, and total bilirubin and fax results to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in Infectious Disease clinic at : [**Telephone/Fax (1) 1419**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home therapy
Discharge Diagnosis:
1. MSSA bacteremia
2. Addison's disease
3. Acute on chronic renal failure
4. Anemia
5. Thrombocytopenia
6. Coronary Artery disease
7. Peripheral vascular disease
8. history of Transient Ischemic Attack
Discharge Condition:
Stable, good
Discharge Instructions:
Please take all of your medications and keep all of your
appointments.
If you get worsening pain around the site of the line, or
increased drainage, or if you have fevers, chills, or other
concerning symptoms, please call your primary care doctor or go
to the emergency room.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-5-14**] 1:00
2. Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2108-5-14**] 1:00
3. Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-5-14**] 1:30
4. Provider: [**First Name8 (NamePattern2) 1037**] [**Last Name (NamePattern1) **], MD INFECTIOUS DISEASE CLINIC. Your
appointment has been set for: [**2108-6-6**] at 10:30am. Please
call [**Telephone/Fax (1) 457**] if you have questions.
Completed by:[**2108-5-8**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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|
[
[
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,982
| 147,709
|
39770
|
Discharge summary
|
report
|
Admission Date: [**2181-8-24**] Discharge Date: [**2181-9-18**]
Service: SURGERY
Allergies:
Cardizem / Procardia
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Self inflicted GSW to head
Major Surgical or Invasive Procedure:
[**2181-8-29**] EXAMINATION UNDER ANAESTHESIA, REMOVAL OF
PACKING,PERCUTANEOUS ENDOSCOPIC GASTROSTOMY, OPEN TRACHEOSTOMY
History of Present Illness:
[**Age over 90 **] y/o male s/p self-inflicted GSW to head with extensive soft
injury to the tongue. Initially seen at OSH talking with intact
neuro exam; he was intubated for airway protection. He was
transferred to [**Hospital1 18**] for definitive management. On arrival, CT
of the orbits and CTA of the head and neck were obtained. There
was a fragmented appearance of C1 ring on the left side, no
vascular injury was identified.
Past Medical History:
CAD, HTN, BPH
Social History:
Per family, no tob, etoh, ivda
Family History:
Noncontributory to this disease process
Physical Exam:
Upon arrival:
HR 40s-50s, BP 129/66 16 100 Fio2 on CMV 100 O2 sat vent
Vent, sedated, moves all 4, follows commands
by report - large L posterior neck hematoma
Left TM without blood
Pupils 2->1.
Neck flat, no eccymosis, no crepitus.
No facial eccymosis, step off
packing in oral cavity placed by ED, removed. Large midline rent
in mid tongue active bleeding bright red blood. Unable to fully
examine OP. Wet kerlex repacked into oc/op without evidence of
bleeding after this.
in c collar with unstable c1 fx
Pertinent Results:
[**8-24**] CT Orbits: Fragmented appearance of C1 ring on the left
side with multiple metallic bullet fragments along the
trajectory of the gunshot wound. Given the involvement of the
left transverse foramen of C1, injury to the vertebral artery is
suspected. Extensive injury to the tongue with large soft tissue
defect and deviation
of the tongue to the left.
[**8-24**] CTA Head/Neck: No extravasation or pseudoaneurysms
identified. Diffuse atherosclerotic disease of the carotid
system bilaterally without hemodynamically significant stenosis.
Bullet fragments along left posterior soft tissue, within the
canal at the C1 level with some high density material likely
representing blood. Shrapnel extending into oral cavity and
tongue without definite area of extravasation.
[**8-24**] CXR: LT SCL line crosses the midline, tip in the upper SVC,
no ptx, retrocardiac opacities atelectasis v pneumonia
[**8-24**] Angio: No intervention required
[**9-1**] LENI left UE: no DVT
[**9-1**] Urine culture: e.coli>100K
[**9-2**] sputum culture: sparse growth commensal respiratory flora,
2+ GNR
[**9-4**] CT c-spine: no significant change
[**9-10**], [**9-11**] c.diff negative x2
[**2181-8-24**] 08:00PM GLUCOSE-180* UREA N-20 CREAT-1.0 SODIUM-138
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-24 ANION GAP-10
[**2181-8-24**] 08:00PM CALCIUM-7.4* PHOSPHATE-3.5 MAGNESIUM-1.7
[**2181-8-24**] 08:00PM WBC-9.5 RBC-4.14* HGB-12.0* HCT-34.2* MCV-83
MCH-29.1 MCHC-35.1* RDW-14.1
[**2181-8-24**] 08:00PM PLT COUNT-126*
[**2181-8-24**] 08:00PM PT-13.8* PTT-28.4 INR(PT)-1.2*
Brief Hospital Course:
[**Age over 90 **] yo old male transfer from [**Hospital3 3583**], after self
inflicted GSW through the mouth. Patient transferred through
[**Location (un) **] hemodynamically stable; intubated for airway
protection and sedated. CT scan showing fragmentation of left
side of C1. He was admitted to Trauma ICU for close monitoring,
frequent neuro checks, propofol drip for sedation, and fentanyl
drip for pain.
HEENT: He underwent early tracheostomy during his examination
and removal of packings. He was evaluated by Speech for
Passey-Muir valve on [**9-3**] and [**9-5**] and failed, but passed his
trial on [**9-10**] after trach downsized from 8->6. He has tolerated
his trach capped for the past several days and is near readiness
for decannulation. ENT was consulted for this and was agreeable
to this plan. He will follow up as an outpatient with Dr.
[**Last Name (STitle) 1837**].
CV: Hemodynamically stable on admission with HR in the mid-40s
to low 50s and sbp around 100. On [**8-24**], did have an episode of
hr down to low 40s with decrease in blood pressure, resolved
spontaneously. Pt taken to angio-no intervention required. In
the ICU, he was noted to be intermittently hypertensive, and was
treated with hydralazine. However since transfer to the floor on
[**8-31**], pt has been stable from a cardiovascular standpoint and is
currently receiving standing beta blockers. On [**9-1**], he was
noted to have swollen LUE; LENIS were performed and were
negative. Central line was removed.
Pulm: His saturations have ranged between 95-96% on room air; he
is receiving scheduled nebulizer treatments and humidified air
via his trach.
GI/GU: PEG placement and tongue repair done at the same time as
trach placement on [**8-29**]. Tube feeds were started through the
PEG on [**8-30**]. By [**8-31**], he was tolerating tube feeds to goal. On
[**9-10**], he failed swallow evaluation and remains NPO on tube feeds.
On [**9-12**], pt was noted to have low UOP, bladder scan revealed
900cc, Foley placed with 2.5L of urine returned. Foley
continued.
Neuro/Psych: Between [**9-9**] and [**9-12**] he was noted to have several
episodes of [**Doctor Last Name 688**] mental status; Geriatric Medicine was
consulted. Several recommendations were made pertaining to
minimizing delirium. Psychiatry also followed along closely
during his stay given his self inflicted injuries. Initially it
was recommended that he go to an inpatient psych but it was
later determined by Psychiatry that he no longer required this
and was safe for discharge to a rehab facility with Psychiatric
services.
He was evaluated by Physical and Occupational therapy and is
being recommended for acute rehab.
Medications on Admission:
Saw [**Location (un) **] (recently stopped all prescritption medications)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day) as needed for bowel regimen.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours).
7. Acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) MG PO Q6H (every 6 hours) as needed for fever or pain.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
s/p Self-nflicted gun shot wounds to face
Comminuted C1 fracture
Left vertebral artery injury
Base of tongue avulsion
Discharge Condition:
Mental Status: Clear and coherent oriented x2.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Maintain cervical collar x 6 weeks.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1837**], ENT in [**2-10**] weeks; call ([**Telephone/Fax (1) 26106**].
Follow up in [**5-15**] weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery; patient
should maintain cervical collar for at least 6 weeks. Call
[**Telephone/Fax (1) **] for an appointment.
Completed by:[**2181-9-18**]
|
[
"285.9",
"518.5",
"401.9",
"806.10",
"873.65",
"E955.0",
"600.00",
"874.4",
"275.41",
"599.0",
"293.0",
"873.64",
"294.8",
"041.4",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"25.51",
"38.91",
"97.23",
"88.41",
"96.6",
"25.1",
"38.93",
"88.44",
"31.1",
"96.72",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7180, 7246
|
3119, 5820
|
254, 377
|
7408, 7408
|
1529, 3096
|
7662, 8000
|
942, 983
|
5944, 7157
|
7267, 7387
|
5846, 5921
|
7602, 7639
|
998, 1510
|
188, 216
|
405, 840
|
7423, 7578
|
863, 878
|
894, 926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,377
| 182,555
|
43327
|
Discharge summary
|
report
|
Admission Date: [**2107-2-20**] Discharge Date: [**2107-2-23**]
Date of Birth: [**2026-10-28**] Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
1. EGD
2. Barium small bowel follow through
History of Present Illness:
Pt is 80F with h/o CAD s/p CABG, HTN, anemia, afib recently
started on coumadin who presented with melena x3 days. Pt
noticed dark green vs black stool for 2-3 days PTA. INR last
Wednesday was 3.7 - pt instructed to take coumadin 5mg Th-[**Doctor First Name **]
rather than her usual 6mg during those days. Usual doses are 4mg
MWF and 6mg Tu, Th, [**Last Name (LF) **], [**First Name3 (LF) **]. Pt denies chest pressure during
this time - did have episode of her stable angina last
Wednesday, relieved by NTG. No CP since then. On day of
admission, pt did have more shortness of breath and fatigue with
climbing the stairs as she usually does every day. Had been
slightly lightheaded yesterday as well. Pt also notes that she
had a nosebleed, but this has resolved. Mild abd pain 3 days
ago, relieved by BM. Pt has not had recent abd pain in general,
no h/o PUD. Had a colonoscopy 1 year ago, polyp removed,
diverticulosis noted. No recent [**Name (NI) **], pt denies any EtOH. No
NSAIDs, is on ASA.
.
In the ED, her hct was found to be 17.9 with an INR of 7.6. NG
lavage was nonbloody and nonbilious. Pt was given 10mg SC
vitamin K, pantoprazole 40mg IV x1, 1 unit PRBCs, 1 unit FFP.
Pt was then admitted to the MICU.
.
In the MICU, pt received an additional 2 U PRBC's and 2 U FFP.
She was given several doses of PO vitamin K. Her hct stabilized,
and she is now called out to the medical floor.
.
Pt currently denies CP, SOB. She had one black BM today, with
minor abd pain which was relieved s/p BM.
Past Medical History:
- atrial fibrillation - started on coumadin [**1-23**]
- CAD s/p CABG, has stable angina
- peripheral vascular disease
- hypertension
- anemia of chronic disease
- obesity
- arthritis
- irritable bowel syndrome
- bilateral renal artery stenosis status post right stent [**8-/2103**]
- s/p left hip replacement
- s/p appendectomy
- s/p tonsillectomy
- s/p cataract surgery
Social History:
Lives alone. Smoked about 1 1/2-2ppd x15 years, quit in the
[**2070**]. Denies any EtOH or IVDU. Widowed. Has 5 grown children in
the [**Location (un) 86**] area. She used to work as a substitute teacher
part-time.
Family History:
Mother deceased 94 DM/CAD/MI
Father deceased 81 DM/CAD
Sister deceased Breast CA/DM
Sister deceased [**Name2 (NI) 93302**] child birth/bleed
Physical Exam:
Vitals: Tm 99.0 Tc 98.9 BP 150/48 HR 78 RR 22 O2sat 98% RA
Gen: pleasant, NAD, pale
HEENT: PERRL
Cardio: irreg irregular, S1S2, [**2-22**] sys murmur across precordium
Resp: CTAB
Abd: soft, nt, nd, +BS
Ext: no c/c/e
Neuro: A&0x3
Pertinent Results:
[**2107-2-20**] 02:50PM PT-61.3* PTT-37.8* INR(PT)-7.6*
[**2107-2-20**] 02:50PM PLT COUNT-286
[**2107-2-20**] 02:50PM NEUTS-73.1* LYMPHS-22.8 MONOS-3.3 EOS-0.8
BASOS-0.1
[**2107-2-20**] 02:50PM WBC-9.2 RBC-2.00*# HGB-6.0*# HCT-17.9*#
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.0*
[**2107-2-20**] 02:50PM CK-MB-3 cTropnT-<0.01
[**2107-2-20**] 02:50PM GLUCOSE-116* UREA N-44* CREAT-1.3* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
[**2107-2-20**] 11:35PM HCT-21.7*
.
STUDIES/IMAGING:
[**2107-2-22**] COLONOSCOPY:
.
[**2107-2-22**] UPPER GI/SBFT: Normal small bowel follow through with
no mucosal lesions or masses identified.
Brief Hospital Course:
Ms. [**Known lastname **] is an 80 year old female with CAD s/p CABG in [**2089**] and
atrial fibrillation (anticoagulated with coumadin) who presented
with 3 days of melena, a hematocrit of 17.9 and supratherapeutic
INR.
.
Melena was most likely secondary to an upper GI source in the
setting of a supratherapeutic INR. However, the patient was
fairly well compensated despite her low hematocrit suggesting an
acute on chronic process. The patient received a total of 3
units of PRBCs, 3 units of FFP and 10mg of vitamin K. Her
hematocrit responded appropriately and remained stable. EGD and
UGI series with SBFT were unremarkable. Aspirin and coumadin
were held initially. Coumadin was restarted prior to discharge
with instructions for INR follow up. The patient was instructed
to follow up with GI for outpatient capsule endoscopy.
.
Medications (aspirin/beta-blocker) for CAD were held given GI
bleed and concern for exacerbating the bleed or inducing
hypotension. Beta-blocker was restarted prior to discharge.
.
Synthroid was continued for hypothyroidism per her outpatient
regimen.
.
FULL CODE
Medications on Admission:
aspirin 325 mg daily
synthroid 75mcg daily
atenolol 50mg daily
pravachol 20mg daily
terazosin 5mg [**Hospital1 **]
prilosec 20mg daily
MVI
norvasc 10mg daily
Nasonex spray
coumadin - up to 5-6mg daily
.
MEDS (on transfer):
Diphenhydramine HCl 25 mg IV PRN transfusion
Levothyroxine Sodium 75 mcg PO DAILY
Pravastatin 20 mg PO DAILY
Pantoprazole 40 mg IV Q12H
.
ALLERGIES:
Keflex
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
8. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. Outpatient Physical Therapy
Please draw INR twice weekly. Standing order. One blood draw
will be done by [**Hospital1 882**] Services on Wednesdays.
Please fax results to [**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 2716**], RN at [**Hospital1 18**] in Dr.[**Name (NI) 5786**]
office. Fax: [**Telephone/Fax (1) 7531**]. Phone: [**Telephone/Fax (1) 22476**].
10. Outpatient Lab Work
Please draw creatinine on Monday [**2107-2-28**].
.
Please fax results to [**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 2716**], RN. Fax: [**Telephone/Fax (1) 7531**].
Phone: [**Telephone/Fax (1) 22476**].
11. Terazosin 5 mg Capsule Sig: Five (5) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. GI bleed
2. supra-therapeutic INR
.
Secondary:
1. coronary artery disease
2. atrial fibrillation
Discharge Condition:
Stable. Afebrile. No melena.
Discharge Instructions:
You were admitted to the hospital because you had blood in your
stool. You were found to be very anemic and required blood
transfusions. You should return to the emergency room or call
your doctor if you experience any of the following symptoms:
fever > 101.5, black/tarry stools,
weakness/dizziness/fatigue/chest pain/shortness of breath,
intractable nausea/vomiting or any other concerning symptoms.
.
Please take all medications as prescribed. We have increased
your dose of metoprolol to 50mg twice a day and decreased your
amlodipine to 5mg per day.
.
Please follow up with all appointments.
Followup Instructions:
1. Please have your blood drawn twice weekly. The first blood
draw should be on Monday, [**2107-2-28**] at your PCP's office. You
should have your blood drawn at your PCP's office once weekly.
The other blood draw will be done by [**Hospital1 882**] Services. They
will come by your house to draw your blood on Wednesdays,
beginning on [**2107-3-2**]. A prescription has been provided for these
blood draws.
2. Gasteroenterology: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2107-3-9**] 8:00. This is for a
capsule endoscopy study. They will send you all of the
information you need to prepare for the study.
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2107-5-30**] 1:00
4. Please make an appointment to see your PCP, [**First Name8 (NamePattern2) 745**] [**Last Name (NamePattern1) 13248**],
in 2 weeks. You can make an appointment by calling [**Telephone/Fax (3) **].
|
[
"272.0",
"244.9",
"584.9",
"414.01",
"401.9",
"V45.81",
"578.9",
"V58.61",
"790.92",
"427.31",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6680, 6686
|
3576, 4680
|
273, 319
|
6839, 6870
|
2903, 3553
|
7515, 8567
|
2496, 2638
|
5109, 6657
|
6707, 6818
|
4706, 5086
|
6894, 7492
|
2653, 2884
|
227, 235
|
347, 1852
|
1874, 2248
|
2264, 2480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,751
| 172,233
|
44864
|
Discharge summary
|
report
|
Admission Date: [**2116-6-9**] Discharge Date: [**2116-6-12**]
Date of Birth: [**2049-9-12**] Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / Zithromax / Keflex
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 4033**] is a 66 year old man with history of CAD s/p CABG,
EtOH cirrhosis s/p TIPS, and COPD (unknown PFT's) who presents
with one day history of shortness of breath. He reports that the
evening of [**6-6**], he started feeling more short of breath. His
home oxygen and home nebulizers were not helpful, and his
shortness of breath worsened on [**6-7**], so he came to the ED. He
is on home oxygen (2L) at all times.
In the ED, his triage vitals were T97.9F, HR 68, BP 104/58, RR
26, Sat 97% (unclear oxygen). He received 500mg azithromycin,
aspirin suppository, 125mg methylprednisolone, and albuterol and
ipratropium nebs. The patient repeatedly stated that he did not
want to be intubated, and ED staff confirmed this with his PCP.
On arrival to the ICU, he was on BiPap, which was quickly
converted to face mask when he appeared dissynchronous. He
confirms history as above. ABG on arrival is pH 7.36, pCO2 72,
pO2 83, HCO3 42. His oxygen was downtitrated to nasal cannula.
He reports improvement in his breathing, and denies chest pain,
orthopnea, palpitations, abdominal pain, pleuritic chest pain,
nausea, vomiting, hematemesis, constipation, diarrhea, fevers,
chills, productive cough.
Past Medical History:
- Coronary artery disease, s/p PTCA to mid LAD in [**2097**], CABG
([**2106**])
- Chronic obstructive pulmonary disease (no PFT's in system)
- Alcohol cirrhosis status post TIPS in [**2106**]
- Bladder carcinoma status post resection in [**2104**]
- Umbilical hernia repair in [**2106**]
- Depression
- History of benign prostatic hypertrophy
- History of carotid disease bilaterally, right greater than
left with right carotid endarterectomy in [**10-28**]
- History of left intertrochanteric hip fracture s/p ORIF
([**6-/2109**])
- Chronic back pain
- Apparent past diagnosis of OSA, past BiPAP use
Social History:
Patient wiht long history of alcohol abuse, with 12 to 15 drinks
per day until recently (now decreased due to fatigue). He notes
that he has been in detoxification about 30 times in the past
and completed detox and rehab and half-way house in late
80's-early 90's and was sober for 4 years. He denies any history
of seizures or delirium tremors related to his alcohol abuse in
the past. He is a current smoker.
Family History:
Non-contributory
Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL, No Sclera edema
Head, Ears, Nose, Throat: No(t) Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t)
Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion:
Hyperresonant: ), (Breath Sounds: No(t) Wheezes : , Diminished:
throughout)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: DP pulses: Right: Absent, Left: Absent
Pertinent Results:
[**2116-6-9**] 05:13AM BLOOD WBC-6.3 RBC-4.45* Hgb-11.1* Hct-36.8*
MCV-83# MCH-24.9*# MCHC-30.1*# RDW-15.8* Plt Ct-172
[**2116-6-9**] 01:07PM BLOOD WBC-3.4* RBC-4.12* Hgb-10.8* Hct-33.6*
MCV-82 MCH-26.3* MCHC-32.2 RDW-16.0* Plt Ct-153
[**2116-6-9**] 05:13AM BLOOD Neuts-71.8* Lymphs-20.5 Monos-5.6 Eos-1.4
Baso-0.6
.
[**2116-6-9**] 05:13AM BLOOD Glucose-111* UreaN-18 Creat-0.5 Na-134
K-4.5 Cl-90* HCO3-39* AnGap-10
[**2116-6-9**] 01:07PM BLOOD ALT-17 AST-23 LD(LDH)-163 CK(CPK)-79
AlkPhos-139* TotBili-0.2
.
.
[**2116-6-9**] 05:48AM BLOOD Type-[**Last Name (un) **] pO2-32* pCO2-89* pH-7.30*
calTCO2-46* Base XS-12 Comment-GREEN TOP
[**2116-6-9**] 09:36AM BLOOD Type-ART FiO2-40 O2 Flow-10 pO2-83*
pCO2-72* pH-7.36 calTCO2-42* Base XS-11
.
[**2116-6-9**] 05:13AM BLOOD cTropnT-0.05* CK-MB-NotDone
[**2116-6-9**] 01:07PM BLOOD CK-MB-9 cTropnT-0.03*
[**2116-6-9**] 05:13AM BLOOD PT-12.9 PTT-33.7 INR(PT)-1.1
.
[**2116-6-9**] 01:07PM STOOL BLOOD-NEGATIVE
Brief Hospital Course:
66yM with history of COPD, CAD, EtOH cirrhosis presenting with
shortness of breath x 1 day, without cough, fever, chills, or
chest pain, consistent with exacerbation of known COPD.
#) Shortness of breath. Given constellation of symptoms, known
history, physical exam findings, ABG, and chest x-ray,
consistent with COPD exacerbation. Blood gas is quite reassuring
with near-normal acid-base status (despite quite elevated pCO2),
indicative of severe COPD. Azithromycin was started given the
severity of his exacerbation, although as his initial MICU stay.
He got methylprednisolone 125mg q8h, azithromycin 500 followed
by 250 x4 more days, and albuterol/ipratropium nebs. In the
MICU, he was stable and did not require additional ventilatory
support. He has a past diagnosis of OSA and apparently has
sometimes used BiPAP at home, although not recently because his
machine is broken; also he seems not to like the mask. He
declined BiPAP with the MICU team and at any rate was satting
better on his 30% face mask. On the floor, patient did have
intermittent bouts of shortness of breath , often at times in
the setting of agitation. He refused additional nebulizers or
morphine. However, overall he remained stable with oxygenation
of 95% on 2L even while appearing more short of breath. He
stated that he was close to his baseline at time of discharge.
.
Given severity of lung disease, attempt was made to discuss
hospice care, however, patient refused to speak with our
palliative care service. He also refused acute rehab at this
time. Per discussion with PCP, [**Name10 (NameIs) **] refusal of therapies and
rehab are not uncommon.
#) CAD. Has known history of coronary artery disease, s/p CABG
with PCI in [**2097**]. He was ruled out for MI. Continued aspirin,
statin.
#) EtOH cirrhosis s/p TIPS. Not active. Tylenol maximum 2g
daily.
#) Anemia. Baseline hematocrit ~40. No history of melena or
hematemesis. Will check iron studies, guaiac stool.
#) Depression. Continued paroxetine 10mg daily.
#) BPH. Continued dutasteride and tamsulosin.
#) Code Status. DNI, confirmed with patient.
Medications on Admission:
Confirmed with pharmacyt:
Advair 500-50 twice daily
Albuterol MDI and nebulizer PRN
Ipratropium MDI and nebulizer PRN
Percocet 5mg-325mg - 2 tabs twice daily
Lactulose 10gm twice daily
Spironolactone 25mg daily
Nexium 40mg daily
Atorvastatin 20mg daily
Neurontin 800mg three times daily
Paroxetine 10mg daily
Tamsulosin 0.4mg daily
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Taper: Take 4 pills for 2 days, then 3 pills for 2 days, then 2
pills for 2 days, then 1 pill for 2 days, then [**1-24**] pill for 2
days.
Disp:*24 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
7. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: [**1-24**] puff
Inhalation every six (6) hours.
16. Atrovent HFA 17 mcg/Actuation Aerosol Sig: [**1-24**] puff
Inhalation every six (6) hours.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) COPD exacerbation
Discharge Condition:
Stable; On 2L home oxygen
Discharge Instructions:
You were admitted with an acute COPD exacerbation. You were
started on prednisone and antibiotics. We recommended that you
go to rehabilitation, but you did not want to go.
.
Please call your doctor or return to the emergency room should
you develop worsening shortness of breath, fevers/chills, or any
other concerning synmptoms.
.
Do not smoke or be near people smoking while you are using your
home oxygen.
Followup Instructions:
You should follow-up with your Dr. [**Last Name (STitle) **] in the next 1-2 weeks.
|
[
"305.1",
"V12.04",
"303.90",
"285.9",
"V45.81",
"V46.2",
"600.00",
"493.22",
"433.10",
"707.22",
"311",
"571.2",
"707.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8398, 8455
|
4336, 6440
|
312, 318
|
8520, 8548
|
3357, 4313
|
9006, 9093
|
2637, 2655
|
6822, 8375
|
8476, 8499
|
6466, 6799
|
8572, 8983
|
2670, 3338
|
252, 274
|
346, 1567
|
1589, 2192
|
2208, 2621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,984
| 127,776
|
3925
|
Discharge summary
|
report
|
Admission Date: [**2186-12-24**] Discharge Date: [**2186-12-29**]
Date of Birth: [**2127-9-2**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine / Robaxin / Lomotil / Metoprolol Tartrate /
Linezolid / Synercid / Rifampin / Optiray 300 / Percodan
Attending:[**First Name3 (LF) 8115**]
Chief Complaint:
Right facial swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 59 yo F with PMH significant for Breast CA with last
chemotherapy on [**12-16**] (Taxotere, carboplatin, and Herceptin)
with an ANC 686 now with increased right sided facial swelling,
erythema, warmth, and pain for 1 day.
The pt was in her usual state of health until 1 week prior when
she began to notice oral lesions occuring over the lips and on
the oral mucosa. These lesions were painful and were limiting
PO intake. She was reportedly perscribed Acyclovir by her
oncologist to treat presumed HSV infection, however she never
filled the perscription. Over the course of the week the
lesions largely improved with decreased pain and erythema.
However, on the morning of admission she awoke with right-sided
facial swelling, redness, and pain. She felt feverish and her
temperature measured at home was 100.9. She called her
oncologist who recomended that she go to the ED.
Of note, Pt reports change in vision in the right eye which
started 3 days before admission. She reports a "wavey line" in
her field of view. It does not interfere with her acuity, she
denies diplopia, pain with movement, seeing halos, and
associated headaces.
Also of note, pt noted diarrhea begining on Monday, which
largely resolved by Wednesday. On Friday she was started on
Cipro and since then diarrhea has completely resolved.
In the ED Febrile to 101.7, HR 126, 175/90 RR 18 SpO2 99%RA. Pt
received Unasyn and Penacillin G. Pt reported substernal Chest
pain along with sinus tachycardia that subsided as tachycardia
resolved. Facial swellin was evaluated with CT face, which was
concerning for subcutaneous air,raising concern for necrotizing
process. ENT evaluation found oral lesions which may be
responsible for the entrance of air into her facial soft tissue
structures. ID was conslted, and recommended daptomycin,
meropenem, and clindamycin.
Past Medical History:
1) Type I Diabetes mellitus
2) CAD
- [**1-29**] cardiac cath: 50% mid LAD, 80% distal LCx; stents placed
to LAD and LCx
- [**5-30**] PMIBI: SOB w/o ischemic changes. Nl myocardial perfusion
- [**12-30**] TTE: mild LA enlargement, mildly dilated RA, LVEF >55%,
trivial MR, trace AR
3) Hypothyroidism [**2184-3-2**] TSH 0.78
4) Depression/anxiety
5) Breast cancer: Stage II infiltrating ductal carcinoma dx [**2182**]
- s/p right lumpectomy followed by 4 cycles of
Adriamycin/Cytoxan and 7 weekly Taxotere treatments. Arimidex
since [**1-29**]
- right mastectomy [**2183-3-26**] when mammogram showed new
calcifications
6) GERD
7) Low back pain s/p placement of neural stimulator
8) Right shoulder osteomyelitis:
- Right humeral fracture [**5-30**] s/p ORIF
- [**2183-7-27**] MRSA bacteremia from chemo port -> right septic
shoulder/osteomyelitis
- initially tx with linezolid, stopped due to thrombocytopenia,
changed to daptomycin changed to synercid/rifampin due to
daptomycin resistance. Synercid/rifampin caused pancytopenia, so
she was changed to PO minocycline.
- [**3-31**] right shoulder joint and upper humerus removed by Dr.
[**First Name (STitle) **] at [**Hospital1 2025**] and antibiotic spacer inserted. Intra-op cultures
grew 1 colony of MRSA
--> desensitized to vancomycin and d/c [**2184-3-26**] on planned 6 week
course of vancomycin prior to shoulder replacement, which would
be followed by an additional 4-6 weeks of vancomycin
Social History:
Lives with her husband in [**Name (NI) 17448**], MA. Smoked 20 pack-years,
quit 20 years ago; drinks [**12-27**] cocktails per week; no illicit
drug use. Retired, previously worked with troubled young
adults.
Family History:
1. DM type 1: 2 Siblings, both deceased
2. Mother d. Ovarian CA
Physical Exam:
VS: Temp: 100.0 BP: 108/54 HR:101 RR:18 O2sat 100 RA
GEN: pleasant, comfortable, NAD
HEENT: R facial edema/erythema. No crepitus. PERRL, EOMI with
no pain, anicteric, Acuity intact. No gross deficits in visual
fields. Two 2-4mm linear breaches in the right buccal mucosa
opposite the R pre-molar; the lesions easily increase in length
with minimal manipulation. Oral mucosa pink and healthy
appearing. Tongue mobile, no masses or lesions, airway patent.
NECK: Right neck with extension of erythema, no supraclavicular
or cervical lymphadenopathy appreciated, no jvd, no carotid
bruits, no thyromegaly
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: trace bipedal edema; warm, 1+ DP pulses bilaterally. No
foot ulcers
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact.
RECTAL: Not Performed
Pertinent Results:
CBC:
[**2186-12-24**]
WBC-1.4* RBC-3.11* Hgb-10.1* Hct-29.8* MCV-96 MCH-32.6*
MCHC-34.0 RDW-13.8 Plt Ct-123* Neuts-49* Bands-0 Lymphs-30
Monos-20* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2186-12-25**]
WBC-3.8*# RBC-2.69* Hgb-8.9* Hct-26.9* MCV-100* MCH-32.9*
MCHC-32.9 RDW-13.6 Plt Ct-123*
[**2186-12-29**]
WBC-5.1 RBC-3.24* Hgb-10.4* Hct-31.1* MCV-96 MCH-32.2* MCHC-33.6
RDW-14.8 Plt Ct-141*
.
CHEM:
[**2186-12-24**]
Glucose-170* UreaN-9 Creat-0.9 Na-139 K-4.3 Cl-102 HCO3-26
AnGap-15
[**2186-12-25**]
Glucose-93 UreaN-11 Creat-0.9 Na-139 K-3.3 Cl-106 HCO3-26
AnGap-10
[**2186-12-29**]
Glucose-153* UreaN-12 Creat-1.0 Na-137 K-4.0 Cl-97 HCO3-32
AnGap-12
.
LFTs:
[**2186-12-24**] 12:30PM BLOOD ALT-18 AST-22 CK(CPK)-140 AlkPhos-67
TotBili-0.3
.
CEs:
[**2186-12-24**] 12:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2186-12-24**] 09:45PM BLOOD CK(CPK)-112 CK-MB-3 cTropnT-<0.01
[**2186-12-25**] 04:48AM BLOOD CK(CPK)-93 CK-MB-3 cTropnT-<0.01
.
[**2186-12-24**] 01:12PM BLOOD Lactate-1.5
.
ANEMIA AND IRON STUDIES:
[**2186-12-29**]
Iron-69 calTIBC-250* VitB12-1088* Folate-12.8 Ferritn-345*
TRF-192*
.
[**2186-12-24**] 2:00 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2186-12-25**]**
URINE CULTURE (Final [**2186-12-25**]): <10,000 organisms/ml
.
[**2186-12-24**] BCx: negative
.
[**2186-12-24**] 4:25 pm SWAB RIGHT ORAL PHYRNX.
**FINAL REPORT [**2186-12-28**]**
GRAM STAIN (Final [**2186-12-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2186-12-26**]): MODERATE GROWTH
OROPHARYNGEAL FLORA.
ANAEROBIC CULTURE (Final [**2186-12-28**]): NO ANAEROBES ISOLATED.
.
[**2186-12-25**] 12:17 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2186-12-25**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2186-12-25**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2186-12-28**] 2:10 pm SWAB Source: L lower lip.
**FINAL REPORT [**2187-1-4**]**
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2187-1-4**]):
HERPES SIMPLEX VIRUS TYPE 1.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.
.
EKG: NSR @ 97 BPM, NML Axis, nml intervals, TW flattening in
leads v2-v5, more pronounced when complared to [**2186-11-7**].
Imaging:
CXR [**2186-12-24**]:
port catheter, The lungs are clear. The pulmonary vasculature
is
normal. The heart and mediastinal contours are stable. A
spinal device is unchanged. The patient is status post right
shoulder arthroplasty. Saline implants are again evident.
IMPRESSION: No evidence for pneumonia.
.
CT Sinus/Mandible/maxilla [**2186-12-24**]:
Large amounts of subcutaneous emphysema involving the right side
of the face as described. Findings are concerning for diffuse
infection, however, other sources of subcutaneous emphysema such
as line placement should be considered.
.
CT SINUS W/ CONTRAST [**2186-12-27**]
IMPRESSION: Interval improvement in right face soft tissue
emphysema with persistent inflammatory changes of the right
cheek and buccal tissues. No abscesses.
Brief Hospital Course:
59 year old female with PMH significant for Breast CA with last
chemotherapy on [**12-16**] (Taxotere, carboplatin, and Herceptin) and
ANC on admission of 686 presenting with increased right facial
cellulitis. Patient initially admitted to MICU for management
given borderline low neutrophil count along with possible
nectrotizing fascitis of right face. Hospital course by problem:
#. Facial Swelling due to HSV : This was initially thought to
be a cellulitis. ENT was consulted regarding air in soft
tissues of right cheek seen on CT scan. ENT believed that this
air was due to tracking from open sores in right oral mucosa.
ID was also consulted and patient was placed on daptomycin for
Gram-positive coverage, Meropenem for GRN and anaerobe coverage,
and Clindamycin to limit toxin production if indeed this was a
toxin-mediated cellulitis or necrotizing process. Facial
erythema improved on 2nd day of admission. ANC also increased to
2590. Patient was then transferred to the medicine floor. A
repeat CT sinus showed interval improvement with no abscess. Pt
was noted to develop oral lesions, and n HSV culture of her oral
lesions was performed. Given concern of ophthalmic involvement
of a possible HSV outbreak, ophtho was consulted, and there was
no concern for eye involvement. She was empirically started on a
course of acyclovir. In-house bacterial cultures were all
negative, so she was discharged with VNA services for
antibiotics (clinda/dapto), with close ID followup. Of note, her
lower lip viral culture performed [**12-28**] did return as positive for
HSV type I several days after her discharge.
.
# CAD: Ms. [**Known lastname 5700**] had a complaint of substernal, nonradiating
Chest pain in the Emergency Department. Given her history of
CAD with stents to the LAD and LCx; It is likely that in the
setting of sinus tachycardia, she had some anginal symptoms.
EKG was without significant ischemic changes and cardiac enzymes
were negative x 3.
Home Aspirin and Lipitor were continued while in the hospital.
Atenolol was briefly held due to an episode of hypotension, but
was restarted without hypotension. She may benefit from
outpatient stress testing.
.
# chronic diastolic CHF: Pt has history of CHF for which she
takes lasix at home. Echo from [**2186-10-13**] shows mild symmetric
left ventricular hypertrophy with normal cavity size and
systolic function (LVEF>55%), so CHF is presumably [**1-27**] diastolic
dysfunction. Held home lasix briefly because of hypotension, but
was restarted at home dose prior to d/c.
.
#. Hypertension: Patient had one episode of hypotension on
admission which responded to IVF bolus. Antihypertensives were
initially held and were restarted on the floor without further
episodes of hypotension.
.
# Breast Cancer: management deferred to outpatient oncology
team. Of note, she did receive herceptin while in-house.
.
# DM type 1: continued home insulin [**Month/Day (2) 4581**] with [**Last Name (un) **] following.
.
# Depression/Anxiety: continued home dose effexor, wellbutrin,
clonazepam, and ativan
# Hyperlipidemia: continued lipitor
# GERD: Patient takes omeprazole at home, she was given
pantoprazole while in the hospital
# Hypothyroidism: continued home dose levothyroxine
Medications on Admission:
ASA 325 mg Daily
Atenolol 25 mg daily
Diovan 40 mg daily
Clonazapam 1 mg QHS
ativan 1 mg TID
Effexor XL 150 mg TID
Fosamax 1 tab Q week (sundays)
Lactulose PRN
colace prn
Lasix 40 mg PO daily
Levoxyl 125 mcg daily
lipitor 10 mg Daily
wellbutrin 150 TID
Mobic 15 mg Daily PRN
Vicodin 5 mg-500 mg Tablet Q4-6h PRN
Gabapentin 600 mg TID
omeprazole 20 mg [**Hospital1 **]
Cipro 500 mg [**Hospital1 **] (started [**12-23**])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H
(every 8 hours) as needed for constipation.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin [**Month/Year (2) **]
please continue using your insulin [**Month/Year (2) 4581**] as before
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for pain.
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
13. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia, anxiety.
14. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
15. Daptomycin 500 mg Recon Soln Sig: Three Hundred (300) mg
Intravenous Q24H (every 24 hours) for 2 weeks.
Disp:*QS mg* Refills:*0*
16. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 2 weeks.
Disp:*112 Capsule(s)* Refills:*0*
17. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
18. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Facial Cellulitis [**1-27**] HSV
.
Secondary:
bilateral breast CA s/p b/l mastectomy, undergoing adjuvant
chemo
coronary artery diease
chronic diastolic CHF
Type 1 diabetes
hypertension
hyperlidemia
hypothyroidism
GERD
Discharge Condition:
stable, improved
Discharge Instructions:
You were admitted to the hospital with facial cellulitis
(infection of the tissue below the skin). We started you on
broad antibiotic coverage to treat the infection. We looked at
your mouth, blood, urine, and stool, and could not find a bug
that caused the infection
.
We had our infectious disease doctors [**Name5 (PTitle) 788**] [**Name5 (PTitle) **] and they initially
had you on broad spectrum antibiotics. Since you were afebrile
your repeat CT scan looked much better, we narrowed you
antibiotics down to 2 medicines. You will be discharged with VNA
to come to your house and administer the 1 antibiotics that is
given IV.
.
You also began to develop lesions on your lip that look like
they might be viral. We tested them but they did not grow any
virus. Nonetheless, we are beginning you on an antiviral
medicine called acyclovir, which you should take for 7 days as
prescribed.
.
Please keep all your followup appointments. Please take all
medicines as prescribed. If you experience any symptoms that
disturb you, such as fevers/chills, worsening facial or eye
pain, or problems with your vision, please call your doctor or
go to the ED.
Followup Instructions:
Onc:
Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-1-3**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-1-3**] 11:30
.
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 17488**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-1-3**] 11:30
.
ID:
Provider: [**Name (NI) 4623**] [**First Name8 (NamePattern2) 4952**] [**Last Name (NamePattern1) 4624**] CHIMIENTI Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2187-1-1**] 11:00
[**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13757, 13763
|
8310, 8667
|
405, 412
|
14035, 14054
|
5015, 8287
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|
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|
342, 367
|
8696, 11569
|
440, 2301
|
2323, 3772
|
3788, 4000
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,212
| 117,561
|
22771
|
Discharge summary
|
report
|
Admission Date: [**2189-8-20**] Discharge Date: [**2189-8-24**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Perirectal abscess/ pain x 7 days.
Major Surgical or Invasive Procedure:
I and D of abscess
History of Present Illness:
55 year old cantonese speaking male , PMH of ESRD on tri weekly
dialysis, DM, HTN, who presents with perirectal pain and
perirectal mass x 7 days.
Past Medical History:
-- HTN: difficult to control, multiple agents used
-- DM: with retinopathy, nephropathy
-- ESRD due to IgA nephropathy/DM
-- diabetic retinopathy- Blindness
-- R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**]
-- Anemia of chronic disease
-- Hyperlipidemia
-- CAD - not an intervetional or CABG candidate. Cardiac
catheterization from [**2188-2-4**] showed 3VD with a 30% left
main, a diffusely diseased LAD with 80% mid stenosis, 90%
diagonal, 60% second diagonal, and 90% OM1. None suitable for
PCI or CABG. EF 60-70% TTE [**2188-10-14**]
Social History:
Cantonese/Mandarin speaking, limited English, immigrated to the
US 10 yrs ago, currently lives with wife and 3 children, has
been blind for approx 3 years, has not worked recently; No
history of tobacco use, alcohol, or illicit drug use. Wife
injects insulin.
Family History:
No family history of DM, CAD, Stroke, HTN, or Renal Disease
Physical Exam:
per surgery team
VS
Gen: Drowsy, hard to keep awake ( per wife is baseline state ).
Chest: Left dialysis catheter in Left subclavian vein.
CVS: RRR II/Vi Harsh systolic murmur at LSB and L 5th
intercostal space midclavicualr. No carotid bruits.
Pulm: CTAB no w/r/r
Abd: Soft NT/ ND + BS
Ext: No C/E bl
.
per icu team a day later:
VS: T 96.2; HR 68; BP 205/68; RR 22; SpO2 100% 3L NC
GEN: NAD, dyskinesia of mouth (lip smacking, tongue thrusting)
HEENT: mmm, poor dentition, small lesion on L side tongue, no
LAD, neck supple, no masses, blind, L eye: cloudy bloody cornea
no discernible pupil, R eye: small fixed pupil, injected
conjunctiva
CV: RRR, no M/R/G
LUNGS: CTA B, 100% 3L NC, episodes of panting
ABD: decreased bs, soft, ntnd
EXT: warm, dry, 2+ pedal and radial pulses, no edema or cyanosis
Perirectal area: packing is saturated with blood, edema
surrounding I/D site, very tender
Pertinent Results:
138 96 19
-------------< 79
3.4 29 6.0
Ca: 8.6 Mg: 1.6 P: 2.4 D
.
WBC: 11.4
HCT: 36.2
PLT: 198
.
PT: 14.3 PTT: 33.9 INR: 1.2
.
CXR: FINDINGS: In comparison with the study of [**5-11**], there is
again enlargement of the cardiac silhouette, although less
prominent than on the previous study. There is again
engorgement of the pulmonary vessels consistent with substantial
elevation of pulmonary venous pressure. The costophrenic angles
have cleared, consistent with decreased pleural effusion
Brief Hospital Course:
Mr. [**Known lastname 724**] is a 55 year old man with a PMH significant for ESRD on
MWF HD, CAD, DM, anemia, poorly controlled HTN, and anemia
transferred from the surgical service for monitoring s/p
perirectal I/D.
1. Perirectal Abscess: The patient was admitted for a perirectal
abscess status post I/D on [**8-19**]. Mr. [**Known lastname 724**] was initially treated
with ciprofloxacin and flagyl. After wound culture speciated out
as MRSA, vancomycin was added to the patient's antibiotic
therapy. Per Dr. [**Last Name (STitle) **] of surgery, antibiotic therapy will
need to be continued for 14 days (stop on [**9-5**]). The patient was
treated with oxycodone PRN for pain control, which he did not
require in the 48 hours prior to discharge. A follow-up
appointment was scheduled for the patient with Dr. [**Last Name (STitle) **] in
outpatient clinic in 2 weeks.
2. HTN: After the patient's I/D procedure, he became
hypertensive with SBP >200 and was transferred to the [**Hospital Ward Name 332**] ICU
for closer monitoring. His home medications were continued and
he was also placed on a nitroglycerin drip which was continued
until his hemodialysis on [**8-21**], at which point he became
hypotensive and the nitroglycerin was discontinued. Upon
transfer to the medicine floor, his blood pressure remained
stable. At discharge, patient was continued on his home regimen
of labetolol, minoxidil, clonidine, imdur, and amlodipine.
3. CAD: Patient's ASA and plavix was held for the I/D procedure.
At discharge, patient was resumed on all home medications
including ASA, plavix, losartan, labetolol, lisinopril.
4. DM 2: Patient continued on 70/30 and RISS Q6H during his
hospital course.
5. Hyperlipidemia: Patient continued on home statin therapy.
6. ESRD: Patient on MWF hemodialysis, which was continued during
his hospital course. Last HD was on day of discharge ([**Month/Year (2) 766**]).
Nephrocaps continued during hospital course. The patient will
need vancomycin dosed per HD protocol.
7. Anemia of chronic disease: On discharge, patient's HCT stable
and at baseline.
Medications on Admission:
Allergies: NKDA
Home meds (per OMR):
Atorvastatin 40mg po daily
Aspirin 325mg po daily
Clonidine patch
Epogen (2xper wk)
Hydralazine 50mg po daily
Insulin (NPH 10 units [**Hospital1 **])
Lisinopril 40mg daily
Losartan 100mg daily
Metoprolol tartrate 150mg po bid
Minoxidil 2.5mb po bid
Amlodipine 10mg daily
Nephrocaps
Calcium 500mg po tid
Plavix 75mg po daily
Protonix 40mg po daily
Reglan 5mg q8h IV
Fluticasone 2 puffs IH [**Hospital1 **]
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
7. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Before every
meal.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day) as needed.
15. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: 8 units in the morning and 6 units at night . Subcutaneous
daily.
16. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
17. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days: Stop on [**9-5**].
Disp:*36 Tablet(s)* Refills:*0*
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 12 days: STOP ON [**9-5**].
Disp:*12 Tablet(s)* Refills:*0*
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol) for 12 days: STOP ON
[**9-5**]. gram
20. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: 8 units in the AM and 6 units in the PM Subcutaneous twice
a day.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
22. Outpatient Lab Work
Vancomycin trough to be drawn on Friday ([**8-28**]) prior to
hemodialysis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary
1. Perirectal abscess
2. Hypertension
Secondary
Diabetes
ESRD qMWF due to IgA nephropathy/DM
Diabetic retinopathy
R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**]
Anemia of chronic disease
Hyperlipidemia
CAD
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted for a perirectal abscess, which was
surgically drained. You will need to take antibiotics for a
total of 14 days (STOP ON [**9-5**]). Your antibiotic regimen is:
Vancomycin 1000mg per HD protocol
Flagyl 250mg po TID (to be given after hemodialysis)
Ciprofloxacin 500 mg by mouth every 24 hours (to be given after
hemodialysis)
2. You will need to have a blood test (vancomycin trough) drawn
on Friday (8/285) prior to hemodialysis.
3. You should resume all of your home medications as prior to
admission. It is important that you take all of your medications
as prescribed.
4. You have a follow-up appointment with the surgeon as listed
below. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
5. If you develop a fever, chest pain, shortness of breath, or
other concerning symptoms, you should contact your PCP or go to
the local Emergency Department immediately.
Followup Instructions:
You are scheduled for a follow-up appointment with Dr. [**Last Name (STitle) **]
of surgery on [**2189-9-3**] at 4pm at [**Street Address(2) 1126**] in [**Location (un) **],
MA.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-4**]
weeks. You can [**Month/Day (2) **] an appointment by calling ([**Telephone/Fax (1) 58911**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2189-11-19**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2190-4-6**] 11:20
Completed by:[**2189-8-24**]
|
[
"403.01",
"250.50",
"566",
"585.6",
"250.40",
"362.01",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"48.81"
] |
icd9pcs
|
[
[
[]
]
] |
7634, 7709
|
2942, 5046
|
350, 370
|
7994, 8040
|
2417, 2919
|
9013, 9791
|
1427, 1488
|
5539, 7611
|
7730, 7973
|
5072, 5516
|
8064, 8990
|
1503, 2398
|
276, 312
|
398, 546
|
568, 1133
|
1149, 1411
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,339
| 165,674
|
48441
|
Discharge summary
|
report
|
Admission Date: [**2163-9-23**] Discharge Date: [**2163-9-28**]
Date of Birth: [**2097-7-18**] Sex: M
Service: MEDICINE
Allergies:
Pine Tar
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
fatigue/melena
UGIB
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
History of Present Illness:
66 male with h/o hemochromatosis with cirrhosis no h/o varices,
pulmonary fibrosis on chronic steroids and intermittent home
oxygen transfered from OSH with melena and anemia. Pt noted
feeling dizzy and weak for several days, + black stool/diarrhea
for several days. Notes that for the past two days he was using
his 02 more, usually only uses 4L NC at night. Had been using
during the day to the point where he was unable to walk to
bathroom without becoming SOB. Very fatigued and weak. Presented
to OSH, had guaiac + stool. BP 80s (pt and family insist that
pt's BPs are normally in 80s-90s), got 2 U prbcs there and 2
units PRBCs in ED, getting 2 units FFP as well. Hct in ED 18
after 2U PRBCs at OSH, per report hct at [**Hospital1 **] 19. Baseline Hct
27 from our records. Seen by liver fellow in ED. NG lavage
revealed coffee grounds without BRB, cleared with ~200-300 cc
NS. Pt comfortable and mentating with BP still in 80s. Got
octreotide bolus now on gtt, got PPI. Per liver fellow, as
doesn't look like he is actively bleeding with plan to scope in
am.
VS in ED at time of transfer:86/37 86 100% 2L, had gotten 1.4L
NS in addition to blood. Had 2PIVs placed. Noted to have 800cc
of UOP during ED stay. Had blood cultures drawn as was noted to
be rigoring, although rectal temp 98.
On ROS, endorsed fatigue, SOB, weakness and "black water"
diarrhea x 2 days. Denied fevers, + chills in ed, no nausea or
vomiting. No CP or abdominal pain. Has chronic ascites but has
not noted any increased abdominal girth.
Past Medical History:
* Hemochromatosis - diagnosed 3yrs ago, treated with QOmonth
phlebotomy for 1.5 years.
* Cirrhosis due to hemochromatosis and ?EtOH cirrhosis
* h/o EtOH abuse, no h/o withdrawals, continues to drink daily
* Hypertension
* Coronary artery disease (per OMR but pt denies; also normal
cath in [**2158**] essentially unremarkable echo [**2-14**] (trace MR, mild
AS)
* Pulmonary fibrosis - diagnosed 3yrs ago, on chronic steroids
recently tapered from 10mg daily to 2.5mg daily. Currently uses
4L NC 02 at night only.
* Asthma??
* Hyperlipidemia
* Psoriatic arthritis
* s/p right rotator cough injury
* Anemia of unclear etiology, receives transfusions. Per report
pt had negative EGD/colonoscopy in [**12-16**], last transfusion 4
weeks ago
Social History:
married, retired but has been consulting as office manager
EtOH: h/o abuse, denies h/o withdrawl. Drinks 2-3 glasses wine
per day.
Tob: h/o 20-30 pack-yr, quit 20yrs ago
Family History:
sister died of lung ca at age 60, brother with DM, sister with
hemachromatosis, breast Ca
Physical Exam:
Vitals: T: 98.7 BP:86/53 P: 80 R: SaO2: 96% 3L NC
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, mild scleral icterus. No oral lesions.
MMM
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs with crackles at right base
Cardiac: RR, nl S1 S2, [**3-16**] high pitched holosystolic [**Month/Day (4) 9413**],
does not radiate to carotids
Abdomen: Obese, soft, CCY scar, HSM 3 fingerbreadths below
costal margin, minimally tender RUQ. + BS, no rebound or
guarding.
Extremities: No edema, 2+ radial, DP pulses b/l. Chronic stasis
changes b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: diffuse telangiectasias and cherry angiomata
Neurologic: A+O x 3, cooperative and appropriate, PERRL, no
focal asymmetry. + b/l tremor, no flap
Pertinent Results:
[**2163-9-23**] 07:40PM BLOOD WBC-3.3* RBC-2.10*# Hgb-6.5*# Hct-18.9*#
MCV-90 MCH-30.6 MCHC-34.1 RDW-17.5* Plt Ct-73*
[**2163-9-24**] 01:32AM BLOOD WBC-3.0* RBC-2.68*# Hgb-8.2*# Hct-24.0*#
MCV-90 MCH-30.5 MCHC-34.0 RDW-17.2* Plt Ct-61*
[**2163-9-25**] 02:47AM BLOOD WBC-2.0* RBC-2.92* Hgb-9.0* Hct-26.5*
MCV-91 MCH-30.7 MCHC-33.8 RDW-16.8* Plt Ct-76*
[**2163-9-26**] 05:55AM BLOOD WBC-3.3*# RBC-2.97* Hgb-8.9* Hct-26.8*
MCV-90 MCH-30.1 MCHC-33.3 RDW-16.4* Plt Ct-66*
[**2163-9-27**] 05:10AM BLOOD WBC-3.1* RBC-3.06* Hgb-9.4* Hct-27.4*
MCV-90 MCH-30.7 MCHC-34.3 RDW-16.8* Plt Ct-69*
[**2163-9-28**] 06:07AM BLOOD WBC-3.3* RBC-3.01* Hgb-8.9* Hct-26.7*
MCV-89 MCH-29.8 MCHC-33.5 RDW-16.2* Plt Ct-85*
[**2163-9-28**] 12:35PM BLOOD Hct-27.1*
[**2163-9-23**] 07:40PM BLOOD Neuts-83.6* Lymphs-10.1* Monos-4.9
Eos-1.1 Baso-0.3
[**2163-9-24**] 01:32AM BLOOD PT-14.8* PTT-29.0 INR(PT)-1.3*
[**2163-9-25**] 02:47AM BLOOD PT-14.9* PTT-27.6 INR(PT)-1.3*
[**2163-9-28**] 06:07AM BLOOD PT-14.8* PTT-31.0 INR(PT)-1.3*
[**2163-9-27**] 05:10AM BLOOD Ret Aut-2.0
[**2163-9-23**] 07:40PM BLOOD Glucose-114* UreaN-96* Creat-3.0*# Na-143
K-4.3 Cl-116* HCO3-16* AnGap-15
[**2163-9-24**] 01:32AM BLOOD Glucose-171* UreaN-109* Creat-3.5* Na-142
K-5.0 Cl-110* HCO3-20* AnGap-17
[**2163-9-26**] 05:55AM BLOOD Glucose-124* UreaN-38* Creat-1.7* Na-144
K-4.0 Cl-114* HCO3-23 AnGap-11
[**2163-9-27**] 05:10AM BLOOD Glucose-97 UreaN-24* Creat-1.4* Na-142
K-3.9 Cl-112* HCO3-22 AnGap-12
[**2163-9-28**] 06:07AM BLOOD Glucose-127* UreaN-22* Creat-1.5* Na-142
K-3.9 Cl-112* HCO3-22 AnGap-12
[**2163-9-24**] 01:32AM BLOOD ALT-21 AST-23 LD(LDH)-165 AlkPhos-80
Amylase-109* TotBili-2.1*
[**2163-9-26**] 05:55AM BLOOD ALT-17 AST-21 LD(LDH)-167 AlkPhos-78
TotBili-0.9
[**2163-9-27**] 05:10AM BLOOD ALT-18 AST-25 LD(LDH)-172 AlkPhos-89
TotBili-1.1
[**2163-9-28**] 06:07AM BLOOD ALT-17 AST-23 LD(LDH)-183 AlkPhos-98
TotBili-0.8
[**2163-9-24**] 01:32AM BLOOD Albumin-3.2* Calcium-8.3* Phos-4.3#
Mg-1.9
[**2163-9-25**] 02:47AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.0
[**2163-9-27**] 05:10AM BLOOD TotProt-5.0* Mg-1.8 Iron-40*
[**2163-9-28**] 06:07AM BLOOD Mg-1.9
[**2163-9-27**] 05:10AM BLOOD calTIBC-218* Ferritn-92 TRF-168*
[**2163-9-26**] 05:55AM BLOOD VitB12-561 Folate-8.7
[**2163-9-25**] 02:47AM BLOOD AFP-1.2
[**2163-9-27**] 05:10AM BLOOD PEP-NO SPECIFI
[**2163-9-23**] 09:58PM BLOOD Lactate-2.1*
[**2163-9-24**] 04:14AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2163-9-24**] 05:41PM URINE Eos-POSITIVE
[**2163-9-24**] 05:41PM URINE Hours-RANDOM UreaN-847 Creat-54 Na-40
[**2163-9-27**] 10:56AM URINE Hours-RANDOM TotProt-9
[**2163-9-27**] 10:56AM URINE U-PEP-NO PROTEIN
Studies-
Cardiology Report ECG Study Date of [**2163-9-24**] 1:05:30 AM
Sinus rhythm with first degree A-V delay
Left atrial abnormality
Left anterior fascicular block
Low precordial lead QRS voltages - is nonspecific
Modest nonspecific ST-T wave changes
No previous tracing available for comparison
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 94 382/417 0 -41 -1
-------------
CXR [**2163-9-24**]
Again seen is slight prominence to interstitial markings in left
perihilar region, but these are unchanged. There is no focal
consolidation or effusion. Cardiac silhouette is enlarged but
unchanged. The mediastinal contours are otherwise unremarkable.
IMPRESSION:
Stable chest x-ray with no evidence for acute cardiopulmonary
disease.
--------------
EKG [**2163-9-25**]
Sinus tachycardia with ventricular premature complexes
First degree A-V delay
Left atrial abnormality
Left anterior fascicular block
Low precordial lead QRS voltages
Nonspecific ST-T abnormalities
Findings are nonspecific
Since previous tracing of [**2163-9-24**], sinus tachycardia present,
ventricular
ectopy seen and ST-T wave changes increased
-----------
[**2163-9-25**]
Abdominal ultrasound
IMPRESSION:
1. Heterogeneous predominantly hyperechoic liver parenchyma that
may relate to underlying hemachromatosis. More severe forms of
liver disease including hepatic fibrosis/cirrhosis cannot be
excluded by ultrasound. Patent vasculature. Trace free fluid.
2. Nonobstructing left renal calculi. Probable upper pole left
renal cyst.
3. Splenomegaly.
----------------
The left atrial volume is markedly increased (>32ml/m2). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Moderate Pulmonary artery systolic hypertension.
Preserved regional and global biventricular function. Mild
aortic stenosis and mitral regurgitation.
Compared with the prior study (images reviewed) of [**2162-3-9**],
LVH is not seen on the current study. The degree of mitral
regurgitation has increased. The degree of aortic stenosis is
similar.
Brief Hospital Course:
66 year old male with history hemachromatosis and cirrhosis who
was transferred from an outside hospital with an UGIB.
## UGIB. The pt had an EGD performed by the liver service which
demonstrated significant portal gastropathy but no focal site of
bleeding. Likely [**3-12**] cirrhosis. Pt also at risk since on chronic
steroids, could contribute to mucosal ulceration. Also Pt has
history of ETOH use that could worsen liver disease and
gastropathy. The pt was transfused 4 units pRBCs at [**Hospital1 18**] in the
ICU (had been given two units at OSH) and he was also given two
units of FFP pre-procedure. At the time of admission, the pt was
initiated on an octreotide gtt as well as Cipro; these were
discontinued once the results of the EGD were known and he was
started on nadolol 20mg and Carafate. The pt was treated with
[**Hospital1 **] PPI. His home BB, spironolactone, Bumex and [**Last Name (un) **] were held in
the setting of acute GI bleeding. Over the rest of his admission
he was given 2 more units of pRBCs and his hct was between 26
and 31, 27.1 at discharge.
## ESLD: The pt had no evidence of SBP on exam. Patent liver
vessels on U/S. As above, he was initially treated with Cipro
for possible variceal bleed and his diuretics were held while
hypotensive with his acute bleeding. He was instructed to stop
drinking alcohol in order to improved his liver function and
decrease the risk of bleeding from his gastropathy. If after he
stops drinking the gastropathy bleeds again, he may need a TIPS
procedure in the future. He will have follow up in the liver
clinic.
## Pulmonary fibrosis: Exact etiology and prior w/u unclear. [**Name2 (NI) **]
was treated with O2 by nasal canula, until the day before
admission, when he was saturating >92% on RA. Home steroids were
continued at 2.5mg per day.
## Anemia: likely multifactorial, normal B12 and folate. Seen by
a hematologist as out patient. SPEP and UPEP were normal. Iron
studies were borderline low, pt was started on iron 325mg per
day. He was given 6 units pRBCs during his hospitalization.
Anemia likely worsened by portal gastropathy bleeding.
Colonoscopy was performed and only showed grade 1 hemorrhoids
and diverticulosis. Patient will need continued anemia
monitoring as out patient.
## ARF: Cr peaked at 3 from a baseline of 0.8 on [**3-17**]. Unclear
etiology. With transfusions Cr improved to 1.5 at discharge.
FEUN was 56. UA was normal. UPEP and SPEP were normal. [**Month (only) 116**] need
renal follow up as out patient.
## Asthma: Continued on home Advair.
##HTN :Hold BB, [**Last Name (un) **] and diuretics for now while hypotensive.
##CAD: He had no history of CAD or prior MI, stated had "false
positive" stress test here in [**2158**] followed by negative cath.
Had TTE from [**2-14**] with mild AS, trivial MR. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9413**] was noted
on physical exam concerning for AS, thus a repeat TTE was
obtained which was unchanged from prior study except for
increase in mild MR and no LVH. The patient's home statin was
continued.
Medications on Admission:
Lipitor 10mg daily
Avapro 150mg daily
Toprol XL 25mg daily
Spironolactone 50mg daily
Bumex 2mg daily
Glucosamine 2 tabs daily
Loratidine 10mg PO daily
Prednisone 2.5mg daily
Advair 250/50 [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. 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*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): take for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
12. Bumex 2 mg Tablet Sig: One (1) Tablet PO once a day.
13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Multifactorial Anemia
Portal gastropathy
Cirrhosis
Hemachromatosis
Discharge Condition:
Afebrile, hemodynamically stable, ambulating without difficulty
Discharge Instructions:
You were admitted with a gastrointestinal bleed and anemia. You
underwent an upper endoscopy which showed stomach congestion
called "portal gastropathy." Your colonoscopy showed
diverticulosis and hemorrhoids. You were given multiple blood
transfusions. Your anemia is due in part to your liver disease
and portal gastropathy. It is VERY IMPORTANT that you abstain
from future alcohol use.
Please take medications as prescribed. You will be given an
iron supplement to take for 3 months.
Dr.[**Name (NI) 948**] office will call you with an appointment in the
Liver Center in the next 1-2 weeks.
Please return to the hospital if you experience fevers/chills,
shortness of breath. Bloody or black stool, bleeding, or any
other symptoms that concern you.
Followup Instructions:
You will be contact[**Name (NI) **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office for an
appointment.
Please follow up with your primary doctor, hematologist, and
nephrologist as soon as possible.
Completed by:[**2163-9-30**]
|
[
"455.0",
"276.52",
"572.3",
"401.9",
"305.01",
"272.0",
"584.9",
"493.90",
"571.2",
"238.72",
"515",
"288.50",
"562.10",
"696.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.23",
"96.33",
"99.04",
"45.13",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
13730, 13736
|
9100, 12181
|
290, 331
|
13847, 13913
|
3818, 9077
|
14723, 14986
|
2846, 2938
|
12437, 13707
|
13757, 13826
|
12207, 12414
|
13937, 14700
|
2953, 3799
|
231, 252
|
359, 1881
|
1903, 2642
|
2658, 2830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,340
| 127,374
|
11830+56291
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-5-29**] Discharge Date: [**2187-6-2**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
s/p fall with SDH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 5263**] is a 88yo female with dementia who has recent history
of falls, presents with SDH s/p fall on Sunday. She was found to
have left head swelling and a laceration over her left eyebrow.
On day PTA she fell out of her wheelchair and was found to be
more lethargic with garbled speech and progressively became more
somnolent. She presented to [**Hospital3 **] and was then
transferred to [**Hospital1 18**] MICU on [**5-29**]. Neurosurgery followed patient
closely and did not feel that surgery was indicated. She was
loaded with Dilantin and maintained on IV dilantin. CT scan was
unchanged from OSH. She was then transferred to medical floor.
Past Medical History:
1)Alzheimers
2)Hypertension
3)Hypothyroidism
4)CAD s/p stent in [**2181**] to LCx
5)LBP
6)DJD
7)Hyperlipidemia
Social History:
Lives in [**Location **] [**2-9**] to dementia for 3 weeks, prior was I ADLs
Family History:
NC
Physical Exam:
vitals: T 98 BP 180/70 AR 81 RR 20 O2 sat 98%RA
Gen: Patient somnolent; responsive to sternal rub but does not
follow simple commands.
HEENT: PERRLA
Heart: RRR, nl s1/s2, no s3/s4, +systolic murmur
Lungs: CTAB
Abdomen: soft NT/ND, +BS
Extremities: no LE edema, 2+ DP/PT pulses bilaterally; left
raccon eye hematoma with laceration on eyebrow
Neuro: unable to assess given mental status
Pertinent Results:
Laboratory results:
[**2187-5-29**] 04:20PM BLOOD WBC-8.5 RBC-4.07* Hgb-10.7* Hct-32.7*
MCV-80* MCH-26.3* MCHC-32.8 RDW-16.9* Plt Ct-227
[**2187-5-29**] 04:20PM BLOOD PT-13.4* PTT-30.5 INR(PT)-1.2*
[**2187-5-29**] 04:20PM BLOOD Glucose-97 UreaN-21* Creat-1.2* Na-133
K-6.0* Cl-99 HCO3-26 AnGap-14
[**2187-5-30**] 02:23AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.3
[**2187-5-29**] 04:20PM BLOOD calTIBC-328 Ferritn-63 TRF-252
Relevant Imaging:
1)Cxray ([**5-29**]): No acute cardiopulmonary process.
2)CT Head ([**5-29**]): 1. Left convexity acute subdural hematoma,
with associated mass effect and minimal rightward shift of
normally midline structures.
3)CT Head ([**5-31**]): Evolving left subdural hematoma without
increase in size or mass effect.
4)MRI head ([**5-31**]): Subdural and subarachnoid hemorrhages on the
left as described above, very similar in appearance to prior
studies.
Brief Hospital Course:
Ms. [**Known lastname 5263**] is a 88yo female with underlying dementia with recent
history of multiple falls, who presents s/p fall with SDH.
1)Subdural hematoma: Occurred in the setting of recent fall.
Etiology of fall likely mechanical. Infectious work-up was
negative. She was initially loaded with Dilantin and then
continued on an infusion. Neurosurgery was consulted on
admission and followed patient closely. They did not feel that
she was a surgical candidate since the bleed was thought to be a
chronic process. It was recommended that she undergo drainage in
1 month but the family does not want any invasive procedures to
be done. Patient's mental status was waxing and [**Doctor Last Name 688**]
throughout her stay and repeat CT scan
was mostly unchanged. Dilantin was stopped as per family
requests given plan for hospice care. She is being discharged on
Haldol, Ativan, Morphine, and Acetaminophen which she be given
if patient is agitated or appears to be in pain. Please monitor
for symptoms closely.
2)Hypertension: Patient was on Propranolol as outpatient. This
was initially held but then never restarted as per outcome of
the family meeting.
3)Dementia: Patient has dementia at baseline. No further work-up
at this time.
4)Anemia: Patient presented with Hct~ 31.7. Decreased to 24.9
during hospital stay. Unclear cause. Possibly related to SDH. No
further labs were checked after decision was made for hospice
care.
5)Hypothyroidism: Patient was initially started on Levothyroxine
IV since she was not able to take PO. After a family meeting
with the family the decision was made to stop all medications.
Levothyroxine was stopped at this time.
6)Code status: DNR/DNI. Housestaff team had family meeting with
patient and decision was made to arrange for hospice care.
Family does not want any agressive measures to be done including
IVFs and invasive procedures.
Medications on Admission:
FE 325 mg qd
Propanolol 120 mg qd
Levothyroxine 50 mcg qd
Sertraline 50 mg qd
ASA 81 mg qd
MVI
Ativan 0.5 mg po q 6 prn
Oral peridex
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours).
2. Haloperidol 1 mg IV TID:PRN
3. Lorazepam 0.5 mg IV Q4H:PRN
4. Morphine Sulfate 1-5 mg IV Q4H:PRN
Discharge Disposition:
Extended Care
Facility:
Hellenic - [**Location (un) 2624**]
Discharge Diagnosis:
Primary diagnoses:
1)Subdural hematoma
Secondary diagnoses:
1)Anemia
2)Hypertension
3)Hypothyroidism
Discharge Condition:
Stable to be discharged to nursing home with hospice services
Discharge Instructions:
1)Patient was admitted and found to have a subdural hematoma.
After discussions with the family, the decision was made to make
patient DNR/DNI with arrangement for hospice services. All
medications were stopped except for anxiolytics, pain, and
sedative medications which should be continued.
Followup Instructions:
None
Name: [**Known lastname 4345**],[**Known firstname 6705**] Unit No: [**Numeric Identifier 6706**]
Admission Date: [**2187-5-29**] Discharge Date: [**2187-6-2**]
Date of Birth: [**2098-12-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 653**]
Addendum:
Per family request, PICC line was d/c'ed. As a result her IV
pain and sedative medications were changed to oral concentration
and IM forms.
Discharge Disposition:
Extended Care
Facility:
Hellenic - [**Location (un) 271**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]
Completed by:[**2187-6-2**]
|
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"294.10",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
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|
2531, 4423
|
245, 251
|
5028, 5092
|
1620, 2037
|
5433, 5936
|
1194, 1198
|
4606, 4797
|
4903, 4943
|
4449, 4583
|
5116, 5410
|
1213, 1601
|
4964, 5007
|
188, 207
|
2055, 2508
|
279, 950
|
972, 1084
|
1100, 1178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,010
| 185,994
|
41523
|
Discharge summary
|
report
|
Admission Date: [**2109-2-18**] Discharge Date: [**2109-4-5**]
Date of Birth: [**2066-6-25**] Sex: M
Service: SURGERY
Allergies:
Furosemide / Daptomycin
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
transfer for liver transplantation workup
Major Surgical or Invasive Procedure:
[**2109-2-20**] paracentesis (5L)
[**2109-2-23**] paracentesis (3.5L)
[**2109-3-15**]: ABO incompatible liver transplant with splenectomy
Plasmapheresis [**3-14**], [**3-21**], [**3-24**], [**3-27**], [**3-28**], [**3-29**], [**3-30**], [**3-31**]
History of Present Illness:
Mr. [**Known lastname 1557**] is a 42M with history of cirrhosis likely
multifactorial in etiology (alpha-1-antitrypsin / autoimmune /
EtOH) presenting from [**Hospital1 1774**] for in-patient transplant
evaluation. To summarize his overall course, he was doing well
until [**2108-10-26**] when he developed new onset ascites.
Further evaluation revealed underlying cirrhosis during
inpatient evaluation at [**Doctor Last Name 15594**] Hospital. Mr [**Known lastname 1557**] required
several hospitalizations (at Saints and [**Hospital1 1774**]) between [**Month (only) **]
and [**Month (only) 404**] for several issues, including severe hyponatremia to
122 which improved on tolvaptan. He has also had recurrent
enterococcal urinary tract infections. Most recently, he was
hospitalized at [**Hospital1 1774**] for hepatic encephalopathy which required
a MICU stay including brief intubation with rapid improvement on
lactulose and rifaximin. While on the floor at [**Hospital1 1774**], his course
was complicated by SBP with peritoneal fluid growing out VRE and
repeat tap growing out [**Female First Name (un) 564**]. He was started on daptomycin,
fluconazole, as well as courses of cefepime and flagyl
empirically. He also developed florid diarrhea with up to 8
bowel movements per day and lactulose was stopped given
worsening renal failure. The diarrhea was felt secondary to
lactulose as it improved off it. Renal failure was felt
secondary to dehydration secondary to diarrhea however
hepatorenal syndrome could not be ruled out. Albumin and fluids
were given with continued renal improvement. Transplant
evaluation was initiated, however insurance would not cover
cadaveric transplant at [**Hospital1 1774**] - he was transferred to [**Hospital1 18**] for
consideration of transplant here. Upon transfer, the patient is
doing well, with some discomfort given abdominal distension in
setting of ascites however is breathing well with no pain. He
endorses continued diarrhea of about 5 bowel movements per day
which has been stable since on rifaximin. Review of systems
otherwise negative. His laboratory assessment at time of
transfer is significant for a MELD score of 37, an INR of 3.8, a
Creatinine of 3.0. Hemodynamically stable at time of transfer.
Past Medical History:
Cirrhosis secondary to (a) autoimmune hepatitis (b)
alpha-1-antitrypsin deficiency (c) Et OH cirrhosis
complicated by:
1. hyponatremia -> now improved with tolvaptan with stable Na
off tolvaptan
2. flares of ? autoimmune hepatitis requiring prior pred courses
3. hepatic encephalopathy -> being tx with rifaximin (lactulose
caused significant diarrhea leading to prerenal azotemia)
4. ascites -> previously tx with diuretics, currently off these
in setting of renal failure
5. SBP -> currently being treated for VRE and [**Female First Name (un) **]
6. No known varices (EGD negative per patient for varices)
7. ?hepatoma on [**12/2108**] CT (not seen on subsequent MRI)
Social History:
Wife is a nurse. 2 young children at home. He was working full
time until recently. Nonsmoker, except socially in past. Per OSH
records, patient had abused ETOH in past, drinking up to 1 case
of beer per week for many years, ending about 4 yrs ago. He then
became a social drinker until about 1 yr ago when he stopped
drinking ETOH entirely. Per patient's wife, in [**9-/2108**], he did
have 1 beer but has not had any ETOH since then. Several family
members interested in liver donation.
Family History:
No known liver disease or cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 90/70, HR 95, afebrile, 98% RA
Gen: Pleasant Caucasian male in no apparent distress
Cardiac: Nl s1/S2, RRR, no murmurs appreciable
Pulm: Clear lung fields bilaterally
Abd: soft, nontender, +fluid wave and distended
Ext: 2+ lower extremity edema with stasis change bilaterally
Discharge Physical Exam:
VS: 97.9 82 127/80 18 100 RA
HEENT: CN intact, no e/o epistaxis
Gen: A&O x 3, NAD
Cardiac: RRR no m/g/r
Pulm: CTAB
Abd: soft, nontender, subcostal/midline incision CDI
Ext: no c/c/e
Pertinent Results:
===========================================================
[**2108-12-31**] SEROLOGY FROM [**Hospital3 **]
.
IgG 3220 ([**Telephone/Fax (1) 90324**]), IgA 996 (75-310), IgM 172
Anti-mitochondrial Ab negative, Anti-smooth muscle Ab positive,
[**Doctor First Name **] negative
.
Ferritin 1205 (16-287), Iron 55, transferrin 135 (200-340), TIBC
171 (250-430), %Sat 32, Ceruloplasmin 32 (14-58)
.
Hep A (IgG+IgM) positive; IgM negative
Hep B sAb, sAg, cAb negative
Hep C negative
.
A1AT 104 (100-250)
AFP 7 (0-10)
===========================================================
[**2108-12-17**] LIVER BIOPSY FROM [**Hospital3 **]
Cirrhosis with prominent ductular reaction. Minimal septal
chronic inflammation without prominent plasma cells. Minimal
steatosis. Glygogenated hepatocytic nuclei. Large cell change
and periseptal intrahepatocytic and extracellular PAS-positive
diastase globules.
These findings are consistent with histologically advanced
chronic liver disease.
Possible etiologies include steatohepatitis and/or A1AT
deficiency.
.
[**2108-12-3**] EGD FROM [**Hospital3 **]
Potential grade I esophageal varices.
No gastric varices. No bleeding. No portal hypertensive
gastropathy.
===========================================================
PEAK LABS FROM [**Hospital3 **]
Cr 3.2 on [**2109-2-16**]
T bili 7.9 on [**2109-2-7**]
INR 3.8 on [**2109-2-18**]
===========================================================
MICRO DATA FROM [**Hospital3 **]
.
[**2109-2-6**]
Ascites Labs: WBC 170, 60%Polys
Ascites Culture: negative
.
[**2109-2-10**]
Ascites Labs: WBC 5450 (96% PMNs)
Ascites Culture: Enterococcus faeceum
MIC:
Ampicillin >8 resistant
Daptomycin 2 susceptible
Linezolid <=1 susceptible
Vancomycin >16 resistant
.
[**2109-2-13**]
Ascites Labs: WBC 380 (43% PMNs)
Ascites Culture: [**Female First Name (un) 564**] Albicans
===========================================================
[**Hospital1 18**] ADMISSION LABS [**2109-2-19**]
WBC-8.6 RBC-2.82* Hgb-9.0* Hct-27.5* MCV-98 MCH-32.0 MCHC-32.9
RDW-20.4* Plt Ct-107*
Neuts-71.7* Lymphs-9.0* Monos-7.5 Eos-11.3* Baso-0.5
PT-37.2* PTT-65.5* INR(PT)-3.8*
Glucose-99 UreaN-51* Creat-2.7* Na-139 K-3.6 Cl-108 HCO3-20*
AnGap-15
ALT-27 AST-43* LD(LDH)-336* CK(CPK)-42* AlkPhos-79 TotBili-4.9*
Albumin-3.5 Calcium-7.7* Phos-2.3* Mg-1.7 Iron-51
===========================================================
Post Op Day 1 Liver transplant [**2109-3-16**]
WBC-12.3* RBC-3.22* Hgb-10.1* Hct-28.3* MCV-88 MCH-31.3
MCHC-35.7* RDW-19.4* Plt Ct-98*
PT-13.7* PTT-26.6 INR(PT)-1.2*
Glucose-212* UreaN-48* Creat-1.6* Na-142 K-4.8 Cl-104 HCO3-26
AnGap-17
ALT-964* AST-620* AlkPhos-40 TotBili-2.7* DirBili-1.8*
IndBili-0.9
Albumin-3.2* Calcium-10.2 Phos-6.5* Mg-1.8
[**2109-4-4**] 4:55 A ANTI-A 4 SALINE
ANTI-A 2 IgG
ANTI-B NEG SALINE
ANTI-B NEG IgG
[**2109-4-2**] 4:04 A ANTI-A1 2 SALINE
ANTI-A1 1 IgG
ANTI-B NEG SALINE
ANTI-B NEG IgG
[**2109-4-1**] 6:00 A ANTI-A1 2 SALINE
ANTI-A1 1 IgG
ANTI-B NEG SALINE
ANTI-B NEG IgG
[**2109-3-29**] 4:26 A ANTI-A 2 SALINE
ANTI-A 4 IgG
ANTI-B 1 SALINE
ANTI-B 1 IgG
[**2109-3-28**] 3:37 A ANTI-A 4 SALINE
ANTI-A 4 IgG
ANTI-B 1 SALINE
ANTI-B 2 IgG
[**2109-3-27**] 8:43 A ANTI-A1 4 SALINE
ANTI-A1 4 IgG
ANTI-B 1 SALINE
ANTI-B 2 IgG
[**2109-3-26**] 8:21 A ANTI-A1 4 SALINE
ANTI-A1 4 IgG
ANTI-B 1 SALINE
ANTI-B 1 IgG
[**2109-3-25**] 4:11 A ANTI-A 2 SALINE
ANTI-A 2 IgG
ANTI-B 2 SALINE
ANTI-B 2 IgG
[**2109-3-24**] 4:09 A ANTI-A 4 SALINE
ANTI-A 8 IgG
ANTI-B 2 SALINE
ANTI-B 4 IgG
[**2109-3-23**] 2:48 A ANTI-A 4 SALINE
ANTI-A 4 IgG
ANTI-B 2 SALINE
ANTI-B 2 IgG
[**2109-3-22**] 3:13 A ANTI-A 4 SALINE
ANTI-A 2 IgG
ANTI-B 2 SALINE
ANTI-B 2 IgG
[**2109-3-21**] 3:03 A ANTI-A 2 SALINE
ANTI-A 8 IgG
ANTI-B 2 SALINE
ANTI-B 8 IgG
[**2109-3-20**] 3:19 A ANTI-A 2 SALINE
[**2109-4-1**] 6:00 A UNRESOLVED POS NEG
[**2109-3-28**] 3:37 A UNRESOLVED POS NEG
[**2109-3-25**] 4:11 A UNRESOLVED POS NEG
[**2109-3-22**] 3:13 A O POS NEG
[**2109-3-19**] 4:14 A O POS NEG
Brief Hospital Course:
BRIEF HOSPITAL COURSE PRIOR TO TRANSPLANTATION ON [**2109-3-15**]:
42y/o gentleman with cirrhosis due to EtOH and
alpha-1-antitrypsin heterozygosity transfered from [**Hospital1 1774**] for
in-patient transplant evaluation in setting of rapid
decompensation. Course complicated by encephalopathy, SBP, and
recurrent asciteswith renal failure. MELD remained above 30
throughout admission and he ultimately was transferred to the
surgical service for transplant.
Cirrhosis with multifactorial etiology (EtOH as an additional
insult due to alpha-1 antitrypsin heterozygote). He had
recurrent ascites that was managed with repeat paracenteses
followed by albumin (in the setting of HRS). Ascites improved
with improvement of renal function and increase in his urine
output following initiation of diuretics.
#. Polymicrobial Peritonitis: At [**Hospital3 2358**], initial
paracentesis was negative but subsequent taps showed evidence of
infection and cultured out VRE and [**Female First Name (un) 564**], possibly suggesting
bowel microperforation. He was initially transferred on
Daptomycin for VRE, Fluconazole for [**Female First Name (un) 564**], and also empiric
Cefepime & Zosyn. I.D. consult was obtained. The empiric
medications were stopped when he arrived. He received >2 full
weeks of treatment and repeat paracentesis showed that his
infection had cleared. The patient was kept on Fluconazole and
Daptomycin, initially with the thought of carrying them through
transplant. Daptomycin was switched to Linezolid as per below.
All antibiotics were eventually stopped as their continued use
no longer seemed clinically warranted and that the risks of
continued antibiosis outweighed the benefits.
.
#. Leukocytosis with Eosinophilia: Patient continued to have a
leukocytosis despite treatment of his peritonitis. WBC rose to
>12. Repeated infectious workups were negative. He was found to
have eosinophilia and rash concerning for drug reaction. Lasix
was changed to ethacrynic acid and he was started on Prednisone
5 mg daily. The eosinophilia resolved to some degree but not
completely so Daptomycin was changed to Linezolid. Prednisone
was tapered to 2.5 mg daily following significant improvement in
his leukocytosis.
.
#. Acute Renal Failure due to Hepatorenal Syndrome: His peak Cr
at [**Hospital1 1774**] had been 3.2 and was 2.7 upon transfer. Despite
aggressive volume challenge with albumin, and max doses of
Octreotide/Midodrine, his creatinine continued to rise to above
4. His urine sodium was <10, FENa<1%, urine sediment was mostly
bland but did have a few muddy brown granular casts, reflecting
a mixed picture of prerenal/HRS and ATN. Likely hepatorenal
syndrome triggered by SBP at [**Hospital1 1774**]. The patient was subsequently
started on diuretics following consultation with nephrology. His
creatinine subsequently improved and his ascites resolved.
.
BRIEF HOSPITAL COURSE FOLLOWING TRANSPLANTATION
Mr [**Known lastname 1557**] [**Last Name (Titles) 1834**] ABO-incompatible orthotopic liver
transplantation with splenetcomy on [**2109-3-15**]. See Dr[**Name (NI) 8584**]
and Dr[**Name (NI) 1381**] reports for details. The liver was AB and Mr
[**Known lastname 1557**] is type O. He was prepared for surgery using our standard
ABO-incompatible protocol including plasmapheresis, rATG,
mycophenolate and methylprednisolone. He tolerated the procedure
well and was taken directly to the ICU for monitoring. He was
extubated on POD 1 and was transferred out of the ICU on POD 2.
In the immediate post op period, the liver enzymes decreased
daily and bilirubin which was 5.8 was down to 2.0, and stayed in
that range for a few days and then increased back to 3.3 by POD
10 at which time the AST, ALT and Alk Phos increased again.
During this time of elevation of the enzymes, liver duplex
showed absent diastolic flow within the main and right hepatic
arteries, worsened compared to the prior (post op) study in
addition to complete absence of flow within the left hepatic
artery, worrisome for thrombosis. No PV thrombus was seen. He
then [**Known lastname 1834**]
Hepatic arteriogram that demonstrated normal caliber of the
common hepatic, right and the left main hepatic arteries. No
obvious areas of narrowing or stenosis were seen. Filling of
segmental hepatic artery branches is also noted within both
liver lobes. During the procedure the patient developed a right
groin hematoma and pseudoaneurysm measuring 2.5 cm in diameter.
This was injected with thrombin and ultrasound showed complete
thrombosis of the pseudoaneurysm sac.
On POD 6 the patient's Cr which had trended to a low 1.6 on POD
4, began increasing (2.6, peak 6.4 on POD 14). Since the
transplant the patient had also required multiple transfusions
of PRBC's and platelets. A hematology consult was obtained and
given the elevated LDH and numerous schistocytes seen on his
peripheral smear it was determined the patient was undergoing a
microangiopathic, hemolytic process. This was thought to be due
to the FK being administered and that medication was
discontinued and replaced by rapamycin. The patient's Cr slowly
decreased throughout the rest of his hospitalization and was 2.9
at the time of discharge. The patient continued to require
multiple transfusions and received two units on [**3-15**], [**3-31**],
and [**4-2**]. he did not require further transfusions during the rest
of his hospitalization. his hct on discharge was 27.2
Due to ABO incompatibility Anti A and Anti B titers were checked
after transplantation. The goal being to plasmapherese the
patient above a threshold of 1:8 for each. The patient [**Month/Day (4) 1834**]
plamapheresis on [**4-5**], [**3-28**], [**3-29**], [**3-30**], [**3-31**], [**4-1**]. He did not
require furter plasmapheresis from [**2109-4-2**] through [**2109-4-5**].
The patient's diet was advanced to sips on POD 2, clears on POD
3, and regular on POD 4. The patient had regular bowel funtion
throught the rest of his hospitalization. JP's x 2 were removed
on POD 6 and 17 respectively.
He will be discharged to home after two days of not requiring
further blood product transfusions. He will follow up in liver
clinic next week.
Bactrim stopped and pentamidine given on [**3-26**]. S/p splenectomy
(vaccinations given for pneumococcal, meningococcal and
haemophilus on [**4-1**]).
Medications on Admission:
MEDS on TRANSFER:
daptomycin 400 mg IV q24
cefepime 1 gm IV q12
flagyl 500 mg IV q8
fluconazole 100 mg daily
protonix 40 mg IV daily
rifaximin 550 mg PO BID
maalox 30 mL PO q8
duonebs
.
HOME MEDICATIONS:
Multivitamin
Lactulose 30ml Q6h PRN
Benadryl 50mg QHS PRN
Aldactone
Furosemide
Discharge Medications:
1. prednisone 5 mg Tablet Sig: 3 1/2 Tablets PO DAILY (Daily):
Follow transplant clinic taper.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-27**] Sprays Nasal
QID (4 times a day) as needed for dry nostrils.
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
8. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO every
other day.
9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. sirolimus 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
cirrhosis (alcohol and alpha-1-antitrypsin deficiency
heterozygote)
ABO incompatible liver transplant with splenectomy
TMA
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications.
Monitor the incision for redness, drainage or bleeding. The scar
will flatten over time, staples will come out in clinic.
When showering do not rub incision, pat area dry.
You will have labwork drawn at the [**Hospital **] Medical Building lab
every Monday and Thursday when you are discharged. The frequency
will decrease over time.
No heavy lifting
No driving if taking narcotic pain medication
Take all medications as ordered, follow the prednisone taper,
and only change rapamycin dosing when clinic informs you of
changes.
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-4-12**] 12:15
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-4-19**] 1:40
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-4-26**] 1:40
Completed by:[**2109-4-5**]
|
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"572.8",
"E930.5",
"572.2",
"288.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"99.10",
"86.07",
"00.93",
"88.47",
"99.71",
"50.59",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
16392, 16398
|
8700, 15044
|
324, 574
|
16585, 16585
|
4671, 8677
|
17474, 17934
|
4084, 4120
|
15377, 16369
|
16419, 16564
|
15070, 15070
|
16736, 17451
|
4160, 4443
|
15274, 15354
|
243, 286
|
602, 2864
|
16600, 16712
|
2886, 3562
|
3578, 4068
|
15088, 15256
|
4468, 4652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,226
| 161,610
|
45491
|
Discharge summary
|
report
|
Admission Date: [**2179-2-20**] Discharge Date: [**2179-3-5**]
Date of Birth: [**2102-1-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22990**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
76 y.o. female with severe COPD x 25+ years, supplemental oxygen
for over a year, DMII, vascular dementia, presenting from home
with respiratory distress.
.
Patient was brought in by EMS after family called due to
increased work of breathing. Patient lives in multi family home
with daughter living in next door house. They report that
patient was recently discharged from rehab on [**2178-2-5**] for
similar complaint, and had been home for about 2 weeks.
Approximately 4 days prior to presentataion, family noted she
was having productive cough with greenish / brown streaked
sputum. They deny any fevers, chills or diaphoresis. On the day
prior to presentation, physical therapy evaluated her at home
and found her oxygen saturation in 80's. Since, she has been
receiving increasing frequency of nebulizer treatments.
.
On date of admission, patient reportedly went to the restroom
where she called for help due to "crushing chest pain" and
difficulty breathing. Family immediately called EMS. During my
evaluation, she denied this chest pain prior to presentation.
.
In the ED, vital signs were initially: 122, 134/116, RR32.
Patient noted to have significant respiratory distress, placed
on NRB with O2 sat in 100's, however initial blood gas
7.19/98/90. Patient given nebulizer treatments, solumedrol,
azithromycin, magnesium and started to CPAP @ 40%, PEEP6, ~20 TV
400's. HR 100, BP 103/53 on nitro initially given for severe
hypertension (200' systolic); however off at time of transfer.
Patient admitted to MICU for further management.
.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, nausea, vomiting, abdominal
pain, constipation, diarrhea, melena, pruritis, easy bruising,
dysuria, skin changes, pruritis.
Past Medical History:
COPD on 2L home O2
DM2
Dementia
HTN
Dyslipidemia
Goiter s/p RAI
R breast nodule
RUL opacity on CT--thought to be scarring from pneumonia, but
ddx includes cancer
Social History:
She continued to smoke one to two packs of cigarettes/day until
[**Month (only) 404**] of this years. She is retired from the post office. She
no longer drinks alcohol but has a remote history of alcohol
abuse.
Family History:
The patient's father died at 71 of complications of diabetes.
She is the oldest of seven siblings of whom only four are
living. There is no history of known dementia in the family.
Physical Exam:
VS: 97.5, 136/79, 102, 28-30, 98% 2L NC, BG 274
GEN: The patient is in some distress with breathing, somewhat
short of breath with long sentences
SKIN: No rashes or skin changes noted
HEENT: JVP = 5-7 cm, neck supple, No lymphadenopathy in
cervical, posterior, or supraclavicular chains noted.
CHEST: Lungs with markedly decreased BS and expiratory wheezing
CARDIAC: Tachycardic, regular rhythm, faint grade I-II systolic
murmur at LLSB.
ABDOMEN: Non-distended, and soft without tenderness
EXTREMITIES: no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-26**], and BLE [**5-26**] both proximally and distally. No pronator
drift. Reflexes [**1-23**]+ and symmetric. Downward going toes.
Pertinent Results:
LABS ON ADMISSION:
[**2179-2-20**] 06:43PM BLOOD WBC-9.1 RBC-3.58* Hgb-10.4* Hct-32.3*
MCV-90 MCH-29.0 MCHC-32.1 RDW-13.0 Plt Ct-253
[**2179-2-22**] 04:59AM BLOOD Neuts-75.2* Lymphs-19.3 Monos-5.2 Eos-0.3
Baso-0.1
[**2179-2-20**] 06:43PM BLOOD Plt Ct-253
[**2179-2-20**] 06:43PM BLOOD Fibrino-528*
[**2179-2-20**] 06:43PM BLOOD UreaN-16 Creat-0.8
[**2179-2-20**] 06:43PM BLOOD CK(CPK)-189
[**2179-2-20**] 06:43PM BLOOD Lipase-22
[**2179-2-20**] 06:43PM BLOOD cTropnT-<0.01
[**2179-2-20**] 06:43PM BLOOD CK-MB-5 proBNP-66
[**2179-2-21**] 03:31AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.5
[**2179-2-20**] 07:00PM BLOOD Type-ART O2 Flow-6 pO2-90 pCO2-98*
pH-7.19* calTCO2-39* Base XS-5 Intubat-NOT INTUBA
Comment-NEBULIZER
[**2179-2-20**] 06:44PM BLOOD Glucose-237* Lactate-0.9 Na-134* K-4.5
Cl-86* calHCO3-34*
.
LABS ON DISCHARGE:
[**2179-3-2**] 06:30AM BLOOD WBC-13.6* RBC-3.81* Hgb-10.6* Hct-34.2*
MCV-90 MCH-28.0 MCHC-31.2 RDW-13.9 Plt Ct-289
[**2179-3-1**] 07:55AM BLOOD Neuts-73.6* Lymphs-20.3 Monos-5.5 Eos-0.3
Baso-0.3
[**2179-3-2**] 06:30AM BLOOD Plt Ct-289
[**2179-3-1**] 07:55AM BLOOD Glucose-154* UreaN-26* Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-34* AnGap-9
[**2179-3-1**] 07:55AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2
[**2179-2-26**] 12:13PM BLOOD Type-ART pO2-59* pCO2-51* pH-7.41
calTCO2-33* Base XS-5
.
STUDIES:
.
CHEST X-RAY: ([**2179-2-20**])
PORTABLE UPRIGHT AP VIEW OF THE CHEST: Cardiac silhouette is top
normal in
size. The aorta is tortuous with calcifications present. There
are mild
increased interstitial markings bilaterally, suggestive of mild
interstitial pulmonary edema. Blunting of the costophrenic sulci
bilaterally suggest the presence of small bilateral pleural
effusions. No pneumothorax is visualized. No acute skeletal
abnormalities are visualized.
IMPRESSION: Mild interstitial pulmonary edema with small
bilateral pleural
effusions.
.
CXR ([**2179-2-27**])
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Large lung volumes consistent with COPD. Mild bilateral
apical
thickening. Normal size of the cardiac silhouette, mild
tortuosity of the
thoracic aorta. No focal parenchymal opacities suggesting
pneumonia. Pleural effusions.
.
[**2179-2-22**] CT OF THE CHEST WITH IV CONTRAST:
The heart size is normal. There is no pericardial effusion. Mild
coronary
and aortic calcifications are present. The aorta and main
pulmonary artery
are normal in caliber. Scattered mediastinal and hilar lymph
nodes do not
meet CT criteria for lymphadenopathy.
.
A multinodular goiter is present, with hypoechoic lesions
measuring up to 16 mm. This is unchanged since [**2178-1-26**]. There
is no cervical or axillary lymphadenopathy.
.
The lungs are well aerated to the subsegmental levels. No
pulmonary embolism is seen, although the study is slightly
limited due to respiratory motion-related artifact. There is
diffuse centrilobular emphysema, unchanged since the prior CT
exam from 1/[**2178**]. Within the right upper lobe, there is a 14 x
11 mm enhancing nodule with surrounding ground-glass opacity
(3:21). Previous CT examinations since [**2176**] have shown a
confluent reticular and ground-glass opacity in this area,
compatible with a focal area of scarring. However, the current
study demonstrates a new solid central region, so an underlying
solid mass can no longer be excluded. Within the left upper
lobe, there is a vaguely defined linear region of ground-glass
opacity (3:22), unchanged since prior [**2176**], and compatible with
mild scarring. No other nodules or masses are appreciated. There
is no pleural effusion or pneumothorax.
.
Included views of the upper abdomen demonstrate multiple
gallstones within a normal-appearing gallbladder. The included
views of the liver and spleen are unremarkable.
.
OSSEUS STRUCTURES: Minimal dextroscoliosis is present. Mild
degenerative
changes are present throughout the thoracic spine. Old left
fifth and sixth rib fractures are unchanged. There is no acute
fracture or dislocation. No sclerotic or lytic lesions are
detected.
.
IMPRESSION:
1. No pulmonary embolism detected.
2. Previously seen right upper lobe density now demonstrates a
central solid component. A solid mass cannot be excluded. PET
examination is recommended for further assessment.
3. Persistent vaguely-defined linear area of ground-glass
opacity within the left upper lobe is unchanged and compatible
with mild scarring.
.
[**2179-2-22**] LOWER EXTREMITY ULTRASOUND
FINDINGS: Waveforms of the common femoral veins are symmetric
bilaterally
with appropriate response to Valsalva maneuvers. In both lower
Extremities, the common femoral, proximal greater saphenous,
superficial femoral, and popliteal veins are normal with
appropriate compressibility, wall-to-wall flow and color
analysis and response to augmentation. Wall-to-wall flow is also
present in the posterior tibial and peroneal veins bilaterally.
.
IMPRESSION: No deep venous thrombosis in either lower extremity.
Brief Hospital Course:
Ms [**Known lastname 97068**] is a 77 year old woman with COPD on home O2,
pulmonary hypertension, htn, hyperlipidemia, presenting with
acute COPD exacerbation with unclear trigger, now improved on
BIPAP/steroids/nebs, and noted to have spiculated lung mass
concerning for malignancy.
.
# ACUTE COPD EXACERBATION: At time of admission, patient with
significant respiratory distress. Patient with longstanding
COPD, on supplemental oxygen for the past few years, with single
prior intubation about 1 year ago. Patient does have with very
depressed FEV1 (33% predicted in 2/[**2178**]). No clear preceeding
prodrome, no fevers or chills, however does note sputum color
change. Given degree of acidosis with metabolic compensation,
suspect this has been a slowly progressing decompensation.
Patient was initially placed on BiPAP which she tolerated well,
along with IV solumedrol, q2 prn nebulizers, and Abx. She
received IV solumedrol 125mg and was transitioned to oral
prednisone 60mg PO with a slow taper. She completed 5 days of
azithromycin. Her respiratory virus panel was negative, lower
extremity ultrasound negative and CT negative for PE, although
with incidental finding of interval change in lung mass (see
below). Pulmonary was consulted given slow improvement, and felt
that she would benefit from slow steroid taper along with
chronic low dose PO steroids.
.
# RESPIRATORY ACIDOSIS: At admission very significant acidosis
(pH 7.19/ pCO2 98 /pO2 90) which normalized to her baseline
after BiPAP and above treatment. Suspect large degree of chronic
respiratory acidosis with metabolic compensation, as noted by
chronically elevated bicarbonate.
.
# LUNG MASS: Previously noted on CTA Chest from [**2178-1-26**], however
this admission's CTA demonstrated a 14 x 11 mm right upper lobe
density with central solid component. A solid mass cannot be
excluded. These findings were discussed with patient and family,
and will be pursued with outpatient work-up at next pulmonary
appointment.
.
# SINUS TACHYCARDIA: resolved. DDx included hypovolemia vs.
nebulizer treatment vs. anxiety/COPD flare vs. infection. No
localizing sx of infection and cultures were negative. Improved
with treatment of COPD and slight volume resuscitation.
.
# URINARY TRACT INFECTION: in setting of dysuria and
enterococcus urine culture, patient started on amoxicillin 500
mg [**Hospital1 **]. She has 4 more days of treatment to complete on
discharge.
.
# HYPERLIPIDEMIA: continued pravastatin
.
# DIABETES: Patient was continued glargine and SSI. Discharged
on NPH, and will be titrated based on QID fingersticks at rehab.
.
# VASCULAR DEMENTIA: Per family patient at baseline during
admission.
.
# DEPRESSION: continued Sertraline and Trazodone per outpatient
regimen
.
# Dispo: discharge to rehab, f/u appt with PCP/pulmonary
Medications on Admission:
ALBUTEROL
FLUTICASONE 50 mcg Spray
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/ [**Hospital1 **]
IPRATROPIUM BROMIDE
TIOTROPIUM BROMIDE - 1 capule inhaled once a day
.
VERAPAMIL - 180 mg Tablet Sustained Release daily
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day
PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime
ASPIRIN - 81 mg Tablet
.
SERTRALINE - 25mg Tablet at bedtime
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
ACETAMINOPHEN - (Prescribed by Other Provider) - Dosage
uncertain
CHOLECALCIFEROL (VITAMIN D3) - 400 unit Tablet
DOCUSATE CALCIUM - (Prescribed by Other Provider) - Dosage
uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 22 untis QAM
INSULIN LISPRO [HUMALOG] ?
Discharge Medications:
1. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
11. Prednisone 5 mg Tablet Sig: 40 mg by mouth for 3 days, then
30 mg by mouth for 5 days, then 20 mg by mouth for 5 days, then
10 mg by mouth for 5 days, then 5 mg daily Tablets PO once a day
Tablets PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
12. 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*
13. Humalog 100 unit/mL Solution Sig: as per sliding scale sheet
units Subcutaneous four times a day.
14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
15. Humulin N 100 unit/mL Suspension Sig: Thirty Four (34) units
Subcutaneous once a day.
Disp:*1 vial* Refills:*2*
16. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY:
1. acute exacerbation of chronic COPD
2. right upper lobe mass, concerning for malignancy
.
SECONDARY:
1. diabetes, type II
2. vascular dementia
3. 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:
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with severe shortness of
breath and a cough productive of greenish/yellow sputum felt to
be from COPD exacerbation. You were placed on BIPAP, given
steroids, and around the clock albuterol nebs to improve your
breathing and oxygenation. You were treated with 5 days of
azithromycin. Your breathing is now back to your baseline on 2
liters of oxygen. You should continue to take oral steroids
according to the following regimen outlined below.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START prednisone 40 mg for 3 days, then go to 30 mg for 5
days, then 20 mg for 5 days, then 10 mg for 5 days, and then 5
mg daily until evaluated by the pulmonary doctors.
- INCREASE NPH insulin to 34 units at bedtime
- START humalog insulin sliding scale as needed for blood sugar
control
- START omeprazole 20 mg daily
- START amoxicillin 500 mg twice a day for 4 days for urinary
tract infection
.
In addition, a lung mass was found on your CT scan. The
pulmonary doctors [**Name5 (PTitle) **] be [**Name5 (PTitle) 62115**] this mass further during
your clinic appointment.
.
Please seek medical attention for any worsening shortness of
breath, difficulty breathing, chest pain, fevers, chills,
abdominal pain, inability to tolerate food, blood in your stool,
or any other concerning symptoms.
Followup Instructions:
We have made an appointment with your primary care doctor, Dr.
[**Last Name (STitle) **], on [**2179-3-10**] at 11:30 AM. Provider [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2179-3-10**] 11:30
.
We have made an appointment with pulmonary clinic with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2179-3-25**] at 9:30 AM. These physicians will also manage
your lung nodule evaluation as well.
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**]
Date/Time:[**2179-3-23**] 10:30
.
Provider PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2179-3-25**] 9:40
Completed by:[**2179-3-5**]
|
[
"276.2",
"416.8",
"276.51",
"599.0",
"290.40",
"786.3",
"437.0",
"162.3",
"250.00",
"311",
"241.1",
"041.04",
"491.22",
"272.4",
"593.9",
"V15.82",
"276.3",
"401.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13942, 14013
|
8521, 11335
|
335, 342
|
14227, 14227
|
3553, 3558
|
15792, 16585
|
2587, 2769
|
12185, 13919
|
14034, 14206
|
11361, 12162
|
14407, 14949
|
2784, 3534
|
1937, 2158
|
14969, 15769
|
276, 297
|
4374, 8498
|
370, 1918
|
3572, 4355
|
14242, 14383
|
2180, 2343
|
2359, 2571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,618
| 102,234
|
34525
|
Discharge summary
|
report
|
Admission Date: [**2124-8-24**] Discharge Date: [**2124-9-5**]
Date of Birth: [**2049-3-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Byetta / Hydrocodone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2124-8-28**] - Redo Sternotomy, CABGx1 (Vein graft->Posterior
descending artery), Interposition of Vein graft->Right coronary
artery), Aortic Valve Replacement (21mm CE Magna Pericardial
Valve).
History of Present Illness:
75 year old female s/p CABG five years ago who is now
complaining of progressive exertional dyspnea with associated
angina. A cardiac catheterization revealed distal right coronary
artery disease. An echo revealed severe aortic stenosis. She is
now referred for surgical management.
Past Medical History:
CABG x2, AS, DM, diverticulosis, esophageal stricture in remote
past, polypectomy, hysterectomy, appy, bladder suspension,
hyperlipidemia, HTN, Osteoarthritis
Social History:
Retired. Denies smoking or alcohol use.
Family History:
Brother and sister with CAD prior to age of 55.
Physical Exam:
67 102/52 4'[**27**]" 155lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally, mild kyphosis. Well healed sternotomy.
HEART: RRR, II/VI SEM
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities
NEURO: No focal deficits.
Pertinent Results:
[**2124-8-24**] 07:00PM WBC-5.2 RBC-3.36* HGB-11.9* HCT-33.8*
MCV-101* MCH-35.5* MCHC-35.3* RDW-13.0
[**2124-8-24**] 07:00PM ALT(SGPT)-35 AST(SGOT)-37 LD(LDH)-257* ALK
PHOS-55 AMYLASE-92 TOT BILI-0.3
[**2124-8-24**] 09:26PM URINE RBC-17* WBC-250* BACTERIA-MANY
YEAST-NONE EPI-2
[**2124-8-24**] 09:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2124-8-26**] CTA
1) Unremarkable CT appearance of the sternotomy. No evidence of
dehiscence, focal fluid collection, or significant inflammatory
changes. Minimal retrosternal soft tissue, largely obscurred by
streak artifact from the adjacent surgical clips, of uncertain
clinical significance.
2) Prominent aortic valve calcification.
3) 2-mm lingular nodule; if patient has a history of smoking or
other lung
cancer risk factors, this could be reassessed in one year's
time, otherwise no follow up recommended, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] Society
guidelines.
4) A few scattered calcified pleural plaques, the sequela of
remote asbestos exposure, with basilar subpleural reticulation,
greater at the right base, suggestive of possible early fibrotic
changes. This could be further assessed by dedicated CT which
includes prone and high-resolution images as clinically
indicated.
[**Known lastname **],[**Known firstname 10900**] L [**Medical Record Number 79308**] F 75 [**2049-3-9**]
Radiology Report CHEST (PA & LAT) Study Date of [**2124-9-3**] 10:30
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2124-9-3**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79309**]
Reason: s/p cabg discharge xray
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with
REASON FOR THIS EXAMINATION:
s/p cabg discharge xray
Final Report
HISTORY: CABG.
Two radiographs of the chest demonstrate the patient to be
status post CABG.
There is a left-sided PICC line with its tip in the right
atrium, unchanged
from [**2124-8-31**]. Increased perihilar airspace opacities and small
bilateral
pleural effusions are present. Right basilar atelectasis may be
slightly
improved. Trachea is midline. No pneumothorax detected.
IMPRESSION:
Mild CHF.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: MON [**2124-9-4**] 10:37 AM
Imaging Lab
[**2124-8-28**] ECHO
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with borderline normal free
wall function. There are simple atheroma in the aortic root.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
[**2124-8-31**] CXR
In comparison with the study of [**8-30**], there is little change in
this patient following cardiac surgery. Basilar atelectatic
changes,
especially on the right, are again seen. Relatively lower lung
volumes. Mild blunting of the costophrenic angles and
enlargement of the cardiac silhouette persists.
[**2124-9-4**] 05:21AM BLOOD WBC-7.2 RBC-3.33* Hgb-10.4* Hct-31.0*
MCV-93 MCH-31.3 MCHC-33.6 RDW-16.5* Plt Ct-177
[**2124-9-4**] 05:21AM BLOOD Glucose-105 UreaN-12 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-30 AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] via transfer form [**Hospital 5279**]
Hospital on [**2124-8-24**] for surgical management of her aortic valve
and coronary artery disease. She was worked-up by the cardiac
surgical service in the usual preoperative manner. A CTA
revealed prominent aortic valve calcification, a 2-mm lingular
nodule; if patient has a history of smoking or other lung cancer
risk factors, this could be reassessed in one year's time,
otherwise no follow up recommended, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] Society
guidelines and a few scattered calcified pleural plaques, the
sequela of remote asbestos exposure, with basilar subpleural
reticulation, greater at the right base,
suggestive of possible early fibrotic changes. Ciprofloxacin was
started for a urinary tract infection. On [**2124-8-28**], Mrs. [**Known lastname **]
was taken to the operating room where she underwent a redo
sternotomy, coronary artery bypass grafting to one vessel,
interposition of the saphenous vein graft to the right coronary
artery and an aortic valve replacement using a 21mm magna
pericardial valve. Please see operative note for details.
Postoperatively she was transferred to the intensive care unit
for monitoring. Amiodarone was started for A Fib.On
postoperative day one, Mrs. [**Known lastname **] awoke neurologically intact
and was extubated. As she was thrombocytopenic, a HIT was sent
which was negative. A serotonin assay was then sent which is
pending. On postoperative day two, she was transferred to the
step down unit for further recovery. She was gently diuresed
towards her preoperative weight.Chest tubes and pacing wires
removed per protocol. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. She
had several episodes of hypotension which responded to fluid and
albumin. As she had a slightly enlarged cardiac silouette on
chest x-ray, an echo was obtained. She continued to make good
progress and was cleared for discharge to rehab on POD #8. Pt.
is to make all followup appts. as per discharge instructions.
Medications on Admission:
aggrenox 25/100", baclofen 2 tabs", Toprol XL 25', Detrol LA 4',
Vitamin A, Zetia 10', Acyclovir 200', Meclizine PRN, Protonix
40', Nexium 40', Actos 15', Levotabs 15 mcg', Trazadone 50 hs
prn, Cozaar 50"
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*45 Tablet(s)* Refills:*0*
3. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
6. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200 mg [**Hospital1 **] through [**9-5**]; then start 200 mg daily ongoing
on [**9-6**].
Disp:*60 Tablet(s)* Refills:*1*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*1*
12. Baclofen 10 mg Tablet Sig: 1-2 Tablets PO every twelve (12)
hours.
13. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once for one
doses: prior to transfer.
14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Aggrenox 200-25 mg Cap, Multiphasic Release 12 hr Sig: One
(1) Cap, Multiphasic Release 12 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 79310**]healthcare center
Discharge Diagnosis:
CAD/AS s/p Redo CABG/AVR(Tissue)
postop A Fib
Hyperlipidemia
HTN
PUD
Diabetes
Osteoarthritis
Diverticulosis
Esophageal stricture
Sciatica
Colonic polyps
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 2 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 39975**] in 6 weeks. ([**Telephone/Fax (1) 78432**]
Follow-up with Dr. [**Last Name (STitle) 34488**] in [**4-4**] weeks. [**Telephone/Fax (1) 79311**]
Please call all providers for appointments.
Completed by:[**2124-9-5**]
|
[
"424.1",
"997.1",
"599.0",
"E878.2",
"427.31",
"562.10",
"V45.79",
"276.2",
"414.01",
"530.81",
"533.90",
"707.03",
"401.9",
"V12.72",
"715.90",
"414.02",
"287.4",
"250.00",
"E849.7",
"724.3",
"V45.77",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"35.21",
"38.93",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
9602, 9674
|
5483, 7628
|
304, 504
|
9871, 9880
|
1501, 3265
|
10622, 10979
|
1071, 1120
|
7885, 9579
|
3305, 3328
|
9695, 9850
|
7654, 7862
|
9904, 10599
|
1135, 1482
|
245, 266
|
3360, 5460
|
532, 816
|
838, 998
|
1014, 1055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,325
| 120,830
|
26071+57482
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-1-9**] Discharge Date: [**2103-1-31**]
Date of Birth: [**2074-4-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Acyclovir
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
referred for evaluation of persistent S aureus pericarditis with
constrictive etiology
Major Surgical or Invasive Procedure:
Median sternotomy
Lysis of pericardial adhesions
Anterior pericardiectomy
History of Present Illness:
28 year-old right-handed man with a history of recent IVDU, hepC
transferred from OSH with persistent S aureus pericarditis
despite ~8days ox/gent with with constrictive physiology now
transferred to C-med since he is not a candidate for surgery.
Pt presented to OSH [**12-20**] (after using IV heroin that day) with
chest and left shoulder pain and found to have pericarditis and
pericardial effusion. He was treated supportively with
prednisone and indocin, and was discharged [**12-30**] (?). He then
presented to a different OSH ([**Hospital1 **]) on [**12-31**] with increased
chest, epigastric and left shoulder pain. TTE showed pericardial
effusion with early tamponade physiology. Pericardial drain was
attempted but with only minimal fluid drained. He went to OR
[**1-1**] for pericardial window and 400cc of pus was drained which
grew oxacillin sensitive S aureus. Presently he still has
significant drainage through the JP drain despite treatment with
oxacillin and gentamicin. He also still has significant dyspnea
and peripheral edema consistent with a constrictive
pericarditis. He is transferred for consideration of a
pericardectomy.
Additionally, pt fell the night prior to admission. He reports a
mechanical fall secondary to leg edema and getting tangled in
lines. He reports some bilateral leg weakness "due to how big
they are." He also reports that the right-sided paresthesias
have resolved.
Upon admission to [**Hospital1 18**] the patient was seen by thoracic
surgery, cardiac surgery, ID and neurology. Patient was switched
to vancomycin and ox and gent were d/c'ed. He underwent a CT of
thorax which demonstrated wedge shaped defect of kidney
concerning for infarct along with ground glass opacity of lungs
and anasarca. Neurology recommedended MRI of spine to evaluate
for epidural abcess. Neither thoracic nor cardiac surgery
thought that he would be a good candidate for invasive surgery
because of his risk of infection and thus thoracic surgery opted
to infuse TPA via [**Doctor Last Name 406**] drain to treate loculated pericardial
effusion. S/P injection of TPA this pm.
Past Medical History:
1. Hepatitis C
2. IVDA, most recently heroin on [**2102-12-20**]
3. ?h/o head injury with LOC
Social History:
Unemployed construction worker, lives with parents, has
girlfriend. +Tobacco, marijuana, cocaine, IV heroin
Family History:
noncontributory
Physical Exam:
PE: Tm = 100.6, BP 108/70 HR 110-120 RR 22-24 O2 sat 95-96% RA
General: Appears stated age, mildly uncomfortable
HEENT: NC/AT Sclera anicteric. OP clear
Lungs: Decreased BS to 1/3 up from the bases.
Back: No spinal tenderness
CV: Tachy, RR, nl S1, S2, no murmur or rub. 2+ carotids without
bruit, JP drain in place, c/d/i
Abd: Soft, nontender, normoactive bowel sounds
Extr: [**2-23**] pitting edema, warm
Neurologic Examination:
Mental Status: Alert and oriented to person, place and date,
cooperative with exam, normal affect
CN II-XII symmetrical and intact.
Motor: Normal bulk and tone bilaterally. No fasiculations. No
tremor. No pronator drift. Full strength throughout.
Reflexes: DTRs slightly [**Name2 (NI) 19912**] and symmetric. Toes down
bilaterally
Coordination: Finger-nose-finger, rapid alternating movements
intact.
Gait: [**Name (NI) 64716**] pt did not want to stand up.
Pertinent Results:
[**2103-1-12**] 06:11AM BLOOD WBC-11.6* RBC-3.88* Hgb-10.9* Hct-32.8*
MCV-85 MCH-28.0 MCHC-33.1 RDW-16.0* Plt Ct-488*
[**2103-1-12**] 01:27AM BLOOD Hct-32.1*
[**2103-1-11**] 08:56PM BLOOD Hct-33.5*
[**2103-1-11**] 06:35AM BLOOD WBC-15.8* RBC-4.24* Hgb-11.8* Hct-35.2*
MCV-83 MCH-27.9 MCHC-33.6 RDW-15.7* Plt Ct-592*
[**2103-1-10**] 06:54AM BLOOD WBC-15.1* RBC-3.40* Hgb-10.1* Hct-29.3*
MCV-86 MCH-29.7 MCHC-34.4 RDW-15.3 Plt Ct-463*
[**2103-1-9**] 06:10PM BLOOD WBC-13.5* RBC-3.59* Hgb-10.3* Hct-30.3*
MCV-84 MCH-28.8 MCHC-34.1 RDW-14.9 Plt Ct-326
[**2103-1-12**] 06:11AM BLOOD Neuts-65.6 Lymphs-27.0 Monos-6.5 Eos-0.6
Baso-0.3
[**2103-1-11**] 06:35AM BLOOD Neuts-83.6* Lymphs-11.7* Monos-4.2
Eos-0.4 Baso-0.1
[**2103-1-9**] 06:10PM BLOOD Neuts-77.6* Lymphs-14.9* Monos-4.1
Eos-3.1 Baso-0.2
[**2103-1-12**] 06:11AM BLOOD Plt Ct-488*
[**2103-1-12**] 06:11AM BLOOD PT-14.4* PTT-29.8 INR(PT)-1.4
[**2103-1-11**] 06:35AM BLOOD Plt Ct-592*
[**2103-1-10**] 06:54AM BLOOD Plt Ct-463*
[**2103-1-9**] 06:10PM BLOOD Plt Ct-326
[**2103-1-9**] 06:10PM BLOOD PT-14.1* PTT-29.5 INR(PT)-1.3
[**2103-1-10**] 06:54AM BLOOD ESR-27*
[**2103-1-12**] 06:11AM BLOOD Glucose-101 UreaN-14 Creat-1.1 Na-137
K-4.4 Cl-105 HCO3-20* AnGap-16
[**2103-1-9**] 06:10PM BLOOD ALT-100* AST-44* LD(LDH)-196 CK(CPK)-317*
AlkPhos-83 Amylase-32 TotBili-0.2
[**2103-1-12**] 06:11AM BLOOD Calcium-8.5 Phos-5.1* Mg-1.9
[**2103-1-11**] 06:35AM BLOOD Calcium-8.7 Phos-5.6* Mg-1.4*
[**2103-1-9**] 06:10PM BLOOD Albumin-2.6* Calcium-8.3* Phos-4.3
Mg-1.5*
[**2103-1-10**] 06:54AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2103-1-10**] 06:54AM BLOOD CRP-38.0*
[**2103-1-9**] 06:10PM BLOOD HIV Ab-NEGATIVE
.
Brief Hospital Course:
The patient is a 28 male with a history of recent IVDU, hepatits
C who was transferred from an outside hospital with a persistent
Staph aureus pericarditis despite ~8days oxacillin/genttamycin
therapy. The pt is status post pericardial window with drain
placement and status post-fall who was referred for further
management of infected pericarditis.
Pericarditis:
On admission the patient was consulted by the thoracic surgery,
cardiac surgery, ID and neurology teams. Both thoracic and
cardiac surgery thought that the pt was not a a good candidate
for invasive surgery because of his risk of infection. Thus,
thoracic surgery initially opted to infuse TPA via [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain
to treat the loculated pericardial effusion. The patient was
also started on Vancomycin after consultation with the
infectious diseases team. He continued to have blood-tinged
serosanguinous discharge in his drain daily and his hematocrit
remained stable. Cultures from the outside hospital demonstrated
oxacillin sensitive staph coag aureus with a MIC = 8 for
oxacillin. Given the patient's deffervesence on vancomycin with
decreasing WBC, it was decided that a complete course of
Vancomycin be given. The initial culture of pericardial fluid
was negative. The patient underwent a cardiac echo that showed
that the LV inflow pattern was borderline suggestive of a
restrictive filling abnormality, with elevated left atrial
pressure. There was a small pericardial effusion (that was
partially echodense suggestive of organization). The pericardium
was thought to be thickened. There was significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling. Follow-up of the
cultures showed now growth from the pericardial fluid. The
patient was initially scheduled to go to the OR on [**1-18**] for
pericardiectomy for worsening right heart symptomatology. This,
however, was delayed secondary to the patient developing C.
difficile colitis. Once this was treated, however, the patient
was taken to the operating room on [**2103-1-23**]. The patient tolerated
this procedure well. He was initially kept in the cardiac
surgery recovery unit post-operatively, but was transferred to
the floor on post-op day #2. His diet was advanced, and his
wounds were well-healing at the time of discharge. He was able
to ambulate well.
Pain control:
Patient initially on MSO4 PCA for post-op pain control.
Tolerance high considering hx of substance abuse. Acute Pain
Service following patient. [**2103-1-26**]- pt converted to po pain
regimen of MS [**First Name (Titles) **] [**Last Name (Titles) **] at this time and cont @ 330mg TIC. APS
consulted [**2103-1-31**] for specific discharge pain medication
recommedations- continue current dose and extended care facility
to taper prn.
Infectious disease:
The patient was seen by the infectious diseases team. He was
started on vancomycin for the treatment of infectious
pericarditis. The patient was noted to have pyuria and a 4-mm
renal hypodense focus with a wedged appearance. It was unclear
if this lesion represented a tiny infarct versus a small cyst or
other pathology. The wedge shape was concerning for a tiny
infarct, however. The patient's urine culture showed no growth.
The patient's HIV test was negative. The patient's blood and
urine cultures showed no growth. The pt underwent a TEE that did
not show any evidence for endocarditis. On [**1-15**], the patient
had a C. difficile assay come back positive after complaining of
diarrhea. He was started on a two-week course of Flagyl, which
he completed during his hospital stay. The recommendations for
the Vancomycin were that he complete a 6-week (42 day) course of
IV antibiotics. This was started on [**2103-1-9**] and to be completed
[**2103-2-19**].
Neurology:
The pt is status post-fall recently and reported back pain and
paresthesias. His clinical exam was notable for spinal and
paraspinal pain, and inconsistent sensory exam with posterior
but not anterior level. Given fever, Staph pericarditis, and
history of IVDU the neurology team was concerned about a
possible epidural abscess as etiology of back pain and
paresthesias. However a C-spine and T-spine MRI was negative for
an epidural abscess. The patient's neurological issues resolved
during the hospital course.
Medications on Admission:
On transfer:
Oxacillin 2g IV q4h
gentamicin 60 IV q12h,
indocin, ativan, dilaudid, protonix
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 20 days.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Restrictive pericarditis
Hepatitis C
History of substance abuse
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**]/Thoracic Surgery office for any psot
surgical issues.
Please complete the entire antibiotics course as prescribed.
Vancomycin course =42 days to be completed [**2-19**]. [**2103**].
Followup Instructions:
- Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2103-2-22**] 9:00: this is the infectious disease team,
you should call to confirm this appointment
- Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**]. Appointment
[**2103-2-27**] at 2pm. Cardiac echo to be scheduled on same
day prior to appointment. Thoracic Surgery office will call you
to give you time of Cardiac Echo.
Completed by:[**2103-1-31**] Name: [**Known lastname 1985**],[**Known firstname **] Unit No: [**Numeric Identifier 11434**]
Admission Date: [**2103-1-9**] Discharge Date: [**2103-1-31**]
Date of Birth: [**2074-4-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Acyclovir
Attending:[**First Name3 (LF) 3454**]
Addendum:
See medications
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 20 days.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Morphine 100 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**]
Completed by:[**2103-1-31**]
|
[
"304.01",
"041.11",
"305.1",
"304.31",
"008.45",
"280.9",
"070.70",
"304.21",
"423.8",
"420.99",
"790.7",
"292.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"94.65",
"88.72",
"37.12",
"37.31",
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
13465, 13677
|
5469, 9846
|
361, 437
|
11179, 11188
|
3773, 5446
|
11447, 12324
|
2832, 2849
|
12347, 13442
|
11092, 11158
|
9872, 9966
|
11212, 11424
|
2864, 3270
|
235, 323
|
465, 2572
|
3309, 3754
|
3294, 3294
|
2594, 2690
|
2706, 2816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,753
| 154,929
|
15157
|
Discharge summary
|
report
|
Admission Date: [**2133-11-8**] Discharge Date: [**2133-11-16**]
Date of Birth: [**2061-8-12**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: This is a 72-year-old male
status post motor vehicle collision, restrained driver, who
was hit on the driver's side. No loss of consciousness. The
patient starred windshield, deployed air bag. Transferred
from outside hospital with x-rays which showed a right tibia
fracture, left femur fracture, and right subclavian line
placed.
PAST MEDICAL HISTORY: Abdominal aortic aneurysm which was
repaired in [**2133-3-13**], and a coronary artery bypass
graft ten years ago.
MEDICATIONS: Metoprolol 50 mg twice a day, isosorbide 10 mg
three times a day, Zocor 40 mg once daily, Zantac 150 mg
twice a day, Zestril 5 mg once daily, Nitrostat .04 as needed
for chest pain, [**Doctor First Name **] 60 mg twice a day, Colestid 300
grams, Flomax 0.4 mg once daily, Prilosec 20 mg once daily,
and aspirin 81 mg once daily.
PHYSICAL EXAMINATION: Blood pressure 112/palp, heart rate
60, oxygen saturation 97% on non-rebreather mask. Generally,
the patient was alert, [**Location (un) 2611**] coma scale 15. Head, eyes,
ears, nose and throat: Normocephalic, atraumatic, pupils
were 2 mm bilaterally and reactive to light, tympanic
membranes clear, oropharynx clear. Neck: No cervical spine
tenderness, left neck seat belt sign/ecchymosis, no gross
deformities. Cardiovascular: Bradycardic, regular rhythm.
Lungs: Clear to auscultation. Chest wall stable, no
crepitus, breath sounds bilaterally. Back: No step-off,
limited examination secondary to leg pain. Abdomen: Mild
bilateral lower quadrants tenderness. Pelvis stable.
Extremities: Left lower extremity shortened and externally
rotated. Dorsalis pedis Dopplerable but not palpable. Right
knee swollen, tender to palpation, dorsalis pedis 2+, no
abrasions or lacerations on legs. Dorsalis pedis and
posterior tibial were Dopplerable bilaterally. Left elbow 1
cm laceration, tendon visualized. Moving all extremities,
sensation grossly intact.
LABORATORY DATA: CBC 18.7/32.8/170. Coags 13.4/22.3/1.2.
Chem 7: 145/4.4/109/25/22/1.2/130. Serum toxicology screen
negative. Urinalysis had 0-2 red cells. Lactate 2.4.
RADIOLOGY: CT of the head was negative. CT of the cervical
spine was negative. CT of the chest was negative. Abdomen
negative. CT of the pelvis was negative except for fractures
which will be noted below. X-ray of the thoracic spine
negative. Lumbosacral spine showed L5 upon S1
anterolisthesis, Grade II, likely chronic. Chest x-ray
showed right subclavian line placement and cardiomegaly.
Pelvic x-ray showed femur fracture, otherwise negative.
Cervical spine with C1-C7 visualized was negative. Left
elbow negative. Left hip showed comminuted fracture of the
distal neck of the femur, proximal left femoral shaft
fracture with displacement. Left femur showed proximal
comminuted femoral neck fracture and proximal shaft fracture.
Right knee proximal tibia fracture with displacement into the
articular surface and right proximal fibula fracture. Right
tibia-fibula showed the fractures noted above. CT of the
lower extremities again showed this information and was used
for operative planning.
HOSPITAL COURSE: Orthopaedics was consulted for the patient,
and a traction pin was placed in the left lower leg and the
elbow laceration was repaired. The patient was subsequently
transferred to the Surgical Intensive Care Unit, where an
arterial line was placed. The patient had decreased
hematocrit from 32 to 28. Two units of packed red blood
cells were transfused.
On [**11-9**], the patient went to the operating room for
an intramedullary rod of his left femur with Dr. [**Last Name (STitle) 284**],
placed on Kefzol for 48 hours, and started on deep venous
thrombosis prophylaxis of Lovenox. The patient remained
non-weight bearing bilaterally and out of bed to chair with
Physical Therapy.
On [**11-11**], the patient returned to the operating room with
Dr. [**Last Name (STitle) 284**] for an open reduction and internal fixation of
the right tibia and the left ankle.
On [**11-14**], the central line was removed.
DISCHARGE DIAGNOSIS:
1. Left femoral neck fracture status post pinning and open
reduction and internal fixation
2. Right comminuted tibia fracture extending into the
articular surface status post open reduction and internal
fixation
3. Left elbow laceration status post suture repair
4. Right fibula nondisplaced fracture
5. Left medial malleolus fracture status post open reduction
and internal fixation
6. Past history of abdominal aortic aneurysm and coronary
artery bypass graft
DISCHARGE CONDITION: Stable.
DISPOSITION: To rehabilitation.
DISCHARGE PLAN:
1. Follow up with Dr. [**Last Name (STitle) 284**] at [**Telephone/Fax (1) 44162**] for a
repeat MRI on [**11-25**].
2. Follow up with the Trauma Clinic, [**Telephone/Fax (1) 274**], two weeks
after discharge.
DISCHARGE MEDICATIONS:
1. The patient should be on Lovenox for six weeks, which was
started on [**2061-11-7**] mg subcutaneously every 12 hours.
2. Ranitidine 150 mg by mouth twice a day
3. Sodium chloride 0.9% flush 3 ml intravenously every day
as needed each shift
4. Percocet one to two tablets by mouth every six to eight
hours as needed for pain
5. Colace 100 mg by mouth twice a day
6. Dulcolax 10 mg per rectum once daily as needed
7. Nitroglycerin sublingual 0.4 mg as needed for chest pain;
call house officer
8. Metoprolol 12.5 mg by mouth twice a day; hold for blood
pressure less than 110 or heart rate less than 160
9. Isosorbide dinitrate 10 mg by mouth three times a day;
hold for the above parameters
10. Lisinopril 5 mg by mouth once daily
11. Insulin sliding scale per flow sheet
12. Enteric-coated aspirin 81 mg by mouth once daily
13. Tocopherol 400 IU by mouth once daily
14. Tamsulosin 0.4 mg by mouth daily at bedtime
15. Colestid NS 300 mg orally once daily
16. Fexofenadine 60 mg by mouth twice a day
17. Simvastatin 40 mg by mouth once daily
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 44163**]
MEDQUIST36
D: [**2133-11-15**] 20:38
T: [**2133-11-16**] 00:00
JOB#: [**Job Number 42252**]
|
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68,579
| 161,848
|
38955
|
Discharge summary
|
report
|
Admission Date: [**2196-3-16**] Discharge Date: [**2196-4-20**]
Date of Birth: [**2131-7-13**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Cefepime / Aztreonam
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fatigue.
Major Surgical or Invasive Procedure:
1. Bronchoscopy
2. TFN nailing
History of Present Illness:
This is a 64yom with hx of relapsed AML s/p double-cord
transplant, now C3D24 of dacogen presenting with fatigue x 3
days. Patient was recently admitted from [**3-4**] to [**3-10**] for fever,
neutropenia and sore throat. Patient was treated empirically
with meropenem for pharyngitis and was switched to PO
Moxifloxacin . He was to complete his course on [**2196-3-17**]. He
reports however that he stopped taking the antibiotic because he
was feeling well. He felt well on Saturday and Sunday however
Monday morning described feeling "tired." He denied any fevers,
chills, malaise, rash, URI symptoms, sinus pressure, chest pain,
abdominal symptoms, or urinary symptoms. He did endorese however
decreased PO intake and dark urine. He remained tired on Tuesday
and yesterday. He reported dyspnea on exertion yesterday without
cough, chest pain, palpitations, or lower extremity edema. He
presented to clinic today and was directly admitted for further
work-up.
.
Of note patient was seen in clinic also on [**3-14**] during which
time, he also reported fatigue. His creatinine was checked and
was 1.2. Diovan was held for this elevated creatinine.
.
On the floor, patient appeared fatigue but was otherwise not in
any distress. Other than feeling tired, he had no complaints.
Past Medical History:
ONCOLOGIC HISTORY:
[**2195-3-27**]: Sent to [**Hospital6 33**] by PCP for
pancytopenia - WBC: 0.7, Hb: 7, HCT:19.8, PLT: 8.
[**2195-3-31**]: Bone marrow biopsy that showed 50% blasts.
Transferred to [**Hospital1 18**] for treatment of acute leukemia
[**2195-4-2**]: 7+3 chemo
[**2195-4-4**]: Febrile neutropenia. Developed significant rash
from drug allergy
[**2195-4-15**]: Day 14 7+3 bone marrow demonstrated
hypocellularity, but persistence of AML
[**2195-4-21**]: fungal pneumonia, had bronchoscopy on [**2195-4-24**]
[**2195-4-22**]: Repeat marrow again showed persistent disease
[**2195-5-2**]: Discharged from [**Hospital1 18**]
[**2195-5-11**]: C1D1 Dacogen
[**2195-6-8**]: C2D1 Dacogen
[**2195-8-3**]: Admission for double cord transplant, Day 0
[**2195-8-10**]: Course complicated by neutropenic fever,
respiratory distress/heart failure requiring
intubation, and acute kidney injury.
[**2195-9-18**]: Discharged after above complicated post-tx course
.
Other PMHx:
- NSTEMI in post-transplant period.
- [**Last Name (un) **] in post-transplant course, improving, current Cr 1.4.
- History of C.Diff in post-transplant course, on Vanco taper.
Repeated C.diff negative.
- Hypertension: borderline. Per pt, he did not take any
medication before BMT.
- Dyslipidemia: not on medication.
- Non-insulin dependent diabetes.
- Tubular adenoma in 2/[**2190**].
- BPH, not on medication.
- Shoulder and back surgery following MVA in [**2187**]
Social History:
- Divorced, lives with son, who is a freshman in college.
- Former smoker - 1.5 packs of cigarettes/daily, quit prior to
transplant.
- Drinks 1-2 drinks / week with no heavy drinking in the past.
- No recreational drug use.
Family History:
- Diabetes and breast cancer in mother.
- Brother died at age 23 of brain tumor.
- Has 3 sisters all in good health.
- Daughter age 31 and son is a college freshman.
Physical Exam:
Admission Physical Exam:
VS: T 98.1 BP 104.72 HR 85 RR 18 SpO2 100% RA
GEN: AOx3, NAD, flat affect
HEENT: PERRLA. dry MM. no LAD. No pharyngeal erythema. Neck
supple. No cervical, supraclavicular LAD. No tenderness to
palapation over the neck
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes, no stridor
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN). gait
deferred.
Exam upon discharge: Expired.
Pertinent Results:
Admission Labs:
[**2196-3-16**] 08:05AM BLOOD WBC-1.5* RBC-2.69* Hgb-8.8* Hct-23.8*
MCV-89 MCH-32.7* MCHC-36.9* RDW-13.5 Plt Ct-27*
[**2196-3-16**] 08:05AM BLOOD Neuts-49* Bands-0 Lymphs-48* Monos-1*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 Blasts-1*
[**2196-3-16**] 08:05AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Spheroc-1+
Ovalocy-1+ Tear Dr[**Last Name (STitle) **]1+
[**2196-3-17**] 07:00AM BLOOD PT-15.9* PTT-30.4 INR(PT)-1.4*
[**2196-3-17**] 07:00AM BLOOD Gran Ct-403*
[**2196-3-16**] 10:20AM BLOOD UreaN-13 Creat-1.3* Na-136 K-3.4 Cl-101
HCO3-30 AnGap-8
[**2196-3-16**] 10:20AM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.8 Mg-1.6
[**2196-3-18**] 06:10AM BLOOD Vanco-17.2
Labs prior to discharge:
There were no labs drawn from [**Date range (3) 86410**].
Micro:
[**2196-4-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2196-4-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2196-4-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2196-4-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2196-4-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2196-4-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL
[**2196-4-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-4-6**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY
[**2196-4-6**] URINE URINE CULTURE-FINAL
[**2196-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-4-5**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL
[**2196-4-5**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL
[**2196-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-30**] Immunology (CMV) CMV Viral Load-FINAL
[**2196-3-28**] MRSA SCREEN MRSA SCREEN-FINAL
[**2196-3-28**] URINE URINE CULTURE-FINAL
[**2196-3-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-25**] URINE URINE CULTURE-FINAL
[**2196-3-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-23**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL
[**2196-3-23**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL {YEAST}; LEGIONELLA CULTURE-FINAL;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL {POSITIVE FOR PNEUMOCYSTIS JIROVECII (CARINII)};
FUNGAL CULTURE-FINAL {YEAST}; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-PRELIMINARY
[**2196-3-22**] URINE URINE CULTURE-FINAL
[**2196-3-21**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Antigen Screen-FINAL; Respiratory Viral
Culture-FINAL
[**2196-3-21**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-21**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-21**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL
[**2196-3-21**] Immunology (CMV) CMV Viral Load-FINAL
[**2196-3-21**] URINE URINE CULTURE-FINAL
[**2196-3-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}; FUNGAL CULTURE-FINAL {YEAST};
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL
[**2196-3-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL; FUNGAL CULTURE-FINAL
[**2196-3-19**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL
[**2196-3-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-18**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-18**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-16**] URINE Legionella Urinary Antigen -FINAL
[**2196-3-16**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2196-3-16**] BLOOD CULTURE Blood Culture, Routine-FINAL
Imaging:
[**2196-3-16**] CHEST (PA & LAT): An ill-defined opacity is identified
in the right lower lobe, findings consistent with pneumonia. The
remainder of the lungs appear clear. There is no vascular
congestion or pleural effusions. The mediastinal and hilar
contours are normal. The cardiac silhouette is moderately
enlarged, though unchanged. IMPRESSION: 1. New right lower lobe
pneumonia. 2. Stable moderate cardiomegaly.
[**2196-3-18**] CT CHEST W/O CONTRAST: The evaluation of the
mediastinum demonstrates several small non-pathologically
enlarged mediastinal lymph nodes. The aorta and pulmonary
arteries are normal in diameter. There are coronary
calcifications, unchanged. Heart size is normal. There is
prominence of the left ventricle, in particular at the level of
the apex. Patient has anemia given the high density of the
myocardium as compared to the blood in the cardiac [**Doctor Last Name 1754**]. The
imaged portion of the upper abdomen demonstrates splenic
calcification, nonspecific stranding in the perirenal area and
otherwise is unremarkable within the limitations of the study
that was not designed for evaluation of intra-abdominal
pathology. Airways are patent to the level of subsegmental
bronchi bilaterally. The evaluation of the lungs demonstrates
new anterior segment of right upper lobe and posterior segment
of right lower lobe and part of right middle lobe tree-in-[**Male First Name (un) 239**]
opacities as well as peribronchial opacities. There are also
nodules seen in left lower lobe, highly concerning for
infectious process. There is no pleural effusion. There is no
pneumothorax. The major of those opacities might be consistent
with bacterial etiology but invasive aspergillosis remains a
possibility given nodular character of some of the findings, in
particular one in the left lower lobe, 4:200, 186, in the right
upper lobe, 4:87. There are additional small pulmonary nodules
that might be related or not related to the infectious process
and some of them were present on the prior study. There are no
lytic or sclerotic lesions worrisome for infection or neoplasm,
but extensive degenerative changes are noted throughout the
spine. IMPRESSION:
1. New multilobular opacities consistent with infectious
process. Bacterial infection vs. invasive aspergillosis would
remain high in the differential list. 2. Extensive coronary
calcifications, hemodynamical significance is unclear.
[**2196-3-26**] CT HEAD W/O CONTRAST: There is no evidence of
hemorrhage, edema, masses, mass effect or acute territorial
infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is extensive periventricular hypodensity compatible with
chronic small vessel ischemic changes. The ventricles and sulci
are stable in size and configuration, demonstrating prominence
most compatible with atrophic change. There is no acute
fracture. The visualized portions of the paranasal sinuses and
mastoid air cells are well pneumatized and aerated. Note is made
of atherosclerotic calcification in the bilateral carotid
siphons. IMPRESSION: No acute intracranial process. No
intracranial hemorrhage.
[**2196-4-5**] CXR FINDINGS: In comparison with the study of [**3-31**],
there is persistent and probably increasing opacification at the
left base consistent with pneumonia. Scattered areas of
opacification are also seen in the right upper and lower zones,
consistent with multifocal pneumonia. No definite vascular
congestion.
[**2196-4-7**] MRI of the head: 1. No acute intracranial hemorrhage or
infarction. Unchanged chronic small vessel ischemic disease. 2.
No enhancing lesion.
Brief Hospital Course:
BMT course:64 yo male with relapsed AML s/p double cord
transplant, who presented on C3D24 of dacogen on day of
admission with fatigue and fevers found to have PCP pneumonia on
bronch whose hospital course was complicated by right hip
fracture and delirium.
# Fevers/Fatigue/Shortness of breath: Admission chest CT
demonstrated bilateral infiltrates, and BAL was positive for PCP
(patient had been noncompliant w outpatient PCP [**Name Initial (PRE) 1102**]).
Pt started on 21 day course of Bactrim (20mg/kg/day of
trimethoprim), first day [**3-30**], initially w increased O2
requirement and clinical worsening. Patient was transferred to
ICU for monitoring. Patient was started on steroids for
treatment of PCP immune reaction. Follow-up CXR [**3-31**]
demonstrated persistant bilateral pneumonia, but patient
respiratory status improved and as transfered back to the floor.
On the floor his respiratory status continued to improve on
Bactrim which was later changed to Clindamycin/Primaquine due to
the potential of Bactrim induced Delirium per below. Because of
the inability to swallow liquids he was changed to Pentamidine
IV however this was later discontinued because of pentamidine
induced hypotension. No further treatments for his PCP was
initiated given his delirium and subsequent goals of care.
#Altered Mental status: The patient on arrival to the floor from
the ICU was alert and oriented. He progressively became more
lethargic, stuporous, and disoriented which was most noticeably
after he fell. Medications changes such as disontinuing
acyclovir or Bactrim which have been known to cause delirium did
not improve his mental status. MRI of the head, CT of the head
and LP was unremarkable for a acute process. EEG revealed a
pattern of mild to moderate encephalopathy. Multiple CSF PCR
viral tests were pending at the time of death.
# Right Hip Fracture: On hospital day #11, patient fell by
tripping on chair while in room. Patient was immediately
evalauted and was noted to have a right shortened and externally
rotated leg. Films were obtained and demonstrated a right hip
fracture. Patient underwent TFN nailing with the orthopedic
service in the OR on [**3-30**].
# Relapsed AML: Patient was admitted on C3D24 of dacogen. He was
noted to ne neutropenic. Daily blood counts were trended and was
transfused several units of blood and platelets. Patient was
continued on prophylactic antibiotics. Blasts were noted to be
slowly increasing during the admission. A family discussion
with the [**Hospital 228**] health care proxy was carried out, after
which he was confirmed DNR/DNI with stipulation that there be no
escalation of care or ICU transfers. He was subsequently made
CMO and expired on [**2196-4-20**].
# Transfusion Reaction: Patient was noted to have a raise in
temperature of > 2 degrees during a blood transfusion. Blood
sample was sent to blood bank for review and patient was noted
to have new anti-E antibody (see full transfusion work-up
summary in OMR).
#Inactive issues: The following were inactive issues during this
hospitalization. No changes were made to medications:
- Hypertension
- Chronic Kidney Disease
[**Hospital Unit Name 13533**]:
Patient was transferred to the [**Hospital Unit Name 153**] for worsening hypoxia.
Bactrim was continued and steroids were added (initially on an
extended course that was then shortened after fracture repair to
aid wound healing; now for a five day taper starting [**3-31**]; 40mg
qday x1day, then 20mg qday x2, then 10mg qday x2day .)
Vancomycin, Meropenem, Voriconazole, Acyclovir were also given,
with Meropenem stopped [**3-31**] and plan to stop Vancomycin [**4-1**]
given clinical improvement. Of note, CXR on [**3-31**] showed
bilateral infiltrates but this was thought to be due to
continued PCP. [**Name10 (NameIs) **] patient went to the OR for replacement hip
fracture on [**3-30**] with an uncomplicated surgery; there was
concern for an extended NMJ blockade after surgery with
hyperkalemia the subsequent day. Patient had HCT drop after
surgery, was given 2 U PRBCs with stable HCT after that. He also
had hypotension to 80s/50s overnight post-surgery, with IVF
resuscitation. Temporary IVC filter was placed on [**3-31**] for
post-operative prevention of PE. Of note, the patient had
delirium initially on tranfer to the [**Hospital Unit Name 153**] which improved
somewhat after hip fracture repair. Patient was restarted on
valsartan which had been held earlier in setting of hypotension.
Medications on Admission:
- ACYCLOVIR 400 mg PO Q8h
- ATOVAQUONE 750 mg/5 mL Suspension - 10 ml Suspension(s) PO
DAILY
- FLUCONAZOLE 200 mg daily
- FOLIC ACID 2mg DAILY
- LANSOPRAZOLE 30 mg Tablet DAILY
- LORAZEPAM 0.5 mg 1-2 Tabs q6h prn
- METOPROLOL SUCCINATE 50mg daily
- NITROGLYCERIN prn
- ONDANSETRON HCL 8 mg PO Q8h prn
- OXYCODONE 5 mg PO q4h prjn
- PROCHLORPERAZINE 10 mg q6h prn
Discharge Medications:
Expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
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4210, 4221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,968
| 156,855
|
23324
|
Discharge summary
|
report
|
Admission Date: [**2165-12-19**] Discharge Date: [**2166-1-6**]
Date of Birth: [**2089-11-11**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA (5.4cm)
Major Surgical or Invasive Procedure:
[**2165-12-19**]: Resection and repair of abdominal aortic aneurysm
with 16 x 8 bifurcated aorto, right iliac and left femoral
graft.
[**2165-12-20**]:Exploratory laparotomy (There was no evidence of
ischemia)
History of Present Illness:
76M with 5.4cm infrarenal AAA and Lt. CIA aneurysm admitted for
surgical repair.
Past Medical History:
COPD, HTN
Social History:
Married
Family History:
N/C
Physical Exam:
VS: 98.2, 87, 119/53, 18, 98%RA
Abd: soft, n-tender. Incision CDI
Lungs: CTAB
Cardiac: no M/R/G
Pertinent Results:
[**2166-1-6**] 04:40AM BLOOD WBC-10.2 RBC-2.93* Hgb-9.4* Hct-27.6*
MCV-94 MCH-32.0 MCHC-33.9 RDW-14.2 Plt Ct-511*
[**2166-1-6**] 04:40AM BLOOD Plt Ct-511*
[**2166-1-6**] 04:40AM BLOOD Glucose-104 UreaN-19 Creat-1.0 Na-137
K-3.5 Cl-100 HCO3-29 AnGap-12
[**2166-1-2**] 03:49AM BLOOD ALT-53* AST-17 AlkPhos-106 Amylase-207*
TotBili-0.3
[**2166-1-6**] 04:40AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0
[**2165-12-20**] 10:16AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2165-12-24**] 03:18AM BLOOD Triglyc-294*
Brief Hospital Course:
76M admitted on [**2165-12-19**] for open repair of 5.4cm AAA and 3cm
Lt. CIA aneurysm.
[**2165-12-19**]: Resection and repair of abdominal aortic aneurysm with
16 x 8 bifurcated aorto, right iliac and left femoral graft;
uneventful perioperative course. admitted to SICU post-op,
intubated, with a-line, PA line, NGT, Foley, epidural.
[**2165-12-20**]: Later that evening of the 16th, he had a large loose
bowel movement. This was guaiac positive. His white count
increased to 15,000, and while he had no abdominal tenderness,
he continued to pass blood-tinged stool. Surgical consultation
was obtained on [**2165-12-20**]. We performed a rigid
sigmoidoscopy at the bedside and demonstrated significant
mucosal ischemia. We were unable to tell if this was
full-thickness. On physical examination, he had some left lower
quadrant tenderness. Exploratory laparotomy performed with no
evidence of intra-abdominal pathology.
Abdominal ultrasound showed patent hepatic vasculature. 2.5-cm
conglomerate of cysts in L medial lobe of the liver. 2-cm cyst
at the interpolar region of the R kidney. Gallstones and sludge.
There is a small focal area of gallbladder wall thickening.
LFT's elevated. Transplant surgery consulted.
[**2165-12-22**]: RML atelectasis on CXR-bronchoscopy performed by
general surgery at beside, showing multiple large mucoid plugs.
Lesser plugging of RUL. Good clearance with saline lavage.
Minimal airway erythema. No Complications during procedure.
Follow up CXR showed slight improved expansion.
[**2165-12-23**]: LFT's beginning to trend down. Bronchoscopy repeated,
to evaluate infiltrate on CXR. Sputum spec sent for culture.
Results: GRAM STAIN (Final [**2165-12-23**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
Procedure done without complication. Vent weaning started today,
TPN ordered. Continued diuresis for TBB -2L.
[**2165-12-24**]: Repeat bedside flexible sigmoidoscopy showed no
evidence of ongoing mucosal ischemia.
[**2165-12-25**]: CTA of chest negative for PE, revealed B/L pleural
effusions, with mild airspace disease. RLL reexpanded. Abdominal
US unchanged from [**12-20**].
[**2165-12-26**]: All LFT's down, transplant service continuing to
monitor. Vent weaning and diuresis continued.
[**2165-12-29**]: Extubated. Tube feeds held. TPN continued.
[**2165-12-30**]: NG tube removed. axillary a-line removed(RUE
cellulitis, afebrile, but WBC elevated). Transferred to [**Hospital Ward Name 121**]
11(VICU).
[**2165-12-31**]: Transferred to floor status. Tolerating soft solids,
OOB with PT. Lasix gtt off, appears euvolemic. 5fr Left Basilic
PICC line inserted for IVabx & TPN, without incident.
[**2166-1-1**]: Using IS, productive cough, white sputum. Upper
extremity cellulitis resolving.
[**2166-1-2**]: D/C rectal tube, ambulated with walker. continued
discharge planning.
[**2166-1-3**]: Had episodes of non-sustained V-tach with episodes of
bradycardia. Pt. asymptomatic. Cardiology consult ordered.
Restarted metoprolol dose, not concerned unless patient is
symptomatic, or occurs while patient is awake. Gentle diuresis,
no further intervention at this time.
[**2166-1-6**]: Plan to discharge home with PT services with rolling
walker.
Medications on Admission:
Aspirin 325mg daily, HCTZ 50mg daily, Norvasc 5mg daily, Lipitor
10mg hs, Atenolol 50mg daily, Accupril 40mg daily,Fluticasone
110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **],
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: Not to exceed more than
4,000mg of tylenol in 24hour period.
Disp:*40 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: to
be taken while taking narcotic pain medication to prevent
constipation.
8. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Abdominal aortic aneurysm(s/p repair), Ischemic colitis(s/p
ex-lap, no resection).
Discharge Condition:
Stable
Vital Signs: 98.2, 87, 119/53, 18, 98%
Labs:
Hct: 27.6
Plt: 511
Cr: 1.0
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-11**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-8**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Please call Dr.[**Name (NI) 5695**] office at ([**Telephone/Fax (1) 18181**] to make a
follow up appointment for one month after discharge.
Completed by:[**2166-1-6**]
|
[
"578.1",
"442.2",
"E912",
"518.5",
"519.19",
"441.4",
"518.0",
"440.0",
"401.9",
"557.0",
"427.89",
"278.00",
"682.2",
"496",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"54.11",
"00.42",
"38.44",
"38.91",
"96.6",
"96.72",
"99.15",
"38.46",
"48.23",
"45.24",
"00.44",
"38.14",
"88.72",
"38.48",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6011, 6067
|
1347, 4738
|
284, 496
|
6194, 6275
|
817, 1324
|
9013, 9183
|
680, 685
|
4967, 5988
|
6088, 6173
|
4764, 4944
|
6299, 8560
|
8586, 8990
|
700, 798
|
233, 246
|
524, 606
|
628, 639
|
655, 664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,787
| 173,266
|
42223
|
Discharge summary
|
report
|
Admission Date: [**2117-8-26**] Discharge Date: [**2117-8-31**]
Date of Birth: [**2061-10-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
Shortness of breath and lactic acidosis
Major Surgical or Invasive Procedure:
Thoracentesis ([**8-24**])
History of Present Illness:
55M with hep B/C, HCC who presents to [**Hospital1 18**] ED with SOB.
.
He was recently admitted from [**Date range (1) **] for a large right-sided
pleural effusion, which was drained by interventional
pulmonology on [**2117-8-24**]. The fluid was bloody with negative
gram stain and cytology. He initially felt less dyspnea
following the thoracentesis, but his breathing has worsened over
the past day.
.
He presented to [**Hospital3 **] Hospital, where CXR showed elevation of
the right hemidiaphragm. He was given cefepime 1 gm IV and was
transferred to [**Hospital1 18**] for futher management.
.
In the ED at [**Hospital1 18**], initial vital signs were T 96.7, BP 125/87,
HR 110, RR 24, Sat 100%/4L NC. He was noted to be in respiratory
distrss. Labs were notable for pH 7.14, lactate 19.9, Na 126, K
5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso showed Mod right
pleural effusion. Medial RML and medial basal RLL atelectasis.
No PE. Large 4.5cm pre-carinal node is unchanged. Diffuse HCC
with peritoneal implants. Ascites. He was given 3L NS,
vancomycin 1 gm IV, thiamine 100 mg IV, and morphine 4 mg IV x
2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache. Denies cough. Denies
chest pain. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria.
Denies arthralgias or myalgias.
.
HPI UPON PATIENT ARRIVAL TO OMED SERVICE FROM MICU
.
In brief patient was recently admitted from [**Date range (1) **] for a
large right-sided pleural effusion, which was drained by
interventional pulmonology on [**2117-8-24**]. The fluid was bloody
with negative gram stain and cytology. Prior to his transfer to
[**Hospital1 18**] he presented to [**Hospital3 **] Hospital, where CXR showed
elevation of the right hemidiaphragm. He was given cefepime 1 gm
IV and was transferred to [**Hospital1 18**] for futher management, where he
was admitted to the medical ICU.
.
Hospital course significant for ED initial vital signs: T 96.7,
BP 125/87, HR 110, RR 24, Sat 100%/4L NC. He was noted to be in
respiratory distrss. Labs were notable for pH 7.14, lactate
19.9, Na 126, K 5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso
showed Mod right pleural effusion. Medial RML and medial basal
RLL atelectasis. No PE. Large 4.5cm pre-carinal node is
unchanged. Diffuse HCC with peritoneal implants. Ascites. He was
given 3L NS, vancomycin 1 gm IV, thiamine 100 mg IV, and
morphine 4 mg IV x 2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints. Thoracentesis was contemplated however
ultimately decided to hold. Per house staff sing out, patient
was given IVF with bicarb, which ultimately improved acidemia,
and lactic acidosis. Infection is not thought to be present,
therefore antibiotics were not continued. Paracentesis to rule
out SBP was not performed to avoid further metastasis. Lovenox
for caval vein thrombus was not continued due to elevated INR.
Patient being now transferred to oncology floor given fall in
lactic acidosis and stable condition.
.
currently patient reports significant improvement in respiratory
symptoms, with oxygen supplementation being per patient the main
reason for this
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No cough,GI: No nausea, vomiting,
diarrhea, constipation or abdominal pain, but some occasional
dyscomfort. No recent change in bowel habits, no hematochezia or
melena. GUI: No dysuria or change in bladder habits. MSK: No
arthritis, arthralgias, or myalgias. DERM: No rashes or skin
breakdown. NEURO: No numbness/tingling in extremities. All other
review of systems negative.
Past Medical History:
Past Oncologic History:
locally-advanced HCC who started using
sorafenib on [**2117-8-9**]
.
Other Past Medical History:
- Hepatitis B cab +, sag and sab (-)
- Hepatitis C cirrhosis, genotype 1
- GERD
- Hyperglycemia
- PE
.
Past Surgical History:
- Tonsillectomy
- Right inguinal hernia
Social History:
Works full-time as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**] contractor. Married and his wife is
in remission from breast cancer s/p lumpectomy and
chemoradiation in [**2115**]. She works full-time at [**Company 25795**]. Has a
son and a daughter in their 20s who are healthy. 50 pack year
smoking history, now quit. Last alcoholic drink around [**2117-5-2**]
and drank 2-3 beers daily x 25 years at his most. Born in the
U.S. and his ancestors are from [**Location (un) 22627**]/Poland. No IVDU,
cocaine use, tattoos, incarceration, significant overseas
travel.
Family History:
Brother - alive in his 50s, lupus arthritis and is s/p renal
transplant x 2
Brother - alive in his 60s, HCV
Sister - alive in her 50s, Mother - alive in her 70s
Father - alive in his 80s
No known family history for liver cancer, colon cancer, CAD or
DM
Physical Exam:
ADMISSION
Vitals: T:99 BP:138/87 P:99 R:20 O2 Sat:96%/3L NC
General: Alert, mildly tachypneic, taking deep breaths; jaundice
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 1+ RLE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM ICU:
Vitals: 95.5 121-124/84-86 103-106 20-21 90-93 6L NC
I/O: 2600/1240
General: Alert, mildly tachypneic, no SOB; jaundice,
malnourished appearing
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L, no inc
work of breath.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 2+ LE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM OMED:
VS: 95.4-96.4 114-129/82-94 101-102 20-22 94-95% 4L NC
GEN: A&O x 3, NAD, fatigued appearing, odd affect, does not make
good eye contact, sunken eyes, icteric, wasted appearing
HEENT: PERRL. MMM. no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: breath sounds diminished at right, dullness to percussion
[**1-3**] way up R posterior lung fields, scattered crackles on left
Abd: BS+, significantly distended, non-tender, no
hepatosplenomegaly appreciated
Extremities: 3+ pitting to knees bilaterally
Skin: no rashes or bruising
Pertinent Results:
ICU LABS & STUDIES & IMAGING
CBC TREND:
[**2117-8-25**] 11:20PM BLOOD WBC-26.3*# RBC-4.38* Hgb-10.6* Hct-36.8*
MCV-84 MCH-24.2* MCHC-28.8* RDW-19.7* Plt Ct-191
[**2117-8-25**] 11:20PM BLOOD Neuts-88.1* Lymphs-9.0* Monos-2.3 Eos-0.3
Baso-0.3
[**2117-8-26**] 09:21AM BLOOD WBC-25.5* RBC-3.68* Hgb-8.8* Hct-30.4*
MCV-82 MCH-24.0* MCHC-29.1* RDW-19.9* Plt Ct-129*
[**2117-8-26**] 09:21AM BLOOD Neuts-84.1* Lymphs-13.5* Monos-2.1
Eos-0.1 Baso-0.2
[**2117-8-27**] 01:59AM BLOOD WBC-14.6* RBC-3.96* Hgb-9.5* Hct-31.0*
MCV-78* MCH-24.1* MCHC-30.7* RDW-19.3* Plt Ct-110*
COAGS TREND:
[**2117-8-25**] 11:20PM BLOOD PT-31.7* PTT-50.3* INR(PT)-3.1*
[**2117-8-26**] 09:21AM BLOOD PT-31.3* PTT-55.3* INR(PT)-3.1*
[**2117-8-27**] 01:59AM BLOOD PT-28.0* PTT-45.5* INR(PT)-2.7*
CHEM TREND:
[**2117-8-25**] 11:20PM BLOOD Glucose-32* UreaN-35* Creat-1.5* Na-126*
K-5.7* Cl-86* HCO3-6* AnGap-40*
[**2117-8-26**] 09:21AM BLOOD Glucose-278* UreaN-35* Creat-1.3* Na-126*
K-5.3* Cl-91* HCO3-11* AnGap-29*
[**2117-8-27**] 01:59AM BLOOD Glucose-96 UreaN-40* Creat-1.2 Na-128*
K-4.8 Cl-89* HCO3-23 AnGap-21*
LFT TREND:
[**2117-8-25**] 11:20PM BLOOD ALT-175* AST-568* LD(LDH)-520*
AlkPhos-459* TotBili-3.8*
[**2117-8-25**] 11:20PM BLOOD Lipase-96*
[**2117-8-25**] 11:20PM BLOOD Albumin-3.5
[**2117-8-26**] 09:21AM BLOOD ALT-160* AST-530* LD(LDH)-510*
AlkPhos-371* TotBili-3.5*
[**2117-8-26**] 09:21AM BLOOD Lipase-181*
[**2117-8-27**] 01:59AM BLOOD ALT-172* AST-549* LD(LDH)-526*
AlkPhos-345* TotBili-3.1*
[**2117-8-27**] 01:59AM BLOOD Lipase-229*
[**2117-8-27**] 01:59AM BLOOD Albumin-4.5 Calcium-9.4 Phos-2.5*# Mg-2.4
TOX SCREEN:
[**2117-8-25**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
VENOUS LACTATE:
[**2117-8-26**] 01:40AM BLOOD Lactate-19.9*
[**2117-8-26**] 04:44AM BLOOD Lactate-15.2* K-5.2
[**2117-8-26**] 09:58AM BLOOD Lactate-13.1*
[**2117-8-26**] 02:52PM BLOOD Lactate-10.8*
[**2117-8-26**] 09:20PM BLOOD Lactate-7.7*
[**2117-8-27**] 03:07AM BLOOD Lactate-6.1*
CXR: CHEST (PORTABLE AP) Study Date of [**2117-8-25**] 10:49 PM
FINDINGS: The right hemidiaphragm is persistently elevated.
Right basilar
atelectasis has increased from the prior study. Right and middle
lobes remain collapsed. No pneumothorax or effusion is
identified. There is no definite consolidation. Mediastinum is
persistently widened due to known mediastinal mass.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2117-8-26**]
12:31 AM
FINDINGS: Centrilobular emphysema is seen. A moderate right
pleural effusion is present. Middle lobe and medial basilar
right lower lobe atelectasis is present. No pneumothorax is
seen. Pulmonary arteries are patent to the segmental level. No
embolism or filling defect is noted. A 2.4 x 4.6 cm precarinal
mass impinges on the right middle lobe pulmonary artery
(5:42,5:48). No additional mediastinal, axillary or hilar
adenopathy is present. A multilobulated dense liver lesion is
seen in the right lobe expanding out from segment VIII.
Perihepatic ascites is present. Several rim-enhancing peritoneal
implants are present in the right upper quadrant and
midepigastrium (5:108, 5:99). The dense ascites measures complex
density of 30 Hounsfield units. The adrenal glands are normal.
IMPRESSION:
1. Large precarinal and mediastinal mass consistent with
metastatic disease.
Stable middle and right lower lobe atelectasis and moderate
right pleural
effusion. No pulmonary embolism.
2. Large mass consistent with known hepatocellular carcinoma
with peritoneal carcinomatosis and complex ascites.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2117-8-26**] 2:46 AM
FINDINGS: Right middle and medial basilar lobe atelectasis is
unchanged since [**2117-8-3**]. A small right pleural effusion
is also similar in size. The left lung base is clear.
A multilobulated hypodense lesion infiltrates the right lobe of
the liver,
predominantly involving segment VIII but extending medially and
inferiorly.
The overall size of the lesion appears similar to [**2117-8-3**]. A large 5.2 x 6.1 cm necrotic portacaval node has
increased in size from [**2117-6-23**] when it measured 4 x 4 cm.
A second enlarged necrotic lymph node measures 3.1 x 2.7 cm.
Dense perihepatic ascites is present with peritoneal implants
which are better visualized on the CT of the chest with
contrast. The ascites has attenuation consistent with complex
fluid. Mild ascites is seen throughout the mesentery and both
paracolic gutters with the largest pocket in the right lower
quadrant. The small and large bowel have normal caliber without
obvious wall thickening. The abdominal aorta is atherosclerotic
without any focal aneurysms. The pancreas, spleen, and adrenal
glands are normal. The kidneys excrete contrast symmetrically.
The hypodensity in the upper pole of the left kidney is too
small to characterize and most likely a cyst.
BONE WINDOWS: No concerning lytic or sclerotic lesions are seen.
IMPRESSION: Large infiltrative liver lesion consistent with
known
hepatocellular carcinoma. Increased size of mesenteric
metastasis. Dense
ascites consistent with metastatic peritoneal disease. No
dilated or
abnormally thickened bowel, though evaluation is limited without
intravenous or oral contrast.
DUPLEX DOPP ABD/PEL Study Date of [**2117-8-26**] 10:54 AM
CLINICAL INDICATION: Patient with known and previously ruptured
hepatoma with invasion of the hepatic veins in inferior vena
cava. Now with markedly elevated lactate levels and rising INR.
The liver demonstrates a coarsened and hyperechoic echotexture.
There is a
moderate volume of perihepatic ascites most of which is
relatively clear but some of which has a complex appearance
consistent with the prior
hemoperitoneum. A 5 x 8 cm hypoechoic mass is seen in segment I
and a much
larger mass is seen in segment VII and VIII which is difficult
to measure with precision but is at least 10-11 cm in diameter.
This extends to the liver capsule. Fluid adjacent to this shows
some complexity compatible with hematoma.
The right hepatic vein and inferior vena cava were also assessed
and appear again to be filled with thrombus which extends well
into the inferior vena cava towards the right atrium. The upper
extent cannot be demonstrated by this study. Color flow on pulse
Doppler demonstrates full patency of the right, left and main
portal vein although the main portal vein is somewhat narrowed
as it courses over the segment I liver mass. The left hepatic
vein is patent but the middle hepatic vein could not be
identified and is presumably obliterated by the tumor. As
previously stated the right hepatic vein has tumor thrombus
which extends into the IVC.
CONCLUSION: Multiple hepatic masses as described, with segment
VII-VIII mass invading the right hepatic vein and inferior vena
cava as noted on prior CTA study from [**2117-7-30**]. Portal venous
system remains patent. Perihepatic ascites is somewhat complex
but much more clear than on the prior studies at the time of the
ruptured hemoperitoneum.
OMED LABS & STUDIES & IMAGING:
[**2117-8-31**] 06:10AM BLOOD WBC-19.5* RBC-3.99* Hgb-9.6* Hct-31.4*
MCV-79* MCH-24.0* MCHC-30.5* RDW-19.1* Plt Ct-77*
[**2117-8-31**] 06:10AM BLOOD Neuts-82.7* Lymphs-10.5* Monos-6.3
Eos-0.3 Baso-0.1
[**2117-8-31**] 06:10AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Ovalocy-1+
Target-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2117-8-31**] 06:10AM BLOOD PT-19.4* PTT-61.5* INR(PT)-1.8*
[**2117-8-31**] 06:10AM BLOOD Glucose-140* UreaN-47* Creat-1.3* Na-125*
K-4.2 Cl-90* HCO3-23 AnGap-16
[**2117-8-30**] 06:50AM BLOOD ALT-163* AST-369* LD(LDH)-407*
AlkPhos-278* TotBili-4.1*
[**2117-8-31**] 06:10AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.9*
.
CXR [**2117-8-29**]: Large right pleural effusion has increased.
Cardiac size cannot be evaluated.
Small left pleural effusion has probably increased. Left lower
lobe atelectasis has increased. The upper lobes are clear. There
is no evident pneumothorax.
.
CXR [**2117-8-30**]: Unchanged appearance of right pleural effusion.
Brief Hospital Course:
HOSPITAL COURSE
55yo M PMHx HBV/HCV HCC, recent hospital stay w R-sided
exudative pleural effusion s/p thoracentesis, now re-presenting
with worsening shortness of breath, found to have marked lactic
acidosis, thought to be secondary aggressive tumor metastasis,
stable and transferred to floor. Patient was given IV fluids to
neutralize acid levels which caused swelling in his lower
extremities.
.
ACTIVE
#Metabolic Acidosis: Patient w recent pleural effusion s/p
thoracentesis re-presenting with dyspnea; no signs of infectious
pulmonary process on CT, UA; no PE on CTA; culture from recent
thoracentesis remained without growth arguing against infected
pleural effusion; imaging notable for marked progression of
tumor burden; respiratory findings were thought to be
compensatory for severe metabolic acidosis [**2-3**] type B
(non-ischemic) lactic acidosis. Lactic acid was markedly
elevated out of proportion to patient's overall hemodynamic
stability, and was thought to be related to lactate secretion by
the patient's known hepatocellular carcinoma. Patient was
treated with IV bicarbonate with improvement in respiratory
status. Lactate (initially 19.9) trended to 10.8 w hydration;
as no clear sources of infection were identified, leukocytosis
was attributed to tumor burden.
.
#Worsening Hepatic Function: Rapid increase in INR, and tbili,
lactate concerning for worsening hepatic function, thought to be
secondary to worsening tumor burden. RUQ u/s did not
demonstrate new thrombosis of portal vein. Lovenox was held
given elevated INR
.
#Acute renal failure: Admitted with Cr 1.5 from 0.7, thought to
be hypovolemic, trended to 1.3 with rehydration.
.
#HCC: Patient on Sorafenib as an outpatient, but with w marked
increase in tumor burden on imaging. Patient expressed interest
in being able to go home and maximize comfort; paliative care
was consulted.
.
# SIADH: Patient with SIADH on prior admissions, w Na 126 on
this admisison (up from 122 on prior admission). Na will need
to be monitored.
.
#HYPOTHERMIA: Patient has remained hypothermic throughout stay
(94.2 - 95.6). Patient presented with SIRS with no obvious
source of infection, but with broad coverage antibiotics.
Patient was temporarily put on bearhugger with little response.
At time of discharge, temperature trending upward at 95.6.
.
ELEVATED LIPASE: Patient's lipase has been trending upward. On
admission 96; on discharge 229. Patient complains of minor
epigastrium tenderness to deep palpation but not of pain. CT
scan does not show any evidence of
INACTIVE
# CAD: Continued metoprolol
.
#GERD: Continued pantoprazole
.
# DM: Conservative sliding scale insulin given episode of
hypoglycemia
.
TRANSITIONAL FROM ICU -> OMED -> DISCHARGE
-IP thought effusion too small to tap so did not
-Followed lactate and temperatures closely for signs of rapid
clinical decline
-Followed lipase as trending upward toward end of ICU stay
-Followed sodium closely as history of SIADH
Medications on Admission:
1. metoprolol tartrate 12.5 mg PO BID
2. oxycodone 5 mg PO Q4H prn pain
3. pantoprazole 40 mg PO BID
4. prochlorperazine maleate 10 mg PO Q6H prn nausea
5. enoxaparin 70 mg Subcutaneous Q12H
6. sodium chloride 1 gram Tablet PO TID
7. sorafenib 400 mg PO twice a day.
8. ferrous sulfate 300 mg PO Daily
9. docusate sodium 100 mg Capsule PO BID
10. acetaminophen 650mg PO Q6H prn pain/fever
Discharge Medications:
1. Equipment
Please provide home O2 apparatus.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-3**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
8. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*2*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
11. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
One (1) 0.25mL spoonful PO every four (4) hours as needed for
pain for 1 weeks.
Disp:*1 container* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Country 28334**] oxygen
Discharge Diagnosis:
Metastatic Hepatocellular Carcinoma
Discharge Condition:
Ambulatory: requires assistance or aid (walker or cane).
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were transferred to [**Hospital1 18**] because you were having shortness
of breath and had a lot of acid in your blood. We think this
happened because of your tumor in your liver. We gave you a lot
of fluid to help clear this acid which resulted in swelling of
your belly and legs.
You continued to have low oxygen levels. The interventional
pulmonary team looked at the fluid around your right lung and
they did not feel that there was enough fluid to remove.
After a long discussion, you decided that you wanted to go home
and not pursue further interventions for your cancer. We
arranged for you to have home oxygen and hospice services.
There were no changes to your home medications from before. We
did add a prescription for Trazadone 75mg every night to help
you sleep. Additionally, since the hospice services take a
little time to completely set-up, you were discharged with some
liquid Morphine which you can take to help with pain or
shortness of breath. The hospice will provide all other
medications and services to make your time at home as
comfortable and easy as possible.
Please keep your appointments as scheduled below or call and let
the office know if you cannot make it.
We wish you a smooth and peaceful return home.
Followup Instructions:
Department: TRANSPLANT
When: FRIDAY [**2117-9-17**] at 9:00 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2117-9-10**] at 2:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2117-9-10**] at 2:30 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2117-9-28**]
|
[
"401.9",
"276.1",
"070.54",
"530.81",
"584.9",
"197.6",
"570",
"571.5",
"155.0",
"276.2",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
19771, 19828
|
15244, 18212
|
346, 375
|
19908, 20014
|
7177, 15221
|
21349, 22274
|
5247, 5501
|
18653, 19748
|
19849, 19887
|
18238, 18630
|
20076, 21326
|
4579, 4620
|
5516, 7158
|
3752, 4310
|
266, 308
|
403, 1611
|
20029, 20052
|
4453, 4556
|
4636, 5231
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,294
| 162,911
|
51977+59390
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-4-28**] Discharge Date: [**2190-5-8**]
Date of Birth: [**2115-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 74 yo nursing home resident with a history of
CAD, HTN, DM, aphasia and ? seizure disorder who presents with
an episode of being unresponsive at his nursing home. Per
neurology documentation in speaking directly with the nursing
home, he is non-verbal at baseline. He will nod his head, smile
and make good eye contact, but he does not follow commands. He
can feed himself and he eats a mechanical soft diet. The patient
had recieved Baclofen, tylenol 650 and prilosec at 6am. At
7:40, he was found flaccid and unresponsive to painful stimuli.
His puils were pinpoint; vitals were 102/62, HR 100, RR 16, O2
100% RA, fingerstick 178. EMS was called the the patient was
given nasal narcan with significant improvement in
his mental status. When he arrived to the ED, the patient was
awake and appeared at baseline. He was afebrile, but labs
showed a UTI. Per his nursing home records, the patient had
been on a course of antibiotics for a VRE+ UTI and had been on
bactrim, levaquin but recent transitioned to macrobid on [**4-26**].
.
The patient has a decubitus ulcer which as been causing pain and
he had been on dilaudid 2mg prior to dressing but this was
ineffective. As such, his pain medication have recently been
adjusted. Oxycontin was increased to 30mg QAM on [**2190-4-22**] but
on [**4-26**], an extra dose of oxycodone 15mg was added.
.
On further review from his daughter, he was initially placed in
a nursing home after developing PNA [**1-29**]. This was around the
time of the death of his wife which occurred suddenly. Here he
developed pressure ulcers. He went home in [**Month (only) 958**] and these
ulcers were healing. He then developed somnolence in the
setting of opioid use at home and was admitted to the WXVA about
1 month ago. He was there for 2 weeks and has been at rehab for
the the past 2 weeks. He has had multiple UTIs and his condom
catheter was changed to a foley a few weeks ago.
.
In the ED, initial vs were: T98.2 78 125/75 18 100% NRB. He was
initially awake and appeared at baseline. At 2:30pm he was
noted to less responsive with eye twitching which appeared to
possibly be seizure activity. Neurology was consulted and
stated that he was likely somnolent from opoiod overdose and
UTI. He was given an additional dose of Narcan and was more
awake. He was given total of 3L IVF, 1gm CTX for positive UA,
aspirin 325mg PO x 1 and 200mg IV Dilantin.
.
On the floor, he is awake and able to communicate. He has
significant pain which is worse with any movement. He denies
chest pain, shortness of breath or abdominal pain.
.
Review of sytems: difficult to obtain due to non-verbal and
somnolence.
Past Medical History:
CAD
DM with PVD s/p bilateral BKAs
HTN
Sacral decubitus ulcers
Seizure disorder, NOS
Depression
Aphasia, ? prior CVA
Social History:
Lives at [**Hospital **] [**Hospital 169**] Center. Previously married, has
3 children.
Family History:
Non-contributory
Physical Exam:
On admission:
General: Awake, unable to assess orientation, responds to
questions with yes and no head notions, then falls asleep.
Overall he is cachectic, frail African American man.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: s/p bl BKAs. Multiple pressure ulcers on the back ribs,
sacrum and coccyx. Sacral ulcers show exposed bone.
.
Discharge exam:
T max 98.7 Tc 98.2 BP 92-145/50s-70s 100% RA
General: Awake, unable to assess orientation, responds to
questions with yes and no head notions, then falls asleep.
GU: + foley in plavce
Ext: s/p bl BKAs. Small area of protruding bone on left stump
Skin: large 6 cm 3 cm deep ulcer on sacrum, stage IV, without
evidence of infection. Stage 2 ulcer on right buttock. Stage 2
ulcer on right mid thoracic ribs.
Pertinent Results:
[**2190-5-6**] URINE URINE CULTURE-PENDING INPATIENT
[**2190-4-29**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2190-4-28**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2190-4-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2190-4-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2190-4-28**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
IMAGING
-------
CT head on admission:
1. Extensive encephalomalacia of the left cerebral hemisphere
and left
cerebral peduncle, likely secondary to prior CVA. Focal
calcified structures, which may represent areas of prior
hemorrhage, although other lesion not entirely excluded.
Recommend correlation with prior imaging; if further
characterization is desired to exclude other mass lesion,
findings could be further evaluated on MRI if no
contraindication.
2. No evidence of acute intracranial hemorrhage.
3. Mucosal thickening of the maxillary sinuses and ethmoid air
cells.
.
CXR on admission:
IMPRESSION: No acute cardiopulmonary process.
.
[**2190-5-7**] 06:25AM BLOOD WBC-7.6 RBC-4.05* Hgb-10.6* Hct-33.7*
MCV-83 MCH-26.2* MCHC-31.5 RDW-16.3* Plt Ct-310
[**2190-5-6**] 06:23AM BLOOD WBC-7.3# RBC-3.70* Hgb-9.7* Hct-30.3*
MCV-82 MCH-26.2* MCHC-32.0 RDW-16.0* Plt Ct-330
[**2190-5-2**] 07:30AM BLOOD WBC-4.2 RBC-3.42* Hgb-8.7* Hct-28.5*
MCV-83 MCH-25.4* MCHC-30.4* RDW-15.8* Plt Ct-348
[**2190-5-1**] 07:20AM BLOOD WBC-4.3 RBC-3.40* Hgb-8.7* Hct-28.3*
MCV-83 MCH-25.7* MCHC-30.9* RDW-16.0* Plt Ct-295
[**2190-4-30**] 06:47AM BLOOD WBC-5.8 RBC-3.51* Hgb-9.0* Hct-30.2*
MCV-86 MCH-25.5* MCHC-29.7* RDW-15.1 Plt Ct-392
[**2190-4-28**] 12:40PM BLOOD WBC-10.1 RBC-3.71* Hgb-10.0* Hct-30.5*
MCV-82 MCH-26.9* MCHC-32.6 RDW-15.4 Plt Ct-407
[**2190-4-28**] 12:40PM BLOOD Neuts-83.1* Lymphs-11.2* Monos-2.6
Eos-2.7 Baso-0.4
[**2190-5-7**] 12:55PM BLOOD Na-136 K-4.5 Cl-104
[**2190-5-7**] 06:25AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-135
K-5.7* Cl-104 HCO3-23 AnGap-14
[**2190-5-6**] 06:23AM BLOOD Glucose-50* UreaN-17 Creat-0.6 Na-139
K-4.4 Cl-108 HCO3-27 AnGap-8
[**2190-5-5**] 06:20AM BLOOD ALT-10 AST-14 AlkPhos-171* TotBili-0.1
[**2190-4-30**] 06:47AM BLOOD CK(CPK)-104
[**2190-4-28**] 12:40PM BLOOD ALT-11 AST-31 LD(LDH)-113 AlkPhos-158*
TotBili-0.1
[**2190-4-28**] 12:40PM BLOOD Lipase-19
[**2190-4-30**] 06:47AM BLOOD CK-MB-2 cTropnT-0.03*
[**2190-4-28**] 12:40PM BLOOD cTropnT-0.06*
[**2190-5-7**] 06:25AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.2
[**2190-5-7**] 06:25AM BLOOD Phenyto-8.9*
[**2190-5-6**] 06:23AM BLOOD Phenyto-12.6
[**2190-5-5**] 06:20AM BLOOD Phenyto-9.8*
[**2190-5-4**] 06:20AM BLOOD Phenyto-9.0*
[**2190-5-1**] 07:20AM BLOOD Phenyto-11.9
[**2190-4-30**] 06:47AM BLOOD Phenyto-8.4*
[**2190-4-28**] 12:40PM BLOOD Phenyto-1.5*
[**2190-4-28**] 01:01PM BLOOD Lactate-1.2
Brief Hospital Course:
Mr. [**Known lastname **] is a 74 year old man with history of DM s/p bilateral
BKAs, aphasia, ? seizure disorder, CAD who presents from a
nursing home with acute encephalopathy due to opioids, as well
as severe decubitus ulcers.
.
ACTIVE ISSUES
-------------
#.Toxic metabolic encephalopathy due to opioid overdose or
possibly undertreated UTI. The patient recently had pain
medications increased and responded well to narcan, which made
opioid overdose most likely. UTI was not present, with urine
culture with mixed flora. No evidence of seizure with negative
EEG.
Initially, patient's long-acting oxycontin was held as well as
oyxcodone and dilaudid. He was given a lidocaine patch and
standing tylenol for pain. Palliative care consult was obtained
for assistance in pain control and dispo planning. His mental
status returned to baseline.
.
#. Pressure Ulcers: Present on admission, unclear duration.
Wound care consult was obtained. There was no evidence of
active infection. It appears that the patient has been followed
at the VA for wound care and prior surgical evaluation
previously. Wound care recommended treatment as detailed in the
page 1 wound care recommendations. Pt should continue to follow
up with his care at the VA after discharge for wound care and
consideration of surgical intervention if any indicated or pt is
a candidate.
.
# Seizure disorder, with eye twitching visualized in ED.
Neurology was consulted and followed patient. Neurology
recommended dilantin load of 1gm on [**4-29**] and another on [**4-30**],
then increased dosing to dilantin 200mg [**Hospital1 **]. 24 hr EEG did not
show evidence of epileptiform activity.
He will need repeat dilantin level checked in [**12-20**] weeks.
.
#. Urinary tract infection: History of multiple UTIs, presumably
VRE per notes. Pt was initally placed on linezolid and
ceftriaxone pending culture. Culture showed mixed genital flora
and repeat culture showed yeast. Foley was changed and
antibiotics were stopped.
.
#. Elevated Troponin: Unknown baseline. No chest pain or ECG
changes. No known renal dysfunction for explanation of troponin
elevation. Patient was continued on home doses of metoprolol,
lisinopril and aspirin. Troponin trended down and pt never had
cardiac symptoms.
.
#. Sacral decubitus ulcer with associated pain -Initially home
regimen was discontinued due to somnolence. Pt was placed on
standing tylenol, lidocaine patch. However, pt did report
significant pain and no longer had periods of somnolence.
Discussed risk/benefits of opioid pain medication with patient
and his daugther. Pt and HCP reported that pain control and
wound care were of prime importance. PT and HCP were aware of
the possible risks of opioids causing respiratory depression as
well as worsening apneic episodes at night (see below) and did
agree to restart opioid pain medication. Oxycodone was restarted
initially at 5mg Q6prn, then uptitrated to 5-10mg q6hprn
dressing changes. IV dilaudid 0.5mg [**Hospital1 **] was given prn dressing
changes. Despite, this regimen pt did still report significant
wound pain. Given that he did not have any further episodes of
somnolence/AMS, oxycontin 10mg [**Hospital1 **] was again tried, but with
recurrent somnolence. Therefore, final regimen at this time is
5mg oxycodone q4-6hrs prn pain with 5mg [**Hospital1 **] prn 1hr prior to
dressing changes. In addition, pt should continue tylenol and
lidocaine patch, and ibuprofen 200mg maximum daily for pain.
.
Unfortunately pharmacy here was not able to perform the below.
However, please consider the above for additional pain control.
.
Consider compound morphine into an intra-site gel for
application to his ulcers. This has little (if any) systemic
absorption. It can be used as a mixture of 10 mg of
morphine sulfate injection (10 mg/ml) in 8 gm of Intrasite gel.
This gel (usually using [**4-27**] ml) should be applied to are
instructed to cover it and then loosely dress it with gauze.
.
#apneic episodes at night. ?central sleep apnea. Pt with
witnessed episodes overnight. Initially thought related to
opioids, however this was then found to occur without opioids.
Likely due to CNS disease/CVA history, or central sleep apnea.
Neurology followed the patient. Pt should discuss need for sleep
study with his PCP/neurologist. 24hr EEG did not show seizure
activity.
.
#goals of care-discussed with pt's daughter [**5-4**]. Dtr stated
that eventually she would like to take pt home with hospice
care, but then decided that no decisions would be made at this
time. However, wounds are quite extensive and therefore she
would like tx of decubitus ulcers prior to home with hospice.
Would be interested further future options, if applicable, if
this would alleviate pain. Daughter would like pt to go to
LTAC/[**Hospital1 1501**] for further wound care. Did discuss, with pt and
HCP/dtr delicate balance of using opioid therapy given the above
as well as achieving good pain control. At this time, pt is
without delerium on current therapy. However, would have to
discuss goals of care further if pain control still becomes an
issue, to discuss initiation of hospice care as increasing
further doses, may lead to apnea and further somnolence. Pt and
dtg aware this may happen.
.
#bradycardia with 1st degree AVB-thought to be beta blocker
effect. Pt was asymptomatic. His bb dose was decreased to 6.25mg
[**Hospital1 **]
.
#hypoglycemia- patient's metformin dose was held, and patient
was provided NPH per his home dose, as well as Humalog insulin
sliding scale coverage. He can resume metformin upon discharge.
NPH was held at discharge, and can be restarted depending on
clinical course and blood sugars.
.
INACTIVE ISSUES
---------------
#. Hypercalcemia: Likely in the setting of immobility and
possibly dehydration. Improved.
.
#.normocytic anemia-likely due to chronic disease and acute
illness. HCt trended. Pt did not have any evidence of active
bleeding.
.
#depression-on day prior to discharge, pt's HCP/dtr reported
that she feels her father may be a little depressed as his wife
recently passed. She was inquiring about increased doses of
antidepression. This was deferred to outpt setting as pt would
be discharged soon.
.
TRANSITION OF CARE
------------------
Code Status Discussion:
After discussion with the patient's daughter and HCP [**Name (NI) **]
[**Name (NI) **], he was determined to be DNR. She would be okay with him
being intubated if medically necessary. Palliative care and
hospice was discussed for symptom management and she was
initially interested in having her father at home with hospice
services in place upon discharge.
.
Key current issues:
Wound care as above
Dilantin level in 10 days.
Palliative care and pain control management.
.
# Communication: HCP is daughter [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 107599**]
(cell) [**Telephone/Fax (1) 107600**] (home)
Medications on Admission:
Diclofenact 1% gel TD [**Hospital1 **] apply to painful areas
Citalopram 10mg PO daily
Lisinopril 20mg PO daily
Metoprolol Tartrate 12.5mg PO BID
Metformin 500mg PO qday
Macrobid 100mg PO BID x 7 days (last dose [**2190-5-3**])
Oxycodone 5mg PO q6H PRN pain
Oxycontin 30mg PO BID
Oxycontin 15mg PO qHS
Aspirin 81mg PO daily
Baclofen 10mg PO TID
Vitamin D 1,000 units PO daily
Colace 100mg PO BID
Combivent 18mcg/103mcg q4-6H PRN
Dilaudid 2mg PO BID PRN dressing changes
NPH 7 units SC BID
Imudr 30mg PO daily
MVI 1 tab PO daily
Oxybutynin 5mg PO daily
Phenytoin 200mg PO qAM, 100mg qHS
Prilosec 20mg PO daily
Tylenol 1000mg PO TID
Discharge Medications:
1. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
2. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. phenytoin 125 mg/5 mL Suspension Sig: 200mg PO Q12H (every
12 hours).
13. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO once
a day.
16. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily) as needed for dressing change/pain.
17. oxycodone 5 mg/5 mL Solution Sig: One (1) PO BID (2 times a
day) as needed for dressing changes.
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for c.
19. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-20**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for
constipation.
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
22. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO twice a
day: hold for sbp < 100, hr < 55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**]
Discharge Diagnosis:
toxic metabolic encephalopathy
s/p CVA
s/p b/l BKA
CAD
HTN
DM
aphasia
stage 4 sacral decub
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with confusion and decreased responsiveness.
This was likely due to recently increased doses of your pain
medications. Initially, these medications were held. However,
you were more alert and you still had significant pain and short
acting pain medications were gradually reintroduced. You were
also found to have a large wound on your lower back and were
evaluated by the wound care team for this, who made
recommendations for better wound care. You will be going to a
nursing facility to continue care of your wounds.
.
Medication changes:
-start tylenol 1000mg q6hours
-start oxycodone 5mg prn pain q6hrs, 5mg [**Hospital1 **] prn wound dressing
changes
-started on lidocaine patch for pain
-decreased metoprolol to 6.25mg [**Hospital1 **]
-STOP oxycontin and dilaudid
-stop NPH insulin
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14973**] at
[**Telephone/Fax (1) 133**] after discharge. Depending on your clinical
course, you may benefit from seeing a surgeon regarding the
ulcer on your sacrum.
Name: [**Known lastname **],[**Known firstname 441**] Unit No: [**Numeric Identifier 17569**]
Admission Date: [**2190-4-28**] Discharge Date: [**2190-5-8**]
Date of Birth: [**2115-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4842**]
Addendum:
Second urine culture also grew yeast. I contact[**Name (NI) **] the facility
([**Hospital1 **] at [**Name (NI) 1699**]) and recommended treatment for a week. I
communicated this to the covering physician at the facility.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4843**] MD [**MD Number(2) 4844**]
Completed by:[**2190-5-8**]
|
[
"275.42",
"250.70",
"401.9",
"311",
"349.82",
"E849.8",
"276.0",
"414.01",
"V58.69",
"345.90",
"285.29",
"250.80",
"707.23",
"438.11",
"426.11",
"596.54",
"438.21",
"707.03",
"707.25",
"V49.75",
"707.09",
"440.29",
"E935.2",
"707.05",
"707.24"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
19141, 19340
|
7315, 14220
|
327, 333
|
17115, 17115
|
4448, 4933
|
18222, 19118
|
3311, 3329
|
14902, 16911
|
17001, 17094
|
14246, 14879
|
17295, 17835
|
3344, 3344
|
4017, 4429
|
17855, 18199
|
264, 289
|
2992, 3048
|
361, 2974
|
5505, 7292
|
17130, 17271
|
3070, 3189
|
3205, 3295
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,438
| 118,722
|
1945
|
Discharge summary
|
report
|
Admission Date: [**2188-8-19**] Discharge Date: [**2188-9-1**]
Date of Birth: [**2125-11-26**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Sulfa (Sulfonamides) / Aspirin / Codeine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
PICC line, TEE
History of Present Illness:
62 yo F with h/o CAD s/p CABG, COPD, HTN, CHF, chronic pain,
CRI, s/p partial gastrectomy, with recent admission for MRSA
port-a-cath infection and sacroilitis currently week 3 of 6
Vancomycin course, who returns from rehab with reported
yellow/green discharge from port site over the past few days.
Per Pt Tm 101 initially with associated chills. Per transfer
nursing notes, Tm 99 overnight. Pt denies feeling unwell other
than a chronic non-productive cough. No CP or SOB. Pt expressing
concerns about care she is recieving at [**Hospital3 537**]. Thinks
they are not properly dressing or caring for her wound.
Past Medical History:
#Hypothyroidism
#HTN
#CAD s/p CABG [**2170**] on plavix (ASA allergy)
#CHF (EF 60%; nl TTE [**7-/2188**])
#h/o C.Diff & MRSA
#Hip,Spine fusion age 17
-Patient unsure of original diagnosis
#Gastrectomy ([**2-7**] gastric ulcers, 10 years ago)
#COPD
#TB (Dx age 14; s/p Rx)
# Chronic LBP
# Recent proteus UTI
# Osteoporosis
# Odynophagia
# Chronic Anemia (b/l Hct ~30)
# Depression/Anxiety
# Seizure Disorder (since [**2152**]'s; unspecified; on dilantin)
# Osteoporosis
# Chronic Renal Insufficiency
Social History:
Divorced, three sons, 1 of whom lives in the area. Patient has
resided at [**Hospital **] Rehab for the past 3 years [**2-7**] multiple
chronic health complaints. TOB: Quit age 40. 20 pack year
history. Denies ETOH and drugs.
Family History:
Father-committed suicide at the age of 44
Mother-87 years old, currently diagnoised with gastric cancer
Physical Exam:
VS: 98.7, 122/88, 16 99% RA
Gen: lying in bed, NAD
HEENT: PERRL, EOMI, OP wnl, MMM
Neck: supple, no LAD, no JVD
Chest: no erythema, warmth or tenderness on palpation of former
port site. No discharge. Surrounding contact dermatitis at
dressing site.
CV: RRR. nl s1 and s2, [**2-11**] SM
Lungs: CTAB
Abd: Active bowel sounds, soft, non-tender, no masses
appreciated
Ext: No lower extremity edema, dorsalis pedal pulses palpated
bilaterally (1+)
Skin: no rash
Neuro: A&Ox3, CNII-XII intact, mentation intact
Pertinent Results:
[**2188-8-19**] 05:20PM BLOOD WBC-4.7 RBC-3.00* Hgb-9.7* Hct-29.8*
MCV-100* MCH-32.4* MCHC-32.6 RDW-16.0* Plt Ct-161
[**2188-8-19**] 05:20PM BLOOD Neuts-65.4 Lymphs-24.6 Monos-3.6 Eos-6.3*
Baso-0.2
[**2188-8-19**] 05:20PM BLOOD Plt Ct-161
[**2188-8-21**] 04:31PM BLOOD PT-13.9* PTT-27.5 INR(PT)-1.2*
[**2188-8-19**] 05:20PM BLOOD Glucose-100 UreaN-25* Creat-0.9 Na-139
K-5.1 Cl-110* HCO3-22 AnGap-12
[**2188-8-20**] 11:50AM BLOOD ALT-20 AST-22 AlkPhos-206*
[**2188-8-21**] 02:25PM BLOOD CK(CPK)-34
[**2188-8-21**] 02:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2188-8-22**] 12:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2188-8-22**] 03:54AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2188-8-21**] 05:29AM BLOOD VitB12-424 Folate-5.3
[**2188-8-21**] 05:29AM BLOOD TSH-0.73
[**2188-8-22**] 03:54AM BLOOD HIV Ab-NEGATIVE
[**2188-8-21**] 02:25PM BLOOD Phenyto-12.1
[**2188-8-22**] 03:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
[**2188-8-19**] 05:31PM BLOOD Lactate-1.3
[**2188-8-22**] 01:40AM URINE bnzodzp-POS barbitr-POS opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
[**2188-8-19**] 5:35 pm BLOOD CULTURE PICK,LFT AC.
AEROBIC BOTTLE (Final [**2188-8-22**]):
REPORTED BY PHONE TO [**Doctor Last Name 10280**] [**Doctor First Name **] [**2188-8-20**] 11:30 AM.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
PENICILLIN------------ 2 S
VANCOMYCIN------------ =>32 R
.
[**2188-8-24**] 3:49 pm CATHETER TIP-IV Source: picc.
WOUND CULTURE (Final [**2188-8-26**]): No significant growth.
.
[**2188-8-21**] 9:44 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2188-8-22**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
MRI Pelvis: Slight improvement of right sacroiliitis at the
inferior/posterior aspects of the joint, with unchanged
appearance at the
anterior/superior aspect of the joint. No drainable fluid
collection.
.
CT C-spine: Question of rotation versus rotary subluxation of
C1 on C2. Cervical spondylosis. Other findings as noted above.
.
CT head: Technically limited study due to patient motion. No
definite signs for an intracranial hemorrhage.
.
CT C-spine (flex/ext): Degenerative changes, particularly at
C4-C5 and C5-6. No evidence of instability.
.
EEG: This is an abnormal EEG in the drowsy state due to the
presence of diffuse background slowing as well as bursts of
generalized [**1-7**] Hz slowing. These abnormalities suggest an
encephalopathy, which may be seen with medications, toxic
metabolic abnormalities or infections.
.
U/S chest: Ultrasound of the right anterior chest wall in the
site of the previous Port- A-Cath was performed. In the
subcutaneous area, note is made of an area of low echogenicity
which measures 0.8 x 0.8 x 1.8 cm. This represents a small
pocket of fluid which may be resolving post Port-A-Cath removal.
.
MR [**Name13 (STitle) 2854**]: Mild degenerative changes. No evidence of discitis
or
osteomyelitis in the thoracic region. No evidence of spinal
cord compression or abnormal intrinsic signal within the spinal
cord.
.
MR [**Name13 (STitle) **]: Signal changes within the L5-S1 disc with subtle
enhancement are suspicious for early changes of discitis. No
epidural mass or epidural phlegmon seen or paraspinal abscess
identified. Mild degenerative changes. Findings suggestive of
previous fusion at L4-L5 level.
.
Video oropharyngeal swallow: Mild oropharyngeal dysphagia
resulting in trace aspiration of thin liquids. A small
esophageal web is noted.
.
Barium swallow: Limited study. No obstruction or strictures
within the esophagus.
.
TTE: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
70%). No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2188-7-23**], no major change is evident. The absence of a
vegetation by 2D echocardiography does not exclude endocarditis
if clinically suggested.
.
TEE: 1. The left atrium is dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3. There are mobile, complex (mobile) atheroma in the aortic
arch.
4. The aortic valve leaflets (3) are mildly thickened.
5. No echocardiographic evidence of endocarditis is seen.
.
CXR [**2188-9-1**]:
No evidence of pneumonia or failure is present.
Brief Hospital Course:
Addressed by problem:
.
# ID: The patient arrived on the floor afebrile with stable
hemodynamics. She was continued on vancomycin for treatment of
her recent MRSA bacteremia and port-a-cath infection with L5-S1
disciitis and right sacroiliitis. There was no evidence of
cellulitis at the former port-a-cath site in the right upper
chest wall. The surgical site appeared well-healed and no
drainage was noted. Ultrasound was performed at this site and
revealed a small simple fluid collection (0.8x0.8x1.8cm) that
was likely due to post-operative changes. Surgery evaluated the
former port-a-cath site and recommended no need for drainage. MR
of the right hip, lumbar, and thoracic spine were performed and
revealed resolving discitis, sacroiliitis, and no evidence of
osteomyelitis or epidural abscess. The patient requested HIV
test and was antibody negative. C. Diff stool toxin was negative
x 1. On hospital day #2, surveillance blood cultures drawn in
the ED grew high-grade vancomycin-resistant enterococcus. The
patient remained afebrile with stable vitals. The source of this
bacteremia was unknown but thought to be most likely related to
the indwelling PICC line. ID team was consulted and the patient
was switched to IV daptomycin. Her right antcubital PICC line
was removed on [**2188-8-24**]. Subsequent daily blood cultures have
shown no growth. A new PICC line was placed in the right upper
extremity by Interventional [**Date Range **] on [**2188-8-26**] for antibiotics
and blood draws as there was no other venous access available
despite multiple attempts by both IV nursing and the MICU team
(failed left subclavian line placement, no complications).
Regarding the etiology of her VRE bacteremia: line infection,
cardiac, and GI sources were considered. Although believed to be
the most likely source, there was no evidence of line infection
as the culture from the PICC tip was negative. There was also no
evidence of endocarditis or valvular vegetations on both TTE and
TEE. Abdominal sources were considered but believed unlikely
given no complaints, normal exam and LFTs, and therefore an
abdominal CT scan was not performed. ID desired to transition
the patient to oral antibiotics, however the patient was taking
effexor and had to be weaned off this medication given the
theoretical risk for serotonin syndrome. Pharmacy and psychiatry
were consulted regarding effexor weaning which was successfully
performed over 5 days without noted withdrawal symptoms and then
discontinued completely on [**2188-8-26**]. Daptomycin was discontinued
on [**2188-8-28**] and the patient was started on linezolid PO 600mg [**Hospital1 **]
to complete at least a 2 week course. She remained afebrile with
stable vital signs and serial neurological exams revealed no
evidence of serotonin syndrome. She will need weekly CBC, BUN,
Creatinine, and LFTs to monitor for side effects while on
linezolid. She will f/u with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from Infectious
Disease.
- CBC, BUN, Creatinine, LFTs qweekly --> fax results to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] @ [**Numeric Identifier 10738**]
.
# Loss of consciousness: On [**2188-8-21**], the patient was found by
staff lying on the floor of her room responding only to painful
stimuli with no spontaneous movement of extremities. The event
was unwitnessed. She was placed in a hard cervical collar. CT
head was negative; CT c-spine revealed no fracture but there was
a question of C1-C2 rotational instability. She was transferred
to the MICU for close observation. Neurology who suggested
unlikely to be CVA. Neurosurgery requested c-spine flexion and
extension films which showed no signs of instability, however
given the C1-C2 rotational instability noted in her c-spine she
was continued with a hard collar. She was ruled-out for MI with
serial cardiac enzymes. EEG suggested encephalopathy [**2-7**]
medications vs. toxic/metabolic vs. infection. As her symptoms
resolved, she displayed evidence of a post-ictal state. Her
mental status gradually improved and her neurological exam
resolved back to baseline. Given her h/o seizure disorder, this
event appeared to be most likely a seizure, however her dilantin
level was therapeutic. Given her positive blood cx, there was
concern for septic emboli, however given the transient nature of
her symptoms it was believed less likely. One possible etiology
in light of the cervical CT findings was atlantoaxial
subluxation. The patient stabilized in the MICU and was
transferred back to the floor for continued care on [**2188-8-22**].
Daily dilantin levels were followed and were therapeutic. Per
neurology, she was transitioned to keppra 1000mg po bid and
weaned off dilantin. She had no further LOC episodes while on
the floor and her neurological examination remained non-focal.
She is scheduled to follow-up in with Dr. [**Last Name (STitle) **] in [**Hospital 875**]
Clinic.
.
# C1/C2 rotational instability: (see above LOC for description
of event) Neurosurgery evaluated the patient s/p unwitness fall.
C-spine flexion/extension films were stable but rotation of C1
on C2 was noted on c-spine CT. It was recommended that the
patient wear a hard cervical collar (Aspen) for 4 weeks given
concern about rotational instability in her cervical spine.
Despite frequent reminders about the severity of this potential
problem, the patient continued to occasionally remove and refuse
to wear the cervical collar. She was counseled extensively
regarding the risks including paralyzation and death. She should
call to schedule a f/u appointment with Dr. [**Last Name (STitle) **] from
Neurosurgery in 3 weeks for evaluation.
.
# Dysphagia: The patient reported difficulty swallowing large
pieces of meat for at least one year. She stated that frequently
she would have to vomit to remove the obstruction. Denies
difficulty swallowing liquids or odynophagia. Also states she
was told by her PCP that she had an esophageal stricture that
needed to be dilated. Her last EGD was approximately [**2178**]
following partial gastrectomy for peptic ulcers. GI and was
consulted for evaluation, and believed the problem to likely be
oropharyngeal in nature. She was noted to have a small cervical
esophageal web on video swallow study; barium swallow was
limited due to cervical collar but revealed no evidence of
obstruction or stricture. Speech and swallow evaluation was
performed and negative for signs of aspiration, however it she
did struggle swallowing mixed consistency liquids (e.g. cereal
with milk, soup with peas) and therefore her diet was changed to
eliminate these components. GI suggested outpatient evaluation
including EGD. She will follow-up with Dr. [**First Name (STitle) **] from GI after
discharge.
.
# HTN: Her BP was well-controlled throughout admission, however
chagnes were made to her regimen to optimize long-term
management. She was changed from metoprolol to atenolol 100mg po
qd. Lisinopril was started and increased 2.5mg qod to reach goal
dose of 10mg qd. She was begun to be weaned off clonidine by
decreasing 0.1mg qod. She tolerated these medication changes
without difficulty and showed no signs of rebound hypertension
during clonipine taper. She should be monitored as an outpatient
by her PCP and her medications titrated for goal BP<130/80.
- follow BP's as outpatient and titrate regimen
.
# CAD: The patient is s/p CABG [**2170**]. Cardiac cath [**2183**] with
patent grafts. ETT c myoview [**2185**] normal. Stable c no active
ischemia. She was r/o for MI with serial cardiac enzymes. EKG's
were unchanged from prior studies. She was continued on beta
blocker, lipitor, and imdur. Plavix (patient has aspirin
allergy) was briefly discontinued s/p fall and transfer to MICU
but reinstituted shortly after returning to the floor. Of note,
on TEE the patient had mobile atheroma present in the aortic
arch.
.
# CHF: Carries this diagnosis but EF 60-70% and requires no
diuretics at home. She had both TTE and TEE while inpatient
which were within normal limits. She remained euvolemic
throughout admission. I&Os and daily weights were monitored. She
had no SOB or signs of volume overload during admission and
required no lasix.
.
# Hypothyroidism: Currently euthyroid with TSH 0.73 at
admission. She was continued on her home dose of levothyroxine.
.
# Chronic Anemia: Etiology is likely due to chronic disease. B12
and folate levels were within normal levels. She was guaiac
negative x 1 and positive x 1. The patient reports occasional
BRBPR that she attributes to hemorrhoids. Reports colonoscopy
approximately 5 years ago at [**Last Name (un) **] (Dr. [**Last Name (STitle) **] which was
negative. Her hematocrit remained stable throughout admission.
- consider outpatient colonoscopy referral, patient has
appointment for [**Hospital **] clinic
.
# GERD: No active issues, she was continued on proton pump
inhibitor.
.
# Chronic LBP: Possibly related to disciitis, although per
report and prior notes obtained from [**Hospital3 417**] Medical
Center this appears to be a chronic problem. She has had prior
back surgery while a teenager. She was continued on her
outpatient regimen while in house and required no breakthrough
pain medications.
.
# Psych: Patient wih history of depression and anxiety.
Initially she was continued on effexor, xanax, and serax. As it
was desired that she start linezolid, she was weaned off of
effexor with no obvious adverse side effects noted. Psychiatry
was consulted regarding management of depression off effexor and
benzodiazepines. She was not restarted on a new anti-depressant
as she was not currently showing signs of major depression and
did not desire continued treatment. Regarding her
benzodiazepines, zanax and serax were discontinued and she was
started on klonapin 0.5mg po tid and slowly weaned to klonapin
0.5mg po qd prn prior to discharge. She was closely monitored
and displayed no active signs of benzo withdrawal
.
# Tremors: The patient complained of occasional chronic tremors
involving her arms and legs that occur with activity. She was
evaluated by neurology. No resting or intention tremors were
noted and she had a normal neurological exam. It was though that
this may be related to deconditioning and chronic illness,
however other possibilities include medication side effects from
her polypharmacy. She will be followed by Neurlogy as an
outpatient.
.
# Osteoporosis: The patient was continued with vitamin D and
calcium supplements. Consideration should be given for starting
alendronate after the cervical collar is removed. Outpatient
bone density scan may also be helpful in management.
.
# Cough: Patient complained of a dry cough on day of discharge.
Afebrile, no leukocytosis. CXR without PNA.
.
# FEN: diabetic/cardiac diet (no mixed consistency liquids, give
pills in applesauce); electrolytes were monitored daily and
repleted as needed
.
# PPX: pneumoboots (pt refuses sc heparin), PPI
.
# Dispo: return to [**Hospital **] Rehabilitation Facility
Medications on Admission:
1. Clopidogrel 75 mg PO DAILY
2. Venlafaxine 150 mg PO DAILY
3. Isosorbide Mononitrate 60 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Oxazepam 10 mg PO HS as needed for insomnia.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO MONDAY, WEDNESDAY, FRIDAY ().
7. Phenytoin Sodium Extended 100 mg Capsule Sig: Six (6) Capsule
PO SUNDAY, TUESDAY, THURSDAY, SATURDAY ().
8. Allopurinol 100 mg PO DAILY
9. Levothyroxine 175 mcg PO DAILY
10. Alprazolam 0.25 mg PO QID
11. Calcium Carbonate 500mg PO TID
12. Clonidine 0.1 mg PO DAILY
13. Tizanidine 4 mg PO TID
14. Metoprolol Tartrate 100 mg PO BID
15. Miconazole Nitrate 2 % Powder TID
(3 times a day) as needed.
16. Bacitracin Zinc 500 unit/g Ointment
17. Docusate Sodium 100 mg PO BID
18. Senna 8.6 mg PO BID
19. Hydromorphone 9 mg PO Q6H as needed.
20. Gabapentin 300 mg PO Q8
21. Oxycodone 10 mg PO Q4-6H PRN
22. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
23. Morphine 100 mg Tablet Sustained Release PO Q12H
24. Cholecalciferol 800 unit DAILY
25. Pantoprazole 40 mg PO Q12H
26. Vancomycin 1000 (1000) Intravenous Q 24H (Every 24 Hours):
Patient to complete 6 weeks of abx, with start date being
[**2188-7-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. High Grade VRE Bacteremia and Line Sepsis
2. Stable MRSA Right Sacroiliac Osteomyelitis and L5-S1
Discitis
3. Seizure w/ LOC and Neck Trauma.
4. Rotary subluxation of C1 on C2.
5. Oropharyngeal Dysphage NOS
6. Esophageal Web
Past Medical History:
1. MRSA Port-a-Cath Infection c/b Sacro/Vertebral
Osteomyelitis.
2. Coronary Artery Disease s/p CABG [**2171**].
2. Hypertension.
3. Chronic Obstructive Pulmonary Disease.
4. Seizure Disorder NOS.
5. Hypothyroidism.
6. Osteoporosis.
7. Depression/Anxiety.
9. S/P L4-L5 Laminectomy and Fusion.
10. Peptic Ulcer Disease S/P Gastrectomy.
11. Tuberculosis treated at age 14.
12. Left Upper Extremity DVT.
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prescribed.
.
New medications: linezolid, lisinopril, levetiracetam,
clonazepam
.
Discontinued medications: phenytoin, metoprolol, alprazolam,
oxazepam, venlafaxine
.
You will need weekly blood tests (CBC, BUN, Creatinine, and
LFTs) while on antibiotics (linezolid). Please have the results
faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] of Infectious Disease at ([**Telephone/Fax (1) 10739**].
.
If you experience worsening pain, fever, nausea, vomiting,
chills, headache, vision changes, weakness, numbness, tingling,
seizures, shortness of breath, or other concerning symptoms
please call your doctor immmediately or return to the Emergency
Department for evaluation.
Followup Instructions:
You have the following appointments scheduled. Please contact
the appropriate provider with questions or in the event that you
need to reschedule.
.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10740**]: ([**Telephone/Fax (1) 10741**]. Dr. [**Last Name (STitle) 10742**] is retiring and has
transferred your care to Dr. [**Last Name (STitle) 10740**]. You are scheduled to see
Dr. [**Last Name (STitle) 10740**] on [**2188-9-4**] Thursday at 2:45pm. Please call your
insurance to report that you are switching PCP's.
.
You will need weekly blood tests (CBC, BUN, Creatinine, and
LFTs) while on antibiotics (linezolid). Please fax the results
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] of Infectious Disease at ([**Telephone/Fax (1) 1353**].
.
Infectious Disease: DR. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone: ([**Telephone/Fax (1) 4170**]
Date/Time:[**2188-9-9**] 11:00
.
Gastroeneterology: DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2188-9-22**] 8:30
.
[**Hospital 875**] clinic: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2442**] & Dr. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2188-10-9**] 8:30
.
Neurosurgery: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: ([**Telephone/Fax (1) 88**]. Call
for appointment in 3 weeks regarding cervical spine collar.
.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2188-9-1**]
|
[
"414.01",
"585.9",
"V45.81",
"496",
"V12.01",
"428.0",
"041.04",
"300.00",
"311",
"530.81",
"733.00",
"722.93",
"041.11",
"584.9",
"787.2",
"959.09",
"333.1",
"E887",
"805.01",
"720.2",
"780.39",
"V12.51",
"780.09",
"412",
"790.7",
"401.9",
"V09.0",
"750.3",
"244.9",
"996.62",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20437, 20508
|
8122, 19175
|
323, 340
|
21228, 21237
|
2413, 5181
|
22023, 23645
|
1766, 1872
|
20529, 20773
|
19201, 20414
|
21261, 22000
|
1887, 2394
|
273, 285
|
368, 982
|
5190, 8099
|
20795, 21207
|
1520, 1750
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,071
| 115,739
|
11461
|
Discharge summary
|
report
|
Admission Date: [**2155-2-8**] Discharge Date: [**2155-2-24**]
Date of Birth: [**2072-10-24**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Sudden fall and aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82y/o gentleman with history of prostate cancer, presented
with sudden fall and aphasia.
He was dressing. Wife witnessed in the same room. He suddenly
fell onto the bed and became aphasic. He was not able to stand
up. The wife saw that his left (right?) leg was not moving.
EMT was called and brought him to [**Hospital1 18**] ED. Neurology was called
for code stroke.
Past Medical History:
Prostate cancer: surgically resected and seeding implant placed
10y ago.
Hypertension? (on Atnenolol)
Social History:
Unknown.
Family History:
Unknown.
Physical Exam:
T 98.2 HR 106, reg BP 134/59 RR 21 SO2 98% r/a
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums
clear.
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, flat, no tenderness
Ext: No arthralgia, no deformities, no edema
Neurologic examination:
Mental status: Keeps eyes opening. Non verbal. No following
commands.
Cranial Nerves: No blink to the right sided visual stimuli.
Conjugated left gaze deviation, which did not break with OCR.
Pupils reactive and equal. Slightly shallower Right NLF. ? R
mouth angle droop. Gag positive.
Motor: Able to lift Left arm for 10 secs, Left leg [**4-12**] secs with
drift. Right arm showed posturing for noxious stimuli. Right leg
showed extension of knee to the noxious stimuli (posturation).
Sensation: Withdrawal x4 as above.
Reflexes: B T Br Pa Ankle
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes were upgoing bilaterally
Coordination: Unable to perform FNF due to limited
comprehension.
Meningeal sign: Negative Brudzinski sign. No nucal rigidity.
Pertinent Results:
[**2155-2-8**] 11:00AM BLOOD WBC-8.4 RBC-3.84* Hgb-13.0* Hct-36.7*
MCV-96 MCH-34.0* MCHC-35.5* RDW-12.0 Plt Ct-228
[**2155-2-9**] 01:56AM BLOOD WBC-11.0 RBC-4.07* Hgb-13.4* Hct-38.3*
MCV-94 MCH-33.0* MCHC-35.0 RDW-12.0 Plt Ct-248
[**2155-2-10**] 02:19AM BLOOD WBC-14.1* RBC-3.75* Hgb-12.5* Hct-35.7*
MCV-95 MCH-33.2* MCHC-34.9 RDW-12.0 Plt Ct-251
[**2155-2-11**] 03:47AM BLOOD WBC-14.7* RBC-3.54* Hgb-12.3* Hct-34.3*
MCV-97 MCH-34.8* MCHC-35.9* RDW-12.1 Plt Ct-249
[**2155-2-12**] 03:10AM BLOOD WBC-11.8* RBC-3.22* Hgb-11.3* Hct-31.4*
MCV-98 MCH-35.2* MCHC-36.1* RDW-12.1 Plt Ct-215
[**2155-2-13**] 03:55AM BLOOD WBC-12.3* RBC-3.38* Hgb-11.2* Hct-32.9*
MCV-97 MCH-33.1* MCHC-34.1 RDW-12.1 Plt Ct-265
[**2155-2-14**] 04:24AM BLOOD WBC-13.0* RBC-3.14* Hgb-10.4* Hct-30.5*
MCV-97 MCH-33.2* MCHC-34.2 RDW-12.1 Plt Ct-266
[**2155-2-15**] 03:00AM BLOOD WBC-15.2* RBC-3.07* Hgb-10.1* Hct-29.8*
MCV-97 MCH-32.8* MCHC-33.9 RDW-12.0 Plt Ct-272
[**2155-2-16**] 03:47AM BLOOD WBC-12.8* RBC-3.10* Hgb-10.2* Hct-29.9*
MCV-97 MCH-33.0* MCHC-34.1 RDW-12.0 Plt Ct-310
[**2155-2-17**] 03:14AM BLOOD WBC-12.1* RBC-3.08* Hgb-10.2* Hct-29.5*
MCV-96 MCH-33.0* MCHC-34.4 RDW-12.0 Plt Ct-314
[**2155-2-18**] 01:59AM BLOOD WBC-11.2* RBC-3.08* Hgb-10.0* Hct-29.9*
MCV-97 MCH-32.4* MCHC-33.4 RDW-12.1 Plt Ct-340
[**2155-2-19**] 01:51AM BLOOD WBC-12.0* RBC-3.03* Hgb-9.7* Hct-29.3*
MCV-97 MCH-31.9 MCHC-32.9 RDW-12.0 Plt Ct-349
[**2155-2-22**] 02:12AM BLOOD WBC-12.9* RBC-2.99* Hgb-9.9* Hct-28.7*
MCV-96 MCH-33.2* MCHC-34.5 RDW-12.3 Plt Ct-464*
[**2155-2-22**] 02:12AM BLOOD PT-16.4* PTT-29.9 INR(PT)-1.5*
[**2155-2-19**] 01:51AM BLOOD PT-14.4* PTT-30.6 INR(PT)-1.3*
[**2155-2-18**] 01:59AM BLOOD PT-14.5* PTT-30.5 INR(PT)-1.3*
[**2155-2-14**] 04:24AM BLOOD PT-14.1* PTT-31.3 INR(PT)-1.2*
[**2155-2-11**] 03:47AM BLOOD PT-13.2 PTT-27.6 INR(PT)-1.1
[**2155-2-8**] 11:00AM BLOOD Fibrino-462*
[**2155-2-22**] 02:12AM BLOOD Glucose-121* UreaN-25* Creat-1.1 Na-133
K-4.8 Cl-98 HCO3-28 AnGap-12
[**2155-2-20**] 02:40AM BLOOD Glucose-75 UreaN-29* Creat-1.2 Na-139
K-5.0 Cl-105 HCO3-29 AnGap-10
[**2155-2-18**] 01:59AM BLOOD Glucose-192* UreaN-34* Creat-1.3* Na-138
K-4.2 Cl-104 HCO3-27 AnGap-11
[**2155-2-16**] 05:17PM BLOOD Creat-1.3* K-4.0
[**2155-2-16**] 03:47AM BLOOD Glucose-163* UreaN-36* Creat-1.3* Na-139
K-4.2 Cl-106 HCO3-26 AnGap-11
[**2155-2-15**] 03:00AM BLOOD Glucose-176* UreaN-29* Creat-1.2 Na-139
K-4.1 Cl-107 HCO3-25 AnGap-11
[**2155-2-14**] 04:24AM BLOOD Glucose-196* UreaN-29* Creat-1.1 Na-142
K-3.9 Cl-109* HCO3-25 AnGap-12
[**2155-2-13**] 03:55AM BLOOD Glucose-186* UreaN-26* Creat-1.0 Na-139
K-3.9 Cl-109* HCO3-24 AnGap-10
[**2155-2-12**] 03:10AM BLOOD Glucose-187* UreaN-32* Creat-1.0 Na-136
K-3.9 Cl-106 HCO3-25 AnGap-9
[**2155-2-11**] 03:19PM BLOOD Glucose-155* UreaN-29* Creat-1.1 Na-141
K-4.2 Cl-107 HCO3-24 AnGap-14
[**2155-2-11**] 03:47AM BLOOD Glucose-125* UreaN-27* Creat-1.0 Na-139
K-4.2 Cl-108 HCO3-23 AnGap-12
[**2155-2-10**] 04:02PM BLOOD Glucose-168* UreaN-26* Creat-1.0 Na-138
K-4.7 Cl-106 HCO3-24 AnGap-13
[**2155-2-9**] 01:56AM BLOOD Glucose-118* UreaN-22* Creat-1.0 Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
[**2155-2-8**] 11:00AM BLOOD UreaN-31* Creat-1.4*
[**2155-2-10**] 02:19AM BLOOD CK(CPK)-474*
[**2155-2-9**] 01:56AM BLOOD CK(CPK)-589*
[**2155-2-8**] 06:34PM BLOOD ALT-27 AST-54* LD(LDH)-476* CK(CPK)-409*
AlkPhos-78 Amylase-38 TotBili-0.4
[**2155-2-9**] 10:15AM BLOOD CK-MB-16* MB Indx-2.3 cTropnT-<0.01
[**2155-2-9**] 01:56AM BLOOD CK-MB-15* MB Indx-2.5 cTropnT-<0.01
[**2155-2-8**] 06:34PM BLOOD CK-MB-10 MB Indx-2.4 cTropnT-<0.01
[**2155-2-8**] 11:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-2-22**] 02:12AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0
[**2155-2-11**] 03:47AM BLOOD %HbA1c-5.8
[**2155-2-11**] 03:47AM BLOOD Triglyc-53 HDL-34 CHOL/HD-3.6 LDLcalc-77
[**2155-2-11**] 03:47AM BLOOD TSH-0.91
[**2155-2-16**] 07:26AM BLOOD Vanco-26.2*
[**2155-2-16**] 03:47AM BLOOD Vanco-30.0*
[**2155-2-15**] 07:45PM BLOOD Vanco-19.9
[**2155-2-8**] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-2-19**] 12:25PM BLOOD Type-ART pO2-114* pCO2-37 pH-7.49*
calTCO2-29 Base XS-4
[**2155-2-8**] 11:15AM BLOOD Glucose-98 Lactate-2.1* Na-135 K-4.4
Cl-99* calHCO3-28
[**2155-2-8**] CT-head
IMPRESSION:
4.0 x 2.4 cm left posterior limb internal capsule
intraparenchymal hemorrhage with very mild mass effect and
minimal rightward shift of the midline. No evidence of
hydrocephalus. No evidence of intraventricular hemorrhage.
[**2155-2-8**] CT-head
IMPRESSION: Acute 29-mm left basal ganglion intracranial
hemorrhage with mild mass effect as described.
Brief Hospital Course:
The patient had a devastating hemorrhage from which his
neurological condition was severely impaired. He recieved life
support here, but was certain to at least require a PEG tube and
possibly a tracheostomy for further support. Numerous family
meetings with social work, the ICU physicians, and the Neurology
service were held. There was considerable disagreement about
how aggressively to pursue care, especially between the patients
son and the patients daughter and wife. In the end the family
came to a concensuss that he should be made CMO. He passed away
on [**2155-2-24**].
Medications on Admission:
ASA "2 pills" QPM per wife
Atenolol 25mg [**Name2 (NI) 244**]
Prevacid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage.
Discharge Condition:
deceased.
Discharge Instructions:
x
Followup Instructions:
x
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2155-3-13**]
|
[
"427.31",
"784.3",
"790.29",
"431",
"599.0",
"933.1",
"593.9",
"348.4",
"342.90",
"999.9",
"V66.7",
"401.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.91",
"33.22",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7364, 7373
|
6624, 7213
|
297, 303
|
7442, 7453
|
2012, 6601
|
7503, 7627
|
871, 882
|
7335, 7341
|
7394, 7421
|
7239, 7312
|
7477, 7480
|
897, 1214
|
234, 259
|
331, 702
|
1324, 1993
|
1253, 1308
|
1238, 1238
|
724, 828
|
844, 855
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,452
| 175,505
|
4591
|
Discharge summary
|
report
|
Admission Date: [**2135-6-1**] Discharge Date: [**2135-6-2**]
Date of Birth: [**2080-11-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Reglan / Protonix
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
hypotension, sepsis
Major Surgical or Invasive Procedure:
.
History of Present Illness:
Mr. [**Known lastname 10936**] is a 54yo M w/hx ESRD with failed tx on PD, DM-I, CAD,
CHF with EF ~15% who presents to the ED with hypotension. He
"thinks" that he took too much off with PD at home today but
cannot quantify exact amount. He states he usually takes off
1500ml but knows it was a lot higher than this number.
.
Of note, he was recently admitted [**Date range (2) 19491**] for cellulitis
and abscess of the R thigh which was I&D'd on [**5-18**]. He was
treated initially with Vanc/Unasyn, then changed to Unasyn when
cultures came back with MSSA. He was discharged on Augmentin
for a further 10 day course to end [**2135-6-2**].
.
In the ER, initial vitals were T98.6F, HR 74, BP 70/37, RR 17
and oxygen sat 99% RA. Blood pressures dropped to 56 systolic
and he was given 2L NS and systolics came up to 70s-80, so he
was placed on peripheral dopamine. He was given vanc/zosyn in
the ED for broad coverage, with particular concern for
cellulitis spread / abscesses in legs. Renal was consulted and
will plan to follow patient as inpatient. His PD fluid was sent
for culture and cytology. Cell count from the PD fluid showed
50 WBCs and 9% polys. ECG showed ST depressions anterolaterally
which are similar to prior ECGs. He had a central line placed
for access to continue monitoring hemodynamics and for easy
pressor use.
.
On evaluation in the MICU, patient was very lethargic and
attention waxed and waned during exam. He seemed to be in no
acute distress or pain. Arrived with right IJ in place and was
on dopamine pressor with blood pressures stable at 118/67.
Past Medical History:
# Insulin dependent diabetes type I - complications of
neuropathy, retinopathy, gastroparesis (somewhat responsive to
erthromycin)
# Renal transplant, [**2119**], now on PD since [**5-27**] - followed by Dr
[**First Name (STitle) 805**]
# CAD - 3VD, DES to OM [**3-26**], following MI (deferred placing
multiple stents d/t excessive dye load in setting of renal
insufficiency). Recent NSTEMI during ICU stay from admission
3/[**2135**].
# Systolic CHF: LVEF 10-15%, akinesis of the inferior,
inferoseptal, and inferolateral walls and severe hypokinesis of
the other segments, RV dilation/failure, moderately elevated PA
pressures, 2+ MR.
# History of C. diff ([**2-27**])
# Polycythemia [**Doctor First Name **]
# PVD
# HTN
# h/o Osteomyelitis of R 5th metatarsal in [**2128**]
# s/p L toe amputation after ICU stay for sepsis/osteomyelitis
(MSSA) [**1-26**]
# Eosinophilic gastritis
# Stoke in [**2123**] with right hand weakness, resolved on its own.
Social History:
Mr. [**Known lastname 10936**] lives with his wife and 2 children who are in early
20s. . He is a retired auto mechanic. Denies any tobacco use.
Rare alcohol use , no illicit drug use.
Family History:
One sister has a congenital [**Last Name 4006**] problem. Mother and another
sister with bipolar disorder on lithium.
Physical Exam:
Vitals: Temp 96F, HR 110, BP 118/67, RR 22, saturation 100% NC
2L
General: alert and oriented x2, NAD, mildly lethargic
[**Last Name 4459**]: EOMI, PERRL, OP clear
Neck: supple, Right IJ clean/dry/in tact, JVP 6-7cm
Pulm: mild bibasilar crackles, no wheezes
CVS: S1/S2 regular, RRR, no other murmurs/rubs
Abdomen: nontender, nondistended, PD site appears clean,
normoactive bowel sounds
Extremities: 2+ pedal pulses, trace edema, 2-3cm round ulcerated
lesions over both heels, scraped knees bilaterally
Neuro: CNs [**4-1**] grossly in tact, sensation light touch in tact,
moving 4 extremities
Derm: skin
Pertinent Results:
EKG - rate 74, NSR, qwaves [**Last Name (LF) 1105**], [**First Name3 (LF) **] depressions in V2-V6, similar
to prior EKGs
LABS
[**2135-6-1**] 07:10PM BLOOD WBC-6.4# RBC-3.75* Hgb-10.3* Hct-33.3*
MCV-89 MCH-27.4 MCHC-30.8* RDW-19.9* Plt Ct-128*
[**2135-6-2**] 01:49PM BLOOD WBC-14.2*# RBC-3.64* Hgb-9.9* Hct-31.9*
MCV-88 MCH-27.2 MCHC-31.1 RDW-20.4* Plt Ct-107*
[**2135-6-2**] 11:49AM BLOOD PT-15.0* PTT-34.6 INR(PT)-1.3*
[**2135-6-2**] 01:49PM BLOOD Plt Ct-107*
[**2135-6-1**] 07:10PM BLOOD Glucose-225* UreaN-44* Creat-9.9* Na-130*
K-3.9 Cl-92* HCO3-22 AnGap-20
[**2135-6-2**] 01:49PM BLOOD Glucose-154* UreaN-45* Creat-8.8* Na-140
K-4.5 Cl-95* HCO3-25 AnGap-25*
[**2135-6-1**] 07:10PM BLOOD ALT-11 AST-20 LD(LDH)-289* CK(CPK)-35*
AlkPhos-85 TotBili-0.2
[**2135-6-2**] 01:49PM BLOOD CK(CPK)-194
[**2135-6-2**] 11:49AM BLOOD CK-MB-17* MB Indx-8.5*
[**2135-6-2**] 01:59PM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-47* pH-7.24*
calTCO2-21 Base XS--7
[**2135-6-2**] 01:59PM BLOOD Glucose-135* Lactate-9.0* Na-135 K-3.8
Cl-98*
Brief Hospital Course:
Mr. [**Known lastname 10936**] is a 54 yo M w/hx of ESRD (s/p failed renal transplant
on PD), DM1, CAD, CHF (EF 10%) who was initially admitted to
MICU with hypotension consistent with shock. Differential
included hypovolemia from excessive fluid removal during PD vs.
septic shock from infection. Baseline blood pressures were
90s-100s. Sources of infection include bacteremia from skin
infection given recent abscess/cellulitis vs. abdominal source
given ascites and PD catheter in place, although PD fluid is
negative for infection on cell counts. He also had severe
cardiac disease with baseline EF 10% at high risk for ACS and
arrhythmias or cardiogenic shock. He was admitted overnight,
maintained on broad spectrum antibiotics and pressors (dopamine
which was being weaned down) with improved mental status with
lethargy and stable hemodynamics when he had acute event as
described below.
At 1:35pm, called to room with acute bradycardia down to HR 40s
down from 90s. Patient not breathing, so oral airway placed, and
then intubated at bedside. Given 1mg atropine x 2, found to be
pulseless and code blue called. Compressions started and cardiac
arrest code run per ACLS guidelines for intermittent pulseless
vtach and PEA arrest including 4 shocks, epi x 3, amio boluses x
2 and gtt, vasopressin, 4mg IV mag, 2 rounds bicarb, insulin
10units, 1 amp D50. Unable to regain pulse and after 30 minutes
of coding, time of death called at 2pm. Unclear cause of death:
highest on differential was ACS vs PE vs cardiac tamponade in a
patient with poor cardiac function and reserve at baseline.
Other causes including hypoxia, electrolyte disturbances,
hypoglycemia, were treated during code.
Medications on Admission:
Trazodone 25mg PO qHS PRN insomnia
Sevelamer 2400mg PO TID w/[**Known lastname 16429**]
Augmentin 500-125 PO qday x 10 days
Simvastatin 40mg PO qHS
Prednisone 5mg PO qday
Aspirin 81mg PO qday
Plavix 75mg PO qHS
Vitamin D3 400IU PO qday
Cinacalcet 30mg PO qday
MVI 1 tab PO qday
Oxycodone 5mg PO q4H
Lantus 5 units SC qHS
Lanthanum 1,000mg PO TID
Hydroxyzine 10mg PO BID
Discharge Medications:
Patient passed away of cardiac arrest
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away of cardiac arrest
Discharge Condition:
Patient passed away of cardiac arrest
Discharge Instructions:
Patient passed away of cardiac arrest
Followup Instructions:
Patient passed away of cardiac arrest
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
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302, 305
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7198, 7237
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,492
| 197,766
|
6415
|
Discharge summary
|
report
|
Admission Date: [**2176-4-19**] Discharge Date: [**2176-4-26**]
Date of Birth: [**2109-4-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
N/V/Malaise/Diarrhea
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
Mrs. [**Known lastname 6759**] is a 66 y/o F with a hx NSCLC s/p lobectomy,
laryngeal ca s/p chemo/XRT with hx failure to thrive [**1-23**]
radiotherapy and with 2 days N/V/D, poor PO. Daughter-in-law
called oncologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10351**]) with report that patient is
unwell. Starting yesterday developed nausea and diarrhea.
Malaise has persisted today with additional episodes of diarrhea
after any attempt at eating. Daughter in law reports she is very
weak and appears unwell and worried she is dehydrated.
Temperature is 100.3 and blood sugar elevated after pedialyte.
Advised ED evaluation.
In ED, initial vs were: T 99.0 HR:135 BP:87/68 RR:22 O2Sat:97.
She triggered on arrival because tachycardic to 130s, BP
systolic 80s. EKG consistent with either flutter or MAT. Has h/o
atrial tachyarrhythmias (Followed by [**Doctor Last Name **]) but usually
well-controlled with dilt and metoprolol but not
anti-coagulated. Was given IVF bolus of 3L NS but remained
tachycardic in the 130s and then got 10mg IV dilt with BP in 100
range. Mentating well and asymptomatic. CXR showed possibility
of acute on chronic aspiration, possible early developing
infiltrate and had crackles on exam. Received ceftriaxone and
flagyl for aspiration pneumonia coverage. Labs revealed
leukocytosis and hyponatremia. She was admitted to the MICU for
persistent tachycardia and hypotension.
She had no complaints other than a dry mouth and some pain in
her throat that is chronic since undergoing radiation for her
laryngeal cancer.
Past Medical History:
- Pancoast RUL lung SCC s/p excision, chemotherapy and
radiation. (1st surgery [**6-24**], seconded after XRT [**2171-10-18**])
- Laryngeal CA: squamous cell carcinoma with focal
superficial invasion and adjacent squamous cell carcinoma
in-situ
of the right false vocal cord. s/p 30 treatments of radiation.
s/p GTube placement
- Post op c/b AF. Treated with amio/coumadin./ d/c'd after
3weeks with conversion to NSR.
Suprventricular Tachycardia
GERD
CAD /p MI [**9-/2162**], s/p RCA stent at [**Hospital1 2025**] [**9-/2162**], s/p LCx stent at
[**Hospital1 2025**] [**3-/2163**]
DMII: on metformin, glucotrol and ACEI
cOPD
Psoriasis
Anxiety
Obesity
Seasonal Allergies
Social History:
former [**Month/Year (2) 1818**], quit [**8-/2175**] (kept smoking after lung cancer).
100pack years. 2pks/day for 50 years. no smoking. lives alone.
no longer works.
Family History:
Mother - MI at 60, diabetes
Father - MI at 73.
5 siblings, several with MIs and dementia, one with laryngeal
cancer
Physical Exam:
Upon admission to the MICU:
General: Alert female in NAD.
HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted,
dry MM, no lesions noted in OP
Neck: supple, no JVP.
Pulmonary: Lungs CTA Ant, bibasilar crackles, no egophony.
Cardiac: Tachy, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Upon admission to the floor:
VS: 97.7, 115/80, HR 79, RR 22, 97% on 3L
General: Alert female in NAD.
HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted,
moist mucous membranes.
Neck: supple, no JVP.
Pulmonary: Lungs rhonchi at bases.
Cardiac: nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Gtube in place
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Pertinent Results:
Admission Labs:
[**2176-4-19**] 07:28PM WBC-12.3* RBC-3.78* HGB-11.9* HCT-34.7*
MCV-92 MCH-31.5 MCHC-34.3 RDW-16.2*
[**2176-4-19**] 07:28PM NEUTS-83.0* LYMPHS-10.8* MONOS-5.6 EOS-0.2
BASOS-0.3
[**2176-4-19**] 07:28PM PLT COUNT-254
[**2176-4-19**] 07:26PM LACTATE-1.6 K+-4.3
[**2176-4-19**] 07:28PM OSMOLAL-254*
[**2176-4-19**] 07:28PM ALBUMIN-3.8
[**2176-4-19**] 07:28PM LIPASE-28
[**2176-4-19**] 07:28PM ALT(SGPT)-28 AST(SGOT)-19 LD(LDH)-146 ALK
PHOS-73 TOT BILI-0.5
[**2176-4-19**] 07:28PM GLUCOSE-163* UREA N-11 CREAT-0.6 SODIUM-127*
POTASSIUM-4.3 CHLORIDE-86* TOTAL CO2-28 ANION GAP-17
Studies:
[**2176-4-19**] CXR: Increased reticular nodular interstitial opacities
of the right lung base. Given history, the possibility of
chronic or possibly acute on chronic aspiration is considered.
An early developing infiltrate, otherwise, may also account for
this appearance. Correlate clinically.
[**2176-4-19**] ECG: Atrial fibrillation with rapid ventricular response
and one ventricular premature beat. Diffuse T wave changes.
Since the previous tracing of [**2176-3-6**] the ventricular response
is markedly increased.
[**2176-4-20**] ECG: Sinus tachycardia with atrial premature beats.
Non-specific ST-T wave
abnormalities. Low QRS voltage in the limb leads. Compared to
the previous tracing of [**2176-4-19**] sinus tachycardia with atrial
premature beats has replaced atrial fibrillation.
[**2176-4-22**] CXR: 1. Persistent but decreased large right pleural
effusion with compressive
atelectasis. Concurrent infection cannot be excluded. Small left
pleural effusion.
2. Increased pulmonary vascular congestion since one day prior.
3. Stable right lung and chest wall postoperative changes.
[**2176-4-24**] Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
This is a 62 yo F with h/o squamous cell lung CA s/p induction
chemotherapy, radiation and surgical resection [RUL lobectomy]
as well as COPD who presents to ED with N/V/D/poor PO intake
noted to be hypotensive with diarrhea.
#, Hypotension: Her hypotension was thought to be due to
hypovolemia from dehydration and recent diarrhea in conjunction
with her continuing to take both her diltiazem and metoprolol at
home. [**Month (only) 116**] also have been related to underlying infection given
concern for a new infiltrate on CXR and h/o chronic aspiration
so vancomycin, cefepime and flagyl were started to cover broadly
for HCAP and aspiration. Her tachycardia, thought to be MAT or
AFlutter, was postulated to be contributing to the low BPs as
well so a diltiazem gtt was started with moderate decrease in HR
but minimal improvement in BP. The pt was gently resuscitated
with IVF boluses in the ICU and maintained sbp's in the high 90s
to low 100s consistently which trended up into the low 110s on
transfer to the floor. After transfer to the floor her BP
remained in normal range.
#. Tachycardia: She has a known history of either MAT or atrial
flutter managed on metoprolol and diltiazem. The tachycardia
improved with IVFs and diltiazem gtt. Gtt was weaned off as pt
was started on metoprolol and diltiazem po, both increased to
more than home dosing. HR in the 80s on transfer to the floor
and remained in normal range.
#. Hypoxia: She had a small O2 requirement on arrival from the
ED, likely [**1-23**] pneumonia on top of malignancy and COPD. The
patient was started on antibiotics as well as solumedrol 60 mg
q8h and started intermittent BiPAP on ICU day 2. The pt
tolerated BiPAP well, particularly at night, and was weaned off
as her respiratory status improved. She was discharged without
oxygen. She was given a quick 5 day burst of prednisone after
transfer from the ICU.
#. Pnuemonia: She completed an 8 day course of levofloxacin for
CAP, although was initially given broader spectrum antibiotics
for possible HCAP. She remained afebrile and her respiratory
status rapidly improved.
#. N/V/D: Pt noted to have profuse diarrhea prior to arrival in
the ICU however stool output was very modest while keeping pt
NPO. C.diff toxin and stool cultures were checked and were
negative. Flagyl for pts possible aspiration covered empirically
for C.diff while waiting for the toxin result.
#. DM2: Pt was maintained on NPH and ISS with QACHS FBSGs while
in the ICU. Metformin was held given pts elevated lactate on
admission. It was restarted at discharge. She had high blood
sugars immediately prior to discharge felt to be related to
steroid administration.
# CAD s/p MI-PTCA: No evidence of active ischemia in the ICU.
Held home beta blocker at first given relative hypotension,
continued daily ASA and statin. She was restarted on her home
meds at discharge.
# FEN: tube feeds that pt receives for poor pos/dysphagia
related to her cancer were continued
Medications on Admission:
Diltiazem 120mg SR daily
Prozac 20mg daily
Advair 250/50 1 puff twice daily
Magic mouthwash swish and spit
Meformin 850mg twice daily
Methadone 5mg/5mL-- 1m: per g tube and 0.5mL in PM
Metoprolol 25mg daily
Omeprazole 10mg daily
Zofran as needed
Prochloperazine 10mg every 6 hours as needed
Simvastatin 20mg daily
Tylenol 650mg daily
Loperamide 2mg every 6 hours as needed
Nebulizer 4times day
Insulin 70/10, 11 Units in the AM, 8 with dinner.
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO four times
a day.
Disp:*120 Tablet(s)* Refills:*2*
5. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Thirty (30) mL Mucous membrane four times a day
as needed for pain or difficulty swallowing.
6. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Methadone 5 mg/5 mL Solution Sig: One (1) mL PO qam (every
morning).
8. Methadone 5 mg/5 mL Solution Sig: 0.5 mL PO qpm (in the
evening).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
12. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for nausea.
13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
15. Loperamide 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for diarrhea.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1)
Nebulization Inhalation Q6H (every 6 hours) as needed for sob,
wheezing .
Disp:*50 doses* Refills:*2*
17. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Eleven (11) units Subcutaneous every morning.
18. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Eight (8) units Subcutaneous in the evening.
19. Mineral Oil Oil Sig: Two (2) Drop PO QID (4 times a day)
as needed for ear itching.
Disp:*1 bottle* Refills:*0*
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast infection.
Disp:*1 tube* Refills:*2*
21. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
22. Humalog 100 unit/mL Solution Sig: One (1) as directed per
sliding scale Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Multifocal Pneumonia
COPD
Lung Cancer
Secondary Diagnosis:
Supraventricular Tachycardia
Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital due to nausea and vomiting,
and were diagnosed with pneumonia. You were given IV
antibiotics for your pneumonia. You also were found to have
fluid around your right lung and you underwent a procedure to
remove this fluid (thoracentesis). The fluid collected because
of your pneumonia. You initially required oxygen while you were
in the hospital but your oxygen saturation improved and you no
longer required oxygen by the time of discharge. You were also
treated for a flare of COPD with prednisone and nebulizers.
You should also check your blood sugars very carefully over the
next several days as we have been giving you steroids which make
your blood sugars increase. Call your doctor if your blood
sugar is greater than 350 or less than 80.
Changes to your medications:
Changed diltiazem SR to diltiazem (short-acting) 90mg by mouth
four times daily
Changed metoprolol SR to metoprolol tartrate 50mg by mouth twice
daily
Followup Instructions:
You have the following appointments scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2176-5-17**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2176-5-17**] 10:30
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2176-5-17**] 11:40
|
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63,701
| 131,036
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40346
|
Discharge summary
|
report
|
Admission Date: [**2146-11-14**] Discharge Date: [**2146-11-29**]
Date of Birth: [**2074-3-2**] Sex: F
Service: MEDICINE
Allergies:
Levaquin / Latex / Keflex / Aspirin
Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Chest pain, shortness of breath, NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stenting of a vein graft
[**11-21**]
History of Present Illness:
Ms. [**Known lastname 27273**] is a 72F with H/O CABG [**56**] yrs ago, DM, HTN,
hyperlipidemia, chronic diastolic CHF, asthma/COPD on home O2,
atrial fibrillation not on Coumadin (hx of cerebral aneurysm s/p
clipping) presenting from [**Hospital3 3583**] with 2 day history of
progressive worsening chest tightness and SOB. She has a
baseline chronic productive cough which worsened over the 2 days
prior to presentation; it did not respond to her home nebs and
and she developed SOB at rest. She concurrently had intermittent
2/10 chest pain which was substernal and radiating to her Right
shoulder, associated with diaphoresis. She also noted blood
tinged phlegm 2 days prior to presentation to OSH, but no
fevers, rigors or chills. Of note, the patient has chronic lower
extremity edema with no significant changes from baseline.
At the OSH, her troponin peaked at 16.5, CK of 513. She was
given Lovenox and Plavix at the OSH. Also given vancomycin 1 g,
Zithromax IV 500mg and started on prednisone 40 mg daily for
possible COPD exacerbation. EKG showed a-fib with underlying
LBBB and freq PVCs; no significant changes noted from prior, no
ST-T changes. CXR showed mild bilateral pleural effusion; final
report pending. The patient was transferred to [**Hospital1 18**] for cardiac
catheterization tomorrow, chest pain free and in stable
condition.
Labs at OSH: [**11-14**] WBC 16.1, RBC 3.91, HGB 12.2, HCT 35.3, Plt
216; Na 137, K 4.4, Cl 102, CO2 28, BUN 37, Cr 1.46, Gluc 418.
ABG on [**11-13**] @ 8am pH 7.36, pCO2, 47.9, PO2 94.4, O2sat 97.2,
CO2 27.8, FiO2 36%. BNP 556.
[**11-14**] CPK 431 (peak 513), CKMB 42.0, trop 16.5 <-- 13.01 <--
9.97 <-- 4.0 <-- 0.11
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, black stools or red
stools (last bloody stool 1 year ago, hx of UC). She denies
recent fevers, chills or rigors. She denies exertional buttock
or calf pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CAD RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: CAD, s/p MI x 2, chronic atrial
fibrillation, not anticoagulated, chronic diastolic CHF, last
echo [**2145-3-5**] LVEF 61% w/ mod LV hypertrophy and L atrial
dilation
-CABG: 20 yrs ago
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Asthma
COPD on 2L home O2
Left great toe non-healing ulcer followed by vasc surgery
Mild chronic kidney disease from DM/HTN
DJD
MRSA
Ulcerative colitis
Incisional hernia
hx cerebral aneursym, s/p clipping 30 yrs ago w/residual R pupil
defect and strabismus
hx of AAA s/p repair at [**Hospital1 112**] in the 90s
Social History:
-Lives with husband; 4 children.
-Tobacco history: quit in [**2124**]
-ETOH: denies
-Illicit drugs: denies
Family History:
Mother w/ DM died from CVA; father w/ DM died from complications
w/gangrene, 1 brother w/ DM and died from PNA.
Physical Exam:
On admission:
GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
Wt: 91.6 kgs
VS: T= 98.1, BP= 156/66, HR= 89, RR= 20, O2 sat= 92% on RA
HEENT: NCAT. Sclera anicteric. R pupil minimally reactive, R eye
unable to cross midline. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma. NC in place.
NECK: Supple with JVP of 6 cm.
CARDIAC: Irreg irreg, normal S1, S2. No murmurs, rubs or
gallops. No thrills, lifts.
LUNGS: Well healed sternotomy scar. 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 abdominal bruits.
EXTREMITIES: No clubbing or cyanosis. Minimal edema bilaterally.
SKIN: No stasis dermatitis, scars, or xanthomas. Healing L great
toe ulceration.
PULSES:
Right: Carotid 1+ Radial 2+ DP 1+ PT 1+
Left: Carotid 1+ Radial 2+ DP 1+ PT 1+
On day of discharge:
Wt: 88.5kg. Rest of exam unchanged from admission
Pertinent Results:
Admission Labs:
[**11-14**]: WBC: 17.8 H/H: 12.4/36.9 PLT: 205
Glc:231 BUN: 41 Cr: 1.2 Na: 137 K: 3.8 Cl: 99 HCO3: 31
[**11-15**]: Cholest Triglyc HDL CHOL/HD LDLcalc
187 [**Telephone/Fax (2) 88488**]
Troponins: 1.33-1.16-1.44-1.1-1.33-1.92--0.92-0.84
ANCA negative
Discharge labs:
[**11-29**]: WBC: 8.2 H/H: [**10-31**] PLT: 274
Glc: 144 BUN: 33 Cr: 1.6 Na: 140 K: 3.9 Cl: 100 HCO3: 33
[**2146-11-15**] CXR: 1. pulmonary edema. 2. Asymmetric density in the
right upper lobe and right paratracheal region merits further
evaluation on a followup chest radiograph after diuresis to
exclude right upper lobe infection and right paratracheal
adenopathy.
[**2146-11-22**] CXR: As compared to the previous radiograph, there is
unchanged moderate cardiomegaly, a small left pleural effusion,
small retrocardiac atelectasis and evidence of mild
overhydration. The pre-existing right upper lobe and perihilar
parenchymal opacities unchanged in extent.
No newly appeared focal parenchymal opacities. Unchanged
alignment of sternal wires, unchanged position of right-sided
PICC line.
[**2146-11-16**] Echocardiogram:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is severe regional left ventricular systolic dysfunction with
near-akinesis of the inferior wall and inferior septum and
hypokinesis of the other segments. The right ventricular cavity
is mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension.
IMPRESSION: Moderate symmetric LVH. Severe regional and mild
global hypokinesis. Moderate mitral regurgitation, probably due
to posterior leaflet tethering. Dilated and hypokinetic right
ventricle.
[**2146-11-21**] Cardiac catheterization:
1. Coronary angiography demonstrated the following: LMCA 100%
proximal occluded and RCA 100% proximally occluded.
2. Saphenous graft angiography demonstrated a Y graft with RCA
limb occluded proximally and the OM limb with a proximal 95%
graft stenosis.
3. Arterial conduit angiography demonstrated a patent left
internal mammary artery to the LAD.
4. Resting hemodynamics revealed a SBP of 135 mmHg and a DBP 56
mmHg. Right heart cardiac catheterization revealed the following
pressures (mmHg): RA 19, RV [**2107-8-24**], PA 71/32/49 and PCWP 31.
Fick cardiac output was 4.79 L/min and Fick cardiac index was
2.58 L/min/m2.
4. Successful stenting of the proximal 95% stenosis in the OM
limb of the Y graft with a VISION Rx 3.5x18 mm bare-metal stent
(BMS) deployed at 19 atm. Final angiography revealed normal
flow, no angiographically apparent dissection and 0% residual
stenosis in the stent. (see PTCA comments)
5. R 6Fr femoral artery angioseal closure device deployed
without complications.
6. R 8Fr femoral vein sheath sutured into position for removal
post procedure.
R Femoral Vascular U/S [**2146-11-27**]:
There is no evidence of femoral artery pseudoaneurysm, or AV
fistula at the site of catheterization. There is no fluid
collection or hematoma.
Brief Hospital Course:
72F with CAD S/P CABG, DM, HTN, hyperlipidemia, chronic
diastolic CHF, asthma/COPD on home O2, atrial fibrillation not
on Coumadin (H/O cerebral aneurysm s/p clipping) presenting from
OSH with progressive worsening chest tightness and SOB leading
to diagnosis of NSTEMI and transferred for cardiac
catheterization.
# CAD: Known CAD with history of MIx2, CABG [**56**] years ago.
Presented to OSH with NSTEMI, trop peak of 16.5, CK 513. Given
Lovenox at OSH. She had episode of [**9-13**] non-radiating chest pain
with nausea yesterday that resolved with SL TNG x 3, additional
2 episodes overnight that self resolved. Difficult to assess EKG
changes due to LBBB, troponin bumped up to 1.1->1.33, CKs flat.
Cath canceled twice due to respiratory status and persistent
blood tinged sputum. Heparin gtt was initially stopped secondary
to hemotpysis; however, it was restarted due to ongoing chest
pain. Pulmonary cleared patient for cath, planned for [**11-18**].
However, patient developed nausea and epigastric pain, became
hypotensive and was found to have guaic positive stools. She was
transferred to the CCU for closer monitoring. The patient
underwent cardiac cath on [**11-21**] after she became hemodynamically
stable, which revealed PCW 31, PA 49, LMCA 100% proximal, RCA
100% proximal, Y graft with limb to RCA proximally occluded and
limb to OM 95% proximal stenosis; other vein probably stump
occluded; BMS was placed in OM graft. The patient was started on
ASA 325mg (despite H/O epistaxis on full dose ASA, had no
further episodes of epistaxis noted). We increased beta blockade
to 300 mg daily, continued high dose atorvastatin 80 mg daily.
She had been Plavix loaded at the OSH, and we continued Plavix
75 mg daily, which should be continued to 1 month, 3 months
preferably. Post-cath course complicated by Right groin
tenderness on post-cath day 6; ultrasound revealed no fistula or
pseudoaneurysm, and symptoms resolved.
# PUMP: Worsening LV function; LVEF reported to be 61% from OSH,
chronic diastolic CHF with chronically elevated BNP per outside
records. Our echo revealed LVEF of 20-25%. Worsening of LE edema
and respiratory status s/p pre-cath hydration; respiratory
status improved with diuresis. Due to increased pressures seen
on cardiac cath, the patient was diuresed with Lasix gtt and
transitioned to torsemide 60 mg twice daily with daily potassium
repletion. This was decreased to 60 mg torsemide daily with no K
supplementation at discharge. We continued valsartan 80mg daily,
metoprolol.
# RHYTHM: Persistent atrial fibrillation, not anticoagulated
(beyond ASA+Plavix) due to distant history of cerebral aneurysm.
We continued rate control with metoprolol, full dose ASA and
intermittent heparin gtt.
#: Melena: No prior GIB, 1 episode noted prior to transfer to
CCU; GI consulted. Unclear if this was ingested blood versus
slow upper GI bleed, not hemodynamically significant. She
received 1 U PRBCs on admission to the CCU and was started on an
high dose IV PPI. She continued to have guaiac positive stools
post-cath, but remained hemodynamically stable. Hct dropped to
trough of 26.8, received 1 uPRBC while in CCU prior to cath. Hct
27 on day of discharge; she was transitioned to PO PPI, will
have her continue as outpatient. She will follow-up with GI as
outpatient for possible endoscopy.
# Asthma/COPD/bronchitis: 2 L/min supplemental O2 requirement at
baseline while patient asleep or at rest. She was noted to
desaturate to mid 80s with ambulation; she notes no history of
this, and her ambulatory sats improved with diuresis to the low
90s. Concern for COPD exacerbation/PNA at OSH, received
vancomycin 1 gm x 1, azithromycin IV 500 mg x 1 and started on
prednisone. She completed a course of vanc/azithromycin and
prednisone taper for concern for acute bacterial
bronchitis/pneumonitis or COPD exacerbation. She developed blood
tinged sputum with heparin gtt, which was evaluated by
pulmonology. Cardiac cath was initially deferred for hemoptysis,
but pulmonary cleared her for cath and her hemoptysis improved
throughout admission despite ongoing anticoagulation. We
switched the patient to xopenex [**3-8**] tachycardia noted after
albuterol treatment. Patient will require PFT and pulmonology
follow-up as an outpatient; no need for repeat imaging per pulm
and radiology as the abnormal finding at OSH consistent with
ectatic vasculature involving the aorta.
# HTN: BP 127/58 this AM. Increased metoprolol to 300mg daily,
home Diovan d/c'd during stay in CCU, but resumed before
discharge.
# DM: Unknown HgbA1c. Continued home regimen of 70/30 and
covered the patient on insulin sliding scale. Will have patient
restart home regimen upon discharge.
# CRI: unknown baseline, Cr 1.4 at OSH, 1.6 the AM of discharge.
We avoided nephrotoxic medications and administered pre-cath
Mucomyst; pre-hydration was held due to fluid overload/poor
cardiac function. Will have labs drawn later this week.
# Hyperlipidemia: No record of last lipid panel. We continued
home atorvastatin 80mg daily.
# UTI: Found at OSH, Asx. Repeat UCx negative, patient completed
a 3 day course of doxycycline.
# ? Hilar adenopathy: found on chest CT at OSH. However, on
further review of the images by the pulmonologists and
radiologists, it appears to be ectatic vasculature involving the
aorta and will not require follow-up imaging per pulmonary.
# Leukocytosis: 17.8 on admission, now resolved 8.2 on AM of
discharge). [**Month (only) 116**] have been due to steroids or infection. All
cultures to date negative. Legionella antibody negative.
Medications on Admission:
ASA 81 mg daily
Spiriva 18 mcg inh daily
albuterol inh/neb q4h prin
metoprolol 100 mg [**Hospital1 **]
Diovan 80 mg daily
atorvastatin 80 mg daily
Lasix 40 mg daily
potassium supp 1 tab daily
insulin 70/30 45 units in AM, 35 units in PM
Vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily)Disp:*30 Tablet(s)* Refills:*0*
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
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).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Can give up to 3 times, 5 minutes apart. Disp:*30 Tablet,
Sublingual(s)* Refills:*0*
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1-3 months: *3 months recommended. Disp:*30 Tablet(s)*
Refills:*3*
8. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: Forty Five (45) units Subcutaneous q AM.
9. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: 35 units Subcutaneous q PM.
10. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
11. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
13. Outpatient Lab Work
Please check serum sodium, potassium, chloride, bicarbonate,
BUN, creatinine, calcium, and magnesium. Fax results to
Attention Dr. [**Last Name (STitle) 84367**] at [**Telephone/Fax (1) 88489**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
- Coronary artery disease with non-ST segment elevation
myocardial infarction and prior coronary artery bypass surgery
with documentation of vein graft occlusion and stenosis.
- Chronic atrial fibrillation
- Chronic left bundle branch block
- Acute on chronic left ventricular systolic and diastolic heart
failure
- Hypertension
- Diabetes mellitus
- Dyslipidemia
- Hemoptysis
- Abnormal radiographic findings of the chest
- Guaiac positive stools, possible gastrointestinal bleeding,
melena
- Acute blood loss anemia
- Urinary tract infection
- Presumed pneumonia and/or bronchitis
- Chronic obstructive lung disease and/or asthma
- Peripheral arterial disease
- Leukocytosis
- Chronic renal insufficiency
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 during your admission at
[**Hospital1 18**]. You were admitted due to having a heart attack. We had
difficulty with performing your cardiac catheterization due to
the blood tinged sputum that you developed while on heparin and
the blood we found in your stool. You eventually underwent a
cardiac catheterization and a bare metal stent was placed in one
of your coronary arteries.
There was question of concerning findings on your chest CT scan
from the outside hospital; however, upon further review of the
images by the radiologists and pulmonologists, it appears that
the abnormal finding is due to a bundle of blood vessels. You
will not require follow-up imaging of your chest. However, it
has been recommended that you have pulmonary function tests
performed as an outpatient. Also, you should follow-up with a
gastroenterologist as you were found to have blood in your stool
during your admission. The gastroenterologist can tell you
whether you can stop the pantoprazole or take it less
frequently.
Please make the following changes in your medication:
- START Plavix 75mg daily for 1 to 3 months (3 months preferred)
- INCREASE aspirin to 325mg daily
- START Toprol XL (metoprolol succinate) 300mg daily
- START pantoprazole 40mg twice daily
- START torsemide 60mg daily
- STOP metoprolol tartrate
- STOP lasix
**Please do not stop taking Plavix or aspirin unless directed to
do so by a cardiologist**
Please continue all other medications as prescribed.
You should have your labs checked on Thursday, [**12-1**] and the
results faxed to Dr.[**Name (NI) 88490**] office.
You should call your doctor if your weight increases by more
than 3 pounds or you notice difficulty breathing or increased
leg swelling.
Followup Instructions:
You should go to the lab at [**Hospital3 3583**] ([**0-0-**]) on
Thursday, [**2146-12-1**] with the prescription you are given to have
labwork drawn. The results should be faxed to Dr.[**Name (NI) 88490**]
office at [**Telephone/Fax (1) 88489**].
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C.
Location: [**Location (un) **] [**Location (un) **] PRIMARY CARE
Address: [**Location (un) 88491**] [**PO Box 88492**], [**Location (un) **],[**Numeric Identifier 85843**]
Phone: [**Telephone/Fax (1) 84368**]
Appointment: Friday, [**12-2**] at 10am
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD (Cardiology)
Address: [**Doctor Last Name 88493**], [**Location (un) 3320**], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
Appointment: Thursday, [**12-8**] at 9:40am
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Gastroenterology)
Location: [**Location (un) **]-[**Location (un) **] PRIMARY CARE
Address: [**Apartment Address(1) 73839**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 13266**]
Appointment: Friday, [**12-9**] at 10:45AM
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 13378**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: [**Doctor Last Name 88494**], MIDDLEBRO,[**Numeric Identifier 77413**]
Phone: [**Telephone/Fax (1) 88495**]
Appointment: Monday, [**12-12**] at 1:30PM
Name: [**Last Name (LF) 32599**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: PULMONARY & PRIMARY CARE ASSOCIATES, PC
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 18696**]
Appointment: Friday, [**12-16**] at 11:45AM
(They should consider ordering pulmonary function tests and
evaluating the need for nocturnal oxygen supplementation)
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,970
| 100,126
|
36880
|
Discharge summary
|
report
|
Admission Date: [**2196-6-10**] Discharge Date: [**2196-6-14**]
Date of Birth: [**2145-1-10**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51M restrained driver s/p T-bone motor vehicle crash with + LOC.
He was taken to an area hospital where found to have mulitple
injuries and was then transported to [**Hospital1 18**] for further care.
Past Medical History:
HTN, kidney stones, GERD
Family History:
Noncontributory
Physical Exam:
Upon exam:
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: In cervical collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.5 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-10**] throughout. No pronator drift
Sensation: Intact to light touch throughout.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal rapid alternating movements
Pertinent Results:
[**2196-6-10**] 11:38PM GLUCOSE-158* UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2196-6-10**] 11:38PM WBC-17.6* RBC-4.61 HGB-14.1 HCT-40.0 MCV-87
MCH-30.6 MCHC-35.2* RDW-14.4
[**2196-6-10**] 11:38PM PLT COUNT-302
[**2196-6-10**] 11:38PM PT-13.1 PTT-21.5* INR(PT)-1.1
[**2196-6-10**] 08:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-6-10**] 08:54PM WBC-23.7* RBC-5.03 HGB-15.2 HCT-44.6 MCV-89
MCH-30.1 MCHC-34.0 RDW-14.0
CT Head [**2196-6-10**]
IMPRESSION:
1. Longitudinal left temporal bone skull base fracture appears
to spare the carotid canal. This fracture does traverse the
middle ear and ossicular disruption cannot be excluded.
2. Small left posterior frontal subarachnoid hemorrhage.
3. Asymmetric left occipital hypoattenuation is suggested and
acute infarct cannot be excluded. Recommend MRI/MRA versus CTA
for further evaluation
CT C-spine [**2196-6-10**]
IMPRESSION: Non-displaced fracture of right intra-articular
portion of C7, as described. No other fracture or listhesis.
CT Chest/Abdomen/Pelvis [**2196-6-10**]
IMPRESSION:
1. Moderately large mesenteric hematoma may represent a
significant vascular injury to small bowel.
2. Left inferior pole renal infarct. While the left renal artery
appears
intact, a dissection cannot be excluded and CTA is recommended
for further
evaluation.
3. Nondisplaced right first rib fracture.
4. Bilateral transverse process fractures at L3 with left
transverse process fracture at L4.
5. Bibasilar consolidations and lingular consolidation likely
represent
atelectasis, however a component of aspiration is not excluded.
5. Right adrenal nodule, too small to characterize.
CTA Head/Neck [**2196-6-11**]
IMPRESSION:
1. Left parietal subarachnoid hemorrhage is less apparent. No
new
hemorrhage.
2. Normal CT angiography of the neck.
3. Normal CT angiography of the head.
4. Fracture of right C7 is visualized extending to the
transverse foramen,
but the vertebral artery does not enter the foramen
transversarium at this
level but interrupts at C6 level. Right first rib fracture is
identified.
CT Right arm [**2196-6-11**]
FINDINGS: The distal humerus is normal in appearance. There is
no evidence
of acute fracture.
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery and
Orthopedic spine consulted because of his injuries. His left
parietal subarachnoid hemorrhage was managed non operatively;
serial head CT scans were performed and remained stable. He will
follow up with Dr. [**First Name (STitle) **] in 4 weeks for repeat head imaging.
He was noted with a skull base fracture through the left
temporal bone; dedicated CT of the temporal bone was done and he
will require outpatient follow up with ENT for audiogram.
His spine injuries were also managed non operatively with a hard
cervical collar to be worn at all times and a lumbar corset to
be worn when out of bed. He will follow up in 2 weeks with Dr.
[**Last Name (STitle) 363**], Orthopedic Spine surgery.
Orthopedics was consulted for concern of a possible right
humerus fracture given that patient had increased complaints of
right arm pain with movement and upon palpation. A CT of his arm
was performed and no fracture was identified. It was felt that
the pain he had been experiencing was likely related to the
cervical spine fracture and the dermatome path that followed
along the arm. He was started on Neurontin, Ultram and prn
Percocet for the pain which he reported as helpful.
He was evaluated by Physical therapy and was discharged to home
on hospital day 5 with specific instructions for follow up.
Medications on Admission:
hctz, nexium, simvastatin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours) as needed for constipation.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: DO NOT exceed 2,000mg in a day.
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Small subarachnoid hemorrhage
Basilar skull fracture
Left temporal bone fracture
C7 facet fracture
Bilateral tranverse process fractures L3 & left L4
Mesenteric hemotoma
Neuropathic pain
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
You must continue to wear the cervical collar at all times for
the next 10 weeks.
You will need to wear the corsett brace when out of bed for your
lumbar fractures.
Wear the sling for comfort on your left arm.
Return to the Emergency room if you develop any fevers, chills,
headache, weakness/numbness in any of your extremities,
shortness of breath, chest pain, nausea, vomiting, diarrhea,
loss of bowel or bladder function and/or any other symptoms that
are concerning to you.
Followup Instructions:
Follow up next week in [**Hospital **] clinic, you will need an audiogram at
this appointment as well. Call [**Telephone/Fax (1) 41**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 363**], Orthopedics Spine Surgery
for your spine fracture. call [**Telephone/Fax (1) 3573**] for an appointment.
Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery for your
subarachnoid hemorrhage. Call [**Telephone/Fax (1) 1669**] for an appointment.
Inform the office that you will need a repeat head CT scan for
this appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2196-6-22**]
|
[
"801.22",
"385.89",
"V13.01",
"923.11",
"272.4",
"338.11",
"805.4",
"E812.1",
"863.89",
"530.81",
"276.8",
"401.9",
"865.01",
"805.07"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6319, 6325
|
4143, 5507
|
295, 301
|
6579, 6659
|
1843, 4120
|
7189, 7909
|
596, 613
|
5583, 6296
|
6346, 6558
|
5533, 5560
|
6683, 7166
|
628, 811
|
232, 257
|
329, 532
|
1063, 1824
|
826, 1047
|
554, 580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,351
| 157,918
|
33001
|
Discharge summary
|
report
|
Admission Date: [**2121-6-20**] Discharge Date: [**2121-6-27**]
Date of Birth: [**2048-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Stridor
Major Surgical or Invasive Procedure:
Tracheal dilatation and endobronchial stent placement
History of Present Illness:
Mr. [**Known lastname **] is a 73 year old male w/ h/o HTN, asthma who has
had an unfortunate course over the last 2 months after initial
presentation [**2121-4-29**] for sore throat. Of note, he has also had
increasing dysphagia and weight loss of 40lbs over the last
several months. Since then, he was admitted for expedited workup
[**Date range (3) 76745**] of a neck mass thought to be thyroid CA.
He presented this am for endoscopic ultrasound for w/u of this
mass and was noted by GI to be stridorous. Anaesthesia was
called who was concerned about the pts airway and the pt was
referred to the ED. In the ED, he was noted to be stridorous
which per his report this has been worstening over the past 3
days. IP was called and took him to the OR this evening. They
performed repeated dilations of the trachea with a rigid bronch
and placed a 6cm tracheal stent which is 18mm in diameter. It
was also noted that the right vocal chord was paralyzed. Tumor
was noted to be eroding into his airway. He was extubated post
procedure and brought to the ICU.
On arrival to the ICU, the pt is sedated from his procedure but
denies pain. States he has some SOB
Past Medical History:
HTN
Asthma
H/o tobacco dependence
Social History:
50-60 pack year history; recently stopped smoking. Drank [**2-8**]
pints / week but not recently. Retired. Lives with wife.
Family History:
- No known fm hx of HTN, diabetes, or renal disease. Pt states
that his sister died of breast cancer in her 70's.
Physical Exam:
Tmax: 35.8 ??????C (96.5 ??????F)
Tcurrent: 35.8 ??????C (96.5 ??????F)
HR: 108 (107 - 108) bpm
BP: 149/78(96) {149/78(96) - 156/78(96)} mmHg
RR: 21 (21 - 22) insp/min
SpO2: 100%
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal
Pertinent Results:
Admission Labs:
[**2121-6-20**] 04:30PM WBC-23.5*# RBC-4.17* HGB-11.8* HCT-36.8*
MCV-88 MCH-28.3 MCHC-32.1 RDW-13.5
[**2121-6-20**] 04:30PM NEUTS-89.9* LYMPHS-4.3* MONOS-4.3 EOS-1.3
BASOS-0.2
[**2121-6-20**] 04:30PM PLT COUNT-297
[**2121-6-20**] 04:30PM PT-11.9 PTT-27.9 INR(PT)-1.0
[**2121-6-20**] 04:44PM LACTATE-2.2*
[**2121-6-20**] 04:30PM GLUCOSE-82 UREA N-27* CREAT-1.8* SODIUM-137
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
Studies:
[**2121-6-21**] CXR: No evidence of acute cardiopulmonary process.
Possible narrowing of the trachea at the cervical level.
Brief Hospital Course:
Mr. [**Known lastname **] is a 73 year old male with h/o HTN and asthma
who was admitted to the MICU for stridor due to a large mass
compressing his airway which required a tracheal stent
placement.
.
#. Stridor due to tracheal mass: His breathing significantly
improved after tracheal stent placement by IP on admission.
Several bronchoscopies with biopsies and an EGD with biopsies
were performed for further characterization of the mass, but a
final diagnosis was not available at time of discharge.
Flexible bronchoscopy on the AM of [**6-23**] (3 days after placement)
found that the stent had migrated lower and was pulled up to the
cricoid cartilage. Repeat biopsies of mass were taken at that
time and another flex bronch on [**6-25**] revealed no migration of
his stent and no further intervention was performed. Endoscopy
with biopsy was performed on [**6-26**] and significant for
non-obstructive mass visualized in middle third of esophagus.
He will likely get radiation to his mass as an outpatient, but
there was no indication for emergent XRT as an inpatient per the
rad/onc consult obtained. He was written for Mucomyst nebs q6h
and Duonebs q6h but the patient often refused them. He would
also often refuse chest PT. An outpatient steroid taper with
prednisolone prescribed for asthma was continued and completed
on [**6-25**]. If the patient were to become unstable from a
respiratory standpoint and require intubation, it would likely
need to be done fiberoptically with a size 6 ETT along with
Heliox. The final pathology of his tumor will be followed up at
his outpatient oncology appointments.
.
#. Low-grade Fever: Continued to have low grade temperatures
daily most likely due to underlying tumor. CXR showed no
evidence of infection. He did have a leukocytosis but it
improved without antibiotic treatment. A UA and urine culture
was negative.
.
#. HTN: Continued on his home HCTZ and lisinopril with holding
parameters.
.
#. Asthma: Continued albuterol/ipratropium nebs as above. He
had been on a prednisolone taper at home since [**6-2**] for a
possible asthma exacerbation which was continued and ended on
[**6-25**].
.
#. Stage IV CKD. His creatinine remained slightly below his
previous baseline of 1.9-2.2.
.
#. Communication: Patient and wife [**Telephone/Fax (1) 76746**] (home),
[**Telephone/Fax (1) 76747**] (cell)
.
#. Code: Full (discussed with HCP in MICU)
Medications on Admission:
Aspirin 81 mg PO daily
Albuterol inhaler and nebulized solution
Hydrochlorothiazide 25 mg PO daily
Lisinopril 40 mg PO daily
Sodium Chloride 0.9% nebulized solution
Prelone 15mg/5ml oral solution
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Albuterol Sulfate 5 mg/mL Solution for Nebulization Sig:
0.5mL with 0.3mL normal saline ampule Inhalation every [**5-13**]
hours as needed for shortness of breath or wheezing.
3. Sodium Chloride 0.9 % Solution for Nebulization Sig: 3cc
ampule with 0.25cc of albuterol solution via nebulizer
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
4. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
5. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q3H (every 3
hours) as needed for pain.
Disp:*240 mL* Refills:*0*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours).
Disp:*360 ML(s)* Refills:*2*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 nebs* Refills:*2*
12. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing: Please use with spacer.
Disp:*1 inhaler* Refills:*2*
13. Spacer
Please provide the patient with a spacer for his inhaler.
Dispense-1 spacer, No refills
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Squamous cell carcinoma, likely of esophageal origin
Secondary Diagnosis:
Chronic renal insufficiency
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for evaluation of stridor,
which means that your breathing tube was narrowed causing noise
when you breathe. You had a procedure where a stent was placed
in your airway to help keep it open. You then had two more
similar procedures to look into your breathing tube to make sure
the stent was in place and also to get biopsies of the mass that
was found in your breathing tube. You also had another
procedure called an EGD which showed that the tumor was also
present in your eating tube. The final report on the type of
tumor you have is still pending. You will need radiation as an
outpatient to help prevent the tumor from continuing to grow
which would cause blockage of your breathing or eating tubes.
.
The following changes have been made to your home medication
regimen:
- You have been started on several medications to help your
breathing including Mucomyst, ipratropium nebs, Combivent
inhaler
- Your pain will be controlled with oxycodone extended release
20mg tablets twice daily and oxycodone liquid 10mg every 3 hours
as needed for pain
- You should be on a bowel regimen with Senna and Colace because
the pain medication will make you constipated
Followup Instructions:
You have the following appointments scheduled in follow-up:
.
1. Primary care physician-- [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11980**], MD
Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2121-7-1**] 9:00AM
.
2. Radiation Doctor-- Provider: [**First Name4 (NamePattern1) 2353**] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 9710**] Date/Time:[**2121-7-3**] 8:30AM in [**Hospital 332**] [**Hospital 1422**]
Clinic
.
3. Kidney doctor-- Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2121-7-8**] 10:30AM
.
4. Cancer doctor-- Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**]
Date/Time:[**2121-7-8**] 10:30AM in [**Hospital Ward Name 23**] 9 Clinic
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"V10.79",
"478.32",
"197.3",
"244.9",
"288.60",
"780.61",
"785.0",
"493.90",
"585.4",
"305.1",
"307.9",
"193",
"403.90",
"150.4",
"V16.3",
"788.41",
"V16.0",
"196.0",
"553.3",
"294.8",
"E945.7",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"33.23",
"31.99",
"31.44"
] |
icd9pcs
|
[
[
[]
]
] |
7760, 7818
|
3458, 5864
|
322, 377
|
7991, 7991
|
2846, 2846
|
9367, 10318
|
1778, 1893
|
6110, 7737
|
7839, 7839
|
5890, 6087
|
8142, 9344
|
1908, 2827
|
275, 284
|
405, 1564
|
7933, 7970
|
2862, 3435
|
7858, 7912
|
8006, 8118
|
1586, 1621
|
1637, 1762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,310
| 180,608
|
18072+56860
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-3-23**] Discharge Date: [**2116-3-26**]
Service: VSU
CHIEF COMPLAINT: Nonhealing ischemic right heel ulceration.
HISTORY OF PRESENT ILLNESS: This is an 88-year-old gentleman
with known peripheral vascular disease who underwent a right
fem to AK [**Doctor Last Name **] bypass graft with PTFE for claudication in
[**2113-2-18**]. The patient's graft thrombosed and he
underwent thrombectomy with graft revision, femoral to AT
bypass, in [**2113-12-21**]. Follow-up duplex after this surgery
showed distal graft stenosis. The patient underwent AVD jump
graft from the fem AT graft to the distal AT with nonreversed
greater saphenous vein in [**2114-12-22**]. The patient returns
now for a diagnostic arteriogram secondary to right foot rest
pain and chronic nonhealing ulcers on the right heel. The
patient is admitted postarteriogram for vascular monitoring,
hydration, and elective bypass surgery. The arteriogram
demonstrated right renal artery was single. The left renal
artery was a duplicate with stenosis of the superior artery.
The left iliac common was stenosed 50 percent. The right and
left external/internal iliacs were patent. The right common
femoral was occluded but reconstructed by the right internal
iliac artery by collaterals. The femoral and popliteal
arteries were occluded with collateralization of the anterior
tibial by the anterior tibial. The tibial peroneal trunk was
diseased. The posterior tibial peritoneal were occluded. The
anterior tibial perfused the dorsalis pedis which was patent.
The peroneal fills distally by collaterals. The plantars were
diseased.
REVIEW OF SYSTEMS: Negative for stroke, shortness of breath,
dyspnea on exertion, PND, peptic ulcer disease, bowel
changes, gallbladder or liver disease, back pain, renal
stones. He does have a history of arrhythmia as he is status
post pacemaker/AICD for type 2 AV block/Wenckebach. Also
history of angina described as chest pressure, last episode
was 2 months ago relieved with a singular nitroglycerin.
Frequency is infrequent. The patient is also hard of hearing,
left greater than right.
ALLERGIES: Contrast causes hives.
MEDICATIONS ON ADMISSION:
1. Folic acid 1 mg a day.
2. Mirtazapine 15 mg [**12-23**] tablet at bedtime.
3. Nexium 40 a day.
4. Lopressor 75 mg b.i.d.
5. Lisinopril 2.5 mg daily.
6. Lipitor 20 mg daily.
7. Isosorbide 10 mg t.i.d.
8. Lasix 40 mg a day.
9. Digoxin 0.125 a day.
10. Plavix 75 mg a day.
11. Sublingual nitroglycerin 0.4 mg p.r.n.
12. Mobic 7.5 mg a day p.r.n.
SOCIAL HISTORY: The patient lives with a daughter. [**Name (NI) **] denies
tobacco or alcohol use.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a myocardial infarction,
remote, with an EF of 20 percent.
2. History of hypertension.
3. History of secondary AV block with Wenckebach phenomena,
status post AIC pacemaker.
4. History of hyperlipidemia.
5. History of bilateral renal artery stenosis by
arteriogram.
6. History of depression.
7. History of chronic anemia.
8. History of congestive heart failure compensated.
9. Questionable history of CVA as recorded in the previous
hospital documents, the patient denies or recalls having
a CVA.
PHYSICAL EXAMINATION: Vital signs were stable. He is
generally oriented x 3, extremely hard of hearing. HEENT:
Bilateral carotid bruits. No JVD. No thyromegaly. Lungs:
Clear to auscultation bilaterally. Heart: Irregular rhythm
with extra beats. There was no murmur, gallop, or rubs.
Abdomen: Unremarkable. Without bruits or masses. Peripheral
vascular exam: Right foot rubrous toes x 5. The right heel is
a small pinpoint area of dry gangrenous changes. Office exam
shows palpable radials bilaterally. Femoral on the right is
Dopplerable signal only. On the left is palpable 2 plus. The
right popliteal is absent. The left popliteal is 1 plus
palpable. The DP and PT are monophasic on the right. The
graft is monophasic on the right. The DP and PT on the left
are biphasic Dopplerable signals. Left groin is clean, dry,
and intact without hematoma. Neurological exam shows oriented
x 3 with a mild left foot drop.
HOSPITAL COURSE: The patient was admitted post angio to the
vascular service and was prepared for surgery. He had a
carotid ultrasound done which showed right internal carotid
had 40-59 percent stenosis. The left less than 40 percent
stenosis with patent vein studies. The left greater saphenous
was patent as well as the left basilic and cephalic vein. The
patient underwent an echocardiogram which showed an ejection
fraction of 40 percent with mild level ventricular
hypertrophy. The left ventricle showed hypertrophy. The left
ventricular cavity size was borderline and dilated. The
overall left ventricular systolic function is severely
depressed with an EF of 25 percent. The resting regional wall
abnormalities include an inferior, inferolateral akinesis
with hypokinesis and akinesis elsewhere. There was no LV
thrombus, right-sided [**Doctor Last Name 1754**] were normal. The aortic root
was mildly dilated. The ascending aorta was mildly dilated.
Aortic valves were trileaflet with mild thickening. There was
no aortic stenosis or aortic regurg. Mitral valve leaflets
were mildly thickened with mild mitral regurg of [**12-23**] plus.
The tricuspid valves were mildly thickened with moderate
tricuspid regurg. There was mild pulmonary systolic
hypertension.
The patient proceeded to surgery on [**2116-3-24**] and
underwent a right femoral artery endarterectomy and a right
fem to AT bypass graft with PTFE. He tolerated the procedure
well and was transferred to the PACU in stable condition
where he developed decreased urinary output and the right
groin dressing was saturated. The patient's heart rate was
68, blood pressure 155/70. PA pressures were 35/20, CVP 6.
The 02 sat was 100 percent on 3 liters. The patient was given
a liter bolus with improvement in his urinary output. He
returns to surgery for evacuation of a groin hematoma with
ligation of a vein branch bleeder. The patient tolerated the
procedure well and was returned to the PACU in stable
condition. He remained hemodynamically stable. His dressings
remained dry and intact and he had a Dopplerable palpable DP.
His hematocrit was 39.1. The patient continued to do well
from a hemodynamic standpoint with borderline urinary output
and he was transferred to the VICU for continued monitoring
and care. IV heparinization was started at 500 units per
hour.
Postoperative day number 1 was marked with overnight
confusion requiring a sitter for the patient. IV fluids were
Hep-locked. He was maintained on a heparin drip.
Anticoagulation with Coumadin 5 mg was instituted. His diet
was advanced as tolerated. His fluids were Hep-locked. He
remained in the VICU.
On postoperative day #2 there were no overnight events. He
was afebrile. Ambulation was begun. Physical therapy was
requested to see the patient and assist with discharge
planning. The patient will be discharged to home versus rehab
pending on physical therapy's assessment and when he is
medically stable.
DISCHARGE MEDICATIONS:
1. Folic acid 1 mg daily.
2. Mirtazapine 7.5 mg daily.
3. Protonix 40 mg a day.
4. __________ 75 mg b.i.d.
5. Lisinopril 2.5 mg daily.
6. Atorvastatin 20 mg daily.
7. Isosorbide dinitrate 10 mg t.i.d.
8. Digoxin 125 mcg a day.
9. Oxycodone/acetaminophen 5/325 tablets [**12-23**] q.[**3-26**] h. p.r.n.
pain.
10. Bisacodyl tablets 5 mg delayed release 2 p.r.n. daily.
11. Colace 100 mg b.i.d., hold for loose stools.
12. Nitroglycerin 0.4 mg tablets sublingual p.r.n.
13. Lasix 40 mg a day.
14. Warfarin 5 mg a day at bedtime.
15. Sarna lotion to affected areas p.r.n.
DISCHARGE INSTRUCTIONS: The patient may ambulate essential
distances, full weightbearing with ACE wrap from foot to knee
on the operative side. Should follow-up with his primary care
physician within the week of discharge. He may shower but no
tub baths. When not ambulating, sitting in a chair his legs
should be elevated. Our office should be called if he
develops a fever greater than 101.5 or the wounds look
infected, there is groin swelling or drainage. The patient
should follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks time. He should
call for an appointment at [**Telephone/Fax (1) 1393**].
DISCHARGE DIAGNOSIS:
1. Heel ulceration with rest pain.
2. History of peripheral vascular disease, status post right
lower extremity bypass, thrombectomy, and graft revision.
3. History of hypertension.
4. History of coronary artery disease and myocardial
infarction, ejection fraction of 20 percent.
5. History of congestive heart failure, compensated.
6. History of hyperlipidemia, on statins.
7. History of AV block 2, status post AICD in [**Month (only) 404**] of
[**2114**].
8. History of chronic anemia.
9. History of depression.
10. Questionable history of cerebrovascular accident.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2116-3-26**] 12:10:31
T: [**2116-3-26**] 13:13:00
Job#: [**Job Number 50009**]
Name: [**Known lastname 9054**],[**Known firstname 1500**] Unit No: [**Numeric Identifier 9055**]
Admission Date: [**2116-3-23**] Discharge Date: [**2116-3-30**]
Date of Birth: [**2028-1-4**] Sex: M
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 231**]
Addendum:
Patient continued to do well, he was maintained on coumadin with
a therapeutic INR and was OOB with physical therapy. His right
heel ulcer was monitored and wound care was continued. He was
discharged to rehab on POD6 in good condition and will follow up
with Dr. [**Last Name (STitle) **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 6463**] Health of [**Hospital3 7189**] - [**Location (un) 7190**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2116-3-30**]
|
[
"272.4",
"440.23",
"311",
"413.9",
"E878.2",
"707.14",
"998.12",
"428.0",
"998.11",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.18",
"88.48",
"86.04",
"00.40",
"38.89",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
9847, 10109
|
7115, 7699
|
8334, 9824
|
2186, 2542
|
4158, 7092
|
7724, 8313
|
3247, 4140
|
1649, 2160
|
107, 151
|
180, 1629
|
2665, 3224
|
2559, 2643
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,552
| 153,595
|
8170
|
Discharge summary
|
report
|
Admission Date: [**2124-9-12**] Discharge Date: [**2124-9-13**]
Date of Birth: [**2050-2-8**] Sex: F
Service: NEURO MED
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female with a history of hypertension, transferred from
[**Location (un) **] [**Hospital1 **], where she was admitted with a sudden onset
of drowsiness after an occipital nerve block for occipital
neuralgia. Per the patient's neurologist's notes, she
complained of feeling weak, and then became unresponsive and
had some jerking eye movements to the right. Her oxygen
saturations dropped, and the patient was subsequently
intubated. The examination showed response to pain
bilaterally, and bilateral plantar flexor response. Initial
head CT was negative. The events occurred at 9 A.M., and the
patient was transferred to [**Hospital1 188**] at approximately noon.
She was initially admitted to the Medical Intensive Care
Unit, and then subsequently transferred to the Surgical
Intensive Care Unit.
PAST MEDICAL HISTORY: As above. Previous occipital blocks
have relieved occipital neuritis. Hypertension for 25 years,
cervical spondylosis.
MEDICATIONS: Atenolol.
PHYSICAL EXAMINATION: On admission, the patient was
intubated, on a ventilator, occasional over-breathing the
ventilator. She was afebrile, with stable vitals. The neck
was without bruits. Cardiovascular was regular rate and
rhythm. The chest was clear to auscultation. Neurological
examination: Initially the patient was awake, responding
appropriately to simple questions. Pupils were small and
unreactive to light. Eye movements were intact. There were
no horizontal eye movements. There was decreased tone
bilaterally. The patient was able to move her left toes on
command.
HOSPITAL COURSE: The patient was transferred to the
Surgical Intensive Care Unit after an MRI which revealed a
left medulla, left pontine, left cerebellar, and small left
thalamic infarction. In the Surgical Intensive Care Unit,
the patient was alert and following commands. Neurologically
she remained stable overnight. However, on the morning of
the 15th, the patient's T-max was 100.6. Vital signs were
otherwise stable on a Neo-Synephrine drip. The white count
had increased to 31, and the patient became minimally
responsive, only responding with the left lower extremity to
painful stimulus.
The Neurology team was informed, and a head CT was deferred
at this time. Throughout the day, the patient remained
minimally responsive. After discussion was held with the
family with the Neurology team and the Intensive Care Unit
team, the patient was made Do Not Resuscitate/Do Not
Intubate, and was extubated. The [**Hospital 228**] health care proxy
understood that this would likely result in the patient's
expiration.
Shortly after extubation, the patient expired. The patient
was pronounced dead at 10:10 P.M. on [**2124-9-13**]. The
Medical Examiner was informed, and declines autopsy.
CAUSE OF DEATH: Respiratory failure secondary to large brain
stem infarction
A separate Neurology Medicine discharge summary will follow.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] M. 11-685
Dictated By:[**Last Name (NamePattern1) 13197**]
MEDQUIST36
D: [**2124-9-14**] 02:57
T: [**2124-9-14**] 03:49
JOB#: [**Job Number 29062**]
|
[
"514",
"434.91",
"401.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1788, 3354
|
1202, 1769
|
172, 1006
|
1030, 1178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,931
| 197,108
|
8812
|
Discharge summary
|
report
|
Admission Date: [**2199-3-18**] Discharge Date: [**2199-3-22**]
Date of Birth: [**2132-7-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 yo right-handed M with history of renal/bladder cell
carcinoma s/p b/l nephrectomies c/b ESRD on HD x 3 weeks,
CABGx3, IDDM, HTN who presents with garbled speech, left arm
shaking, and left arm weakness after a fall two weeks ago. Two
weeks ago, he was trying to get through the doorway when he fell
backwards and hit the back side of his head without LOC.
Starting one week ago he started having daily morning episode of
garbled speech that would last 15-25 minutes without language
difficulties. Three days ago, he complained of left lip
numbness that last few seconds. On the day of admission at 3
am, his wife noticed left arm trembling x 1 min with then
occured again at 5 am while patient was asleep. He then woke up
at 6 am with inability to put his robe on because he had left
arm weakness. At [**Hospital 1727**] hospital he had 2 min GTC seizure after
getting out of car, requiring 1 mg ativan. OSH noted [**11-21**]
weakness of the left arm and got CT head that showed acute on
chronic left SDH. He was then transferred to [**Hospital1 18**]
.
Pt was loaded with dilantin 1 g, then bolused with 300 mg x2 for
continued seizure activity. Neurology and Neurosurgery both saw
the patient and recommend medical management. Serial CTs of
head did not shown any extension of the hematoma. His neuro
exams did not show focal neuro deficits.
Past Medical History:
1. transitional renal and bladder cancer s/p left nephrectomy
and
bladder removal in [**11/2195**], then right nephrectomy in [**2199-2-25**]
2. IDDM
3. HTN
4. Appendectomy
5. CAD s/p CABG
6. axonal and demyelinating sensorimotor polyneuropathy and
myopathy of unknown etiology, worked up by [**Location (un) **] [**Doctor Last Name 557**] with
muscle biopsy and EMG/NCS
Social History:
He is a former engineer who lives with wife. no tobacco or
ivdu. occasional etoh.
Family History:
non-contributory
Physical Exam:
V:
GEN: lying in bed, nad, communicating fluently
HEENT: eomi, perrl, mmm, op clear, no jvd
CV: rrr, nl s1/s2, no mrg
PULMO: crackles at bases anteriorly, portacath w/o signs of
edema, erythema, increased warmth; central line placed in left
subclavian
ABD: bs+, nt, nd, stoma on right lower abdomen w/o signs of
edema, erythema, increased warmth
EXT: warm, no c/c/e, 2+ left dp/pt pulses, 1+ right dp/pt pulses
NEURO: CN2-12 intact, strength equal b/l, biceps/platellar
reflexes equal b/l, sensation intact throughout.
Pertinent Results:
CT HEAD [**2199-3-18**]: moderate-sized subdural hemorrhage
surrounding the right superior parietooccipital region,
measuring 11.2 mm in maximum diameter. A small focus of
hypodensity within the anterior aspect of the hemorrhage
indicates possible acute supermiposed upon chronic bleeding.
There is minimal mass effect, and no shift of normally midline
structures. No additional areas of intracranial hemorrhage are
seen. There is no major vascular territorial infarction. Density
values of the brain parenchyma are preserved. The [**Doctor Last Name 352**]- white
matter differentiation is preserved. The surrounding soft tissue
and osseous structures are normal.
.
CT HEAD [**2199-3-19**]: Mixed density subdural hematoma is again
evident along the right cerebral convexity. This displaces the
right cerebrum away from the skull and there is narrowing of the
sulci of the superior frontal and parietal lobes, as well as the
inferior temporal lobe. There is mild mass effect on the right
lateral ventricle and mild shift of structures towards the left.
This is unchanged since the previous study. IMPRESSION: Stable
appearance of the brain, compared to the study of the previous
day.
.
[**2199-3-18**] 11:55AM BLOOD WBC-8.2 RBC-3.39* Hgb-10.3* Hct-30.8*
MCV-91 MCH-30.4 MCHC-33.5 RDW-17.1* Plt Ct-246
[**2199-3-22**] 05:27AM BLOOD WBC-5.0 RBC-3.90*# Hgb-11.6*# Hct-33.9*
MCV-87 MCH-29.7 MCHC-34.1 RDW-18.2* Plt Ct-159
[**2199-3-18**] 11:55AM BLOOD Neuts-85.9* Lymphs-7.2* Monos-5.2 Eos-1.1
Baso-0.6
[**2199-3-18**] 05:15PM BLOOD PT-13.3 PTT-22.3 INR(PT)-1.2
[**2199-3-20**] 02:19PM BLOOD Ret Aut-3.5*
[**2199-3-18**] 05:15PM BLOOD Glucose-144* UreaN-29* Creat-4.0* Na-139
K-3.7 Cl-94* HCO3-30* AnGap-19
[**2199-3-22**] 05:27AM BLOOD Glucose-108* UreaN-41* Creat-5.1*# Na-141
K-4.5 Cl-101 HCO3-26 AnGap-19
[**2199-3-18**] 07:43PM BLOOD Albumin-3.4 Calcium-8.7 Phos-3.6 Mg-1.6
[**2199-3-18**] 07:43PM BLOOD Phenyto-8.5*
Brief Hospital Course:
66M CAD s/p CABG, metastatic bladder cancer s/p b/l
nephrectomies c/b ESRD on HD x 3 weeks presents from OSH s/p
fall 2 weeks ago. Over past week, was noted by wife to have
garbled speech, and on day of presentation developed "shaking"
of left arm and generally looked unwell. At OSH, had witnessed
seizure; CT head showed SDH
.
FEVER: Fever at time of presentation which resolved early on in
hospitalizaiton. No obvious source was identified. Pt with
stoma on right lower abdomen and portacath in right thorax (both
did not show obvious signs of infection). Pt had no elevated
WBC, no symptoms. All blood cultures were negative.
.
SUBDURAL HEMATOMA: repeat CTs showed stable hematoma.
Neurologic checks did not reveal a change in neurologic
condition from time of admission. Neurosurgery followed Pt
during hospitalization and did not think surgucal intervention
to be appropriate.
.
SEIZURES: Question of generalized tonic clonic seizure activity
at presentation. Pt was loaded with dilantin and then given
standing dilantin therapy. Dilantin levels were followed and
doses adjusted accordingly. The Neurology service followed the
Pt during the hospitalization.
.
CV: s/p CABG. Continued bb, norvasc, lipitor; held asa, plavix
.
ESRD: HD as necessary. Continued tums, nephrocaps
.
DM: FS qid, RISS; diet controlled
Medications on Admission:
norvasc
asa 81
plavix
lopressor 50 [**Hospital1 **]
lipitor 10
nephrocap
tums
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*5*
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. regular insulin
sliding scale
8. Outpatient Occupational Therapy
cognitive therapy to address attention, memory.
9. Outpatient Physical Therapy
PT balance, transfers, ambulation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
--subdural hematoma
--generalized seizure
SECONDARY:
--metastatic bladder cancer
--insulin dependent diabetes
--hypertension
--coronary artery disease
--neuropathy
Discharge Condition:
stable subdural hematoma, no headaches, no visual disturbances
Discharge Instructions:
--Please take all medications as prescribed
--Please follow-up on all appointments
[**Hospital 30759**] medical attention if experiencing fever, headaches,
visual changes, dysequilibrium, chest pain, shortness of breath,
palpitaitions, nausea, vomiting.
Followup Instructions:
please call for an appointment with [**Last Name (LF) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 30760**]
within two weeks of discharge.
.
please call for an appointment within one month from time of
discharge with Dr. [**Last Name (STitle) 739**] (Neurosurgery) [**Telephone/Fax (1) 3571**]
.
please call for an appointment within one month from time of
discharge with Dr. [**First Name (STitle) **] (Neurology) [**Telephone/Fax (1) 30761**]
.
|
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icd9cm
|
[
[
[]
]
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[
"38.93",
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icd9pcs
|
[
[
[]
]
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7167, 7173
|
4745, 6077
|
321, 328
|
7389, 7453
|
2801, 4722
|
7755, 8211
|
2227, 2245
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6205, 7144
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6103, 6182
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7477, 7732
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2260, 2782
|
274, 283
|
356, 1714
|
1736, 2110
|
2126, 2211
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,924
| 155,590
|
27378
|
Discharge summary
|
report
|
Admission Date: [**2184-4-1**] Discharge Date: [**2184-4-14**]
Date of Birth: [**2153-10-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Iron
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
worsened dystonia, incontinence, worsened gait
Major Surgical or Invasive Procedure:
REMOVAL OF DBS BATTERIES AND HARDWARE
History of Present Illness:
Ms. [**Known lastname 67059**] is a 30 year old woman with intractable generalized
dystonia s/p bilateral DBS placement, with stage II placement on
[**3-15**], who now returns with worsening movement disorder,
inattentiveness and new onset urinary incontinence. Bilateral
Globus Pallidus interna DBS leads were placed [**2184-3-9**], stage II
operation on [**3-15**], the pt had worsened dystonic jerks, worsening
retrocollis, sleeping poorly, falling out of bed (a rare
occurrence at baseline) resulting in an abrasion to her forehead
walking into walls, and new onset urinary incontinence. The pt
was seen by Dr. [**First Name (STitle) **] today in [**Hospital **] clinic and referred to the ED
for urgent head CT and further evaluation.
In the ED, serum WBC elevated to 18.8, pt was given Ceftriaxone
2g IV, Vancomycin 1g IV. Ativan 2mg x 1. Propofol was needed for
sedation to obtain at Noncontrast head CT, which revealed R
frontal hemorrhage tracking down DBS lead with 4mm R-->L midline
shift. Patent ventricular system.
At present the pt and her family deny and fevers at home, or any
headache or neck pain. She has been pocketing food in her mouth.
She normally sustains eye contact, but per her sister now has a
right gaze preference. At baseline she attends a day program
where she makes jewlery. She completed high school and was able
to type a few words on the computer, but she is not fully
literate.
ROS: no fevers, no headache or neck pain. Denies SOB, CP.
Past Medical History:
1. Hypothyroidism
2. Dystonia, uncontrollable chorea
3. s/p DBS placement in [**2180**]
4. s/p DBS removal [**2181**]
5. s/p Baclofen pump placement
Social History:
resides at home with mother and sister in one level home.
Denies smoking, ETOH, or other substances.
Family History:
Non-contribuitory
Physical Exam:
Vitals: T 99.6, BP 114/94, HR 90, RR 14, 100% RA
Gen- intractable slow truncal posturing with retrocollis
followed
by occasional bilateral arm and leg movements, pt does not
appear
to be in distress. attends to examiner.
HEENT: R frontal and parietal surgical wounds appear
erythematous
with scale, left frontal and parietal surgical sites are CDI.
anicteric sclera, MMM, OP clear.
Neck- nontender, no rigidity, no carotid bruits bilat.
CV- RRR, no MRG
Pulm- CTA B
Abd- scar from prior baclofen pump in RUQ, nT, ND, BS+
Extrem- thin, L lateral malleolus appear erythematous and warm
vs. the right, non-tender to Passive and Active ROM. no CCE
NEUROLOGIC EXAM:
MS- nods/mouths yes or no to questions appropriately. She
follows
all midline and appendicular commands, but appears impersistent.
When asked to uncross her legs, she does so, but then re-crosses
the other leg. She waves goodbye appropriately.
CN- PERRL 4-->2, funduscopic exam could not be performed, EOM's
are intact without nystagmus, her face appear symmetric, no
facial weakness, localizes to finger snapping bilaterally,
palate
elevates symm, SCM and trap could not be tested, tongue
protrudes
at midline without fasciculation.
Motor- intractable slow truncal posturing with prominent
retrocollis followed by occasional bilateral arm and leg
extension. She has generalized muscle wasting. Her tone appears
increase throughout. She is able to hold her arms and legs
antigravity for 10 seconds bilaterally. Formal strength testing
was difficult.
Sensory- intact to light touch, PP, vibration throughout.
proprioception not tested.
Reflexes- difficult to obtain given mvmt disorder.
Right toe is upgoing (new per prior records), left toe is
equivocal.
Gait- did not test due to frequent movements.
ON DISCHARGE
Pt with increased awareness and level of consciousness. She is
oriented x 3 and able to make needs known through yes/no
questions and simple answers.
Her dystonia remains severe.
Her surgical incisions are well healed - the sutures have been
removed.
Pertinent Results:
[**2184-4-1**] 06:50AM GLUCOSE-91 UREA N-9 CREAT-0.4 SODIUM-138
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-28 ANION GAP-10
[**2184-4-1**] 06:50AM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.8
[**2184-4-1**] 06:50AM WBC-10.8 RBC-3.19* HGB-9.9* HCT-28.9* MCV-91
MCH-31.1 MCHC-34.4 RDW-12.3
[**2184-4-1**] 06:50AM PT-13.2 PTT-30.1 INR(PT)-1.1
[**2184-3-31**] 09:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2184-3-31**] 09:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2184-3-31**] 06:00PM GLUCOSE-106* UREA N-15 CREAT-0.5 SODIUM-141
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-32 ANION GAP-12
[**2184-3-31**] 06:00PM CRP-19.9*
[**2184-3-31**] 06:00PM WBC-18.8*# RBC-3.73* HGB-11.4* HCT-33.1*
MCV-89 MCH-30.7 MCHC-34.5 RDW-12.3
[**2184-3-31**] 06:00PM NEUTS-89.0* BANDS-0 LYMPHS-7.5* MONOS-2.6
EOS-0.5 BASOS-0.4
[**2184-3-31**] 06:00PM SED RATE-33*
CTH: [**3-31**]: 2.1 x 2.0 cm parenchymal hemorrhage in the right
frontal lobe along the course of the right deep brain stimulator
catheter. A tiny focus of air is noted in this region with edema
surrounding both stimulators suggests recent manipulation; this
could explain the hemorrhage. Please correlate with the
patient's history. There is associated 5 mm leftward subfalcine
herniation.
CXR: Limited evaluation due to patient rotation. Hazy opacity in
the right chest could be a summation artifact. A lateral view
would be helpful for further evaluation if indicated.
CT chest: IMPRESSION: Expiratory study showed posterior
dependent atelectasis. No evidence of lung consolidations,
masses, or abscess.
CTH+/-: [**4-1**]:
1. Right frontal hemorrhage with surrounding vasogenic edema; a
superimposed infection cannot be excluded but abscess formation
is not apparent on the present study.
2. No definate CTV evidence for venous sinus thrombosis.
3. Increased prominence of the right cavernous sinus of
uncertain clinical significance.
Brief Hospital Course:
Pt admitted to neurologic service with concern for CNS infection
after DBS placement on [**2184-3-14**]. Her Ct was noted to have
bilateral frontal edema and L midline shift - likely responsible
for her urinary incontinence and increased confusion. Pt with
elevated WBC and inflammatory markers concerning for infection.
Pt was started on broad spectrum coverage - vancomycin and
ceftazidime - per ID recommendations.
With concern for hardward infection, CTH +/- and CT chest +/-
was performed without evidence of abscess in either location,
although significant artifact from DBS hardware. US of area was
performed which demonstrates a small amount of subcutaneous
fluid over the anterior aspect of device. This fluid measures
2-3 mm which appears simple and encapsulated, conforming to the
anterior aspect of the device. No specific signs of infection
are detected such internal complexity or hyperemia on color
evaluation. An MRI of the brain was done which demonstrated 1.
Bifrontal edema along the proximal portion of the both
electrodes. The right-sided edema extends to the basal ganglia
region. 2. Hematoma in the right frontal lobe with intense
enhancement at the margin is suspicious for superimposed
infection. 3. Small acute infarct in the corpus callosum.
She was started on mannitol for 2 days and then weaned to off to
see if her mental status would improve with relation to the
cerebral edema and midline shift. Her exam did improve. Before
she was transfered out of the ICU, she had a picc line placed in
the left arm. For nutrition as well as failre to thrive, an NGT
was placed and feedings started. PEG placement was discussed
with the family and refused. Their concern was that she would
end up wiht another post operative infection. They also felt
that she was stressed and confined during the hospital stay and
she would do well at home. Her dobhoff was removed in the am of
[**2184-4-12**] mainly because it needed to be advanced and the
guidewire was out. She did not have feeds runnning at the time.
She was made NPO briefly for possible peg which was refused by
the family. PT and OT evals also were done - recommendations
were for the pt to go to rehab - the family is refusing this as
well.
Her antibiotics were switched to Nafcillin per ID recs. They
will continue until at least [**2184-5-15**] .
Her medications for her dystonia were adjusted by neurology and
are reflected in the discharge orders.
Sutures to her scalp and anterior chest wall were removed. She
remained afebrile during the course of her stay.
Medications on Admission:
synthroid 50mcg daily
Artane 8mg TID
clonazepam 2mg TID
Discharge Medications:
1. Outpatient Lab Work
PLEASE DRAW THE FOLLOWING LABORATORY VALUES WEEKLY AND FAX
RESULTS TO DR. [**First Name (STitle) **] IN THE [**Hospital **] CLINIC AT [**Telephone/Fax (1) **]
CBC, CHEM 7, LFT'S
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): YOU SHOULD TAKE THIS IF TAKING THE PAIN MEDICINE
TO AVOID CONSTIPATION.
Disp:*60 * Refills:*0*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. Trihexyphenidyl 5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*1*
8. Nafcillin 2 gram Piggyback Sig: One (1) Intravenous every
four (4) hours: 2gm every four hours until [**2184-5-15**].
Disp:*QS QS* Refills:*0*
9. picc
PICC line care per PHCS protocol
Discharge Disposition:
Home With Service
Facility:
Bayada
Discharge Diagnosis:
DYSTONIA
FAILURE TO THRIVE
CNS INFECTION
HYPOKALEMIA
Discharge Condition:
NEUROLOGICALLY IMPROVED / DYSTONIA REMAINS SEVERE
Discharge Instructions:
please follow up with Dr. [**First Name (STitle) **] as outpatient. please contact
her with any fever, worsening symptoms, worsened gait, or for
any other patient concerns.
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL Dr. [**First Name (STitle) **] AT [**Telephone/Fax (1) 1942**] TO SCHEDULE A FOLLOW UP
APPOINTMENT. DO THIS WHEN YOU GET HOME, SHE WILL TELL YOU WHEN
SHE WANTS TO SEE YOU IN THE OFFICE.
PLEASE CALL DR. [**Last Name (STitle) **] AT [**Telephone/Fax (1) **] FOR AN APPOINTMENT
TO BE SEEN IN ONE MONTH. YOU WILL NEED AN MRI OF THE BRAIN WITH
AND WITHOUT CONTRAST UNDER SEDATION WITH AN ANESTHESIOLOGIST.
PLEASE NOTIFY THE OFFICE OF THIS WHEN YOU CALL FOR THE
APPOINMENT.
YOU HAVE BEEN GIVEN A PRESCRIPTION FOR LABORATORY VALUES TO BE
DRAWN WEEKLY AND FAX'D TO DR. [**First Name (STitle) **] AT THE [**Hospital **] CLINIC AT
[**Telephone/Fax (1) **] THIS [**Month (only) **] BE DONE BY THE INFUSION/PICC NURSE.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-4-23**]
10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-5-14**]
9:30
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2184-4-14**]
|
[
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"276.8",
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"333.6",
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"244.9",
"682.2",
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] |
icd9cm
|
[
[
[]
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[
"01.22",
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"96.6"
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|
[
[
[]
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10050, 10087
|
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|
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|
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2049, 2152
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,415
| 160,928
|
9248
|
Discharge summary
|
report
|
Admission Date: [**2143-4-7**] Discharge Date: [**2143-4-18**]
Date of Birth: [**2058-2-2**] Sex: F
Service: MEDICINE
Allergies:
Antihistamines - 1st Generation Classif. / Antihistamines - 2nd
Generation Classif / Antihistamine / Vicodin
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Left hip intertrochanteric fracture, hypotension.
Major Surgical or Invasive Procedure:
-Hemiarthroplasty with #9 cemented stem, 46-mm bipolar head with
+5 mm neck.
-Open reduction internal fixation greater trochanter.
History of Present Illness:
Patient is an 85-year-old woman with h/o critical aortic
stenosis ([**Location (un) 109**] 0.5 cm2, peak gradient 74), dCHF with exacerbation
in [**10/2142**] c/b paroxysmal atrial fibrillation now on amiodorone,
NSTEM versus demand ischemia ([**10/2142**]) on aspirin and Plavix
(both stopped on [**4-6**]), transferred to [**Hospital1 18**] for treatment of
hip fracture and hypotension.
Per OSH report, patient had a mechanical fall on Saturday night
in which she landed on her left side. She says that she lost her
footing and fell backwards (this report was confirmed with
patient's daughter). She presented to OSH where x-ray showed
evidence of L-hip intertrochanteric fracture. At OSH, patient
was evaluated by orthopedics. She was initally hypotensive to
SBPs 80s and got bolused in ER and admitted to the ICU (getting
NS at 100 cc/hr), so far has gotten 1L normal saline. SBP at
time of transfer 92/43, HR 72, satting 96-97% 2L. No pain, so
not getting any meds. Per report, patient is AAOx3 and stable.
For access, she has 2 PIVs (20 gauge and 18 gauge).
REVIEW OF SYSTEMS:
Currently patient endorses no leg pain, shortness of breath,
chest pain or pressure. She says she feels well except when she
is moved in bed, when her left leg hurts her. She has a rash on
her left chest for several weeks, which is improving. ROS
negative for diarrhea, constipation, fevers, chills, joint pain,
melena, bright red blood per rectum, epistaxis, hemoptysis, or
hematemsis. She has had mild nausea with no emesis since
arriving from OSH.
Past Medical History:
- critical aortic stenosis ([**Location (un) 109**] 0.5 cm2) on echocardiogram [**2141**]
- diagnosed initially in [**10/2142**]
- congestive heart failure with grade 3 diastolic dysfunction
(with evidence of LVH on EKG from OSH)
- NSTEMI [**10/2142**] ?demand ischemia, no intervention
- hypertension
- chronic back pain
- status post cataract surgery
- status post cholecystectomy
Social History:
Lives at home by herself. Daughter is very involved. Does not
smoke or drink. Walking with walker at baseline. Able to take
care of ADLs. Mostly confined to household activities.
Family History:
Positive for diabetes. Sister died from uterine cancer.
Physical Exam:
On admission:36.0 75 85/48 RR17 97% RA
General: elderly woman, awake, AAOx3, in no acute distress
HEENT: PERRLA, no scleral icterus, normocephalic, atraumatic;
pus noted to be draining from right external auditory canal. No
skin erythema or periauricular lymphadenopathy
Neck: supple, no JVD
Lungs: clear anterior field
Heart: 4/6 systolic crescendo-decrescendo murmur radiating to
neck bilaterally
Abdomen: soft, non-tender
Extremities: warm, well-perfused bilaterally; dressing in place
with ttp over lateral left hip, which is deviated outward w/
external rotation
Neurological: moving all extremities, feet warm and
well-perfused bilaterally without edema
.
On discharge: 97.4 89 74-89 117/66 R24 98% RA
General: elderly woman, awake, AAOx3, anxious
HEENT: PERRLA, no scleral icterus, normocephalic, atraumatic
Neck: supple, no JVD
Lungs: clear anterior field
Heart: 3/6 systolic crescendo-decrescendo murmur radiating to
neck bilaterally
Abdomen: soft, non-tender
Extremities: warm, well-perfused bilaterally; dressing in place
over L hip, pneumoboots in place. Linear ecchymoses on LLE.
Neurological: moving all extremities, feet warm and
well-perfused bilaterally without edema
Skin: open lesions in L T5 dermatomal distribution, also with
several vesicular lesions on an errythematous base on trunk and
LEs. Linear bruising on LLE.
Pertinent Results:
Labs at Admission:
.
[**2143-4-7**] 03:59PM BLOOD WBC-10.1 RBC-3.13* Hgb-9.9* Hct-29.8*
MCV-95 MCH-31.5 MCHC-33.1 RDW-13.8 Plt Ct-270
[**2143-4-7**] 03:59PM BLOOD PT-15.2* PTT-28.0 INR(PT)-1.3*
[**2143-4-7**] 03:59PM BLOOD Ret Aut-1.5
[**2143-4-7**] 03:59PM BLOOD Glucose-132* UreaN-20 Creat-0.9 Na-135
K-3.7 Cl-98 HCO3-27 AnGap-14
[**2143-4-7**] 03:59PM BLOOD ALT-11 AST-19 LD(LDH)-203 AlkPhos-61
TotBili-0.4
[**2143-4-7**] 03:59PM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.1 Mg-1.9
Iron-17*
[**2143-4-7**] 03:59PM BLOOD calTIBC-229* Ferritn-580* TRF-176*
.
Imaging Studies:
.
Left hip x-ray ([**4-7**]):
Very limited exam due to technique. Mildly displaced and
impacted
intertrochanteric fracture of L femur with superior displacement
of distal
fragment is redemonstrated. Severe L hip joint DJD without
dislocation of
femoral head. Evaluation of lateral femoral condyle deformity
limited and of uncertain chronicity. No definite new fracture.
Probable diffuse bony
demineralizaiton.
.
Chest x-ray ([**4-7**]):
Severe cardiomegaly and mediastinal and pulmonary vascular
engorgement have
worsened indicating progressive cardiac decompensation. Left
lower lobe
remains severely consolidated. Whether this is due to lower lobe
collapse or pneumonia is radiographically indeterminate. Heavy
calcification in the heart that could be due to severe aortic
stenosis and mitral annulus degeneration respectively would
require a lateral view for localization.
.
Transthoracic echocardiogram ([**4-8**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
severe regional left ventricular systolic dysfunction with
apical aneurysm and near akinesis of all segments except for the
basal inferolateral wall. The septum is hypokinetic. No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal with
moderate global free wall hypokinesis. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Critical aortic valve stenosis. Symmetric left
ventricular hypertrophy with extensive regional dysfunction c/w
multivessel CAD. Moderate pulmonary artery systolic
hypertension.
CLINICAL IMPLICATIONS:
The patient has severe aortic stenosis. Based on [**2138**] ACC/AHA
Valvular Heart Disease Guidelines, if the patient is symptomatic
(angina, syncope, CHF) and a surgical candidate, surgical
intervention has been shown to be beneficial. The left
ventricular ejection fraction is <40%, a threshold for which the
patient may benefit from a beta blocker and an ACE inhibotor or
[**Last Name (un) **]. Dr. [**Last Name (STitle) **] was notified in person of the results on XX at XX.
Dr. [**Last Name (STitle) **] was notified in person of the results on XX at XX.
.
CT orbit, sella, and IAC without contrast ([**4-8**]):
Bilateral soft tissue masses centered within the external
auditory canals most likely represent keratosis obturans, more
advanced on the right. Additional differential considerations
include cholesteatomas. More aggressive etiologies such as
squamous cell carcinoma are unlikely.
.
Cardiac cath [**4-9**]
COMMENTS:
1. Coronary angigoraphy in this right-dominant system
demonstrated no
flow-limiting coronary disease. The LMCA had no angigoraphically
apparent disease. The LAD had a 20% proximal stenosis and a 40%
mid-vessel stenosis. A small first diagonal branch was totally
occluded
proximally. The LCx had no angigoraphically apparent disease.
The RCA
had mild luminal irregularities.
2. Resting hemodynamics revealed elevated right- and left-sided
fillign
pressures, with an RVEDP of 20 mm HG and a PCWP of 25 mm Hg.
There was
sevrere pulmonary arterial systolic hypertension, with a PASP of
84 mm
Hg. The cardiac index was preserved at 2.5 L/min/m2. The
systemic
arterial blood pressure was normal.
.
FINAL DIAGNOSIS:
1. No flow-limiting disease in the LMCA, LAD, LCx or RCA.
2. Elevated right- and left-sided filling pressures.
3. Severe pulmonary hypertension.
.
[**4-10**] pathology
1. Trabecular bone fragments with intramedullary hemorrhage,
necrosis, fibrin, and acute and chronic inflammation, consistent
with fracture site.
.
2. Articular cartilage with degenerative changes.
.
[**4-10**] Intraoperative fluoro:Four intraoperative spot films of the
left hip are submitted. There is adequate alignment of the left
hip prosthesis.
.
[**4-15**] CXR
Small-to-moderate bilateral pleural effusions are larger on the
left side
minimmaly increased on the right. There is no evidence of CHF.
Moderate
cardiomegaly has improved. Radiolucency projecting in the
retrocardiac region is a large hiatal hernia.
.
Bibasilar atelectases are larger on the left side, superimposed
infection
cannot be totally excluded.
.
Labs on DC:
WBC 14.6
Hct 30.5
Plt 494
.
Gluc 84
BUN 15
Creat .5
Na 132
K 4.5
Cl 97
HCO3 29
Ca 8.0
Phos 3.1
Mg 1.9
.
UA: nl on [**4-15**]
.
MICRO:
Skin scrapings
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
[**2143-4-16**]): Negative for Herpes simplex by
immunofluorescence.
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
[**2143-4-16**]):
REPORTED BY PHONE TO E.O'DONNEL [**2143-4-16**] AT 1545.
POSITIVE FOR VARICELLA ZOSTER.
Viral antigen identified by immunofluorescence.
BACTERIAL CXS PENDING ON DC
External auditory canal:
GRAM STAIN (Final [**2143-4-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SHORT CHAINS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2143-4-11**]):
WORK-UP DISCONTINUED Due to mixed bacterial types ( >= 3
colony
types) an abbreviated workup will be performed appropriate
to the
isolates recovered from this site.
HEAVY GROWTH BACTERIA RESEMBLING NORMAL SKIN/RESPIRATORY
FLORA.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). HEAVY GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2143-4-8**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
URINE CX: NO GROWTH
Brief Hospital Course:
In summary this is an 85-year-old woman with critical AS ([**Location (un) 109**]
0.5 cm2) presenting from OSH for treatment of left-hip fracture
after mechanical fall at home.
.
# S/p hip fracture. Patient with evidence of left
intertrochanteric fracture on OSH plain films. Per daughter,
prior to this injury, patient was ambulatory and relatively
independent, although largely homebound. With respect to her
perioperative risk, she has no history of MI (NSTEMI in [**10/2142**]
was likely demand-related per OSH records), stroke, IDDM, or
CKD. She does have history of decompensated CHF in 12/[**2141**].
Currently with no signs or symptoms of decompensated CHF. She
was evaluated by cardiology prior to surgical intervention. They
initially recommended metoprolol (given low dose 12.5mg) but
then recommended she have cardiac catheterization and may
require cardiac surgery prior to orthopedic procedure. She
underwent uncomplicated L hip hemiarthroplasty. Pain well
controlled after procedure and pt started on Lovenox x1 month.
Recovery period complicated by pt unwillingness to participate
in physical therapy.
.
# Herpes zoster rash: L breast/back in T5 dermatomal
distribution. Skin scrapings were positive for VSV, cxs pending
on discharge. She was seen by ID and dermatology, started on
acyclovir and treated with wound care and topical
Neomycin-Bacitracin-Polymyxin. She was kept on contact
[**Name (NI) 31731**] which will need to be continued until lesions crust
over. She will continue acyclovir for 10 days post discharge.
Bacterial cxs were still pending on DC.
.
# Hypotension. This was felt to be secondary to intravascular
volume depletion, blood loss from fracture, and severe
AS/systolic dysfunction. She was given gentle IV fluid boluses
and transfused to maintain hct >28. With these interventions,
her blood pressure improved and systolic pressures stabilized
between 90-100.
.
# Aortic stenosis. She has critical aortic stenosis with an
aortic valve area of less than 0.8 cm2. Although symptomatic at
home, further evaluation for repair was on hold given multiple
comorbidities and pt unwillingness to participate in rehab. She
will follow up with cardiology on discharge.
.
# Anxiety: interfering with pts ability to recover and
participate in care plan. Pt was seen by psychiatry who
recommended quetiapine in addition to home dose of fluoxetine.
.
# Anemia. Stable compared with OSH labs. Iron studies were
indicative of deficiency. She required several transfusions to
maintain crit >25, however crit stable in high 20s/low 30s in
the days prior to discharge.
.
# Paroxysmal afib: in NSR this admission. Her home dose of
amiodarone was continued.
.
# Acute on chronic sCHF: pt with some evidence of volume
overload this admission, requiring 1-2 L O2 by nasal cannula,
weaned by time of admission with sats in 90s. Attempts to
diurese were complicated by hypotension, therefore we attempted
to minimize attempts at diuresis.
.
# Leukocytosis: Possible sources of infx include herpes zoster,
lung, urine. Also could be due to stress rx in setting or
recent surgery. Concern for superinfx of rash with pseudomonas,
which is being treated with topical abx. Low concern for PNA
given pt maintaining sats, no cough, fever. Urine cx with no
growth. Would recommend monitoring fever curve/WBC while in
rehab.
.
# Soft tissue in the right external auditory canal: per OSH CT
report. Exam was notable for pus in the right external auditory
canal. ENT service was consulted and noted the left ear with
impacted cerumen; right ear had a perforated tympanic membrane
and whitish fluid; suspect cholesteatooma; no antibiotics needed
but will need outpatient follow-up. If increased drainage, would
use CiproDex gtts.
.
# GERD: famotidine was continued this admissino.
.
# Overactive bladder: she was continued on tolterodine
.
# Vaginal itch: she was started on a course of clotrimazole.
# Code status. FULL code, confirmed with daughter and HCP
# Communication. Daughter [**Telephone/Fax (1) 31732**]
Medications on Admission:
- amiodorone 200 mg daily
- aspirin 81 mg daily
- clopidogrel 75 mg daily
- Pepsid 20 mg daily
- fluoxetine 10 mg daily
- furosemide 20 mg daily
- Zestril 20 mg daily
- potassium chloride 10 mEq daily
- Detrol 2 mg twice daily
- Tylenol arthritis
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q
24H (Every 24 Hours) for 3 weeks: please take through [**5-11**].
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain. Tablet(s)
11. Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day).
12. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 9 days: last dose on [**4-26**].
13. Clotrimazole 1 % Cream Sig: One (1) Appl Vaginal HS (at
bedtime) for 3 days.
14. Fluoxetine 10 mg Tablet Sig: One (1) Tablet PO once a day.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses
Left hip intertrochanteric fracture
Right cholesteatoma
Herpes zoster infection
.
Secondary Diagnoses
Critical aortic stenosis
Hypertension
Chronic diastolic heart failure
Paroxysmal atrial fibrillation
.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Discharge Instructions:
You were transferred to [**Hospital1 69**] for
treatment of left hip fracture. You have severe narrowing of the
aortic valve in the heart and as a result underwent pre-surgical
evaluation. Afterwards you had an operation to fix the hip
fracture. In addition, during this admission you were noted to
have a cholesteatoma in your right ear. You will need to
follow up with ENT for further evaluation on discharge. You
were also treated for shingles and will receive medications to
treat this on discharge.
.
Please take your medications as prescribed and follow up with
your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. We have made the following
changes to your medicines:
- we ADDED Lovenox. Please continued to take for through [**5-11**]
days
- we ADDED valaacyclovir. Please take for 9 days after
discharge.
- we STOPPED your lisinopril
- we STOPPED your furosemide
- we STOPPED your potassium
- we ADDED quetiapine (seroquel)
- we ADDED Neomycin-Bacitracin-Polymyxin for your rash
- we ADDED clotrimazole for yeast infection
- we ADDED a bowel regimen because you have not moved your
bowels recently.
.
Please note your follow-up appointments below, and please call
the doctor should you develop worsening pain, fevers, chills,
chest pain or pressure, worsening fatigue, or other new
concerning symptoms.
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2143-5-28**] 10:40
.
Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 31733**]) on [**5-1**] at 1:30
.
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP, in the Orthopedic
Trauma clinic in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule
that appointment.
.
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
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icd9pcs
|
[
[
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11383, 15419
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417, 550
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328, 379
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578, 1645
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2819, 3468
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17332, 17470
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2138, 2522
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2538, 2718
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4740, 6943
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,355
| 193,050
|
41801
|
Discharge summary
|
report
|
Admission Date: [**2131-12-28**] Discharge Date: [**2132-1-11**]
Date of Birth: [**2058-5-22**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Sulfa (Sulfonamide Antibiotics) / aspirin
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Right internal jugular dailysis catheter placement ([**2132-1-1**])
Percutaneous cholecystostomy catheter placement ([**2132-1-7**])
PICC line placement ([**2132-1-9**])
History of Present Illness:
The patient is a 73 year old man with h/o afib on Coumadin, CHF,
CAD, HTN, DM, CKD, morbid obesity, LE cellulitis, recent
hospitalization at an OSH for RP bleed, transferred to [**Hospital1 18**] 2
days prior for hyperbilirubinemia and worsening renal function,
who is now being transferred from the medical floor to the ICU
for hypotension.
.
Patient initially presented to an OSH on [**2131-12-19**] for increasing
SOB. He was being treated with Cipro as an outpatient for
cellulitis, Coumadin for afib. He was hypotensive (SBP 80s) on
arrival and had a HCT 24.5 and INR 17.8 on admission, so was
admitted to the ICU. He received a total of 5units pRBCs and
11units of FFP over the course of his hospitalization from
[**Date range (3) 90787**], with HCT 28.3 on transfer. He had an EGD that
showed erosive gastritis, but otherwise unremarkable. ECHO
showed normal LVEF 55-60%, moderate TR, and moderate pulmonary
HTN. CT abd/pelvis notable for generalized ileus and 12cmx5cm L
retroperitoneal hematoma along the iliopsoas muscle. The patient
also finished a course of Ceftazidime for a polymicrobial UTI
(Ecoli and Providencia stuartii). Developed acute on chronic
renal failure, with Cr up to 4, thought likely to be ATN vs
prerenal azotemia. Also with new onset jaundice and elevated
bili up to 7.8 of unknown etiology. New bandemia up to 63% two
days prior to transfer, 39% on the day of transfer. WBC count at
that time was 11.0. CT abd showed ?SBO, but passing stool and
gas. Afib with RVR, treated with Dilt gtt and transitioned to PO
Dilt. CoNS in 1bottle of blood cultures.
.
On the floor, the patient was started on full liquids and had
imaging of his stomach repeated (KUB and abd u/s) yesterday.
Diltiazem was uptitrated from 60mg to 90mg QID, given several
one-time doses of Metoprolol 25mg PO, and started on Metoprolol
25mg PO QID this morning. The patient was found to be
hypotensive with SBP in the 80s this afternoon. He was slightly
more lethargic than prior, but was mentating well. He was
bolused 1L NS and a second peripheral IV was placed. Repeat labs
showed stable HCT, increasing INR, and worsening renal function
(Cr 4.2). The patient was transferred to the ICU for closer
hemodynamic monitoring.
.
The patient is currently c/o 2/10 L sided flank/shoulder pain.
He is not having any trouble breathing, lightheadedness, or
palpitations.
Past Medical History:
Atrial fibrillation
Chronic Kideney Disease
Morbid obesity
Sleep apnea
Nephrolithiasis
s/p extended hospitalization for pneumonia
s/p removal of right arm benign tumor one year ago
Diabetes Mellitus Type 2
Hypothyroidism
Diastolic CHF
Hypertension
Hyperlipidemia
s/p lithotripsy
Ulcer -- many years ago
Social History:
Lives at home with wife. Alcohol on holidays. No recreational
drugs. Smoked socially, but stopped at age 38.
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: T: 96.4 BP: 98/51 P: 112 R: 26 O2: 96% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, unable to assess JVP
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: irregular, tachycardic, S1 + S2, no murmurs, rubs, gallops
Abdomen: morbidly obese, chronic skin changes, anasarca, soft,
mild ttp in RUQ, bowel sounds present, no rebound tenderness or
guarding, no organomegaly, no ecchymoses at flanks
GU: foley
Ext: chronic venous stasis changes, +distal pulses
Neuro: A&Ox3, no focal deficits
.
Physical Exam on Discharge:
GENERAL - well-appearing in NAD, comfortable, appropriate, obese
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTAB anteriorly, good air movement, respiration
unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, perc chole drain in place in RUQ with no
surrounding erythema, clean dressing
EXTREMITIES - WWP, 3+ pitting edema and venous stasis changes to
above knees, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3
Pertinent Results:
LABS ON ADMISSION:
[**2131-12-28**] 11:25PM BLOOD WBC-9.1 RBC-3.24* Hgb-9.3* Hct-27.9*
MCV-86 MCH-28.6 MCHC-33.2 RDW-15.9* Plt Ct-271
[**2131-12-28**] 11:25PM BLOOD Neuts-71* Bands-3 Lymphs-12* Monos-11
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2131-12-28**] 11:25PM BLOOD PT-47.4* PTT-38.1* INR(PT)-5.0*
[**2131-12-28**] 11:25PM BLOOD Glucose-91 UreaN-138* Creat-3.7* Na-140
K-3.8 Cl-105 HCO3-20* AnGap-19
[**2131-12-28**] 11:25PM BLOOD ALT-19 AST-33 LD(LDH)-301* CK(CPK)-130
AlkPhos-109 TotBili-7.7* DirBili-6.5* IndBili-1.2
[**2131-12-28**] 11:25PM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.7
Mg-2.8*
[**2131-12-28**] 11:25PM BLOOD TSH-0.24*
.
LABS ON DISCHARGE:
[**2132-1-11**] 05:18AM BLOOD WBC-7.6 RBC-2.88* Hgb-7.9* Hct-25.4*
MCV-88 MCH-27.5 MCHC-31.2 RDW-16.1* Plt Ct-252
[**2132-1-11**] 05:18AM BLOOD PT-19.1* PTT-32.8 INR(PT)-1.8*
[**2132-1-11**] 05:18AM BLOOD Glucose-120* UreaN-47* Creat-2.2* Na-142
K-3.9 Cl-102 HCO3-31 AnGap-13
[**2132-1-11**] 05:18AM BLOOD ALT-20 AST-29 LD(LDH)-250 AlkPhos-136*
TotBili-2.0*
[**2132-1-11**] 05:18AM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.5*
Mg-1.7
.
IMAGING / STUDIES:
# Portable TTE ([**2131-12-31**] at 3:19:44 PM):
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and low normal
systolic function. Right ventricular cavity enlargement with
free wall hypokinesis. Mild mitral regurgitation. Pulmnonary
artery hypertension.
.
# CT ABD & PELVIS W/O CONTRAST ([**2132-1-4**] at 2:55 PM):
IMPRESSION:
1. Unchanged appearance of left iliopsoas hematoma.
2. Enlarged gallbladder with no surrounding stranding likely
secondary to NPO status.
.
# LIVER OR GALLBLADDER US ([**2132-1-5**] at 5:49 PM):
IMPRESSION: Unchanged appearance of a distended gallbladder
containing sludge and a small stone at the neck. No
pericholecystic fluid or wall edema is present. While no
findings specific for acute cholecystitis are seen, this cannot
be excluded and a HIDA scan can be considered for further
evaluation.
.
# GALLBLADDER SCAN ([**2132-1-6**]):
IMPRESSION: Abnormal hepatobiliary scan. No gallbladder tracer
activity after 280 minutes. Findings consistent with acute
cholecystis.
.
Brief Hospital Course:
The patient is a 73 year old man with morbid obesity, AFib on
Coumadin, DM, HTN, diastolic CHF (EF 55-60%), CKD, chronic LE
cellulitis/stasis, transferred from an OSH with recent RP bleed
in the setting of supratherapeutic INR, worsening renal function
and hyperbilirubinemia.
.
#. Hypotension: Initial differential was sepsis vs bleed vs
medication effect vs severe fluid overload and R heart failure.
The patient was given increasing doses of Diltiazem and started
on Metoprolol in the setting of liver and kidney dysfunction.
However, it took longer for his hypotension to improve than
would have been expected with an adverse effect of nodal agents.
His hematocrit remained stable, making a recurrence of the
retroperitoneal bleed unlikely, despite his rapidly rising INR.
With his extreme volume overload, there was concern for R-sided
heart failure, however this was not supported by
echocardiography. He had severe left shift on admission, raising
concern for sepsis, presumably secondary to cholecystitis.
Notably all cultures were negative and there was also no change
in his chest x-ray. He was covered with eight days of empiric
vancomycin and piperacillin-tazobactam. He had an arterial line
placed and his metoprolol and diltiazem were held. Around [**1-4**]
his pressures began to improve, likely from resolving sepsis. He
became increasingly tachycardic with AFib w/ RVR during this
same period, so his metoprolol and diltiazem were restarted.
.
#. Acute on chronic renal failure: Likely ATN in the setting of
hypotension. Because of concerns for fluid overload, he was
started on CVVH [**1-1**]. On [**1-4**] his urine output began to
improve and he was no longer as fluid overloaded, so the CVVH
was stopped. He was started on a Lasix gtt with good response,
though this was held on [**1-6**] when a rising white count created
concern for a new septic process. He began to autodiurese
towards the end of his stay, with Furosemide 60 mg PO daily for
additional gentle diuresis and negative fluid balance. His
resolving [**Last Name (un) **] will need close followup with labs at least [**3-15**]
times weekly until stabilized.
.
#. Cholecystitis: Diagnosed after abdominal CT [**2132-1-4**] and US
[**2132-1-5**] showed distended gallbladder. HIDA scan on [**2132-1-6**]
was concerning for acute cholecystis. Percutaneous
cholecystostomy drain was placed [**2132-1-7**] and antibiotics were
continued. His WBC count and LFTs improved. Acute
cholecystitis was likely the cause of his sepsis. Final bile
cultures were pending at time of discharge, but no organisms
were seen on gram stain. He was transitioned to Augmentin on
[**2132-1-10**] with continued improvement. Per Hepatology recs, the
drain will need to remain in place for at least 4 weeks, with
continued antibiotics. He will need close followup with
Hepatology after discharge regarding further management.
.
#. Hyperbilirubinemia: Direct bilirubinemia of unclear cause.
Differential includes congestive hepatopathy vs acalculous
cholecystis vs biliary obstruction, now improving with treatment
of cholecystitis and conservative management. He may have an
element of chronic liver disease and will need Hepatology
followup.
.
#. RUQ pain: On [**1-4**] the patient acutely developed RUQ pain.
The next day, this was accompanied by a rising WBC count. RUQ
U/S, limited by habitus, did not show clear signs of
cholecystitis. Non-contrast abd/pelvis CT showed a large
gallbladder w/o clear surrounding inflammation. Because WBC
count continued to rise, a HIDA scan was done [**1-6**] and was
positive. In this setting decision was made to intubate a
patient and have IR place a percutaneous biliary drain. Surgery
consult felt that cholecystectomy was not required at this time.
Since placement of the biliary tube his WBC counts have
normalized and his abdominal pain has also resolved.
.
#. Coagulopathy: After admission, patient had a rapidly rising
INR to a maximum of 10.6. He has received a total of about 20 mg
vitamin K. He also received a total of six units of FFP, largely
in the setting of procedures. Etiology is unclear but likely
related to undiagnosed chronic liver disease, congestive
hepatopathy, antibiotic use, or poor nutritional status. No
evidence of further bleeding after the initial retroperitoneal
bleed. He was restarted on a low dose of Warfarin the day
before discharge for his atrial fibrillation.
.
#. Acute on chronic diastolic CHF: Patient appeared grossly
volume overloaded, although fluid balance is difficult to assess
given body habitus. Given ATN, initially held on Lasix and did
CVVH for fluid removal. Patient now satting well and not having
shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] diuresis was done slowly. He was
discharged on Furosemide 60 mg PO daily with goal fluid balance
negative 1000 to 1500 ml daily.
.
#. Atrial fibrillation: Rate controlled on Diltiazem and
Metoprolol at baseline. Received extra doses of nodal agents for
AFib w/ RVR just before admission. All medications were held for
hypotension, and patient had no tachycardia for 4 or 5 days
until hemodynamic stability returned. He was eventually
transitioned off Diltiazem to single [**Doctor Last Name 360**] rate control with
Metoprolol.
.
#. Anemia: Patient with recent RP bleed. HCT remained stable
throughout this admission. Also with erosive gastritis on OSH
EGD, so started on PPI.
.
#. Diabetes Mellitus: The patient was noted to be hyperglycemic
during this hospitalization. He was maintained on Insulin
sliding scale throughout his hospital course, although his daily
insulin requirement was minimal.
.
#. Hypothyroidism:
At the time of admission, the patient was taking Levothyroxine
175 mcg alternating with 150 mcg. The patient was noted to have
a TSH level of 0.24 on [**2131-12-28**]. His regimen was decreased to
150 mcg PO daily on which he was maintained for the remainder of
his hospitalization.
.
Medications on Admission:
Home Medications:
Furosemide 120 mg QAM and 40 mg QPM
Ciprofloxacin
Cardizem 360 mg PO daily
Potassium
Diovan
Levothyroxine 175 mcg alternating with 150 mcg
Warfarin 8 mg PO daily
Acetaminophen PRN
.
Medications on Transfer:
Vancomycin 1000 mg IV Q48H
Levothyroxine Sodium 150 mcg PO/NG DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash
Benzonatate 100 mg PO TID:PRN cough
Metoprolol Tartrate 25 mg PO/NG QID
Morphine Sulfate 2 mg IV Q4H:PRN pain
Diltiazem 90 mg PO/NG Q6H
Ondansetron 4 mg IV Q8H:PRN nausea
Pantoprazole 40 mg IV Q12H
Guaifenesin [**6-19**] mL PO/NG Q6H:PRN cough
Phytonadione 5 mg PO/NG ONCE
Guaifenesin-CODEINE Phosphate [**6-19**] mL PO/NG Q6H:PRN cough
TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
Ipratropium Bromide Neb 1 NEB IH Q8H wheezing
Insulin SC
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
2. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of [**Hospital1 1440**] or wheezing.
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Hold for sedation or RR<12.
7. petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of [**Hospital1 1440**] or
wheezing.
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for flatus/bloating.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
for SBP<90 or HR<60.
14. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 4 weeks.
16. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: Before meals and at bedtime
according to attached sliding scale.
17. 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.
18. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
Acalculous Cholecystitis
Acute Kidney Injury
Coagulopathy with elevated INR
Liver Disease
Acute on Chronic Diastolic Heart Failure
Retroperitoneal Hematoma
Secondary Diagnoses:
Morbid Obesity
Atrial Fibrillation
Chronic Kidney Disease
Sleep Apnea
Diabetes Mellitus
Hypothyroidism
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were transfered to [**Hospital1 18**] after presenting to another
hospital with shortness of [**Hospital1 1440**] and hypotension. You were
found to have significant retroperitoneal bleeding requiring
transfusion. After arriving at [**Hospital1 18**], you had low blood
pressure and were sent to the ICU. Your kidney function was
impaired, likely due to kidney injury from your low blood
pressure. Your liver function was also found to be impaired.
Because of your severe illness, you developed a serious
condition in your gallbladder called acalculous cholecystitis.
This was treated with antibiotics and a drain to remove the bile
building up in the gallbladder.
During your stay, your multiple medical issues started to
improve, and you were released from the ICU to the regular
medical floor. You are now being transferred to a rehad
facility for further recovery. You will need close monitoring
of your gallbladder, liver, and kidneys. Appointments have been
schedueld with several specialists at [**Hospital1 18**] in these areas.
Multiple medication changes were made during your stay. You
should refer to your discharge medication sheet for details.
You will need to continue an extended course of antibiotics for
your acalculous cholecystitis. This will be addressed by the
Liver Center. You will need careful observation of your kidney
function and fluid status, with continued diuresis using
Furosemide to prevent volume overload.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2132-1-23**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2132-2-13**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 13365**], MD [**Telephone/Fax (1) 3201**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appointment in the Liver Center
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The office will contact you at the
facility with the appointment information. If you have not heard
within 2 business days or have any questions please call
[**Telephone/Fax (1) 2422**].
|
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29,016
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Discharge summary
|
report
|
Admission Date: [**2100-11-25**] Discharge Date: [**2100-12-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Lethargy, refusal to take PO
Major Surgical or Invasive Procedure:
Foley Catheter
History of Present Illness:
History of present illness: [**Age over 90 **] yo woman with severe dementia,
chronic atrial fibrillation presents from nursing home with 3
days of lethargy.
.
At her nursing home, the pt developed a UTI (apparently her
third in 2 months) with an initial WBC of 25 on [**11-16**]. Her urine
culture grew out >100,000 Klebsiella. She was not treated, as
this was thought to be chronic colonization and there was little
or no pyuria on the U/A. On [**11-22**], she was seen by her primary
RN and was started on levofloxacin PO.
.
In the ambulance, her initial VSs were 98.3, 130, 108/78, 20,
97% on RA. In the ED, her HR was in the 160s at times. Her CXR
revealed mild vascular engorgement and ? LLL haziness, and her
abdominal CT showed no evidence of an infectious process. She
received ~1.5 L NS, and she was given azithromycin 500,
ceftriaxone 1 g and metronidazole 500 mg to cover her broadly.
.
Unable to obtain ROS given the pt's dementia.
Past Medical History:
Advanced dementia (oriented only to self at baseline)
HTN
h/o multiple UTIs
Chronic atrial fibrillation
h/o C. difficile
Social History:
No family, lives in [**Hospital3 2558**], has guardian
Family History:
NC
Physical Exam:
Vitals: afebrile, VSS on 2L oxygen
General: Sleeping, difficult to rouse
HEENT: PERRL, no scleral icterus, MM dry
Neck: no significant JVD appreciated
Pulmonary: rales bilaterally
Cardiac: tachy, irregular, no obvious murmurs
Abdomen: soft,normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema,
Skin: no rashes.
Neurologic: intermittent alertness, oriented to nothing.
Pertinent Results:
[**2100-11-24**] 07:42PM BLOOD WBC-9.3 RBC-4.51 Hgb-14.2 Hct-44.2 MCV-98
MCH-31.5 MCHC-32.1# RDW-13.7 Plt Ct-210 Neuts-72.6* Lymphs-19.9
Monos-5.1 Eos-2.2 Baso-0.2
PT-13.4 PTT-31.9 INR(PT)-1.2*
Glucose-94 UreaN-19 Creat-0.7 Na-143 K-4.3 Cl-112* HCO3-21*
AnGap-14
ALT-11 AST-22 LD(LDH)-271* AlkPhos-75 Amylase-24 TotBili-1.1
Lipase-23
[**2100-11-24**] 07:42PM CK(CPK)-24* cTropnT-<0.01
[**2100-11-24**] 07:42PM proBNP-2690*
[**2100-11-24**] 07:42PM Digoxin-0.4*
[**2100-11-24**] 07:37PM Lactate-2.7*
CT PELVIS W/CONTRAST [**2100-11-24**] 5:25 PM
CT ABDOMEN WITH IV CONTRAST: There are small bilateral pleural
effusions with associated atelectasis. The left hepatic lobe is
atrophic and replaced by multiple cysts. There is a large 3.3 x
2.1 cm gallstone, however the gallbladder is not distended or
inflamed. The spleen is unremarkable. Small hypodensities within
the right kidney likely represent cysts, but are not fully
characterized.
The pancreas is atrophic. There are multiple low attenuation
cystic lesions within the tail of the pancreas measuring 13 mm
in greatest dimension. An additional low attenuation 2.4 x 2.4
cm cystic lesion abuts the uncinate process of the pancreas,
possibly arising from the minor pancreatic duct. There is no
peripheral wall enhancement. There is no free air or free fluid
within the abdomen. An NG tube is appropriately positioned.
CT PELVIS WITH INTRAVENOUS CONTRAST: A moderate amount of stool
is seen within the rectum. There are scattered sigmoid
diverticula without evidence of diverticulitis. A Foley catheter
is seen within the bladder. There is a 1.4 cm cyst within the
right adnexa. There is no free fluid in the pelvis.
Osseous structures demonstrate no suspicious lytic or sclerotic
lesions.
IMPRESSION:
1. Multiple cystic lesions within the pancreatic tail and 2.4 x
2.4 cm cystic lesion abutting the uncinate process of the
pancreas. Given the multiple hepatic cysts, these likely
represent simple pancreatic cysts. However, a cystic pancreatic
neoplasm such as IPMN cannot be excluded. This could be further
evaluated by MRCP.
2. 3.3 x 2.1 cm gallstone without evidence of cholecystitis.
3. Small bilateral pleural effusions with associated
atelectasis.
CHEST (PORTABLE AP) [**2100-11-24**] 5:16 PM
IMPRESSION:
1. Mild interstitial edema.
2. Retrocardiac density may represent atelectasis or
consolidation
EKG [**2100-11-24**] 4:58:56 PM
Atrial fibrillation with mean ventricular rate 138. Low QRS
voltage in
the limb leads. Diffuse non-diagnostic repolarization
abnormalities.
Compared to previous tracing of [**2096-6-28**] cardiac rhythm is now
atrial
fibrillation with rapid ventricular rate.
[**2100-12-1**] 05:15AM BLOOD WBC-4.9 RBC-3.62* Hgb-11.5* Hct-34.7*
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.4 Plt Ct-221
[**2100-12-2**] 07:05AM BLOOD PT-16.6* INR(PT)-1.5*
[**2100-12-2**] 07:05AM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-143
K-3.6 Cl-111* HCO3-23 AnGap-13
[**2100-11-24**] 07:42PM BLOOD ALT-11 AST-22 LD(LDH)-271* AlkPhos-75
Amylase-24 TotBili-1.1
[**2100-11-27**] 03:15AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9
Brief Hospital Course:
ASSESSMENT: [**Age over 90 **] yo F with PMH of severe dementia, frequent UTIs
and chronic atrial fibrillation presents with 3 days of lethargy
following diagnosis of UTI.
.
## Klebsiella UTI/sepsis: Culture from [**Hospital3 2558**] revealed
pan sensitive Klebsiella. She was treated with ceftriaxone and
hemodynamic status improved. She was changed to once daily
levofloxacin for discharge (as she only takes AM pills). Plan
to treat until [**2100-12-5**].
## Atrial fibrillation with rapid ventricular response: Chronic,
on digoxin and metoprolol at baseline for rate control. Likely
tachycardic [**1-8**] infection.
We continued metoprolol [**Hospital1 **], digoxin and anticoagulation. Given
decreased mental status, she usually did not take her evening
metoprolol dose, which resulted in early AM RVR. Feeding tube
was discussed with ethics and guardian [**Name (NI) **] [**Name (NI) **], for
nutrition as easier medication administration. After much
discussion, all parties agreed a feeding tube was not
appropriate for this severely demented [**Age over 90 **] year old woman. Her
rapid heart rate is asymptomatic, and will not be treated if she
declines her meds.
.
## Dementia: progressive, likely with delerium during acute
illness.
.
## Papullary Cyst of the Pancreas: incidental finding on abd CT
scan
- outpt f/u, further evaluation recommended by radiology with
MRCP
.
## Cholelithiasis: no evidence of acute cholecystitis
- outpt f/u
.
## Aspiration pneumonia: treated with IV clindamycin and
ipratropium nebs. Advise only to feed when completely alert and
upright.
.
## Code status: FULL CODE, discussed with guardian
Medications on Admission:
Warfarin 3 mg daily
Metoprolol 75 mg [**Hospital1 **]
Potassium 20 mg daily
Mirtazapine 7.5 mg qhs
Aspirin 81 mg daily
[**Name (NI) 10687**]
MVI
MOM
Acetaminophen
Levofloxacin
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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. [**Name (NI) 10687**] 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QAM (once a day
(in the morning)).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Klebsiella urosepsis
2. aspiration pneumonia
3. dementia with delerium
Discharge Condition:
stable, waxing/[**Doctor Last Name 688**] mental status
Discharge Instructions:
Ms. [**Known lastname **] was hospitalized with Klebsiella UTI, hypotension
and atrial fibrillation with rapid ventricular response. She
has had decreased mental status during her stay, particularly in
the evenings. Please try to give all medications in the
morning, when she is more alert. Call her physician and
guardian to discuss hospice, if he/she feels it is indicated.
Please return to the emergency department if she has fever
greater than 101.0, respiratory distress, pain or other
concerns.
Followup Instructions:
1. House ECF physician to follow.
|
[
"599.0",
"294.8",
"995.91",
"041.3",
"038.9",
"263.0",
"787.20",
"311",
"427.31",
"577.2",
"574.20",
"401.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7848, 7918
|
5055, 6700
|
291, 307
|
8035, 8092
|
1950, 5032
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1515, 1519
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6927, 7825
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7939, 8014
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6726, 6904
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8116, 8621
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1534, 1931
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223, 253
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363, 1282
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1443, 1499
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,191
| 158,326
|
50003
|
Discharge summary
|
report
|
Admission Date: [**2159-9-26**] Discharge Date: [**2159-10-2**]
Date of Birth: [**2103-7-16**] Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4360**]
Chief Complaint:
Abdominal pain two days after LEFT ESWL
Major Surgical or Invasive Procedure:
During this admission: LEFT IJ central venous catheter
placement
s/p [**2159-9-21**] Left extracorporeal shock wave lithotripsy for
1.5 cm renal stone
History of Present Illness:
56 year old female s/p lithotripsy 5 days ago presented to
urology clinic complaining of continued flank pain, decreased PO
intake, and decreased urinary output for the past two days.
Patient reports onset of abdominal pain 3 days ago, associated
with nausea and vomiting. Pain is in the central part of her
abdomen, sharp, non-radiating, intermittent with movement or
palpation, non-radiating. At home, patient Naprosyn three times
for pain, without relief. She then was prescribed hydrocodone,
with minimal relief. Given her symptoms and recent procedure,
the patient was seen in clinic yesterday.
.
In the office, patient was noted to have T 99.4, BP 68/46, and
HR 104 with new [**Last Name (un) **], creatinine 0.9 -> 3.2. She was transferred
to [**Hospital1 18**] ED for further eval. She reports having some chills
this morning. Reports nausea/vomiting, no diarrhea. No chest
pain or shortness of breath.
Past Medical History:
Grave's disease s/p RAI therapy
Hypothyroidism
positive PPD, treated for 9 months in [**2143**]
HYPERCHOLESTEROLEMIA
HYPOTHYROIDISM
HYPERTENSION, ESSENTIAL
Glucose intolerance (impaired glucose tolerance)
DISC DISEASE - CERVICAL
COLONIC ADENOMA
URTICARIA, UNSPEC
Menopause on ET [**5-/2153**]
NERVE ENTRAPMENT
ROSACEA
S/P supracervical hysterectomy
HEARING LOSS, UNSPEC
POSITIVE PPD
Social History:
Lives alone in [**Location (un) 669**]. Works as administrative assistant at
[**Hospital3 **]. Rare alcohol use. 1 pack tobacco use
every two days. Rare cocaine use.
Smoking: Current Everyday Smoker 1 ppd, 15 pack-years
Smokeless Tobacco: Never Used
Alcohol: 0.0 - 1.0 oz alcohol/week
Adv Directives: Not On File
Family History:
no history of nephrolithiasis
Other [Other] [OTHER]
Brother Alive
Father Deceased
Maternal Aunt [**Name (NI) 24046**] Onset
Maternal Grandmother Hypertension
Mother Deceased [**Name (NI) 3730**]
Sister Alive Hypertension
Physical Exam:
AVSS
General: Alert, oriented, pleasant, cooperative
HEENT: Sclera anicteric, MMM, Bilateral proptosis.
Neck: Left IJ has been removed
Abdomen: soft, non-tender, no rebound/guarding, non-distended,
GU: voiding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
No calf pain
Pertinent Results:
[**2159-10-2**] 07:55AM BLOOD WBC-16.3* RBC-3.22* Hgb-9.2* Hct-29.5*
MCV-91 MCH-28.7 MCHC-31.4 RDW-14.8 Plt Ct-161#
[**2159-10-1**] 04:11AM BLOOD WBC-15.5* RBC-2.95* Hgb-8.8* Hct-25.6*
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.7 Plt Ct-79*
[**2159-9-30**] 06:36PM BLOOD WBC-13.4* RBC-3.27* Hgb-9.5* Hct-28.1*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.8 Plt Ct-53*
[**2159-9-28**] 05:17AM BLOOD WBC-17.0* RBC-3.37* Hgb-10.0* Hct-28.8*
MCV-85 MCH-29.6 MCHC-34.7 RDW-14.1 Plt Ct-42*#
[**2159-9-27**] 03:40AM BLOOD WBC-20.6*# RBC-3.22* Hgb-9.8* Hct-28.8*
MCV-90 MCH-30.4 MCHC-34.0 RDW-13.8 Plt Ct-86*
[**2159-9-26**] 08:04PM BLOOD WBC-10.7 RBC-3.45* Hgb-10.6* Hct-30.5*
MCV-89 MCH-30.7 MCHC-34.6 RDW-13.6 Plt Ct-108*
[**2159-10-2**] 07:55AM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-139
K-4.4 Cl-106 HCO3-24 AnGap-13
[**2159-10-1**] 09:20PM BLOOD Glucose-119* UreaN-14 Creat-1.0 Na-137
K-3.4 Cl-105 HCO3-23 AnGap-12
[**2159-10-1**] 04:11AM BLOOD Glucose-81 UreaN-15 Creat-1.0 Na-137
K-3.2* Cl-104 HCO3-24 AnGap-12
[**2159-9-27**] 10:31AM BLOOD Glucose-72 UreaN-31* Creat-1.8* Na-143
K-3.5 Cl-112* HCO3-20* AnGap-15
[**2159-9-27**] 03:40AM BLOOD Glucose-87 UreaN-31* Creat-2.0* Na-140
K-3.0* Cl-109* HCO3-18* AnGap-16
[**2159-9-26**] 08:04PM BLOOD Glucose-73 UreaN-35* Creat-2.6* Na-138
K-2.4* Cl-102 HCO3-21* AnGap-17
[**2159-9-29**] 11:20AM BLOOD LD(LDH)-294* TotBili-0.8
[**2159-9-26**] 08:04PM BLOOD ALT-13 AST-25 AlkPhos-110* TotBili-0.8
[**2159-10-2**] 07:55AM BLOOD Calcium-8.6 Mg-1.8
[**2159-10-1**] 10:45 am CATHETER TIP-IV Source: LEFT IJ TLC.
**FINAL REPORT [**2159-10-3**]**
WOUND CULTURE (Final [**2159-10-3**]): No significant growth.
[**2159-9-27**] 1:47 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2159-9-29**]**
MRSA SCREEN (Final [**2159-9-29**]): No MRSA isolated.
[**2159-9-26**] 8:04 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2159-9-28**]**
URINE CULTURE (Final [**2159-9-28**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2159-9-26**] 7:50 pm BLOOD CULTURE #1.
**FINAL REPORT [**2159-9-29**]**
Blood Culture, Routine (Final [**2159-9-29**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2159-9-27**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2159-9-27**]
AT 0635.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2159-9-27**]): GRAM NEGATIVE
ROD(S).
CTA [**2159-10-1**] IMPRESSION:
1. Due to suboptimal opacification of the pulmonary artery, the
study was
limited for evaluation of pulmonary embolism within the lobar,
segmental and subsegmental pulmonary arteries. However, no
filling defect was seen in the main pulmonary artery to suggest
pulmonary embolism.
2. Pulmonary artery hypertension.
3. Moderate-to-severe pulmonary edema.
4. Moderate right and minimal left non-hemorrhagic and non
loculated pleural effusion.
5. Mild hiatal hernia.
Brief Hospital Course:
56 year old female with history of nephrolithiasis s/p left
lithotripsy presented to emergency department with severe
sepsis, likely secondary to recent procedure and pyelonephritis.
Severe sepsis likely etiology is left pyelonephritis. Exam is
more consistent with hepatobiliary or pancreatic etiology,
although no clear evidence of pathology on initial imaging.
Patient aggressively resuscitated in ED. On low dose
norepinephrine when transfered to unit. Normal mental status
throughout. Appears to be volume resuscitated, with no evidence
of hypoperfusion. Acute renal insufficiency, likely pre-renal
in setting of sepsis, exacerbated by NSAID use. No evidence of
hydroureter or obstruction on CT. Improved UOP with volume
resuscitation.
She was transferred from the unit to the urology service on the
general surgical floor after her [**Hospital Unit Name 153**] course and stabilization.
She came to the urolgy service:
56yF with large L renal stone s/p ESWL 5 days ago presents with
hypotension, 3 days of abdominal pain and nausea + vomiting. CT
reveals steinstrasse within L ureter, L pyelonephritis, no
evidence of hematoma. She is septic most likely from bacteria
released from infected stone after ESWL. She has steinstrasse
within ureter, but she does not have hydronephrosis. Her
hospital course was complicated by pulmonary edema most likely
due to the rapid fluid resuscitation. She was followed with
aggressive pulmonary support and given nicotine transdermal
patch. She was gradually weaned to room air after aggressive
diuresis. While diuresing with both oral and intravenous lasix
and her complete blood count and electrolytes were monitored and
repleted daily.
Over the course of her stay her fevers, wbc trend and complete
blood count were monitored. CT Angiogram was obtained hospital
day 6 to rule out pulmonary embolism given her drop in
saturation levels with oxygen and persistent wbc and overall
presentation. Her blood pressure remained low and she was not
restarted on her home dose of nifedipine or triamterene.
The remainder of the hospital course was unremarkable. The
patient was discharged in stable condition, eating well,
ambulating independently, voiding without difficulty, and with
pain control on oral analgesics. She had a clear follow-up plan
for Thursday, [**2159-10-4**], with her primary care physician
and [**Name9 (PRE) 702**] labs. All of her questions were answered.
Medications on Admission:
estradiol 0.025 mg transdermal weekly
nifedipine 30 mg daily
HCTZ/triamterene 25/37.5 daily
simvastatin 20 mg daily
naproxen dose unknown
cyclobenzaprine 10 mg daily PRN neck pain
fexofenadine 180 mg daily PRN
levothyroxine 88 mcg
fluoxetine 40 mg daily
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day: START on day after completing the Ciprofloxacin.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
-Do NOT resume your pre-admission anti-hypertension medications
unless explicitly advised to do so by your PCP at your Thursday
appointment (see below).
11. Outpatient Lab Work
-You will need to have repeat blood work including a CBC and
Chem 10 at your PCP [**Name9 (PRE) 702**] appointment.
12. Outpatient Lab Work
-Complete a 2 week course of antibiotics (Ciprofloxacin). You
will then go on a once daily dose of Bactrim as antibiotic
suppresant therapy per Dr. [**Last Name (STitle) **].
13. Estradiol Transdermal Patch Transdermal
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis, pulmonary edema, nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Do NOT resume your pre-admission anti-hypertension medications
unless explicitly advised to do so by your PCP at your Thursday
appointment (see below).
-You will need to have repeat blood work including a CBC and
Chem 10 at your PCP [**Name9 (PRE) 702**] appointment.
-Do not resume smoking if you are wearing the Nicotine patch.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
MEDICATIONS:
-Resume all of your pre-admission medications, except HOLD
aspirin until you see your urologist in follow-up
-Complete a 2 week course of antibiotics (Ciprofloxacin).
You will start once daily dose of Bactrim as antibiotic
suppresant therapy per Dr. [**Last Name (STitle) **].
-Colace has been prescribed to avoid post surgical
constipation and constipation related to narcotic pain
medication. Discontinue if loose stool or diarrhea develops.
Colace is a stool softener, NOT a laxative
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery.
Followup Instructions:
Call your Urologist's office today to confirm your follow-up
appointment AND if you have any questions.
Wednesday, [**2159-10-10**] 11:30 AM Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 104403**],
MD, PHD
[**Location (un) 2274**] - [**Location (un) **] Office (Atrius Health) DEPARTMENT OF UROLOGY
Address: [**Location (un) 4363**] [**Location (un) 86**], [**Numeric Identifier 4364**]
Telephone: [**Telephone/Fax (1) **]
You had a CT scan during your admission that showed an
incidentally noted pulmonary nodule. This nodule may be
nothing, may be related to your acute infection, or may be
related to an early lung cancer. Given your history of smoking,
you should have a repeat CT scan in 6 months ([**2160-3-25**]). Your
primary care doctor can help order this. PLEASE speak with your
primary care doctor about this, to make sure this nodule is
nothing to worry about.
You have a pre-arranged appointment w/your on THURSDAY,
[**2159-10-4**] 10:00 AM.
Please report to the [**Location (un) 2274**] LAB for blood work between 8 and 9 am
on Thursday, [**2159-10-4**]. You do not have to fast for these labs.
PCP: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 89020**]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**] Fax: [**Telephone/Fax (1) 6808**]
Completed by:[**2159-10-3**]
|
[
"244.9",
"272.0",
"518.89",
"285.9",
"995.92",
"785.52",
"786.52",
"584.9",
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"401.9",
"799.02",
"592.0",
"287.5",
"590.80",
"514",
"276.8",
"038.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11669, 11675
|
7457, 9892
|
343, 497
|
11763, 11763
|
2757, 7434
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13592, 15058
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2203, 2430
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10196, 11646
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11696, 11742
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9918, 10173
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11914, 13569
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2445, 2738
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264, 305
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525, 1445
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11778, 11890
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1467, 1852
|
1868, 2187
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,216
| 118,326
|
3599
|
Discharge summary
|
report
|
Admission Date: [**2182-10-21**] Discharge Date: [**2182-10-24**]
Date of Birth: [**2130-3-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
S/p fall, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 yo F w/ h/o MDS, hypothyroidism, questionable seizures,
presents after fall x 2 at home, found to be hypotensive. Pt
states that she falls "occasionally" at home, and can predict
when she does; she associates with having a seizure. Over the
past 4-5 days pt reports not feeling well; first had 2 days of
migraines, then during the following days she had persistent
n/v, anorexia, and watery diarrhea, several bowel movements per
day. She had no po intake. She noted a low grade temp to 99 F
four days ago, but has since denied fevers or sick contacts.
Yesterday morning while getting up from bed she was light
headed, vertiginous, and felt herself falling forward. She
states she was unable to keep herself from falling forward and
hit her nose. She then hit her neck/back as she flung herself
backwards to try to get up. She suffered a nosebleed but no LOC.
She finally came to the ED after her PCP's suggestion.
In ED here on arrival she was noted to have a BP of 66/40, P 66
which improved to SBP 70s after 2L NS. However, because of
persistent hypotension, she eventually received total 9L NS. She
was also placed on DA which was gradually weaned off. She had a
head CT showing no bleed but + paravertebral soft tissue
thickening concerning for ?bleed vs. other fluid. Her neck MRI
demonstrated a prevertebral fluid collection without enhancement
or evidence of fracture. no cord compresssion appreciated.
ROS: denies URI sxs, cough, current nausea, abdominal pain,
melena, BRBPR, hematemesis. +sensation of lump in throat,
thirst, hunger.
Past Medical History:
1. Chronic macrocytic anemia w/ mild pancytopenia
2. Status post bone marrow biopsy [**2179-7-28**]-MDS v EtOH
toxicity
3. Hypothyroidism
4. h/o questionable seizures, but neg 48h EEG and nL MRI in
past.
5. Migraine headaches.
6. Questionable history of cardiac arrhythmias. [**Doctor Last Name **] of Hearts
in past showed some tachys to 180s.
7. Peptic ulcer disease status post Nissen fundoplication.
8. Status-post hemorrhoidectomy.
9. Asthma s/p intubation x 1 in past.
10. Osteoarthritis.
11. b/l cataracts
12. R knee surgery
Social History:
SH: Lives with her boyfriend in [**Name (NI) 4628**]. Three college aged
daughters. [**Name (NI) **] tobacco. Occ EtOH. No drugs/herbals. Used to be a
photographer before recent illnesses
Family History:
Father died of CAD at age 80. Mother-alive and healthy. No
family with MDS or leukemia
Physical Exam:
T 96.3, BP 136/67, P 67, R 24, 100% RA
Gen: AAO x 3, sitting up in bed with foam collar on
HEENT: PERRLA, EOMI, mmm, clear OP, +laceration +ecchymosis over
nose
Neck: in foam collar
CV: RRR, nl S1, S2 without m/r/g
Pulm: CTA bilaterally, faint bibasilar rales
Abd: +bs, soft, NT/ND, no masses
Back: +ecchymoses
Extr: no c/c/e
Neuro: normal motor strength of upper extremities bilaterally,
moves [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] with 4/5 strength U/E [**5-1**] strenght;
difficult to assess all CN given neck collar. CN II-X intact.
Pertinent Results:
[**2182-10-21**] 11:10AM WBC-4.3 RBC-2.67* HGB-10.1* HCT-29.7*
MCV-112* MCH-37.9* MCHC-34.0 RDW-16.5*
[**2182-10-21**] 11:10AM PLT SMR-LOW PLT COUNT-101*#
[**2182-10-21**] 11:10AM NEUTS-79.2* BANDS-0 LYMPHS-14.9* MONOS-3.4
EOS-2.5 BASOS-0.1
[**2182-10-21**] 11:10AM PT-13.2 PTT-27.7 INR(PT)-1.1
[**2182-10-21**] 11:10AM ALBUMIN-2.9* CALCIUM-7.6* PHOSPHATE-4.4
MAGNESIUM-1.2*
[**2182-10-21**] 11:10AM GLUCOSE-94 UREA N-13 CREAT-1.6* SODIUM-126*
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-17* ANION GAP-13
[**2182-10-21**] 11:10AM ALT(SGPT)-11 AST(SGOT)-22 ALK PHOS-93
AMYLASE-23 TOT BILI-0.3
[**2182-10-21**] 07:40PM GLUCOSE-162* UREA N-7 CREAT-0.8 SODIUM-139
POTASSIUM-3.4 CHLORIDE-119* TOTAL CO2-12* ANION GAP-11
CXR: Interval development of interstitial edema with septal
lines and upper zone redistribution
CT head: no hemorrhage, paravertebral soft tissue thickening on
scout image
CT spine: Diffuse infiltration of retropharyngeal space from
inferior pharynx to C5 laterally to bilateral carotids
CT abdomen: 1. Marked diffuse symmetric wall thickening seen
throughout the stomach extending into the first portion of the
duodenum, likely represents edema. Given the patient's recent
chest x-ray documenting short-interval development of
interstitial edema, ?volume overload, possibly vasculitis. 2.
Small amount of ascites and pelvic free fluid. 3. Bibasilar
atelectasis and small bilateral pleural effusions. 4. No
evidence of solid organ injury within the abdomen
ECG: NSR at 60 bpm, nl axis, slightly prolonged QTc
[**10-21**] Cervical MRI: FINDINGS: There is no evidence of cord
compression or abnormal signal. There is no evidence of discitis
or epidural abscess. There is prevertebral fluid accumulation in
the upper cervical region. There is no definite evidence of
focal disc protrusion or canal stenosis. Alignment is
maintained. There is no definite evidence of marrow injury.
IMPRESSION: Prevertebral fluid accumulation as described. This
could represent an infectious process and abscess formation,
although I do not see a great deal of marginal contrast
enhancement. There is no evidence of epidural abscess or
discitis. The collection does not appear to represent blood nor
do I see definite evidence of vertebral fracture
Brief Hospital Course:
A/P: 52 yo F w/ h/o MDS, multiple other medical problems, here
w/ hypotension after several days of n/v/d.
1. Hypotension:
We thought that her hypotension was probably secondary to
intravascular volume depletion due to several days of nausea,
vomiting and diarrhea. She responded to IV fluids and was
easily weaned off her dopamine drip with her systolic blood
pressures consistently in the 130s with concomitant transfer
from the ICU to the medicine floor. We also entertained the
diagnosis of sepsis but thought that this was less likely since
her WBC was normal, she was afebrile and no longer hypotensive.
Blood cultures and urine cultures were drawn. The urine culture
was negative and the results of the blood culture are still
pending at this time. We did not find evidence for a cardiogenic
etiiology of her hypotension since her cardiac enzymes were
normal and there were not ECG changes. The diagnosis of adrenal
insufficiey was also considered by her electrolytes were normal
making this less likely.
2.Nausea/vomiting/diarrhea:We thought that her GI symptoms may
have been secondary to a viral infection as they resolved upon
admission and did not recur.
3. S/p Fall
We were unsure about the etiology of her fall and thought that
it could possibly have been due to her hypovolemia leading to
orthostasis, questionable vasovagal (although not a classic
story), seizures, h/o arrhythmia, holter in past reportedly had
+ tachyarthymia to 180s in the past and the pt is currently
followed by cardiologist. Upon completion of fluid resucitation
and the maintenance of a stable of blood pressure, the patient
was evaluated by PT and was considered to be safe to go home.
Thus, we thought that her fall was probably secondary to
orthostatis caused by volume depletion base on its response to
re-hydration.
4. Prevertebral fluid collection: The patient was evluated by
neurosurgery and this fluid collection was not thought to be
secondary to fracture or infection. She was instructed to wear
a neck collar and will follow up in neurosurgery clinic two
weeks after discharge. (See discharge follow up.)
5. Seizures: She was continued on her neurontin as advised by
her PCP.
-
6. MDS: She continued to receive epogen.
7. Acute Renal Failure: Her elevated creatinine responded well
to re-hydration and thus her acute renal failure was considered
to be secondary to hypovolemia.
8. Metabolic acidosis: Upon fluid resuscitation with normal
saline the patient devloped a mild metabolic acidosis which
resolved with IV bicarb supplementation.
8. Hypthyroidism: The patient's TSH was checked and it was found
to be elevated. Although this was felt to be seconary to sick
euthyroid syndrome her levothyroxine was emperically increased
to 200 mcg per day which the patient tolerated.
In light of patient's continued improvement, the paitient's
request was honored and she was discharged to home with close
follow up.
Medications on Admission:
1. Albuterol neb Q6H prn
2. Ipratropium neb Q6H prn
3. Epogen 20,000 unit/mL Solution Sig: 3mL Qweek.
4. Zolpidem 5 mg po qhs prn
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID
6. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO QD
7. Prilosec 20 mg Capsule, 1 [**Hospital1 **]
9. Ativan 1 mg Tablet Sig: One (1) Tablet PO TID prn
10. Soma 350 mg Tablet Sig: One (1) Tablet PO tid prn h/a
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QAM
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QPM
13. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO QD
14. Imitrex 50 mg Tablet Sig: One (1) Tablet PO QD prn migraine
15. Skelaxin 400 mg Tablet Sig: One (1) Tablet PO TID pain
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime).
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-28**]
Tablets PO Q6H (every 6 hours) as needed.
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please take only 50 mg of atenolol in the morning as your
previous dose (morning and evening) may lower your blood
pressure too much at this time.
8. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday): as previously
scheduled.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Nausea and vomiting
2. Hypotension
3. S/p fall
Discharge Condition:
Good, ambulating independently and tolerating po intake without
incident.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
feel light headed, experience severe nausea and vomiting, chest
pain, shortness of breath.
Please take all medications as prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 742**] NEUROSURGERY WEST Where: LM
[**Hospital Unit Name 12011**] Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2182-11-8**] 11:00
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) 16380**]/US+DXWIRE LOCS RADIOLOGY Where: [**Hospital 4054**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-11-14**]
2:00
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
|
[
"780.39",
"244.9",
"584.9",
"276.5",
"238.7",
"276.2",
"787.01",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10253, 10259
|
5670, 8598
|
339, 346
|
10362, 10438
|
3385, 4209
|
10684, 11190
|
2701, 2789
|
9342, 10230
|
10280, 10341
|
8624, 9319
|
10462, 10661
|
2804, 3366
|
278, 301
|
374, 1924
|
4218, 5647
|
1946, 2480
|
2496, 2685
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,945
| 142,877
|
32265
|
Discharge summary
|
report
|
Admission Date: [**2152-10-22**] Discharge Date: [**2152-10-24**]
Date of Birth: [**2081-6-16**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Slurred speech and right sided numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 71 year-old right-handed man with no significant
PMH who presented to as OSH with dysarthria and R arm tingling.
There is some discrepancy between the patients report and that
of
the records. Earlier today, he noted R arm tingling and then
developed dysarthria. Neither the patient nor his wife can give
an exact time course, however it does not appear that there was
a
clear [**Month (only) **] associated with the onset of his symptoms. Per the
OSH records, he also had R leg tingling, however he denied this.
They went to the OSH where his symptoms resolved. He had a CT
scan which showed a large L temporal chemerage with mild edema
but no shift. He was also noted to be hypertensive while there
with a SBP up to 190. He was therefore started on a Nipride drip
and transferred for further evaluation.
The pt denied headache, loss of vision, blurred vision,
diplopia,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denied difficulties producing or comprehending
speech
despite clearly having difficulties with this during the exam.
Denied focal weakness. No bowel or bladder incontinence or
retention. Denied difficulty with gait.
On review of systems, the pt denied recent fever or chills. No
night sweats or recent weight loss or gain. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denied arthralgias or myalgias. Denied rash.
Of note, he has never had any age appropriate cancer screening.
Past Medical History:
- appy (remote)
- borderline HTN
Social History:
-married, retired and worked for [**University/College **]
-remote tobacco > 15 yrs ago, rare EtOH, no drugs
Family History:
-Father w/ [**Name2 (NI) 499**] CA
Physical Exam:
Vitals: T:97 BP: 145/85 HR: 75 R 18 O2Sats 99%
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.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Has difficulty relating
history secondary to intermittent paraphasic errors, such as
ballpoint pencil as well as some dysarthria. His speech
fluctuates from periods of fluency to periods with aphasia.
[**Location (un) **] is intact however repetition is somewhat impaired for
complex phrases. Comprehension appears intact. Naming is largely
intact with a few small errors as above. Normal prosody. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves: Olfaction not tested. PERRL 4 to 3mm and
brisk.
VFF to confrontation. There is no ptosis bilaterally.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. EOMI without nystagmus. Normal saccades. Facial
sensation intact to light touch. No facial droop, facial
musculature symmetric. Hearing intact to finger-rub bilaterally.
Palate elevates symmetrically. 5/5 strength in trapezii and SCM
bilaterally. Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense or proprioception throughout. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1-------> 0 0
R 1-------> 0 0
Plantar response was flexor bilaterally.
-Gait: deferred due to patient request, awaiting opportunity to
use bathroom
Pertinent Results:
CT-Head without contrast [**2152-10-22**]
IMPRESSION: Large intraparenchymal hemorrhage in the left
temporal lobe in the region of the left sylvian fissure with
mild surrounding edema, but no significant mass effect or
midline shift. Given its location within the sylvian fissure, a
dedicated CTA or MRA examination is recommended to rule out
underlying vascular etiology such as aneurysm.
EEG: This is an abnormal portable EEG in the waking and drowsy
states due to persistent mixed theta and delta frequency focal
slowing
in the left anterior temporal region. There were no associated
epileptiform features. The findings suggest an area of
subcortical
dysfunction in that region.
MRI:
1) Recent intraparenchymal hemorrhage in the left temporal lobe
without evidence for an associated enhancing mass.
2) Numerous punctate susceptibility artifacts consistent with
prior tiny hemorrhages in the cerebral hemispheres. Most of
these are located peripherally. The appearance is overall highly
suggestive of amyloid.
3) Moderate to severe extent of T2-hyperintense areas in the
cerebral white matter and pons, most suggestive of chronic small
vessel ischemic disease.
Echo: EF > 55%
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. No definite
structural cardiac source of embolism identified.
[**2152-10-22**] 03:45PM BLOOD WBC-9.8 RBC-4.04* Hgb-14.1 Hct-40.3
MCV-100* MCH-35.0* MCHC-35.1* RDW-13.2 Plt Ct-267
[**2152-10-23**] 04:11AM BLOOD WBC-9.8 RBC-3.95* Hgb-14.0 Hct-40.2
MCV-102* MCH-35.5* MCHC-34.9 RDW-12.7 Plt Ct-293
[**2152-10-24**] 11:25AM BLOOD WBC-8.7 RBC-4.04* Hgb-14.3 Hct-39.6*
MCV-98 MCH-35.5* MCHC-36.2* RDW-13.3 Plt Ct-269
[**2152-10-22**] 03:45PM BLOOD PT-13.1 PTT-26.2 INR(PT)-1.1
[**2152-10-24**] 11:20AM BLOOD PT-12.9 PTT-23.9 INR(PT)-1.1
[**2152-10-24**] 11:25AM BLOOD PT-12.6 PTT-24.0 INR(PT)-1.1
[**2152-10-22**] 03:45PM BLOOD ESR-15
[**2152-10-22**] 03:45PM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-25 AnGap-14
[**2152-10-24**] 09:15AM BLOOD Glucose-213* UreaN-10 Creat-1.1 Na-137
K-4.3 Cl-100 HCO3-25 AnGap-16
[**2152-10-24**] 11:25AM BLOOD Glucose-121* UreaN-11 Creat-1.1 Na-136
K-4.7 Cl-103 HCO3-25 AnGap-13
[**2152-10-22**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2152-10-22**] 10:27PM BLOOD CK-MB-4 cTropnT-<0.01
[**2152-10-23**] 04:11AM BLOOD CK-MB-4 cTropnT-<0.01
[**2152-10-23**] 04:11AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.6* Mg-2.4
Cholest-231*
[**2152-10-24**] 11:20AM BLOOD Calcium-9.6 Phos-2.9 Mg-2.6
[**2152-10-24**] 11:25AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.5
[**2152-10-23**] 04:11AM BLOOD %HbA1c-5.5
[**2152-10-23**] 04:11AM BLOOD Triglyc-74 HDL-56 CHOL/HD-4.1
LDLcalc-160*
[**2152-10-23**] 04:11AM BLOOD TSH-1.1
[**2152-10-22**] 03:45PM BLOOD CRP-1.7
[**2152-10-23**] 04:11AM BLOOD Phenyto-8.3*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the Neurology Service for further
evaluation. He was monitored on tele and ruled out for an MI. He
was maintained normothermic and euglycemic. His Aspirin was held
and he was given pneumoboots for DVT prophylaxis. His blood
pressure was controlled to systolic 120-160 and MAP <130. His
A1c and FLP were checked and she was noted to have an elevated
LDL, therefore he was started on Simvastatin 40.
He had an MR which showed multitude of punctate hemorrhages
suggestive of amyloid angiopathy. A CTA did not reveal an AVM.
He was started on Dilantin for seizure prophylaxis and EEG was
obtained that demonstrated focal slowing in the left anterior
temporal region but no epileptiform discharged.
He was discharged on dilantin for a total of 10 days and will
have outpatient neurology follow-up.
Medications on Admission:
ASA 325
MVI
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Intracerebral hemorrhage
Amyloid
Discharge Condition:
Stable: no focal deficts, mild paraphasic errors
Discharge Instructions:
1. DO NOT TAKE ASPIRIN OR OTHER NSAIDS UNLESS INSTRUCTED BY YOUR
DOCTOR
2. Please call your doctor or come to the closed ED if you
develop new symptoms
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2152-12-19**] 11:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"401.9",
"432.9",
"277.39"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8431, 8437
|
7372, 8211
|
359, 365
|
8514, 8565
|
4525, 7349
|
8765, 9019
|
2192, 2229
|
8273, 8408
|
8458, 8493
|
8237, 8250
|
8589, 8742
|
3244, 4506
|
2244, 2691
|
279, 321
|
393, 1992
|
2706, 3227
|
2014, 2049
|
2065, 2176
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,818
| 141,564
|
23835+23836+57379
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2184-6-3**] Discharge Date: [**2184-6-20**]
Date of Birth: [**2143-1-25**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Left hip insicion drainage, fevers, cellulitis
Major Surgical or Invasive Procedure:
[**2184-6-4**]: Irrigation adn debridement of left hip, Replacement of
acetabular liner and femoral head components, incisional VAC
dressing placement
[**2184-6-9**]: Irrigation and debridement of left hip, component
explantation, VAC dressing placement
History of Present Illness:
Patient is a 41 year old male who underwent total hip
replacement on [**2184-5-20**] for underlying posttraumatic
osteoarthritis secondary to a fall from a ladder in [**2179**]. He did
well post-op until around [**5-28**], when he noted pain with
movement of hip, drainage and redness. Orthopedics NP advised
him to be evaluated at the Emergenct Department at that time,
though he did not present for treatment. On [**2184-5-31**], developed
fevers to 103 at home. He presented to [**Hospital1 18**] ED on [**2184-6-3**] with a
temperature of 100.7. Vancomycin was started [**6-3**]; blood cultures
sent but unclear if sent after vancomycin [**Name8 (MD) **] RN notes. he was
admitted to orthopedics.
Past Medical History:
PMH:
-Status post fall in [**4-/2180**]: fell off a ladder approx 20 feet.
No LOC, underwent ex-lap with resection of his small bowel, ORIF
of his right femur, T10-L3 fusion, transpedicular decompression
at T12, multiple laminotomies, right iliac crest bone graft.
PPH:
-Polysubstance abuse (cocaine on tox at admit). Pt reports he
has used MJ, EtOH and crack cocaine and opiates in the past.
Reports several years sober from MJ and EtOH. States he last
used crack "a couple of days ago." Multiple detox stays.
-No current outpt treatment. Hospitalized x1 at [**Hospital 882**]
Hospital in [**2181**] following 5 week cocaine binge which pt states
was an attempt to kill himself. Attempted to kill himself with
excessive drug use in the past.
Social History:
B/R in [**Location (un) 86**], younger of 2 sibs. States his brother "might as
well be dead" and that they have been estranged since their
mother's death in [**2179**]. Of note, pt's mother died 2 days after
his fall in [**2179**], while he was in a
coma. States he did not learn of her death for several weeks.
States "I didn't like her anyway," but declines to say why.
completed one year of college, dropped out "because my dad told
me to." Worked "on highrises" doing "iron work" and as a
foreman. Has not been able to work since fall, now on SSDI.
States "I'm a grown man, I shouldn't be on that shit." Has been
living in sober house, but is otherwise homeless. States there
is
"no one" in his life."
Per OMR, incarcerated 11 yr ago for approx. 10 yr.
Family History:
NA
Brief Hospital Course:
Patient is a 41 year old male who underwent total hip
replacement [**2184-5-20**] for underlying posttraumatic osteoarthritis
secondary to a fall from a ladder in [**2179**]. He did well post-op
until around [**5-28**], when he noted pain with movement of hip,
drainage and redness. Orthopedics NP advised him to be evaluated
a the Emergency Room, though he did not present at that time. On
[**2184-5-31**], developed fevers to 103 at home. He presented to [**Hospital1 18**]
ED on [**2184-6-3**] with t 100.7. Vancomycin started [**6-3**]; blood
cultures sent but unclear if sent after vancomycin [**Name8 (MD) **] RN notes.
He was subsequently dmitted to orthopedics. A hip aspirate
revealed frank pus and he was taken to the OR for washout and
liner exchange by Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1005**] on [**2184-6-4**]. Swabs wer sent
from hip
during washout and grew MRSA. Blood cultures from [**6-3**] are
growing staph aureus
and cultures from L hip from OR are growing MRSA.
His course had been complicated by recurrent, asymptomatic SVT
requiring ICU monitoring immediately following his initial
washout. he was seen by cardiology and improved with the
initiation of PO diltiazem. he required frequent doses of IV
Diltiazem to break intermittent runs of SVT to the 200's. Has
also had some agitation and delirium, possibly due to narcotics.
On the evening of [**2184-6-7**], he once again became very agitated
and self discontinued his hemovac drains and his incisional VAC
dressing. He was evaluated by Psychiatry who recomended
Seroquel PRN as the patient had repeatedly refused PRN
benzodiazepines. Infectious Disease had followed the patient
since his initial admission. He was treated with Vancomycin and
his dose was steadily increased based on his trough. Despite
antibiotics, the patient remained persistently febrile with an
elevated WBC and was subsequently taken to the OR on [**2184-6-9**]
for repeat incision and drainage and explantation of all
existing hardware. He continued on IV vancomycin. On the
morning of [**2184-6-10**], he was noted to have a creatinine of 2.1 up
from 1.0. Renal was consulted to aid in managment of his care.
He was diagnosed with ATN. All medicine were renally dosed.
On [**6-13**] patient underwent a repeat ID with placement of a cement
spacer. Again, intraoperative cultures, which ultimately showed
no growth. His creatine trended down. He continued to have
fevers, as high as 103F, despite repeatedly negative blood and
urine cultures. His CXR was clear. He underwent a TEE on [**6-16**],
which was negative for vegetations.
Patient left AMA on [**2184-6-20**]. Patient soon returned after he was
unable to get into his car. See subsequent DC summary for most
recent hospital course.
Medications on Admission:
motrin, naproxen, gabapentin, prozac, tylenol
Discharge Medications:
None, left AMA
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Infected left total hip arthroplasty
Discharge Condition:
Poor, left AMA
Discharge Instructions:
Patient left AMA.
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out by a visiting nurse at 2 weeks
after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 4 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to
prevent deep vein thrombosis (blood clots). After completing
the lovenox, please take Aspirin 325mg twice daily for an
additional three weeks.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by VNA in 2 weeks. If you are going to
rehab, the rehab facility can remove the staples at 2 weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at 2 weeks after
surgery.
12. ACTIVITY: NBW LLE. No strenuous exercise or heavy lifting
until follow up appointment.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2184-6-25**]
9:20
Completed by:[**2184-7-1**] Admission Date: [**2184-6-20**] Discharge Date: [**2184-7-13**]
Date of Birth: [**2143-1-25**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Infected right hip
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 41M s/p L THR for post traumatic OA [**2184-5-20**]
complicated by infection. On [**5-28**] he noticed redness and
drainage from wound and then had fevers [**5-31**]. Presented to
[**Hospital1 18**] ED at that time. A hip aspirate revealed frank pus and he
then ermergently underwent ID with liner exchange and placement
of an incisional VAC by Dr. [**Last Name (STitle) 2637**] on [**6-4**]. Intraoperative
cultures eventually grew MRSA. He was continued on vancomycin
postoperatively and followed by ID. Post operative course was
complicated by ARF secondary to ATN, recurrent SVT, and
delirium. Depsite antibiotics, he continued to have a
leukocytosis and ongoing fevers. He underwent repeat IDs with
antibiotic spacer placement on [**7-24**] and [**6-13**].
Intraoperative cultures from [**6-9**] grew sparse staph aureus. No
grow from [**6-13**] culture. Postoperatively he continued to spike
temps despite vancomycin and repeated I/Ds. Serial blood
cultures repeatedly were negative. CXR was normal. TEE on [**6-16**]
was negative for vegatations. Recurrent SVT was managed by
cardiology with PO diltiazem. Everyone was quite perplexed by
his continued fevers.
On [**6-20**] patient left AMA. However, he could not get into his
car and decided to immediately return to the ED that same day.
Patient was then readmitted to our service for continued
management.
Past Medical History:
-See HPI
ex-lap with resection of his small bowel, ORIF R femur, T10-L3
fusion, transpedicular decompression, at T12, multiple
laminotomies, right ICBG, h/o polysubstance abuse, depression
Social History:
Disability. Tobacco 1ppd. ETOH, crack cocaine, opiate use in
past but none recently. Denies IVDU.NVC
Family History:
NC
Physical Exam:
At the time of discharge:
AVSS
NAD
wound c/d/i without erythema
[**Last Name (un) 938**]/FHL/TA/GS intact
SILT distally
Pertinent Results:
Labs on admission:
[**2184-6-19**] 06:00AM BLOOD WBC-5.4 RBC-2.89* Hgb-8.3* Hct-26.0*
MCV-90 MCH-28.8 MCHC-32.0 RDW-15.8* Plt Ct-269
[**2184-6-21**] 06:20AM BLOOD Neuts-77.5* Lymphs-14.4* Monos-5.2
Eos-2.6 Baso-0.3
[**2184-6-19**] 06:00AM BLOOD Plt Ct-269
[**2184-6-19**] 06:00AM BLOOD Glucose-129* UreaN-20 Creat-1.9* Na-133
K-3.6 Cl-98 HCO3-22 AnGap-17
[**2184-6-19**] 06:00AM BLOOD Calcium-7.2* Phos-3.7 Mg-1.3*
Labs prior to DC:
Micro:
[**6-20**], [**6-21**], [**6-23**] blood cultures: no growth
[**6-22**] urine cxr: no growth
[**6-30**] stool cdiff: negative
Brief Hospital Course:
Patient readmitted shortly after leaving AMA for continued
fevers s/p infected left THR. Hospital course summarized by
systems below.
Neuro: Patient maintained on seroquel PRN, which he did not
require during stay. He remained calm throughout stay. He was
not suicidal.
CV: Patient was HD stable during stay. He continued to have
intermittent SVTs responding to PO diltiazem. PO dilt regimen
was increased for continued SVTs with good effect. Rate of SVTs
significantly reduced with resolution of fever. Cardiology
reconsulted, no new recs. When made NPO for abdominal pain (see
GI), AV node suppression maintained with standing IV Lopressor
with good effect. Cardiology saw patient several times in
house. Given a structurally normal heart, they are not
recommending any additional diagnostic or therapeutic
interventions besides PO diltiazem at this time. He can follow
up with cardiology as needed.
Resp: Stable. Ongoing fevers were concerning for PNA. CXR was
negative for infiltrate.
Renal: Improved. Patient renal function recovered to baseline
following ARF secondary to ATN. U/O adequate during stay.
GI: On [**6-30**] patient developed severe diffuse abdominal pain with
recurrent N/V in the setting of a grossly bloody bowel movement.
KUB showed dilate SB loops without free air. Given prior
history of ex lap with SBR in [**2179**], we were worried about a high
grade SBO. General surgery was immediately consulted. He was
made NPO, placed on mIVFs, and a NGT was placed, which showed
bilious return without bright red blood. He was placed on IV
Protonix. Subsequent I+/O+ ABD CT showed thickening of the
duodenum and distal ileum. No SBO or signs of colitis. His
abdominal labs were unremarkable. Given grossly blood stool
suggestive of a GIB and ABD CT findings, GI was immediately
consulted. GI recommended both a colonoscopy and EGD. Patient
refused proposed procedures. He was deemed in capacity. He is
highly recommended to follow up at [**Hospital **] clinic with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 1256**]
at ([**Telephone/Fax (1) 11048**] to schedule a colonoscopy and EGD.
ID: ID service actively followed patient during stay.
Continued fevers while on vancomycin and clean incision was
concerning. Patient developed a significant full body rash
concerning for a drug reaction. Dermatology was consulted and
agreed that vancomycin, the newest drug introduced to this pt,
was the most likely culprit. A WBC scan showed likely
osteomyelitis of the left hip, as expected, but was without
other hot spots suggestive of a missed infections focus. Given
these findings, in addition to an unremarkable standard fever
workup, we decided to stop the vancomycin and switch to
daptomycin. Within 2-3 days of switch, his fevers subsided and
his rash improved. These findings confirmed our suspicion to a
vancomycin-induced fever and skin rash. Incidentally, we also
believe he developed drug-induced thrombocytopenia (see hem). A
new rash developed while on daptomycin on [**7-7**] limited to
bilateral feet and shins. ID did not think this was related to
daptomycin. Rash was stable prior to discharge and should be
monitored closely for progression. Patient scheduled to
continue daptomycin until follow up appointment with ID,
potential end date being [**7-26**]. Patient is scheduled to see Dr.
[**First Name (STitle) **] in clinic on [**2184-7-16**]. Patient afebrile and WBC WNLs
prior to discharge. He will need weekly CBC/diff, CK, BUN/Cr
drawn and faxed to [**Hospital **] clinic as instructed.
Hem: Patient was chronically anemic during stay. He received 2
units pRBC on [**6-23**] for a HCT of 22.8 in the setting of frequent
SVTs. Pt developed significant thrombocytopenia on [**6-25**]. Nadir
of 50. Hematology was consulted and believed thrombocytopenia
was drug induced. HIT was less likely, but was nevertheless
ruled out with a negative HIT antibody. DIC and TTP/K??????SS were
unlikely. There were no signs of active hemolysis. Platelets
slowly rose following discontinuation of vancomycin, as
expected. Unclear if low platelets contributed to GIB.
Platelet count returned to [**Location 213**] by time of discharge. HCT 24
prior to discharge, which again reinforced the importance of GI
follow up with upper and lower endoscopy. Patient again refused
inpatient scopes, and reassured me that he will make a GI
appointment in the near future.
Ortho: His hip incision was clean/dry/intact during stay.
Patient afebrile soon after vancomycin discontinued. No
immediate plans for another I/D. On [**7-1**] patient developed LLE
edema concerning for DVT. LE??????O was negative. Staples were
removed on [**7-9**].
Medications on Admission:
fluoxetine, vancomycin, nicotine, docusate, senna, diltiazem,
gabapentin, fentanyl patch, enoxaparin 40 daily, valium,
omeprazole
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal once a day.
Disp:*30 Patch 24 hr(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for severe pain: Do not drive or operate heavy
machinery.
Disp:*90 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
8. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
TID (3 times a day): Apply to affected skin area. Do not apply
around hip incision.
Disp:*1 tube* Refills:*0*
9. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Continue until instructed otherwise.
Disp:*21 syringes* Refills:*0*
10. Daptomycin 500 mg Recon Soln Sig: Seven Hundred (700) mg
Intravenous once a day.
Disp:*30 bags* Refills:*0*
11. Valium 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for muscle spasm.
Disp:*14 Tablet(s)* Refills:*0*
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO DAILY
(Daily).
14. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
infected left THR
Discharge Condition:
good
Discharge Instructions:
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy machinery or drink alcohol when taking these
medications. As your pain improves, please decrease the amount
of pain medication. This medication can cause constipation, so
you should drink plenty of water daily and take a stool softener
(e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox until your
follow up appointment to prevent deep vein thrombosis (blood
clots).
10. WOUND CARE: Please keep your incision clean and dry. Please
place a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks.
12. ACTIVITY: Partial weight bearing as tolerated on the
operative leg. No strenuous exercise or heavy lifting until
follow up appointment.
Physical Therapy:
Non-weight bearing LLE.
Treatments Frequency:
Wound checks, daily daptomycin infusions, lovenox injections.
Prescribed Antibiotic Information:
Daptomycin 700mg IV daily
Needs weekly CBC/diff, CK, BUN/Cr
Other medications of note for drug inteactions, other oral
antibiotics taken in conjunction etc.
access changes
comments
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**]
Followup Instructions:
Please schedule a 2 week follow up appointment with Dr. [**Last Name (STitle) **] at
([**Telephone/Fax (1) 2007**].
Please call Dr. [**Last Name (STitle) 20540**] at the [**Hospital **] clinic to schedule an outpatient
upper endoscopy and colonoscopy at ([**Telephone/Fax (1) 11048**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2184-7-16**] 10:00
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-8-24**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-8-24**] 9:30
Completed by:[**2184-7-13**] Name: [**Known lastname 6577**],[**Known firstname **] Unit No: [**Numeric Identifier 11083**]
Admission Date: [**2184-6-20**] Discharge Date: [**2184-7-13**]
Date of Birth: [**2143-1-25**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 370**]
Addendum:
For clarification, weightbearing status is non-weightbearing LLE
and weightbearing as tolerated in RLE. This was communicated to
rehab and an updated DC summary will be faxed.
Discharge Disposition:
Extended Care
Facility:
Rosscommon
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 372**] MD [**MD Number(2) 373**]
Completed by:[**2184-7-14**]
|
[
"E878.2",
"V15.81",
"584.9",
"304.02",
"301.7",
"311",
"995.91",
"427.0",
"E878.1",
"V43.64",
"996.66",
"E849.8",
"287.5",
"038.12",
"711.05",
"304.21",
"730.25",
"427.81",
"584.5",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.56",
"38.93",
"80.75",
"80.85",
"80.05",
"00.71",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
21681, 21873
|
11349, 16068
|
8818, 8824
|
18027, 18034
|
10756, 10761
|
20364, 21658
|
10597, 10601
|
16248, 17850
|
17986, 18006
|
16094, 16225
|
18058, 19283
|
10616, 10737
|
19779, 19803
|
19825, 20341
|
8760, 8780
|
19295, 19761
|
8852, 10249
|
10775, 11326
|
10271, 10462
|
10478, 10581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,560
| 155,429
|
38334
|
Discharge summary
|
report
|
Admission Date: [**2124-7-11**] Discharge Date: [**2124-7-16**]
Date of Birth: [**2054-2-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2124-7-10**] - Aortic Valve Replacement (25mm St. [**Male First Name (un) 923**] mechanical
valve) and Ascending aorta replacement
History of Present Illness:
This is a 70 year old male who presented with periodic episodes
of palpitations, often associated with lightheadedness,
diaphoresis, and an overall warm sensation. At one point, he was
seen at outside hospital emergency department and EKG noted SVT.
He was successfully treated with IV Adenosine and started on
Metoprolol. Since initiation of the Metoprolol, he reports
decreasing severity of his symptoms but no change in the
frequency of his episodes. Further cardiac workup revealed
severe aortic stenosis with an incidental finding of ascending
aortic aneurysm. He is now referred for cardiac surgical
intervention.
Past Medical History:
- Biscuspid Aortic Valve,Aortic Stenosis
- Ascending Aortic Aneurysm
- History of Supraventricular tachycardia
Social History:
Lives with: spouse
Occupation: mechanic for airline
Tobacco: denies
ETOH: rare
Family History:
Father with abd aortic aneursym. No premature coronary artery
disease.
Physical Exam:
BP: 124/80 Pulse: 73 Resp: 16 O2 sat: 97% RA
Height: 185 cm Weight: 83.9 kg
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anterior
Heart: RRR [] Irregular [] Murmur 3/6 systolic ejection murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable massess
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact, no focal deficits noted
Pulses:
Femoral Right:cath site Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: murmur vs bruit Left: no bruit
Pertinent Results:
[**2124-7-11**] ECHO
PRE-CPB:1. The left atrium is mildly dilated. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal.
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is mildly dilated at the sinus level. The
ascending aorta is markedly dilated with a saccular shaped
aneurysm. The aortic arch is moderately dilated. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation
is seen.
6. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of Phenylephrine. AV pacing for frequent
pac's, svt. Well-seated mechanical valve in the aortic position
with some AI on the interatrial side that is improved after
protamine. Normal washing jets are visible. No AS. MR [**First Name (Titles) **] [**Last Name (Titles) **] are
as pre-cpb. Preserved biventricular systolic
[**2124-7-16**] 05:26AM BLOOD WBC-7.6 RBC-3.47* Hgb-10.2* Hct-29.2*
MCV-84 MCH-29.3 MCHC-34.8 RDW-12.8 Plt Ct-152
[**2124-7-16**] 05:26AM BLOOD PT-30.3* INR(PT)-3.0*
[**2124-7-16**] 05:26AM BLOOD Glucose-103* UreaN-30* Creat-0.9 Na-139
K-4.4 Cl-104 HCO3-27 AnGap-12
[**2124-7-14**] 04:07PM BLOOD ALT-14 AST-31 LD(LDH)-279* AlkPhos-49
Amylase-77 TotBili-0.4
Brief Hospital Course:
Mr. [**Name14 (STitle) 85410**] was admitted to the [**Hospital1 18**] on [**2124-7-11**] for surgical
management of his aortic valve stenosis and ascending aortic
aneurysm. He was taken directly to the operating room where he
underwent an aortic valve replacement using a mechanical valve
and replacement of his ascending aorta. Please see operative
note for details. Postoperatively he was taken to the intensive
care unit for monitoring. Over the next few hours, Mr. [**First Name (Titles) 85410**] [**Last Name (Titles) **]e neurologically intact and was extubated. Beta blockade was
titrated. On postoperative day one, he was transferred to the
step down unit for further recovery. He went into A Fib and
converted to SR on amiodarone. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. He was gently diuresed towards his preoperative
weight. Coumadin was dosed for an INR on 2.5-3.0 for a
mechanical aortic valve.
Mr. [**Known lastname 85411**] continued to make steady progress and was discharged
home on postoperative day five by Dr. [**Last Name (STitle) 914**]. He will follow-up
with Dr. [**Last Name (STitle) **], his cardiologist and his primary care
physician as an outpatient. First blood draw with VNA on Monday
[**7-17**] with results to Dr. [**Last Name (STitle) 18323**].
Medications on Admission:
METOPROLOL TARTRATE 25 mg twice a day
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. 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:*1*
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: 400 mg [**Hospital1 **] through [**7-20**]; then 200 mg [**Hospital1 **]
[**Date range (1) 21202**]; then 200 mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? mechanical AVR
Goal INR 2.5-3.0
First draw Monday [**7-17**]
Results to be called to Dr.[**Name (NI) 72943**] office
phone[**Telephone/Fax (1) 18325**]
7. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
1 doses: Labs: PT/INR for Coumadin ?????? mechanical AVR
Goal INR 2.5-3.0
First draw Monday [**7-17**]
Results to be called to Dr.[**Name (NI) 72943**] office
phone[**Telephone/Fax (1) 18325**] .
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
- Biscuspid Aortic Valve,Aortic Stenosis
- Ascending Aortic Aneurysm
- History of Supraventricular tachycardia
- postop A Fib
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
edema:
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
7) first blood draw for INR Sunday [**7-16**] with VNA; results to be
called to Dr.[**Name (NI) 72943**] office [**Telephone/Fax (1) 18325**]
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **], [**2124-8-10**] 3:15PM ([**Telephone/Fax (1) 1504**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 18323**] in [**1-15**] weeks [**Telephone/Fax (1) 18325**]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] in [**1-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? mechanical AVR
Goal INR 2.5-3.0
First draw Monday [**7-17**]
Results to be called to Dr.[**Name (NI) 72943**] office
phone[**Telephone/Fax (1) 18325**]
Completed by:[**2124-7-16**]
|
[
"427.31",
"427.89",
"416.8",
"997.1",
"746.4",
"785.1",
"441.2",
"424.1",
"397.0",
"E878.2",
"239.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61",
"39.73"
] |
icd9pcs
|
[
[
[]
]
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7095, 7166
|
3887, 5233
|
333, 469
|
7336, 7505
|
2234, 3864
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8419, 9194
|
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5322, 7072
|
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5259, 5299
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7529, 8396
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281, 295
|
497, 1120
|
1142, 1254
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1270, 1351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,103
| 190,052
|
47607
|
Discharge summary
|
report
|
Admission Date: [**2158-1-17**] Discharge Date: [**2158-1-19**]
Date of Birth: [**2078-6-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Zithromax / Bactrim
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
'feeling unwell'
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 y/o lady with ulcerative colitis presents to the Emergency
Department with 'not feeling well'. Patient has been recently
diagnosed with UTI and was started on Bactrim approx 10 days
ago. Patient has continued to experience increased urgency and
frequency. However her total urine output has been decreased
per patient. She denies any fever, chills, chest pain,
shortness of breath, abdominal pain, nausea, vomitting,
diarrhea, bleeding. No other complaints.
In the ED her vitals were T 99.2 BP 84/52 HR 79 RR 16 99% in
RA.
She was given 1 gram of ceftriaxone given urinanalysis
suspicious for UTI and 10 mg of dexamethasone given prior
history of steroid use.
On arrival to the MICU her vitals were T 97.5 HR 72 BP 97/60
RR 14 99% in RA. Patient felt 'well' after receiving IVF in
ED.
Past Medical History:
Past Medical/Surgical history:
# Ulcerative colitis- dx [**2154**], started on steroids [**2-6**] and
tapered off - on Remicaide. Her last dose was on [**1-2**]
discontinued midway due to ?Redman's syndrome.
# Hypertension
# Anemia- baseline Hct 30, iron deficiency on supplements
# Osteoporosis- on vit D
# Hearing loss (complete deafness in spring but now with only
25% loss)
# Hyperparathyroidism- vit D deficiency
# Hypothyroidism
# h/o PE - on coumadin
# Lung nodule
Social History:
Married to a physician from [**Name9 (PRE) 112**], 5 grown children. Still active
in her own business finding homes for international American
medical students. Her husband has retired and is her full-time
care-giver. She does not currently have services at home.
Family History:
Father died of lung ca at 67; mother died of MI at 50 (1st MI in
40s), had eclampsia.
Physical Exam:
T 97.5 HR 72 BP 97/60 RR 14 99% in RA.
Gen: Pleasant, well appearing lady, following commands
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple. No JVD.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: NABS. Soft, NT, ND. No HSM. No CVA tenderness.
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. Spontaneously moving all 4
extremities. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
On admission:
[**2158-1-17**] 10:15AM PT-47.6* PTT-61.5* INR(PT)-5.4*
[**2158-1-17**] 10:15AM PLT COUNT-304
[**2158-1-17**] 10:15AM NEUTS-83.0* LYMPHS-7.8* MONOS-8.8 EOS-0.2
BASOS-0.2
[**2158-1-17**] 10:15AM WBC-8.2 RBC-3.66* HGB-10.6* HCT-30.7* MCV-84#
MCH-28.9 MCHC-34.4 RDW-15.1
[**2158-1-17**] 10:15AM CK-MB-NotDone
[**2158-1-17**] 10:15AM cTropnT-<0.01
[**2158-1-17**] 10:15AM CK(CPK)-30
[**2158-1-17**] 10:15AM GLUCOSE-116* UREA N-26* CREAT-1.6*
SODIUM-132* POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-20* ANION
GAP-12
[**2158-1-17**] 12:00PM URINE RBC-21-50* WBC->50 BACTERIA-MOD
YEAST-NONE EPI-0
[**2158-1-17**] 12:00PM URINE BLOOD-LGE NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2158-1-17**] 01:28PM LACTATE-0.7
[**2158-1-17**] 08:11PM URINE EOS-NEGATIVE
[**2158-1-17**] 08:11PM URINE RBC-[**12-22**]* WBC-21-50* BACTERIA-MOD
YEAST-OCC EPI-0-2
[**2158-1-17**] 08:11PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2158-1-17**] 08:11PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2158-1-17**] 08:11PM URINE HOURS-RANDOM UREA N-924 CREAT-91
SODIUM-38
.
Labs on discharge:
[**2158-1-19**] 04:35AM BLOOD WBC-6.1 RBC-2.89* Hgb-8.5* Hct-25.3*
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.6* Plt Ct-272
[**2158-1-19**] 02:12PM BLOOD Hct-25.7*
[**2158-1-19**] 04:35AM BLOOD PT-40.8* PTT-55.5* INR(PT)-4.5*
[**2158-1-19**] 04:35AM BLOOD Glucose-82 UreaN-22* Creat-0.7 Na-143
K-4.3 Cl-118* HCO3-20* AnGap-9
[**2158-1-18**] 03:16AM BLOOD ALT-8 AST-10 LD(LDH)-118 AlkPhos-87
TotBili-0.1
[**2158-1-19**] 04:35AM BLOOD Calcium-8.5 Phos-1.5* Mg-2.0
.
CXR: No acute intrathoracic process.
.
Renal US:
FINDINGS: Right kidney measures approximately 9.3 cm in length.
Left kidney
measures approximately 10.6 cm in length. There is no
hydronephrosis. There
is no perirenal fluid collection. Cortical architecture is
within normal
limits.
Renal veins are patent bilaterally.
Both main renal arteries demonstrate a sharp systolic upstroke.
Resistive
index is 0.78 on the right. On the left, the resistive index
within the mainrenal artery measures 0.78. Peak systolic
velocity of the right main renal artery measures 54 cm/s. On the
left, peak systolic velocity of the main renal artery measures
35 cm/s.
The bladder is decompressed by a Foley catheter. There is a cyst
within the
left adnexa measuring approximately 1.8 x 1.5 cm. The size is
slightly
smaller when compared with the previous CT dated [**2156-1-12**].
.
IMPRESSION:
1. No hydronephrosis or perirenal fluid collection.
2. Mildly elevated resistive indicies, without evidence of renal
artery
stenosis.
Brief Hospital Course:
79 y/o lady Ulcerative Colitis admitted with UTI and not feeling
well. Also found to have acute renal insufficiency.
.
# Hypotension: Her hypotension on admission was likely a result
of atenolol toxicity as she was in ARF and likely not clearing
her atenolol. She was unable to mount tachycardia while
hypotensive which was likely due to decreased atenolol
clearance. Urosepsis was also possible but her blood cultures
were negative. She was given a large amount of IVF and her
blood pressure meds atenolol, ramipril, and hctz were all held.
They were not restarted at the time of discharge. Her husband,
who is a physician, [**Name10 (NameIs) **] monitor he blood pressure until her
follow up appointment with her PCP and will restart her hctz if
needed. Her blood cultures were negative.
.
#Urinary tract infection: The patient had a UTI which resulted
in discomfort in urination and likely her feeling weak. She was
previously being treated for a UTI prior to admission. She was
placed on ceftriaxone for treatment of her UTI. Her UA was
positive on admission but her cultures were negative. Her prior
urine cx showed sensitivity to bactrim, cipro, and
nitrofurantoin. The family did not want her taking cipro due to
a previous bad response. The patient was ultimately discharged
on bactrim because the bacteria were more sensitive to this than
the nitrofurantoin. The patient was asked to hold her coumadin
and have it rechecked at her follow up appointment.
There was concern for ascending infection given hx of chills. A
renal ultrasound was done looking for ascending infection. The
ultrasound showed no hydronephrosis, no perirenal fluid
collection, and mildly elevated resistive indicies without
evidence of RAS. The ultrasound also showed a cyst within the
left adnexa measuring approximately 1.8 x 1.5 cm which is
slightly smaller than the cyst from a previous CT on [**2156-1-12**].
This cyst should continue to be followed.
.
# Ulcerative colitis: Her current symptoms are not consistent
with a ulcerative colitis flare. She is currently not on
remicaide because of question of a Redman's syndrome like
reaction to remicaide prior to admission. She was briefly
placed on steroids in the beginning of her admission but was
discharged off prednisone.
.
# Acute renal failure: Her acute renal failure was likely due to
a decreased PO intake and her urine lytes were consistent with a
prerenal etiology. However, given her recent bactrim use AIN was
also a possibility. Her creatinine was elevated to 1.6 on
admission as was 0.7 on the day of discharge after receiving a
substantial amount of fluids. Her HCTZ and ramipril were both
held and her meds were renally dosed.
.
# Anemia: Her recent baseline HCT was approx 35. Her HCT was 30
on admission and 24.4 after getting fluids. It then trended
back up to 28.2 and was stable at 25 on the day of discharge.
She was discharged with instructions to have her HCT rechecked
when she follows up with her PCP. [**Name10 (NameIs) **] was guaic positive in ED
in the setting of having ulcerative colitis.
.
# h/o Pulmonary Embolism: Her coumadin was held because her INR
was 5.4 on admission. Her INR was 4.5 on the day of discharge
and she was instructed to hold her coumadin given that she was
started bactrim until. She will then have her INR checked at
her follow up appointment.
.
# Hypothyroidism/Parathyroidism: She was continued on her home
levothyroxine and calcium.
.
# Hypercholesterolemia: Her colesevelam was held early on in her
hospitalization but restarted prior to discharge.
Medications on Admission:
Medications on admission:
Alendronate 70 mg daily
Atenolol 50 mg daily
Colesevelam 1835 mg [**Hospital1 **]
Ergocalciferol Vit D2 - 50 000 unit monthly
Hydrochlorothiazide 12.5 mg daily
Levothyroxine 75 mcg daily
Ramipril 5 mg daily
Warfarin 3 mg Mon-Sat and 1.5 mg on sunday
Acetaminophen prn
Calcium carbonate 1250 mg [**Hospital1 **]
Ferrous Sulfate 134 mg daily
Loperamide 2 mg daily
Trimethaprim-sulfamethoxazole approx 10 days
Prednisone 30 mg peri remicaide
Fexofenadine peri remicaide
Infliximab every 8-12 weeks
.
Allergies:
Penicillins / Ciprofloxacin / Zithromax
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 134 mg (27 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
3. Calcium carbonate
1250mg PO BID
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
5. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
6. Colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) as needed for 1875mg.
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day) for 7 days.
Disp:*21 Powder in Packet(s)* Refills:*0*
9. Lo-Peramide 2 mg Tablet Sig: One (1) Tablet PO once a day.
10. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please get a CBC, chem 10, and INR drawn on [**2158-1-23**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atenolol toxicity secondary to Acute Renal Failure
Acute renal failure
Urinary tract infection
Ovarian cyst
.
Secondary Diagnosis:
Ulcerative Colitis
Hypertension
Anemia
Osteoporosis
Hearing loss
Hyperparathyroidism
Hypothyroidism
h/o Pulmonary Embolism
Lung Nodule
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with a urinary tract infection, low blood
pressure, and worsening kidney function. Your kidney function
was decreased because you were not drinking enough fluids. Your
blood pressure was low because your kidneys were not processing
your blood pressure medication so it was staying in your blood
for too long. You were given a lot of fluids and both your
blood pressure and kidney function improved. You can have your
husband take your blood pressure twice a day over the weekend
and if it is elevated you can restart your blood pressure
medications. If your blood pressure is not elevated you should
stay off your blood pressure medications and you can talk to
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] morning about when to restart
them. You should also not take your coumadin. You can discuss
with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 766**] about when you should restart this.
Your urinary tract infection is going to be treated with bactrim
because the bacteria you previously grew are most sensitive to
this medication. Please remember to drink water. You were
walking well on discharge and do not need to be seen by PT.
.
You were started on the following new medications:
Bactrim double strength
Phosphate (as your phospate was low). Please have this rechecked
with your doctor. Discuss with your doctor if you should
continue taking this.
.
The following medications were discontinued:
Remicaid
Prednisone
Coumadin
Atenolol
Hydrochlorothiazide
Ramipril
Fexofenadine
.
There were no changes to the following medications:
Alendrontate
Colesevelam
Ergocalciferol
Loperamide
.
Please return to the ED if you experience discomfort with
urination, blood in your urine, weakness, chest pain, dizziness,
or any new concerning symptom.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 719**]) on [**Telephone/Fax (1) 766**] [**2158-1-23**] at 9:30 am.
.
She should have her INR, Phosphate, and BP checked on [**Year (4 digits) 766**].
At this time it may be appropriate to restart her blood pressure
medications and possibly coumadin. She is being discharged on
phosphate repletion.
Completed by:[**2158-3-26**]
|
[
"V58.61",
"E942.9",
"401.9",
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
[]
]
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,952
| 197,882
|
5122
|
Discharge summary
|
report
|
Admission Date: [**2129-9-18**] Discharge Date: [**2129-9-30**]
Date of Birth: [**2071-6-27**] Sex: M
Service: MEDICINE
Allergies:
Tapazole
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Nausea and vomiting
Transferred to MICU for Medical Complexity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 58 yo M with DM 1 and ESRD on HD (last HD
yesterday) who presented with nausea and vomiting since this
morning. At that point, his blood sugar was >400, which improved
to 250 after 4 units humalog.
In the ED, the vitals were 97 87 137/88 24 100%. He refused exam
including rectal exam, multiple lab draws and an ECG. His legal
[**First Name3 (LF) 18297**] was not called. He was noted to have coffee grounds
emesis and GI was called. He refused NG tube. He eventually
allowed labs which were notable for a hematocrit of 35, a
respiratory alkalosis and a metabolic acidosis. He eventually
allowed an ECG which showed T wave inversions in the anterior
leads. He was not given any aspirin given concern for GI bleed.
His only access was a 22 gauge and he refused attempts at
additional access.
His father reports that he was recently hospitalized at [**Hospital1 2177**]. He
was admitted threre for hypoglycemia. He was discharged to HD on
saturday and was feeling unwell afterwards. At that time his
blood sugar was 17. He did not complain of nausea/vomiting until
the morning of admission. His father did not observe the emesis
but was not told that there was blood or coffee grounds. He is
not aware of whether the patient had hematochezia or melena.
Past Medical History:
1. Type 1 diabetes with questionable insulin autoantibody
receptor syndrome
-since age 16 on insulin, followed by Dr. [**Last Name (STitle) 10088**]
[**Name (STitle) 21002**] hypoglycemic episodes, has required intubation for
altered MS in the past
-complicated by nephropathy, retinopathy (s/p R eye laser
surgery [**8-2**])
2. ESRD on HD Tu/Th/Sa
3. Diastolic/Systolic heart failure (LVEF>55% [**6-/2127**] -> LVEF 15%
[**8-/2129**])
4. Hypertension
5. Hyperlipidemia
6. Peripheral vascular disease s/p amputation of R 5th digit and
chronic foot ulcers followed by Dr. [**Last Name (STitle) **] in [**Hospital1 2177**]
7. Hypothyroidism
8. Anemia
9. Burn on his left upper extremity, now s/p skin graft
10. S/p left first toe distal phalangectomy in [**2127-9-28**]
11. Pancreatic lesions seen on an abdominal CT done in [**2127-5-28**]
Social History:
Lives with [**Year (4 digits) **]. Previously worked in construction but is now
unemployed. No alcohol, drugs, or tobacco. He has never been
married and has two adult children.
Family History:
Mother - Type 2 Diabetes [**Year (4 digits) **], Rheumatoid Arthritis
Maternal Aunt - Type 2 Diabetes [**Name (NI) **]
Nephew - Type 1 Diabetes [**Name (NI) **]
Physical Exam:
Physical Exam upon arrival to MICU
General Appearance: No acute distress
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing, right
foot, surgical scar 5th metatarsal, no e/o infection
Skin: Warm
.
DISCHARGE EXAM:
Vitals: 96.4 SBP 140s 74 18 98% RA
GEN: No acute distress, lying in bed comfortably
HEART: RRR, nl S1/S2, no m/r/g
LUNG: CTAB, no crackles or wheezes
ABD: Soft, Non-tender, Bowel sounds present
EXT: no edema, R foot ulcer s/p debridement by podiatry
Pertinent Results:
[**2129-9-18**] 06:48PM BLOOD WBC-4.7 RBC-4.33* Hgb-12.3* Hct-35.3*
MCV-82 MCH-28.4# MCHC-34.8 RDW-16.2* Plt Ct-171
[**2129-9-19**] 07:41AM BLOOD WBC-5.8 RBC-4.20* Hgb-11.7* Hct-35.6*
MCV-85 MCH-28.0 MCHC-32.9 RDW-16.0* Plt Ct-190
[**2129-9-21**] 06:40AM BLOOD WBC-5.0 RBC-4.86 Hgb-13.8* Hct-41.8
MCV-86 MCH-28.4 MCHC-33.0 RDW-16.0* Plt Ct-225
[**2129-9-18**] 06:48PM BLOOD PT-13.1 PTT-29.6 INR(PT)-1.1
[**2129-9-18**] 06:48PM BLOOD ALT-31 AST-29 CK(CPK)-79 AlkPhos-106
Amylase-64 TotBili-0.3
[**2129-9-18**] 06:48PM BLOOD Glucose-232* UreaN-19 Creat-4.3* Na-139
K-4.1 Cl-100 HCO3-22 AnGap-21*
[**2129-9-18**] 06:48PM BLOOD Lipase-41
[**2129-9-18**] 06:48PM BLOOD cTropnT-0.15*
[**2129-9-19**] 07:41AM BLOOD CK-MB-3 cTropnT-0.16*
[**2129-9-19**] 08:41PM BLOOD CK-MB-3 cTropnT-0.16*
[**2129-9-18**] 06:48PM BLOOD ASA-NEG
[**2129-9-18**] 06:57PM BLOOD pO2-199* pCO2-20* pH-7.67* calTCO2-24
Base XS-5 Comment-[**Known lastname **] TOP
[**2129-9-18**] 11:39PM BLOOD Type-ART pO2-55* pCO2-45 pH-7.38
calTCO2-28 Base XS-0
[**2129-9-19**] 04:12AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2129-9-21**] 06:40AM BLOOD Triglyc-164* HDL-48 CHOL/HD-2.5
LDLcalc-38
[**2129-9-21**] 06:40AM BLOOD TSH-5.8*
[**2129-9-21**] 06:40AM BLOOD Free T4-1.6
DISCHARGE LABS:
[**2129-9-29**] 06:28AM BLOOD WBC-5.6 RBC-4.00* Hgb-11.5* Hct-34.5*
MCV-86 MCH-28.8 MCHC-33.5 RDW-16.2* Plt Ct-201
[**2129-9-29**] 06:28AM BLOOD Glucose-102* UreaN-40* Creat-4.8* Na-133
K-4.1 Cl-95* HCO3-29 AnGap-13
[**2129-9-29**] 06:28AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.2
IMAGING:
CXR [**2129-9-18**]:
Previously noted right basilar consolidative opacity has
essentially resolved. There are mild patchy opacities at the
lung bases most likely reflective of atelectasis though early
infection cannot be completely excluded.
ECHO [**2129-9-19**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5 mmHg.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated. There
is severe global left ventricular hypokinesis (LVEF = 15 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels 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 moderately thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
MICROBIOLOGY:
[**2129-9-19**] BCx: no growth
[**2129-9-19**] MRSA screen: positive
Brief Hospital Course:
58 yo M with DM1, ESRD presenting with nausea/vomiting and ECG
changes, found to have new systolic heart failure with EF of
15%. Had a hypoglycemic episode in the hospital to 12,
transferred to MICU for monitoring. Nausea resolved and blood
glucose better controlled with new regimen and improved
appetite. Family meeting was had to discuss goals of care in
light of his frequent hospitalization for hypoglycemia and this
new systolic heart failure. Patient was made DNR/DNI after the
discussion with his mother and his father (who is his [**Month/Day/Year 18297**]).
Decision was also made that patient cannot return home as it was
considered to be an unsafe environment, so he is being
discharged to rehab.
# Systolic heart failure: The patient presented with symptoms
and ECG changes concerning for ischemia for which Cardiology was
consulted. While there was low suspicion for ACS, an ECHO was
ordered and showed global hypokinesis and EF<15%. Cardiology
recommended cardiac catherization, but patient stated that he
would rather follow up with an outside cardiologist for cardiac
cath and work up of his heart failure. He was started on low
dose ace-inhibitor during his hospitalization in addition to
continuing his beta blocker and statin. Renal thought this could
be due to L-carnitine deficiency, and it is being worked out
with his insurance for treatment with L-carnitine during
hemodialysis.
# ECG changes: He had new T wave inversions in setting of
nausea, which given his history as a diabetic vasculopath was
concerning for ischemia. Cardiology was consulted and felt
suspicion for ACS was low and recommended continuing cardiac
medication if no contraindication. Troponin not elevated
compared to priors. An ECHO showed new systolic CHF as above.
Aspirin was continued once hematocrit was determined to be
stable. Beta blocker and statin were continued. Per [**Hospital1 2177**] record
(though no EKG available for comparison), this T wave inversion
was present during his hospitalization earlier in [**2129-8-27**].
# Nausea/vomiting: Initially concerning for cardiac ischemia (as
described above). It was not felt to be due to DKA given pt's
normal pH on presentation. It was likely related to
hyperglycemia. It resolved on its own with better glucose
control.
# Likely [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear: Pt presented with coffee ground
emesis concerning for upper GI bleed, but pt's hct remained
stable. GI was consulted, but patient refused NG lavage and EGD.
He was started on PPI and coffee ground emesis resolved. Thought
to be due to [**Doctor First Name 329**] [**Doctor Last Name **] in the setting of nausea/vomiting
which were his presenting symptoms.
# DM 1: Patient with very brittle diabetes, thought to have
insulin autoantibody syndrome, which predisposes him to frequent
episodes of hypoglycemia. He was initially covered with last
insulin regimen in hospital ([**5-/2129**]) which was glargine 2 units
q breakfast and HISS. Patient returned to the MICU on [**2129-9-21**]
given hypoglycemia and unresponsiveness. He received 1 unit of
glargine and 3 units of Humalog on [**2129-9-22**] for glucose of >
300. [**Last Name (un) **] was consulted and agreed on slow and small
uptitration of his insulin. He was started on new regimen with 2
[**Location **] in AM, 2 [**Location **] at bedtime IF BG >200, and low
humalog SSI with no episodes of hypoglycemia.
# ESRD on HD Tu/Th/Sa: He was continued on normal HD schedule
and nephrocaps, calcitriol, sevelamer.
# Foot ulcer: Wound appeared clean without e/o infection. Pt is
followed by outside podiatrist. Wound consult was obtained and
felt that callus around the wound edge was impeding healing.
Podiatry was consulted and his callus was debrided.
# HTN: His home minoxidil, diltiazem, doxazosin and furosemide
were held as his blood pressure was not very elevated. His
metoprolol was continued for his heart and lisinopril was added
for his heart failure. His home medications can be restarted in
the future as needed.
# Gout: continued allopurinol.
# Glaucoma: continued home dorzolamide-timolol drops.
# Hypothyroidism: continued levothyroxine.
Transitional Issues:
[ ] Patient will need a cardiologist as an outpatient for his
new heart failure. Patient initially stated that he wanted to
follow up with his [**Location **]' cardiologist at [**Hospital6 **]
Medical Center.
[ ] ?L-carnitine treatment with hemodialysis - will need follow
up with insurance for approval
[ ] Follow up appt with GI made, pt will need to see GI and
decide on outpatient EGD
Medications on Admission:
Procrit 10,000 unit/mL Injection 1 Solution(s) three times a
week
Crestor 20 mg Tab 1 Tablet(s) by mouth once a day
Levemir 100 unit/mL Sub-Q 3 units QAM
Humalog 100 unit/mL SubQ Cartridge 1 Cartridge(s) four times a
day
Renvela 800 mg Tab 1 Tablet(s) by mouth three times a day
Dorzolamide-Timolol 2 %-0.5 % Eye Drops both eyes twice a day
Aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth daily
allopurinol 100 mg Tab 1 Tablet(s) by mouth Every other day
Diltiazem SR 180 mg Cap 1 Capsule(s) by mouth twice a day
Calcitriol 0.25 mcg Cap 1 Capsule(s) by mouth DAILY (Daily)
furosemide 20 mg Tab 1 Tablet(s) by mouth once a day
Minoxidil 2.5 mg Tab 2 Tablet(s) by mouth twice a day
tramadol 50 mg Tab 1 Tablet(s) by mouth every 6 hours as needed
Levothyroxine 75 mcg Tab 1 Tablet(s) by mouth DAILY (Daily)
Doxazosin 4 mg Tab 1 Tablet(s) by mouth at bedtime
metoprolol succinate ER 50 mg 24 hr Tab 1 Tablet(s) by mouth QPM
metoprolol succinate ER 100 mg 24 hr Tab 1 Tablet(s) by mouth
QAM
Nephrocaps 1 mg Cap 1 Capsule(s) by mouth once a day
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis:
Type 1 diabetes [**Location (un) **] with complications
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
Systolic heart failure with ejection fraction of 15%
Secondary Diagnosis:
End stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
|
[
"365.9",
"403.91",
"250.83",
"272.4",
"585.6",
"V45.11",
"682.7",
"285.9",
"428.42",
"274.9",
"V49.72",
"250.43",
"V58.67",
"V18.0",
"428.0",
"244.9",
"530.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12684, 12776
|
7001, 11182
|
331, 338
|
13081, 13081
|
3818, 5119
|
2709, 2872
|
12797, 12797
|
11619, 12661
|
5135, 6978
|
2887, 3532
|
3548, 3799
|
11203, 11593
|
229, 293
|
366, 1637
|
13018, 13060
|
12816, 12997
|
13096, 13241
|
1659, 2499
|
2515, 2693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,400
| 103,011
|
43018
|
Discharge summary
|
report
|
Admission Date: [**2131-12-29**] Discharge Date: [**2132-1-7**]
Service: GENERAL SURGERY
CHIEF COMPLAINT: Pneumoperitoneum.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 92834**] is an 84 year-old
female transferred to [**Hospital1 69**]
from [**Hospital 1281**] Hospital. Ms. [**Known lastname 92834**] has a past medical
history significant for coronary artery disease status post
stent, congestive heart failure, hypertension. She was
evaluated at [**Hospital 1281**] Hospital for fatigue, heme positive stool.
Her hematocrit was found to be 17 and an
esophagogastroduodenoscopy was negative. She then underwent
a bowel prep and then colonoscopy at [**Hospital 1281**] Hospital. They
found a right arterial venous malformation. That
malformation was fulgurated on [**12-27**], which was two days
prior to presentation to [**Hospital1 188**]. The patient then developed increased temperatures,
abdominal distention. This prompted the physicians taking
care of her to order a KUB. This KUB showed free air. She
then received a CT, which showed free air, pelvic fluid and
stranding. This CT accompanied her to [**Hospital1 190**] and was seen by us. The patient had been
started on antibiotics and transferred to [**Hospital1 346**] for further evaluation and
treatment.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post stenting.
2. Congestive heart failure.
3. Aortic stenosis.
4. Hypertension.
5. Colon cancer.
6. Left colectomy.
7. Left lumpectomy secondary to breast cancer.
8. Bilateral carotid end arteriectomies.
MEDICATIONS: 1. Lipitor. 2. Zestril. 3. Lasix. 4.
Aspirin. 5. Tamoxifen. 6. Aricept. 7. K-ciel. 8.
Protonix. 9. Meclozine.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: In general, she is awake, alert and in
no acute distress. Vital signs temperature 101.8. Heart
rate 124. Blood pressure 158/70. Respirations 28. Her
lungs are clear to auscultation bilaterally. Her heart is
regular rate and rhythm. She has a 3 out of 6 systolic
ejection murmur. Her abdomen is dissented, tympanic. It is
diffusely tender. She has right lower quadrant rebound
tenderness. She also has guarding. Extremities they are
warm and well perfuse.
PERTINENT IMAGING: CT of abdomen and pelvis from [**Hospital 1281**]
Hospital shows positive free air, pelvic stranding and fluid.
HOSPITAL COURSE: Ms. [**Known lastname 92834**] was admitted to the hospital
the night of [**12-29**] with an apparent cecal perforation
from her colonoscopy. She was made NPO, given intravenous
fluids and antibiotics and laboratories were checked. It was
soon apparent after she was admitted that she would need a
repair of her cecal perforation. Therefore she went to the
Operating Room. In the Operating Room she underwent an
exploratory laparotomy, a colorrhaphy, and an abdominal
irrigation. In the Operating Room there was seen gross fecal
soilage of her abdominal cavity. The patient tolerated the
procedure well. Please refer to the official operative note
for all the details.
Immediately postoperatively the patient was admitted to the
PACU and was followed by the Intensive Care Unit team mostly
due to the patient's critical aortic stenosis. The patient
received a Swan-Ganz catheter for monitoring and adequate
fluid resuscitation. Her postoperative antibiotics included
Ampicillin, Levofloxacin and Flagyl. There were some
difficulties in correctly placing her Swan secondary to her
anatomy, but after multiple manipulations the Swan was placed
correctly. Of note the patient also had some postoperative
psychosis, which from past medical records the patient was
found to have a history of. Therefore she was put on
scheduled Haldol intravenous. This was soon discontinued
after a couple of days when the patient slowly returned to
baseline in mental status. Also immediately postoperatively,
the patient was started on total parenteral nutrition
secondary to the patient's deconditioned state.
The patient did well in the Intensive Care Unit. The only
issue being her high blood pressure and heart rate and the
patient was switched to intravenous hypertension medications
as the patient was not tolerating po. By postoperative day
four the patient was able to be transferred to the floor. At
this point she was also having return of her bowel function
and was started on clears, however, the total parenteral
nutrition was continued. By postoperative day five the
patient was continued to have high blood pressures and heart
rate. The patient was able to be switched to po hypertension
medications to which she had much better blood pressure
control. She was also being diuresed with intravenous Lasix
with good response and over the next few days the patient was
slowly weaned off of her total parenteral nutrition,
restarted on a po diet and restarted on all of her home
medications.
The patient was discharged of all of her antibiotics, which
were Ampicillin, Levofloxacin and Flagyl on postoperative day
seven after a seven day course. She had been afebrile and
her white count had returned to [**Location 213**]. Physical therapy and
occupational therapy consults had been obtained during the
[**Hospital 228**] hospital stay. They felt due to her deconditioned
status that the patient would need an acute rehab stay
immediately upon discharge from the hospital. This was also
reinforced as the patient did have a fall the day before
discharge in the bathroom while nursing was waiting outside.
CONDITION ON DISCHARGE: The patient is stable tolerating a
po diet and po medications, ambulating well with assistance,
however, unstable without assistance. The patient was
somewhat incontinent of urine.
DISCHARGE STATUS: To rehab facility [**Hospital1 **],
staples still in place to be discontinued in one week.
DISCHARGE DIAGNOSIS:
Status post exploratory laparotomy, colorrhaphy for cecal
perforation secondary to colonoscopy.
DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q day. 2.
Protonix 40 po q day. 3. Tamoxifen 10 mg po b.i.d. 4.
Atenolol 75 mg po q.d. 5. Donepazil 5 mg po q.h.s. 6.
Isosorbide dinitrate 10 mg po q day. 7. Lisinopril 40 mg po
q day prn. 8. Heparin subQ 5000 units b.i.d. until fully
functional. 9. Albuterol inhalers prn. 10. Percocet one
to two tabs po q 4 to 6 hours prn pain.
FOLLOW UP: 1. The patient is to follow up with Dr. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) **] in one to two weeks. 2. The patient is to follow
up with her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48579**] in one to
two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Doctor Last Name 46822**]
MEDQUIST36
D: [**2132-1-7**] 09:18
T: [**2132-1-7**] 09:26
JOB#: [**Job Number 38781**]
|
[
"401.9",
"V45.82",
"E879.8",
"569.83",
"V10.05",
"998.2",
"428.0",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.41",
"46.75",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5979, 6345
|
5858, 5955
|
2392, 5518
|
6357, 6906
|
1773, 2374
|
119, 138
|
167, 1302
|
1324, 1750
|
5543, 5837
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,148
| 131,864
|
12175
|
Discharge summary
|
report
|
Admission Date: [**2183-4-21**] Discharge Date: [**2183-4-30**]
Date of Birth: [**2122-4-9**] Sex: M
Service: UROLOGY [**Doctor First Name **]
HISTORY OF PRESENT ILLNESS: This is a 61 year old male with
left renal cell carcinoma admitted status post renal
embolization by Interventional Radiology, in anticipation for
a debulking left radical nephrectomy. Approximately two
months prior to his presentation, the patient had a chest
x-ray obtained by primary care physician secondary to [**Name Initial (PRE) **]
progressive cough. The chest x-ray revealed a pulmonary
nodule. A chest CT scan was then obtained which revealed
multiple bilateral pulmonary nodules. The needle-biopsy was
consistent with metastatic disease from renal cell carcinoma.
An abdominal CT scan revealed a 6 cm necrotic left renal
mass.
The patient denied hematuria or bony pain, fever or chills,
appetite changes or weight loss. An MRI obtained on [**4-10**], revealed an 8.1 by 7.1 by 6 cm left renal mass.
PAST MEDICAL HISTORY:
1. Left knee arthroscopy in [**2165**].
MEDICATIONS:
Ativan p.r.n.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs were temperature of 96.3
F.; heart rate 69; blood pressure 117/64; respiratory rate
16; O2 saturation 93% on room air. Cor: Regular rate and
rhythm. Lungs are clear to auscultation. Abdomen soft,
nontender, nondistended. The patient had renal embolization
performed on the 25th. On [**4-22**], the patient was brought
to the Operating Room where a left radical nephrectomy was
performed. The mass/kidney was adherent to the pancreas but
was dissected free. An intraoperative consultation was
obtained with Dr. [**Last Name (STitle) 1305**].
Postoperatively, the patient was on perioperative Ancef, NG
tube, [**Location (un) 1661**]-[**Location (un) 1662**] drain, epidural, Foley catheter, PCA,
chest tube. The patient was transferred to the Medical
Intensive Care Unit postoperatively for aggressive fluid
resuscitation. On postoperative day one, the patient was
transferred to the Floor. By postoperative day two, the
chest tube was removed. A chest x-ray obtained after
removing the chest tube revealed no pneumothorax.
The patient continued to ambulate and await return of bowel
function. On postoperative day five, the patient's epidural
and NG tube were removed. A Physical Therapy consultation
was obtained at that time also. On postoperative day six,
the patient's Foley catheter was removed. On postoperative
day seven, a clear liquid diet was started as the patient
reported some flatus. This was tolerated well with no nausea
or vomiting and therefore the diet was advanced to regular.
This was also tolerated well. All of the patient's
medications were converted to oral form including oral pain
control.
On postoperative day eight, the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain
was noted to be minimal, approximately 20 cc per 24 hours. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] amylase was sent and the value was 110.
Therefore, the [**Location (un) 1661**]-[**Location (un) 1662**] was removed.
LABORATORY DATA: Upon discharge, sodium 139, potassium 3.9,
chloride 108, bicarbonate 28, BUN 7, creatinine 1.1, glucose
102.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
2. Colace 100 mg p.o. twice a day.
3. Ativan 1 mg p.o. q. six hours p.r.n.
DISCHARGE STATUS: Home with home Physical Therapy.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (STitle) **], in one to two
weeks.
DISCHARGE DIAGNOSES:
1. Status post left radical nephrectomy.
2. Metastatic renal cell carcinoma.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2183-4-30**] 13:35
T: [**2183-4-30**] 14:01
JOB#: [**Job Number 38115**]
|
[
"428.0",
"189.1",
"285.9",
"458.2",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.45",
"99.29",
"55.51",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
3737, 4083
|
3401, 3603
|
3627, 3716
|
1161, 3353
|
3369, 3378
|
189, 1007
|
1029, 1138
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,085
| 178,911
|
53209
|
Discharge summary
|
report
|
Admission Date: [**2156-11-9**] Discharge Date: [**2156-11-13**]
Date of Birth: [**2110-11-7**] Sex: M
Service: MEDICINE
Allergies:
E-Mycin / Aspirin / Ketorolac / Ibuprofen / Nsaids / Gabapentin
/ Levofloxacin
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46yo gentleman with history of Crohn's on prednisone, type 2 DM
on insulin, depression with h/o suicidal gestures, and CAD s/p
DES to LAD who presented with altered mental status.
Over the last two days, he has been markedly thirsty, and has
started drinking large amounts of milk or chocolate milk. He is
not sure if he took his dose of lantus the night before
admission and admits to skipping sugar checks during the day.
+Polyuria. +Cough productive of yellow sputum x 1 week.
+Nausea but no vomiting. He has been having 2 BMs per day,
which is much better than is normal for his Crohn's.
He walked a block to CVS in order to buy cigarettes and fill his
prescriptions. He was walking over to smoke his cigarette when
he noticed he was feeling unsteady. He leaned against a tree
and then slumped down to the ground. A bystander came to his
aid and EMS was called.
In the ED, initial VS were 100.2 (Tmax 102.2) 174/100 140
18 96%. He denied CP or SOB. He was profusely diaphoretic.
Neurologic exam was nonfocal but he had increased muscle tone.
He was empirically treated with stress dose hydrocortisone and
valium. Somewhat later, he became increasingly somnolent. He
received narcan, and just as the team was about to intubate him,
he sat up on the table and was entirely awake. He had a VBG,
which was 7.33/49/60 with a lactate of 4.7. EKG did not show
acute ischemia, and intervals were normal. Head CT was negative
and CXR showed what was thought to be LLL pneumonia, so he was
given vancomycin and levofloxacin. Just prior to transfer to
the ICU, he was given 10 units of IV insulin for BS 373. He
received 2.5 L IVF in ED.
Upon arrival to the ICU, he wanted to have a bowel movement and
he asked immediately for some water to drink. He specifically
denied taking any extra or new medications. He states his mood
has been good lately and that he is not suicidal: "I would not
walk in front of a bus, but if a bus came and hit me, that would
be okay."
Past Medical History:
- CAD s/p NSTEMI with BMS to LAD [**11-8**] followed by instent
restenosis with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LAD and POBA of jailed diagonal [**6-9**]
- Crohn's (Dx age 12, s/p multiple resections & subtotal
colectomy, s/p 5-aza, 6-MP, and remicade for 5 years. Presently
managed on prednisone 20 mg daily)
- Type II diabetes
- SBO with lysis of adhesions
- Major depressive disorder, history of SI and hospitalizations
for overdose (halcion, lisinopril and lopressor, gas stove
inhalation by report, but not clearly substantiated). Treated
with ECT.
- Borderline Personality Disorder (per review of psych notes)
- Admitted to [**Hospital3 5097**] [**Date range (1) 38649**] for possible seizure, EEG neg
- ADHD
- Osteoporosis
- Polysubstance abuse, history of cocaine and marijuana use
- Hypertension
- Migraine headaches
- Hypoandrogenism
- Hemorrhoids
- Rectal Prolapse, s/p abdominal rectopexy 5/[**2154**].
- Deep vein thrombosis in [**2130**] during bedrest for fx.
- H/o Renal stones
- H/o MRSA skin abscesses
- H/o Perirectal abscess
- H/o Lyme Disease
Social History:
Single MSM, lives in "section 8" housing in [**Location (un) **]; brother
and sister living in area but he is currently not talking to his
family after an argument a few weeks ago. Smokes [**12-6**] PPD x 29
years, uses marijuana every other day, remote h/o cocaine use.
Denies alcohol. Not currently sexually active.
Family History:
Mother - MI at age 67
Many family members with diabetes
States sister had [**Name (NI) 4522**] but "was cured when she got pregnant."
Physical Exam:
VS: 96.1 129/82 100 18 98% RA
GENERAL: Pleasant, unshaven man in no acute distress.
HEENT: No conjunctival pallor. No scleral icterus. PERRL/EOMI.
++Mucous membranes dry. OP clear. Neck Supple, No LAD, No
thyromegaly or nodule.
CARDIAC: Regular tachycardia. Normal S1, S2. +[**12-9**] soft blowing
systolic murmur at apex. No rubs or gallops. JVP not elevated.
LUNGS: Moving air well. Coarse crackles at bases b/l but no
bronchial breath sounds or egophany.
ABDOMEN: Midline scar, well-healed. +BS. Soft, minimally
tender diffusely. [**Doctor Last Name 515**] sign absent. No epigastric
tenderness.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: Narrowed and thickened nails on his fingers and toes b/l.
Small cuts with dirt on his fingers. Becomes diaphoretic with
minimal activity.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. Fine resting tremor b/l. Tone in UE is
normal, although there is some tremor superimposed. [**4-6**]
strength throughout. Gait assessment deferred
PSYCH: Talkative and tangential. Excitable.
Pertinent Results:
EKG: Sinus tachycardia at 136 with normal axis and QTC of
425ms. Poor R wave progression. As compared to baseline from
[**10/2156**], the rate is faster.
LABS:
WBC 14.1
Hgb 12.0
Hct 37.9
Plt 260
83% N, 14.5 L, 1.4 M, 0.3 E, 0.2 B
Na 131
K 5.3
Cl 91
Bicarb 26
BUN 20
Crt 1.0
Gluc 546
Serum tricyclics positive
Serum ASA, EtOh, Acetaminophen, Benzo, Barb: negative
Urine benzos, barbs, opiates, cocaine, amphet, methadone
negative
7.33/49/61/27/0
Lactate 4.7
U/A negative with trace blood, 30 prot, 1000 glucose
Urine Legionella Ag neg
Influenza DFA neg
CXR [**11-9**]:
Heterogeneous left lung base opacity concerning for pneumonia.
Right lung base atelectasis. Follow up radiographs after
treatment is
recommended to document resolution of this finding.
CT Head without contrast [**11-9**]: FINDINGS: There is no
intracranial hemorrhage, edema, shift of normally midline
structures, or evidence of major vascular territorial infarcts.
Ventricles and sulci are normal in size and configuration. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The basilar
cisterns are symmetric. There is no fracture. Paranasal sinuses
and mastoid air cells are well- aerated.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
# Altered Mental Status: DDx at admission hyperosmolar
hyperglycemic state (though not hyperosmolar at admission), drug
overdose (TCA level high at admission), suicide attempt, sepsis,
serotonin syndrome, or seizure. Patient's home medications of
Prednisone and metoprolol could also contribute. Most likely
developed pneumonia, which caused hyperglycemia. He then
developed marked dehydration, which led to his presentation.
Pt. had a recent w/u for questionable seizure at OSH. Patient
was given 3L NS in the ICU. Sedating medications (fentanyl,
temazepam, tizanidine) were held. Treatment was started for CAP
with levofloxacin (day 1 = [**11-9**]) for planned 5 day course. He
was treated with tamiflu X 2 days until Influenza swab was
negative. Urine legionella antigen was negative, as was a NCHCT.
His respiratory status and mental status remained stable during
this admission and he was discharged home.
# Hyperglycemia and Type 2 DM: Patient was put on a sliding
scale with home glargine (decreased dose 12/9 am as patient not
taking good PO). Serum electrolytes in the ICU were checked and
repleted twice daily. He continued to have difficult to control
blood surgars during this hospitalization. Insulin was
increased. Morning blood glucose was in the 100s, but by noon
glucose was often as high as 400, but with no gap. Patient was
seen by nurses exhibiting nonadherence to recommended diet,
often with overconsumption of diabetic products.
# Suspected Community Acquired PNA: Started on levofloxacin x
5 days (day 1 = [**11-9**]).
# Acute Respiratory Acidosis: Likely due to hypoventilation in
setting of altered mental status. Anion gap at admission 14
with a lactate of 4.7, suggesting he may have had a concurrent
anion gap acidosis, however lactate decreased day after
admission and MS improved.
# Hyponatremia and hyperkalemia: Likely has pseudohyponatremia;
elevated K+ is likely due to transcellular shifts as it
resolved.
# Leukocytosis: Likely due to pneumonia or stress reaction. No
bands.
# CAD s/p NSTEMI with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LAD in [**2154**]: Continued plavix,
beta blocker, and statin. Pt. has ASA allergy. CEs were
negative.
# h/o Crohn's disease: Patient was continued on Prednisone and
home medications. His fentanyl patched was restarted on [**11-10**]
due to improved MS.
# h/o major depression: Continued lamictal, held nortriptyline
and lexapro, and temazepam at admission for AMS. Contact[**Name (NI) **]
psychiatrist and....
# ADHD: no need for methylphenidate in house
# h/o polysubstance abuse: tox screen negative with exception
of elevated TCA
# HTN: continued beta blocker
# Hypoandrogenism: restart androgel as outpatient
#Diaphoresis: Patient often found diaphoretic and tremulous,
which he said is is baseline and necesitates carrying around
extra shirt. Unclear if this was low-grade withdrawal vs.
autonomic dysfunction. This has been a longstanding issue.
Medications on Admission:
(confirmed with patient):
Clopidogrel 75 mg po daily
Atorvastatin 80 mg po daily
Lamotrigine 200 mg po daily
Escitalopram 20 mg po qAM, 10mg po qPM
Metoprolol Tartrate 25 mg po bid
Prednisone 20 mg po daily
Nortriptyline - "fairly new" takes 4 pills but doesn't know dose
Temazepam 15 mg po qhs prn anxiety
Testosterone Transdermal
Pantoprazole 40 mg po bid
Insulin Glargine Forty two (42) units SQ qhs
Insulin Lispro sliding scale
Dronabinol 5mg TID prn
Fentanyl 175 mcg/hr Patch (one 100mcg/hr and one 75mcg/hr) q72
hr
Tizanidine 4mg TID prn muscle spasm
Cholestyramine-Sucrose 4 gram Packet [**Hospital1 **] prn
Lomotil 2.5-0.025mg Q6H prn diarrhea
Loperamide 2-4mg QID prn
Compazine 10mg prn nausea
Nitroglycerin 0.3 mg SL Q5 MIN as needed for chest pain.
Methylphenidate 40 mg [**Hospital1 **]
Sudafed prn (took day of admission)
Vitamin D 400 unit po bid
ALLERGIES:
E-Mycin -- "heart stopped"
Aspirin -- abdominal pain
Ketorolac -- unknown
Ibuprofen -- abdominal pain
Nsaids --Crohn's Flare
Gabapentin -- swelling
Discharge Medications:
1. Insulin Glargine 100 unit/mL Cartridge Sig: Forty Six (46)
units Subcutaneous at bedtime.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
8. Tizanidine 4 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a
day.
10. Marinol 5 mg Capsule Sig: One (1) Capsule PO three times a
day.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. Cholestyramine Light 4 gram Packet Sig: Fourteen (14) grams
PO once a day.
16. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
17. Nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at
bedtime: Home dose listed as 80mg.
18. Avelox 400 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Pneumonia
2) Mental Status Changes
3) Diabetes
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Ambulatory sat 96% on room air
Discharge Instructions:
You were admitted with a pneumonia, mental status changes, and
hyperglycemia. You were started on an antibiotic. Please resume
your usual medications and take the antibiotic as prescribed.
Please check your sugars regularly and call your PCP if your
glucose is over 400. We increased your lantus dose.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: PCP
Date and time: Thursday, [**11-25**] at 10:50am
Location: [**Hospital6 5242**] CENTER, [**Location (un) 5243**],
[**Location (un) **],[**Numeric Identifier 718**]
Phone number: [**Telephone/Fax (1) 798**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: [**Last Name (NamePattern1) **]
Date and time: [**Last Name (LF) 766**], [**12-7**] at 10:10am
Location: [**Hospital1 41690**], [**Hospital Ward Name 121**] Complex, [**Hospital Ward Name **] Bldg [**Location (un) 3202**], [**Location (un) 86**], MA
Phone number: ([**Telephone/Fax (1) 4335**]
|
[
"276.1",
"311",
"276.2",
"276.7",
"486",
"280.9",
"780.97",
"V12.51",
"412",
"V45.82",
"414.01",
"555.9",
"250.00",
"401.9",
"338.29",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11994, 12000
|
6420, 6430
|
361, 367
|
12094, 12094
|
5152, 6397
|
12597, 13312
|
3857, 3992
|
10480, 11971
|
12021, 12073
|
9434, 10457
|
12270, 12574
|
4007, 5133
|
301, 323
|
395, 2382
|
12108, 12246
|
2404, 3503
|
3519, 3841
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,662
| 138,393
|
45397
|
Discharge summary
|
report
|
Admission Date: [**2170-12-21**] Discharge Date: [**2171-1-3**]
Date of Birth: [**2091-5-8**] Sex: F
Service: SURGERY
Allergies:
Compazine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
cline insertion
History of Present Illness:
Pt is a 79 y/o F well known to the service who was transferred
from [**Location (un) 745**] [**Hospital 3678**] rehab for evaluation fo a change in her
mental status. She was at her baseline mental status until 3
days ptp at which time she developed decreased responsiveness
and increased somnolence and confusion. On the night ptp she
did not recognize her husband, which has never happend with her
waxing and waining MS in the past. This am she is responsive
only to pain and aphasic.
Past Medical History:
Pancreatic CA s/p whipple, xrt, and chemo
Seizures
S/p L hepatic lobectomy
s/p J tube placement
hx c-diff colitis [**11-5**]
hx depression
hx anxiety
Social History:
pt has never used tobacco, alcohol, or recreational drugs.
worked as an assistant at [**Hospital3 328**]
Family History:
Non-contributory
Physical Exam:
102.4 114 193/102 21 88% on RA, 100% on NRB FS glucose 135
Thin, cachetic, but NAD
Pt opens eyes briefly to voice, does not follow commands,
aphasic
Anicteric, LCTA b/l, RRR but tachy, s1s2 no M/r/g,
Abd: soft, nt, nd, bs present, no rebound, no guarding, J tube
site without erythema
EXT: pedal pulses present, no edema
Pertinent Results:
[**2170-12-21**] 12:00PM AMMONIA-70*
[**2170-12-21**] 12:10PM PT-14.9* PTT-22.7 INR(PT)-1.5
[**2170-12-21**] 12:10PM PLT COUNT-306#
[**2170-12-21**] 12:10PM WBC-20.2*# RBC-4.09* HGB-12.9 HCT-36.5 MCV-89
MCH-31.6 MCHC-35.4* RDW-17.3*
[**2170-12-21**] 12:10PM ALBUMIN-3.3* CALCIUM-9.1 PHOSPHATE-3.1
MAGNESIUM-2.0
[**2170-12-21**] 12:10PM ALT(SGPT)-21 AST(SGOT)-44* ALK PHOS-193*
AMYLASE-120* TOT BILI-0.8
[**2170-12-21**] 12:10PM GLUCOSE-131* UREA N-34* CREAT-1.2* SODIUM-139
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
Brief Hospital Course:
Pt was admitted after initial resuscitation to the SICU.
CT of the head was negative, and an EEG was obtained which
showed possible recent siezure activity. Pt was continued on
her anticonvulsants, and pt's cardiac enzymes were cycled to
ROMI. CXR showed no acute process, and ct abdomen demonstrated
a 4X2cm collection of fluid and gas in the hepatic resection
bed. Repeat EEG showed signs of non-convulsive status. Pt was
given ativan, and placed on EEG monitoring.
On HD3 she spiked a fever and her cultures returned GNR in
blood and urine. She was treated empirically with
zosyn/vanco/levo. ID was consulted, and these antibiotics were
continued. On HD5 her cultures were idenitfied as Klebsiella.
Her EEG on HD5 showed that her siezure activity had stopped, and
Neuro began to taper her ativan. On HD7, she was transferred to
the floor. Her TFs were increased slowly, with an interruption
on HD 9 when bilious drainage was noted from the pt's JP drain.
The TFs were held briefly but she tolerated them and they were
increased until she was able to tolerate goal nutrition. She
continued to make slow improvement until she was discharged to
rehab on HD14 with plans to follow up with an ERCP to evaluate
the bilious drainage from her JP drain.
Medications on Admission:
Keppra 750 [**Hospital1 **]
Vit C
ASA 325 qday
Creon
MVI
Protonix 40 q day
Zoloft 50 q day
Reglan 10 q 8
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*1*
5. Vancomycin 500 mg Recon Soln Sig: Two [**Age over 90 1230**]y (250) mg
Intravenous four times a day: Take Orally.
Disp:*28 * Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
uti
seizures
s/p Left hepatic lobectomy, caudate lobectomy/wedge
segmentectomy [**2170-10-29**]
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 673**]if mental status changes, fevers,
chills, nausea, vomiting, inability to take medications,
abdominal pain, redness/bleeding/pus at JP insertion site,
urinary frequency or pain/burning/urgency with urination or
incontinence
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2171-1-9**] 10:20
Call [**Hospital **] clinic to schedule follow up with Dr. [**Last Name (STitle) 724**] [**Telephone/Fax (1) 49736**]
Call Neurology to schedule follow up appointment with Dr. [**First Name (STitle) 3322**]
[**Name (STitle) **] on [**2-1**], 9:30AM call [**Telephone/Fax (1) 2928**] if any questions
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2171-1-17**]
|
[
"998.59",
"790.7",
"276.51",
"V10.09",
"345.3",
"599.0",
"263.9",
"V44.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
4125, 4184
|
2089, 3354
|
291, 309
|
4324, 4333
|
1518, 2060
|
4668, 5298
|
1141, 1159
|
3509, 4102
|
4205, 4303
|
3380, 3486
|
4357, 4645
|
1174, 1499
|
228, 253
|
337, 828
|
850, 1002
|
1018, 1125
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,557
| 116,093
|
4240
|
Discharge summary
|
report
|
Admission Date: [**2123-11-19**] Discharge Date: [**2123-11-23**]
Date of Birth: [**2043-2-23**] Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending:[**Known firstname 134**]
Chief Complaint:
Fever, malaise, fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80yoM with a history of DM, PVD, s/p mechanical AVR (19 years
ago) for AI is transferred from [**Hospital6 3105**] after
initially presenting with a fever and s/p a fall. The patient
was apparently in his USOH until two days prior to admission
when per his wife had chills. He then got up to go to bed and
fell, unwitnessed, no LOC. He got up and went to the kitchen
and his wife noticed he had an abrasion on his head, she said he
never lost consciousness and it seemed that he had tripped on
the stairs. He was walking normally and had normal speech. He
then went to sleep. The next a.m. he awoke and continued to
have chills, he then went to the bathroom. While on the toilet
he asked his wife for his jacket as he felt very cold. When she
arrived with his jacket he had shaking chills and was conscious
and conversive. Then he all of a sudden started staring
straight ahead and was no longer conversing and seemed to have
lost consciousness. His wife called 911 and she returned to
find him still on the toilet but leaning on the wall. He had no
abnormal movements while unconscious and no abnormal eye
movements. Per wife his speech now seems the same as his speech
when he is not wearing his dentures.
.
No measured temps at home, he has been more somnolent and having
body aches over the past 2 weeks. No cough or rhinorrhea. No
urinary symptoms. No chest pain or shortness of breath per his
wife. [**Name (NI) **] [**Name2 (NI) **] contacts but does have 8 grandchildren. No recent
dental work.
.
At [**Hospital3 **] his initial BP was 200/110, he was noted to
have a superficial abrasion on his R scalp and a negative Head
CT. He was given IV labetalol and his BP then was 180/90. He
was noted to be febrile to 102 F and blood cultures were drawn,
an LP was performed which was negative, and he was given 2g IV
ceftriaxone. In addition he was noted to have "seizure like"
activities in the ER and was given IV ativan.
On review of systems, he denies any headache, blurred vision, he
states he has had difficulty speaking for the last 2 days.
Denies any weakness or numbness. No shortness of breath or
orthopnea, no Chest pain or discomfort. No abdominal pain. No
diarrhea or constipation, last BM today and was normal. No
blood in stool or melena.
Past Medical History:
1. Coronary artery disease s/p CABG (1 Vessel in [**2104**] with AVR)
2. Hypertension
3. Dyslipidemia
4. Diabetes mellitus on PO meds only
5. Peripheral [**Year (4 digits) 1106**] disease
6. Cerebrovascular accident in [**2114**] manifest by slurred speech
and L hand paresthesia.
7. Transient ischemic attack with therapeutic INR so INR range
increased to 3-4 range
8. bladder cancer in [**2113**], s/p resection
9. CRI
PAST SURGICAL HISTORY:
1. [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] aortic valve replacement [**2104**].
2. One vessel coronary artery bypass graft.
3. Status post bladder resection for bladder carcinoma in '[**13**]
4. Status post femoral popliteal bypass in [**2115-1-19**]
5. [**2119-12-7**]-Left lower extremity angiography, angioplasty of
anterior tibial artery, angioplasty and stenting of
superficial femoral artery.
Social History:
-Tobacco history: denies
-ETOH: denies
-Illicit drugs:
lives with wife, independent in ADLs, functional at baseline
Family History:
Mother with DM
Father with DM and renal failure
Physical Exam:
VS: T 98.7 BP 154/84 HR 71 RR 18 O2 sat 95% on RA
GENERAL: NAD, AOX2, date is [**12-19**] but knows it is
Halloween and year [**2121**].
HEENT: JVP 8. OP clear, MM dry, sclera anicteric, PERRL, EOMI,
conjunctiva are pink without lesions, no carotid bruits
CARDIAC: RRR, [**2-24**] diastolic murmur at LUSB, no thrill, no
radiation
PULM: Dullness at R base, otherwise CTAB
ABD: SOFT, NT, ND, no masses or organomegaly, BS+
EXT: doppler DP and PT bilaterally, warm, no c/c/e
NEURO: as above AOx2, able to follow commands and answer
questions appropriately. PERRL, EOMI, CN2-12 intact. Slightly
dysarthric speech but no assymetry of mouth and upper jaw is
adentate. [**5-24**] stregnth in UE bicep, tricep, deltoid, grip,
wrist flex / extend. [**5-24**] stregnth in LE quad, hams, abduct,
adduct, dorsiflex, plantar flex. Normal sensation to light
touch throughout. Diminished reflexes in UE brachioradialis and
biceps but bilat symmetric and 1+ bilat patellar reflexes bilat
symmetric. Toes downgoing.
Pertinent Results:
[**2123-11-23**] 07:25AM BLOOD WBC-7.7 RBC-3.71* Hgb-11.6* Hct-34.7*
MCV-94 MCH-31.3 MCHC-33.5 RDW-13.9 Plt Ct-197
[**2123-11-19**] 12:09PM BLOOD Neuts-79.0* Lymphs-15.0* Monos-5.4
Eos-0.4 Baso-0.4
[**2123-11-22**] 06:55AM BLOOD PT-33.8* PTT-35.0 INR(PT)-3.5*
[**2123-11-19**] 12:09PM BLOOD Fibrino-579*#
[**2123-11-19**] 12:09PM BLOOD ESR-44*
[**2123-11-23**] 07:25AM BLOOD Glucose-114* UreaN-47* Creat-2.2* Na-141
K-4.3 Cl-110* HCO3-25 AnGap-10
[**2123-11-19**] 12:09PM BLOOD ALT-16 AST-35 LD(LDH)-298* CK(CPK)-1263*
AlkPhos-142* TotBili-0.5
[**2123-11-19**] 12:09PM BLOOD CK-MB-7 cTropnT-0.07*
[**2123-11-22**] 06:55AM BLOOD Mg-1.9
[**2123-11-19**] 12:09PM BLOOD CRP-4.3
[**11-21**] MR [**Name13 (STitle) **]:
1. No acute infarction.
2. Patent major intracranial arteries, without flow limiting
stenosis,
occlusion or aneurysm more than 3 mm, within the resolution of
MR angiogram. Some stenosis of the left distal vertebral,
cavernous segments, and the middle cerebral artery on the right
are noted, as described above.
[**11-20**] CXR:
In comparison with the study of [**11-19**], there are continued low
lung
volumes in this patient with intact sternal sutures. The
nasogastric tube has been removed.
Some increasing opacification is seen at the left base in the
retrocardiac
region. Although this could merely represent atelectasis, in
view of the
patient's fever of the possibility of supervening pneumonia
cannot be
excluded.
ECHO [**11-19**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are complex (>4mm) atheroma
in the descending thoracic aorta. A bileaflet aortic valve
prosthesis is present and appears well-seated. The aortic valve
prosthesis leaflets appear to move normally. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. No vegetation or
abscess seen.
LABS/STUDIES
OSH labs [**11-18**]: Na 143, K 4.1, Cl 113, Bicarb 25, BUN 37, Cr
2.2, Glucose 122, Ca 8.5
Dilantin 7.1
WBC 9.3 (normal diff), HCT 35, plt 160
INR 3.2
.
u/a negative
alk phos 128, alb 3.4
ck 334, ast 26, alt 18, t prot 6.8, t bili 1.0
ck mb 7, MBI 2.1
.
CSF: `WBC 3, RBC 44, no bacteria
CSF protein 85 (high), Glucose 61
.
CT HEAD W/O CONTRAST [**2123-11-18**]: no acute bleed. Microvascular
changes c/w chronic infarcts, moderate ventriculomegaly.
.
EKG: NSR rate of 80. Normal axis and QRDS / QT intervals. PR
prolonged at 240ms. no ST / T wave changes, normal RWP, isolate
Q wave in III. No changes from prior in [**2121**].
Brief Hospital Course:
FEVER: Patient presenting with vague febrile illness and
fatigue. Pulmonary infection seemed most likely, given some
evidence of progression of pulmonary infiltrates on CXR.
Presentation would also be consistent with viral infection,
although flu test negative. Originally transferred for TEE but
this was negative for valvular pathology. Blood cultures
negative. Story not very concerning for seizure. Since
admission was afebrile with no leukocytosis. LP was negative.
ESR and CRP elevated suggesting some subacute organic illness.
UA suggested dehydration but no UTI. He was started on empiric
Vancomycin for endocarditis on [**11-19**]. which was stopped. He was
treated with a three day course of azithromycin of CAP. He
improved with IV fluids.
.
ALTERED MENTAL STATUS: He was on dilantin at OSH for question
of possible seizure. However, the story was more consistent
with rigors. He had a normal head CT at the OSH and a non-focal
neuro exam. He has a history of CVA and TIAs while on coumadin
but none since his INR goal has been increased to [**3-23**], making
TIA / CVA very unlikely especially given a non-focal neuro exam.
An MRI/MRA showed mild stenosis in distal vessels.
He also had several episodes of night-time delerium, at times
requiring haldol and ativan for sedation.
He was seen by geriatrics who felt he was at significantly
elevated risk for the development of delirium given advanced
age, multiple medical comorbidities, acute hospitalization w/
multiple transfers, and question of underlying cognitive
impairment. While pt does not meet CAM criteria by evaluation
this evening, there is clear evidence of delirium by history and
given typical fluctuating course. His delerium improved after
leaving ICU and he will follow up with geriatrics.
.
CORONARY ARTERY DISEASE: CAD s/p single vessel CABG in
conjunction w/ AVR in [**2104**], per wife no chest pain and CABG was
reportedly LIMA to LAD. He had no ischemic changes on EKG and
was continued on crestor.
.
HISTORY OF ATRIAL FIBRILLATION: He was in sinus rhythm but has
had AF at OSH, in addition has had CVA in past and TIA while on
coumadin, so INR range is [**3-23**] for him. He was continued on
coumadin and metoprolol.
.
ACUTE RENAL FAILURE: On admission, he had a creatinine slightly
above baseline. He had a FeNa of 0.7 % suggesting good kidney
function with avid sodium retention. He also appeared dry on
exam in the setting of possible infection. He was rehydrated
with IV NS@150cc.
.
DIABETES: His oral hypoglycemic (actos) was held. He was
started on NPH 14u sc bid with humalog sliding scale and
switched to 14 U SC QAM and 12 U SC QPM. He was discharged on
his home regimen including actos and insulin.
.
FEN: Heart healthy, diabetic diet. IVF as above
ACCESS: PIV's
PROPHYLAXIS: INR supratherapeutic, PPI, pneumoboots
CODE: FULL
Medications on Admission:
Insulin 75/25 60 units daily (? in OMR is 25 units [**Hospital1 **])
Coumadin 2mg M,F, 4mg daily on other days
Neurontin 300mg po bid
Crestor 20mg daily
Prilosec 20mg daily
Lopressor 50mg daily
Actos 15mg daily
Allopurinol 100mg daily
Avodart 0.5mg daily
Flomax 0.4mg daily
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR)
as needed for ON MONDAY AND FRIDAY.
2. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 5X/WEEK
([**Doctor First Name **],TU,WE,TH,SA).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Metoprolol Succinate 100 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*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
9. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
10. home equipment
Commode for use at the bedside please.
11. Insulin
Please continue your home insulin regimen
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Delerium
Community acquired pneumonia
Viral syndrome with fevers
Syncope
Acute Renal Failure
Diabetes
Discharge Condition:
BUN 47
creat 2.2
Hct 34.7
K 4.3
Discharge Instructions:
You had a likely viral illness with a fever. All of your culture
results were negative and you did not have any signs of
infection in your heart. You became acutely confused and
received some medicine to calm you down. A follow-up
appointment with Dr. [**First Name (STitle) 1022**] in the gerontololgy department here at
[**Hospital1 18**] was made on [**12-13**]. A MRI was done that preliminarily does
not show any sign of an acute problem. There is a question of a
pneumonia on your chest Xray, you have 1 more day of antibiotics
(azithromycin) to take when you go home.
.
New medicines:
1. Your Metoprolol was replaced by a long acting type,
Metoprolol Succinate
2. We have held your Furosemide.
3. Continue to take the insulin dose you were on at home.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation. A nicotine patch of 14 mg per day
was used during your hospital stay and should be used after
discharge instead of smoking.
Followup Instructions:
[**Month/Year (2) **] Surgery:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2123-12-20**] 10:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2123-12-20**] 11:00
Cardiology:
Provider: [**Known firstname 122**] [**Last Name (NamePattern1) **], MF Phone: [**Telephone/Fax (1) 18438**] Date/Time:
[**2124-1-7**] 03:00pm
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-1-7**]
2:00
Primary Care:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] MD Phone: [**Telephone/Fax (1) 3110**] Date/Time:
Gerontology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 1022**], MD Phone: [**Telephone/Fax (1) 719**] Date/Time: [**12-13**] at 1:30. [**Last Name (NamePattern1) 439**], [**Location (un) 18439**] in the
garage right next door.
Please make a Neurology appointment with Dr.[**Name (NI) 5255**] office.
Their number is [**Telephone/Fax (1) 1694**].
Completed by:[**2123-11-26**]
|
[
"293.0",
"486",
"585.9",
"V45.81",
"V43.3",
"443.9",
"079.99",
"584.9",
"276.51",
"414.00",
"V10.51",
"V12.54",
"272.4",
"403.90",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11582, 11629
|
7434, 8204
|
287, 294
|
11775, 11809
|
4742, 7411
|
12835, 13985
|
3646, 3695
|
10608, 11559
|
11650, 11754
|
10310, 10585
|
11833, 12812
|
3071, 3497
|
3710, 4723
|
227, 249
|
322, 2604
|
8220, 10284
|
2626, 3048
|
3513, 3630
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,687
| 173,897
|
18677
|
Discharge summary
|
report
|
Admission Date: [**2116-9-21**] Discharge Date: [**2116-9-27**]
Date of Birth: [**2067-10-16**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CAD sp MI
Major Surgical or Invasive Procedure:
sp CABG X 4 [**9-23**]
History of Present Illness:
48 yo M w/ hx of CAD sp MI and stent to diagonal [**2112**] and stent
to PTL in [**6-27**] p/w recurrent anginal symptoms. + stress test.
Cath showed 3 vessel disease.
Past Medical History:
as above, CRI, GERD, HTN, hyperlipidemia, renal calculi
Social History:
Tobacco: 60 yr pack hx; quit in [**2112**]. ETOH: 2 beers per day
Family History:
F: MI @ 39 yr
M: MI @ 69 yr
Physical Exam:
Ht: 6 ft 3 in
Wt: 255 lb
RRR, No M, G, R
CTAB
obese, soft, NT
1 + Fem B. 2 + rad, DP, PT B.
Pertinent Results:
[**2116-9-21**] 12:30PM GLUCOSE-96 UREA N-20 CREAT-1.1 SODIUM-142
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
[**2116-9-21**] 12:30PM ALT(SGPT)-19 AST(SGOT)-17 CK(CPK)-138 ALK
PHOS-28* TOT BILI-0.4
[**2116-9-21**] 12:30PM CK-MB-3 cTropnT-<0.01
[**2116-9-21**] 12:30PM ALBUMIN-4.2
[**2116-9-21**] 12:30PM WBC-5.7 RBC-4.36* HGB-12.8* HCT-36.0* MCV-83
MCH-29.3 MCHC-35.5* RDW-13.3
[**2116-9-21**] 12:30PM PLT COUNT-203
[**2116-9-21**] 12:30PM PT-14.3* INR(PT)-1.3
Brief Hospital Course:
PT underwent a CABG X 4 [**9-23**]. Pt was transferred to the CSRU in
a stable condition. Pt required minimal blood products post
operatively.
Hospital course was remarkable for transient post operative
Atrial fibrillation. BBlocker was given post operatively and
amiodarone was added. Conversion to sinus rhythm occurred in
less than 24 hrs, so anticoagulation was never started.
Pt's chest tubes and paing wires were DC'd without problem.
Pt's foley came out and the pt was voiding on his own upon DC.
The pt tolerated a cardiac diet and pain was well controlled on
PO pain medications. Pt was cleared by PT for home and the pt
was DC'd with VNA.
Pt was DC'd on the below medications.
Medications on Admission:
nexium 40 PO [**Month/Year (2) **], folic acid PO [**Month/Year (2) **], tricor 160 PO [**Month/Year (2) **],
lopressor 75 PO [**Month/Year (2) **], Norvasc 5 PO [**Last Name (LF) **], [**First Name3 (LF) **] 81 PO [**First Name3 (LF) **]', Plavix
75 PO [**First Name3 (LF) **]
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
8. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
qd ().
Disp:*30 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Coronary artery disease
Chronic renal insufficiency
Gastroesophageal reflux disease
Hypertension
Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Follow up with your PCP regarding new medication called lipitor.
You will need intermittent lab tests while taking this
medication.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
Please refrain from driving yourself for one month and/or while
taking pain medications.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Followup Instructions:
Call and schedule a follow up appointment in [**2-27**] weeks with Dr.
[**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**]).
Please follow up with PCP [**Last Name (NamePattern4) **] [**1-28**] weeks.
Completed by:[**2116-9-28**]
|
[
"794.39",
"530.81",
"996.72",
"412",
"V13.01",
"401.9",
"272.4",
"411.1",
"414.01",
"V17.3",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"36.15",
"37.22",
"36.13",
"99.07",
"99.05",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
4043, 4087
|
1389, 2085
|
323, 348
|
4243, 4251
|
881, 1366
|
5165, 5401
|
725, 754
|
2413, 4020
|
4108, 4222
|
2111, 2390
|
4275, 5142
|
769, 862
|
274, 285
|
376, 546
|
568, 625
|
641, 709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,579
| 119,124
|
40944
|
Discharge summary
|
report
|
Admission Date: [**2155-5-15**] Discharge Date: [**2155-5-18**]
Date of Birth: [**2111-4-23**] Sex: M
Service: MEDICINE
Allergies:
dilating eye drops
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
44 yo man with h/o hyperlipidemia who presented to OSH with 1
hour of chest pain. The patient states that he was in his normal
state of health until the day of admission, when he developed
chest pain, which he has never had before, while walking up the
stairs 5 minutes after lifting 50lbs suitcases. He described
the chest pain as substernal pressure, like a weight, [**4-20**] in
severity, radiating to his arms bilaterally with some associated
paresthesias, L>R. This was associated with diaphoresis,
lightheadedness, and nausea, but no vomiting. He had symptoms to
suggest a PE - no pleuritic CP. He took 567 mg of ASA and then
presented to the ED.
.
In the [**Location (un) 620**] ED, initial VS were T 98.5, P 60, R 20, BP
148/95, O2 100% on RA. His CP on presentation was [**2-20**].
Presenting EKG showed STE in II, III, AVF; STD in I, AVL, V2-V6;
TWIs in V1-V3. Cardiac enzymes showed Trop: < 0.01, CK 200,
CK-MB 3.10. He was given NTG x3; second EKG (30 minutes after
first) showed interval deepening of STD and evolving Q in III.
He was started on a Nitro gtt, Plavix 600 mg, Ativan IV, and
heparin, integrilin gtts. He was then transferred to [**Hospital1 18**] for
emergent cardiac catheterization.
.
At [**Hospital1 18**], Cardiac Cath showed occlusive thrombus involving
proximal to distal RCA and involving the PDA; thrombectomy was
performed with multiple passes, restoring TIMI [**1-12**] slow flow.
RCA was large and ectatic with < 50% mid lesion and mild
proximal disease; stenting was deferred for a re-look in the AM.
Angioseal was placed. Tolerated the procedure well, but SBP
decreased to 80, responded to fluids and low dose dopamine,
which was then promptly stopped once in the ICU.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative. Cardiac review of systems
is notable for absence of chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. Dyslipidemia (familial)
2. Anxiety
3. Allergic Rhinitis
Social History:
-Tobacco history: negative
-ETOH: 1-2 per month
-Illicit drugs: None
-Lives at home with wife and 4 children (4, 6, 9, 12 boys)
-Works as a commercial pilot; enjoys flight simulators, time
with his children
Family History:
-Father had valvular disease in his 50s, underwent porcine valve
replacement, then bypass/stent in 60s; expired in his 70s
-No history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death
-Otherwise non-contributory
Physical Exam:
Admission Exam:
VS: T=AF...BP=131/58...HR=81...RR=9...O2 sat=98%RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP 2cm above the clavicle.
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 abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
GROIN, RIGHT: No bruits; blood soaked dressing; sheath in place
PULSES:
Right: Popliteal 2+ DP 2+ PT 2+
Left: Popliteal 2+ DP 2+ PT 2+
.
Notable Changes at Discharge:
Tm/Tc 98.7, BP (107-110)/(54-72), 108/58, HR (71-82), 71, RR 16,
SO2 100% on RA
CARDIAC: no changes
EXT: right inguinal bruising with band-aid in place, left
inguinal region without evidence of hematoma and band-aid in
place
Pertinent Results:
Admission Results:
[**2155-5-15**] 10:33PM BLOOD WBC-11.0 RBC-3.81* Hgb-11.7* Hct-34.5*
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.8 Plt Ct-199
[**2155-5-15**] 10:33PM BLOOD PT-14.0* PTT-63.2* INR(PT)-1.2*
[**2155-5-15**] 10:33PM BLOOD Glucose-140* UreaN-16 Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-25 AnGap-13
[**2155-5-15**] 10:33PM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
.
Cardiac Labs:
[**2155-5-15**] 10:33PM BLOOD CK-MB-155* MB Indx-8.2* cTropnT-5.27*
[**2155-5-16**] 04:43AM BLOOD CK-MB-177* MB Indx-8.2* cTropnT-6.65*
[**2155-5-16**] 03:43PM BLOOD CK-MB-118* MB Indx-7.0* cTropnT-4.38*
[**2155-5-17**] 06:45AM BLOOD CK-MB-36* MB Indx-4.2 cTropnT-3.16*
.
Other Notable Labs:
[**2155-5-16**] 03:43PM BLOOD calTIBC-313 VitB12-397 Folate-14.8
Ferritn-77 TRF-241
[**2155-5-16**] 04:43AM BLOOD %HbA1c-5.6 eAG-114
[**2155-5-16**] 04:43AM BLOOD Triglyc-50 HDL-40 CHOL/HD-4.5 LDLcalc-128
[**2155-5-16**] 03:43PM BLOOD TSH-2.5
.
EKG ([**2155-5-15**]):
Sinus arrhythmia and probable three beat run of irregular atrial
tachycardia at the end of the tracing. There are non-diagnostic
inferior Q waves and anterior ST-T wave abnormalities of
uncertain significance. Clinical correlation is suggested.
.
EKG ([**2155-5-15**]):
Sinus rhythm. Non-diagnostic inferior Q waves with mild ST
segment elevation. RSR' pattern in lead V2. Since the previous
tracing the inferior ST segment elevation is more apparent with
less artifact. There is also no atrial tachy-arrhythmia on the
present tracing. Clinical correlation is suggested.
.
Cardiac Catheterization Preliminary Report ([**2155-5-15**]):
1. Selective coronary angiography in this right dominant system
demonstrates single vessel coronary artery disease. The right
coronary
artery is totally occluded with extensive thrombus from the
proximal
vessel past the PDA bifurcation and into the distal vessel.
2. Hemodynamics demonstrate normal cardiac output with
low-normal
biventricular filling pressures.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
.
EKG ([**2155-5-16**]):
Sinus rhythm at lower limits of normal rate with inferior Q
waves and
ST segment elevation. RSR' pattern in lead V2 with precordial T
wave
abnormalities. Since the previous tracing probably no
significant change.
Consider inferior myocardial infarction - possibly acute.
.
TTE ([**2155-5-16**]):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler
imaging suggests normal diastolic function, and 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
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Very mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. IMPRESSION: Suboptimal image quality.
Normal biventricular cavity sizes with preserved global
biventricular systolic function. Very mild aortic regurgitation.
.
EKG ([**2155-5-16**]):
Sinus rhythm at lower limits of normal rate. Non-diagnostic
inferior Q waves with ST segment elevation which is probably
more prominent than on the previous tracing. Precordial T wave
abnormalities persist. Consider inferior myocardial infarction
in evolution. Clinical correlation is suggested.
.
Discharge Labs (no labs drawn the morning of discharge):
[**2155-5-17**] 06:45AM BLOOD WBC-10.3 RBC-4.31* Hgb-13.0* Hct-36.8*
MCV-86 MCH-30.1 MCHC-35.2* RDW-13.9 Plt Ct-179
[**2155-5-17**] 06:45AM BLOOD PT-14.1* PTT-24.1 INR(PT)-1.2*
[**2155-5-17**] 06:45AM BLOOD Glucose-94 UreaN-16 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-28 AnGap-11
[**2155-5-17**] 06:45AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9
Brief Hospital Course:
Brief Hospital Course:
44 yo man with h/o hyperlipidemia who presented to OSH with
inferior STEMI, whose initial catherization showed single vessel
disease with total occlusion of the RCA due to extensive
thrombus associated with a < 50% mid-RCA lesion without evidence
of ulceration. The thrombus was removed and TIMI 1-2 blood flow
was restored. He was transferred briefly to the CCU for
post-procedural hypotension and briefly required pressors but
his blood pressure quickly improved with hydration and pressors
were discontinued. He was maintained on a Heparin gtt during
this time. The following day, a repeat catheterization was
performed that demonstrated improved blood flow. No stent was
placed during this repeat intervention. Patient returned to the
floor to continued maximum medical management. He did have
post-cath bleeding at his femoral sites that resolved with
pressure. Patient was started on ASA 325 daily, Plavix 75 daily,
and Metoprolol tartrate. His statin was changed from
Atorvastatin 80 mg to Rosuvastatin 40 mg as his LDL was 128.
Prior to discharge his Metoprolol was titrated up to 37.5 mg of
succinate at discharge to achieve a heart rate in the 60s.
Patient had initially received Captopril but was converted to
Lisinopril 5 mg daily at discharge. Patient was instructed to
limit his activity for a brief time following discharge, and was
specifically informed to limit heavy lifting. Patient was given
an appointment to be seen at [**Hospital1 18**] [**Location (un) 620**] Cardiology and
contact information for the [**Hospital1 18**] Lipid Center prior to
discharge.
Medications on Admission:
1. Lipitor 80 mg daily
2. Nasonex NS prn
3. Fish Oil
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
3. 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*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
5. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
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. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal ASDIR.
8. Fish Oil Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial Infarction
Hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 449**]:
.
You were admitted to [**Hospital1 18**] after an episode of chest pain. An
cardiac catherization demonstrated the presense of a clot in
your right coronary artery. This clot was removed and proper
flow was restored to your heart muscle. There was no indication
for additional procedures such as stenting. A follow-up
ultrasound of your heart demonstrated normal pumping functions.
You were started on medications to decrease the work of your
heart.
.
CHANGES TO YOUR MEDICATIONS:
To treat your high cholesterol
-- STOP taking Atovastatin 80mg daily.
-- START taking Rovustatin 40mg tablets. Take one tablet daily
.
To decrease the work of your heart after heart attack:
-- START taking Lisinopril 5 mg daily. Your outpatient doctor
will likely make changes to the dose of this medication.
-- START taking Metoprolol succinate 37.5 mg daily.
.
To adequately prevent new clot formation:
-- START takling Aspirin 325mg tablets. Take one tablet daily.
-- START talking Plavix 75mg tablets. Take one tablet daily. DO
NOT SKIP ANY DOSES OF THIS MEDICATION.
.
Again it was a pleasure taking care of you. Please feel free to
contact with any questions or concerns.
Followup Instructions:
1. Please follow-up with a cardiologist at [**Hospital1 18**]-[**Location (un) 620**] in the
next few weeks. You should receive a call tomorrow with your
appointment date and time. If you do not receive a call by
Tuesday, please call [**Hospital1 18**] at [**Telephone/Fax (1) 37846**] and have a member of
the CCU team paged. The number to cardiology at [**Hospital1 18**] [**Location (un) 620**] is
[**Telephone/Fax (1) 4105**], if needed.
.
2. Please follow up with the [**Hospital 18**] [**Hospital **] Clinic. Please call
[**Telephone/Fax (1) 5251**] in the next week to make an appointemnt to be seen.
Completed by:[**2155-5-18**]
|
[
"V17.3",
"272.4",
"410.21",
"458.29",
"998.12",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"00.44",
"00.42",
"00.59",
"37.23",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
11039, 11045
|
8431, 10012
|
290, 316
|
11132, 11132
|
4346, 6273
|
12496, 13136
|
2913, 3144
|
10115, 11016
|
11066, 11111
|
10038, 10092
|
6290, 8385
|
11283, 11766
|
3159, 4087
|
4101, 4327
|
11795, 12473
|
240, 252
|
344, 2591
|
11147, 11259
|
2613, 2673
|
2689, 2897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,528
| 114,518
|
7440
|
Discharge summary
|
report
|
Admission Date: [**2190-2-8**] Discharge Date: [**2190-2-11**]
Service: NEUROLOGY
Allergies:
Keflex / Lipitor
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Transient right hand weakness and speech arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an 88 year-old right-handed man with a PMH of recent
SDH in addition to seizures, CAD and afib now off Coumadin. He
was admitted on [**1-24**] after a fall from a tread mill while on ASA
and coumadin. He was found to have a 7mm L
parietal/occipital SDH. He was admitted to the neurosurgery
service for evaluation. His hospital course at the time was
complicated by a worsening mental status on admission and he was
found to have an expanding bleed. His INR was 2.8 on arrival and
he was reversed with Factor 9, FFP, Plts, and VitK. He was
intubated and admitted to the ICU and his course was also
remarkable for significant HTN which required a Nipride drip at
times. After extubation his exam was felt to be non-focal and he
was eventually discharged to rehab.
He presented again today after transfer from an OSH with a 20
minute episode of R hand weakness and difficulty getting words
out. He states that he was in his USOH this morning when he sat
down to eat breakfast. He was speaking on the phone with his
wife when he abruptly felt that his R hand was "weak" and he
dropped the spoon. He did not see any additional movements or
jerking. He then felt that his mouth "was full of cotton" and
when he tried to speak his words were both slurred and difficult
to produce. He recalls that he knew what he wanted to say but
had difficulty producing the words. He did not make paraphasic
errors but after a minute or so from the onset he stopped
speaking. He was able to understand others however.
The entire episode lasted about 20 minutes after which he was
back to baseline. He denied HA or vision changes as well as
numbness or tingling. He was not aware of any involvement of the
leg but recalls that [**Name8 (MD) **] RN at the rehab thought he had a facial
droop.
He was taken to an OSH where he was hypertensive to the 200's
and a head CT was done. This allegedly showed new hyperintensity
in his persistent L parietal subdural hematoma. He was then
transferred here where he was seen in the ED by neurosurgery who
felt that his CT was stable without of evidence mass effect or
shift and recommended that he start Keppra as he was "not been
on seizure prophylaxis". Additionally, he remained severely
hypertensive and was given atenolol and lisinopril PO,
hydralazine 10mg IV, labetalol 10mg IV.
ROS:
The pt denied headache, loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Pt unsure if he has had any bowel or bladder
incontinence or retention. Denied difficulty with gait. The pt
denied recent fever or chills but has felt cold in the ED.
Past Medical History:
- A-fib now off coumadin
- HTN
- HLD
- CAD
- Parkinson's ?
- ? CAROTID STENOSIS
- PUD
- pacemaker implantation in [**2179**]
- BPH
- Seizure disorder (last seizure 15-20 yrs ago) with GTC
- Appy
- Eye surgery for congenital cataracts/lens implants
- Hernia surgery
- Glomerulonephritis 2 yrs ago
- recent SDH as above
- ? IVC filter
Social History:
-currently resides at rehab
-EtOh: denies
-tobacco: denies
-drugs: denies
Family History:
NC
Physical Exam:
Vitals: T: 97.7 P: 61 R: 12 BP: 193/82 SaO2: 98% 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: decreased breath sounds bilaterally
Mental Status:
Alert, oriented x 3. Able to relate history without difficulty.
Attentive, language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors. Speech was not dysarthric. Able to follow commands.
There was no evidence of apraxia or neglect. Recent and remote
memory intact.
Cranial Nerves:
No evidence of anosmia. PERRL 3 to 2mm and brisk. VFF to
confrontation. There is no ptosis bilaterally. Fundoscopic exam
revealed no papilledema, exudates, or hemorrhages. EOMI without
nystagmus. Facial sensation intact to pinprick. No facial
droop, facial musculature symmetric. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. [**5-25**]
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
Motor System:
Normal tone throughout. Muscle bulk normal. No pronator drift
bilaterally.
No asterixis noted. Full motor strength in all groups tested.
Reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Sensory System:
Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception.
Coordination:
R sided postural tremor and intention tremor.
Gait: deferred given concern for severe HTN
Pertinent Results:
[**2190-2-10**] 06:06AM BLOOD WBC-5.8 RBC-3.60* Hgb-11.4* Hct-32.7*
MCV-91 MCH-31.7 MCHC-35.0 RDW-14.8 Plt Ct-206
[**2190-2-10**] 06:06AM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-29 AnGap-9
[**2190-2-8**] 01:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-2-8**] 10:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-2-9**] 06:38AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2190-2-10**] 06:06AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7
[**2190-2-9**] 06:38AM BLOOD %HbA1c-5.8
[**2190-2-9**] 06:38AM BLOOD Triglyc-94 HDL-49 CHOL/HD-2.9 LDLcalc-72
[**2190-2-8**] 10:30PM BLOOD TSH-4.1
[**2190-2-9**] 06:38AM BLOOD Carbamz-3.5*
Echocardiogram: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (LVEF 50~55%). Mild mitral
regurgitation.
CT Head: Evolving Left frontoparietal subdural hematoma is
unchanged in
size and distribuation.
CTV: No evidence of intracranial venous thrombus.
Carotid US: Bilateral 60~69% stenosis.
EEG: Drowsy but normal EEG otherwise.
Brief Hospital Course:
The pt is an 88 year-old RH man with a complex PMH including
seizures, CAD and afib off coumadin and a recent SDH. He
presented with transient difficulty producing
speech and R hand weakness. His exam is remarkable for
parkinsonian features but is otherwise non-focal. Given his
presentation, his symptoms could be due to a TIA vs. seizure
hence he was admitted for possible stroke work-up and seizures.
Because of his pacemaker, it was not possible to obtain a MRI
but CT was obtained which showed stable, old SDH without signs
of increase in size or new hemorrage. He has R IJ thrombus
hence CT venogram was obtained but he has no evidence of
intracranial venous thrombus. Also echo and carotid US plus
labs including fasting lipid panel and HbA1C were obtained - all
within normal range and/or stable.
His Tegretol level was subtherapeutic hence his dose was
increased to 300mg daily from 200 and EEG was also obtained
which was essentially normal. His Na+ dropped to 132 from 136
and likely due to Tegretol hence he will ne discharged with labs
of chem 7 every Friday to monitor for his sodium.
He remained symptom-free during this admission and he was
evalutated per PT and OT for return to [**Hospital3 7665**].
As for his atrial fibrillation, he was restarted on aspirin 81mg
during this admission but given his risk factor and the fact
that his SDH was "traumatic," will consider restarting Coumadin
in ~ 2 weeks when he follows up with Dr. [**Last Name (STitle) **]. He will also
get a head CT prior to seeing Dr. [**Last Name (STitle) **].
Medications on Admission:
1. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO DAILY (Daily).
2. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO QD ().
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
18. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed).
20. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Qday ().
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-22**] Inhalation Q6H (every 6 hours) as needed.
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Carbamazepine 100 mg Tablet Sustained Release 12 hr Sig:
Three (3) Tablet Sustained Release 12 hr PO DAILY (Daily).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
18. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
19. Outpatient Lab Work
Chem 7 (Na+, K+, Cl-, HCO3-, BUN, Cr and Glucose) every Friday.
20. Non-contrast head CT on the morning before seeing Dr. [**First Name8 (NamePattern2) **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Discharge Disposition:
Extended Care
Facility:
northeast acute rehab
Discharge Diagnosis:
TIA
Seizure disorder
hx of L SDH
Atrial fibrillation - off Coumadin since SDH ([**2190-1-24**])
Discharge Condition:
Stable - Bilateral (L>R) intention and postural tremor plus
Parkinsonian features but otherwise non-focal exam.
Intermittent stuttering of speech as well.
Discharge Instructions:
You were admitted after an episode of R arm weakness and speech
trouble concerning for small stroke/transient ischemic attack or
seizure activity. Due to your pacemaker, you were not able to
get a MRI but repeat CTs were not indicative of new infarct or
worsening of your prior SDH.
Given that your Tegretol (carbamazepine) level was low, it was
increased to 300mg daily with improved level on repeat check.
You did not have further episodes of weakness during this
admission but your speech was stuttering at times hence CT of
head was again repeated on [**2-11**] which was stable. Also, you
were restarted on Aspirin 81mg daily.
You will be returning to [**Hospital 5130**] Rehab for continued
physical and occupational therapy. You will be following up
with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] during which you will have a repeat
head CT prior to the appointment and if no new bleed, you will
likely be restarted on Coumadin for your atrial fibrillation.
Please take your meds as prescribed. You will also need weekly
labs including Na+ because Tegretol can cause hyponatremia. On
the day of your discharge, your Na+ was 132.
Please call your PCP or go to the nearest ED if you have
worsening weakness, speech trouble, numbness and/or visual
problems.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2190-3-15**] 2:30 - you may be called to reschedule this
appointment; also you will have a head CT on the morning before
your appointment.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-3-10**] 8:40
Provider: [**Name10 (NameIs) 27270**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-7-8**] 9:00
Completed by:[**2190-2-11**]
|
[
"433.10",
"V45.61",
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"427.31",
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"433.30",
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"V45.01",
"276.1",
"533.90",
"332.0",
"E936.3",
"272.4",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11329, 11377
|
6083, 7644
|
280, 286
|
11517, 11674
|
5056, 5832
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13055, 13661
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3403, 3407
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193, 242
|
314, 2939
|
4054, 5037
|
5841, 6060
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3715, 4038
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2961, 3295
|
3311, 3387
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,244
| 122,911
|
45756
|
Discharge summary
|
report
|
Admission Date: [**2112-1-18**] Discharge Date: [**2112-1-22**]
Date of Birth: [**2033-8-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Erythromycin Base / Bactrim
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
IR mesenteric angiography
colonoscopy
History of Present Illness:
This is a 78 year-old female with a history of CAD s/p stent to
RCA in [**2108**], chronic pancreatitis, who presents with two
episodes of bright red blood per rectum this morning. Over the
past 2 days, she has had dull, epigastric pain, says she feels
as though she was punched in the stomach, which is mild
intensity and unremitting; it is unchanged by eating or by
defecation. Shortly after waking this morning, she went to the
bathroom and after defecating noticed bright red blood in the
toilet bowl, but otherwise felt well, no lightheadedness,
dizziness, nausea, or vomiting, no change in the dull abd pain.
She went to work, thinking this was a [**Last Name 97498**] problem, but
then, on arrival at work, felt "wet" in her pants and there was
bloody, loose stool. Her PCP, [**Name10 (NameIs) **] whose office she works,
examined her and brought her to the ED.
She had two BMs here, bright blood, 50-100 mL each, VS in the ED
96.3 56 150/80 20 100%RA. Same Epigastric pain. 2 PIV 18. NG
lavage negative. Received protonix 40mg IV and GI will flex sig
tomorrow per ED resident. 1 L of NS.
ROS: + Nausea, almost every morning. + Constipation. The patient
denies any fevers, chills, weight change, vomiting, diarrhea,
melena, chest pain, shortness of breath, orthopnea, PND, lower
extremity oedema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
1. h/o left intraductal breast cancer, dx in [**2098**], treated with
lumpectomy and radiation followed by a lobular carcinoma in the
same breast, dx in [**2107**] and treated with mastectomy. She had no
endocrine therapy following this treatment. She is stable from a
breast cancer perspective. Most recent imaging: [**2-21**]: Right
mammogram-negative.
2. Parathyroid disease
3. Hernia
4. CAD s/p RCA stent placement in [**2108**]
5. Depression
6. HTN
7. h/o chronic pancreatitis, not on enzymes/no active issue
since ~[**2109**]
8. coloscopy in [**2110**] showed benign polyps, sigmoid diverticula
Social History:
Lives alone works as a office manager in a [**Hospital1 18**] physician's
office. No tobacco, no ETOH or illicits.
Family History:
Breast cancer in MGM-unknown age. Brother-thyroid cancer.
Physical Exam:
On Presentation:
Vitals: T:98.8 BP:119/82 HR:56 RR:14 O2Sat:97% 2L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mild TTP in R&L UQ, ND, +BS, no HSM, no masses. BRB
with clots in rectal vault.
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: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
Pertinent Results:
IMAGING:
Bleeding Scan:
Blood flow images show hyperemia in the left pelvis overlying
the sigmoid.
Dynamic blood pool images show extravasation of tracer into the
region of the sigmoid colon within the first five to ten minutes
of the study with subsequent progression of tracer to the
rectum. Lateral view confirms pooling of tracer in the rectum.
IMPRESSION: Active GI bleeding localizing to the sigmoid colon.
Brief Hospital Course:
Assesment: This is a 78 year-old female with a history of CAD
s/p stent >3 years ago, chronic pancreatitis, h/o breast CA, who
presents with hematochezia. Bleeding scan showed bleeding in
sigmoid colon. Colonoscopy planned. Surgery consulted -
offered elective partial colectomy which patient declined.
# BRBPR: Had 2 episodes prior to hospital and then passage of
two small volume stools with bright red blood and some clot in
the ED. NG lavage in ED negative. Suspected diverticular
bleeding vs AVM; prior unremarkable coloscopy makes malignancy
less likely. Bleeding scan showed sigmoid bleed, likley
diverticular; pt did pass a large amount of clot shortly after
bleeding scan with vasovagal event, and then went for angio
which did not identify any active bleeding. She received 2
units of PRBC and for the rest of her hospitalization her Hct
was stable in the low 30s. Surgery was consulted and offered an
elective partial colectomy which she declined. Flex sig done but
unable to visualize as stool in colon. She was called out to the
medical floor where she was prepped for colonoscopy.
Diverticulosis was seen in the sigmoid colon but no active
bleeding. Two benign looking polyps were seen but not removed
because she had been on Plavix before admission. She will remain
off aspirin and plavix for the time being and follow up with her
PCP, [**Name10 (NameIs) **], and cardiologist.
# Epigastric pain: Inital concern for pancreatitis given her
history of prior history of it. Checked amylase and lipase
which were normal. Per out patient providers and the patient,
abdominal pain is chronic. This was not changed from her
baseline on discharge.
# CAD s/p stent: stent was >3 years ago, and given bleeding,
held aspirin and clopidogrel. She will follow up with her
outpatient cardiologist who will advise on possibly restarted
either of these medications in the future.
# HTN: her antihypertensives were initially held in the setting
of acute GIB but these were restarted as she showed stability
after transfusion.
# DM2: Held metformin after IR study, covered with sliding
scale. Restarted metformin on discharge after she was tolerating
good POs.
Medications on Admission:
Plavix 75 mg PO daily
LEXAPRO 10mg daily
Pravastatin 20mg daily
HCTZ 12.5mg daily
METFORMIN 500mg daily, after dinner
Toprol XL 25mg daily
ASA 81mg daily
wellbutrin daily (pt unsure of dose)
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO after dinner.
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: diverticulosis
Secondary: chronic pancreatitis, GERD, HTN, irritable bowel
syndrome, breast CA
Discharge Condition:
good, stable Hct, no blood in stool, tolerating POs
Discharge Instructions:
You were evaluated for blood in your stool. This was likely from
diverticulosis as seen on a colonoscopy done during your
hospitalization. You should NOT take your aspirin or Plavix for
now; discuss with your cardiologist about if and when to restart
either of these medications. We recommend you adhere to a low
residue diet to reduce the risk of diverticular bleeding.
If you have further bloody stools, abdominal pain,
lightheadedness, episodes of loss of consciousness, shortness of
breath, chest pain, or any other concerning symptoms, call your
doctor or seek medical attention immediately.
Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**], in
1 week. Since you work in his office, you may see him at your
convenience.
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] in [**2-16**] weeks. We have offered to
make an appointment for you but you have decided to make this
appointment yourself; call his office ([**Telephone/Fax (1) 2306**] to do this.
Follow up with your cardiologist in [**2-16**] weeks. His office will
call you with an appointment and to discuss whether or not you
should restart aspirin or Plavix.
|
[
"211.3",
"564.1",
"530.81",
"V10.3",
"577.1",
"401.9",
"562.12",
"414.01",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"88.47",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
6881, 6887
|
3939, 6111
|
302, 342
|
7035, 7089
|
3499, 3916
|
7735, 8405
|
2598, 2657
|
6353, 6858
|
6908, 7014
|
6137, 6330
|
7113, 7712
|
2672, 3480
|
259, 264
|
370, 1822
|
1844, 2447
|
2463, 2582
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,480
| 158,725
|
1200
|
Discharge summary
|
report
|
Admission Date: [**2171-1-29**] Discharge Date: [**2171-2-8**]
Date of Birth: [**2106-4-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Elective admission for decitabine cycle #1 for MDS.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 7597**] is a 64 year old gentleman with a PMH of MS, and a
recent diagnosis of myelodysplastic syndrome, now being admitted
electively for decitabine(15mg/m2 Q8 x3 days), cycle one. He
was diagnosed with MS in [**2154**], and felt that his MS symptoms of
fatigue were progressing in the fall of [**2170**], at which point he
was found to have progressive LE edema and a new systolic murmur
at his [**Year (4 digits) 3390**]'s. Labs at that time showed pancytopenia, ARF and
transaminitis. He was admitted to the hospital from [**Date range (1) 7599**],
with anemia and UTI. After transfusion of 9 units PRBCs and 6
units of platelets, patient developed volume overload and
high-output heart failure (EF>55%), and susequent respiratory,
requiring ICU admission, intubation and aggressive diuresis.
Patient also received empiric antibioitcs for HCAP. ICU course
also complciated by slow lower GIB, and partially occlusive L
tibial DVT. Bone marrow biopsy during that admission showed
hypercellular marrow with extensive fibrosis, trinlineage
dysplasia, and increased myeloblasts. 12% Findings highly
suspicious for a myelodysplastic disorder best classified as
refractory anemia with excess blasts (RAEB-2) based on the # of
myeloblasts in the peripheral blood. Peripheral blood w/
deletion 7q, and 5q.
.
Since his last admission, the patient has been improving at
rehab (at [**Hospital1 **]). He continues to have dyspnea on exertion,
but this is stable. He also continues to have neuropathic pain,
related to his MS, which includes burning dysethesias, painful
vibratory sensations and spasticity. These symptoms improve
with lorazepam. In the past, his symptoms had been
well-controlled with copaxoen, which was discontinued at the
time of his MDS diagnosis. Additionally, patient notes
significant anxiety, especially surrounding his MS symptoms. He
has been taking lorazepam consistently on a q3-4 hour basis.
.
On arrival to the floor, the patient was comfortable and
optimistic regarding the initiation of treatment.
.
Review of systems:
Positive as noted in the HPI. Also positive for chronic
constipation with intermittent hematochezia.
Negative for fevers, chills, weight loss/gain, chest pain,
shortness of breath at rest, abdominal pain, dysuria, hematuria.
Otherwise negative.
Past Medical History:
- Multiple Sclerosis - Diagnosed in [**2154**]. Multiple resolving
flares. Multiple lesions detected on [**Year (4 digits) 4338**]. Has been treated with
alternative medications and acupuncture after having a bad
experience with amantadine.
- Osteoporosis
- Vitamin D deficiency
- MDS, dx [**12/2170**]
Social History:
Patient coming in from [**Hospital3 **] now. Previously lived
alone and has since college. No current alcohol. Quit smoking
~20 years ago. Continues to smoke marijuana occasionally for
spasticity. No other illicit drug use.
Family History:
Mother: Ovarian [**Name (NI) 3730**] - Died at age 60 .
Father: Died in accident at age 50.
Siblings: No siblings.
No other significant illnesses in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 110/60 96 18 95%RA
Gen: Thin, elderly, white male, looks older than stated age
HEENT: Anicteric sclerae, EOMI, PERRL, oropharynx with erythema
on posterior pharynx and white plaques on soft palate
Neck: No cervical or supraclavicular lymphadenopathy
Lungs: Crackles at left lung base
Heart: RRR, Nl S1/S2, no MRG
Abd: Normoactive bowel sounds, soft, ND, slight TTP in RUQ
Extr: No edema, 2+ peripheral pulses
Neuro: Awake, alert and oriented x3. CN's II-XII intact.
Sensation intact and equal bilaterally. [**5-18**] in UE's
bilaterally. 4+/5 strength in RLE.
Access: left antecubital PIV.
Pertinent Results:
ADMISSION LABS:
[**2171-1-29**] 09:08AM BLOOD WBC-0.9* RBC-3.52*# Hgb-10.5*# Hct-30.1*#
MCV-86 MCH-29.8 MCHC-34.8 RDW-16.2* Plt Ct-36*
[**2171-1-29**] 09:08AM BLOOD Neuts-26* Bands-0 Lymphs-60* Monos-6
Eos-6* Baso-2 Atyps-0 Metas-0 Myelos-0
[**2171-1-30**] 01:11AM BLOOD PT-14.6* PTT-30.4 INR(PT)-1.4*
[**2171-1-30**] 01:11AM BLOOD Fibrino-517*#
[**2171-1-29**] 09:08AM BLOOD UreaN-19 Creat-0.6 Na-139 K-4.6 Cl-98
HCO3-33* AnGap-13
[**2171-1-29**] 09:08AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.1 UricAcd-4.0
[**2171-1-29**] 09:08AM BLOOD ALT-30 AST-19 LD(LDH)-172 AlkPhos-101
TotBili-0.6
.
[**2171-1-30**] CXR: IMPRESSION: Cardiac size is normal. Right PICC tip
is in the lower SVC. The left lung is clear. Right lower lobe
opacity is the combination of moderate-to-large right pleural
effusion with adjacent atelectasis, underlying infectious
process cannot be excluded. There are no new lung abnormalities.
.
[**2171-1-31**] CXR: IMPRESSION:
1. New opacification at the left base may represent early
pneumonia or atelectasis. Would recommend short term follow up
with subsequent radiographs.
2. Slight decrease in size of moderate right pleural effusion.
3. Persistent consolidation in the right base is likely
atelectasis, although pneumonia cannot be excluded.
.
[**2171-2-5**] CXR: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Relatively extensive and probably
loculated right pleural effusion. Subsequent areas of right
atelectasis. The left lung is unremarkable. Unchanged size of
the cardiac silhouette. Unchanged course of the right PICC line.
.
DISCHARGE LABS:
[**2171-2-8**] 06:14AM BLOOD WBC-0.4* RBC-3.05* Hgb-9.0* Hct-25.4*
MCV-83 MCH-29.6 MCHC-35.6* RDW-15.7* Plt Ct-9*
[**2171-2-3**] 06:00AM BLOOD Neuts-21* Bands-0 Lymphs-69* Monos-5
Eos-0 Baso-2 Atyps-0 Metas-0 Myelos-0 Blasts-3*
[**2171-2-8**] 06:14AM BLOOD PT-18.4* PTT-33.1 INR(PT)-1.7*
[**2171-2-7**] 06:27AM BLOOD PT-18.9* PTT-44.3* INR(PT)-1.8*
[**2171-1-30**] 01:11AM BLOOD Fibrino-517*#
[**2171-1-31**] 09:13PM BLOOD Fibrino-494*
[**2171-2-8**] 06:14AM BLOOD Fibrino-657*#
[**2171-2-6**] 05:42AM BLOOD Thrombn-14.6
[**2171-2-3**] 06:00AM BLOOD Ret Aut-1.8
[**2171-2-6**] 05:42AM BLOOD Inh Scr-NEG
[**2171-2-8**] 06:14AM BLOOD Glucose-93 UreaN-16 Creat-0.5 Na-139
K-3.5 Cl-101 HCO3-31 AnGap-11
[**2171-2-7**] 06:27AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.7 UricAcd-3.7
[**2171-2-8**] 06:14AM BLOOD Calcium-9.8 Phos-4.0 Mg-1.8
[**2171-1-31**] 09:13PM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-2-1**] 04:50AM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-2-1**] 01:32PM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-2-5**] 10:06AM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-2-5**] 09:48PM BLOOD CK-MB-1
[**2171-2-5**] 05:25AM BLOOD CK(CPK)-20*
[**2171-2-5**] 10:06AM BLOOD CK(CPK)-23*
[**2171-2-5**] 09:48PM BLOOD CK(CPK)-23*
[**2171-2-7**] 06:27AM BLOOD ALT-17 AST-17 LD(LDH)-197 AlkPhos-71
TotBili-0.5
[**2171-2-5**] 05:25AM BLOOD TSH-1.4
Brief Hospital Course:
64yo man with MS and recently diagnosed MDS RAEB-2 admitted for
cycle #1 decitabine. Course complicated by hypoxia and
hypotension. CXR showed RLL and LLL infiltrate. Transferred to
ICU for hypotension, which resolved with IV fluids. Vancomycin,
cefepime, and metronidazole started. Diarrhea resolved, C. diff
negative.
.
# MDS/pancytopenia: Started cycle #1 decitabine [**2171-1-29**], but
interrupted [**2171-1-31**] due to hypoxia/hypotension/ICU transfer.
Restarted [**2171-2-3**] and finished [**2171-2-4**]. Transfused 1U pRBC
[**2171-2-1**], [**2171-2-6**], [**2171-2-7**], and [**2171-2-8**]. Low retic index.
Transfused PLTs [**2171-2-8**]. Continued TMP-SMX and acyclovir
prophylaxis. Continued allopurinol for hyperuricemia.
.
# Hypoxia: Likely due to recurrent aspiration pneumonia +
right-sided pleural effusion considering hypoxia, fever to 102F
[**2171-1-31**], tachypnea (RR 30), hypotension, and CXR findings. BNP
3543 on [**2170-12-13**]. Echo [**2170-12-14**] showed LVEF >55%, moderate MR,
and mild pulmonary HTN. He refused a repeat video swallow
having had one last week as an outpatient. He was explained the
risks of aspiration including pneumonia and death, but still
refused. Bedside swallow eval was normal. Overt aspiration
[**12/2170**] resolved, but this event seemed to be a recurrence.
Completed a course of cefepime and metronidazole for
hospital-acquired pneumonia with neutropenia and history of
aspiration (started [**2171-1-30**], stopped day of discharge).
Vancomycin stopped earlier given negative cultures and
resolution of symptoms. Continued albuterol/iptratropium.
Thoracentesis of right-sided pleural effusion (new since
[**12/2170**]) was not done considering infectious risk while
neutropenic and no hypoxia or dyspnea.
.
# Hypotension: Due to sepsis/infection (pneumonia) and
hypovolemia (diarrhea +/- furosemide). Resolved with IV fluids
and abx, but this AM is hypotensive again after re-instituting
metoprolol for tachycardia. Improved again more IV normal
saline [**2171-2-6**].
.
# Neutropenic fever: Due to aspiration pneumonia. Treated as
above.
.
# Tachycardia: Cardiology consulted. EKG consistent with AVNRT.
Metoprolol stopped [**2171-1-31**] for hypotension (ICU transfer), so
restarted at 12.5mg [**Hospital1 **]. Repeat CXR unchanged. Cardiac enzymes
negative. TSH normal. Increased metoprolol to 25mg [**Hospital1 **].
.
# Diarrhea: Possibly antibiotic-induced. C. diff toxin negative
x3. Stool cultures negative x1. Resolved.
.
# Thrush: Continued fluconazole while neutropenic.
.
# Coagulopathy: Getting vitamin K on Saturdays. Mixing study
negative. Fibrinogen elevated. Occasional schistocytes
reported suggesting a mild compensated DIC as opposed to
decreased hepatic synthetic function from malnutrition.
.
# Multiple sclerosis: Continued lorazepam for spasticity/pain as
needed. Changed dronabinol to scheduled for chronic pain from
spasticity. Continued modafenil and oxcarbazepine. Indwelling
Foley for urinary retention. He had previously been on [**Hospital1 7595**]
for years, however this was discontinued on dx of MDS. He has
severe body aches "from head to toe" from neuropathic pain and
decreased mobility from spastic paraparesis.
.
# Osteoporosis: Continued Ca, vitamin D, and alendronate.
.
# FEN: Regular diet. IV fluids given for hyponatremia.
Repleted hypomagnesemia.
.
# GI prophylaxis: PPI and bowel regimen.
.
# DVT PPx: Thrombocytopenia.
.
# IV access: Peripheral.
.
# Precautions: Neutropenic.
.
# Code status: DNR/DNI.
Medications on Admission:
ACYCLOVIR 400 mg PO TID
ALENDRONATE [FOSAMAX] 70 mg PO weekly
ALLOPURINOL 100 mg PO DAILY
DRONABINOL 5 mg PO q6HR PRN nausea/pain
FLUCONAZOLE - received in clinic today
KETOCONAZOLE 2% Shampoo daily
LORAZEPAM 0.5-1 mg PO q4HR PRN
METOPROLOL TARTRATE 25 mg PO BID
MODAFINIL [PROVIGIL] 200 mg PO in morning
MODAFINIL [PROVIGIL] 100 mg PO in afternoon, as needed
OXCARBAZEPINE 150 mg PO BID
PHYTONADIONE [MEPHYTON] 5 mg Tablet by mouth on Saturday
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] 400 mg-80 mg Tablet by
mouth daily
ACETAMINOPHEN 325-650mg PO q6HR PRN fever/pain
ASCORBIC ACID 500 mg Tablet by mouth daily
CALCIUM CARBONATE-VITAMIN D3 600mg-400unit PO BID
DOCUSATE SODIUM [COLACE] 100 mg PO BID
MULTIVITAMIN WITH MINERALS 1 Tablet(s) by mouth daily
SENNOSIDES [SENNA] 8.6 mg PO BID PRN constipation
Discharge Medications:
1. acyclovir 400 mg PO Q8H.
2. alendronate 70 mg PO QSUN.
3. allopurinol 100 mg PO DAILY.
4. dronabinol 5 mg PO Q6H PRN nausea/pain.
5. ketoconazole 2 % Shampoo Sig: One (1) Appl Topical once a
day.
6. lorazepam 0.5-1.0 mg PO Q4H PRN anxiety/spasticity/pain.
7. modafinil 200 mg PO qAM.
8. modafinil 100 mg PO qPM as needed.
9. oxcarbazepine 150 mg PO BID.
10. phytonadione 5 mg PO 1X/WEEK (SA).
11. sulfamethoxazole-trimethoprim 400-80 mg PO DAILY.
12. acetaminophen 325-650 mg PO Q6H PRN Pain.
13. ascorbic acid 500 mg PO DAILY.
14. calcium carbonate 200 mg calcium (500 mg) Chewable PO BID.
15. cholecalciferol (vitamin D3) 400 unit PO BID.
16. multivitamin,tx-minerals 1 Tablet PO DAILY.
17. docusate sodium 100 mg PO BID.
18. senna 8.6 mg PO BID PRN constipation.
19. dronabinol 5 mg PO BID.
20. fluconazole 400mg PO Q24H.
21. metoprolol tartrate 25 mg PO BID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Cycle #1 decitabine chemotherapy.
2. MDS (myelodysplastic syndrome).
3. Hypoxia (low oxygen level).
4. Hypotension (low blood pressure).
5. Aspiration pneumonia.
6. Right-sided pleural effusion (fluid on the lung).
7. Multiple sclerosis.
8. Anemia (low red blood cell count).
9. Thrombocytopenia (low platelet count).
10. Coagulopathy (abnormal clotting tests).
11. Supraventricular tachycardia (fast heart rate).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for cycle #1 decitabine
chemotherapy for myelodysplastic syndrome (MDS). This three day
course was interrupted due to hypoxia (low oxygen levels) and
low blood pressure. Because of the severity of the low blood
pressure, you were temporarily transferred to the Intensive Care
Unit. A chest x-ray showed a new pneumonia and fluid in the
right lung (pleural effusion). You were given IV antibiotics
and IV fluids and recovered quickly. Chemotherapy was restarted
and finished [**2171-2-4**]. Concern was raised about recurrent
aspiration as the cause of your recent pneumonias. However, you
refused a video swallow test because of severe pain from the
multiple sclerosis. Also during your stay, your heart rate
became very fast, so you were evaluated by Cardiology and
restarted on metoprolol, a blood pressure medication that also
controls heart rate. After starting this, your blood pressure
became very low for a short while and improved with IV fluids.
You blood counts remain low from myelodysplastic syndrome and
chemotherapy. You should have your blood counts checked at
least every other day until they stabilize because you will
continue to need frequent transfusions. You are also
susceptible to infections because of a low white blood cell
count. Avoid sick contacts.
.
MEDICATION CHANGES:
1. Metoprolol 25mg 2x a day.
2. You completed a course of antibiotics while in the hospital.
Followup Instructions:
HEMATOLOGY/ONCOLOGY
WHEN: THURSDAY, [**2-14**] AT 2:00PM.
WHERE: [**Hospital Ward Name **] [**Location (un) **], [**Hospital1 **], [**Hospital Ward Name **].
WITH: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
[]
]
] |
12311, 12381
|
7021, 10568
|
322, 329
|
12841, 12841
|
4091, 4091
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357, 2416
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4107, 5676
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12856, 12992
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2705, 3009
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3025, 3255
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,045
| 173,930
|
3201+55453
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-9-26**] Discharge Date: [**2149-9-29**]
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo female with history of TB sp treatment, bronchiectasis,
untreated MAC (diagnosed [**6-/2149**]), atrial fibrillation who
presents with worsening shortness of breath. Patient was
hospitalized in [**6-/2149**] with hemoptysis and shortness of breath.
At that time she was diagnosed with pneumonia/bronchiectasis and
treated with ceftriaxone/azithromycin with improvment in
symptoms. After discharge sputum samples revealed MAC. She
underwent no treatment of MAC given her frail state and the
feeling that she would not live through treatment. Since the
last DC she has been on home 02.
.
Patient states the last several weeks her breathing has become
progressively worse. She saw her PCP the day prior to admission
and declined hospital admission at that time. Today she felt her
breathing was worse with ambulation and agreed to evaluation at
the hospital. Denies fever, chills, chest pain, productive
cough. Denies lower extremity edema, orthopnea, PND.
.
Initial VS in the ED: 97.9 99 152/89 18 95%. Labs revealed a
normocytic anemia with hematocrit of 28.1 which is down from 32
in [**6-/2149**], INR 3.5, Lactate of 1.4, UA with 31 WBC and few
bacteria, nitrite negative. CXR with bilateral lower lobe
effusion with possible peripneumonic effusions. Patient was
given Vancomycin and Levofloxacin. EKG with A. Fib. VS prior to
transfer: 98.9 87 AF 150/74 25 99% 3L.
.
On the floor, feels fine, comfortable.
Past Medical History:
- Paroxysmal atrial fibrillation
- History of pulmonary tuberculosis
--->treated with pneumothoraces and subsequently with PAS/INH 50
years ago
--->PFTs [**2144**]: FEV1 0.86, FEV1/FVC 128% predicted. DLSO not
performed
--->prior CT revealing for calcified granulomas in the right
lower lobe and left lower lobe, calcified pleural scar on the
right, and fibrotic changes in the right lower lobe leading to a
mediastinal shift to the right
- MGUS
- Osteoporosis
- Cervical Osteoarthritis
- s/p cataract extraction
Social History:
The patient is currently a resident at [**Location (un) 5481**] independent
living. She has two children, who do not live in the area. She
was previously employed as a dental hygienist. She is
independent in her ADL's. She denies tobacco or EtOH use.
Family History:
Mother: Died age 80 [**2-12**] MI
Father: Died in 80s [**2-12**] MI
No family history of lung cancer or other lung disease.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.9 BP: 133/63 P: 63 R: 18 O2: 97 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decrease BS bilateral bases, with fine rales, occasional
wheeze right lower lung fields, no egophony, minimal dullness to
percussion along the lower lung fields, no accessory muscle use
CV: Irregular, 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, left
lower extremity with trace edema (patient notes this to be
chronic.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
[**2149-9-26**] 11:55AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.0* Hct-28.1*
MCV-87# MCH-27.9 MCHC-32.1 RDW-15.8* Plt Ct-317
[**2149-9-26**] 11:55AM BLOOD PT-35.0* PTT-27.1 INR(PT)-3.5*
[**2149-9-26**] 11:55AM BLOOD Glucose-104* UreaN-19 Creat-0.6 Na-143
K-3.8 Cl-102 HCO3-34* AnGap-11
[**2149-9-26**] 12:04PM BLOOD Lactate-1.4
Discharge Labs:
Studies:
CXR ([**2149-9-26**]): IMPRESSION: 1. Moderate pulmonary edema. 2.
Increased size of moderate right and small left pleural
effusions. 3. Bibasilar airspace opacities which could reflect
atelectasis though infection or aspiration cannot be excluded.
4. Large hiatal hernia.
Brief Hospital Course:
[**Age over 90 **] yo female with history of TB s/p treatment, bronchiectasis,
untreated MAC (diagnosed [**6-/2149**]), atrial fibrillation who
presented with worsening shortness of breath, CXR concerning for
bilateral lower lobe opacification with possible peripneumonic
effusion.
.
Active issues:
.
#SOB/Cough: Upon admission, the patient described an increasing
oxygen requirement for the past few days without fever, and with
no evidence of leukocytosis. At that time, she demonstrated no
signs of volume overload and her CXR was thought to be due to
untreated MAC infection. However, overnight, she desaturated
down to the low 80%, required 10L on a non-rebreather to
maintain her oxygen saturation, and was thought to be volume
overloaded with evidence of pulmonary edema on her subsequent
CXR. She was subsequently transferred to the MICU for BIPAP
given her worsening oxygen requirement. In the ICU the family
decided to make the patient CMO wo continuation of lasix, abx,
or other non-comfort medications (inhalers, bowel regimen, and
beta blocker continued). Her geriatrician from the NH arranged
for dispo back to the NH with hospice services under new code
status on [**2149-9-29**].
.
# Pyuria: No symptoms. Lots of epis on UA. No antibiotics given
current goals of care.
.
# Atrial Fibrillation: Rate Controlled. Continued metoprolol for
comfort.
.
# Normocytic Anemia: HCT down from 32 to 28. No evidence of
acute bleed. Labs discontinued.
.
#. Depression: Continue Mirtazapine for sleep assistance.
.
Pt will be discharged to hospice services. Palliative care
consult initiated at [**Hospital1 18**] w/ follow-up to be managed by hospice
at outpatient facility.
Medications on Admission:
- Calcium Carbonate 200mg PO three times a day
- Omeprazole 20mg PO daily
- conjugated estrogens 0.3 mg Daily
- multivitamin one tab daily
- donepezil 5 mg Tablet QHS
- mirtazapine 45 mg daily
- fluticasone-salmeterol 250-50 mcg/dose one inhalation daily
- B complex vitamins one daily
- cholecalciferol (vitamin D3) 1,000 unit daily
- atorvastatin 10 mg Tablet Sig: 0.5 tablet daily
- metoprolol tartrate 25 mg Tablet [**Hospital1 **]
- warfarin 3mg Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. ipratropium bromide 0.02 % Solution Sig: One (1) ml
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. morphine 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Pulmonary edema
Atrial fibrillation
MAC - untreated
Discharge Condition:
Mental Status: Confused - sometimes.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 **].
You were admitted with shortness of breath related to fluid in
your lung and your heart arrhythmia (atrial fibrillation). A
meeting was held with you and your family to determine the most
appropriate management for you given your recently declining
health and wish to prioritize quality of life. Plans were made
to transition you to hospice at your current nursing home with
an emphasis on comfort care.
The following changes were made to your medications:
STOPPED all non-comfort medications
Continued: inhalers, betablocker, bowel regimen, sleep aids
STARTED morphine orally as needed for dyspnea and pain
You have several follow-up appointments with [**Hospital1 18**] physicians.
These appointments have been detailed in the follow-up section
below.
Should you desire medical evaluation in the future, please call
your primary care physician to make an appointment, or if you
need more immediate attention seek care at the emergency
department.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2149-10-1**] at 12:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2149-10-1**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2149-10-1**] at 1 PM
Completed by:[**2149-10-2**] Name: [**Known lastname 2406**],[**Known firstname 1683**] Unit No: [**Numeric Identifier 2407**]
Admission Date: [**2149-9-26**] Discharge Date: [**2149-9-29**]
Date of Birth: [**2058-1-6**] Sex: F
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 2408**]
Addendum:
To clarify several points from this [**Hospital 1325**] hospital course:
. #SOB/Cough: Upon admission, the patient described an
increasing oxygen requirement for the past few days without
fever, and with no evidence of leukocytosis. At that time, she
demonstrated no signs of volume overload and her CXR was thought
to be due to untreated MAC infection. However, overnight, she
desaturated down to the low 80%, required 10L on a
non-rebreather to maintain her oxygen saturation, and this was
thought to be volume overloaded with evidence of pulmonary edema
on her subsequent CXR. The pulmonary edema was acute in nature,
cardiac in etiology. On discharge pneumonia had been ruled out,
and therefore not associated with MAC, which is her underlying
pulmonary disease.
Brief Hospital Course:
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1267**] TCU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2409**] MD [**MD Number(2) 2410**]
Completed by:[**2149-11-11**]
|
[
"799.02",
"530.81",
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"427.31",
"553.3",
"031.2",
"V49.86",
"733.00",
"721.0",
"428.33",
"494.0",
"428.0",
"V46.2",
"300.4",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10692, 10905
|
10669, 10669
|
237, 243
|
7606, 7606
|
3433, 3433
|
8893, 9927
|
2526, 2651
|
6281, 7432
|
7531, 7585
|
5799, 6258
|
9945, 10645
|
7826, 8870
|
3785, 4069
|
2691, 3388
|
178, 199
|
4391, 5773
|
271, 1706
|
3449, 3768
|
7658, 7802
|
1728, 2242
|
2258, 2510
|
3414, 3414
|
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