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31,493
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46835
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Discharge summary
|
report
|
Admission Date: [**2163-4-6**] Discharge Date: [**2163-4-20**]
Service: SURGERY
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
persistent epigastric
pain and nonbilious/nonbloody vomiting
Major Surgical or Invasive Procedure:
*ERCP
* Exploratory laparotomy with exploration and wide
drainage of the retroperitoneum.
*Cholecystectomy with common bile duct exploration and
placement of 12-French T-tube.
* [**Last Name (un) **] gastrostomy with 20 French Foley catheter.
*Placement of 14 French whistle-tip feeding jejunostomy
tube.
History of Present Illness:
Mrs. [**Known lastname 99395**] is an 87-year-old
female, with a history of chronic lymphocytic leukemia and
renal insufficiency, who was admitted to Dr.[**Name (NI) 12822**] service
for the
diagnosis of gallstone pancreatitis and acute cholecystitis.
Past Medical History:
CLL, CRI (Cr 2.2-2.6), HTN, OA, gout, cataracts, TAH
Social History:
widowed, lives in [**Hospital3 **], three daughters live
locally
Family History:
no family history of blood disorders
o/w non-contributory
Physical Exam:
Vitals on transfer
95.5 105 122/70 18 95RA
PE:
RRR, tachycardic, no MRG appreciated
CTAB, rapid breathing noted
Abdomen: firm, distended, pain to palpation in all quadrants,
BS+, RT and guarding present
EXT MAE [**3-28**] b le and ue
Pertinent Results:
[**2163-4-20**] 03:00AM BLOOD WBC-6.03# RBC-2.70* Hgb-8.5* Hct-26.2*
MCV-97 MCH-31.4 MCHC-32.4 RDW-17.9* Plt Ct-79*
[**2163-4-19**] 09:14PM BLOOD WBC-13.8*# RBC-2.96* Hgb-9.5* Hct-29.1*
MCV-98 MCH-32.2* MCHC-32.7 RDW-18.2* Plt Ct-102*
[**2163-4-19**] 09:14PM BLOOD WBC-13.8*# RBC-2.96* Hgb-9.5* Hct-29.1*
MCV-98 MCH-32.2* MCHC-32.7 RDW-18.2* Plt Ct-102*
[**2163-4-19**] 11:41AM BLOOD WBC-28.4* RBC-3.15* Hgb-10.1* Hct-30.7*
MCV-97 MCH-32.1* MCHC-32.9 RDW-17.8* Plt Ct-148*
[**2163-4-19**] 03:25AM BLOOD WBC-30.7* RBC-3.09* Hgb-9.8* Hct-29.4*
MCV-95 MCH-31.8 MCHC-33.4 RDW-18.2* Plt Ct-151
[**2163-4-18**] 08:00PM BLOOD WBC-28.0* RBC-3.44* Hgb-10.9* Hct-32.4*
MCV-94 MCH-31.7 MCHC-33.7 RDW-18.0* Plt Ct-152
[**2163-4-18**] 03:35AM BLOOD WBC-33.4* RBC-3.34* Hgb-11.1* Hct-31.4*
MCV-94 MCH-33.1* MCHC-35.3* RDW-18.0* Plt Ct-154#
[**2163-4-17**] 02:56AM BLOOD WBC-22.8* RBC-3.15*# Hgb-10.0*# Hct-29.2*
MCV-93 MCH-31.9 MCHC-34.4 RDW-18.7* Plt Ct-78*
[**2163-4-16**] 04:11PM BLOOD Hct-33.6*#
[**2163-4-16**] 04:00AM BLOOD WBC-20.2* RBC-2.18* Hgb-6.9* Hct-21.2*
MCV-98 MCH-31.7 MCHC-32.5 RDW-17.4* Plt Ct-85*
[**2163-4-16**] 04:11PM BLOOD Hct-33.6*#
[**2163-4-16**] 04:00AM BLOOD WBC-20.2* RBC-2.18* Hgb-6.9* Hct-21.2*
MCV-98 MCH-31.7 MCHC-32.5 RDW-17.4* Plt Ct-85*
[**2163-4-15**] 05:27PM BLOOD Hct-22.7*
[**2163-4-15**] 02:35AM BLOOD WBC-28.2* RBC-2.52* Hgb-8.0* Hct-24.2*
MCV-96 MCH-31.9 MCHC-33.3 RDW-17.3* Plt Ct-88*
[**2163-4-14**] 08:00PM BLOOD WBC-29.4* RBC-2.56* Hgb-8.4* Hct-25.0*
MCV-98 MCH-33.0* MCHC-33.8 RDW-17.1* Plt Ct-79*#
[**2163-4-14**] 04:30PM BLOOD Hct-24.8*
[**2163-4-14**] 08:55AM BLOOD Hct-24.5*
[**2163-4-14**] 02:08AM BLOOD WBC-30.6* RBC-2.83* Hgb-9.1* Hct-27.6*
MCV-98 MCH-32.2* MCHC-33.0 RDW-16.9* Plt Ct-50*
[**2163-4-13**] 09:10PM BLOOD WBC-27.2* RBC-2.88* Hgb-9.5* Hct-28.3*
MCV-98 MCH-32.9* MCHC-33.5 RDW-16.9* Plt Ct-61*
[**2163-4-13**] 02:26AM BLOOD WBC-28.7* RBC-2.91* Hgb-9.3* Hct-28.0*
MCV-96 MCH-31.9 MCHC-33.1 RDW-16.9* Plt Ct-41*
[**2163-4-10**] 04:18PM BLOOD WBC-14.2* RBC-3.39* Hgb-10.9* Hct-32.2*
MCV-95 MCH-32.2* MCHC-34.0 RDW-17.6* Plt Ct-40*
[**2163-4-10**] 10:02PM BLOOD Hct-30.7*
[**2163-4-11**] 04:00AM BLOOD WBC-17.4* RBC-2.99* Hgb-9.8* Hct-28.5*
MCV-95 MCH-32.7* MCHC-34.3 RDW-17.8* Plt Ct-35*
[**2163-4-11**] 03:32PM BLOOD WBC-23.3* RBC-3.03* Hgb-10.1* Hct-28.8*
MCV-95 MCH-33.4* MCHC-35.1* RDW-17.4* Plt Ct-45*
[**2163-4-12**] 03:04AM BLOOD WBC-23.0* RBC-3.05* Hgb-9.7* Hct-28.8*
MCV-94 MCH-32.0 MCHC-33.8 RDW-17.2* Plt Ct-43*
[**2163-4-12**] 08:30AM BLOOD WBC-21.4* RBC-2.93* Hgb-9.5* Hct-27.6*
MCV-94 MCH-32.3* MCHC-34.2 RDW-17.3* Plt Ct-41*
[**2163-4-12**] 02:40PM BLOOD WBC-22.7* RBC-2.96* Hgb-9.4* Hct-28.0*
MCV-94 MCH-31.9 MCHC-33.7 RDW-17.3* Plt Ct-38*
[**2163-4-13**] 02:26AM BLOOD WBC-28.7* RBC-2.91* Hgb-9.3* Hct-28.0*
MCV-96 MCH-31.9 MCHC-33.1 RDW-16.9* Plt Ct-41*
[**2163-4-13**] 09:10PM BLOOD WBC-27.2* RBC-2.88* Hgb-9.5* Hct-28.3*
MCV-98 MCH-32.9* MCHC-33.5 RDW-16.9* Plt Ct-61*
[**2163-4-10**] 09:56AM BLOOD WBC-13.2* RBC-2.77* Hgb-9.1* Hct-25.8*
MCV-93 MCH-32.9* MCHC-35.3* RDW-18.2* Plt Ct-40*
[**2163-4-10**] 04:00AM BLOOD WBC-9.8 RBC-2.65* Hgb-8.6* Hct-24.8*
MCV-94 MCH-32.5* MCHC-34.7 RDW-18.2* Plt Ct-39*
[**2163-4-19**] 03:25AM BLOOD Neuts-12* Bands-12* Lymphs-72* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-1*
[**2163-4-16**] 04:00AM BLOOD Neuts-45.6* Lymphs-52.4* Monos-1.3*
Eos-0.3 Baso-0.5
[**2163-4-15**] 02:35AM BLOOD Neuts-42* Bands-1 Lymphs-53* Monos-2
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2163-4-7**] 10:58PM BLOOD Neuts-38* Bands-3 Lymphs-53* Monos-1*
Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0
[**2163-4-6**] 03:25PM BLOOD Neuts-29* Bands-0 Lymphs-67* Monos-1*
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2163-4-15**] 02:35AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL
[**2163-4-7**] 10:58PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Schisto-1+
Burr-1+
[**2163-4-6**] 03:25PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2163-4-20**] 03:00AM BLOOD Plt Ct-79*
[**2163-4-20**] 03:00AM BLOOD PT-20.1* PTT-36.2* INR(PT)-1.9*
[**2163-4-19**] 09:14PM BLOOD Plt Ct-102* LPlt-1+
[**2163-4-19**] 09:14PM BLOOD PT-19.9* PTT-33.6 INR(PT)-1.9*
[**2163-4-19**] 11:41AM BLOOD Plt Ct-148*
[**2163-4-19**] 11:41AM BLOOD PT-19.0* PTT-40.9* INR(PT)-1.8*
[**2163-4-19**] 03:25AM BLOOD Plt Smr-NORMAL Plt Ct-151
[**2163-4-19**] 03:25AM BLOOD PT-16.4* PTT-32.3 INR(PT)-1.5*
[**2163-4-18**] 08:00PM BLOOD Plt Ct-152
[**2163-4-18**] 03:35AM BLOOD Plt Ct-154#
[**2163-4-17**] 02:56AM BLOOD Plt Ct-78*
[**2163-4-17**] 02:56AM BLOOD PT-13.2 PTT-27.8 INR(PT)-1.1
[**2163-4-14**] 08:00PM BLOOD Plt Ct-79*#
[**2163-4-14**] 08:00PM BLOOD PT-12.9 PTT-28.6 INR(PT)-1.1
[**2163-4-14**] 02:08AM BLOOD Plt Smr-VERY LOW Plt Ct-50*
[**2163-4-14**] 02:08AM BLOOD PT-12.3 PTT-29.9 INR(PT)-1.0
[**2163-4-13**] 09:10PM BLOOD Plt Smr-VERY LOW Plt Ct-61* LPlt-2+
[**2163-4-13**] 09:10PM BLOOD PT-12.2 PTT-29.4 INR(PT)-1.0
[**2163-4-13**] 02:26AM BLOOD Plt Ct-41*
[**2163-4-12**] 02:40PM BLOOD Plt Ct-38*
[**2163-4-12**] 02:40PM BLOOD PT-11.1 PTT-28.2 INR(PT)-0.9
[**2163-4-12**] 08:30AM BLOOD Plt Ct-41*
[**2163-4-12**] 08:30AM BLOOD PT-11.1 PTT-29.2 INR(PT)-0.9
[**2163-4-12**] 03:04AM BLOOD Plt Smr-VERY LOW Plt Ct-43*
[**2163-4-10**] 04:18PM BLOOD Plt Ct-40* LPlt-1+
[**2163-4-10**] 09:56AM BLOOD Plt Ct-40*
[**2163-4-10**] 04:00AM BLOOD PT-12.7 PTT-35.4* INR(PT)-1.1
[**2163-4-9**] 03:12PM BLOOD Plt Smr-LOW Plt Ct-98*
[**2163-4-9**] 03:12PM BLOOD PT-13.2 PTT-35.8* INR(PT)-1.1
[**2163-4-9**] 10:00AM BLOOD PT-13.8* PTT-33.7 INR(PT)-1.2*
[**2163-4-9**] 04:10AM BLOOD Plt Ct-116*
[**2163-4-9**] 04:10AM BLOOD PT-15.4* PTT-137.0* INR(PT)-1.4*
[**2163-4-8**] 10:39PM BLOOD Plt Ct-132*
Brief Hospital Course:
Mrs. [**Known lastname 99395**] is an 87-year-old
female, with a history of chronic lymphocytic leukemia and
renal insufficiency, who was admitted to the surgical service
for the
diagnosis of gallstone pancreatitis and acute cholecystitis.
She was resuscitated and placed on intravenous antibiotics
and then was taken to the ERCP suite by Dr. [**Last Name (STitle) **] of GI
medicine for an ERCP. A sphincterotomy was performed in the
12 o'clock position and a small stone which was impacted
within the intraduodenal portion of the bile duct was
extracted. A small amount of pus and obstructed bile was
relieved. The biliary tree and pancreatic duct were otherwise
normal. During the course of the procedure on the scout films
a small amount of free air was apparent. Accordingly, a CT
scan was obtained post procedure and this demonstrated a
large amount of free intraperitoneal air and fluid, as well
as some retroperitoneal air just adjacent to the second
portion of the duodenum. Dr. [**Last Name (STitle) 1924**] had a detailed discussion
with the
family at this point regarding their wishes, given that the
patient was do not resuscitate and do not intubate secondary
to her advanced age and chronic medical comorbidities. The
family wished to have some time to discuss the aggressiveness
of her care. In the meantime, the patient was transferred to
the ICU for very close invasive monitoring, as well as for
resuscitation and the administration of intravenous
antibiotics. Over the course of the evening, her clinical
condition worsened with a rise in her white blood count and
her creatinine. Dr. [**Last Name (STitle) 1924**] advised an urgent trip to the
operating
room and the family consented and wished to pursue aggressive
treatment at this point. The risks of the surgery were
clearly explained to the family, specifically her daughter
[**Name (NI) 1494**], and he emphasized a very high perioperative morbidity
and mortality rate, perhaps as high as 50%. he explained the
likely need for prolonged ventilatory support, hemodynamic
support and the need for dialysis. The family also understood
that he would place a feeding tube as well as multiple
drainage catheters in the abdomen and they consented to
proceed in this fashion.
OPERATIVE FINDINGS:
1. A large amount of free intraperitoneal air and bile was
evacuated upon opening the abdomen. The bile was clear
green and was sent for Gram stain and culture.
2. A wide generous [**Doctor Last Name **] maneuver was performed all the
way to the level of the fourth portion of the duodenum.
There was no obvious rent in the duodenum. The head of
the pancreas appeared normal with the exception of some
saponification consistent with her known diagnosis of
gallstone pancreatitis. The common bile duct was
carefully explored from its bifurcation all the way down
to its passage behind the first portion of the duodenum.
This was normal. No common duct stones were identified
upon choledochotomy and T-tube placement. The
gallbladder was markedly distended with a thickened
wall. It had stones but there was no evidence of
gallbladder perforation.
3. Careful inspection of the entire length of small bowel
from the ligament of Treitz all the way to the ileocecal
valve showed no abnormality.
4. The stomach and large bowel also appeared normal without
evidence of abnormality.
Patient was returned to the ICU from the operating room
in stable condition. In the immediate post-operative
period, however, the patient remained oligoanuric, so an
appropriate access line was placed and CVVHDF started on [**4-9**].
For two days the patient remained stable and continued a CVVH
without difficulty. On [**4-14**] the SICU team placed a left
subclavian central access line for continued hemodialysis and
pulled the femoral catheter that had been used. Line placement
was complicated by tension pneumothorax and hypotension that
required emergent chest tube placement. The patient required
pressors and fluids overnight and had hemodialysis held.
By the next day the patient was off pressors, stable, and was in
the process of weaning off the ventilator; CVVH was restarted
instead of using IHD in the hope of extubation.
After a few days the patient was able to extubate with minimal
difficulty, and CVVH was discontinued since the 25th. By the
27th, the patient Underwent full session of regular HD.
Additionally, the patient's CXR continued to demonstrated
concern for VAP vs continued atelectasis, while the patient
continued to appear septic. Vancomycin and Zosyn were started.
The patient continued to have a need for pressor support, and a
family meeting was undertaken. Given the patient's continued
grave prognosis, a decision was made to pronounce the patient as
"Comfort Measures Only".
By the evening of the 28th, the patient required maximum pressor
support to maintain
blood pressure and eventually expired.
Medications on Admission:
iron 325', calcitriol 0.25', premarin 0.3', levoxyl 112',
allopurinol ?dose, lasix 80QAM 40QPM, procrit 20K Q2wks, benicar
10', renagel 800'''
Discharge Medications:
not applicable as patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"568.89",
"E870.8",
"785.51",
"998.59",
"403.91",
"577.0",
"998.2",
"995.92",
"512.1",
"204.10",
"585.5",
"584.9",
"038.9",
"574.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"54.0",
"96.6",
"38.95",
"51.85",
"43.19",
"51.51",
"46.39",
"33.24",
"51.88",
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12474, 12483
|
7264, 12223
|
278, 597
|
12534, 12543
|
1383, 7241
|
12599, 12609
|
1055, 1114
|
12416, 12451
|
12504, 12513
|
12249, 12393
|
12567, 12576
|
1129, 1364
|
178, 240
|
625, 879
|
901, 955
|
972, 1039
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,050
| 129,637
|
22500
|
Discharge summary
|
report
|
Admission Date: [**2111-6-2**] Discharge Date: [**2111-6-12**]
Date of Birth: [**2042-10-3**] Sex: F
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Brain biopsy
History of Present Illness:
68 yo woman c/o "worst headache of her life" on day of
admission, called EMS, en route became unresponsive, intubated
in
ED. [**Name (NI) **] sister visited with patient x 3 weeks, left on
[**5-27**]. During that visit, they both went to [**Location (un) 5354**]. Sister
is
healthy. The only complaint the patient had (per sister) was
headache, "off and on x several weeks", no visual complaints,
able to go about daily activities. No personality changes, no
c/o weakness/numbness. Unaware of any alternative medication
use. No h/o prior neurologic illness such as shaking (seizure
activity), no hearing loss.
Past Medical History:
HTN
Hyperchol
Social History:
lives alone, only family is a sister in [**Last Name (LF) **], [**Name (NI) **]
[**Name (NI) 58424**] [**Telephone/Fax (1) 58425**], never married, no children, used to work
in a factory, retired. No tob/etoh/drugs.
Family History:
sister has severe osteoporosis, no other family.
Physical Exam:
VITALS: Tm 101.2, Tc 100.6, BP 156/78, HR 78, RR 17, O2 sat 100%
on CPAP + PS 5/5, Vt 380, FiO2 0.4. I/O: -1.8L LOS.
GEN: intubated, sedated, obese woman
SKIN: no rash
HEENT: mmm,ETT in place
NECK: supple
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm without murmurs
ABD: nontender, softly distended, + BS
EXTREM: no edema
NEURO:
Mental status:
Patient is alert, awake when propofol weaned. Unable to assess
speech or verbal answers to questions as is intubated. Nods
head to questions "Are you cold?" "Are you in pain?" Unclear
how accurate her answers are.
Cranial Nerves:
I: deferred
II: Unable to assess Visual acuity or fields. Fundoscopic
exam:
discs flat, fundi clear, no hemorrhages or exudates. Pupils:
3mm-
>2mm bilat, consenual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or
ptosis.
V: unable to assess sensation on face, + corneal reflex (tested
when more sedated)
VII: unable to assess facial strength
VIII; unable to reliably test hearing
IX, X: gag reflex present (gagging on ETT occasionally)
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
Sensory: unable to assess fully, patient withdrawls right
sided limbs only from pain, nods head "yes" when asked if she
can
feel me touching her on right arm and leg only.
Motor:
Normal bulk, tone. No fasciculationst. No adventitious
movements. Lifts right leg partially to gravity. Wiggles left
toes (leg falls when lifted).
Reflexes: 2+ throughout, toes downgoing bilaterally.
Coordination:
unable to assess
Gait:unable to assess
Pertinent Results:
[**2111-6-2**] 08:32PM WBC-14.1* RBC-4.57 HGB-14.3 HCT-40.1 MCV-88
MCH-31.4 MCHC-35.8* RDW-14.4
[**2111-6-2**] 08:32PM PLT COUNT-271
[**2111-6-2**] 08:32PM GLUCOSE-134* UREA N-18 CREAT-0.7 SODIUM-141
POTASSIUM-2.9* CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2111-6-2**] 08:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2111-6-2**] 08:32PM PT-12.0 PTT-19.1* INR(PT)-1.0
Brain MR:
1. Innumerable nodular enhancing foci predominantly in a
watershed distribution in the cerebrum but also within the
cerebellum with associated edema. A focus of restricted
diffusion in the right posterior parietal region without
evidence of minimal hemorrhage appears to represent a small
associated infarction. Given the watershed distribution, small
vessel vasculitis should be considered in the differential
diagnosis. The appearance and distribution is not classical for
acute disseminated encephalomyelitis. The differential diagnosis
also includes an unusual encephalitis, sarcoidosis, or other
granulomatous disorder.
2. Normal Circle of [**Location (un) 431**] MRA.
Brief Hospital Course:
The patient was admitted and managed for her headache and loss
of consciousness. She was initially intubated and sent to the
NICU. Her head MRI showed multiple white matter lesions
consistent with a leukoencephalopathy of unclear etiology. An
LP was done which was unrealing. A rheumatology consult was
obtained to help us work up a possible cerebral
vasculitis/angitis. An EEG showed bursts of generalized
slowing. A brain biopsy was performed which showed "acute
hemorrhagic leukoencephalopathy". She was started initially on
iv steroids and then switched to po steroids in addition to
seizure prophylaxis with phenytoin. Her neurologic exam
improved over the course of her stay to where she was more alert
and oriented. Her speech became more fluent. She still
remained with a mild left hemi-neglect and weakness in the
distal left extremities.
Medications on Admission:
amoxacillin
lipitor
atenolol
triamterene/hctz
kcl
reglan
zofran
ibuprofen
caltrex
tramodol
celebrex
Discharge Medications:
lisinopril 40 qd
levofloxacin 500 qd x 5 more days
metoprolol 50 [**Hospital1 **]
protonix 40 qd
phenytoin 100 qd
prednisone 60 qd
vitamin d 400 qd
calcium 500 [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
1. leukoencephalopathy
2. hypertension
Discharge Condition:
Stable
Discharge Instructions:
Please take medications as prescribed.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2111-6-12**]
|
[
"780.09",
"323.9",
"401.9",
"486",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"01.14",
"96.6",
"93.90",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5284, 5356
|
4073, 4931
|
318, 332
|
5438, 5446
|
2949, 4050
|
1266, 1316
|
5082, 5261
|
5377, 5417
|
4957, 5059
|
5470, 5631
|
1331, 1697
|
270, 280
|
360, 979
|
1947, 2930
|
1712, 1931
|
1001, 1016
|
1032, 1250
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,195
| 143,886
|
28998
|
Discharge summary
|
report
|
Admission Date: [**2111-11-9**] Discharge Date: [**2111-11-12**]
Date of Birth: [**2058-4-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Increased tracheal secretions
Major Surgical or Invasive Procedure:
Trach change - [**11-12**]
History of Present Illness:
This is a 53 year old lady with tracheomalacia s/p tracheostomy,
mental retardation, DM, HTN, peripheral vascular disease who
presents with increased tracheal secretions, fever to 103 and
dyspnea.
Per EMS, patient was noted to have a high fever with elevated
blood sugars to 500s this AM at nursing facility. She was given
10 units of insulin per sliding scale and 650mg tylenol rectally
at her facility. When EMS arrived, pt was found to be
tachycardic 140s and tachypneic to the 40s with o2 sats in the
80s on unclear O2 delivery. En route to [**Hospital1 18**], EMS stopped at
[**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 3714**] for increasing dyspnea in the ambulance. Vitals
on arrival were to OSH were 156/70 133 103.8 97 pm vent. At OSH
CXR was concerning for RLL pna. She was given 1.5 grams of
unasyn and 1 Liter of NS was started at 100cc/hr. Blood sugar on
EMS arrival was 160. There she was suctioned and given more
tylenol.
Of note she was most recently admitted in [**Month (only) **] with similar
symptoms of dyspnea. She presented with a leukocytosis, fever
and lactate of 4.5. The etiology of her presenting sepsis was
felt to be secodary to urosepsis versus pseudomonal/MRSA
pneumonia for which [**Last Name (un) 12315**] as treated with a 14 day course of
vancomycin and cefepime. Her sputum culture grew pseudomonas
and MRSA although it was initially unclear whether these
cultures reflected chronic colonization of her trach. Treatment
for pneumonia was based on CT evidence of RLL consolidation. Her
urine grew pansensitive ecoli in addition to her blood. Her
hospital course was complicated by altered mental status and
delirium. At the time of discharge she was alert and able to
answer yes-no questions by nodding her head. Per her PCP, [**Name10 (NameIs) **] is
able to answer questions, read and write normally.
She at baseline lives at [**Hospital3 105**] Northeast - [**Hospital1 **].
She has co-guardian ship with her father and brother.
In the ED inital vitals were, 120 104/73 36 92% on ??. Initial
labs were significant for WBC 24.3, Hct 34.0, Creatinine 1.0,
lactate 2.1. A UA was positive for large leukocytes, moderate
blood, negative nitrates. Blood cultures were sent. Initial ABG
7.4/53/218/34. A chest xray demonstrated no effusion or
consolidation and low lung volumes. She was given 750mg
Levofloxacin, Zosyn 4.5 and Vancomycin 1g. Vitals on transfer:
101.8, 110-120s, 112/82, 28 (36 on arrival) 96% on 4L (2L on
arrival). Unknown baseline O2 requirement. She was placed on
assist control ventilatory support prior to transfer.
On arrival to the ICU, initial vital signs were: 115 115/70 18
95% on AC 50% PEEP 5 TV of 0.3.
Review of systems: (could not obtain)
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Mental retardation
tracheomalacia s/p tracheostomy
h/o aspiration pneumonia
diabetes mellitus
h/o C. difficile infection,
glaucoma
hypertension
HLD
osteoarthritis
depression/anxiety,
constipation
psychosis
.
PAST SURGICAL HISTORY:
Tracheostomy and PEG [**2107**],
R total knee replacement
R hip replacement
Right common iliac artery stent placement and right external
iliac recanalization with stent placement x2. [**1-/2111**]
Social History:
lives at [**Hospital **] Nursing Home in [**Hospital1 **], MA.
Father and Brother are [**Name2 (NI) **]-guardians
Family History:
unable to obtain
Physical Exam:
Admission Exam:
Vitals: 115 115/70 18 95%
General: arousable, responds to simple commands by nodding her
head
HEENT: Sclera anicteric, mucous membrane dry
Neck: supple, JVP difficult to appreciate [**1-14**] obesity, but does
not appear elevated
Lungs: anterior lung field, diffused expiratory wheeze,
diminished air movement, no rhonchi or crackles
CV: tachycardic, difficult to appreciate any murmur, rub, or
gallops [**1-14**] breath sounds
Abdomen: large well healed scar in the RUQ. soft, non-tender,
non-distended, obese, bowel sounds present, no guarding, no
organomegaly. G-tube in place
GU: foley, clear yellow urine
Ext: warm. Distal pulses (DP and PT) non-palpable but
dopplarable. black 3rd digit of right foot, non tender, non
erythematous appearing.
Pertinent Results:
Labs on Admission:
[**2111-11-9**] 11:00AM BLOOD WBC-24.3*# RBC-3.78*# Hgb-11.1*
Hct-34.0*# MCV-90 MCH-29.4 MCHC-32.6 RDW-15.7* Plt Ct-251
[**2111-11-9**] 11:00AM BLOOD Glucose-88 UreaN-15 Creat-1.0 Na-137
K-3.5 Cl-96 HCO3-35* AnGap-10
[**2111-11-9**] 11:26AM BLOOD Type-ART Rates-/14 Tidal V-350 PEEP-5
FiO2-100 pO2-218* pCO2-53* pH-7.40 calTCO2-34* Base XS-6
AADO2-448 REQ O2-76 -ASSIST/CON
[**2111-11-9**] 11:12AM BLOOD Lactate-2.1*
.
Labs on Discharge:
[**2111-11-12**] 04:29AM BLOOD WBC-8.6 RBC-2.92* Hgb-8.8* Hct-27.3*
MCV-94 MCH-30.0 MCHC-32.1 RDW-15.4 Plt Ct-148*
[**2111-11-12**] 04:29AM BLOOD Glucose-136* UreaN-16 Creat-0.9 Na-142
K-4.5 Cl-105 HCO3-36* AnGap-6*
[**2111-11-12**] 04:29AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.4
.
Micro:
[**11-9**]: Blood Culture, Routine (Preliminary):
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
Aerobic Bottle Gram Stain (Final [**2111-11-10**]):
GRAM NEGATIVE ROD(S).
.
CXR: [**11-9**]:
IMPRESSION: Increased bronchovascular markings could reflect
bronchitis. No lobar consolidation.
.
Brief Hospital Course:
53 year old lady with tracheomalacia s/p tracheostomy, mental
retardation, DM, HTN, peripheral vascular disease who presents
with increased tracheal secretions, fever to 103 and dyspnea.
.
# Dyspnea/Increased Secretions: Etiology of increased
dyspnea/secretions w/ associated leukocytosis, fever and
increased rr meeting SIRS criteria concerning for infectious
etiology. Growing GNRs which was found to be pan sensitive e.
coli. Improved ventilatory status; tolerating trach mask, with
some short requirements for pressure support. Initial antibiotic
regime of vancomycin/ zosyn/ tobra was stopped and po
ciprofloxacin was started (14 day course). Albuterol/ipratropium
nebs q4hrs were started for wheezing.
.
# GNR bacteremia: Patient meets SIRS criteria with leukocytosis,
fever, and increased respiratory rate to 36. Likely etiology of
inflammatory reaction was pulmonary given increased secretions
and dyspnea. Urinary and stool etiologies also possible, h/o
pansensitive ecoli infx in [**Month (only) **] w/ similar pyuria. H/o cdiff in
past. Dry gangrene on toes look stable to improved. No evidence
of decubs on skin exam.
E. coli X 2 grew from blood smaples drawn in the ED and the pt
was started on cipro.
.
# Tracheomalacia s/p Tracheostomy: Patient is trach dependent
given the severity of her tracheomalacia and requires trach
changes every 6 months for the rest of her life. She was s/p
emergent intubation with a size #5 ETT last [**Month (only) 956**]. She
currently has a #7 portechs. Trach was changed by pulmonary
fellow/RT on the floor.
.
# Diabetes: Insulin dependant diabetes melitus. She was
hyperglycemic this AM to 500 likely in setting of infection. S/p
10 units insulin sliding scale w/ improvement to 160 in ED.
Continued insulin sliding scale, lantus qHS 56 units and NPH 4
units qAM.
.
# Mental Retardation/Psychosis: Continued home anti-psychotics:
seroquel and valproic acid.
.
# Hypothyroidism: continued levothyroxine.
.
# Vascular Disease/: Patient had bilateral iliac stents placed
by Vascular in 2/[**2110**]. Chronic issue.
.
# Peripheral Dry Gangrene: Stable to improved from review of
prior notes. Non tender or erythematous to suggest source of
infection.
.
#Transitional Issues:
- Please continue ciprofloxacin through [**11-23**]
- Trach changed on [**2111-11-12**]
.
Medications on Admission:
1 aspirin 325 mg Tablet daily
3 cholecalciferol (vitamin D3) 400 unit Tablet daily
4 valproic acid (as sodium salt) 250 mg/5 mL Syrup 750mg qHS,
500mg qAM
6 quetiapine 250mg tid
7 levothyroxine 25 units qDaily
8 fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day.
9 calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension 5mL
daily
10 Lantus 100 unit/mL Solution Sig: Fifty Six (56) units SC qHS
11 Insulin NPH 100unit/mL, 4 units sc qAM.
12 Insulin Humun regular 100units/mL 1 dose SC as directed per
ISS
13 levothyroxine 25 units qDaily
14 lactobacillus acidophilus 100 million cell Capsule Sig: daily
15 acetaminophen 650 mg q4hrs prn
16 guaifenacin prn congestion
17 Milk if mag prn constipation
18 multivitamin dily
19 loperimide prn
20 lorazepam 1mg q6hrs for anxiety
21 Lanotprost 0.05% opth 1 drop qAM both eyes
22 Albuterol 0.083 neb q8hrs as needed for congestion
23 artificial tears [**Hospital1 **] prn
24 biacodyl per rectum prn
25 fleets per recutum prn
26 ipratropium nebs 0.02% inh every 8 hrs prn wheeze
Discharge Medications:
1 aspirin 325 mg Tablet daily
3 cholecalciferol (vitamin D3) 400 unit Tablet daily
4 valproic acid (as sodium salt) 250 mg/5 mL Syrup 750mg qHS,
500mg qAM
6 quetiapine 250mg tid
7 levothyroxine 25 units qDaily
8 fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day.
9 calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension 5mL
daily
10 Lantus 100 unit/mL Solution Sig: Fifty Six (56) units SC qHS
11 Insulin NPH 100unit/mL, 4 units sc qAM.
12 Insulin Humun regular 100units/mL 1 dose SC as directed per
ISS
13 levothyroxine 25 units qDaily
14 lactobacillus acidophilus 100 million cell Capsule Sig: daily
15 acetaminophen 650 mg q4hrs prn
16 guaifenacin prn congestion
17 Milk if mag prn constipation
18 multivitamin dily
19 loperimide prn
20 lorazepam 1mg q6hrs for anxiety
21 Lanotprost 0.05% opth 1 drop qAM both eyes
22 Albuterol 0.083 neb q8hrs as needed for congestion
23 artificial tears [**Hospital1 **] prn
24 biacodyl per rectum prn
25 fleets per recutum prn
26 ipratropium nebs 0.02% inh every 8 hrs prn wheeze
27 Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 14 Days Order
date: [**11-11**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
E. Coli Bacteremia
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Name14 (STitle) 69893**] was admitted for increased secretions and
respiratory distress. She was found to have e. coli bacteremia
and was started on PO cipro to complete a total 14 day course
(through [**11-23**]). Her trach was changed on [**2111-11-12**].
Followup Instructions:
- Please ensure completion of course of ciprofloxacin through
[**11-23**].
|
[
"440.24",
"244.9",
"443.9",
"V43.65",
"V55.0",
"276.2",
"319",
"519.19",
"250.00",
"V44.1",
"518.81",
"507.0",
"995.92",
"V43.64",
"401.9",
"272.4",
"038.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11420, 11495
|
6890, 9090
|
335, 363
|
11568, 11568
|
4999, 5004
|
12035, 12113
|
4177, 4195
|
10284, 11397
|
11516, 11547
|
9228, 10261
|
11746, 12012
|
3830, 4029
|
4210, 4980
|
5796, 6867
|
9111, 9202
|
3111, 3577
|
266, 297
|
5456, 5752
|
391, 3091
|
5018, 5437
|
11583, 11722
|
3599, 3807
|
4045, 4161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
854
| 176,032
|
21806+57264
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-10-27**] Discharge Date: [**2140-10-31**]
Date of Birth: [**2079-6-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transient speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 57230**] is a 61 year old male with a history of HTN,
CAD-s/p angioplasty x2, TIA (x2 in [**2130**] and [**2135**]), high
cholesterol, paroxysmal Afib, and hx of PFO and Atrial septal
aneurysm with both right to left and left to right shunts (on
Coumadin) who was transfered from an outside hospital for
evaluation of intracranial hemorrhage.
He was in his USOH until Wednesday evening ([**10-26**]) at 7:15 when
he had an acute onset of speech difficulty. He was having a
conversation with his wife, when he noticed that he "couldn't
get his words out". According to his wife, he was making sounds
(some words and some nonsense), but not saying complete phrases.
He was responding inappropriately to questions (i.e. saying
"no" when he meant to say "yes"), but appeared to understand
what was being said to him. He was aware of his deficit and
frustrated by his inability to communicate. He denies
associated numbness, weakness, dysarthria, visual deficits or
swallowing problems. [**Name (NI) **] did not have CP, palpitations, or
dizziness prior to this episode. His wife called EMS. He was
at the OH ER in about 30 minutes by which time his symptoms had
resolved. He had a head CT there which showed 2.5 cm left
temporal hemorrhage. He was then transferred here for further
management.
On arrival to the [**Hospital1 18**] ER, his BP was 220/98 and his speech
was normal. Then, around 3:00AM he had another episode of
language problems which lasted for a minute or so, then
spontaneously resolved. He has been asymptomatic since. He was
started on nipride in the ER for BP control. He developed a
headache and chest pain (right sided, radiating to neck). This
resolved with BP was better controlled.
He has had similar episodes of language problems in the past.
The first episode was in [**2130**] when he had an episode of slurred
speech and mild right facial droop. He had a second episode of
"inability to talk" in 8/[**2135**]. He was found to have "aphasia"
and mild right hemiparesis at that time. He had a head CT which
was negative and echo which showed PFO and atrial septal
aneurysm. He was started on coumadin at that time.
Past Medical History:
1. CAD, s/p PTCA in [**2115**] (s/p angioplasty x2)
2. HTN (historically difficult to control)
3. Hypercholesterolemia
4. TIA (x 2)
5. Paroxysmal Afib
6. PFO with ASD on echo with right to left and left to right
shunts
Social History:
Lives with his wife. His is a high school buisness and
government teacher. He has a 20 year old son who is in college.
He denies smoking, EtOH or drugs
Family History:
Uncle: Died of MI in 70's
Father: Leukemia, MI at age 65
Uncle: Died of MI in 40's
Physical Exam:
T 97 ; BP 220/98 (decreased to sbp 170s initially with
nipride); HR 76; RR 18; O2 sat 96% RA
gen - no acute distress. appears comfortable.
heent - mmm. o/p clear. no scleral icterus or injection.
neck - supple. no lad or carotid bruits appreciated.
lungs - cta bilaterally
heart - rrr, nl s1/s2, +sm
abd - soft, nt/nd, nabs
ext - warm, 2+ peripheral pulses throughout. no edema.
neurologic:
MS: Alert and Oriented x3. Cooperative with exam. Able to say
[**Doctor Last Name 1841**]
backwards. Registration intact to [**2-24**] objects at 30seconds,
recall intact to [**2-24**] objects at 5 minutes. Repitition and Naming
intact. Speech fluent without paraphasic errors or hesitancy.
Follows commands well. Able to relate coherent and detailed HPI.
CN: PERRL. EOMs intact without nystagmus. Fundi normal with
sharp
disc margins. Visual fields full to confrontation. Facial
sensation and movement intact bilaterally. Hearing intact to
finger rub. Tongue protrudes midline without fasiculations.
Sternocleidomastoids intact bilaterally. Shoulder shrug intact
bilaterally.
Motor: Normal bulk and tone throughout. No fasiculations. No
pronator drift.
B T D WE WF FF FE IP Hams. Quad AT G [**Last Name (un) 938**]
R 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5
Reflexes: symmetric throughout. toes
Sensation:
Intact bilaterally to light touch, temperature, pinprick and
vibration in all extremities.
Coordination:
[**Last Name (LF) 43945**], [**First Name3 (LF) **], and FFM intact bilaterally
Gait: deferred
Pertinent Results:
[**2140-10-28**] 03:00AM BLOOD WBC-13.9* RBC-3.94* Hgb-11.5* Hct-33.5*
MCV-85 MCH-29.1 MCHC-34.2 RDW-15.0 Plt Ct-211
[**2140-10-27**] 02:00AM BLOOD WBC-10.7 RBC-4.95 Hgb-14.6 Hct-41.4
MCV-84 MCH-29.5 MCHC-35.2* RDW-14.7 Plt Ct-242
[**2140-10-27**] 02:00AM BLOOD Neuts-83.4* Lymphs-12.4* Monos-3.1
Eos-0.4 Baso-0.7
[**2140-10-28**] 07:00PM BLOOD PT-14.4* PTT-23.4 INR(PT)-1.3
[**2140-10-28**] 03:34PM BLOOD K-3.5
[**2140-10-27**] 02:00AM BLOOD Glucose-141* UreaN-14 Creat-1.0 Na-143
K-3.4 Cl-103 HCO3-28 AnGap-15
[**2140-10-27**] 05:27PM BLOOD CK-MB-4 cTropnT-<0.01
[**2140-10-27**] 11:25AM BLOOD CK-MB-4 cTropnT-<0.01
[**2140-10-27**] 02:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2140-10-27**] 02:00AM BLOOD CK(CPK)-161
[**2140-10-28**] 03:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
[**2140-10-28**] 03:45AM BLOOD Type-ART pH-7.40
Brief Hospital Course:
He was admitted to the neuro-ICU for close observation and blood
pressure control, he was initially on a nipride drip which was
changed to a labetalol drip for blood pressure control. All
antiplatelet agents were held and his INR was reversed. He was
started on dilantin for seizure prophylaxis. He had an MRI/MRA
with gadolinium to evaluate the extent of the bleed and to
assess for vascular malformation or underlying mass. The MR
showed:
1. MRI of the brain demonstrates an acute left lateral temporal
lobe hematoma with mild surrounding edema, as seen on the CT
scan of earlier in the day. There is no enhancement in this
location. There are numerous small foci of susceptibility
artefact within the brain, likely representing hemorrhages from
amyloid angiopathy or hypertension. Thus, the new hemorrhage may
be of the same etiology.
2. There is no abnormal vascularity detected on MR angiography
and there is flow in the major branches of this circulation.
He had a repeat head CT on [**10-27**] which showed no progression of
the bleed. He remained neurologically intact and did not have
another episode of aphasia during his admission.
On hospital day #2, his blood pressure medications were
transitioned to oral meds and his blood pressure remained
resonably well controlled although he required several doses of
IV metoprolol to maintain SBP<140. An cardiac ehco was
performed on [**10-28**]. The echo showed:
1. The left atrium is moderately dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall
left ventricular systolic function is difficult to assess but is
probably
normal (LVEF>55%).
He was transfered to the neurology floor on [**10-28**] where his
neurologic exam remained unchanged. His anti-hypertensives were
increased to improve BP control.
FOLLOW UP PLANS;
He will be discharged with follow up with his PCP next week. He
will resume taking an aspirin (325mg) next week. He will have a
repeat head CT in 6 weeks (on [**2140-12-28**]) and should follow
up with Dr. [**Last Name (STitle) **] the following week ([**2141-1-3**]). At
his follow up visit, we will consider the option of re-starting
Coumadin (perhaps low dose to maintain INR between 1.5-2.5). We
will also consider whether he may be a candidate for a PFO
closure procedure at that time.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Intracranial hemorrhage
2. Amyloid Angiopathy
3. Hypertension
Discharge Condition:
Improved-no neurologic deficit
Discharge Instructions:
Please continue to take your medications as directed. In one
week, you should start to take a regular aspirin (325mg). You
should NOT take coumadin. You may stop taking dilantin (for
seizure prevention) in two weeks. You should have a repeat CT
scan of the head in six weeeks (see appointments below).
If you experience difficulty with speech, visual problems,
numbness, weakness, dizziness, or increased headache, please
come to the emergency room for evaluation.
Followup Instructions:
1. Follow up with your primary care doctor next week. Please
have your blood pressure monitored. Your systolic blood
pressure should be maintained under 140. Please have your
dilantin level checked (goal level [**10-7**]).
2. CT SCAN: [**Hospital6 29**] RADIOLOGY ([**Location (un) **])
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-12-28**] 10:45
3. Follow up with Dr. [**Last Name (STitle) **] in [**2141-1-3**] at 2:30PM.
([**Telephone/Fax (1) 7394**]. [**Hospital Ward Name 23**] building [**Location (un) 858**].
3. [**Hospital **] Clinic: [**Last Name (LF) **],[**First Name3 (LF) **] Where: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) NUTRITION Phone:[**Telephone/Fax (1) 3681**]
Date/Time:[**2141-1-11**] 10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Name: [**Known lastname 10656**],[**Known firstname 657**] Unit No: [**Numeric Identifier 10657**]
Admission Date: [**2140-10-27**] Discharge Date: [**2140-10-31**]
Date of Birth: [**2079-6-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 608**]
Chief Complaint:
see previous
Major Surgical or Invasive Procedure:
see previoius
Physical Exam:
Pt weighs 283 lbs!!!Make sure he is losing weight at follow up
visit!
Brief Hospital Course:
See previous
Discharge Disposition:
Home
Discharge Diagnosis:
See previous
Discharge Condition:
See previous
Discharge Instructions:
See previous
Followup Instructions:
See previous
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]
Completed by:[**2140-10-31**]
|
[
"401.9",
"427.31",
"431",
"459.9",
"V45.82",
"277.3",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11434, 11440
|
11397, 11411
|
11273, 11288
|
11496, 11510
|
4735, 5557
|
11571, 11707
|
2999, 3085
|
8001, 9257
|
11461, 11475
|
11534, 11548
|
11303, 11374
|
11221, 11235
|
381, 2568
|
2590, 2811
|
2827, 2983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,485
| 187,828
|
54875
|
Discharge summary
|
report
|
Admission Date: [**2109-7-7**] Discharge Date: [**2109-7-14**]
Date of Birth: [**2059-12-6**] Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
1. Irrigation and debridement of open fractures to left
index, middle, ring and small fingers.
2. Ablation of small finger germinal matrix.
3. Placement of a V.A.C. sponge.
4. IF filet turnover flap, MF & RF amp revisions/closure and
STSG (from left thigh) to dorsal hand.
History of Present Illness:
49 w/ h/o IVDU, HCV who is s/p high speed MVC rollover. She was
found in the passenger seat, no LOC but was lethargic on arrival
to an OSH. She was given narcan with neurological reponse and
had a GCS of 9T. She had a degloving injury of the L hand.
Past Medical History:
HCV, hypothyroidism, drug abuse, depression, anxiety
and ADD.
Social History:
IVDU
Family History:
unable to confirm
Physical Exam:
Obtained from anesthesia record of [**2109-7-9**]
Gen: intubated/sedated
CV: RRR
Resp: CTAB
Abd: nondistended
MSK: L arm bandaged
Pertinent Results:
[**2109-7-7**] 10:05PM WBC-10.7 RBC-3.04* HGB-9.5* HCT-29.3* MCV-96
MCH-31.3 MCHC-32.5 RDW-14.1
[**2109-7-7**] 11:11PM GLUCOSE-98 LACTATE-0.4* NA+-136 K+-3.0*
CL--112*
Brief Hospital Course:
She was transferred to the TSICU for close monitoring. She was
intubated and sedated. She was kept NPO. She went to the OR with
hand surgery service on [**7-9**] for I&D left hand, loose closure of
fingers, VAC to dorsum of hand and index finger. splint. A nerve
block catheter with Ropivacaine was inserted and used until
[**7-13**]. She was transfered from acute care surgery to our service
on [**7-10**]. On [**7-11**] her medication list was able to be obtained
from her pharmacy and her home meds were started. On [**7-12**] the
patient returned to the OR for IF filet turnover flap, MF & RF
amp revisions/closure and STSG (from left thigh) to dorsal hand.
On [**7-13**] the nerve block infusion was stopped and she was put on
PO pain medications. She was started on a regimine recommended
by pain service: oxycontin 20mg [**Hospital1 **], oxycodone 10q3 prn, tylenol
650 q6 staggered with motrin 600 q3. Increase gabapentin to 600
TID. The nerve block catheter was removed on [**2109-7-14**].
Medications on Admission:
Unknown on admission.
Discharge Medications:
1. cefaDROXil *NF* 500 mg Oral [**Hospital1 **] Duration: 7 Days
RX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
2. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
Monitor for resp. depression.
RX *oxycodone 10 mg 1 tablet(s) by mouth every three (3) hours
Disp #*80 Tablet Refills:*0
3. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*20 Tablet Refills:*0
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Ibuprofen 600 mg PO Q6H
Standing order. Stagger with tylenol
RX *ibuprofen 600 mg 1 tablet(s) by mouth every three (3) hours
Disp #*60 Tablet Refills:*0
7. Fluoxetine 80 mg PO DAILY
8. Clonazepam 0.5 mg PO TID anxiety/insomnia
may give 1 mg QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Crush avulsion injury to left hand
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Followup Instructions:
-You should continue taking the antibiotics as prescribed.
-Elevate your left arm as much as possible and maintain it in a
splint.
-Please keep your left arm dry
- If your left arm begins to worsen after discharge home with an
acute increase in swelling or pain, please call the Hand Clinic
at the number given and ask to speak with a doctor.
- Keep your left leg skin donor site open to air.
.
Medications:
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so
make sure that your Tylenol intake does NOT exceed 4 grams/day.
* Take prescription pain medications for pain not relieved by
tylenol.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication to prevent constipation. You may
use a different over-the-counter stool softener if you wish.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
Followup Instructions:
Hand Clinic: ([**Telephone/Fax (1) 2007**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) 1385**]
Please follow up in the Hand Clinic on Tuesday, [**2109-7-16**].
You must call ([**Telephone/Fax (1) 2007**] to make an appointment. The clinic
is open from 8-12pm most Tuesdays. The clinic is located on the
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please make sure that
you obtain a referral from your insurance company prior to your
clinic appointment.
|
[
"314.00",
"311",
"V12.09",
"816.13",
"244.9",
"300.00",
"E816.0",
"927.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"82.29",
"86.62",
"86.73",
"79.64",
"84.01",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3345, 3351
|
1373, 2381
|
311, 590
|
3430, 3430
|
1177, 1350
|
5301, 5846
|
992, 1011
|
2453, 3322
|
3372, 3409
|
2407, 2430
|
3581, 3581
|
1026, 1158
|
264, 273
|
618, 869
|
3445, 3557
|
891, 954
|
970, 976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,510
| 166,466
|
6640
|
Discharge summary
|
report
|
Admission Date: [**2196-6-26**] Discharge Date: [**2196-6-29**]
Date of Birth: [**2150-1-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
Arterial line
Endotracheal intubation
History of Present Illness:
46M h/o DM1, ESRD, polysubstance abuse found down at home lying
in bed for unclear duration. Last seen the evening prior; he had
been complaining of chills, fatigue, and anorexia for a few days
per his wife. Upon arrival of EMS, patient asystolic and
received epi/atropine with return of VF followed by 200J shock
into PEA; after further epi/atropine (4 rounds total) return of
sinus tach. He was brought to OSH where he was intubated, after
which he became hypotensive and was started on dopamine. Med
flighted to [**Hospital1 18**] for further care.
.
In the ED, his vitals were T 93.2 HR 90s BP 118/75 SaO2 100%. He
was weaned off dopamine. Noted to have fixed dilated pupils and
an abscence of corenal reflexes. Hypokalemic to 2.9. Tox screen
positive for cocaine.
Past Medical History:
DM1 c/b nephropathy, neuropathy
Gastroparesis
ESRD on HD (TueThuSat at the [**Hospital 12074**] [**Hospital **] Clinic)
Severe GERD with h/o upper GI bleed
h/o nephrotic syndrome and IgA nephropathy
PVD
Osteomyelitis
Hypothyroidism
CAD s/p non-ST elevation MI ([**1-26**])
CHF (EF 50%)
Anemia of chronic disease
Polysubstance abuse (crack cocaine, EtOH)
Social History:
He is on disability and lives with his brother. Married, wife
and children live in [**Name (NI) **]. He is a chronic smoker. There is
a prior history of other substance abuse (crack cocaine,
alcoholism).
Family History:
His mother had an MI at the age of 54, and his father has
diabetes.
Physical Exam:
T undetectable HR 85 BP 139/77 RR 13 SaO2 100% on
AC/1.0/450/20/5
General: intubated, cachectic
HEENT: pupils fixed/dilated, rapid horizontal and vertical eye
movements, anicteric, frothing mouth
Neck: supple, trachea midline
Cardiac: RRR, s1s2 normal, 2/6 SEM
Pulmonary: Coarse breath sounds bilaterally
Abdomen: soft, nondistended, flat, +BS
Extremities: warm, 2+ DP?PT pulses, no edema
Neuro: Unresponsive to voice or pain, flaccid extremities, no
apparent gag, toes mute, unable to illicit DTRs
Pertinent Results:
[**2196-6-26**] 03:45PM BLOOD WBC-12.4* RBC-4.26* Hgb-14.2 Hct-41.3
MCV-97 MCH-33.4* MCHC-34.5# RDW-16.7* Plt Ct-145*
[**2196-6-29**] 04:17AM BLOOD WBC-11.8* RBC-3.44* Hgb-11.3* Hct-33.8*
MCV-98 MCH-32.8* MCHC-33.3 RDW-16.7* Plt Ct-131*
[**2196-6-26**] 03:45PM BLOOD Neuts-95.0* Bands-0 Lymphs-1.8* Monos-2.5
Eos-0.4 Baso-0.3
[**2196-6-26**] 03:45PM BLOOD PT-15.6* PTT-28.6 INR(PT)-1.4*
[**2196-6-29**] 04:17AM BLOOD PT-18.6* PTT-37.1* INR(PT)-1.8*
[**2196-6-26**] 03:45PM BLOOD Glucose-192* UreaN-20 Creat-3.0* Na-138
K-2.9* Cl-98 HCO3-29 AnGap-14
[**2196-6-29**] 04:17AM BLOOD Glucose-95 UreaN-67* Creat-4.9* Na-145
K-4.5 Cl-104 HCO3-25 AnGap-21*
[**2196-6-26**] 03:45PM BLOOD ALT-24 AST-76* CK(CPK)-2462* AlkPhos-105
Amylase-316* TotBili-0.8
[**2196-6-27**] 04:55AM BLOOD ALT-34 AST-121* LD(LDH)-464*
CK(CPK)-3748* AlkPhos-93 Amylase-973* TotBili-0.4
[**2196-6-28**] 03:06AM BLOOD ALT-30 AST-67* LD(LDH)-427* CK(CPK)-1429*
AlkPhos-96 Amylase-1044* TotBili-0.6
[**2196-6-29**] 04:17AM BLOOD CK(CPK)-727*
[**2196-6-26**] 03:45PM BLOOD Lipase-15
[**2196-6-27**] 04:55AM BLOOD Lipase-9
[**2196-6-28**] 03:06AM BLOOD Lipase-10
[**2196-6-26**] 03:45PM BLOOD CK-MB-37* MB Indx-1.5 cTropnT-0.41*
[**2196-6-27**] 04:55AM BLOOD CK-MB-46* MB Indx-1.2 cTropnT-0.52*
[**2196-6-28**] 03:06AM BLOOD CK-MB-20* MB Indx-1.4 cTropnT-0.39*
[**2196-6-27**] 04:55AM BLOOD Albumin-2.8* Calcium-7.1* Phos-4.5 Mg-1.7
[**2196-6-28**] 03:06AM BLOOD Albumin-2.9* Calcium-7.3* Phos-5.6*
Mg-1.8
[**2196-6-27**] 04:55AM BLOOD Phenyto-16.0
[**2196-6-28**] 03:06AM BLOOD Phenyto-10.1
[**2196-6-26**] 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-6-26**] 09:52PM BLOOD Type-ART Rates-26/0 Tidal V-450 PEEP-5
FiO2-60 pO2-86 pCO2-42 pH-7.50* calTCO2-34* Base XS-7
Intubat-INTUBATED Vent-CONTROLLED
[**2196-6-26**] 09:52PM BLOOD Lactate-1.2
[**2196-6-28**] 09:11PM BLOOD Lactate-1.1
[**2196-6-29**] 04:50AM BLOOD Lactate-1.4
.
ECG: sinus, 98bpm, normal axis, TWI II/III/aVF
.
CXR: Detail limited secondary to obscuration by overlying trauma
board. Endotracheal tube in good position. NG tube probably in
good position as well. No evidence of acute cardiopulmonary
disease.
.
CT head: Global loss of [**Doctor Last Name 352**]-white differentiation in bilateral
cerebral hemispheres with diffuse hypodense appearance, most
likely representing cerebral edema in this patient with cardiac
arrest. No acute intracranial hemorrhage.
Brief Hospital Course:
46M h/o DM1, ESRD found unresponsive at home in asystole.
.
# s/p cardiac arrest: Found down in asystole for unclear
duration. Unclear cause, but differential included arrythmia,
infection, MI, PE, arrythmia. Cardiac enzymes were elevated but
as the patient did receive shocks in the field this was a more
likely explanation. Tox screen was positive for cocaine so an
arrythmogenic or ischemic event may have been precipitated by
substance abuse [**1-22**] vasospasm. Based on exam and CT head, there
was likely significant anoxic brain injury (see below). Labs
were notable for post-arrest hypokalemia which suggested the
possible presence of a significant hypokalemia post-HD. He was
continued on ASA, but beta-blockers were held given recent
hypotension, arrest, cocaine use. Echocardiogram revealed global
HK likely due to stunning [**1-22**] arrest but no vegetations.
Infectious sources were treated (see below). Hypothermia was not
performed given the prolonged duration prior to presentation
(unclear duration down, first presented to OSH then med-flight
to [**Hospital1 18**] prior to our evaluation).
.
# Respiratory failure: [**1-22**] arrest. No acute process on CXR
initially but then developed left-sided infiltrate likely due to
aspiration event peri-arrest. He was started on levo/flayl for
CAP. Trials of PSV were attempted but unsuccessful.
.
# ?Seizures: Noted to have rhythmic eye and face/upper extremity
movements at presentation. Initially dilantin loaded but then
dilantin stopped per neuro as EEG without cortical seizure
activity.
.
# ID: Infiltrate on CXR likely aspiration and treated with
levoflox/flagyl. Also with 5/6 bottles positive for GPC in
clusters and started on vancomycin; source may have been HD
line. Mildly elevated WBC count but afebrile.
.
# Hypotension: Resolved. Likely [**1-22**] sedatives and vagal
stimulation during intubation vs. sepsis. At present, off
dopamine gtt and maintaining good BPs but became hypotensive
again during dilantin loading that resolved with IV fluids.
.
# ESRD: HD held until goals of care established (see below).
Continued renagel. There was no acute HD need.
.
# DM1: Hypoglycemic initially, then improved. Continued HISS.
Held NPH for now.
.
# ?GI bleed: h/o severe esophagitis and upper GI bleeding.
Bright red blood noted return from OG tube but Hct remained
relatively stable.
.
# Anoxic brain injury: Loss of grey-white junction on CT head
and pronounced deficits on exam suggest significant injury.
Neurology was consulted and, after 72 hours without improvement,
delivered grim prognosis for any significant recovery. At family
meeting it was decided that to make the patient CMO based on his
wishes. The ETT was removed and the patient rapidly expired.
Medications on Admission:
ASA 81 daily
Trazodone 100 daily
Humulin N 7 units daily
HISS
Percocet prn
Imdur 60 daily
Lopressor 100 [**Hospital1 **]
Prilosec
Renagel 400 tid
Folate
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Anoxic brain injury
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"412",
"276.8",
"578.9",
"799.4",
"458.29",
"E854.3",
"996.62",
"507.0",
"305.1",
"995.92",
"970.8",
"518.81",
"250.61",
"414.01",
"357.2",
"250.41",
"427.5",
"427.41",
"443.9",
"V45.1",
"038.49",
"428.0",
"585.6",
"285.21",
"305.90",
"250.81",
"305.00",
"348.1",
"583.81",
"536.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"89.61",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7828, 7837
|
4856, 7596
|
333, 373
|
7916, 7926
|
2389, 4578
|
7979, 7987
|
1786, 1855
|
7799, 7805
|
7858, 7895
|
7622, 7776
|
7950, 7956
|
1870, 2370
|
275, 295
|
401, 1171
|
4587, 4833
|
1193, 1548
|
1564, 1770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,953
| 151,377
|
706
|
Discharge summary
|
report
|
Admission Date: [**2150-12-13**] Discharge Date: [**2150-12-19**]
Service: MEDICINE
Allergies:
Opioid Analgesics
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo F with known CAD s/p MI, baseline LBBB who presented with
chest pain, back pain starting at 10:45 am. "Chest ache and
across back" constant since that time, worst ([**8-28**])--> [**2156-1-21**].
Pain different than previous MI. Associated with + N/V, then
"many bowel movements". No SOB or diaphoresis. Given NTG by EMT
without change. Pain is pleuritic in nature. No
cough/dizzyness/lightheadedness/palpitations. + chills today.
Recent URI/bronchitis improving over last few weeks- has seen
Dr. [**Last Name (STitle) 5263**] in [**Company 191**] several times over last month. At baseline, pt
cannot walk a block before getting very SOB. In ED, given SL
NTG, started on NTG gtt, heparin gtt, MSO4.
Past Medical History:
CAD s/p MI ('[**40**]), s/o OM1 stent x2 ([**7-22**])
CHF (EF 35%), PCWP 25 on cath, 1+ MR
Echo [**7-22**]: basal/inf/lat AK, EF 35%
CRI (1.5)
Depression/anxiety
Osteoarthritis
h/o Pneumonia
Fe-def anemia
h/o breast CA
melanoma s/p excision
hyperlipidemia
SICCA ([**Doctor First Name **]+)
s/p TAH/BSO
s/p CCY
Social History:
No tobacco or EtOH. Lives alone in a home with stairs.
Family History:
Mother had an MI in her 50s
Physical Exam:
Tm 100.3 Tc 99.1 100/44 61 189 97RA
Lying in bed in nad
ctab
nl s1/2
soft, nt, nd, nabs
warm X 4
Pertinent Results:
VQ scan- low prob
CXR- clear
[**2150-12-13**] 11:47PM CK(CPK)-71
[**2150-12-13**] 11:47PM CK-MB-NotDone cTropnT-<0.01
[**2150-12-13**] 11:47PM PTT-102.6*
[**2150-12-13**] 03:35PM GLUCOSE-109* UREA N-30* CREAT-1.5* SODIUM-141
POTASSIUM-7.3* CHLORIDE-105 TOTAL CO2-27 ANION GAP-16
[**2150-12-13**] 05:02PM K+-4.1
[**2150-12-13**] 03:35PM CK(CPK)-170*
[**2150-12-13**] 03:35PM cTropnT-<0.01
[**2150-12-13**] 03:35PM CK-MB-3
[**2150-12-13**] 03:35PM WBC-10.5 RBC-3.20* HGB-10.5* HCT-31.2* MCV-98
MCH-33.0* MCHC-33.8 RDW-14.7
[**2150-12-13**] 03:35PM NEUTS-86.7* BANDS-0 LYMPHS-6.1* MONOS-4.9
EOS-2.0 BASOS-0.2
[**2150-12-13**] 03:35PM PLT COUNT-274
[**2150-12-13**] 03:35PM PT-12.9 PTT-20.4* INR(PT)-1.0
[**2150-12-13**] 03:35PM D-DIMER-1179*
Brief Hospital Course:
1. CHEST PAIN:
The patient was admitted to medicine and placed on heparin for
concern of both MI and PE. Her lasix was held as she appeared
clinically dry. The patient ruled out for MI by serial cardiac
ensymes. VQ was obtained the morning after admission and was
low probability. The patient's hematocrit as <29, so 1 unit of
blood was transfused. Echocardiography was obtained
demonstrating:
The left atrium is mildly dilated. Color Dopper is suggestive of
the presence of a left to right shunt across the interatrial
septum consistent with a probable atrial septal defect. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Resting regional wall motion
abnormalities include anteroseptal, apical and inferolateral
hypokinesis. Views are technically suboptimal for assessment of
regional wall motion. Estimated ejection fraction ?35-40%? No
apical thrombus identified but cannot exclude. Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
Compared with the report of the prior study (tape unavailable
for review) of [**2150-9-7**], tricuspid regurgitation is now more
prominent.
The patient had an p-MIBI done on [**12-16**] which showed:
No anginal symptoms with an uninterpretable ECG. Atrial
irritability as noted. Severe, fixed defects of the lateral and
inferolateral walls,
unchanged from the prior study. There is diffuse hypokinesis
with a calculated
left ventricular ejection fraction of 40%.
Given the abnormal p-MIBI, the patient underwent cardiac
catheterization [**12-17**].
The catheterization revealed a right dominant system with 1 VD -
a complex 60% stenosis involving the bifurcation of the proximal
LAD and D1 branch. The LMCA and RCA had mild luminal
irregularities, without flow limiting stenoses. Resting
hemodynamics revealed significantly elevated left and right
sided filling pressures. PA systolic pressure was markedly
elevated at 75 mmHg. Mean PCWP was elevated at 35 mmHg. Left
sided filling pressures were markedly elevated with LVEDP 30
mmHg. Central hypertension was noted with blood pressure 214/80
mmHg. Cardiac index was preserved at 2.3 L/min/m2 by Fick. After
administration of nitroprusside IV systolic blood pressure fell
to 120/60 mmHg and PA systolic pressures fell to 40 mmHg with a
mean PCWP 12 mmHg. Her swan was discontinued in the PACU, and
the patient was transferred to the CCU for one night
post-catheterization for closer blood pressure monitoring on her
nitroprusside drip.
ICU stay:
In the ICU she was started on Imdur 90 mg daily, and her
Trandolapril was increased to 4 mg [**Hospital1 **] rather than daily. She
was continued on Metoprolol 75 mg [**Hospital1 **] with good rate control.
On this regimen, the nitroprusside was able to be weaned off
within the first 4 hours of arrival to the CCU, with systolic
pressures maintained between 100 and 120 mmHg. She was given
lasix 20 mg x 1 on the evening of arrival in the CCU, as well as
being started on 40 mg PO daily the next morning secondary to
rales on physical exam and the history of elevated filling
pressures during catheterization.
She was able to be transferred back to the floors after 1 night
in the CCU.
On the general cardiac medical floor, the patient continued to
be monitored on telemetry with no events. She continued to
diurese and her weight was decreased to 77.9 kg from 80.7 kg on
admit. Her blood pressure remained stable between systolic blood
pressure of 120 to 155. Her Imdur was titrated up to 120 mg po
daily for improved control. With improved blood pressure
control, the patient experienced no further chest pain.
2. CONGESTIVE HEART FAILURE:
AS states above, in cath patient was felt to be volume
overloaded with elevated left sided filling pressures and rales
on exam. She was actively diuresed and dry weight on discharge
was 77.9 kg. She had trace LE edema on discharge and appeared
euvolemic. Patient was discharged on 40 mg po Lasix. She will
likely need to decrease back to 20 mg po Lasix daily after
several more days on increased dose.
3. MYALGIAS:
Her prednisone taper was continued for her myalgias of unclear
etiology. She is due to follow up with Rheumatology for further
work-up.
4. ANEMIA:
Patient has a history of iron deficiency anemia. Her hematocrit
was noted to trend down during hospital stay and stabilized
around 30. There was no evidence of active bleeding. stools were
reportedly guiac negative. Patient will have follow up CBC
checked by PCP.
5. CHRONIC RENAL INSUFFICIENCY:
Patient had elevated 1.6 on discharge, which was near baseline
1.4 to 1.5. Her creatinine should be rechecked at outpatient
follow up with PCP and Lasix decreased if creatinine rising.
6. DEPRESSION:
Celexa was continued for depression.
7. Prophylaxis:
PPI was continued. Pt was continued on docusate and senna for
bowel regimen.
8. Code:
The patient was full code throughout her stay.
9. DISPOSITION:
The patient was evaluated by physical therapy who felt patient
was safe for discharge home with home safety evaluation on
[**2150-12-19**]. The patient will need to call and schedule
follow up appointment with Dr. [**Last Name (STitle) 5263**] on Monday [**2150-12-21**] to have
BP check, CBC, creatinine, BUN, and potassium checked. Her Lasix
dose may need to be decreased back to 20 mg po daily.
Medications on Admission:
Albuterol
Atorvastatin 40mg QD
Celexa 40mg QD
Ecotrin 325 QD
Femara 2.5 QD
Flonase 50mcg QD
Floven 2 QD
Furosemide 20 QD
Mavik 4mg QD
NTG PRN
plavix 75mg QD
prednisone 1mg QD
Prevacid 30mg QD
Toprol 50mg
Trazadone 100 QD
Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day/Year **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO qd ().
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
7. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
10. Trandolapril 4 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*1*
12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed: If you have chest pain, take 1 tablet.
Can repeat every 5 minutes up to three doses. If pain continues
after 3, call your doctor.
[**Last Name (Titles) **]:*60 tablets* Refills:*2*
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
14. Flonase 50 mcg/Actuation Aerosol, Spray Sig: One (1) spray
Nasal once a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
[**Last Name (Titles) **]:*180 Tablet(s)* Refills:*2*
16. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
[**Last Name (Titles) **]:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
17. Outpatient Lab Work
Please draw CBC and have results sent to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] at
[**Company 191**] [**Telephone/Fax (1) 5264**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1) Atypical CP
2) Congestive Heart failure
3) Coronary artery disease, single vessel disease, s/p MI [**2140**]
4) Hypertension
5) h/o Breast Cancer
6) h/o melanoma s/p excision [**2145**]
7) Hyperlipidemia
8) Chronic Renal Insufficiency
9) Depression
Discharge Condition:
Good, chest pain free
Discharge Instructions:
1)Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
2)Please take your medications as directed.
3)Please attend your follow up appointments.
4)Please see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**], in within one week to get
your hematocrit checked.
5) If you develop recurrent chest pain, shortness of breath,
please call Dr. [**Last Name (STitle) 5263**] for immediate evaluation.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2150-12-30**]
7:45
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2150-12-30**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Where: [**Hospital6 29**] REHAB
SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2150-12-30**] 8:00
Call PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**] to schedule follow up appointment.
|
[
"V10.82",
"280.9",
"272.4",
"426.3",
"V10.3",
"311",
"V45.82",
"401.9",
"428.0",
"786.59",
"414.01",
"593.9",
"412",
"710.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"88.53",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10540, 10598
|
2370, 8174
|
246, 252
|
10894, 10917
|
1581, 2347
|
11429, 12028
|
1415, 1444
|
8445, 10517
|
10619, 10873
|
8200, 8422
|
10941, 11406
|
1459, 1562
|
196, 208
|
280, 988
|
1010, 1326
|
1342, 1399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,333
| 154,009
|
13153
|
Discharge summary
|
report
|
Admission Date: [**2196-6-9**] Discharge Date: [**2196-6-24**]
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: The patient is a 79-year old
female who is status post coronary artery bypass grafting
times three on [**2196-3-14**] - performed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] - with a left internal mammary artery to the left
anterior descending, a saphenous vein graft to the obtuse
marginal, and a saphenous vein graft to the right
posterolateral. Possibly, the patient started developing
abdominal pain. An exploratory laparotomy was performed
which was negative.
The patient was subsequently transferred to a rehabilitation
facility and then to [**Hospital1 69**] for
evaluation of her for a possible sternal nonunion. The
patient is on peritoneal dialysis for end-stage renal
disease; which was changed to hemodialysis after her
exploratory laparotomy and then back to peritoneal dialysis.
PAST MEDICAL HISTORY: This is a 79-year old female with a
past medical history significant for hypertension, insulin-
dependent diabetes mellitus, coronary artery disease, end-
stage renal disease, hypercholesterolemia, peripheral
vascular disease, gout, hypothyroidism, and a history of lung
nodules.
PAST SURGICAL HISTORY: The patient's past surgical history
is significant for coronary artery bypass grafting times
three, status post cholecystectomy, and status post bilateral
cataract surgery.
SUMMARY OF HOSPITAL COURSE: The patient was taken to the
operating room on [**2196-6-10**] for a sternal debridement and
bilateral pectoral advancement flaps. The patient was
transferred from the Operating Suite to the Cardiothoracic
Intensive Recovery Unit in stable condition on a Neo-
Synephrine drip. The patient was extubated while in the
Operating Room without event.
The patient was transfused one unit of packed red blood cells
on postoperative day four for a hematocrit of 28.9; which
brought her hematocrit up to 31.5. She continued to receive
peritoneal dialysis while inhaler and was transferred to the
floor on postoperative day four - hemodynamically stable, in
a sinus rhythm, and with good pain control.
The patient was continued on levofloxacin and vancomycin for
a white blood cell count of 16.3. Cultures were performed
which were sensitive to this antibiotic regimen.
On postoperative day eight, there was mild concern for the
patient's low blood pressure; which systolically ran in the
80s to 90s - for which they lowered the dose of metoprolol
and cut back on the peritoneal dialysis; however, with her
blood pressure still remained low.
The patient continued to progress well. She was
hemodynamically stable. She was in a sinus rhythm with her
systolic blood pressures running in the 100s. She was
afebrile. Her white blood cell count came down. She was
still on levofloxacin. The patient had continued
complications of mild left should pain - for which she was
treated with Vioxx and Tylenol as needed.
DISCHARGE DISPOSITION: The patient was stable condition for
discharge. Discharge planning for a rehabilitation facility
that accepted peritoneal dialysis in the works. The patient
later refused rehabilitation and preferred to be discharged
home with services.
NOTE: Full Discharge Summary to follow in a separate report.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 28488**]
MEDQUIST36
D: [**2196-6-24**] 10:26:39
T: [**2196-6-24**] 12:09:10
Job#: [**Job Number 40137**]
|
[
"443.9",
"E878.2",
"250.00",
"998.31",
"274.9",
"244.9",
"272.0",
"V45.81",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"83.82",
"54.98",
"77.61"
] |
icd9pcs
|
[
[
[]
]
] |
3037, 3612
|
1296, 1470
|
1499, 3013
|
139, 968
|
991, 1272
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,851
| 116,489
|
44435
|
Discharge summary
|
report
|
Admission Date: [**2103-4-11**] Discharge Date: [**2103-5-4**]
Date of Birth: [**2050-1-17**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Tracheostomy and GJ feeding tube placements
Total abdominal colectomy with end ileostomy ([**2103-5-3**])
History of Present Illness:
52 yo female with history of [**Location (un) 805**] Syndrome, atrial
fibrillation, CHF (? diastolic, last EF 70%), history of MVR s/p
valvuloplasty [**2100**], recent recurrent PNAs (last [**1-12**] w/MSSA PNA
s/p intubation), and severe COPD, who presents with shortness of
breath. Has had body aches for the last 2 days. She reports
increased SOB, but denies cough, sputum, fever, chills,
abdominal pain, nausea, vomitting, diarrhea, or dysuria.
Normally, she is on oxygen at rehab on [**1-4**] LNC. Because of the
shortness of breath and fever, she was sent to the ED.
.
In the ED, the patient had the following vital signs: 98.6 120
92/60 18 97% NRB. She was noted to be in a fib with RVR with
rates up to the 140s, however, she was not rate controlled for
fear of patient being periseptic. The patient was given
levofloxacin 750mg IV ONCE, ceftriaxone 1gm IV ONCE. The patient
was given 2L of NS thinking she was tachycardic from
dehydration. She was also given combivent, and morphine 2mg IV x
2 and tylenol 1gm PO ONCE for body pain and dyspnea. Last set of
vitals were: 98.1 131 106/61 22 90%5LNC.
.
In the MICU, she arrived in acute respiratory distress and
tachypneic with heart rate in the 130s in a fib with RVR, and
hypoxic to the 80s on 6LNC. She was given morphine 1mg IV x 2,
lasix 20mg IV x 1 (leading to 300cc of urine in [**1-4**] hrs), a
trial of bipap for 15 minutes with significant improvement in
her symptoms. She was also given 5mg and 10mg IV dilt for HR in
140s, followed by dilt 60mg PO QID with improvement in her rate
down to 110s.
Past Medical History:
PMH: [**Location (un) 805**] syndrome, developmental delay, steroid-induced
diabetes, afib with left atrial clot, diastolic CHF, COPD,
diverticulitis, MR, malnutrition
PSH: mitral valvuloplasty ([**2100**] - [**Hospital1 112**])
Social History:
She was at Bostonian [**Hospital1 1501**] after last discharge. Generally, lives
in [**Hospital1 **] with 2 brothers. [**Name (NI) **] brothers, no longer able to walk
or take care of ADLs; decline in last few months since recurrent
PNAs. Not working. Former smoker, smoked [**12-3**] PPD for 30 years,
quit 2 years ago. No EtOH or ilicit drugs.
Family History:
Coronary artery disease. No other congenital abnormalities in
the family
Physical Exam:
On admission:
GEN: Small, pale, woman with [**Last Name (un) **] facies, tachypneic, using
excessory muscles to breath
HEENT: Anisocoria (old), anicteric, dry MM, op without lesions,
mildly elevated jvd,
RESP: Bibasilar rales R>L, moderately reduced airflow, no
wheezes, positive egophony at right base
CV: Tachycardic, irregular, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3.
Pertinent Results:
[**2103-5-4**] 10:47AM BLOOD WBC-26.0* RBC-2.91* Hgb-7.6* Hct-25.2*
MCV-87 MCH-26.3* MCHC-30.3* RDW-19.5* Plt Ct-86*
[**2103-5-4**] 10:47AM BLOOD ALT-4019* AST-5755* LD(LDH)-PND
AlkPhos-57 TotBili-4.5*
[**2103-5-4**] 10:58AM BLOOD Type-ART pO2-81* pCO2-45 pH-7.11*
calTCO2-15* Base XS--15
[**2103-5-4**] 10:58AM BLOOD Lactate-14.6*
CXR [**4-11**]: COMPARISON: [**2103-2-22**].
FINDINGS: Frontal and lateral views of the chest are obtained.
Patient is
status post median sternotomy. The lungs are hyperinflated,
consistent with chronic obstructive pulmonary disease. Since the
prior study, there has been development of bibasilar, right
greater than left opacities, worrisome for pneumonia. There is
also blunting of the bilateral costophrenic angles concerning
for small pleural effusions with possible pleural thickening.
Cardiac and mediastinal silhouettes are stable. Minimal
superimposed pulmonary vascular congestion may also be present.
IMPRESSION:
1. Large right base opacity and possible small left base
opacity, worrisome for pneumonia. Possible small bilateral
pleural effusions and/or pleural thickening.
2. COPD.
.
CXR [**4-12**]: Comparison is made with prior study performed a day
earlier.
Cardiomegaly is stable. The lungs are hyperinflated consistent
with patient's known COPD. Pneumonic consolidations, right
greater than left are unchanged. There are no new lung
abnormalities. Probable small bilateral pleural effusions are
stable. There are no other interval changes.
.
CXR [**4-30**]:
A tracheostomy tube and left-sided PICC are in unchanged
positions.
Cardiomediastinal silhouette is stable. The lungs are stable in
appearance
with background emphysema, bilateral pleural effusions and
extensive
consolidations which are greater on the right.
.
EKG [**4-23**]:
Diffuse artifact. Probable atrial fibrillation with moderately
controlled
ventricular response. Low QRS amplitude in the limb leads. RSR'
pattern in
lead V1 is probably a normal variant. Compared to the previous
tracing
of [**2103-4-11**] the ventricular response is more controlled.
Non-specific ST-T wave changes persist.
.
ECHO [**4-23**]:
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
borderline normal free wall function. There is abnormal septal
motion/position. 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 or aortic regurgitation. The mitral valve leaflets are
mildly thickened. A mitral valve annuloplasty ring is present.
The mitral annular ring appears well seated with normal
gradient. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
Brief Hospital Course:
53 yo female with history of [**Location (un) 805**] Syndrome, atrial
fibrillation, CHF (? diastolic, last EF 70%), history of MVR,
recent recurrent PNAs, and severe COPD, who presents with
shortness of breath, leukocytosis, bandemia, and RLL infiltrate.
.
#Lactic acidosis: Patient developed abd pain and required
pressors overnight on [**5-3**]. Her lactate rose and her cdiff toxin
returned positive. WBC rose. She was started on pressors at
times maxed levofed and neo. Flaygl was started and surgery was
consulted and determined need for emergent OR for colectomy.
.
#. Dyspnea/hypoxia: Patient with a white count of 29 with
bandemia, and dense RLL consolidation, which raises the concern
for acute bacterial pneumonia. She has a history of MSSA but
also given her stay at a rehab facility, healthcare associated
pneumonia and hospital acquired pneumonia were also considered.
Also there was a component of acute pulmonary edema and COPD. PE
is unlikely given clear precipitant for dyspnea/hypoxia and that
patient has been therapeutic on coumadin. Patient treated with
Vanc/cefepime/levofloxacin given her recent hospitalization
within 90 days, her stay at rehab, and severity of illness as
well as MRSA positive in her Nares. She was put on standing
albuterol and ipratropium nebulizers and home dose of steroids.
Patient was diuresed with 20 IV lasix daily. Over the first 5
days of admission the patient required 60-80% high flow to
maintain sats in the 90s. Due to lack of clear improvement and
concern for increasing sputum, she had a bronch (awake) which
showed minimal secreations but significant airway collapse. BAL
fluid sent for culture and grew sparse coag + staph and spare
yeast. On [**4-19**], the patient desaturated throughout the morning
and on ABG was found to have pCO2 >80. She was intubated for
hypercarbic respiratory failure and afterwards, significant
secretions suctioned out. Her abx were stop and she was given a
bust of methylpred again with plans for long taper. It is
possible she mucus plugged or aspirated on her secretions in the
morning prior to being intubated. Of note, the patient's CT
chests document very little apical parenchymal reserve and
significant blebs. The patient tolerated mechanical ventilation
well and was switched from assist control to pressure support.
Spontaneous breathing trial on [**4-22**] was uneventful and patient
was extubated on [**2103-4-22**]. On [**4-23**], she was weaned down to 5 L
nasal cannula, but that same night, she developed an increasing
O2 requirement.Intermittantly she was having mucuous plugging.
All the while, discussions were held with the family about if
she needed reintubation that she would require trach. Acapella
devicse used to help with chest PT. Her steroids were down
titrated. On [**4-25**], the patient developed incrasing hypoxia and
was reintubated. WBC was noted to rise to 23.8 and abx were
restarted to cover VAP with Linezolid/tobra and zosyn.
Interventional pulmonology performed a tracheostomy on [**4-26**].
However, interventional pulmonology was unable to place a PEG
due to esophageal stenosis. She underwent IR placement of JG
tube on [**4-27**]. She was put on pressure support once trached which
she tolerated initially but would pull low tidal volumes and
needs resting at night or after oxycodone. Her prednisone was
down titrate. She tolerated 2 hours of trach collar on [**4-28**]. On
[**4-26**], she tolerated trach collar for many hours but became
hypercarbic to pCO2 of 57 and was put on the vent to let her
rest. Plan was initiated to use trach collar during the day and
vent at night. She completed 8 day course of zosyn on [**5-2**] and
will complete 10 day course of linezolid on [**5-4**].
- Continue linezolid 600mg twice daily until [**5-4**] (day [**9-10**])
- Continue albuterol nebs every 6 hours, ipratropium 6 puffs QID
and Flovent 6 puffs twice daily
.
#Fungal UTI: s/p 4 days of fluconazole with resolution of
symptoms.
.
# Nutrition: Patient with very poor PO intake during
hospitalization, albumin low at 2.9. Nutrition was consulted and
the patient started on TPN. [**Month (only) 116**] consider eventual esophageal
motility testing for CREST syndrome component to [**Location (un) 805**]
Disease. A Dobhoff was placed on [**2103-4-19**], with placement
confirmed by x-ray. Tube feeds were started on [**2103-4-19**] although
the Dobhoff then clogged. NGT was placed instead, which the
patient tolerated well and maintained during intubation. The
patient received tube feeds during this time. Interventional
pulmonology attempted to place a PEG on [**2103-4-26**] but was
unsuccessful due to esophageal stenosis. Tube feeds started
through G-J tube on [**4-27**].
- Continue tube feeds:
Nutren 2.0 Full strength;
Starting rate: 30 ml/hr; Advance rate by 10 ml q12h Goal rate:
30 ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 30 ml water q6h
- Continue multivitamin, Vitamin B12 50mcg daily and Vitamin D
400mg daily
- Continue lansoprazole, simethicone and zofran for GI upset,
nausea
.
#. Hypotension: Patient became hypotensive overnight on [**4-30**]
likely related to escalating doses of metoprolol amd small doses
of narcotics and ultram which she seems sensitive to. She
required levophed for a brief term. Cortisol levels could not be
checked in setting of recent prednisone. Her blood pressures
were monitored through her arterial line. BPs ranged from
hypotensive (thought [**1-3**] meds) to hypertensive (possibly pain
related) and normalized on their own.
- Continue home digoxin and metoprolol per below
- Limited narcotic medications for pain (oxycodone 2.5mg q8
hours if absolutely necessary). Use acetaminophen for pain.
.
#. Atrial fibrillation with RVR: Most likely precipitant is
infection, hypoxia, and dyspnea. Rate well controlled on PO
diltiazem and home digoxin - this was later decreased to 30mg
QID and her metoprolol decreased from 12.5 mg TID to [**Hospital1 **] given
bradycardia into HR50s (asymptomatic), especially when
intubated. Coumadin was held for supratherapeutic INR and the
patient started on lovenox bridge. Metoprolol was uptitrated
again briefly for BP and HR control, but subsequently was
downtitrated due to bradycardia. Diltiazem was stopped on
[**2103-4-26**]. She was bridged back to coumadin after her procedures.
Metoprolol was increased to 25 mg [**Hospital1 **] on [**4-29**] but held for
hypotension and then decreased to 12.5mg [**Hospital1 **].
- Continue Digoxin 0.125mg daily
- Continue Metoprolol 12.5mg twice daily
- Check INR daily as supratherapeutic on discharge. Resume home
coumadin 5mg daily when INR <2.5
.
#. History of dCHF: Patient with MVR s/p valvuloplasty in [**2100**].
Lasix was initially used for aggressive diuresis and beta
blockers given judiciously. The patient was felt to be overly
diuresed eventually and received a few small fluid boluses while
intubated, for lower urine output. Gentle diuresis was resumed
when she developed lower extremity edema ([**12-3**]+). ECHO was
obtained with showed 3+TR and severe pulmonary hypertension.
- Continue gentle diuresis with Furosemide 20mg daily PRN
(previous home dose was 20mg daily)
.
#. Diabetes Type II: Steroid exacerbated. Patient continued on
lantus and SSI both of which were increased/tightened throughout
hospital course. As the patient's steroids were tapered, her
insulin requirement decreased. Glargine was stopped on [**4-29**] for
hypoglycemia and her sliding scale was made more conservative to
only cover glucose >200.
- Continue low insulin sliding scale (fingersticks every 6
hours, 2 units for BS>200, 4 units for BS>250, 6 units for
BS>300). The patient can possibly be transitioned off insulin
now that she is off steroids.
.
#. COPD: Patient on recent long steroid taper since [**Month (only) 956**]
[**2102**]. Patient is on long acting advair and spiriva. Patient quit
smoking >2 years ago but has >40 pack year history. She was
continued on standing nebs and advair, as well as steroids
(intermittently home 10mg or 30mg vs. IV solumedrol). In
particular, the patient was on IV solumedrol during intubation
and slowed tapered to PO steroids. Her spiriva was ultimately
restarted and atrovent was discontinued.
- Continue albuterol nebs every 6 hours, ipratropium 6 puffs QID
and Flovent 6 puffs twice daily
.
Contact: [**Name (NI) 53228**] (brother and HCP): [**Telephone/Fax (1) 95244**], [**Name (NI) 2092**] (brother)
[**Telephone/Fax (1) 95246**].
Code: DNR, okay to intubate (trach/PEG)
The above discharge summary was dictated by the MICU service.
On [**2103-5-3**] her care was taken over by the surgical team. She
developed fulminant c.difficuile with a dramatically elevated
WBC (18), INR (6.1) and lactate (14) with an increasing pressor
requirement and concern for abdominal compartment syndrome. She
was taken emergently to the OR for a total abdominal colectomy
with end ileostomy. She was taken to the SICU intubated and on
pressors post-operatively. Echo findings demonstrated dramatic
pulmonary hypertension and left-sided heart failure. She
required CVVH for anuric renal failure and dramatic volume
overload. Her liver enzymes increased and she developed shock
liver. She was difficult to ventilate and began having
arrythmias. She was treated with zosyn, flagyl and vanco enemas
for her rectal remanant but remained floridly septic with
hypotension, hypothermia and profound acidosis. After
discussion with her two brothers the decision was made to make
her CMO as her chance of recovery was thought to be very slim
and she had previously expressed a desire that no extraordinary
measures be taken to extend her life. Medications were
discontinued and she expired shortly thereafter.
Medications on Admission:
1. senna 8.6 mg Tablet Sig: One Tablet PO BID PRN Constipation.
2. bisacodyl 2 5 mg Tablet TabletPO DAILY PRN Constipation.
3. docusate sodium 50 mg/5 mL 10cc PO BID
4. digoxin 125 mcg Tablet PO DAILY
5. montelukast 10 mg Tablet One Tablet PO DAILY
6. therapeutic multivitamin 5cc PO DAILY
7. cholecalciferol (vitamin D3) 400 unit Two TAB PO DAILY
8. cyanocobalamin (vitamin B-12) 500 mcg 2 TAB PO DAILY
9. guaifenesin 600 mg Tablet Extended Release PO BID
10. tiotropium bromide 18 mcg Capsule INH DAILY.
11. levalbuterol HCl 0.63 mg/3 mL Q4hrs as needed for wheezing,
12. trazodone 50 mg PO HS as needed for insomnia.
13. lorazepam 0.5 mg PO Q8H (every 8 hours) as needed for
anxiety.
14. metoprolol tartrate 25 mg PO QID
15. diltiazem HCl 60 mg Tablet PO QID
16. fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **] (2 times a
day).
17. polyethylene glycol 3350 17 gram PO DAILY
18. warfarin 5 mg PO Once Daily
19. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime
20. furosemide 20 mg PO daily
.
Allergies: NKDA
Discharge Medications:
Not applicable
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Respiratory distress (COPD, pneumonias) s/p intubation and
tracheostomy, malnutrition, steroid-induced diabetes, atrial
fibrillation on anticoagulation, diastolic CHF, fulminant c.diff
with ensuing sepsis
Discharge Condition:
Death
Discharge Instructions:
Death
Followup Instructions:
Death
|
[
"428.0",
"570",
"995.92",
"038.3",
"491.21",
"427.31",
"428.33",
"008.45",
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"729.73",
"112.2",
"276.4",
"789.59",
"280.9",
"263.9",
"V02.54",
"V85.0",
"249.00",
"482.9",
"799.4",
"482.42",
"518.84",
"530.3",
"584.5",
"507.0",
"427.89",
"759.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"33.24",
"33.23",
"46.23",
"43.11",
"96.6",
"43.19",
"31.1",
"96.72",
"45.82",
"44.32"
] |
icd9pcs
|
[
[
[]
]
] |
17448, 17463
|
6548, 16294
|
322, 429
|
17712, 17719
|
3254, 6525
|
17773, 17781
|
2663, 2737
|
17409, 17425
|
17484, 17691
|
16320, 17386
|
17743, 17750
|
2752, 2752
|
263, 284
|
457, 2025
|
2766, 3235
|
2047, 2279
|
2295, 2647
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,334
| 171,697
|
38618
|
Discharge summary
|
report
|
Admission Date: [**2165-4-6**] Discharge Date: [**2165-4-7**]
Date of Birth: [**2137-8-21**] Sex: M
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
27M s/p fall out two story window onto face, found to be
combative with poor respiratory effort, failed intubation on
scene.
Major Surgical or Invasive Procedure:
[**2165-4-7**] emergent craniectomy with neurosurgery
History of Present Illness:
27M s/p fall, found combative below open window 2 stories high,
failed intubation in the field. He was initially moving all
four extremities prior to presentation in the ED.
He presented to the [**Hospital1 18**] ED with obvious facial trauma, with
agonal respirations. He was intubated emergently and CT scan
demonstrated a significant R sided skull fracture with extensive
subarachnoid hemorrhage.
After early consultation with neurosurgery, it was decided to
place a ICP pressure monitor. His initial ICP was elevated and
remained elevated at ~70.
Past Medical History:
unknown
Social History:
married, finished law school, otherwise unknown
Family History:
unknown
Physical Exam:
Gen: Agitated/combatative. Obvious facial
deformities/lacerations.
HEENT: L hemotympanum. Large open lac R temporal skull actively
bleeding. R Eye proptosis Pupils: R pupil blown, L NR EOMs
Neck: In C-Collar
Extrem: no obvious deformities
Neuro:
Mental status: No commands
Pertinent Results:
[**2165-4-6**] 11:23PM TYPE-ART PO2-102 PCO2-38 PH-7.23* TOTAL
CO2-17* BASE XS--10 COMMENTS-GREEN TOP
[**2165-4-6**] 11:23PM GLUCOSE-147* LACTATE-7.2* NA+-140 K+-4.4
CL--104
[**2165-4-6**] 11:23PM HGB-14.5 calcHCT-44 O2 SAT-95 CARBOXYHB-2.0
MET HGB-0.1
[**2165-4-6**] 11:23PM freeCa-1.05*
[**2165-4-6**] 11:10PM UREA N-17 CREAT-1.0
[**2165-4-6**] 11:10PM estGFR-Using this
[**2165-4-6**] 11:10PM LIPASE-80*
[**2165-4-6**] 11:10PM ASA-NEG ETHANOL-89* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-4-6**] 11:10PM WBC-12.7* RBC-4.73 HGB-14.3 HCT-40.1 MCV-85
MCH-30.2 MCHC-35.6* RDW-13.6
[**2165-4-6**] 11:10PM PLT COUNT-382
[**2165-4-6**] 11:10PM PT-13.2 PTT-27.8 INR(PT)-1.1
[**2165-4-6**] 11:10PM FIBRINOGE-233
Brief Hospital Course:
The patient was taken to the operating room urgently by the
neurosurgery team. Upon entering the skull, the patient's brain
was extremely edematous and discolored. Please see the
operative note for further details of this procedure.
The determination was made that the patient's injury was not
survivable, and he was brought to the TSICU intubated to expire.
His family was able to spend time with him, and he expired at
5:05am on [**2165-4-7**].
Medications on Admission:
unknown
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p fall, skull fracture, subarachnoid hemorrhage
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2165-4-7**]
|
[
"801.76",
"807.02",
"E882",
"E849.0",
"868.01",
"738.19",
"800.76",
"873.42",
"348.4",
"802.5",
"E884.9",
"864.04",
"860.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"01.31",
"96.04",
"01.10",
"38.93",
"02.02"
] |
icd9pcs
|
[
[
[]
]
] |
2806, 2815
|
2268, 2720
|
419, 475
|
2909, 2919
|
1494, 2245
|
2971, 3005
|
1172, 1181
|
2778, 2783
|
2836, 2888
|
2746, 2755
|
2943, 2948
|
1196, 1446
|
254, 381
|
503, 1060
|
1461, 1475
|
1082, 1091
|
1107, 1156
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,229
| 130,512
|
26166+57487
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-12-16**] Discharge Date: [**2143-1-24**]
Date of Birth: [**2107-5-3**] Sex: M
Service: SURGERY
Allergies:
Zosyn / Clindamycin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
sp MVC
Major Surgical or Invasive Procedure:
sp ORIF/pin R foot [**1-5**]
sp open tracheostomy [**1-5**]
sp laparoscopic assisted gastrostomy tube placement [**1-5**]
sp central line placement
sp arterial line placement
sp aspiration sinuses [**1-10**]
sp bronch/BAL [**1-12**]
sp TEE [**1-21**]
History of Present Illness:
35M w/ MO sp unrestrained, driver MVC vs pole. Deformed steering
wheel and dashboard.
Injuries: R orbital floor blowout fx, Fx through the sup-med
wall R maxillary sinus, Sinus mucosal thickening, R foot
complete disruption of the Lisfranc joint
Past Medical History:
PMH: DM, HTN, hyperlipidemia
Social History:
married
Family History:
NC
Physical Exam:
Temp 100.2, HR 106, BP 174/50, 100%
PERRLA
TM clear B
CTAB, no crepitus, deformities
soft, obese abdomen, w/ ? diffuse mild TTP, no R/G
rectal: g -, nl tone
R knee abrasion
warm ext B, +2 DP's
TLS: NT, no deformities/step off's
Pertinent Results:
[**2142-12-16**] 08:20PM BLOOD WBC-12.5* RBC-4.34* Hgb-13.4* Hct-37.9*
MCV-87 MCH-30.8 MCHC-35.2* RDW-13.6 Plt Ct-218
[**2142-12-22**] 03:11AM BLOOD WBC-19.3*# RBC-3.45* Hgb-10.3* Hct-30.3*
MCV-88 MCH-29.9 MCHC-34.1 RDW-13.8 Plt Ct-298
[**2142-12-29**] 02:54PM BLOOD WBC-14.5* RBC-3.13* Hgb-9.5* Hct-28.3*
MCV-90 MCH-30.4 MCHC-33.6 RDW-13.9 Plt Ct-277
[**2143-1-2**] 02:09AM BLOOD WBC-9.6 RBC-2.62* Hgb-8.3* Hct-24.1*
MCV-92 MCH-31.6 MCHC-34.4 RDW-14.0 Plt Ct-191
[**2143-1-9**] 03:13AM BLOOD WBC-9.1 RBC-2.70* Hgb-8.3* Hct-24.5*
MCV-91 MCH-30.8 MCHC-34.0 RDW-14.7 Plt Ct-276
[**2143-1-11**] 02:10AM BLOOD WBC-11.9* RBC-2.56* Hgb-8.0* Hct-23.2*
MCV-91 MCH-31.4 MCHC-34.5 RDW-14.3 Plt Ct-274
[**2143-1-15**] 02:28AM BLOOD WBC-12.9* RBC-3.03* Hgb-9.4* Hct-27.0*
MCV-89 MCH-30.9 MCHC-34.6 RDW-14.7 Plt Ct-465*
[**2143-1-21**] 02:00AM BLOOD WBC-9.8 RBC-2.82* Hgb-8.3* Hct-24.9*
MCV-89 MCH-29.6 MCHC-33.5 RDW-15.5 Plt Ct-423
[**2143-1-22**] 02:13AM BLOOD WBC-9.1 RBC-2.74* Hgb-8.0* Hct-23.8*
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.2 Plt Ct-367
[**2143-1-23**] 02:05AM BLOOD WBC-8.2 RBC-2.87* Hgb-8.2* Hct-24.8*
MCV-86 MCH-28.6 MCHC-33.2 RDW-15.3 Plt Ct-318
[**2143-1-14**] 02:19AM BLOOD Neuts-66.9 Lymphs-20.0 Monos-4.3 Eos-8.5*
Baso-0.4
[**2143-1-23**] 02:05AM BLOOD Neuts-77.7* Lymphs-12.9* Monos-3.6
Eos-5.3* Baso-0.5
[**2142-12-16**] 08:20PM BLOOD Fibrino-259
[**2142-12-21**] 12:53AM BLOOD Fibrino-862*#
[**2142-12-23**] 03:03AM BLOOD Fibrino-670*#
[**2142-12-17**] 03:19AM BLOOD Glucose-364* UreaN-25* Creat-1.7* Na-139
K-5.8* Cl-102 HCO3-26 AnGap-17
[**2142-12-19**] 02:30AM BLOOD Glucose-127* UreaN-20 Creat-1.9* Na-137
K-4.1 Cl-104 HCO3-23 AnGap-14
[**2142-12-23**] 07:22PM BLOOD Glucose-133* UreaN-91* Creat-5.4* Na-142
K-4.3 Cl-109* HCO3-18* AnGap-19
[**2142-12-26**] 03:36PM BLOOD Glucose-132* UreaN-112* Creat-4.5*
Na-146* K-5.0 Cl-112* HCO3-21* AnGap-18
[**2143-1-2**] 10:20AM BLOOD Glucose-92 UreaN-86* Creat-2.6* Na-150*
K-4.0 Cl-117* HCO3-23 AnGap-14
[**2143-1-8**] 02:04AM BLOOD Glucose-92 UreaN-45* Creat-1.8* Na-141
K-4.6 Cl-110* HCO3-21* AnGap-15
[**2143-1-9**] 03:13AM BLOOD Glucose-103 UreaN-40* Creat-1.7* Na-142
K-5.2* Cl-107 HCO3-20* AnGap-20
[**2143-1-9**] 01:01PM BLOOD K-5.7*
[**2143-1-10**] 02:31AM BLOOD Glucose-153* UreaN-47* Creat-1.9* Na-144
K-4.4 Cl-109* HCO3-23 AnGap-16
[**2143-1-13**] 03:24AM BLOOD Glucose-188* UreaN-47* Creat-1.3* Na-146*
K-4.8 Cl-110* HCO3-23 AnGap-18
[**2143-1-16**] 02:03AM BLOOD Glucose-167* UreaN-40* Creat-1.3* Na-148*
K-3.9 Cl-112* HCO3-25 AnGap-15
[**2143-1-18**] 02:05AM BLOOD Glucose-133* UreaN-42* Creat-1.9* Na-145
K-4.0 Cl-110* HCO3-23 AnGap-16
[**2143-1-20**] 01:48AM BLOOD Glucose-112* UreaN-35* Creat-2.0* Na-149*
K-4.2 Cl-113* HCO3-23 AnGap-17
[**2143-1-22**] 02:13AM BLOOD Glucose-132* UreaN-28* Creat-1.8* Na-145
K-3.9 Cl-111* HCO3-24 AnGap-14
[**2143-1-23**] 02:05AM BLOOD Glucose-113* UreaN-22* Creat-1.6* Na-143
K-3.7 Cl-107 HCO3-26 AnGap-14
[**2142-12-20**] 02:15AM BLOOD ALT-78* AST-134* CK(CPK)-6263* AlkPhos-51
Amylase-44 TotBili-1.7*
[**2142-12-21**] 12:53AM BLOOD ALT-98* AST-148* CK(CPK)-6100* AlkPhos-51
TotBili-2.7*
[**2142-12-22**] 03:11AM BLOOD ALT-101* AST-85* AlkPhos-60 TotBili-2.0*
[**2142-12-23**] 03:03AM BLOOD ALT-94* AST-61* AlkPhos-72 TotBili-0.9
[**2143-1-10**] 02:31AM BLOOD ALT-41* AST-32 AlkPhos-118* Amylase-47
TotBili-0.5
[**2143-1-18**] 02:05AM BLOOD ALT-216* AST-114* AlkPhos-226* Amylase-61
TotBili-0.4
[**2143-1-19**] 02:48AM BLOOD ALT-191* AST-84* LD(LDH)-253*
AlkPhos-247* Amylase-59 TotBili-0.4
[**2143-1-20**] 01:48AM BLOOD ALT-162* AST-62* LD(LDH)-252*
AlkPhos-246* Amylase-57 TotBili-0.4
[**2142-12-20**] 02:15AM BLOOD Lipase-28
[**2143-1-5**] 01:05AM BLOOD Lipase-123*
[**2143-1-20**] 01:48AM BLOOD Lipase-94*
[**2142-12-20**] 02:15AM BLOOD CK-MB-12* MB Indx-0.2 cTropnT-0.02*
[**2142-12-21**] 11:04AM BLOOD Calcium-7.9* Phos-6.6* Mg-2.3
[**2142-12-25**] 06:26PM BLOOD Calcium-8.2* Phos-7.8*# Mg-2.5
Brief Hospital Course:
Post trauma course c/b ARF, shock liver, ARDS, diffuse ? drug
skin rash w/ desquamation, VRE bacteremia, EColi UTI, coag
negative staph bacteremia.
Respiratory failure: On HD 1, the patient developed respiratory
distress and ABG showed pCO2 73 and a ph 7.12. The patient was
intubated emergently by anesthesia. The pt subsequently
developed pneumonia and was treated appropriately. The patient
was unable to tolerate a ventilator wean and underwent an open
tracheostomy on [**1-5**].
Recurrent fevers: The [**Hospital 228**] hospital course included, VRE
bacteremia, Coag neg staph bacteremia, staph pneumonia, and a
highly resistent Ecoli UTI. An ID consult was obtained. The
patient had a thorough fever evaluation including a RUQ US (neg
for cholecystitis), B LENI's (neg for DVT), and a TEE (neg for
endocarditis). The patient was treated appropriately for each
infection and the patient was afebrile for > 48 hours upon
discharge. Upon discharge, the patient was day 4 of 7 of
linezolid for staph line sepsis. The pt's CVL was DC'd on [**1-18**]
and was DC'd with peripheal access only.
Renal: The pt developed acute renal failure shortly after being
admitted. A renal consult was obtained and pt was treated
conservatively with lasix and the avoidance of nephrotoxic
medications. With time, the pt's creatine came down from a
maximum of 5.3 to 1.5 on discharge. The patient was never
oliguric and was never dialyzed. The pt was diagnosed with ATN
secondary to hypovolemia and hypotension associated with his
intial trauma.
Nutrition: Pt is tolerating goal tubefeeds via a lap assisted G
tube placed on [**1-5**].
Endo: The patient required a high dose insulin ggt for the
first half of the hospital course. After his sepsis was
treated, his FS became managable vis a sliding scale.
Skin: After being started on zosyn at the being of the hospital
stay, the patient developed a diffuse, desquamating skin rash.
Dermatology was consulted and skin biopsies were performed. The
pathology was consistent with an allergic type reaction, most
likely as a result of medications. The presumptive diagnosis
was an allergic reaction to zosyn. The patient's skin
re-epithelialized and returned to baseline upon dischrage.
Prophylaxis: Given the pt's ortho injuries, immobility and
obesity, the pt was started on Lovenox and a pneumoboot to his
LLE.
Medications on Admission:
[**Last Name (un) 1724**]: metformin
Discharge Medications:
1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
2. Acetaminophen 160 mg/5 mL Solution Sig: Four (4) PO Q6H
(every 6 hours) as needed for T > 100.
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day).
8. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
9. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) PO BID (2 times
a day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Haloperidol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Insulin Regular Human Subcutaneous
14. Methadone 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
15. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for K < 4.0.
16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
19. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN
(as needed) as needed for Mg < 2.
20. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1)
Intravenous PRN (as needed) as needed for Ca < 8.
21. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q4H (every 4 hours) as needed for agitation.
22. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q2H (every
2 hours) as needed.
23. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
24. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 4 days: finish course [**2143-1-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 20639**] Rehab - [**Location (un) 38**]
Discharge Diagnosis:
sp MVC
Discharge Condition:
stable
Discharge Instructions:
[**Name8 (MD) **] MD or return to the ED if experiencing fever/chills,
nausea/vomiting, redness/drainage from the incision,
lightheadedness, chest pain, shortness of breath, or any other
questions or concerns. Please follow up as instructed.
Take medications as instructed.
Followup Instructions:
Please follow up at the ortho trauma clinic in 4 weeks with Dr.
[**Last Name (STitle) 7376**] ([**Telephone/Fax (1) 9769**]).
Please follow up at plastics clinic in 2 weeks with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 64893**]).
Please follow up in trauma clinic in 4 weeks ([**Telephone/Fax (1) 12786**]).
Completed by:[**2143-1-24**] Name: [**Known lastname 8882**],[**Known firstname **] M Unit No: [**Numeric Identifier 11464**]
Admission Date: [**2142-12-16**] Discharge Date: [**2143-1-24**]
Date of Birth: [**2107-5-3**] Sex: M
Service: SURGERY
Allergies:
Zosyn / Clindamycin
Attending:[**First Name3 (LF) 3524**]
Addendum:
Patient is a 35 yo male s/p MVC vs. pole and was hospitalized
for a legthy course with multiple injuries (see discharge
summary). He was transferred to rehab on [**2143-1-24**] and readmitted
to [**Hospital1 8**] on [**2143-1-29**] with abdominal pain and fever. Workup of his
fever was initiated. Abdominal CT imaging revealed bilateral
lower lobe consolidations but no abdominal pathology. His
urinanalysis was positive; final culture report pending and will
be forwarded to the rehab facility once the results are back. He
was started on Vancomycin, Levofloxacin and Flagyl empirically
pending final cultures; the Flagyl was discontinued. He will
continue with Vancomycin and Levofloxacin.
Plastic surgery was consulted for antecubital contrast
infiltrate; compression with elevation ans serial examinations
of this region was recommended.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 3436**] Rehab - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2143-1-30**]
|
[
"790.7",
"278.01",
"592.0",
"802.6",
"599.0",
"482.40",
"996.62",
"507.0",
"584.5",
"272.4",
"E823.0",
"250.00",
"401.9",
"553.1",
"518.5",
"E930.0",
"801.00",
"327.23",
"693.0",
"041.4",
"825.25",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.17",
"00.14",
"88.72",
"96.72",
"31.1",
"53.41",
"38.93",
"86.11",
"38.91",
"96.6",
"22.19",
"96.04",
"33.24",
"43.11",
"22.01"
] |
icd9pcs
|
[
[
[]
]
] |
11723, 11956
|
5105, 7473
|
286, 539
|
9817, 9826
|
1176, 5082
|
10150, 11700
|
909, 913
|
7561, 9664
|
9787, 9796
|
7499, 7538
|
9850, 10127
|
928, 1157
|
240, 248
|
567, 815
|
837, 868
|
884, 893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
975
| 175,734
|
43496
|
Discharge summary
|
report
|
Admission Date: [**2142-5-15**] Discharge Date: [**2142-6-21**]
Date of Birth: [**2074-5-16**] Sex: M
Service: SURGERY
Allergies:
Roxicet / Cefepime
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
[**2142-5-16**] CVL and Left IJ line placed.
[**2142-5-17**] Abdominal compartment syndrome due to left
retroperitoneal and sigmoid mesenteric hematoma status post
decompressive laparotomy with evacuation of retroperitoneal
hematoma and packing for hemostasis, placement of silo closure
with reinforced Silastic.
[**2142-5-18**]
Reopening of prior laparotomy for removal of packing, abdominal
washout and partial closure. Hemostasis of spleen.
[**2142-5-21**]
Abdominal washout and partial closure; [**Last Name (un) **] gastrostomy; drain
retroperitoneal hematoma.
[**2142-5-26**]
Reopening of postop abdomen. Adhesiolysis (x3 hours). Drainage
of left retroperitoneal hematomas times 2. Silastic silo closure
with "[**State 19827**] patch".
[**2142-6-2**]
Washout of the abdomen, partial closure.
[**2142-6-5**]
Irrigation and debridement of open abdomen with split-thickness
skin graft 800 sq cm
[**2142-6-11**]
US guided per-chole tube
[**2142-6-14**]
CT-guided drainage of a large retroperitoneal collection
History of Present Illness:
Mr. [**Known lastname 93612**] is a 67 year old male with a St. [**Male First Name (un) 1525**] mechanical
aortic valve admitted [**Date range (3) 93613**] for subtherapeutic [**Date range (3) 263**] who
presents with 2 days of low back pain. There was no associated
trauma or injury. The pain is in his central lower back, is
present almost all the time, and varies in severity up to [**11-4**].
It is throbbing in nature and worse when sitting up or flexing
his legs. It is worse with palpation. He has also noticed
increased abdominal distention in the last few days. He has
tried tylenol for pain without much relief. He was discharged on
[**5-9**] on lovenox bridge and coumadin. Other than his lovenox and
coumadin, he has no new medications or changes in his
medication. He was discharged 7.5 mg daily (up from 5mg 6 days
per week, 7.5mg on sundays), but his [**Month/Year (2) 263**] was 1.9 on [**5-11**] and his
dose was increased to 10 mg qd. His last dose of coumadin was
[**5-14**]. He was taking Lovenox 100mg SC BID, last dose 4/20 in the
morning. He took his antihypertensives and ASA this morning. He
denies any lightheadedness, CP, SOB, nausea, vomiting, diarrhea,
constipation (though no BM today), red/maroon/bloody stools,
hematuria.
.
In the ED, initial vitals were 97.2 66 102/68 18 98. He was then
noted to have systolic pressures in the 70s and he was
complaining of lightheadedness; he was transferred to the core.
EKG showed paced rhythm and hematocrit was noted to be 31.4 from
39.2 one week prior. CTA was done for concern of dissection and
showed a left RP bleed with active extravasation at the left
iliacus muscle. He received D5W with bicarb for renal
protection. [**Month/Year (2) 263**] was 4.2 and creatinine was newly elevated to
1.7. His pressures were noted to increase to the 100s systolic,
and he was given 2 units of FFP, 1 unit PRBCs, 3.2L IVF. He was
noted to void only 100 cc in the ED. Vascular surgery and IR
were both consulted for possible intervention. IR recommended
reversal of coagulopathy for [**Month/Year (2) 263**] < 2, and consider embolization
if HCT continues to fall. The patient received 4mg IV morphine x
2 for abdominal pain when pressures were improved, with
improvement in pain. Repeat vitals: HR 80, BP 111/70 18 100% RA.
FAST exam showed a small pericardial effusion. Cardiology
recommended slow reversal with FFP; no indication for vitamin K.
In ED, unable to place Foley due to resistance.
.
On the floor, patient was given second unit of pRBC. Repeat [**Month/Year (2) 263**]
2.4, and pt was ordered for 2 more units of FFP. Repeat Hct
stable at 26.6. Lactate 3.9. Attempted to place Foley but unable
to due to resistance; urology consulted. Creatinine stable at
1.6. Bladder scan showed 50 cc urine in bladder. IVF were
started at 150 cc/hr.
Past Medical History:
1. Mechanical AV: Pt had bicuspid AV requiring replacement.
Aortic valve replacement with the Bentall procedure done in
[**2124-4-26**] with a redo procedure done in [**2132-5-26**] secondary to
methicillin-sensitive Staphylococcus aureus abscess.
2. Afib: [**Year (4 digits) **] ([**Company 1543**] Sigma dual chamber) placed in
setting of CHB in [**1-/2139**], continues amiodarone.
3. Bronchomalecia and Bronchiectesis
4. H/O GI Bleed ([**2132**])
5. CAD requiring CABG: SVG to LAD, SBG to OM, and SVG to PDA
6. Hypercholesterolemia
7. HTN
8. COPD
9. Endocarditis: Pt has had multiple episodes of endocarditis,
most recently in [**2138**] with concern for culture negative
endocarditis (veg seen on valve), per recommendation of
infectious disease team at [**Hospital1 18**] (consulted in prior
hospitalization) he will require chronic Levofloxacin
10. Herniated disc
12. Thoracic aneurysm
13. Pulmonary hematoma in [**2132**] requiring pulmonary decortication
and surgical evacuation of hematoma from left upper lobe of
lung.
14. Septic Cerebral Emboli ([**2132**]) without residual defecits.
.
Percutaneous coronary intervention, in [**2124**] anatomy as follows:
No report on OMR
.
[**Year (4 digits) **]/ICD, in [**2139-1-26**], [**Company 1543**] Sigma dual chamber
[**Company 4448**] placed for complete heart block.
Social History:
Retired electrician. On disability since sustaining spinal
injury during fall at work. Divorced. Quit smoking in [**2124**]
prior to valve replacement, prior to this he smoked 2 packs per
day. He drinks wine occasionally. No illicit drugs. Lives
alone. Two children who live out of state.
Family History:
Mother died at 78 of intracranial aneurysm rupture
Father lived to 96 - "died of old age"
Two Sisters who are well.
Physical Exam:
Vitals: T: 97.1 BP: 109/66 P: 89 R: 16 O2: 100% on RA
General: Alert, oriented, mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Rhoncorous breath sounds bilaterally, no crackles
CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM at base
Abdomen: firm, tender to palpation in left flank > diffusely,
distended, bowel sounds present, no rebound tenderness or
guarding, multiple ecchymoses present at sites of lovenox
injections; firm mass in left flank at site of increased
tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2142-6-20**] BCx no growth
[**2142-6-20**] EGD severe SB ischemia that would explain GI bleeding
[**2142-6-16**] BCx no growth
[**2142-6-15**] Cdiff NEG
[**2142-6-15**] BCx no growth
[**2142-6-14**] Cdiff NEG
[**2142-6-13**] TEE LVEF > 55%, no veggies on valves or wires
[**2142-6-11**] Bile [**Female First Name (un) **] albicans
[**2142-6-10**] PICC tip Prelim - no significant growth
[**2142-6-6**] CVC Tip STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15
colonies
[**2142-5-28**] CXR ETT 7cm above carina otherwise no sig interval
change
[**2142-5-27**] CXR unchanged
[**2142-5-25**] ECHO nl LVEF, nl fxn mech AV, no mass/veg on valves, tr
AR [**2142-5-24**] CT Torso Sm B pl eff, RPH unchanged, Lg L abd wall
fl collection
[**2142-5-24**] CT head no ICH, no mass effect, no midline shift,
patent art, possible old stoke x2
[**2142-5-24**] pleural fluid gram stain negative, culture no growth
[**2142-5-20**] CXR pre-existing retrocardiac and left basal opacity
stable
[**2142-5-19**] Bcx no growth
[**2142-5-19**] Ucx no growth
[**2142-5-19**] Sputum no legionella, no growth.
[**2142-5-19**] KUB Tubular structure slightly diagonal to the spine is
projecting over the abdomen. No safe evidence for other foreign
bodies
[**2142-5-18**] cath tip culture: no growth
[**2142-5-18**] CXR LLL atelectasis. small bilateral pleural effusions
[**2142-5-17**] mrsa neg
[**2142-5-17**] CXR New RIJ catheter with tip at brachiocephalic-SVC
junction, no ptx
[**2142-5-17**] CXR NG tube appears to have been pulled back, now in
mid-esophagus
[**2142-5-17**] ECG new T wave inversions noted in the limb
leads,frequent PVC's ,NSR
[**2142-5-16**] bcx ngtd
[**2142-5-16**] sputum MORAXELLA SPECIES
[**2142-5-15**] ucx neg
[**2142-5-15**] 05:54PM FIBRINOGE-322
[**2142-5-15**] 12:15PM BLOOD WBC-10.3# RBC-3.43* Hgb-10.7* Hct-31.4*
MCV-92 MCH-31.1 MCHC-33.9 RDW-14.2 Plt Ct-218
[**2142-5-16**] 04:15AM BLOOD WBC-11.5* RBC-2.77* Hgb-8.7* Hct-24.6*
MCV-89 MCH-31.3 MCHC-35.3* RDW-14.9 Plt Ct-132*
[**2142-5-16**] 02:30PM BLOOD WBC-13.2* RBC-2.74* Hgb-8.6* Hct-23.7*
MCV-87 MCH-31.4 MCHC-36.2* RDW-14.7 Plt Ct-119*
[**2142-5-17**] 01:58AM BLOOD WBC-18.5* RBC-3.00* Hgb-9.3* Hct-25.9*
MCV-86 MCH-30.9 MCHC-35.8* RDW-15.1 Plt Ct-131*
[**2142-5-17**] 10:47AM BLOOD WBC-21.6* RBC-3.10* Hgb-9.5* Hct-27.2*
MCV-88 MCH-30.7 MCHC-34.9 RDW-15.2 Plt Ct-131*
[**2142-5-18**] 12:45PM BLOOD WBC-15.0* RBC-3.27* Hgb-10.3* Hct-27.8*
MCV-85 MCH-31.5 MCHC-37.1* RDW-16.2* Plt Ct-131*
[**2142-5-25**] 02:42AM BLOOD WBC-8.7 RBC-3.16* Hgb-9.6* Hct-29.4*
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.7* Plt Ct-409
[**2142-6-1**] 10:23PM BLOOD Hct-24.3*
[**2142-6-2**] 06:13AM BLOOD Hct-25.3*
[**2142-6-2**] 06:22PM BLOOD Hct-28.9*
[**2142-6-5**] 05:52PM BLOOD WBC-10.8 RBC-3.13* Hgb-9.1* Hct-28.3*
MCV-90 MCH-29.2 MCHC-32.4 RDW-16.3* Plt Ct-311
[**2142-6-6**] 01:09AM BLOOD WBC-10.2 RBC-2.93* Hgb-8.5* Hct-26.1*
MCV-89 MCH-28.9 MCHC-32.5 RDW-16.1* Plt Ct-295
[**2142-6-14**] 01:02AM BLOOD WBC-21.6* RBC-2.95* Hgb-8.4* Hct-26.0*
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.8* Plt Ct-423
[**2142-6-20**] 02:40AM BLOOD WBC-19.3* RBC-3.58*# Hgb-10.5*#
Hct-32.1*# MCV-90 MCH-29.3 MCHC-32.7 RDW-16.7* Plt Ct-220
[**2142-6-21**] 04:31AM BLOOD WBC-19.2* RBC-3.54* Hgb-10.1* Hct-31.0*
MCV-88 MCH-28.4 MCHC-32.4 RDW-16.3* Plt Ct-211
[**2142-5-15**] 12:15PM BLOOD PT-40.3* PTT-47.8* [**Month/Day/Year 263**](PT)-4.2*
[**2142-5-15**] 05:54PM BLOOD PT-25.1* PTT-39.2* [**Month/Day/Year 263**](PT)-2.4*
[**2142-5-16**] 04:15AM BLOOD PT-21.4* PTT-33.6 [**Month/Day/Year 263**](PT)-2.0*
[**2142-5-18**] 02:12AM BLOOD PT-13.2 PTT-28.2 [**Month/Day/Year 263**](PT)-1.1
[**2142-5-23**] 03:52AM BLOOD PT-12.7 PTT-38.0* [**Month/Day/Year 263**](PT)-1.1
[**2142-5-25**] 02:42AM BLOOD PT-12.5 PTT-48.4* [**Month/Day/Year 263**](PT)-1.1
[**2142-5-28**] 02:39AM BLOOD PT-13.4 PTT-63.5* [**Year/Month/Day 263**](PT)-1.1
[**2142-5-30**] 02:11AM BLOOD PT-13.3 PTT-60.9* [**Year/Month/Day 263**](PT)-1.1
[**2142-5-31**] 05:21AM BLOOD PT-12.6 PTT-52.3* [**Year/Month/Day 263**](PT)-1.1
[**2142-6-1**] 05:00AM BLOOD PT-12.9 PTT-36.6* [**Year/Month/Day 263**](PT)-1.1
[**2142-6-3**] 12:27AM BLOOD PT-13.0 PTT-32.2 [**Year/Month/Day 263**](PT)-1.1
[**2142-6-8**] 07:00AM BLOOD PT-15.8* PTT-77.9* [**Month/Day/Year 263**](PT)-1.4*
[**2142-6-10**] 05:02AM BLOOD PT-13.6* PTT-40.1* [**Month/Day/Year 263**](PT)-1.2*
[**2142-6-19**] 06:03AM BLOOD PT-13.2 PTT-51.2* [**Month/Day/Year 263**](PT)-1.1
[**2142-6-20**] 12:28AM BLOOD PT-13.9* PTT-150* [**Month/Day/Year 263**](PT)-1.2*
[**2142-6-21**] 12:20AM BLOOD PT-14.8* PTT-35.2* [**Month/Day/Year 263**](PT)-1.3*
[**2142-6-21**] 10:10AM BLOOD PT-13.6* PTT-33.6 [**Month/Day/Year 263**](PT)-1.2*
[**2142-5-15**] 12:15PM BLOOD Glucose-134* UreaN-24* Creat-1.7* Na-139
K-5.0 Cl-102 HCO3-27 AnGap-15
[**2142-5-17**] 10:32AM BLOOD Glucose-151* UreaN-37* Creat-2.9* Na-140
K-4.2 Cl-103 HCO3-26 AnGap-15
[**2142-5-18**] 12:45PM BLOOD Glucose-123* UreaN-38* Creat-2.2* Na-136
K-4.1 Cl-104 HCO3-23 AnGap-13
[**2142-5-21**] 02:49PM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2142-5-24**] 01:45PM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-138
K-4.3 Cl-99 HCO3-31 AnGap-12
[**2142-5-26**] 09:15PM BLOOD Glucose-115* UreaN-18 Creat-1.1 Na-137
K-4.9 Cl-103 HCO3-24 AnGap-15
[**2142-5-29**] 01:51AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-137
K-3.8 Cl-105 HCO3-24 AnGap-12
[**2142-5-31**] 05:21AM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-142
K-3.9 Cl-108 HCO3-25 AnGap-13
[**2142-6-5**] 01:07AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-140
K-4.1 Cl-106 HCO3-29 AnGap-9
[**2142-6-13**] 02:54PM BLOOD Glucose-104* UreaN-46* Creat-1.6* Na-133
K-4.0 Cl-94* HCO3-26 AnGap-17
[**2142-6-19**] 06:03AM BLOOD Glucose-110* UreaN-15 Creat-0.6 Na-142
K-3.1* Cl-107 HCO3-26 AnGap-12
[**2142-6-21**] 08:29AM BLOOD Glucose-111* UreaN-29* Creat-2.2* Na-150*
K-3.9 Cl-118* HCO3-23 AnGap-13
[**2142-5-17**] 10:47AM BLOOD ALT-38 AST-65* LD(LDH)-263* CK(CPK)-2467*
AlkPhos-46 TotBili-1.2
[**2142-5-19**] 01:15AM BLOOD CK(CPK)-2890*
[**2142-6-20**] 12:28AM BLOOD ALT-28 AST-30 LD(LDH)-419* CK(CPK)-98
AlkPhos-127 TotBili-0.5
[**2142-6-20**] 02:45PM BLOOD ALT-102* AST-282* AlkPhos-113 TotBili-0.8
Brief Hospital Course:
67M with St. [**Male First Name (un) 1525**] mechanical aortic valve admitted
[**Date range (3) 93613**] for sub therapeutic [**Date range (3) 263**] now on Lovenox bridge
and Coumadin who presents with 2 days of low back pain and found
to have retroperitoneal hematoma
.
# RETROPERITONEAL BLEED. He was found to have a large
retroperitoneal hematoma with evidence of active arterial
extravasation on imaging in the setting of a supra therapeutic
[**Date range (3) 263**] and Lovenox bridge. He was admitted to the medical ICU for
further management. Initially he remained hemodynamically stable
but with declining hematocrits despite PRBC transfusion
suspicious for active bleeding His home aspirin, Coumadin,
Lovenox, and antihypertensives were held. His supra therapeutic
[**Date range (3) 263**] was reversed with fresh frozen plasma. The general surgery,
vascular surgery, and interventional radiology services were
consulted for possible operative/procedural management. He
underwent mesenteric angiogram although an active source of
bleeding was not able to be identified. He developed hypotension
requiring vasopressor support. He developed worsening renal
failure with limited urine output, elevated bladder pressures,
and elevated CK levels concerning for abdominal compartment
syndrome. He was evaluated by general surgery...
.
# ACUTE RENAL FAILURE. The patient developed oliguric acute
renal failure initially due to hypovolemia in the setting of
acute bleed, later exacerbated by abdominal compartment
syndrome. Medications were renally dosed...
.
# MECHANICAL AORTIC VALVE: The patient was found to have a supra
therapeutic [**Date range (3) 263**] in the setting of anticoagulation with Coumadin
with a Lovenox bridge. Given the active bleed, his
anticoagulation was held and his coagulopathy reversed with
fresh frozen plasma, which was discussed with cardiology.
.
# FEVER: He developed a fever to greater than 101 on hospital
day 3. There was concern for pneumonia given evidence of a new
infiltrate on imaging so he was empirically started on broad
spectrum antibiotics...
.
# ATRIAL FIBRILLATION. He was continued on his home dose of
amiodarone. Metoprolol was initially held in the setting of
active bleeding.
.
# CAD s/p CABG. His home aspirin was initially held in the
setting of an active bleed.
.
# HYPERLIPIDEMIA. His simvastatin was held in the setting of
increasing CK levels.
.
# HYPERTENSION. His home lisinopril, metoprolol, HCTZ were
initially held in the setting of active bleeding.
.
# COPD. He was continued on home Atrovent.
[**2142-5-15**]. General surgery was consulted for retroperitoneal bleed
secondary to anticoagulation. Recommendations: reverse [**Month/Day/Year 263**],
admit to micu, serial hcts, place Foley catheter, secure IV
access, Angio for possible embolization of vessel, type/cross,
transfuse if necessary.
IR consulted, recommended Ultrasound-guided left common femoral
artery access, abdominal aortogram, it reveled extensive
atherosclerotic disease as seen on prior CT, no active contrast
extravasation identified.
Patient was transfused 2 units of blood. Serial hematocrits
slowly treading down. Received 4 Units of FFP and Vitamine K.
Continue fluid resuscitation.
[**2142-5-16**] Patient increase respiratory distress, diaphoresis, cold
and clammy extremities. Attempted BiPAP which help respiratory
status but patient was unable to tolerate it. IV Lasix given
with minimal response. Patient was intubated for anesthesia.
Labs showed CK of 740, bladder presser of 29. Concerning for
abdominal compartment syndrome.
CVL and Left IJ line placed
[**2142-5-17**] patient was taken to the OR for abdominal compartment
syndrome due to left retroperitoneal and sigmoid mesenteric
hematoma status post decompressive laparotomy with evacuation of
retroperitoneal hematoma and packing for hemostasis, placement
of silo closure with reinforced Silastic.
Taking back to the SICU, intubated on PS, IVF resuscitation,
transfused 2U RBC.
[**2142-5-18**] Reopening of prior laparotomy for removal of packing,
abdominal washout and partial closure. Hemostasis of spleen.
[**2142-5-21**] Abdominal washout and partial closure; [**Last Name (un) **]
gastrostomy; drain retroperitoneal hematoma.
[**2142-5-23**] Transfused 1 unit pRBC
[**2142-5-24**] Patient underwent thoracentesis for bilateral pleural
effusions.
Noted to have decreased movement in his right, CT scan head
showed chronic infarct within the right PCA territory (present
on CT from [**2139**]). Hypo density noted within the margin between
the left PCA and MCA, suggestive of possible subacute watershed
infarct, neurology recommended to maintain anticoagulation with
goal PTT 50-70 to avoid new embolic events, though current
infarct was likely watershed in
the context of hypotension to the 70s systolic.
[**2142-5-26**]
Reopening of postop abdomen. Adhesiolysis (x3 hours). Drainage
of left retroperitoneal hematomas times 2. Silastic silo closure
with "[**State 19827**] patch".
Continue management in the ICU. Physical therapy was consulted.
Patient in Levaquin and Zosyn for pneumonia. Intubated and
sedated on mechanical ventilation, fentanyl and versed for
sedation. Neurology checks Q 4 hours. ARF for hypovolemia
improving.
Serial hematocrit checks.
[**2142-5-30**]
Patient transfused 2 RBC for HCT of 23. Patient continue to do
well.
[**2142-6-2**] Washout of the abdomen, partial closure. Patient was
transferred to the floor after procedure.
[**2142-6-3**] Pt extubated
[**2142-6-5**] Irrigation and debridement of open abdomen with
split-thickness skin graft 800 sq cm. Patient returned to the
floor after procedure.
[**2142-6-9**] Tube feeds re started.
[**2142-6-8**] Received 3U of PRBC for HCT drop from 26 to 17 -->
responded to 31
[**2142-6-10**] PICC dc'd, tip sent for culture, 2 PIVs placed. VAC
removed; Adaptic and gauze with wound VAC dressing ng overlying.
[**2142-6-11**] Ct scan torso: Newly distended gallbladder with wall
edema, internal sludge, and a gallstone, concerning for
cholecystitis. Stable retroperitoneal hematoma and anterior
fluid collection, not significantly changed in size since the
prior examination. Interval decrease in size of a previously
seen left lateral conal fascial fluid collection. No new fluid
collection seen. Improved bibasilar atelectasis. Near complete
resolution of a previously seen right pleural effusion.
Large amount of mesenteric stranding and edema about a large
abdominal
wall defect, compatible with post-surgical changes.
US guided per-chole tube. IR draining of gallbladder.
[**2142-6-12**] micafungin started-yeast in bile, + ID approval,
speciation ordered,Foley out.
[**2142-6-13**] TEE without vegetations, remained intubated overnight
[**2142-6-13**] transferred to unit for hypotension, transfused 1 RBC,
intubated, disimpact ed.
[**2142-6-14**] perch drain placement x2 by IR
ID summary: Over the past 10 days he has been intermittently
hypotensive,
febrile with a leukocytosis which raises concern for an infected
source. He is at risk for a number of sources of infection,
most obviously is his RP hematoma and open abdominal wound which
now has a drain placed in the hematoma. This collection of blood
is an excellent medium for varied organisms to grow. We will
await
culture data from this source. His gallbladder was distended on
imaging and now has [**Female First Name (un) **] albicans growing from the bile. This
yeast should be sensitive to fluconazole and we do not need the
micafungin. He has pleural effusions, his nurse reports
increased secretions and now has GNR and GPC's from his sputum
which may
indicate a pulmonary source of infection and a hospital acquired
source of infection is of additional concern. He has been a on a
chronic quinolone prophylaxis for years and now has increased
diarrhea in the setting of a rising WCC, which raises the
possibility of C difficile. Therefore we recommend broad
coverage for this chronically hospitalized critically ill
patient with [**Female First Name (un) **], Levofloxacin, Flagyl, and Fluconazole.
This should provide broad gram positive, fungal and anaerobic
coverage as well as some gram negative coverage. Should he
decompensate
overnight we recommend switching his levofloxacin for Meropenem
which would provide broader gram negative coverage.
Successful CT-guided drainage of a large retroperitoneal
collection likely hematoma. Drain was placed in the left psoas
collection, however no fluid was drained. A drain was left in
situ as requested by the referring physician.
[**2142-6-15**] extubated, WBC treading down, VAC changed, on and off
neo.
[**2142-6-16**] confused but otherwise stable in TSICU
[**2142-6-17**] Ceftriaxone started for E coli in sputum
[**2142-6-18**] d/c VAC
Speech and swallow evaluation suggest initiating a PO diet of
thin liquids and moist, ground solids when fully awake and
alert. 1:1 supervision- hold meals if too lethargic. Continue
tube feeds as needed to meet nutritional needs. Pt
will benefit from continued nutrition input to adjust tube feeds
as needed
[**2142-6-19**] cholecystostomy tube fell out; desat w/ LLL collapse on
CXR .
[**2142-6-20**] Patient had massive GI bleeding, coded in the floor was
intubated on mechanical ventilation, transfused and fluid
resuscitated, on pressors
EGD today revealed severe erythema and ulceration in the entire
visualized area from the duodenum and up to proximal jejunum
consistent with diffuse bowel ischemia.
- Agree with efforts to maintain the hemodynamic status of the
patient via transfusions and fluids. Recommend PPI gtt or
pantoprazole 40 mg IV BID to prevent further acid induced damage
to the duodenum
- Poor prognosis.
EEG
This is an abnormal portable EEG due to a burst suppression
pattern which can be seen in anoxic ischemic encephalopathy
secondary to cardiac arrest or in the setting of high dose
sedating medications like Midazolam. In the absence of high dose
sedating medications, the presence of a burst suppression
pattern is a poor prognostic sign. No epileptiform discharges or
electrographic seizures were seen during this recording.
Family meeting, patient expired on [**2142-7-23**]
Medications on Admission:
Amiodarone 200mg daily
Aspirin 81mg daily
Atrovent
Iron 325mg daily
HCTZ 25mg daily
Lipitor 80mg daily
Lisinopril 20mg daily
Metoprolol 100mg [**Hospital1 **]
MVI
Omeprazole 20mg [**Hospital1 **]
Senna prn
coumadin 10mg daily (increased from 5mg 5 days prior)
Lvenox bridge
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
New diagnosis
Retroperitoneal hematoma secondary to anticoagulation.
Compartment syndrome secondary to retroperitoneal hematoma.
Subacute watershed cerebral infarct.
Acute renal failure dur to hypovolemia
Pneumomia
Gastrointestinal bleeding
Diffuse bowel ischemia
Old diagnosis
1. Mechanical AV: Pt had bicuspid AV requiring replacement.
Aortic valve replacement with the Bentall procedure done in
[**2124-4-26**] with a redo procedure done in [**2132-5-26**] secondary to
methicillin-sensitive Staphylococcus aureus abscess.
2. Afib: [**Year (4 digits) **] ([**Company 1543**] Sigma dual chamber) placed in
setting of CHB in [**1-/2139**], continues amiodarone.
3. Bronchomalecia and Bronchiectesis
4. H/O GI Bleed ([**2132**])
5. CAD requiring CABG: SVG to LAD, SBG to OM, and SVG to PDA
6. Hypercholesterolemia
7. HTN
8. COPD
9. Endocarditis: Pt has had multiple episodes of endocarditis,
most recently in [**2138**] with concern for culture negative
endocarditis (veg seen on valve), per recommendation of
infectious disease team at [**Hospital1 18**] (consulted in prior
hospitalization) he will require chronic Levofloxacin
10. Herniated disc
12. Thoracic aneurysm
13. Pulmonary hematoma in [**2132**] requiring pulmonary decortication
and surgical evacuation of hematoma from left upper lobe of
lung.
14. Septic Cerebral Emboli ([**2132**]) without residual defecits.
Percutaneous coronary intervention, in [**2124**] anatomy as follows:
No report on OMR
[**Year (4 digits) **]/ICD, in [**2139-1-26**], [**Company 1543**] Sigma dual chamber
[**Company 4448**] placed for complete heart block
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2142-7-10**]
|
[
"263.9",
"722.10",
"568.0",
"V43.3",
"729.73",
"414.00",
"568.81",
"V45.81",
"401.9",
"E934.2",
"995.92",
"272.4",
"785.52",
"496",
"V45.01",
"348.1",
"286.7",
"285.1",
"557.0",
"427.31",
"038.9",
"518.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"51.03",
"54.91",
"54.72",
"54.4",
"93.59",
"54.12",
"88.72",
"38.93",
"96.72",
"86.69",
"54.59",
"43.19",
"54.62",
"45.13",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
23336, 23345
|
12777, 22981
|
288, 1310
|
24991, 25000
|
6611, 12754
|
25053, 25088
|
5831, 5948
|
23306, 23313
|
23366, 24970
|
23007, 23283
|
25024, 25030
|
5963, 6592
|
239, 250
|
1338, 4155
|
4177, 5505
|
5521, 5815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,837
| 174,174
|
15297
|
Discharge summary
|
report
|
Admission Date: [**2124-7-18**] Discharge Date: [**2124-8-2**]
Date of Birth: [**2067-1-6**] Sex: F
Service: PODIATRY
Allergies:
Tape / Provera / Antibiotic / Verapamil / Heparin Agents /
Codeine / Dicloxacillin
Attending:[**First Name3 (LF) 3821**]
Chief Complaint:
Bunion and hammertoe deformity R foot
Major Surgical or Invasive Procedure:
Bunionectomy and 2nd toe hammertoe repair R foot
History of Present Illness:
57 DM F known well to podiatry service seen routinely for care
of charcot foot L and for recurrent ulceration and infection of
R 2nd toe. Pt has been undergoing conservative care for 2nd toe
and given the extent of deformity of the toe with severe bunion,
it was decided to take Pt to OR for hammertoe and bunion
correction.
Past Medical History:
1. CHF (Diastolic pMIBI [**3-19**] Mild [**Last Name (LF) **], [**First Name3 (LF) **]=57%)
2. Aortic Valve Insufficiency
3. Bleeding diathesis with neg prior workup which has previously
responded to ddAVP. Pt is followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
of Heme/Onc
4. OSA on bipap at home
5. Insulin Dependent DM complicated by Charcot foot and
peripheral neuropathy.
6. PVD with multiple foot ulcers
7. Hashimoto's Thyroiditis
8. Asthma
9. Anemia
10. IBS
11. Hepatitis C
12. MRSA in past
13. Cataracts
14. Macular degeneration
15. Osteoarthritis
16. Bladder spasms
17. Stress urinary incontinence
18. Fibromyalgia
19. Anxiety
20. Major Depression
21. s/p tonsilletcomy and adenoidectomy
22. s/p c-section with significant post partum bleeding
23. s/p bladder suspension complicated by post op bleeding
24. s/p hernia repair
Social History:
Married. Lives with husband. Daughter is HCP.
Family History:
Non-contributory.
Physical Exam:
GEN: NAD, AAOx3
HEENT: nasal BIPAP, PERRLA, EOMI
CV: RRR, S1, S2
Chest: CTA with mild wheezes
Abd: NT, ND +BS
Ext: Severe R 2nd hammertoe and bunion deformity. Superficial
ulceration dorsal 2nd toe at PIPJ with mild surrounding redness.
No active drainage. Generalized 1+ b/l LE edema. All incisions
completely healed on L foot s/p Charcot recon. No other open
lesions. Pt w/ palpable DP and dopplerable PT R foot with
decreased protective sensation plantarly.
Pertinent Results:
[**2124-7-22**] 10:12 am SWAB Source: R 2nd toe:
_________________________________________________________
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN------------ 4 S =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S 2 S
ANAEROBIC CULTURE (Final [**2124-7-26**]): NO ANAEROBES ISOLATED.
[**Date range (1) 44486**] BLOOD CULTURE: No growth
[**2124-7-18**] Pathology Tissue: BONE FIRST METATARSAL,
A. Bone, 1st right metatarsal (A):
Bone with some reparative changes; cartilage with some
degenerative changes.
B. Skin, right 2nd toe (B):
Skin with ulceration, granulation tissue, fibrosis, chronic
inflammation, and fibrinopurulent exudate.
C. Bone, 2nd toe (C):
Bone with some reparative changes; no significant acute
inflammation noted.
Cartilage with degenerative changes
CHEST (PORTABLE AP) [**2124-7-19**]: A single upright portable film of
the chest on [**7-19**] at 2051 hours. Sternal sutures are in place
from previous surgery, the diaphragm is high bilaterally which
is presumably due to position and a poor inspiratory effort. The
heart is enlarged to the left thoracic margin, unchanged since
[**Month (only) 205**]. There now appears to be some increased density at the left
base consistent with atelectasis or infiltrate
UNILAT LOWER EXT VEINS [**2124-7-19**]: No evidence of deep venous
thrombosis in the left lower extremity
CHEST (PA & LAT) [**2124-7-22**]: Resolving left lower lobe opacity,
likely atelectasis
FOOT AP,LAT & OBL RIGHT [**2124-7-29**]: Post-op films following
amputation of the right second toe at the metatarsophalangeal
joint.
Brief Hospital Course:
[**7-18**]: Pt was admitted same day for correction of severe hammertoe
and bunion deformity of R foot. Pt tolerated the procedure well
without any complications (see op note for details). Pt w/
undiagnosed bleeding disorder and instructions were given from
Pt's Heme/Onc physician for perioperative medications/recs
including pre and post op DDAVP (desmopressin). Postoperatively,
R 2nd digit was noted to be mildly dusky but still warm with
adequate CRT with pin intact. Pt [**Name (NI) 20851**]
[**7-19**]: POD1; Low grade temps, VSS; R 2nd toe continued to be dusky
but warm, pin still in tact. Dsgs clean and dry. c/o L calf
pain. Venous ultrasound neg for DVT.
[**7-20**]: Temp spike o/n to 101.9 w/ c/o nausea and chills. EKG w/ no
changes and portable CXR w/atelectesis, LLL effusion. White
count bump to 12.9. Incisions still dry, sutures in tact to R
foot but 2nd toe remaining dusky so pin was pulled without
incident. IS was encourage and Pt was also pan cultured and
foley d/c'd. Cipro was added for broadened coverage. Pt
evaluated and cleared by PT for TDWB through heel.
[**7-21**]: Cont w/ low grade fevers, VSS. Continued bibasilar crackles
though improving. R 2nd toe cont to be warm but color worsening
with white count increasing to 14. Med consulted for fever who
rec switching to levo and flagyl for questionnable PNA. Also
believe toe is source. ? ECHO if fevers cont. Pt w/ h/o
neurogenic bladder s/o mult bladder suspensions but with urinary
incontinence since foley removed. Bladder scanned showing
>400ccs. Urology curbsided and believed cause likely [**12-17**]
overflow and recommended replace foley until day of discharge
and at that time trial void her and get post void residual. [**Month (only) 116**]
need foley on discharge if doesn't improved
[**7-22**]: (POD4) Pt still spiking fevers to 101.3 while VSS. To date
all Ucx, UA, Bcx were negative but toe worsening in color.
Sutures along dorsal 2nd toe were removed at bedside revealing
necrotic base; Wcx were taken. Lesion flushed and packed open.
White count improving.
[**7-23**]: Cont low grade temps but white count improving. Remaining
sutures prox to 2nd toe removed [**12-17**] incrased drainage and packed
w/ betadine; [**Last Name (un) **] consulted for irregular blood glucose
levels. Medicine unconvinced of any clear signs of PNA but would
cont to monitor for endocarditis/graft infection. Pt made NPO
after MN for possible OR debridment vs amputation next day.
[**7-24**]: OR for open 2nd toe amp. Pt tolerated procedure well (see
op note for details). Postoperatively, Pt doing well still with
low grade temps but white count completely resolved.
[**7-25**]: (POD 7,1) Afebrile o/n w/ VSS. Amp site clean, red and
granular with appropriate bleeding. Cont Abx and NWB RLE.
[**2130-7-27**]: Cont [**Month/Day/Year 20851**]; Amp site clean and granular. 2U PRBC infused
for low Hct with appropriate bump. Bedside wcx growing pseudo,
coag(-) staph and enterococcus. Cultures from sterile intraop
tissue growing coag (-) staph and enterococcus and GNR. Pt made
NPO for amp closure next day.
[**7-28**]: OR for R 2nd toe amp closure (see op note for details). Pt
tolerated procedure well with uncomplicated postop; [**Month/Year (2) 20851**].
[**2033-7-29**]: (POD12,6,2): Pt [**Name (NI) 20851**] over weekend with no events.
Incisions cont to look clean and dry with sutures in tact and no
active drainage for clinical signs of infection. Levo changed to
cipro for better gram(-) coverage.
[**2035-7-31**]: [**Month/Day/Year 20851**] with normal white count. Wcx growing entero (pan
sensitive), GNR, CNS ([**Last Name (un) 36**] to vanc). PT reconsulted for NWB RLE
who was cleared to go home w/ PT services. Incisions cont to be
clean and dry with redness and swelling improving. Found to
have preulcerative lesions along distal achilles tendon of RLE
[**12-17**] having leg elevated on pillows. No signs of infection; began
wet-to-dry dsgs and applied mulitpodus splint.
[**8-2**]: Cont to be [**Month/Year (2) 20851**] without white count. Pt was discharged
home w/ VNA and PT services on 3 weeks of Linezolid and Cipro to
follow up with Dr. [**Last Name (STitle) **] in 1 week.
Medications on Admission:
Alprazolam 0.5', Amitriptyline 150', ASA 81', Desmopressin 1
spray NU PRN, ditropan 10', furosemide 80', levothyroxine
125mcg', Lyrica 50mg, Metoprolol XL 100', Lyrica 50''',
Montelukast 10', Nexium 40', KCL 10', Simvastatin 20', Ultram
100 q4hr, Venlafaxine XR 150'
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. Ultram 50 mg Tablet Sig: 1-2 Tablets PO q6 hr as needed for
pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Amitriptyline 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Levoxyl 175 mcg Tablet Sig: One (1) Tablet PO daily ().
10. Lyrica 50 mg Capsule Sig: One (1) Capsule PO tid ().
11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
15. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO qd ().
16. Oxybutynin Chloride 10 mg Tab,Sust Rel Osmotic Push 24hr
Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO daily ().
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
18. Vancomycin 1000 mg IV Q 12H
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
20. HYDROmorphone (Dilaudid) 1 mg IV Q6H:PRN breakthrough
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] home health
Discharge Diagnosis:
Bunion and 2nd hammertoe deformity R foot
Discharge Condition:
Stable
Discharge Instructions:
Please resume all prehospital medications. You were prescribed
2 antibiotics and a pain medication, please take both as
directed.
You are to remain non-weightbearing on your right foot in
surgical shoe and crutches.
Please keep your dressing clean and dry at all times, also
keeping your foot elevated to prevent swelling. You will have
daily dsg changes performed by visiting nurses.
Please call your doctor to go to the ED for any increase in pain
not managed by pain medication. Any drainage through your
dressing, nauseas, vomiting, fevers greater than 101.5, chills,
nightsweats
Followup Instructions:
Please call [**Telephone/Fax (1) 543**] to schedule an appointment to see Dr.
[**Last Name (STitle) **] in one week.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**] DPM 48-125
Completed by:[**2124-8-2**]
|
[
"440.24",
"730.07",
"428.30",
"713.5",
"428.0",
"V43.3",
"997.62",
"041.04",
"727.1",
"707.15",
"041.7",
"296.20",
"041.11",
"735.4",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.56",
"83.13",
"86.59",
"77.59",
"86.22",
"77.88",
"84.11"
] |
icd9pcs
|
[
[
[]
]
] |
11157, 11216
|
4891, 9076
|
379, 430
|
11302, 11311
|
2303, 4868
|
11950, 12206
|
1788, 1807
|
9394, 11134
|
11237, 11281
|
9102, 9371
|
11335, 11927
|
1822, 2284
|
302, 341
|
458, 785
|
807, 1707
|
1723, 1772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,144
| 152,821
|
44614
|
Discharge summary
|
report
|
Admission Date: [**2138-2-4**] Discharge Date: [**2138-2-18**]
Service: NEUROLOGY
Allergies:
Aspirin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
somnolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 yo F w/ h/o vascular dementia, HTN, possible TIA in
[**2135**], traumatic subarachnoid hemorrhage in [**2134**] who presents
with
decline in mental status. Today at her [**Hospital3 **]
facility,
she was noted to be less responsive and hypertensive. She was
lying down for most of the day which is atypical for her.
Therefore, she was brought to [**Hospital1 18**] ED for further evaluation.
Upon arrival, her BP was initially 136/88 but increased to
205/83
by 14:55. She was started on a nicardipine drip for blood
pressure control. Head CT was done which showed right frontal
intraparenchymal hemorrhage, subarachnoid hemorrhage, and
intraventricular extension. At that point, neurosurgery was
consulted, and it was concluded that no surgical intervention
was
necessary at this point. She was started on seizure prophylaxis
with Keppra 1 gram IV x 1. Patient was agitated requiring
restraints and ativan. Neurology was consulted for further
management.
ROS: Per [**Hospital3 **] facility report, she has had no cough
or
cold symptoms. No complaints of nausea. No vomiting. She
complained of worsening back pain all this week. She has had no
recent falls or trauma.
Past Medical History:
-vascular dementia-Diagnosed in [**2137-12-18**] at [**Last Name (un) 11786**]
-HTN
-mild CAD
-possible TIA in [**2135**]; Per note in chart, work-up included an
echo which showed PFO with atrial septal aneurysm. Apparently,
no further work-up for this was done.
-traumatic subarachnoid hemorrhage in [**2134**] after a fall
-gerd
-hypothyroidism
-chronic back pain,
-hyperlipidemia
-bilateral cataract excisions complicated by retinal injury
Social History:
No children, 2 sisters who are involved in her care. Had been
living independently at home until about 2 months ago, when she
was admitted to [**Doctor First Name 1191**] and then moved into [**Hospital3 **]. She
was required more and more help with ADLs over past months.
Family History:
+ for HTN in father, sister, brother. [**Name2 (NI) **] DM. Brother s/p CABG
no significant history of dementia
Physical Exam:
ADMISSION EXAM:
Vitals: Temp:96.9 HR:894 BP:164/102 Resp:20 O(2)Sat:100 Normal
General: awake, agitated, in restraints
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Opens eyes to voice. Does not answer questions.
Said on ly one word (Repeated "Hello" after examiner said this.)
Very agitated and trying to get off of stretcher. Followed
command to grip examiners hand but followed no further commands.
-Cranial Nerves: Surgical pupils (3 mm, not reactive); EOMI, no
nystagmus, no facial droop, palate elevates symmetrically, + gag
-Motor: Normal bulk, tone throughout. Did not cooperate for
formal motor exam. She is able to move all extremities at least
antigravity and against resistance. [**5-22**] grip bilaterally. No
adventitious movements, such as tremor, noted.
-Sensory: Responds to light touch and pinprick in all
extremities.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes mute
-Coordination: not tested
-Gait: not tested
DISCHARGE EXAM:
Awake, conversant at times. Moves all extremities at least
antigravity, follows some commands.
Pertinent Results:
[**2138-2-5**] 02:20AM BLOOD WBC-7.6 RBC-4.10* Hgb-11.5* Hct-35.6*
MCV-87 MCH-28.0 MCHC-32.2 RDW-14.6 Plt Ct-268
[**2138-2-4**] 12:30PM BLOOD PT-12.2 PTT-25.3 INR(PT)-1.0
[**2138-2-4**] 12:30PM BLOOD Glucose-101* UreaN-19 Creat-0.8 Na-139
K-3.4 Cl-98 HCO3-27 AnGap-17
CEs neg x 3
Urine and blood cx negative
IMAGING:
CXR: No acute cardiopulmonary process.
HEAD CT [**2-4**]:
There is extensive multicompartmental intracranial hemorrhage.
There is right frontal intraparenchymal hemorrhage. There is
intraventricular extension with hemorrhage demonstrated layering
in both occipital horns. In addition, there is multifocal
subarachnoid hemorrhage demonstrated within the right frontal
and left frontoparietal regions. This examination is limited by
patient
motion. Within these limitations, there is no evidence of mass
effect or
acute territorial infarction. The [**Doctor Last Name 352**]-white matter
differentiation is
grossly preserved. The ventricles and sulci are stably
prominent, with
incidental note made of a normal variant cavum septum. There is
extensive
periventricular hypodensity, most compatible with chronic small
vessel
ischemic changes. The left mastoid air cells are
underpneumatized. The right mastoid air cells are well aerated.
Note is made of a benign osteoma within the left sphenoid sinus.
The remainder of the paranasal sinuses and mastoid air cells are
well aerated. There is no acute fracture
CT C-SPINE
1. Study severely limited by patient motion. Within these
limitations, no
gross fracture or malalignment.
2. Multilevel degenerative changes with grade 1 anterolisthesis
of C3 on C4 vertebral body. This predisposes the patient to
spinal cord injury in setting of trauma, and MR can be obtained
as clinically indicated.
PLAIN FILMS T-SPINE L-SPINE
1. Slightly suboptimal lateral lumbar spine radiograph with
overlying
external artifact; however, no obvious evidence of acute
fracture or
dislocation is seen. Additionally, slight suboptimal evaluation
of the upper
thoracic vertebral bodies on the lateral view of the thoracic
spine, although T1 through T3 are included on the C-spine CT.
Given the above, no definite evidence of acute fracture or
dislocation; if clinical concern persists, suggest CT.
2. Multilevel degenerative changes.
CTA HEAD AND NECK
1. No change in extent or distribution of hemorrhage, primarily
parenchymal in right frontal lobe, but also with small
subarachnoid and intraventricular components.
2. No "spot sign," aneurysm or vascular occlusion. No change
since [**2134**].
3. Given the distribution of the hemorrhage (lobar with
overlying
subarachnoid blood, suggestive of associated pial vessel
involvement), patient demographics, and prior imaging, amyloid
angiopathy is the primary diagnostic consideration, with
post-traumatic or hypertensive hemorrhage, less likely.
EEG [**2-6**]
This EEG is markedly abnormal and gives evidence for a
moderate diffuse encephalopathy along with right hemisphere
periodic
lateralized epileptiform discharges and occasional bilateral
synchronous
epileptiform discharges. They did not appear to have a change in
clinical behavior associated with them and their association
with
clinical seizures needs clinical correlation.
EEG [**2-14**]
This is an abnormal routine EEG due to focal slowing in the
right frontal region suggestive of subcortical dysfunction in
this
region and consistent with patient's history of intraparenchymal
hemorrhage. The background was also slow and disorganized
suggestive of
a moderate encephalopathy. Medications, toxic/metabolic
disturbances
and infections are common causes. No epileptiform discharges or
electrographic seizures were seen during this recording.
LUE ULTRASOUND
Partially occlusive left basilic vein thrombosis surrounding
PICC
line. Patent deep veins and cephalic vein.
CXR [**2-14**]
New small left-sided pleural effusion.
Brief Hospital Course:
88 yo F w/ h/o vascular dementia, HTN, possible TIA in [**2135**],
traumatic subarachnoid hemorrhage in [**2134**] who presented to ED
with decline in mental status.
# NEURO:
At her [**Hospital3 **] facility, she was noted to be less
responsive and hypertensive.
In the ED, she was hypertensive with SBP up to 205 and started
on nicardipine drip for BP control. Her exam was notable for
agitation, essentially no speech, only following one command,
and not answering questions. Imaging showed a
multicompartmental intracranial hemorrhage, involving RIGHT
frontal intraparenchymal hemorrhage, subarachnoid hemorrhage and
intraventricular hemorrhage. The most likely etiology is
amyloid angiopathy or hypertension.
She was admitted to the neuro ICU for close monitoring. EEG was
obtained, which showed PLEDS. She was started on Keppra. Blood
pressures were controlled on IV and then PO medications, and she
was transferred when stable to the neurology floor.
On the floor, the patient initially had poor mental status,
barely arousable, with minimal following of commands, but no
focal findings on exam. She improved over the next 48 hours, and
was saying her name, answering some questions and following some
commands. She was cleared by speech/swallow therapy to take POs.
However, she was initially fluctuating between awake and
somnolent, and we were concerned she would not take in
sufficient nutrition on her own. Calorie count was performed and
she steadily took in at least 1000 calories per day. She did
seem to eat whatever was offered to her. Given this improvement,
PEG was not done. In order to optimize her mental status, Keppra
dose was decreased (as this can cause drowsiness in some
patients).
*Keppra to be tapered as follows:
- 500 mg qAM and 750 mg qPM for 1 week upon discharge
- 500 mg [**Hospital1 **] for 1 week
- 250 mg [**Hospital1 **] for 1 week then stop
.
She was transferred to [**Hospital 100**] rehab MACU for further PT/OT/S&S
therapy.
# FEVER
Pt had fever on [**2-15**], found to have LUE superficial venous
thrombosis with surrounding skin erythema, put on 7 day course
of Keflex to complete [**2138-2-21**].
# CONJUNCTIVITIS
- treated with erythromycin eye ointment
Medications on Admission:
Risperdal 0.25 mg tab (dose uncertain)
Provigil 200 mg tab 1-1/2 tab daily
Caltrate Plus
Aspirin 81 mg daily
Tylenol ES 500 mg tabs PRN
Clonazepam 0.5 mg Tab [**1-21**] tab QHS PRN
Verapamil SR 180 mg 1 tab daily
HCTZ 25 mg daily
Lisinopril 30 mg daily
Zocor 40 mg at bedtime
Omeprazole 20 mg daily
Ferrous gluconate 325 mg [**Hospital1 **] to TID as tolerated; Take with 500
mg Vitamin C each dose
Levothyroxine 50 mcg QAM; take at least one hour before iron
tablet
Zoloft 50 mg daily
MVI 1 tab daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/discomfort.
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day as needed for hypertension (home meds).
10. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
11. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-19**]
Drops Ophthalmic PRN (as needed) as needed for irritation.
13. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
14. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
18. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)) for 1 weeks.
19. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO QPM for 1
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
hypertension
right frontal intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with a hemorrhage in your brain due to
hypertension. Your blood pressure was controlled with new
medications.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD
Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2138-4-4**] 12:00
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
|
[
"V12.54",
"V85.1",
"401.9",
"041.4",
"599.0",
"277.39",
"724.2",
"453.81",
"996.74",
"414.01",
"331.0",
"294.10",
"244.9",
"E879.8",
"431",
"530.81",
"V15.88",
"372.30",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12219, 12285
|
7797, 10005
|
234, 241
|
12384, 12384
|
3893, 7774
|
12713, 12921
|
2227, 2342
|
10558, 12196
|
12306, 12363
|
10031, 10535
|
12561, 12690
|
3172, 3761
|
2357, 2902
|
3777, 3874
|
184, 196
|
269, 1452
|
12399, 12537
|
1474, 1921
|
1937, 2211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,724
| 151,508
|
13882
|
Discharge summary
|
report
|
Admission Date: [**2148-8-26**] Discharge Date: [**2148-8-31**]
Date of Birth: [**2075-1-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increased fatigue
Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA->LAD, SVG->OM, RCA) [**2148-8-26**]
History of Present Illness:
73 y/o female with increased fatigue who had a positive stress
test. Underwent cardiac cath which revealed severe three vessel
disease. Referred for surgical intervention.
Past Medical History:
Hypertension, Hypercholesterolemia, Diabetes Mellitus, s/p
Cataract surgery
Social History:
Denies tobacco use. Social ETOH use.
Family History:
No premature CAD
Physical Exam:
VS: 87 134/65
Gen: WDWN female in NAD
Skin: w/d intact
HEENT: EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD, soft right carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**8-26**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the
left atrial appendage. Left ventricular wall thicknesses and
cavity size are normal. Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**12-19**]+) mitral regurgitation is seen. There is
no pericardial effusion. Post-CPB: On phenylephrine, AV paced.
Preserved biventricular systolic fxn. No AI. Aorta intact. MR is
1- 2+. Other parameters as pre-bypass.
[**8-30**] CXR: The heart size is mildly enlarged but stable.
Mediastinal contours are unremarkable. Post-sternotomy wires and
post-CABG surgical clips are unchanged stable position. There is
marked improvement of aeration of both lung bases with still
present right retrocardiac atelectasis. The right pleural
effusion has significantly decreased also still present, better
visualized on the lateral view. The upper lungs are
unremarkable. There is no pneumothorax. There is no evidence of
congestive heart failure. Linear atelectasis extending laterally
from the right hilus is again noted.
[**2148-8-26**] 10:44AM BLOOD WBC-13.6* RBC-2.57*# Hgb-7.7*# Hct-22.1*#
MCV-86 MCH-30.1 MCHC-34.9 RDW-14.2 Plt Ct-287
[**2148-8-30**] 06:15AM BLOOD WBC-8.3 RBC-3.79* Hgb-11.5* Hct-33.0*
MCV-87 MCH-30.3 MCHC-34.8 RDW-14.3 Plt Ct-289
[**2148-8-26**] 10:44AM BLOOD PT-15.1* PTT-37.0* INR(PT)-1.4*
[**2148-8-28**] 12:50AM BLOOD PT-15.2* PTT-32.8 INR(PT)-1.4*
[**2148-8-26**] 11:57AM BLOOD UreaN-10 Creat-0.5 Cl-111* HCO3-25
[**2148-8-30**] 06:15AM BLOOD Glucose-70 UreaN-11 Creat-0.4 Na-143
K-3.6 Cl-104 HCO3-32 AnGap-11
[**2148-8-29**] 03:09AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 41615**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day of admission she
was brought to the operating room where she underwent a coronary
artery bypass graft x 3. Please see operative report for
surgical details. Following surgery she was transferred to the
CSRU for invasive monitoring in stable condition. Later on op
day she was weaned from sedation awoke neurologically intact and
extubated. Post-operatively she initially required a blood
transfusion. Chest tubes were removed on post-op day two. Beta
blockers and diuretics were started and she was gently diuresed
towards her pre-op weight. She was transferred to the telemetry
floor on post-op day three for further care. Epicardial pacing
wires were also removed on this day. She continued to improve
and worked with physical therapy for strength and mobility. On
post-op day five she was discharged home with VNA services and
the appropriate follow-up appointments.
Medications on Admission:
Avapro 150mg qd, Plavix 75mg qd (last dose 9/4), Vytorin 10/80mg
qd, Actonel 35mg qwk, Novolog 20/16 units, MVI
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(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 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*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-22**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Risedronate 35 mg Tablet Sig: One (1) Tablet PO Qwk ().
9. med
Take preop regimen of insulin
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitus, s/p
Cataract surgery
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 14522**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2148-9-2**]
|
[
"458.29",
"413.9",
"414.01",
"250.00",
"401.9",
"272.0",
"V45.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"36.12",
"36.15",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
5098, 5147
|
2949, 3940
|
338, 391
|
5332, 5338
|
1075, 2926
|
5665, 5837
|
761, 779
|
4102, 5075
|
5168, 5311
|
3966, 4079
|
5362, 5642
|
794, 1056
|
281, 300
|
419, 592
|
614, 691
|
707, 745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,161
| 123,316
|
17792
|
Discharge summary
|
report
|
Admission Date: [**2132-7-7**] Discharge Date: [**2132-7-15**]
Date of Birth: [**2055-3-1**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
gentleman with a significant history of coronary artery
disease who experienced difficulty breathing on the day prior
to admission.
The patient used sublingual nitroglycerin with relief, but
later in the evening developed acute shortness of breath and
called 911 for assistance.
He was brought to the Emergency Department and was noted have
an extremely elevated blood pressure of 220/130, and also to
be hypoxic. Electrocardiogram demonstrated ST elevations in
leads V1 through V3. He failed a course of [**Hospital1 **]-level positive
airway pressure and was subsequently intubated.
Upon arrival in the Catheterization Laboratory, the patient
was noted to have elevated left-sided and right-sided filling
pressures and to have in-stent restenosis in both the left
anterior descending artery and right coronary artery. The
patient underwent percutaneous transluminal coronary
angioplasty to the distal left anterior descending artery as
well as placement of a stent in the proximal left anterior
descending artery with good flow. He was treated with
dopamine to maintain blood pressures and was brought to the
floor intubated.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post right coronary
artery and left anterior descending artery stents with
in-stent restenosis; treated with brachy therapy in [**2132-3-8**].
2. Elevated cholesterol.
3. Non-insulin-dependent diabetes mellitus.
4. Hypertension.
5. Peptic ulcer disease.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. once per day.
2. Plavix 75 mg p.o. once per day.
3. Lopressor 25 mg p.o. twice per day.
4. Lisinopril 20 mg p.o. once per day.
5. Lasix 20 mg p.o. once per day.
6. Imdur 60 mg p.o. once per day.
7. Glucotrol.
8. Lipitor.
9. Actos.
SOCIAL HISTORY: The patient is Russian-speaking only. He
has a 100-pack-year tobacco history. He lives at home with
his wife who speaks English.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
intubated and sedated. Vital signs revealed temperature was
99.2, heart rate was in the 80s, and blood pressure was
130/60. Head and neck examination revealed sclerae were
anicteric. Jugular venous pulsation was elevated to the jaw.
The lungs had diffuse crackles bilaterally. Cardiovascular
examination revealed a regular rate and rhythm. A 2/6
systolic murmur and positive fourth heart sound. The abdomen
was benign. Extremities were modeled with no edema and 2+
dorsalis pedis pulses.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
studies demonstrated a white blood cell count of 13.5,
hematocrit was 30.7, and platelets were 289. Chemistry-7
panel was significant for a blood urea nitrogen of 27 and a
creatinine of 1.4. Initial creatine kinases were 199, with a
MB of 10.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray demonstrated
extensive bilateral infiltrates consistent with congestive
heart failure and a small right lower lobe opacity with small
bilateral pleural effusions.
Electrocardiogram demonstrated sinus tachycardia at 120 beats
per minute, with left axis deviation, left bundle-branch
block, and anterior ST elevations in leads V2 through V4.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CORONARY ARTERY DISEASE ISSUES: The patient's creatine
kinase levels peaked at 488 on the second day of admission
and persisted at this level for two days.
After initial intervention on the left anterior descending
artery, the patient returned to the Catheterization
Laboratory on the second day of admission for stenting of the
right coronary artery. Both left anterior descending artery
and right coronary artery were stented with drug-eluting
stents, and creatine kinase levels returned to [**Location 213**]
subsequently.
He was treated with aspirin and Plavix and was continued on
his statin. Later during the course of his hospitalization,
the patient complained of chest pressure which he had not
experienced in the past. These episodes of chest pressure
somewhat responded to sublingual nitroglycerin and did
resolve with morphine.
The patient returned for a Persantine MIBI to evaluate for
reversible defects as an etiology of his chest pressure.
MIBI results demonstrated a fixed moderate inferior wall
defect with an ejection fraction of 35% and global
hypokinesis. His myocardial infarction was likely related to
elevated blood pressures causing pulmonary edema and
increased cardiac wall stress.
Given his history of in-stent restenosis, he should be
followed carefully by Cardiology for this development.
2. PULMONARY ISSUES: The patient remained intubated for
several days as he was weaned off his dopamine drip. He was
extubate successfully on [**2132-7-10**]. He had no further
pulmonary issues.
3. HYPERTENSION ISSUES: Upon extubation, the patient
developed significant hypertension and required much higher
doses of his previous antihypertensive medications.
In the future, he should have careful control of his blood
pressures to prevent the development of flash pulmonary
edema. Since the hypertensive medications were increased,
and blood pressures of 120 to 140 were achieved the last two
days of his hospitalization.
4. CONGESTIVE HEART FAILURE ISSUES: The patient was in mild
failure on presentation and was diuresed with Lasix 40 mg
p.o. once per day. At the time of discharge, he was
oxygenating well, and his Lasix dose was returned back to his
outpatient regimen.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Hypertension.
3. Congestive heart failure.
4. Status post left anterior descending artery and right
coronary artery stents.
5. Non-insulin-dependent diabetes mellitus.
6. Elevated cholesterol.
7. Peptic ulcer disease.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once per day.
2. Plavix 75 mg p.o. once per day (times nine months).
3. Toprol-XL 75 mg p.o. twice per day.
4. Lisinopril 40 mg p.o. twice per day.
5. Norvasc 10 mg p.o. once per day.
6. Imdur 60 mg p.o. twice per day.
7. Lasix 20 mg p.o. once per day.
8. Glucotrol 5 mg p.o. once per day.
9. Actos 15 mg p.o. once per day.
10. Sublingual nitroglycerin 0.5 mg sublingually as needed
(for chest pain).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with his primary cardiologist (Dr. [**First Name8 (NamePattern2) 1026**] [**Name (STitle) 1016**]) in one
week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 6916**]
MEDQUIST36
D: [**2132-7-15**] 14:58
T: [**2132-7-19**] 03:25
JOB#: [**Job Number 49408**]
|
[
"428.0",
"414.01",
"E878.2",
"518.81",
"578.0",
"996.72",
"401.9",
"410.11",
"458.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.56",
"96.07",
"99.20",
"37.23",
"96.71",
"38.93",
"96.04",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
5762, 6017
|
6044, 6487
|
1721, 1985
|
6522, 6944
|
3408, 5640
|
5655, 5741
|
159, 1324
|
1346, 1695
|
2002, 3374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,035
| 103,660
|
14873
|
Discharge summary
|
report
|
Admission Date: [**2110-4-1**] Discharge Date: [**2110-4-25**]
Date of Birth: [**2055-1-15**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
transfer from [**Hospital 1474**] Hospital, fever to 108 and hypotension.
Major Surgical or Invasive Procedure:
endotracheal intubation.
History of Present Illness:
55F s/p lap appy (perforated retrocecal appendix) converted to
open [**3-31**] who had fever to 102 after procedure yesterday and was
tachycardic, received 1 dose unasyn and then was febrile to 108
this am with altered mental status. Pt was intubated for signs
of respiratory distress and was placed on a cooling blanket and
received cold gastric lavage. Unasyn was d/c'd and Zosyn and
Vanc were started and central line placed. CT head, chest, abd
neg for acute processes. Pt was paralyzed and sedated for
presumed seratonin syndrome. Cryptoheptadine was administered.
Prozac was d/c'd (last dose [**2110-4-1**] 1am). At 8:30pm [**4-1**] pt
became hypotensive to SBP <80 mmHg and Levophed started prior to
transfer to [**Hospital1 18**]. During transfer Neosinephrine was addeded for
additional support.
Past Medical History:
Depression
Scoliosis
Ventral hernia
Endometriosis
Migraines
Chronic anemia
s/p back surgery
s/p hernia repair
s/p ex lap
hx uveitis
Social History:
lives alone, never married, works as a data programmer. No EtOH,
remote tob hx, quit 5 yrs ago.
Family History:
non-contributory.
Physical Exam:
VS: T 101.6 BP 123/78 HR 83 AC 500 X 14 P 10 FiO2 50%
Gen: NAD, intubated, not responsive, flaccid
HEENT: EOMI, PERRL (3 mm)
Neck: no LAD
Chest: CTAB
CV: RRR nl s1 s2 no mrg appreciated
Abd: soft, NT, mildly distended + BS, 5 cm horizontal incision
near umbilicus, CDI with staples. 15 cm horizontal incision R
abdomen CDI with staples.
Ext: obese, non-pitting edema
Neuro: flaccid, likely still paralyzed from cisatracurium given
at OSH. PERRL. tracking with eyes.
Skin: no rash
Pertinent Results:
CXR [**4-2**]: Mild cardiomegaly accompanied by moderate distention
of the mediastinal vasculature. Mild pulmonary edema and small
right pleural effusion suggest cardiac decompensation and/or
volume overload. There is no pneumothorax. Tip of the
endotracheal tube ends above the clavicles, at least 5.5 cm
above the carina, probably 2-3 cm above optimal placement.
Nasogastric tube passes to the distal stomach and out of view.
Tip of the right jugular central line projects over the course
of the right brachiocephalic vein. No pneumothorax.
.
TTE [**4-2**]: There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen (probably mildly thickened
leaflets). There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no pericardial effusion.
.
CT abd/pelvis [**4-5**]: 1. Complex cystic focus in the left adnexa
with apparent enlargement of the left ovary. This is worrisome
for an ovarian malignancy. Tuboovarian abscess is considered
less likely as there is no inflammatory reaction surrounding the
ovary. Further evaluation could be obtained with ultrasound. 2.
No fluid collection is identified in the retrocecal space. 3.
Sigmoid diverticulosis. 4. No acute hepatobiliary or pancreatic
abnormalities identified. 5. Small bilateral pleural effusions.
Brief Hospital Course:
A/P: 55yoF s/p appendectomy for ruptured retrocecal appy, still
febrile on Abx.
.
1. Sepsis:
The patient was transferred to [**Hospital1 18**] with sepsis syndrome from
OSH, was hypotensive and with high fevers. Soon after transfer
she was hemodynamically stable. She was continued on broad
spectrum antibiotics. There was no pathogen identified, although
she was treated for a presumed PNA as well as a possible GI
source given the history of appendectomy at the OSH. There was
an initial concern for a Gyn source of infection, possible L
[**Last Name (un) **], Gynecology was consulted, and this was found to be less
likely. The infection resolved with empiric antibiotics
.
2. Altered MS/seizures:
After the sepsis was resolving, the pt was noted to have
persistent coma. She remained unarousable, with flaccid limbs
not withdrawing to pain. Neurology was consulted. She was noted
at one point to have jerking movements suggestive of seizure
activity, initial ECG was negative for epileptogenic activity.
In order to rule out meningitis, LP was attempted by radiology
under fluoro although was unsuccessful. She was treated for
possible HSV and bacterial meningitis empirically. There was
high clinical suspicion for status epilepticus, continuous EEG
monitoring was done and confirmed seizure activity. The patient
was started on depakote for seizure prophylaxis. The etiology of
the initial CNS insult was assessed as likely sustained when
hypotensive and febrile to 108. Over the course of the
hospitalization, the patient's mental status showed minimal
improvement. She was able to interact and follow commands
limited to movements of her eyes and tongue. She demonstrated
extremely limited ability to perform movements below the neck.
She remained quadraplegic She had no gag reflex and could not
breathe off of the ventilator.
.
3. Withdrawal of Life Support:
Extensive discussions were held with the patient as well as
members of her immediate family with the attending physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as well as other members of the medical team. It was
explained to the patient and family that in her current state,
she could not live without life support from the venitalor since
she was not able to breathe on her own. They were explained the
option to have a tracheotomy for ventilation at rehab where she
would have an opportunity for a longer-term recovery, although
there was no guarantee that she would be able to come off of the
ventilator. Whether the patient would make any meaningful
neurological recovery was also uncertain. The patient and
family expressed a clear decision that the patient did not want
to remain on the ventilator and that she wanted to be off of
life support. She indicated that she understood the
implications. The patient was extubated and passed away shortly
therafter with family and friends present.
.
4. Respiratory failure:
The patient remained ventilator dependent during the hospital
stay as noted above,
.
5. Pancreatitis:
There was an isolated elevation of pancreatic enzymes in the
abscence of symptoms. She received a post-pyloric tube for
feeding. After several days, this was trending down and tube
feeds were done through an NG tube.
.
6. Anemia:
Hct remained 25 range stable.
.
7. Trop leak:
trop peak to 0.55 on [**4-3**], elevated CK [**1-16**] rhabdo. Likely demand
ischemia in setting of septic shock.
.
8. Rhabdomyolisis:
CK peaked [**Numeric Identifier 43631**] on [**4-6**], and later resolved. Her renal funtion
remained intact.
# Thrombocytosis:
most likely reactive [**1-16**] infection, trending down.
.
# s/p appy on [**4-1**]: appreciate surgery recs, no active issues.
.
# FEN: continue TFs, new OG tube placed [**4-17**]. electrolyte
repletion as needed.
.
# Ppx: PPI, pneumoboots, heparin SC, bowel regimen.
# Code: Full initially, but then later in the hospitialization
converted to DNR/DNI.
# Access: 20g PIV x 2, RtF A-line [**4-11**]
# Comm: Sister [**Name (NI) 382**] [**Name (NI) 1258**] [**Name (NI) **] [**Telephone/Fax (1) 43632**] or cell
[**Telephone/Fax (1) 43633**].
Medications on Admission:
prozac 20 qhs
premarin 0.625 mg [**Hospital1 **]
Trazodone 100 mg po qd
Atenolol 100 mg po qd
Albuterol prn
Rhinocort
[**Doctor First Name 130**]
flexeril
.
Meds on transfer:
vanc 1 gm
Zosyn
cryptoheptadine 12 mg
tylenol 650 mg
Motrin 600 mg
Versed 5 mg
Nimbex gtt
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
not applicable
Discharge Condition:
deceased
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"414.8",
"278.00",
"287.5",
"780.6",
"584.9",
"038.9",
"518.5",
"428.0",
"345.01",
"625.8",
"486",
"790.5",
"349.82",
"785.52",
"995.92",
"728.88",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"03.31",
"00.17",
"33.24",
"96.72",
"88.73",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8115, 8124
|
3662, 7761
|
364, 390
|
8182, 8192
|
2048, 3639
|
8255, 8398
|
1514, 1533
|
8076, 8092
|
8145, 8161
|
7787, 7944
|
8216, 8232
|
1548, 2029
|
251, 326
|
418, 1230
|
1252, 1385
|
1401, 1498
|
7962, 8053
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,576
| 113,086
|
21933
|
Discharge summary
|
report
|
Admission Date: [**2188-12-17**] Discharge Date: [**2188-12-23**]
Date of Birth: [**2108-9-8**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
somnolence, hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
placement of left radial arterial line
History of Present Illness:
Mr. [**Known lastname 35028**] is an 80 year old man with a history of CAD s/p MI
in [**2181**] and CABG in [**2182**], CHF with EF of 55% in [**11-10**], A. fib on
warfarin, and 2 recent admissions for a right retroperitoneal
abscess and right empyema which grew Pantoea spp (an
Enterobacter-like bacteria) which was resistent to cefazolin and
ampicillin, but sensitive to fluoroquinolones. He was treated
with levofloxacin from [**11-2**] to [**2188-11-8**] for a 7 day course.
Pigtail drains were placed in the retroperitoneal abscess and
VATS was performed to debride the empyema. Warfarin was held to
prevent bleeding. He was discharged to rehab on [**2188-11-17**] but
readmitted on [**2188-11-21**] for subsegmental PE. Cultures from the
residual pleural effusion and retroperitoneal mass were negative
at that time. He was anticoagulated once again with Lovenox as a
bridge to warfarin. That hospitalization was complicated by
delirium and foley trauma. He was discharged to rehab and then
home with VNA.
.
Today VNA found the Found to have spO2 69-80% on RA. He
complained of SOB, PND, and DOE. EMS was called and he was
brought to [**Hospital 1562**] Hospital. There, spO2 was 99% on 3L. A CXR
showed the known RLL effusion as well as a possible new
infiltrate in lingula. BNP was 1100, TnT was 0.17, and INR 2.5.
Given the possible PNA, he was treated with azithromycin 500mg
plus ceftriaxone 1g IV for CAP and transfered to [**Hospital1 18**] for
further evaluation by Thoracic Surgery here.
.
On arrival to ED the patient was somnolent but easily arousable
with verbal or physical stimuli. He denied and SOB or CP. Given
his ongoing somnolence, an ABG was done which showed significant
hypercarbia (pH 7.29 pCO2 94 pO2 81 O2Sat 95%). He was placed on
BiPAP but his mental status worsened and he became unresponsive.
He was intubated for hypercarbic respiratory failure.
.
Given his history of PE, a CTA was done which showed no PE and
stable to improved RLL infiltrates. A CT of the head showed no
bleed or process to explain his respiratory failure. No cultures
were taken but the patient was treated empirically for HAP with
vancomycin 1g IV x 1 on top of the ceftriaxone plus azithromycin
received at [**Hospital 1562**] Hospital.
Past Medical History:
PMH:
- Coronary artery disease s/p myocardial infarction ([**4-/2181**])with
CABG in [**2182**]
- Atrial fibrillation
- Moderate aortic insufficiency
- Moderate mitral regurgitation
- Ischemic cardiomyopathy with EF 45% nuclear study [**2186**]
- Hypertension
- Hyperlipidemia
- GERD
- Prostate cancer [**Doctor Last Name **] score 6
- Hypothyroidism
- Bilateral ankle edema
- Kidney stones
- Right retroperitoneal abscess and right empyema, which grew
Pantoea spp (a beta lactamase producing, Gram negative,
Enterobacter-like bacteria) which was resistent to cefazolin and
ampicillin, but sensitive to fluoroquinolones.
- Segmental pulmonary embolism within the right lower lobe
.
Past Surgical History:
- CABG [**2182**]
- Permanent pacemaker placement [**2183**]
- Left thoracotomy with total lung decortication ([**Hospital1 18**]
[**2183-12-5**])
- Left thoracoscopy with pleural biopsy and drainage of pleural
fluid ([**Hospital1 18**] [**2183-11-10**])
- Bilateral inguinal hernia repairs
- Bilateral total knee replacements
- Laparoscopic cholecystectomy
Social History:
The patient is a retired tool and dye maker; he worked around
chemicals but no asbestos. He has never smoked, and occasionally
drinks alcohol. He lives on [**Location (un) **] with his wife for the past
20 years.
Family History:
Both parents died of coronary artery disease. One brother died
at 72 of heart disease.
Physical Exam:
On Admission:
GEN: Intubated and sedated. Elderly gentleman.
HEENT: MMM, no obvious OP lesions. No cervical LAD.
CV: Irregular rate, NL S1S2 no S3S4, II/VI SEM, JVD to the angle
of the jaw
PULM: Absent breath sounds in the R base, otherwise CTAB
ABD: BS+, somewhat firm abdomen, nondistended, no obvious masses
or HSM
LIMBS: No clubbing, missing several fingers, koilinycchia
SKIN: No skin break down, scattered ecchymoses
NEURO: Intubated and sedated
At discharge:
Pertinent Results:
Admission labs:
12.6
3.8--------139
40.4
.
PMN 75.8
.
148 105 41
----------------111
5.4 35 1.0
.
Ca 9.4
Ph 4.1
Mg 2.2
.
PT 24.4, PTT 34.2, INR 2.3
.
Lactate 0.9
.
TSH 35, Free T4 -
.
1st CE: tropT 0.11 CK 38
2nd CE: tropT 0.15 Ck 23
.
Vit B12 -
Folate -
Ferritin -
TRF -
Iron -
Albumin - 3.9
.
Micro:Sputum cxr - Commensal Respiratory Flora.
Blood cultures -
MRSA nasal screen - positive
.
Imaging:
[**12-17**] CTA Chest - 1. No pulmonary embolus or acute aortic
abnormality.
2. Right pleural fluid collection unchanged or slightly improved
compared to the prior study.
3. No superimposed consolidation or pneumonia.
.
[**12-17**] CT Head - No hemorrhage or edema
.
[**12-17**] CXR - Cardiomegaly, right basilar effusion and
consolidation
.
EKG: Atrial fibrillation with intermittent ventricular paced
beats. ST-T wave abnormalities and intrinsic beats are
non-specific. Since the previous tracing of [**2188-11-8**] intermittent
intrinsic beats are now seen but there is probably no
significant change.
Brief Hospital Course:
This is an 80 year-old man with s/p recent VATS and drainagae of
an empyema and retroperitoneal abscess infected with Pantoea spp
(an Enterobacter-like bacteria) and PE on warfarin as well as
CAD s/p CABG, CHF, and Afib, admitted with hypercarbic
respiratory failure.
.
# Hypercarbic respiratory failure: The etiology of the patient's
respiratory failure is thought to be multifactorial, with likely
aspiration pneumonitis in the setting of the patient's
underlying lung abnormalities (right pleural effusion, PE,
retroperitoneal abscess) and hypothyroidism (TSH 35) all
contributing. Although the patient's respiratory failure was
initially though to be infectious in origin, and he was treated
with Vancomycin Flagyl and Levofloxacin for aspiration
pneumonia (given his history of aspiration--see speech and
swallow notes--as well as his recent history of hospitalization,
rehab and empyema + retroperitoneal abscess growing Pantoea
spp), antibiotics were discontinued after 2 days when the
patient failed to spike a fever, become hypoxic or develop any
significant leukocytosis or infiltrate on chest xray. He was
intubated and mechanically ventilated for one day, and was
extubated without difficulty. Although the OSH was concerned
about CHF, the patient did not become hypoxic at any point and
had no crackles on exam or evidence of CHF on xray. Based on
the patient's ABGs, he seems to be somewhat of a chronic
retainer (possibly due to pulmonary physiology s/p effusions and
empyema and abscess and surgeries) and his pCO2 settled out at
approximately 54. After transfer to the floor he never required
supplemental oxygen, worked easily with physical therapy and had
a rather uncomplicated hospital course.
.
# Aspiration - The patient was evaluated by video swallow, which
showed aspiration with straw sips of thin liquids; penetration
with cup sips of thin liquids. Speech and swallow therapy
recommended: 1. PO diet: regular solids, nectar thick liquids
during meals; 2. Between meals, pt may have single sips of
water, coffee, and
ensure shakes 3. TID oral care; 4. Assist with meals as needed
to maintain aspiration precautions, including:
a) sit fully upright for all PO
b) swallow twice per bite/twice per sip
c) no guzzling - single sips only
5. Repeat videoswallow study in [**1-4**] weeks either as an
outpatient.
.
# Pulmonary embolus: The patient was diagnosed [**2188-11-22**] with
Segmental pulmonary embolism within the anterior basal segment
of the right lower lobe pulmonary artery. Warfarin as an
outpatient. Admission CTA showed no further PE. Although
initially held, the patient was started back on Warfarin while
hospitalized. He should continue this for the previously
prescribed duration at home.
-He must bridge to an INR of 2.0
-lovenox 80mg sc bid until then
.
# CAD: S/p CABG in [**2182**], chronically in Afib. Ventricularly
paced. The patient was continued on his home
medications--aspirin, pravastatin, and metorprolol. His cardiac
enzymes were cycled without elevations, and he was monitored on
telemetry without events. On the floor he did not require tele.
.
# Hypothyroidism: The patient's TSH was found to be 35. His Free
T4 was 0.95. His Levothyroxine was increased from 75mcg daily to
100mcg daily. His TSH will need to be re-checked in 1 month.
It should be noted that this may simply reflect increased recent
compliance (as TSH lags behind free T4) or sick euthyroid, and
should be followed closely as an outpatient.
.
Medications on Admission:
Home Medications:
(per most recent DC summary)
- Acetaminophen 325 -650 mg PO Q6H PRN:pain
- Aspirin 325 mg PO DAILY
- Carvedilol 3.125 mg PO BID
- Enoxaparin 80 mg SQ Q12H
- Furosemide 40 mg PO DAILY
- Levothyroxine 75 mcg PO DAILY
- Lisinopril 10 mg PO DAILY
- Metoprolol Tartrate 50 mg PO BID
- Omeprazole 20 mg PO DAILY
- Pravastatin 80 mg PO DAILY
.
[**Hospital 1562**] Hospital Medications:
- Aspirin 325mg PO dailg
- Colace 100mg PO BID
- Levothyroxine 75mcg PO daily
- Pravastatin 80 mg PO daily
- ASA 325mg PO daily
- Metoprolol Tartrate 50mg PO daily
- Remeron 15mg PO HS
- Warfarin 5mg PO QPM
- ProAir HFA albuterol IH PRN
- Acetaminophen 650mg PO PRN
- Miralax 17g PO PRN
- Azithromycin 500mg PO x 1
- Ceftriaxone 1g IV x 1
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): until INR>2.0.
Disp:*8 Syringes* Refills:*4*
2. Hospital Bed
Indication: Aspiration Pneumonia/Pneumonitis
3. [**3-2**] Commode
per PT/OT recs
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
11. 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*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary: 1. respiratory failure
2. hypothyroidism
3. aspiration
Secondary: 1. pulmonary embolism
2. atrial fibrillation
3. coronary artery disease
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital for respiratory failure.
Although you were intubated for a little while in the ICU, you
were extubated without complication. We think you likely
aspirated (breathed down GI contents) prior to your admission.
These problems quickly resolved while you were in the ICU and
your antibiotics were stopped.
While you were in the ICU you were on antibiotics and your
Coumadin was lowered to 2mg, we restarted your home dose of 5,
however your INR was low at 1.6. You need to have this followed
up on Thursday in coumadin clinic.
The following changes were made to your home medications:
You were started on Lovenox 80mg subcutaneous injection twice
oer day as you were taught in the hospital
You were re-started on your home lasix for your leg swelling.
This is only until your INR is greater than 2 as checked by your
VNA.
You were started on pantoprazole 40mg daily for your GI upset
Your synthroid was changed to 100ug daily.
Followup Instructions:
Thursday in your home coumadin clinic.
Monday with your PCP
[**1-30**] with your home Urologist
Completed by:[**2189-1-12**]
|
[
"428.22",
"272.4",
"428.0",
"V45.81",
"284.1",
"427.1",
"V13.01",
"401.1",
"427.31",
"412",
"530.81",
"507.0",
"414.8",
"V12.51",
"414.01",
"396.3",
"V10.46",
"276.0",
"518.81",
"V12.04",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11186, 11247
|
5643, 9128
|
314, 392
|
11439, 11439
|
4592, 4592
|
12601, 12728
|
4001, 4089
|
9914, 11163
|
11268, 11418
|
9154, 9154
|
11616, 12216
|
3395, 3754
|
4104, 4104
|
12234, 12578
|
4573, 4573
|
231, 276
|
420, 2668
|
4612, 5620
|
4118, 4557
|
11453, 11592
|
2690, 3372
|
3770, 3985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,921
| 141,433
|
40621
|
Discharge summary
|
report
|
Admission Date: [**2141-5-17**] Discharge Date: [**2141-5-22**]
Date of Birth: [**2059-2-15**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache/Vision loss
Major Surgical or Invasive Procedure:
[**2141-5-18**] Cerebral angiogram with embolization of the AV fistula
History of Present Illness:
82M who was in his usual state of health until experiencing a
sudden onset of headache and some vision "loss." He was brought
to an OSH where a head CT showed a R IPH. He was transferred to
[**Hospital1 18**] ER for a Neurosurgical evaluation. The patient denies any
trauma. He denies any Coumadin or Plavix, but reports taking ASA
81mg daily.
Past Medical History:
HTN, high cholesterol, R thigh tumor resected in [**2134**], total
left
hip replacement in [**2135**], ? old infarct vs. vascular anomaly
previously seen on imaging years ago.
Social History:
Retired business man. Married, lives with wife. [**Name (NI) **] nearby. [**Name2 (NI) **]
tobacco, no ETOH, no recreational drugs
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
O: T: 96.7 BP: 155/77 HR: 60
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: able to name current president.
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 to 2 mm
bilaterally. L visual field cut.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-labial
flattening.
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 [**4-6**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger- with deficit on L
secondary to visual field cut
Upon Discharge:
Alert/oriented. Left visual field cut, left drift, left
[**Last Name (un) **]-labial flattening, right groin intact. MAE [**4-6**]
Pertinent Results:
CT Head [**2141-5-17**]:
Large R parietal-occipital IPH with a small assoc SDH.
CTA Head [**2141-5-17**]:
Large parietal/occipital intraparenchymal hemorrhage
measuring 5.1 by 2.5 cm and small subdural hematoma.
9 mm and 7 mm aneurysms off the right PCA in the region of
hemorrhage associated with a AV Fistula.
CXR [**2141-5-20**]:
FINDINGS: Cardiac silhouette is enlarged and is accompanied by
new pulmonary vascular engorgement and moderate pulmonary edema
as well as new small pleural effusions. Patchy opacities at the
lung bases probably reflect dependent areas of pulmonary edema
[**2141-5-22**] 07:15AM BLOOD WBC-8.1 RBC-3.85* Hgb-13.5* Hct-38.1*
MCV-99* MCH-35.0* MCHC-35.3* RDW-13.1 Plt Ct-275
[**2141-5-22**] 07:15AM BLOOD Plt Ct-275
[**2141-5-22**] 07:15AM BLOOD PT-13.8* PTT-24.6 INR(PT)-1.2*
[**2141-5-22**] 07:15AM BLOOD Glucose-112* UreaN-17 Creat-1.3* Na-138
K-3.9 Cl-104 HCO3-25 AnGap-13
[**2141-5-22**] 07:15AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.7 Mg-2.0
[**2141-5-22**] 07:15AM BLOOD Phenyto-8.3*
[**2141-5-20**] 01:25AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
[**2141-5-20**] 11:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Brief Hospital Course:
82M admitted with R IPH, question of a underlying vascular
anomaly. He was admitted to the Neuro ICU under Neurosurgery. He
was monitored closely overnight and on [**5-18**] he underwent a
cerebral angiogram and embolization of the AV fistula.
He remained stable in the ICU and was transferred to the SDU on
[**5-19**]. He had a fever spike and a fever work-up was initiated.
His UA was positive and he was started on Cipro. A urine culture
was sent but the results were contaminated by stool, patient had
been treated since [**5-20**] thus no further culture was sent.
His CXR showed some pulmonary edema and received 10mg Lasix with
good effect. He received Vancomycin for precaution of pneumonia,
the CXR is unclear as there was a question of underlying
pneumonia. Patient responded well to abx and is being discharged
on Cipro PO (started on [**5-21**]).
He was discharged to rehab on [**5-22**].
Medications on Admission:
ASA 81mg
Otherwise patient unable to name
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Dilantin Infatabs 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
7. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Right parietal-occipital IPH
Right subdural hematoma
Cerebral AV fistula with associated aneurysms
Left visual field deficit
UTI
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:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
safely resume taking this only after receiving clearance from
your Neurosurgeon.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Please continue treatment UTI as prescribed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 4 weeks with a Head CTA
w/recons. Please call [**Telephone/Fax (1) 3231**] to make this appointment. You
will need an updated BUN/CRE for this visit.
Completed by:[**2141-5-22**]
|
[
"437.3",
"599.0",
"401.9",
"368.40",
"V45.81",
"V43.64",
"514",
"348.5",
"432.1",
"593.9",
"V45.01",
"272.0",
"715.90",
"414.00",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
5617, 5664
|
3838, 4743
|
329, 402
|
5837, 5837
|
2538, 3815
|
7110, 7346
|
1141, 1159
|
4835, 5594
|
5685, 5816
|
4769, 4812
|
6020, 7087
|
1189, 1315
|
269, 291
|
2386, 2519
|
430, 776
|
1607, 2370
|
5852, 5996
|
798, 976
|
992, 1125
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,225
| 186,113
|
28297
|
Discharge summary
|
report
|
Admission Date: [**2148-2-5**] Discharge Date: [**2148-2-15**]
Date of Birth: [**2068-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
redo sternotomy,Mitral valve replacement (27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue),
tricuspid annuloplasty(28mm ring) [**2148-2-7**]
History of Present Illness:
This is a 79 year old male, s/p coronary bypass in [**2146-11-7**]
who presents with congestive heart failure secondary to severe
mitral regurgitation. His mitral regurgitation was caused by an
Enterococcal mitral valve
endocarditis in [**2146-12-8**] which has been successfully
treated with an extended course of antibiotics. He now is
limited by his dyspnea on exertion and continues to have [**2-8**]
pillow orthopnea. He was referred for mitral valve repair v.
replacement and tricuspid valve replacment/repair.
Past Medical History:
Chronic Systolic Congestive Heart Failure
Mitral Valve endocarditis(Eneterococcus)
Severe mitral regurgitation
Hypertension
Hyperlipidemia
Coronary Artery Disease
History of GI Bleed
Type II Diabetes Mellitus (diet-controlled)
Obstructive Sleep Apnea
Cataracts
Glaucoma bilaterally
Pulmonary nodule left lower lobe
Diverticulitis
ventral hernia
Social History:
Lives with:wife
Occupation:retired engineer
Tobacco:quit 25 years ago; 40-60 PYHx
ETOH:rare occ.
Family History:
son with MI/CABG at 50; brother with MI @ 63
Physical Exam:
Admission:
Pulse: Resp:18 O2 sat:93% 1 L
B/P Right:133/78 Left:
Height: 5'6" Weight:198 #
General:AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] Bibasilar crackles
Heart: RRR [x] Irregular [] Murmur IV/VI murmur best heard at
apex
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] + Ventral hernia with well healed midline scar
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x] Well healed right medial LE scar from groin to ankle
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right:none Left:none
Pertinent Results:
Pre bypass: The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with septal and inferior
wall hypokinesis. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %). The right ventricular free
wall is hypertrophied. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Post bypass: Patient is on epi, milrinone, norepi. Inferior wall
function improved on ionotropes, sill mildly hypokinetic.
Septutm appears dyskinetic, even after discontinuatioin of av
pacing in favor of a pacing. LVEF 40%. Mitral prosthesis well
seated, no MR [**First Name (Titles) **] [**Last Name (Titles) 31820**] leaks. Peak gradients [**7-18**], mean
6-8 mm Hg at cardiac outpu [**4-12**] lpm. Tricuspid annuloplasty ring
insitu with no TR or perivalular leaks. Peak gradient 3, mean 1
mm Hg,. Remaining exam unchanged. All findings discussde with
surgeons at the time of the exam.
[**2148-2-12**] 05:49AM BLOOD WBC-9.8 RBC-3.31* Hgb-8.9* Hct-26.8*
MCV-81* MCH-26.8* MCHC-33.2 RDW-18.0* Plt Ct-194
[**2148-2-13**] 05:49AM BLOOD Hct-28.7*
[**2148-2-13**] 05:49AM BLOOD K-4.1
[**2148-2-12**] 05:49AM BLOOD Glucose-94 UreaN-26* Creat-0.9 Na-138
K-3.7 Cl-99 HCO3-35* AnGap-8
[**2148-2-8**] 01:26AM BLOOD Glucose-150* UreaN-17 Creat-0.8 Na-141
K-4.0 Cl-112* HCO3-23 AnGap-10
[**2148-2-15**] 05:02AM BLOOD PT-13.4 INR(PT)-1.1
[**2148-2-15**] 05:02AM BLOOD PT-13.4 INR(PT)-1.1
Brief Hospital Course:
The patient was admitted to the hospital on [**2148-2-5**] for
pre-operative work-up. Cardiac catheterization revealed three
vessel coronary artery disease with a patent LIMA and SVG-OM.
SVG-RCA with 70% ostial and distal anastomosis lesions. Echo
revealed EF 45%, moderate to severe MR, moderate to severe
tricuspid regurgitation and severe pulmonary hypertension.
Non-invasive carotid exam reveals no stenoses bilaterally.
He was brought to the Operating Room on [**2148-2-7**] where the he
underwent redo sternotomy, mitral replacement and tricuspid
annuloplasty. he weaned from bypass with some difficulty on
Epinephrine, Vasopressin, Levophed, Milrinone and Propofol
infusions. Post operatively he was transferred to the CVICU for
recovery and invasive monitoring. Vancomycin was used for
surgical antibiotic prophylaxis given the inpatient stay of
longer than 24hours.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. He was neurologically intact and
hemodynamically stable. He was weaned from inotropic support
over the next 24 hours. Diuresis was begun towards his
preoperative weight and beta blockers begun.
Physical Therapy was consulted for strength and mobilty
assistance. Chest tubes and temporoary pacing wires were
removed according to protocol. Diuretics were continued at
discharge for an indeterminate time. A CT of the chest was
performed prior to discharge for further characterization of the
LLL pulmonary nodule which was likely unchanged allowing for
technique. . Arrangements were made for follow up with Dr.
[**Last Name (STitle) 68712**] from Thoracic Surgery in 6 months.
He developed brief, controlled rate atrial fibrillation and
Coumadin was begun with a goal INR of [**1-9**].5. Diuresis and
pulmonary toilet improved his oxygenation. He was ambulatory and
wanted to go hoem rather than rehab.
Arrangements were made for his anticoagulation to be monitored
by Dr. [**Last Name (STitle) **] until dose stable then will transition to [**Hospital 197**]
clinic. VNA will draw an INR on Monday, [**2-19**]. Patient to
take 2.5 mg of Coumadin 3/11,12,13,14.
Discharge medications, precautions and follow up were discussed
with him and his wife prior to leaving the hospital.
Medications on Admission:
Furosemide 40mg po qAM, 20mg qPM
Irbesartan 150mg po daily
Protonix 40mg po BID
Potassium Chloride 10mEq daily
Simvastatin 40mg po daily
Vitamin C 250 mg daily
ASA 81mg po daily
Ferrous Gluconate 325 mg daily
brimonidine 0.2% 1 gtt OU [**Hospital1 **]
dorzolamide 2% 1 gtt OU [**Hospital1 **]
KCl 10mEq SR daily ( while on lasix)
travaprost (Benzalkonium/Travatan) 0.004% one gtt OS QHS
MVI daily
Amoxicillin prn dental proc.
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
[**Hospital1 **]:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
[**Hospital1 **]:*50 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
13. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: Take daily as directed by MD.
[**Last Name (Titles) **]:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
mitral regurgitation
s/p redo sternotomy/mitral valve replacement/tricuspid
annuloplasty
h/o mitral valve endocarditis
coronary artery disease
s/p coronary artery bypass grafts [**2145**]
Chronic Systolic Congestive Heart Failure
Hypertension
Hyperlipidemia
Coronary Artery Disease
History of GI Bleed
Type II Diabetes Mellitus (diet-controlled)
Obstructive Sleep Apnea
Cataracts
Glaucoma
Pulmonary nodules LLL
Diverticulitis
s/p partial colectomy
ventral hernia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] on [**2148-3-14**] at 1pm ([**Telephone/Fax (1) 170**])
Primary Care Dr. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 250**]) in [**12-9**] weeks
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-9**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2148-2-15**]
|
[
"327.23",
"272.4",
"276.2",
"427.31",
"E878.1",
"416.8",
"414.02",
"285.9",
"366.8",
"424.2",
"518.89",
"562.10",
"414.2",
"V15.82",
"V45.72",
"428.22",
"424.0",
"518.5",
"414.01",
"365.9",
"250.00",
"428.0",
"998.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"39.61",
"38.93",
"37.22",
"88.56",
"96.71",
"35.33",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
8913, 8996
|
4589, 6839
|
339, 511
|
9503, 9600
|
2435, 4566
|
10140, 10688
|
1559, 1606
|
7318, 8890
|
9017, 9482
|
6865, 7295
|
9624, 10117
|
1621, 2416
|
280, 301
|
539, 1058
|
1080, 1428
|
1444, 1543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,707
| 168,544
|
51680
|
Discharge summary
|
report
|
Admission Date: [**2199-5-6**] Discharge Date: [**2199-5-17**]
Date of Birth: [**2129-2-23**] Sex: M
Service: CARDIAC
CHIEF COMPLAINT: Shortness of breath
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 70-year-old
male with a history of mitral valve prolapse and atrial
fibrillation who is status post cardioversion x3 who presents
with a two year history of shortness of breath. He was
investigated for placement of a pacemaker and subsequently
was referred to Dr. [**Last Name (Prefixes) **] for mitral valve replacement.
PAST MEDICAL HISTORY:
1. Mitral valve prolapse
2. Atrial fibrillation, status post cardioversion x3 with
the last episode in [**2199-1-18**].
3. History of high platelets
4. Spastic colon
5. Urinary frequency
6. Shingles in [**2199-2-15**]
SOCIAL HISTORY:
1. Status post right inguinal hernia repair
2. Status post appendectomy
3. Status post cholecystectomy
4. Status post bilateral knee arthroscopy
MEDICATIONS:
1. Hydroxyurea
2. Coumadin 2 mg qd
3. Tenormin q hs
ALLERGIES: PENICILLIN CAUSING A RASH.
HOSPITAL COURSE: Mr. [**Known lastname 18825**] [**Last Name (Titles) 1834**] a mitral valve
replacement with a mosaic porcine valve #33 and a Maze
procedure with radio frequency on [**2199-5-6**]. He was
transferred to the Intensive Care intubated in a stable
condition. Subsequently, on laboratory tests he was found to
have a lactic acidosis. This was extensively investigated
and followed with a surgical consult which revealed no bowel
ischemia, a thoracic surgery consult and
esophagogastroduodenoscopy to assess for esophageal rupture
or care. This was negative. He also had a CT scan which was
negative. He was ruled out for any cause of lactic acidosis.
Lactic acidosis subsequently improved and he was extubated on
postoperative day #1. He continued to be in atrial
fibrillation during this time. Subsequently, he needed
Neo-Synephrine to keep his blood pressure at a reasonable
level. He was started on amiodarone infusion to control the
heart rate. He was seen by electrophysiology. He stayed in
the Intensive Care Unit over the next few days with slow wean
off his Neo-Synephrine. Because of continuing atrial
fibrillation, he received intravenous amiodarone load and
then was switched to po amiodarone. The decision was made to
cardiovert him. He [**Date Range 1834**] cardioversion on [**2199-5-14**] and
was converted to a sinus rhythm. He was subsequently
transferred to the regular floor after the cardioversion. He
continues to be stable and in sinus rhythm. He was started
on a heparin infusion and restarted on his Coumadin. He had
his Foley catheter discontinued on postoperative day 8, but
he failed to void. He will be sent to rehabilitation with a
Foley catheter in place and this will be followed up with his
primary care physician and [**Name Initial (PRE) **] urology consult at [**Location (un) **]. He
is currently ready for discharge to a rehabilitation
facility.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid
2. Lasix 20 mg qd x1 week
3. KCL 20 milliequivalents qd x1 week
4. Coumadin 3 mg hs. INR to be checked qd until he is
therapeutic and then put on hydroxyurea 500 mg qd.
5. Amiodarone 400 mg qd
6. Flomax 0.4 mg hs
7. Percocet 1 to 2 tablets q 4 to 6 hours prn
TR[**Last Name (STitle) **]TS: He will go to rehabilitation with his Foley and
Maze trial and discontinuation of Foley in a week. He will
follow up with Dr. [**Last Name (STitle) 141**], primary care physician, [**Name10 (NameIs) **] Dr.
[**First Name (STitle) **], primary care physician in two weeks. Follow up at
the urologist referred by the primary care physician. [**Name10 (NameIs) **]
up with Dr. [**Last Name (Prefixes) **] in four weeks.
DISCHARGE CONDITION: Stable
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2199-5-16**] 10:54
T: [**2199-5-16**] 10:09
JOB#: [**Job Number 107066**]
|
[
"424.0",
"276.2",
"427.31",
"997.5",
"788.20",
"250.00",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.99",
"35.23",
"99.29",
"99.62",
"88.72",
"38.93",
"45.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3800, 4073
|
3033, 3778
|
1111, 3010
|
157, 571
|
593, 818
|
834, 1093
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,415
| 100,927
|
21650
|
Discharge summary
|
report
|
Admission Date: [**2191-7-11**] Discharge Date: [**2191-7-19**]
Service: CSU
CHIEF COMPLAINT: Significant dyspnea on exertion which was
significantly restricting her activity.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with known aortic stenosis since age 18. She had serial
echoes for many years. She had a colectomy recently with
positive liver metastases which was stable and nonoperative
at the time of examination. She was cancelled in the holding
area due to an elevated INR. On her previous admission for
aortic valve replacement, she has had a hematology work up
which was by report negative. Please refer to the
hematologist consult note. Prior to surgery she had cardiac
catheterization done in [**2191-2-22**] which showed normal
coronary and severe aortic stenosis with a peak of 62 mm of
mercury gradient. Ejection fraction not shown at that time.
In [**2190-9-24**] she had an echo done which ejection
fraction of 65%, concentric left ventricular hypertrophy,
aortic valve area of 0.7 cm2 with a peak of 90 and mean of 51
mm, a normal aortic root, moderate mitral annulus
calcification, mild MR and mild to moderate TR.
PAST MEDICAL HISTORY:
1. Aortic stenosis.
2. Non-insulin dependent diabetes mellitus.
3. Perforated colon cancer with sepsis.
4. Chemotherapy and radiation therapy and now a stable liver
metastasis, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
5. Hypertension.
6. Bilateral foot neuropathy.
7. Bilateral carotid disease.
8. New thyroid nodule.
PAST SURGICAL HISTORY:
1. Colectomy in [**2189**].
2. Port access device for chemotherapy right anterior chest.
3. Cholecystectomy [**2187**].
4. Tonsillectomy.
5. Bilateral cataract surgery.
6. Bowel resection [**2189**] with right hemicolectomy.
MEDICATIONS:
1. Metoprolol 75 mg PO twice a day.
2. Hydrochlorothiazide 12.5 mg PO twice a day.
3. Vitamin E and C daily.
4. Iron supplements daily.
5. Calcium + V daily.
6. Amoxicillin p.r.n. dental procedure.
ALLERGIES: No known drug allergies.
LABORATORY DATA PREOPERATIVELY: White blood cell count 5.0,
hematocrit 36.5, platelet count 170,000, PT 15.2, PTT 26.6,
INR 1.5 which was stable for an INR of 1.4 prior to her
hematology work up. Sodium 142, K 3.9, chloride 104, bicarb
28, BUN 21, creatinine 0.8 with a blood sugar of 168, ALT 16,
AST 24, alkaline phosphatase 102, total bilirubin 0.5. Total
protein 6.6, albumin 4.1, globulin 2.5, Hb AIC 6.4. Preop
urinalysis negative. Preop EKG showed sinus bradycardia at 49
with nonspecific changes. Please refer to official report
dated [**2191-7-4**], and chest x-ray preoperatively showed no
acute cardiopulmonary process.
CT scan of the chest, abdomen, and pelvis was performed on
[**4-18**], showed stable hepatic metastasis, ventral hernia,
new thyroid nodule and no enlarged lymph nodes. Carotid
ultrasound performed in [**2190-9-24**], showed 40% right
internal carotid artery stenosis and 40 to 60% left internal
carotid artery stenosis with normal antegrade vertebral flow.
The patient was admitted to the hospital as a same day
surgery.
PHYSICAL EXAMINATION: Her heart rate was 51 preoperatively,
blood pressure 158/74 in the right and 156/72 in the left, 5
feet 3 inches tall, 138 pounds. She was in no apparent
distress. She was well nourished. No obvious skin disease.
Pupils are equal, round and reactive to light and
accommodation. Extraocular muscles intact. Normal buccal
mucosa. Nonicteric conjunctiva. She had no jugular venous
distention. She had a positive heart murmur which radiated to
her right neck and carotids, a systolic ejection murmur. Her
lungs were clear bilaterally. She had grade 3/6 systolic
ejection murmur. Her lungs are clear bilaterally. Abdomen is
soft and nontender, nondistended. Heart with regular rate and
rhythm. She had well healed abdominal scars and no
hepatosplenomegaly. Her extremities were warm and well
perfused. No clubbing, cyanosis or edema. There were no
varicosities noted. Her cranial nerves III through XII were
grossly intact with a nonfocal examination. She is moving all
extremities with 5/5 strength. Pulses were 2+ bilaterally for
femoral, 2+ bilaterally DP and 1+ bilaterally PT, and 2+
bilaterally radial.
The patient was readmitted to the hospital again on [**2191-7-11**], and underwent operation on [**2191-7-12**], for an aortic
valve replacement by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], with a 19 mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna pericardial valve and aortic
endarterectomy. She was transferred to the cardiothoracic
intensive care unit in stable condition on Neo-Synephrine
drip at 0.5 mcg per kg per minute and Propofol drip at 20 mcg
per kg per minute.
On postoperative day 1, the patient had been extubated
overnight. Her heart rate was 74, in sinus rhythm, with blood
pressure 111/47. Cardiac index of 3.4, saturating 97% on 3
liters nasal cannula. Postoperative labs were as follows:
White blood cell count 12.6, hematocrit 28.7, platelet count
87,000, K of 4.5, BUN 14, creatinine 0.6.
She was alert and oriented. Lungs were clear bilaterally.
Heart was regular rate and rhythm. The incision was clean,
dry and intact. Abdomen was soft, nontender, and
nondistended. She was doing very well. She was on a
nitroglycerine drip at 1.0 mcg per kg per minute on
postoperative 1 but this was weaned off during the day. She
began Lasix diuresis.
On postoperative day 2, the patient remained hemodynamically
stable. Her chest tubes were removed. Her nitroglycerine
continued to be weaned and it was at 0.85 mcg per kg that
morning. It continued to be weaned off over the course of
postoperative 2. She also began beta blockade with
metoprolol.
On postoperative day 3, she was seen and evaluated by the
clinical nutrition team and physical therapy as well as case
management. Her examination was unremarkable. Her creatinine
was stable at 0.6 and hematocrit at 28.2. Her white count
dropped to 8.5. She began to work on increasing her
ambulation and activity to the tolerance level.
On postoperative day 4, she was steadily improving. She also
began her aspirin. Her beta blockade was increased to 100 mg
of Lopressor twice a day and she was started on Captopril
12.5 mg 3 times a day. She continued with diuresis and her
pacing wires were removed later in the day.
On the 24th, later in the day, the patient went into atrial
fibrillation and was started on amiodarone drip at 0.5 mg per
minute in addition to her beta blockade.
On postoperative day 6, she continued to improve. The patient
did not transfer to the floor until postoperative day 6. She
continued to steadily improve. Her Coumadin was held. The
patient converted to sinus rhythm on her amiodarone drip. On
the 26th, the patient remained in sinus rhythm with blood
pressure of 119/46, respiratory rate 20, saturations 98% on
room air. Her weight was 65.3 kg. She was alert and oriented,
nonfocal. Her examination was unremarkable. Her central
venous line and pacing wires had previously been removed and
the patient was discharged to home in stable condition with
visiting nurses on [**7-19**].
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement and aortic
endarterectomy.
2. Aortic stenosis.
3. Non-insulin dependent diabetes mellitus.
4. Colon cancer with liver metastases.
5. Hypertension.
6. Bilateral foot neuropathy.
7. Bilateral carotid disease.
8. New thyroid nodule.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq package PO b.i.d. for 5 days.
2. Lasix 20 mg PO b.i.d for 5 days.
3. Zantac 150 mg PO twice day.
4. Enteric coated aspirin 81 mg PO once a day.
5. Metoprolol 100 mg PO twice a day.
6. Percocet 5/325 one tablet PO p.r.n. q4 hours for pain.
7. Captopril 25 mg PO 3 times a day.
8. Amiodarone 400 mg PO twice a day for 5 days, then
Amiodarone 200 mg twice a day for 1 week, then Amiodarone
200 mg twice a day for 1 week, then Amiodarone 200 mg once
a day until continued by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], the patient's
cardiologist.
9. Glyburide 5 mg PO twice a day.
The patient was instructed to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], for postoperative surgical visit in the office
approximately 4 weeks after surgery, with Dr. [**Last Name (STitle) 10755**], the
primary care physician [**Last Name (NamePattern4) **] 2 to 3 weeks post discharge and
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], the cardiologist, in 2 to 3 weeks post
discharge.
The patient was discharged home in stable condition on [**2191-7-19**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2191-8-16**] 15:43:20
T: [**2191-8-17**] 03:22:32
Job#: [**Job Number 56967**]
|
[
"357.2",
"197.7",
"250.60",
"396.2",
"397.0",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7176, 7451
|
7474, 8901
|
1575, 3110
|
3133, 7155
|
107, 190
|
219, 1165
|
1187, 1552
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,166
| 174,841
|
17396
|
Discharge summary
|
report
|
Admission Date: [**2129-11-9**] Discharge Date: [**2129-11-14**]
Date of Birth: [**2070-7-27**] Sex: M
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
gentleman with a history of a ruptured aneurysm and
subarachnoid hemorrhage from [**2129-5-7**]. He is status post a
coiling of the basilar tip aneurysm at that time, and then
coiling with stenting on [**2129-9-7**], and then coiling of the
aneurysm neck on [**2129-10-7**]. The patient had an episode of
headache, diplopia and hemiplegia on the right side this
morning, on the morning of admission, and was transferred
from an outside hospital to [**Hospital6 2018**] for further management. He had left pupil dilation
and deviation on the left side at the outside hospital. It is
unclear whether seizure activity was witnessed.
PHYSICAL EXAM: On his arrival to [**Hospital3 **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **], his temp was 98.6, pulse 78, BP 110/59. He
was awake, alert and oriented x 3. His speech was fluent.
His cranial nerve exam was intact. His pupils were 3 down to
2 on the left, and 2.5 to trace reactive on the right. His
EOMS were full. His visual fields were full to
confrontation. He could count fingers at 8'. He did
complain of blurry vision at far distance subjectively. Face
was symmetric. No drift. Grasps were [**5-9**]. His motor
strength was [**5-9**] in all muscle groups. Sensation was intact.
He had an MRI/MRA that was unremarkable, that showed good
flow through the vertebral basilar system.
HOSPITAL COURSE: He was admitted to the ICU for neurologic
observation. He underwent an angio on [**2129-11-10**] which
showed no evidence of stent thrombus, or slow flow, or
stenosis, and the coil mesh was in place. The patient
continued on Plavix and aspirin and heparin. The heparin was
DC'd on [**2129-11-11**]. The sheath was removed. The patient was
out-of-bed ambulating, tolerating a regular diet. He was
seen by the neurology stroke service for this TIA episode.
They recommended getting an echocardiogram, continuing Plavix
and aspirin, and hold BP meds to avoid hypotension. The
transthoracic echo was done this morning. The patient is
being discharged to home on [**2129-11-14**] with follow-up with
Dr. [**Last Name (STitle) 1132**] in 2 weeks.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg po qd.
2. Pantoprazole 40 mg po qd.
3. Aspirin 325 po qd.
4. Plavix 75 mg po qd.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2129-11-14**] 10:16
T: [**2129-11-14**] 10:31
JOB#: [**Job Number 48650**]
|
[
"435.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2401, 2770
|
1594, 2354
|
850, 1576
|
2369, 2378
|
172, 835
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,678
| 146,938
|
11086+11087
|
Discharge summary
|
report+report
|
Admission Date: [**2142-9-14**] Discharge Date: [**2142-9-21**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 79 year-old
male with coronary artery disease, hypertension,
hypercholesterolemia and a positive ETT. In [**2135-12-4**]
the patient had an inferior wall myocardial infarction that
was medically managed. Catheterization in [**Month (only) 216**] showed an
ejection fraction of 72%, mid right coronary artery 100%
occluded, 30% left main, mid left anterior descending
coronary artery 70% occluded, distal left anterior descending
coronary artery 90% occluded, mid circumflex 40% occluded and
obtuse marginal 60% occluded.
PAST MEDICAL HISTORY: Significant for hypertension,
hypercholesterolemia status post cholecystectomy and
tonsillectomy.
HOME MEDICATION: Lopressor 50 mg po q.i.d., Lasix 20 mg po
q.d., Isordil 40 mg po t.i.d., Accupril 10 mg po q.d., Baycol
.8 mg po q.d., aspirin 325 mg po q.d. and sublingual
nitroglycerin prn.
HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) 70**] to
the Operating Room and underwent coronary artery bypass graft
times two on [**2142-9-21**], left internal mammary coronary
artery to left anterior descending coronary artery and right
saphenous vein graft to obtuse marginal one. The patient was
admitted on [**9-14**] for preop for coronary artery bypass
graft times three, however, had an myocardial infarction and
was medically managed. On [**2142-9-21**] the patient was
taken by Dr. [**Last Name (STitle) 70**] the Operating Room. Postoperatively,
the patient did well and was weaned off drips and extubated
in the Intensive Care Unit without incidence. On
postoperative day number two the patient was transferred onto
the floor. Upon transfer onto the floor the patient had
atrial fibrillation that was treated with Lopressor and the
patient was started on Amiodarone. Prior to discharge the
patient was working with physical therapy achieving [**Hospital **]
rehab level three.
DISCHARGE MEDICATIONS: Lopresor 12.5 mg po b.i.d., Lasix 20
mg po q.d. times five days, potassium chloride 20
milliequivalent po q day times five days, aspirin 81 mg po q
day, Percocet one to two tabs po q 4 to 6 h prn, Colace 20 mg
po q.d., amiodarone 400 mg po t.i.d. times three days and 400
mg po b.i.d. times a week and then 400 mg po q d.
Upon discharge the patient's condition was stable. Vital
signs were stable. The patient was afebrile. Chest was
clear. Heart was in normal sinus rhythm. Incision was
clean, dry and intact. No drainage. No pus. Sternum was
stable.
Laboratory wise, the patient postoperatively had an elevated
creatinine, however, it was stabilized and was decreasing.
Upon discharge creatinine was 1.6. The patient will be
discharged to a rehab facility and told to follow up with Dr.
[**Last Name (STitle) 70**] in three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2142-9-21**] 07:42
T: [**2142-9-21**] 08:57
JOB#: [**Job Number 35800**]
Admission Date: [**2142-9-14**] Discharge Date: [**2142-9-21**]
Service:
ADDENDUM: The patient was admitted on [**2142-9-14**] for a
preop for coronary artery bypass graft, however, had
myocardial infarction while in house and that was medically
managed and the patient was taken by Dr. [**Last Name (STitle) 70**] to the
Operating Room on [**9-16**] not 19, [**2141**]. He underwent
coronary artery bypass graft times two.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2142-9-21**] 07:45
T: [**2142-9-21**] 09:14
JOB#: [**Job Number 35801**]
|
[
"412",
"414.01",
"593.9",
"V12.01",
"997.1",
"410.91",
"272.0",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
2030, 3904
|
1005, 2006
|
129, 670
|
693, 987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,492
| 187,438
|
6437+55753
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-2-8**] Discharge Date: [**2178-2-14**]
Date of Birth: [**2109-4-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone / Adhesive Bandage
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68yo F PMHx prior lung Ca, prior laryngeal ca, recent admission
for CAP vs COPD exacerbation ([**Date range (1) 8946**]) treated with 7d
levofloxacin and 10d prednisone, representing w increasing SOB.
Patient reports that since discharge she has not returned to her
baseline respiratory status, and two days prior to admission,
she developed worsening cough with yellow sputum. Symptoms were
not asssociated with fevers/chills, chest pain, N/V/D. Of note,
patient has been around son who is sick and does endorse a runny
nose. She quit smoking 3 weeks ago and has been using her patch
since then.
In [**Hospital1 18**] ED, initial vital signs were 21:29 T 98.1 HR 141 BP
152/86 RR 26 93% .Patient initially triggered for tachypnia,
hypoxia, tachycardia; patient appeared to be in mild resp
distress, RLL rhonchi, no LE edema. Labs were remarkable for
WBC9.5(N81), Hct35.6, Plt365, Cr0.7, BUN13, INR1.3, Lactate0.8,
Trop<.01, BNP804. CXR did not demonstrate acute evidence of
PNA. EKG demonstrated afib w ventricular rate 139, without
ST/Twave changes. Patient was given combivent with good effect
and was rapidly weaned to room air, satting 90-95%, although she
remained moderately tachypneic in mid-20s. She was given IV
diltiazem 20mg and PO dilt 30mg with improvement in heart rate
and subsequent conversion to normal sinus. Patient was admitted
for further management. Patient was given 1 dose of
levofloxacin. Vital signs prior to transfer were 93 96/54 28
100% on neb.
On arrival to the ICU, patient is in good spirits. She is
mildly stridorous and able to clear her secretions well.
Patient endorses a 10 pound weight loss over the past month.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Past Oncologic History:
Larygneal Carcinoma:
- [**4-/2175**] - p/w sore throat / odynophagia / ear pain, found to
have mass effect overlying the right true vocal cord;
- [**9-/2175**] - CT neck on w 1.8x1.4cm heterogeneously enhancing
mass
in R supraglottis extending superiorly to involve the vallecular
base of the tongue bilaterally and extending into the AE fold of
the right false cord and inferiorly to the laryngeal ventricle w
possible extension to the true vocal cord. Bx w squamous
dysplasia, high-grade squamous dysplasia, and low-grade squamous
dysplasia respectively on
three biopsies.
- [**10/2175**] - PET scan on [**2175-10-24**], showed a 1.8 x 1.2 cm mass
centered in R supraglottis extending into the vallecula right AE
fold and right false cord, which has an SUV max of 7.9. No other
abnormal uptake.
- [**12/2175**] - Repeat biopsies w squamous cell carcinoma w focal
superficial invasion and adjacent squamous cell carcinoma
in-situ of the right false vocal cord. Mild to moderate
squamous dysplasia was noted on biopsy of the epiglottis. HPV
testing was negative.
- [**2-/2176**] - Had PEG placed, received XRT, Carboplatin/Pacitazel
Lung Cancer:
- [**9-/2171**] - Squamous cell carcinoma of RUL treated with
neoadjuvant carboplatin and paclitaxel + XRT, then R upper
lobectomy, neg LN
Other Past Medical History:
- DMII
- CAD s/p MI [**9-/2162**], s/p RCA stent at [**Hospital1 2025**] [**9-/2162**], s/p LCx stent at
[**Hospital1 2025**] [**3-/2163**]
- SVT - aflutter vs atrial tachycardia, sees Dr. [**Last Name (STitle) **]
- CVA vs. TIA [**8-31**]
Social History:
Lives with two sons. + tobacco/ recently quit 3 weeks ago
(>100pack-yrs). Denies alcohol/illicits.
Family History:
Mother - MI at 60, diabetes
Father - MI at 73.
5 siblings, several with MIs and dementia, one with laryngeal
cancer
Physical Exam:
Admission:
Vitals: T: 97.3 BP: 91/61 P: 103 R: 23 O2: 97% 3L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, mild stridor over throat.
CV: Soft heart sounds. Regular rate and rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2178-2-14**] 07:04AM BLOOD WBC-9.1 RBC-4.07* Hgb-11.8* Hct-34.3*
MCV-84 MCH-29.1 MCHC-34.5 RDW-14.2 Plt Ct-333
[**2178-2-13**] 07:20AM BLOOD WBC-11.3* RBC-4.20 Hgb-12.1 Hct-36.9
MCV-88 MCH-28.9 MCHC-32.9 RDW-13.7 Plt Ct-391
[**2178-2-12**] 07:30AM BLOOD WBC-8.9 RBC-4.28 Hgb-12.2 Hct-37.3 MCV-87
MCH-28.5 MCHC-32.7 RDW-13.4 Plt Ct-472*
[**2178-2-11**] 07:56AM BLOOD WBC-9.5 RBC-4.41 Hgb-12.7 Hct-38.5 MCV-87
MCH-28.8 MCHC-33.0 RDW-13.3 Plt Ct-503*
[**2178-2-10**] 07:15AM BLOOD WBC-8.3 RBC-4.16* Hgb-11.5* Hct-35.1*
MCV-85 MCH-27.7 MCHC-32.7 RDW-13.7 Plt Ct-376
[**2178-2-9**] 03:22AM BLOOD WBC-7.8 RBC-3.98* Hgb-11.1* Hct-33.5*
MCV-84 MCH-28.0 MCHC-33.2 RDW-13.5 Plt Ct-305
[**2178-2-8**] 09:40PM BLOOD WBC-9.5 RBC-4.11* Hgb-12.2 Hct-35.6*
MCV-87 MCH-29.6 MCHC-34.2 RDW-13.2 Plt Ct-365
[**2178-2-8**] 09:40PM BLOOD Neuts-81.8* Lymphs-11.3* Monos-4.3
Eos-2.0 Baso-0.6
[**2178-2-14**] 07:04AM BLOOD PT-30.0* PTT-36.5 INR(PT)-2.9*
[**2178-2-13**] 07:20AM BLOOD Plt Ct-391
[**2178-2-13**] 07:20AM BLOOD PT-23.9* PTT-36.4 INR(PT)-2.3*
[**2178-2-12**] 07:30AM BLOOD Plt Ct-472*
[**2178-2-12**] 07:30AM BLOOD PT-19.7* PTT-34.0 INR(PT)-1.9*
[**2178-2-11**] 07:56AM BLOOD Plt Ct-503*
[**2178-2-11**] 07:56AM BLOOD PT-14.7* PTT-31.1 INR(PT)-1.4*
[**2178-2-10**] 07:15AM BLOOD Plt Ct-376
[**2178-2-10**] 07:15AM BLOOD PT-13.2* PTT-30.7 INR(PT)-1.2*
[**2178-2-9**] 03:22AM BLOOD Plt Ct-305
[**2178-2-9**] 03:22AM BLOOD PT-14.6* PTT-32.9 INR(PT)-1.4*
[**2178-2-8**] 10:36PM BLOOD PT-14.0* PTT-34.1 INR(PT)-1.3*
[**2178-2-14**] 07:04AM BLOOD Glucose-185* UreaN-16 Creat-0.6 Na-143
K-4.1 Cl-100 HCO3-38* AnGap-9
[**2178-2-13**] 07:20AM BLOOD Glucose-217* UreaN-18 Creat-0.8 Na-140
K-4.7 Cl-96 HCO3-38* AnGap-11
[**2178-2-12**] 07:30AM BLOOD Glucose-116* UreaN-15 Creat-0.7 Na-143
K-5.1 Cl-99 HCO3-43* AnGap-6*
[**2178-2-11**] 07:56AM BLOOD Glucose-142* UreaN-14 Creat-0.6 Na-143
K-4.9 Cl-98 HCO3-40* AnGap-10
[**2178-2-10**] 07:15AM BLOOD Glucose-111* UreaN-8 Creat-0.6 Na-139
K-5.1 Cl-97 HCO3-38* AnGap-9
[**2178-2-9**] 03:22AM BLOOD Glucose-160* UreaN-8 Creat-0.6 Na-133
K-4.7 Cl-96 HCO3-31 AnGap-11
[**2178-2-8**] 09:40PM BLOOD Glucose-127* UreaN-13 Creat-0.7 Na-135
K-4.3 Cl-94* HCO3-32 AnGap-13
[**2178-2-13**] 07:20AM BLOOD CK(CPK)-23*
[**2178-2-9**] 03:22AM BLOOD CK(CPK)-21*
[**2178-2-13**] 07:20AM BLOOD CK-MB-2 cTropnT-<0.01
[**2178-2-9**] 03:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2178-2-8**] 09:40PM BLOOD cTropnT-<0.01
[**2178-2-8**] 09:40PM BLOOD proBNP-804*
[**2178-2-14**] 07:04AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
[**2178-2-13**] 07:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.7
[**2178-2-12**] 07:30AM BLOOD Calcium-9.5 Phos-3.5 Mg-1.9
[**2178-2-11**] 07:56AM BLOOD Calcium-9.9 Phos-2.6* Mg-1.9
[**2178-2-10**] 07:15AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
[**2178-2-9**] 03:22AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.5*
.
BCX-negative
sputum-resp flora
.
CXR [**2-8**]:
FINDINGS: Single AP portable frontal view of the chest was
obtained. Again
seen is asymmetry and volume loss and opacification of the right
hemithorax.
Postoperative changes of the right hemithorax are noted. Right
hemithorax
opacification again likely represents combination of radiation
changes and
volume loss. Given differences in patient position, there
appears to be
slight decrease in the opacification of the right lung. The left
lung is
clear aside from mild left base atelectasis. Cardiac silhouette
is not
enlarged. Mediastinal contours are similar to slightly less
prominent as
compared to the prior study. Hilar contours are similar in
appearance.
.
[**2-8**] EKG:
Atrial fibrillation, average ventricular rate 139.
Non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2178-1-20**]
cardiac rhythm is now atrial fibrillation with a rapid
ventricular rate
.
CTA [**2-9**]:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Status post right upper lobectomy and radiation therapy with
expected
volume loss and post-operative changes.
3. More confluent right middle lobe consolidation and persistent
but improved nodular opacities in the right lower lobe since
[**2178-1-19**], consistent with pneumonia. New focal opacity
in the left base could represent additional
focus of infection or inflammation.
4. Atherosclerotic disease.
.
[**2-10**] video swallow:
VIDEO SWALLOW: The oral phase of swallowing is normal. Laryngeal
penetration is noted with thin liquids, nectars, and pureed
solids. There is no frank aspiration. Secretions are cleared
with repeated coughs and swallows. Solid foods are appropriately
tolerated.
Please refer to speech pathology note for further details.
.
[**2-13**] CXR:
INDINGS: Post-treatment asymmetric appearance of the right
hemithorax is
Preliminary Reportunchanged with upper right rib resection and
volume loss with rightward
Preliminary Reportmediastinal shift and right hemidiaphragm
elevation. Suture chains project
Preliminary Reportover the right hemithorax. The opacification
at the right lung has decreased
Preliminary Reportfrom [**2178-2-8**]. The left lung is clear. No
pleural effusion or pneumothorax is
Preliminary Reportpresent. The cardiac silhouette is normal in
size. The thoracic aorta is
Preliminary Reportslightly unfolded. Degenerative changes are
again seen in the thoracic spine.
Preliminary ReportIMPRESSION:
Preliminary Report1. No acute cardiopulmonary process.
Preliminary Report2. Stable post-treatment appearance of the
right hemithorax with slightly
Preliminary Reportdecreased opacification of the right lung from
[**2178-2-8**].
Brief Hospital Course:
68yo F PMHx prior lung Ca s/p resection, prior laryngeal ca s/p
chemo + XRT + resection, recent admission for CAP vs COPD
exacerbation ([**Date range (1) 8946**]) treated with 7d levofloxacin and 10d
prednisone, represented with increasing SOB without sign of
acute infection.
.
# Hypoxia/dyspnea/acute COPD exacerbation/recent RML PNA -
Presented with shortness of breath and cough, O2 requirement; +
sick contact at home (son); no radiographic changes on CXR,
overall improvement in prior PNA seen on CT scan comparison;
thought to have likely COPD exacerbation; underlying trigger may
be chronic subclinical aspiration events; given recent
prednisone 40mg course, started on prednisone 60mg +
azithromycin. Pt did not have fever or leukocytosis. Responded
well to nebs, able to wean to 3-4L prior to transfer to the
medical floor. Ruled out for MI. CTA was performed and was
negative for PE, post radiation therapy changes were noted.
There was a RML consolidation noted, but improved from prior
images. Pt also had afib with RVR in the ED which may have
contributed to initial dyspnea. Pt was initially given 60mg
prednisone which was tapered to 40mg daily. Pt completed 5 days
of azithromycin during her hospitalization for COPD flare. She
was given albuterol and ipratropium nebs. She can resume advair
upon DC. Pt underwent a speech and swallow examination that was
not suggestive of aspiration. She did not have signs of CHF. She
was encouraged to use incentive spirometry and continued to
encourage smoking cessation. Pt has not smoked cigarettes in 3
weeks. Chest x-ray was repeated on [**2-13**] showing improvement.
Therefore, pt will be discharged to complete a 10 day total
course of steroids. She will be discharged with a plan for 40mg,
30mg, 20mg 10mg daily then stop. Given the RML opacification
that was seen on CTA and prior CXR, PT WILL NEED TO HAVE A
REPEAT CXR OR CT SCAN TO ENSURE RESOLUTION OF OPACIFICATION
GIVEN SMOKING HISTORY AND HISTORY OF MALIGNANCY AND POSSIBILITY
OF RECURRENT MALIGNANCY SHOULD OPACIFICATION NOT IMPROVE. Can
also consider pulmonary consultation prn.
.
# Afib: CHADS2 of 3, initially with RVR in ED, received 30mg PO
dilt and 20mg IV dilt with resumption of sinus rhythm, continued
home diltiazem and metoprolol dosing with good rate control (but
used short acting agents while admitted). Subtherapeutic INR on
admission. Pt's warfarin was increased. She was given 10mg po on
[**2-10**], then 7.5mg daily until [**2-13**] when she was decreased back to
her home dose of 5mg daily. INR on day of discharge was 2.9. She
should hold PM dose of coumadin on [**2-14**] and resume as scheduled
on [**2178-2-15**]. INR recheck on [**2178-2-16**] at PCP's office.
.
#h.o lung and laryngeal ca-currently thought to be in remission.
However, ?unresolving "PNA" and continued dyspnea could be
suspicious for recurrence vs. radiation changes. Pt will need
outpatient follow up and repeat chest imaging in a few week's
time.
.
# CAD: currently stable and patient without chest pain.
Continued atorvastatin 40mg daily, asa 81mg and metoprolol
equivalent of 100mg XL daily.
.
# Hypothyroidism: last TSH 2.2 from [**2178-1-19**]. Continued home dose
levothyroxine 25mcg daily
.
# DM: A1C 6.6 from [**8-1**]. Pt was given HISS, DM diet during
admission. Metformin was held and pt may resume upon discharge.
.
# GERD: continued omeprazole 20mg daily and ranitidine 150mg [**Hospital1 **]
.
#normocytic anemia-appears stable and chronic. No current signs
of active bleeding. Resolved. Should this return, consider
further work up and/or colonoscopy
.
TRANSITIONAL ISSUES
-F/U INR, adjust coumadin prn
-repeat chest imaging to ensure resolution of opacities given
prior malignancy history
-consider outpatient pulmonary evaluation
Medications on Admission:
- atorvastatin 40mg daily
- fluticasone-salmeterol 250-50mcg/dose [**Hospital1 **]
- levothyroxine 25mcg daily
- aspirin 81mg
- diltiazem Extended Release 120mg daily
- warfarin 5mg daily
- metformin 850mg daily
- metoprolol succinate 100mg daily
- omeprazole 20mg daily
- ranitidine 150mg [**Hospital1 **]
- albuterol prn
- ipratropium prn
- Tylenol 650mg q6h prn
Discharge Disposition:
Home
Discharge Diagnosis:
acute COPD exacerbation
hypoxemia
atrial fibrillation
CAD
hypothryoidism
history of lung and larygneal cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with cough and shortness of breath. You were
found to have an exacerbation of your known COPD. For this, you
were given antibiotics, steroids, and nebulizers with good
effect. Please continue to wear your nicotine patch and avoid
smoking.
.
You will need to have a repeat chest x-ray or CT scan in a few
weeks to ensure resolution of your lung findings/prior
pneumonia.
.
Medication changes:
1.start prednisone taper, take 40mg tomorrow, then 30mg the
following day, then 20mg, then 10mg, then stop.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2178-2-19**] at 4:10 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
.
Department: [**Hospital3 249**]
When: TUESDAY [**2178-3-31**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: RADIOLOGY
When: TUESDAY [**2178-12-8**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 4198**],[**Known firstname 540**] Unit No: [**Numeric Identifier 4199**]
Admission Date: [**2178-2-8**] Discharge Date: [**2178-2-14**]
Date of Birth: [**2109-4-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone / Adhesive Bandage
Attending:[**First Name3 (LF) 467**]
Addendum:
PT had acute hypoxemic and likely hypercarbic respiratory
failure during her admission to the ICU. Resolved during her
hospital course.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 468**] MD [**MD Number(2) 469**]
Completed by:[**2178-4-3**]
|
[
"244.9",
"785.0",
"305.1",
"V17.3",
"250.00",
"412",
"486",
"414.01",
"V87.41",
"V10.11",
"799.02",
"V45.82",
"285.9",
"518.81",
"V58.61",
"530.81",
"427.31",
"491.21",
"V12.54",
"V15.3",
"V10.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17348, 17508
|
10439, 14205
|
305, 312
|
14781, 14781
|
4914, 10416
|
15569, 17325
|
4183, 4301
|
14647, 14760
|
14231, 14597
|
14932, 15322
|
4316, 4895
|
2026, 2445
|
15342, 15546
|
258, 267
|
340, 2007
|
14796, 14908
|
3809, 4050
|
4066, 4167
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,402
| 130,655
|
24317
|
Discharge summary
|
report
|
Admission Date: [**2138-5-4**] Discharge Date: [**2138-5-12**]
Date of Birth: [**2069-7-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2698**]
Chief Complaint:
transfer for cath
Major Surgical or Invasive Procedure:
cardiac catheterization, GB drain placement
History of Present Illness:
68 yo M w/ hx HTN, [**Hospital **] transferred from [**Hospital1 487**] w/ acute
MI s/p intubation transferred to [**Hospital1 18**] for evaluation and
treatment. He presented had dry heaving and some SOB over [**12-1**]
days, w/out any CP. His wife called EMS [**1-1**] his worsening
dyspnea and he was found to have elevated jvp and hypoxia by EMS
on arrival. He was intubated in the field and transferred to
[**Hospital3 1443**] hospital. At OSH, pt was started on heparin
and integrillin gtt, s/p ASA, 80IV lasix and nitropaste 1",
morphine and versed. He became hypotensive and was started on a
dopamine gtt. He was transferred to [**Hospital1 18**] for evaluation and
treatment.
.
At cath pt found to LM and diffuse 3vd. He remained hypotensive
and was started on AIBP, dopa gtt and neosynephrine gtt, which
was eventually weaned off. He was bradycardic w/ HR in 40's and
received atropine w/ increased HR.
Past Medical History:
HTN, hyperchol
Social History:
SHX: lives at home w/ his wife, d/c'ed tobacco
Physical Exam:
AF 94.2 HR 55 BP 111/53 PAP 61/33 AIBP 1:1
AC 650 18 5 100% ABG 7.27/36/148
Gen: cauc obese M lying in bed, intubated, sedated in NAD
Neck: obese, thick
Heart: RRR, S1, S2, no m/r/g
Lungs: b/l breath sounds, no wheezing or rhonchi, no crackles
Abd: obese, S/NT/ND/no masses
Ext: 2+ pitting edema
Pertinent Results:
LABS @ [**Hospital1 487**]:
wbc 7.4 hct 33.9 plt 241
Na 138 K 5.4 Cl 108 CO2 18 BUN 60 creat 2.8 glu 318 Ca 9.1 AG 12
PTT 27 INR 1.1
CPK 493 trop I 9.10 [ref 0-0.50]
.
RAD: CXR pending
.
[**2138-5-4**] cath:
LMCA 80-90% distal, LAD 95% proximal, diffuse 50% mid, focal 90%
distal
intermedius: focal 90% prox
LCx 90% large OM1
RCA tubular 60% prox, 80% distal before PDA
CI 3.87 CO 8.98 PCWP 19
.
prelim read - bedside TTE on dopa, AIBP: ant HK, ant wall HK,
base w/ good contractility, LVEF ~ 30%, no significant valvular
disease; + aortic calcification and borderline AS.
.
EKG: sinus 55bpm, 2mm STE aVR, 1mm STD I, II; 2-3 mm STD V3-6
1mm STD V2;RBBB, q in V1, V3-6, III, aVF;
Brief Hospital Course:
This is a 68 yo male with acute MI in pulmonary edema and
cardiogenic shock with severe left main and 3 vessel disease s/p
cath with IABP placed, who was awaiting CABG and then became
septic.
.
# Cardiogenic shock - We continued the IABP, pressors for MAP <
55. Plan was for CABG but this had to be deferred as he became
septic. We continued ASA and statin, heparin gtt. TEE without
evidence of valvular disease.
#Sepsis: He continued to be hypotensive and swan numbers was
consistent with sepsis. Source was felt to be pneumonia with
MSSA and E. coli, pseudomonas in sputum. He was treated with
zosyn. His cortisol stimulation test was WNL. Then his LFT
bumped and he was presumed to have acalculous cholescystitis. A
gall bladder drain was placed by IR. Meropenum was added to
broaden coverage
#Anemia: He had some nose bleeding. ENT eval'd, packed nose. We
kept his hematocrit >30 with several transfusions.
.
# DMII - He was maintained on an insulin gtt for BG control.
.
# ARF - His renal funtion continued to deteroiate. Renal was
consulted. Felt to be secondary to ATN or contrast nephropathy.
He was treated with bicarbonate IVF.
.
#Elevated LFTs: GI consulted for possible acalculous
cholecystitis. Gallbladder drain was placed by Interventional
radiology.
.
#Given his poor prognosis, multiple family meeting were had. On
[**2138-5-12**] he ws made CMO and died comfortably with his family at
his side.
Medications on Admission:
Meds on transfer: integrillin, heparin, atropine, versed, lasix
80mg IV x 1, nitropaste 1", morphine, ASA 81mg x 4.
outpt meds:
lipitor, lopressor, norvasc, accupril, hctz
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased - sepsis, coronary artery disease
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"785.52",
"535.60",
"410.71",
"518.81",
"285.1",
"482.41",
"482.1",
"428.0",
"588.89",
"401.9",
"785.51",
"278.00",
"575.0",
"784.7",
"414.01",
"250.00",
"530.85",
"V15.82",
"995.92",
"584.9",
"272.0",
"038.9",
"428.20",
"482.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.61",
"96.72",
"45.13",
"88.56",
"37.23",
"99.04",
"99.20",
"96.6",
"51.01",
"21.01",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4136, 4145
|
2464, 3885
|
331, 376
|
4231, 4241
|
1760, 2441
|
4293, 4299
|
4108, 4113
|
4166, 4210
|
3911, 3911
|
4265, 4270
|
1443, 1741
|
274, 293
|
404, 1326
|
1348, 1364
|
1380, 1428
|
3929, 4085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
928
| 110,621
|
51843
|
Discharge summary
|
report
|
Admission Date: [**2122-4-25**] Discharge Date: [**2122-4-28**]
Date of Birth: [**2050-9-11**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Lopid
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
71 M with hx CAD and hyperlipidemia was admitted to [**Hospital 107367**]
Hospital for TURP [**4-24**] (day of admission to CCU). ASA was held
for sx which proceeded uneventfully. Postop, he developed CP
and neck pain. ECG was obtained demonstrating SR in the 70s and
5mm inferior ST elevation; pt was given ASA, nitrates, IV
heparin and xferred to [**Hospital1 18**].
.
In the cardiac cath lab, the SVG graft to RCA was down w/biliary
stent visualized. The lesion was felt to be high risk for
intervention and was thus not intervened upon. LCx was
occluded. FIC CO was 7.48.
Past Medical History:
CAD- several right coronary angioplasties in mid [**2096**]. Single
vessel bypass to RCA. Biliary stent to RCA bypass in [**2112**] c/b
MI. Report of LV dysfunction following cath; specific EF not
known.
Prostate hypertrophy s/p TuRP
Multiple urinary infections
Ulcerative colitis
Kidney stones
Arthritis
Colonic polyps
Social History:
Former smoker; quit mid [**2119**]. No excess EtOH. Wife passed away
in recent months.
Family History:
nc
Physical Exam:
81 89/54 20
Lying in bed s/p cath in NAD
PERRLA, MMM, no carotid bruits
CTAB
Nl S1/S
Soft, NT, ND, +BS
Ext warm X 4 w/+DP bil
A&O X 3; moving all 4 ext
Pertinent Results:
138 103 12
101
4.5 28 1.2
...............
15 300
35.5
.
Cath: Graft to RCA w/large biliary stent not patent. CO by Fick
7.48.
Brief Hospital Course:
A/P: 71 M with hx CAD and hyperlipidemia admitted with inferior
MI s/p TURP.
.
IMI: RCA lesion felt to not be ammenable to cath. Medical
management of AMI to consist of ASA 325 daily, Lipitor 80mg
daily, metoprolol 25mg [**Hospital1 **]. Patient was restarted on Toprol XL
at outpatient dose of 50mg QD prior to discharge. He was also
started on cozaar25mg daily. He is to continue the regimen on
discharge. His cardiac enzymes trended down by time of discharge
- 132 on d/c with peak of 1688 on [**2122-3-25**]. He was walking the
floor without chest pain/sob. TTE on [**4-27**] revealed 20%EF and:
1. The left atrium is mildly dilated.
2. The left ventricular cavity is moderately dilated. There is
severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is
severely depressed.
3. The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
4. The aortic valve leaflets are mildly thickened.
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-23**]+)
mitral regurgitation is seen.
EF severely depressed - out of proportion to damage likely to
occur from his acute event. The etiology of this is likely
ischemia vs HTN. Recommend nuclear stress test or other study
(ie cardiac MR) in future to assess viability of cardiac tissue.
Repeat TTE 1 month to consider ICD placement. F/u with
outpatient cardiologist within 2 weeks.
Plan for outpatient cardiac rehab.
.
S/P TURP- Patient was seen by urology during admission. CBI was
continued until early am of [**2122-4-28**]. Foley then d/c'ed and
patient had no difficulty with urination thereafter. Denied
dysuria. On day of d/c, he was day [**1-26**] of cipro with plans to be
placed back on bactrim ppx after cipro course complete.
.
FEN- Cardiac/HH diet.
.
Medications on Admission:
Cardizem CD 180mg QD, Toprol XL 50mg, lipitor 10mg QD, prilosec
20 QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain: Please take one
tablet if you develop chest pain. [**Month (only) 116**] repeat up to 2 more times
every 5 minutes if pain not resolved. Call you PCP if you
require this medication.
Disp:*15 tablets* Refills:*0*
8. Bactrim Oral
9. bactrim
Please continue your outpatient bactrim doses once you have
completed the course of ciprofloxacin.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Inferior MI s/p TURP
2. Hematuria s/p TURP
Secondary Diagnosis:
1. CAD s/p CABG (SVG-RCA) [**2101**]
2. Prostate Hypertrophy s/p TURP
3. ulcerative colitis
4. kidney stones
5. arthritis
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or return to the ED if you develop chest
pain, shortness of breath, difficulty with urination, or other
worrisome symtpoms.
Please complete your course of ciprofloxacin and once complete,
please restart your outpatient bactrim prophylaxis medication
Please take all medications as precribed.
Followup Instructions:
Follow up with your urologist, Dr. [**Last Name (STitle) 107368**] [**Telephone/Fax (1) 88926**]
Please call your cardiologist, Dr. [**Last Name (STitle) **], to schedule a follow up
appointment within 2 weeks of discharge. Please discuss with him
being set up with cardiac rehabilitation.
Please call your PCP to schedule [**Name Initial (PRE) **] follow up appointment within
6 weeks.
|
[
"410.41",
"600.00",
"996.72",
"424.0",
"272.4",
"E878.2",
"397.0",
"414.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
4829, 4904
|
1763, 3547
|
288, 313
|
5156, 5164
|
1587, 1740
|
5525, 5915
|
1395, 1399
|
3668, 4806
|
4925, 4925
|
3573, 3645
|
5188, 5502
|
1414, 1568
|
238, 250
|
341, 925
|
5011, 5135
|
4944, 4990
|
947, 1272
|
1288, 1379
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,528
| 135,392
|
42951
|
Discharge summary
|
report
|
Admission Date: [**2163-2-16**] Discharge Date: [**2163-2-23**]
Date of Birth: [**2083-3-6**] Sex: F
Service: MEDICINE
Allergies:
Natural Tears / Tetracyclines
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
mental status change, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 year-old woman with a history hx of COPD, CAD, DM2 who lives
at [**Hospital3 **], was in her usuall state of health until
yesterday, when she was found to be more lethargic and weak
appearing with VS being stable. Through the course of the day
her MS improved. Today, however her MS deteriorated and she was
found to be barely arousable. Her O2 sat was 82 on RA (87 on 4L
- baseline 96%-97%) and she was found to have a temp of 101.2.
Patient has a histrory of coagh however unbclear since how long.
No sick contacts. [**Name (NI) **] discussion with [**Hospital3 **] RN her
[**Last Name (un) **] was uncomlicated until yeasterday without focal signs ans
symptoms.
ED: Blood pressure noted to be as low as 78/49. Code sepsis was
initiated with a RIJ placed. Two liters of NS were given, along
with vanco/levofloxacin/zosyn. Norepinephrine was also started.
Past Medical History:
1. CAD - s/p mid-LCX [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22594**] to OM1 in [**4-29**], known 90% RCA
occlusion. Admitted with unstable angina [**10-29**], with reversible
lateral defect on MIBI, decision to medically manage.
2. DM type II - last HgbA1C in [**2-27**] was 6.2
3. PAF
4. Seizure disorder
5. COPD
6. Obesity
7. Venous stasis, h/o overlying cellulitis
8. Depression
9. Mycosis fungoides in [**2148**] (treated with phototherapy and put
into remission. Has not been a problem since that time,
according to the patient)
10. Hypothyroidism
11. Hypercholesterolemia
12. s/p bilateral TKR in [**2153**] - walks w/ walker at baseline
13. s/p right shoulder repair
Social History:
Currently lives at [**Hospital3 **]. Previously lived by herself
in [**Hospital1 3494**] in public housing. Continuing to smoke >1ppd+ x
50+ years. Not on O2 at home. No EtOH. Used to work as a banker
for Bank of [**Location (un) 86**], with power of attorney forms. Married and
divorced, no children.
Family History:
non-contributory
Physical Exam:
Vitals - BP 92/51, HR 84, 98% on facemask
Gen - cyanotic, but in NAD and no accessory muscle use,
appropriate affect.
HEENT - dry mm, thick secretions in mouth
CV - RRR
PULM - Bibasilar crackles.
ABD - Soft and non-tender.
EXT - Warm. No edema.
NEURO - Alert. Oriented to "[**Hospital3 **]". Unsure of date.
Pertinent Results:
[**2163-2-16**] 11:05AM WBC-5.7 RBC-4.52 HGB-12.6 HCT-37.7 MCV-84
MCH-27.9 MCHC-33.5 RDW-14.2
[**2163-2-16**] 11:05AM NEUTS-60 BANDS-25* LYMPHS-7* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2163-2-16**] 11:05AM GLUCOSE-133* UREA N-27* CREAT-1.5* SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-18
[**2163-2-16**] 11:10AM LACTATE-2.2*
[**2163-2-16**] 11:05AM ALT(SGPT)-48* AST(SGOT)-81* CK(CPK)-71 ALK
PHOS-108 AMYLASE-35 TOT BILI-0.4
[**2163-2-16**] 09:54PM TYPE-ART PO2-88 PCO2-36 PH-7.36 TOTAL CO2-21
BASE XS--4
.
CXR ([**2163-2-16**]) Markedly limited examination. The study is
degraded by respiratory motion and body habitus. No gross
consolidation is noted; however, there is a subtle increased
density within both lung bases, particularly in the retrocardiac
left lower lobe. The mediastinum is grossly stable. Lung
volumes are markedly diminished likely accentuating the cardiac
silhouette size, although there is a left ventricular
predominance noted. There is slightly asymmetrical left apical
pleural thickening noted. No pneumothorax is seen. The bones
are diffusely osteopenic with degenerative changes throughout
the thoracic spine.
IMPRESSION: Markedly limited study. Suggestion of bibasilar
opacities,
likely atelectasis; however, early developing pneumonias cannot
be excluded.
.
[**2163-2-16**] 11:05 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Anaerobic Bottle Gram Stain (Final [**2163-2-18**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
[**2163-2-16**] 11:41 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2163-2-17**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
Possible penicillin resistance by oxacillin screen.
Resistance to be confirmed by MIC testing.
STAPH AUREUS COAG +. RARE GROWTH.
Please contact the Microbiology Laboratory ([**5-/2461**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
YEAST.
Brief Hospital Course:
79 y/o female admitted with sepsis, believed from pulmonary
source, initially admitted to MICU and called out after rapid
improvement.
.
#. Septic shock: This was thought most likely to be due to
pneumonia. The pt never had clear infiltrate on CXR, however she
did have an impressive bandemia at the time of admission and
subsequently had an elevated WBC count. The pt grew S. Pneumo
and staph non-aureus from her sputum and staph non-aureus from
one blood culture bottle. She was briefly on levophed in the
MICU although blood pressures quickly improved with treatment.
.
#. Pneumonia: The pt was initiated on broad spectrum emperic
coverage (levofloxacin, vanocymicin and Zosyn) for presumed PNA.
When her culture results returned, she was continued on
levofloxacin and vancomycin only.
.
#. Acute renal failure: The pt's Cr was 1.5 at the time of
admission. This was thought to be due to a prerenal state in the
setting of poor PO intake and sepsis. Her Cr improved with IV
hydration and with the normalization of her overall clinical
status. It was 0.9 at the time of discharge.
.
#. AF: During her hospital course, the pt was noted to be in AF
much of the time with poor rate control. Based on a review of
old records, it appeared that she was not anticoagulated because
her AF burden was thought to be very low. As this did not appear
to be the case during her stay, anticoagulation was initiated
and the pt's beta blocker was titrated up to achieve better rate
control. Prior to discharge, the pt's INR was elevated to as
high as 7; she was given vitamin K and her INR was 1.4 on the
day of discharge. She had been receieving 5 mg daily; a dose of
2 mg a day, with frequent INR checks, is advised, particularly
as antibiotics are discontinued.
.
#. CAD: The pt's home ASA was continued. Plavix was stopped as
the pt is more than one year post-stent and she was started on
anticoagulation.
.
#. DM type II: The pt was maintained on an insulin sliding
scale. Her sugars were well-controlled.
.
#. Seizure disorder: Home Dilantin was continued.
.
# COPD: The pt's home albuterol and ipratropium were continued.
.
#: Hypothyroidism: Levothyroxine was continued.
.
#: Hypercholesterolemia: Home statin was continued.
Medications on Admission:
Advair 250/50 [**Hospital1 **]
furosemide 20 daily
gabapentin 200 tid
phenytoin 100 tid
ropinirole 3 mg qhs
isosorbid 45mg qhs
bisacodyl 10 mg supp
milk of magnesia
atrovent inhaler q6h
guiafenesin
proair 90mcg inhaler q6h
tylenol 2x325 q4h
Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO QAM (once a day (in
the morning)).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 100 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days: Day 1 = [**2163-2-17**]. Continue through [**2163-2-27**].
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000
(1000) mg Intravenous Q 24H (Every 24 Hours) for 7 days: Day 1 =
[**2163-2-17**]. Continue through [**2163-2-27**].
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
12. Ropinirole 1 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
13. Biscolax 10 mg Suppository Sig: One (1) Rectal once a day.
14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
15. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours.
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for 7 days.
17. Avandia Oral
18. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
pneumosepsis
renal failure
congestive heart failure
.
Secondary:
coronary artery disease
type two diabetes
seizure disorder
COPD
hypothyroidism
Discharge Condition:
Clinically improved, vitals stable.
Discharge Instructions:
-You were admitted with pneumonia and low pressure. We have
treated you with antibiotics, IV fluids and medicines to raise
your blood pressure. You are now doing much better and are being
transferred back to your nursing home for further care.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> Your metoprolol dose was increased and will continue to be
adjusted at [**Hospital3 2558**].
--> You were started on Coumadin; the exact dose is currently
being adjusted. 5 mg daily was found to be too much; you will
now be at 2 mg daily. You will need to have the effect of the
Coumadin on your blood checked with a test (INR) in the next 1
to 2 days.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please call and schedule an appointment with your primary care
doctor after you are discharged.
|
[
"496",
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"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9284, 9354
|
5086, 7306
|
317, 323
|
9551, 9589
|
2623, 4004
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10597, 10696
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351, 1213
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1235, 1927
|
1943, 2246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,838
| 102,892
|
2761
|
Discharge summary
|
report
|
Admission Date: [**2137-4-26**] Discharge Date: [**2137-6-5**]
Date of Birth: [**2072-11-26**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
abd distension/leg swelling
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram on [**2137-4-26**]
Paracentesis on [**2137-4-29**] and [**2137-5-2**]
EGD on [**2137-5-1**], [**2137-5-7**], [**2137-5-17**]
Colonoscopy [**2137-5-17**]
Transjugular liver biopsy on [**2137-5-3**]
History of Present Illness:
64 year old patient of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] who lives part time in the
[**Country 13622**] and part time in the US, just returned from the
[**Country 13622**]. Hx of CABG/Mechanical MVR in [**2131**] at [**Hospital1 18**], HIV+
(dx'ed approx 7 yrs). Admitted to [**Hospital1 34**] on [**4-23**] with decompensated
heart failure, endocarditis of aortic valve (seen on TTE), LVEF
40-45%. Blood cultures grew Enterococcus but no follow-up blood
cultures drawn. He states prior to admission he was getting
more short of breath, dry cough, his abdomen became more
distended, weight loss 15-20lb weight gain in past couple of
months, some abdominal pain, poor appetite, leg swelling. He
notes one day of fever. He denies any chest pain.
At [**Hospital6 33**], he was started on ceftriaxone and
azithro which was switched to Vancomycin, Gent, Ampicillin,
Azithro after ID was consulted. His CD4 count was checked and
was 50 (Viral load checked but currently do not have these
results). Patient does not know what medications he takes at
home, and has pill bottles of truvada and zerit. He identifies
Dr. [**Last Name (STitle) 6173**] as his ID physician although does not appear he has
seen him since [**2135**]. CT Abd/Pelvis done with old splenic
infarcts, ascites but no acute bowel pathology. Patient/wife
state that approximately one month prior he had a GI Bleed
requiring transfusion. They are unable to provide additional
info and tell me that they think he was admitted here (although
no record of this in our system). Troponin 0.08, CK negative.
They wanted to do TEE at [**Hospital3 **] but he has been too SOB to
tolerate it. As of this morning, nurse states that his
respiratory status looks stable; patient is able to lie flat so
transferred to [**Hospital1 18**] for TEE and further evaluation.
ROS: no CP, (+) DOE, (+) orthopnea, (+) LE edema, (+) fever (but
not currently), abd distension - but much improved, no blood in
stools recently
Past Medical History:
1. HIV (VL 175 on [**2135-6-21**])- on HAART
2. HTN
3. CAD s/p MI x 2 and 5V CABG [**2131**]
4. MVR [**2131**] w/ cabg
5. left thoracotomy [**8-5**] for pleural effusion
6. cord compression/spinal stenosis w/ c4-c6 laminectomy and
decompression [**10-7**]
7. H pylori positive [**9-5**] - unclear whether he got treated
8. EF 40% [**2132**]
9. anemia - fe deficiency (baseline hct 30), had been worked up
for pancytopenia in the past and this was when his HIV dx was
discovered. per pt, his only risk factor was transfusions during
CABG. Family all aware.
10. Type II DM
Social History:
+smoker, 1pack/day for 42 years, occasional EtOH, lives in
[**Hospital1 1474**] with wife and 2 sons. [**Name (NI) **] used to work in business
importing merchandise. Born in [**Country 13622**] Republic.
Family History:
Non-contributory
Physical Exam:
VS - 96.6F HR 67 145/70 16 100%/2L
205lbs
Gen: awake, alert, NAD
HEENT: PERRL, anicteric, OP clear, no evidence of thrush, small
area of erythema under tongue
Neck: supple, no LAD, JVP 9cm
CV: regular, S1, mech S2, soft systolic murmur
Pulm: Crackles bilaterally [**2-6**] way up with exp wheeze
Abd: (+) BS, distended, firm, mild, diffuse TTP, no rebound or
guarding
Ext: WWP, 2+ LE edema b/l, 1+ DP pulse b/l
skin: no rash
Pertinent Results:
TEE ECHOCARDIOGRAM [**2137-4-26**]:
The left atrium is dilated. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is dilated. LV systolic function appears
depressed. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The gradients are
higher than expected for this type of prosthesis. There is a 2.5
x 1 cm mass on the atrial side of the mitral valve prosthesis.
This may represent a vegetation or thombus. Mild to moderate
([**2-5**]+) mitral regurgitation is seen. This regurgitation is
central and there is no evidence of a paravalvular leak,
dehiscence, or abscess. There is no pericardial effusion.
CT TORSO [**2137-4-27**]:
TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and
pelvis are obtained with the administration of intravenous
contrast [**Doctor Last Name 360**], 130 cc of Optiray. Multiplanar reformation
images are reconstructed.
CHEST: The patient is status post CABG with median sternotomy.
Coronary
arteries are calcified. There is moderate cardiomegaly. The
patient is post mitral valve replacement. There is edema in the
mediastinum. Right
hemidiaphragm is eventrated. There is bilateral small pleural
effusion. In
the lung window, note is made of bibasilar plate-like
atelectasis. Evaluation of the lung is somewhat limited due to
motion artifact. There is diffuse anasarca.
ABDOMEN: There is massive ascites, as mentioned in the history.
There is no evidence of free air or fluid collection or abscess
in the abdomen.
Gallbladder is unremarkable without evidence of calcification.
There is a
large cystic lesion in the spleen, measuring 5.6 cm. There is no
evidence of bowel obstruction. There is no calcification in the
gallbladder. Pancreas is unremarkable. Adrenal glands and
kidneys are within normal limits. The hepatic vasculatures are
not completely assessed on this single-phase study, however,
there is no definite clot in the portal vein visualized. There
are several areas of hypodensities in the spleen.
PELVIS: There is massive ascites. Appendix is normal filled with
oral
contrast. There is no evidence of bowel dilatation.
There is no suspicious lytic or blastic lesion in skeletal
structures.
IMPRESSION:
1. Massive ascites and anasarca. No evidence of abscess or fluid
collection in the abdomen.
2. 5.6 cm fluid collection in the spleen with several foci of
hypodensity in the spleen, probably representing infarction with
necrosis. There is no
secondary sign of infection.
3. Atelectasis in the lungs with edema in the mediastinum and
cardiomegaly, post-CABG.
LIVER ultrasound with dopplers [**2137-4-27**]: 1. Heterogeneous nodular
liver consistent with history of cirrhosis with associated free
fluid. No focal liver lesions identified. 2. Normal hepatic
Doppler waveforms.
EGD [**2137-5-1**]: No esophageal varices. Dieulafoy lesion in the
proximal stomach body (ligation). There was no portal
hypertensive gastropathy, andd no gastric varices. Blood in the
stomach body. Otherwise normal EGD to second part of the
duodenum
EGD [**2137-5-7**]: Grade I esophageal varices in the distal esophagus.
Erythema and congestion in the stomach. Normal mucosa in the
duodenum. Recommendations: [**Hospital1 **] proton pump inhibitor. No source
of bleeding seen on this exam. No contraindication to
coumadinization.
CXR [**2137-5-1**]: PICC with tip overlying proximal portion of the
superior vena
cava.
EGD [**2137-5-17**]: Impression: Normal mucosa in the esophagus. Normal
mucosa in the stomach. Normal mucosa in the duodenum.
COLONOSCOPY [**2137-5-17**]: Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum.
Liver Biopsy Pathology [**2137-5-3**]:
Liver, transjugular biopsy:
1. Minimal portal and lobular mononuclear inflammation.
2. No fatty change, features of venous outflow obstruction are
seen..
3. Trichrome stain shows focal increased sinusoidal fibrosis.
4. Reticulin stain shows no definitive features of nodular
regenerative hyperplasia.
5. Iron stain shows no stainable iron.
Brief Hospital Course:
64 year old male with CAD s/p CABG and mech mitral valve [**2131**],
HIV+ CD4 50, DM2, transferred from outside hospital with CHF,
Enterococcal endocarditis, and ascites. Course here complicated
by chronic GI bleeding and fevers. See below for hospital
course by problem.:
1) Endocarditis: TEE done on [**4-26**] revealed a vegetation on his
prosthetic mitral valve. Sensitivities from the outside
hospital indicated sensitive to PCN and vancomycin, with high
resistance to Gentamicin and streptomycin. ID was consulted for
further management and recommended changing to ampicillin and
ceftriaxone, based on sensitivities done at [**Hospital1 18**]. The first
day of these medications is [**4-29**], and he is to continue these
medications for 8-12 weeks as directed by infectious disease,
with whom he will follow up. Daily EKGs were followed, and were
without evidence of abscess or conduction disease. Of note, OSH
TTE showed possible aortic (and not mitral) vegetation which was
not seen on TEE here. Blood cultures were persistently
negative.
2) GI Bleed: On [**5-1**] his Hct was noted to drop from 27 the day
prior to 22. He was guaiac positive. He underwent EGD and
blood was seen in the stomach as well as a Dieulafoy's ulcer,
which was was ligated. He was transfused 2 units pRBCs and Hct
stabilized. He was started on PPI iv bid. He had an episode of
melena on [**5-4**] and was transfused 2 additional units with
appropriate increase in Hct. He underwent repeat EGD on [**2137-5-7**]
and no active bleeding was seen. His hematocrit continued to
gradually trend down, with trace guaiac positive stools,
therefore he had a third EGD, this time with colonoscopy, on
[**5-17**]. Again, these were unrevealing. His anemia was felt to be
multifactorial, possibly with a chronic slow GI bleed, but also
secondary to chronic disease (HIV) and chronic renal failure
(see below). On [**5-31**] the patient had another hematocrit drop to
19, with melena. This time a tagged RBC scan was performed,
which demonstrated a proximal source of bleeding, likely
stomach. He was transferred to the CCU where he had another
EGD, this time with visualization of bleeding from clips at site
of Dieulafoy. This lesion was reclipped, and it was decided to
hold his heparin and coumadin to achieve a period of 24 hours
completely off anticoagulation to see if this lesion would clot.
Heparin was restarted on the evening of [**6-3**] and his hematocrit
was stable >31 after a day. He should be started on Warfarin
starting tonight at 5mg but of note, he required high doses to
be therapeutic in the past (9mg). He will start back on
Warfarin on the evening of [**6-4**] at 5mg and recheck PT/INR daily
and trend up to therapeutic before discontinuing Heparin.
Monitor HCT daily given recent bleed. He should continue on
protonix 40 mg [**Hospital1 **] until instructed otherwise.
3) Chronic renal failure: Creatinine baseline appears to be
around 1.0, however he has been between 1.3 and 2.0 on many
occasions over the last few years, likely related to his fluid
balance, making his clearance < 60. Given his persistent
anemia, he was started on erythropoetin 8,000 units per week as
well as iron. He should have a repeat hemoglobin in 2 weeks and
every 2-4 weeks thereafter. Goal hemoglobin is [**12-16**], so if >
12, stop erythropoetin.
4) CHF: Echo at the outside hospital revealed EF 45-50%, which
is likely underestimated in the setting of mitral regurgitation.
He was diuresed aggressively initially, and ultimately
restarted on PO lasix 80 mg daily, which maintained an even
fluid balance. He should continue lasix, however dose should be
increased if he is consistently gaining weight. He was also
continued on lisinopril 5 mg daily for afterload reduction,
spironolactone 50 mg daily, and metoprolol XL 75 mg daily.
5) Ascites: Etiology remained elusive despite extensive
investigation. In the end, it is felt most likely secondary to
liver cirrhosis with sampling error on the liver biopsy making
fibrosis look less extensive than it is. Reported history of
HBV and HCV, however here he is HCV negative, and has prior HBV
exposure but negative surface antibody and antigen. He does
have a history of heavy EtOH. His transaminases were never
elevated, though alk phos was mildly elevated at 200 (with
elevated GGT). HIV cholestasis is possible. Anti-mitochondrial
antibody was negative (making primary biliary cirrhosis less
likely). [**Doctor First Name **] was mildly positive, with elevated IgG, however
without transaminase elevation auto-immune hepatitis was less
likely. He ultimately underwent liver biopsy which showed only
mild portal inflammation. Hepatology felt that his ascites was
unlikely to be secondary to a primary liver process, however
again, this seems statistically most likely. Additionally, he
had 2 diagnostic/therapeutic paracentesis, both of which
demonstrated SAAG < 1.1, with many WBC and > 250 polys. He was
already on ceftriaxone for his endocarditis, and cultures were
without growth, making an infectious etiology unlikely.
Potential etiologies include liver disease with pseudoexudate
from diuresis, versus TB peritonitis, versus carcinomatosis. CT
abdomen with contrast was negative for peritoneal
carcinomatosis, and cytology was negative from the ascites.
Acid fast smears were negative, though culture is still pending.
Surgery was consulted for consideration of peritoneal biopsy,
however they felt that given the possibility that this is
pseudoexudate from diuresis, he would best be followed up as an
outpatient. They also felt that peritoneal biopsy would be
unlikely to yield the diagnosis. He will see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in outpatient surgery clinic. His last paracentesis was on
[**5-29**], about 10 days after his last one. He will therefore
probably need paracenteses at rehab every 2 weeks or so. This
should be done when his abdomen is tense. He tolerated these
without any difficulty, without any creatinine elevations. He
will continue on lasix 80 mg daily, spironolactone 50 mg daily.
5) Pseudogout: He complained of acute onset left knee pain
shortly before discharge. He had an effusion that was tapped,
revealing calcium pyrophosphate crystals consistent with
pseudogout (no evidence of septic arthritis). His pain actually
remitted on its own without treatment. If this pain recurrs
could use colchicine 0.6 mg daily (decreased dose for renal
failure).
6) Atrial fibrillation: He was in sinus rhythm during this
hospitalization. He was continued on coumadin for
anticoagulation, with heparin drip while subtherapeutic (he
always needs to be anticoagulated with heparin bridge while INR
< 2.5 given structural AF in the setting of mitral regurgitation
and high risk of embolus). His INR was stable at 3.0 on 8 mg of
coumadin.
7) Mechanical mitral valve: His INR subtherapeutic for the
majority of the hospitalization and his coumadin was held at
various times for procedures. Prior to procedures, his INR
seemed to be stable at 3.0 on 8 mg of coumadin. Needs frequent
INR checks until therapeutic consistently on a stable dose of
coumadin.
8) HIV: It was unclear whether or not he had actually been
taking antivirals before admission, and ID recommended holding
HAART for now. CD4 count 50 at outside hospital. Bactrim DS
was started for PCP [**Name Initial (PRE) 1102**]. Azithromycin for MAC
prophylaxis will be considered as an outpatient (once acid fast
cultures from peritoneal fluid are known to be negative).
9) DM: Continued insulin sliding scale and monitored finger
sticks. It is unclear if the patient is on a medical regimen as
an outpatient for this. Meformin is contraindicated given his
creatinine, and thiazolidenediones are difficult in the setting
of CHF (fluid retention). A sulfonylurea is a possibility, but
this can be started at rehab or in the outpatient setting -
given his renal insufficiency would use glipizide rather than
glyburide. For now, continue insulin sliding scale.
10) Nutrition: Ordered for a diabetic/cardiac diet.
11) Access: He had a PICC placed on [**5-1**], confirmed in good
position by CXR and in working order.
Medications on Admission:
Largely unknown. Patient states he was taking coumadin, he also
had bottles of truvada and zerit on admission to OSH.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Enterococcus Endocarditis
Coronary artery disease
Congestive heart failure
Mechanical mitral valve
HIV
Diabetes Mellitus
Ascites
Dieulafoy lesion with upper GI bleeding
Anemia
Chronic kidney disease
Discharge Condition:
Ambulating, afebrile, no joint pain.
Discharge Instructions:
As you know, you had an infection on your heart valve. You will
be at rehab in order to received your IV antibiotics for another
4-6 weeks or so - the duration of the course will be determined
by your infectious disease doctors.
You will need to get the fluid in your abdomen drained out
periodically. This can be done at rehab.
Please call your primary care physician [**Last Name (NamePattern4) **] 911 if you experience
fevers, chills, chest pain, shortness of breath, increased leg
swelling, weight gain, nausea, vomiting, abdominal pain or other
concerning symptoms.
Followup Instructions:
Please schedule follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 8499**] ([**Telephone/Fax (1) 7976**]) within 1-2 weeks after discharge from
Rehab.
Please schedule follow-up with Dr. [**Last Name (STitle) 73**]
(Cardiology),([**Telephone/Fax (1) 1920**], within 1 month from discharge from
the hospital.
You have a follow-up appointment scheduled with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 673**], in transplant surgery clinic for
consideration of peritoneal biopsy: Date/Time:[**2137-6-14**] 2:20p.m.
You have a follow-up appointment scheduled in the Infectious
Disease Clinic with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2137-6-24**] 10:30
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
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icd9cm
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[
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icd9pcs
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16732, 16805
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8316, 16563
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297, 527
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17048, 17087
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3882, 8293
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3175, 3384
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,032
| 195,697
|
23332
|
Discharge summary
|
report
|
Admission Date: [**2140-1-29**] Discharge Date: [**2140-1-30**]
Date of Birth: [**2083-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
femoral line
intubation
History of Present Illness:
56 year-old male with recently diagnosed large cell lung cancer
metastatic to brain, malignant pericardial and pleural effusion,
discharged from [**Hospital1 18**] only 3 days ago, now returns from rehab
with altered mental status.
This all began in mid-[**Month (only) **] when he presented in pericardial
tamponade and underwent emergent pericardiocentesis and window.
He was also found at the time to have a pulmonary embolus and
bulky right hilar lymphadenopathy. Bronchoscopy and
mediastinoscopy for lymph node biopsy performed on [**12-10**] revealed
a poorly differentiated carcinoma on staining, most consistent
with a lung large cell malignancy, with invasion of the large
vessels. Staging PET scan showed extensive disseminated
FDG-avid disease throughout the
neck, chest, abdomen and pelvis. Head MRI showed multiple tiny
ring-enhancing lesions throughout the supra and infratentorial
compartments highly
suspicious for metastatic disease. Patient admitted [**2140-1-8**] with
bilateral malignant pleural effusions that repeatedly recurred
post-thoracentesis. He underwent talc pleurodesis and was
discharged on [**2140-1-26**] to [**Hospital1 **].
He was given cycle #1 of carboplatin/taxol with the plan to get
cyle #2 in 3 weeks followed by whole brain radiation.
.
He was sent from [**Hospital1 **] today for obtundation, hypotension,
and tachycardia with complaint of shortness of breath and per
report, with low grade fevers. On arrival to the ED, vital
signs temp 93.9, BP 92/70, HR 132, RR 32. BP dropped to 64/20,
cordis placed into his right femoral vein, given total of 4L NS,
started on Levophed, seen by cardiology who performed a bedside
echocardiogram which showed no evidence of RA/RV collapse.
Patient's breathing appeared labored and he was reportedly more
confused with ABG of 7.26/45/131, patient was intubated for
respiratory distress, acidosis and airway protection with his
worsening mental status.
CXR showed pulmonary edema.
Past Medical History:
1. Large Cell Lung Cancer metastatic to brain s/p 1 cycle of
carboplatin/taxol (planned for cycle#2 in 3 weeks followed by
whole brain radiation
2. History of Tamponade s/p pericardiocentesis and window on
[**2139-11-20**]
3. Hypertension
4. Chronic Lower back pain.
5. s/p Appendectomy
6. recurrent bilateral pleural effusion s/p left talc
pleurodesis on [**2140-1-19**]
Social History:
Pt is on disability secondary to LBP. He used to work in
construction. He is lives with his partner [**Name (NI) **] of 30 years. He
has no children with [**Doctor First Name **] but [**Doctor First Name **] has a 30-something year old
son. [**Name (NI) **] smoked 2.5-3 ppd for 35 years, quitting a few weeks
ago when he was diagnosed. Smoked a few cigarettes a day still.
1-2 drinks per week. Drank 18 beers per night up until 3 months
ago. Smoke marijuana in past. No IVDU.
Family History:
Mom died of lung cancer.
Dad died of polio.
Three brothers and one sister, who are alive and healthy.
Physical Exam:
Pulseless, Apneic
No breath sounds or heart sounds
No response to nailbed pressure or sternal rub
Pertinent Results:
[**2140-1-30**] 01:14a ABG: pH 7.31 pCO2 39 pO2 120 HCO3 21
Type:Art; Intubated; FiO2%:60; Rate:20/3; TV:500; PEEP:5;
Temp:37.0
K:4.9 Hgb:12.8 CalcHCT:38 freeCa:1.12 Lactate:3.7
[**2140-1-29**] 09:13PM TYPE-ART PO2-131* PCO2-45 PH-7.26* TOTAL
CO2-21 BASE XS--6 INTUBATED-NOT INTUBA
[**2140-1-29**] 09:13PM freeCa-1.17
[**2140-1-29**] 08:09PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2140-1-29**] 08:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2140-1-29**] 07:55PM LACTATE-2.9*
[**2140-1-29**] 07:44PM GLUCOSE-72 UREA N-36* CREAT-0.9 SODIUM-140
POTASSIUM-3.0* CHLORIDE-112* TOTAL CO2-18* ANION GAP-13
[**2140-1-29**] 07:44PM ALT(SGPT)-35 AST(SGOT)-21 CK(CPK)-15* ALK
PHOS-46 TOT BILI-0.4
[**2140-1-29**] 07:44PM cTropnT-<0.01
[**2140-1-29**] 07:44PM CK-MB-NotDone
[**2140-1-29**] 07:44PM ALBUMIN-2.0* CALCIUM-5.5* PHOSPHATE-2.7
MAGNESIUM-1.2*
[**2140-1-29**] 07:44PM WBC-7.4# RBC-3.22*# HGB-9.7*# HCT-29.5*#
MCV-92 MCH-30.0 MCHC-32.7 RDW-19.3*
[**2140-1-29**] 07:44PM NEUTS-80.2* LYMPHS-13.2* MONOS-6.3 EOS-0.2
BASOS-0.1
[**2140-1-29**] 07:44PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-1+
[**2140-1-29**] 07:44PM PLT COUNT-173#
[**2140-1-29**] 07:44PM PT-19.6* PTT-49.1* INR(PT)-2.4
[**2140-1-29**] 07:44PM D-DIMER-170
CT CHEST W/CONTRAST [**2140-1-30**] 2:21 AM
1) Increase in size of right pleural effusion, and decrease in
left pleural effusion. Stable large pericardial effusion, with
nodularity along the anterior and superior aspect of the
pericardium.
2) Bibasilar atelectasis and consolidation. Additional
atelectasis within the lingula.
3) Stable mediastinal and hilar lymphadenopathy.
4) Emphysematous changes and diffuse intralobular septal
thickening and nodularity, suggestive of lymphangitic spread of
tumor.
Brief Hospital Course:
56 year-old male with metastatic large cell lung cancer, h/o
pericardial tamponade s/p pericardiocentesis and window,
malignant pleural effusion s/p talc pleurodesis, pulmonary
embolus, now presents with altered mental status, respiratory
distress, and hypotension.
Patient was intubated (as noted), started on levophed to
maintain blood pressure, however, and patient was thought to be
in sepsis with respiratory compromise from recurrent pleural
effusion. Patient was found to have enlarged right pleural
effusion, with stable left, and pulsus paradoxicus of 10
(similar to last admission). In addition, patient had
intermittent episodes of tachycardia to 190s, thought to be
secondary to myocardial irritability as a result of residual
malignant pericardial effusion.
Plans were made to aggressively treat patient including
diagnostic/therapeutic thoracentesis and aggressive volume
resuscitation for presumed sepsis. However, given his
progressive and rapid clinical decline (including now
lymphangitic spread of NSCLC) despite chemotherapy, a discussion
was held between the patient's primary oncology fellow and the
patient's family with regard to goals of care. Therefore, the
decision was made on hospital day two to withdraw care and
extubate the patient. Patient was given morphine for comfort
following extubation, and expired 20 minutes following
withdrawal of ventilation and blood pressure support.
Medications on Admission:
spironolactone 25mg PO once daily
metoprolol 50mg PO BID
Lasix 40mg PO once daily
Klonopin 0.5mg PO BID
Atrovent nebs prn
albuterol nebs prn
lorazepam 1mg Q6H PRN
lactulose 20mg PO once daily
Lovenox 100mg SC BID
Ambien 5mg PO QHS
senna
colace
APAP
phenergan prn
oxycodone prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Stage IV large cell lung cancer
Probable Bacterial Sepsis
Malignant pleural effusions
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"518.81",
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"995.92",
"518.0",
"709.9",
"198.89",
"785.0",
"428.0",
"785.52",
"198.3",
"707.05",
"197.2",
"458.9",
"038.9",
"162.8",
"196.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"38.91",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7150, 7159
|
5374, 6795
|
336, 361
|
7288, 7297
|
3502, 5351
|
7349, 7355
|
3265, 3369
|
7122, 7127
|
7180, 7267
|
6821, 7099
|
7321, 7326
|
3384, 3483
|
275, 298
|
389, 2360
|
2382, 2755
|
2771, 3249
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,974
| 140,218
|
53706+59539
|
Discharge summary
|
report+addendum
|
Admission Date: [**2125-3-31**] Discharge Date: [**2125-4-9**]
Date of Birth: [**2075-11-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
"left face,arm/leg flushing"
Major Surgical or Invasive Procedure:
[**4-5**] Right craniotomy resection of right parietal mass
History of Present Illness:
This is a 49 year old male who was at work today when he
experienced left facial, arm and leg flushing sensation,
followed
by left facial twitching and loss of consciousness. The patient
was found by his co- workers and came to. He was initially
amnestic to the event but is beginning to recall events now. He
was taken to [**Hospital3 26615**] Hospital via EMS and a Head CT revealed
a right sided brain mass. The patient was transferred here for
further evaluation and treatment. He states that he drinks 6
beers a day and has done that for a very long time. He states
that he was drinking quite a bit last night.
Currently, he states that he has numbness over his left eyes and
forehead and feels generally weak all over. He denies nausea or
vomiting. He denies focal weakness, hearing or vision deficit.
He denies difficulty with speech, bowel or bladder dysfunction.
In [**2124-11-16**], he experienced blood in his urine and was
evaluated by his primary care physician and [**Name Initial (PRE) **] urologist. The
workup was negative and the hematuria has since resolved. He has
been experiencing insomnia for the past 1 month.
Past Medical History:
HTN, hypercholesteremia, ETOH daily use, gout
Social History:
Married with three sons and has a son and daughter from
a prior marriage. He drinks 6 beers a day. He denies smoking.
He works as an electrician
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
O: T:98.3 BP: 136/106 HR:76 R:17 O2Sats:100%
Gen: comfortable, NAD.
HEENT: NO battle sign, No hemotympanum, NO otorrhea.
Pupils:[**3-20**] EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-17**] 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, 4 to 3
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 [**4-21**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements.
On the day of discharge
Nonfocal
Incision c/d/i with sutures
Pertinent Results:
[**2125-3-31**] 05:55PM PT-10.7 PTT-26.8 INR(PT)-1.0
[**2125-3-31**] 05:55PM PLT COUNT-201
[**2125-3-31**] 05:55PM NEUTS-89.0* LYMPHS-7.3* MONOS-3.2 EOS-0.4
BASOS-0.1
[**2125-3-31**] 05:55PM WBC-8.2 RBC-4.23* HGB-13.3* HCT-37.1* MCV-88
MCH-31.3 MCHC-35.7* RDW-12.9
[**2125-3-31**] 05:55PM ALBUMIN-4.4
[**2125-3-31**] 05:55PM ALT(SGPT)-25 AST(SGOT)-30 LD(LDH)-213 ALK
PHOS-61 TOT BILI-0.4
[**2125-3-31**] 05:55PM estGFR-Using this
[**2125-3-31**] 05:55PM GLUCOSE-99 UREA N-16 CREAT-1.4* SODIUM-140
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2125-4-1**] MR [**Name13 (STitle) **] with without contrast *******
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2125-4-1**] 01:25 Straw Clear 1.004
Source: CVS
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2125-4-1**] 01:25 NEG NEG 30 NEG NEG NEG NEG 5.5 NEG
Source: CVS
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2125-4-1**] 01:25 <1 1 NONE NONE 0
Source: CVS
OTHER URINE FINDINGS Mucous
[**2125-4-1**] 01:25 RARE
Source: CVS
[**2125-4-1**]- EKG**********
[**2125-4-2**] Functional MR [**Name13 (STitle) **]- Successful functional MRI
demonstrating the major activation
areas for the movement of the hands and feet, with no
significant activation
adjacent to the right frontal mass lesion. The movement of the
tongue
demonstrates areas of activation adjacent to the mass lesion at
approximately
5 mm. The language paradigm demonstrates the majority of the
activation on
the left cerebral hemisphere, likely related with dominance.
Unchanged mass lesion identified on the inferior aspect of the
right frontal
lobe, the DTI tractography shows deviation of the major fibers
adjacent to
this lesion. The ASL sequence demonstrates a hyperintense ring
suggesting
hyperperfusion.
[**2125-4-2**] CT Chest/Abdomen/pelvis -
1. Millimetric pulmonary parenchymal densities in the left lung
as described.
The lesions are unlikely to be of clinical significance;
however, interval
followup non-contrast CT of the chest in 12 months is advised to
ensure
stability.
2. Thickening of the descending colon and sigmoid and also the
terminal ileum
are suggestive of a colitis and terminal ileitis of uncertain
etiology.
Multiple nonenlarged mesenteric lymph nodes are suggestive of a
chronic
inflammatory process involving the bowel. Correlation with
patient's symptoms
and prior medical history is warranted in addition to direct
visualisation at
colonoscopy.
3. No evidence of a primary tumor.
[**4-5**] BRAIN MRI (WAND) - There is no short interval change with
regard to the previously reported large centrally cystic,
peripherally enhancing 4 x 4 cm mass involving the right frontal
or insular lobe. A relatively moderate perilesional vasogenic
edema is likewise unchanged
[**4-5**] CT Head - s/p right craniotomy, post op changes, cerebral
edema
MR HEAD W & W/O CONTRAST [**2125-4-6**]
Status post right frontal lobe mass resection, expected
post-surgical changes are seen with small amount of blood along
the
frontotemporoparietal region with persistent and unchanged
vasogenic edema.
Nodularity and enhancement is noted in the surgical cavity,
followup with MRI after resolution of the surgical blood
products is recommended. No diffusion abnormalities are detected
to indicate acute or subacute ischemic changes.
Brief Hospital Course:
This is a 49 year old male who was at work on [**3-31**] when he
experienced left facial, arm and leg flushing sensation,
followed
by left facial twitching and loss of consciousness. He was taken
to [**Hospital3 26615**] Hospital via EMS and a Head CT revealed a right
sided brain mass. The patient was transferred here for further
evaluation and treatment and was seen by the Neurosurgery
service. The patient was evaluated and admitted to the floor
with every 4 hour neurological assessment by nursing. A MRI of
the Brain was performed overnight which was consistent with
right parietal brain mass. The patients creatinie was 1.9 and
the CT of the torso was post poned to [**4-2**].
On [**4-1**], The patient's neurological exam was intact. Surgery
for resection and biopsy of the new right sided lesion was
discussed with the patient. Radiology and neurology oncology
were consulted. The Dilantin level was corrected at 8.4 and a
500 mg Dilantin bolus was given for a goal of therapeutic
dilantin level of [**10-6**]. Decadron 4mg po every 6 hours was
initiated. Creatine level was elevated to 1.9 and therefore the
CT Torso was cancelled and rescheduled for monday. IVF normal
saline at 100cc/hr were ordred for hydration in anticipation of
the contrast for imaging studies on Monday.
On [**4-2**], a functional MR was ordered for operative planning and
was completed. He had a seizure with left facial numbness and
thick speech. He was given ativan, his dilantin increased and
then switched to keppra per Dr [**Last Name (STitle) 724**]. On [**4-3**] he remained stable
in the ICU. Neurology was consulted for help with managment of
his seizure medications. Patient has not seized since the [**4-2**],
but to adequately cover him, his keppra was increased to 1500mg
[**Hospital1 **]. He was transferred to the SDU in stable condition. On [**4-4**],
patient was consented for a R craniotomy and pre-operative labs
and imaging ordered. He remains nonfocal on exam.
On [**4-5**], pt underwent the above stated procedure. He tolerated
the procedure well without complications. He was extubated
without incident and was transferred to ICU in stable condition.
A head Ct post op demonstrated post-operative changes and mild
cerebral edema. His blood pressure was elevated in ICU and
required nicardipine gtt for blood pressure control. He was
noted to have a left facial droop at nasolabial fold and
pronator drift. Patient remained on dexamethasone for cerebral
edema. He also required dilaudid PCA for pain management. On
[**4-6**], patient was still hypertensive. He was monitored in the
ICU and placed on a nicardipine gtt to help keep SBP wnl. On
[**4-7**], patient remained intact. He was transferred to the floor
with tele to continue monitoring SBP. On [**4-8**], patient was seen
to be ambulating with nursing independently and neurologic exam
stable. On [**4-9**], patient was discharged home in stable condition
to follow up with brain tumor clinic for further treatment.
Medications on Admission:
amlodipine 5', lisinopril 40'
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. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
10. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
Disp:*10 Patch Weekly(s)* Refills:*2*
11. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
Disp:*60 Tablet(s)* Refills:*2*
12. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Please take 3mg Q8H x 1 day then take 2mg Q8H x 1 day,
then 2mg [**Hospital1 **] until seen in clinic.
Disp:*QS Tablet(s)* Refills:*2*
13. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
right parietal brain mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-26**] days (from your date of
surgery) for removal of your 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 on [**2125-4-16**]
11:30a [**Last Name (LF) **],[**First Name3 (LF) **] TUMOR
[**Hospital6 29**], [**Location (un) **]
NEUROLOGY UNIT CC8 (SB
The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**],
in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
****Please follow up with your primary care physician for
further management of blood pressure medications.*****
Completed by:[**2125-4-9**] Name: [**Known lastname **],[**Known firstname 1558**] Unit No: [**Numeric Identifier 18056**]
Admission Date: [**2125-3-31**] Discharge Date: [**2125-4-9**]
Date of Birth: [**2075-11-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14523**]
Addendum:
Pt requesting codeine instead of dilaudid for pain control. He
also requested some ativan to help with his anxiety. His scripts
were changed at discharge to reflect these.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 6578**] [**Last Name (NamePattern4) 14524**] MD [**MD Number(2) 14525**]
Completed by:[**2125-4-9**]
|
[
"401.9",
"348.5",
"272.0",
"191.1",
"274.9",
"780.39",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
14960, 15128
|
6623, 9623
|
339, 401
|
11265, 11265
|
3204, 6600
|
13317, 14937
|
1824, 1842
|
9703, 11166
|
11216, 11244
|
9649, 9680
|
11416, 13294
|
1872, 2090
|
270, 301
|
429, 1575
|
2383, 3185
|
11280, 11392
|
1597, 1644
|
1660, 1808
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,319
| 177,053
|
10745
|
Discharge summary
|
report
|
Admission Date: [**2124-11-6**] Discharge Date: [**2124-11-11**]
Date of Birth: [**2095-3-3**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: I was asked to see this patient
in consult by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] of cardiology. This
29-year-old male with history of hypertension,
hypercholesterolemia, is status post chemotherapy and x-ray
therapy for Hodgkin's disease. He has had [**3-18**] month history
of exertional chest discomfort which was relieved with rest.
He underwent a stress echocardiogram on [**10-27**] which was
stopped secondary to anginal symptoms. His EF at that time
was 40-45% with wall motion abnormalities. He then underwent
cardiac catheterization on [**10-31**] which showed an ejection
fraction of 40-45%, no MR, a 50% left main lesion, a 99%
proximal LAD lesion. His circumflex and right coronaries
were okay. He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for off pump
coronary artery bypass grafting.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
fatty liver with elevated LFTs, Hodgkin's disease, status
post chemotherapy and radiation therapy at age 15. He had a
remote history of tobacco. He also had a positive family
history in that his mother had a myocardial infarction at age
37.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission include Aspirin 81 mg po q d.
PHYSICAL EXAMINATION: Heart rate 83, blood pressure 121/76,
he was satting 100% on room air. His HEENT exam was benign.
He had 2+ bilateral carotid pulses with no bruits or JVD.
His lungs were clear bilaterally. Heart was regular rate and
rhythm with no murmur, rub or gallop. He had a
noncontributory abdominal exam. His extremities had no
clubbing, cyanosis or edema. His radial artery had 2+
bilateral pulses as well as 2+ DP and PT pulses.
Neurologically is grossly intact, alert and oriented times
three.
Preoperative labs were sent off in preparation for his future
surgery with Dr. [**Last Name (STitle) 1537**] when he was seen on the 18th and the
patient returned on [**11-6**] for surgery and had an off pump
coronary artery bypass grafting times one with a LIMA to the
LAD by Dr. [**Last Name (STitle) 1537**]. He was transferred to cardiothoracic ICU in
stable condition on a Propofol drip.
HOSPITAL COURSE: On postoperative day #1 the patient had
been extubated the day prior. His postoperative labs were
white count 8.1, hematocrit 21.3, platelet count 153,000,
potassium 3.9, sodium 135, chloride 101, CO2 27, BUN 7,
creatinine 0.6 and blood sugar 96. He was tachycardic
slightly at 111, in sinus rhythm with a blood pressure of
98/52 and T max of 101.7. He was satting 95% on two liters
nasal cannula. He started on his beta blocker and Lasix
diuresis. His diet was advanced. His hematocrit was
followed closely. He continued to finish his perioperative
antibiotics and was on no hemodynamic drips at that time. He
was alert and oriented postoperatively and neurologically
intact. On postoperative day #2 he had no events overnight,
he remained tachycardic, in sinus rhythm at 114 on his
Lopressor which was increased to 25 mg [**Hospital1 **]. He also started
his Plavix and continued with Lasix. His hematocrit remained
stable at 21.3 with a potassium of 4.3 and creatinine of 0.5.
Chest tubes put out 275 cc so plan was to watch him during
the day and discontinue his chest tubes later in the day. He
was seen by case management. Given his young age, it was
anticipated he would be able to be transferred out to Far-2
on postoperative day #2.
He continued with tachycardia and was given additional doses
of Lopressor as needed. He was also encouraged to use
incentive spirometer, had poor effort at his own pulmonary
toilet, but he continued to do well on the floor. He was
alert and oriented with good peripheral pulses. He continued
to be slightly tachycardic. He had decreased breath sounds
of the left lobe of his lung, remained persistently
tachycardic. His hematocrit dropped to 20.3 on postoperative
day #3, down from 21.3 and the need for transfusion was
discussed. They continued to follow the patient closely.
The central venous line was removed and repeat EKG and chest
x-ray were done.
He was evaluated again by physical therapy. Catheter tip was
sent for culture given his tachycardia. All his narcotics
were discontinued and he was given Tylenol for pain. As his
systolic pressure was in the 80's to 90's range, he also
received a normal saline bolus but his systolic blood
pressure did not change.
Throughout the course of the day he was monitored for his
blood pressure and tachycardia. Given his persistent,
slightly elevated temperature, the cultures were sent off.
On postoperative day #4 he had some generalized weakness, a
little bit of confusion the evening prior after his Percocet
which was discontinued. On postoperative day #4 he had blood
pressure 114/72 with a pulse of 116 and sinus tachycardia.
He was satting 92% on room air. His hematocrit was 22 with
potassium of 4.2, BUN 14 and creatinine 0.6. He was alert
and oriented. His lungs were clear bilaterally in his upper
lobes but diminished breath sounds in bilateral bases. Heart
was regular rate and rhythm with normal S1 and S2 sounds.
His extremities were warm and well perfused. His sternal
incision was clean and dry and intact. He was encouraged to
ambulate and he was unable to increase his activity level,
then transfusion would be considered after his oxygen had
been weaned off. His Lopressor was increased to 50 mg [**Hospital1 **] at
that time with plan to discharge him home in the next couple
of days as he increased his stamina. He was strongly
encouraged to ambulate and continue aggressive pulmonary
toilet. Given his young age, all of this was thought to be
within reason.
On the night of the 28th he had a T max of 100.1, he was
ambulating in the [**Doctor Last Name **], he continued in sinus rhythm in the
100's to 120's, he was receiving Tylenol, Motrin po for his
incisional discomfort. He was given regular insulin on a
sliding scale and his incisional discomfort was treated as
needed. He was encouraged to use incentive spirometry every
hour. Patient was instructed to use his Percocet sparingly
once he did arrive at home and on the day of discharge the
patient had no acute events overnight on postoperative day
#5, but he did complain of a slight headache. His blood
pressure was 106/63 with a T max of 100.1, hematocrit 22,
potassium 4.2 and a creatinine of 0.6. He remained on
Metoprolol 50 mg [**Hospital1 **] with heart rate of 118. He had
decreased breath sounds in both bases. His hematocrit was
rechecked, his beta blocker was increased to 75 [**Hospital1 **] and
discharge planning was completed. The patient was discharged
to home in stable condition on [**2124-11-11**].
DISCHARGE MEDICATIONS: Lasix 20 mg po bid for 10 days, KCL
20 mEq po bid for 10 days, Colace 100 mg po bid, Zantac 150
mg po bid, Aspirin 325 mg po q d, Plavix 75 mg po q d, iron
complex 150 mg po q d, Metoprolol 50 mg po bid and Percocet
5/325 1-2 tabs po prn q 4-6 hours prn. Please note the
patient was instructed to use his narcotics sparingly.
DISCHARGE DIAGNOSIS:
1. Status post off pump coronary artery bypass grafting
times one.
2. Hypertension.
3. Hypercholesterolemia.
4. Fatty liver with elevated LFTs.
5. Hodgkin's disease status post chemotherapy and radiation
therapy at age 15.
Again, the patient was discharged to home in stable condition
on [**2124-11-11**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2124-11-28**] 12:02
T: [**2124-12-1**] 12:32
JOB#: [**Job Number 35143**]
|
[
"785.0",
"272.0",
"414.01",
"V10.72",
"401.9",
"571.8",
"780.6",
"411.1",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"38.91",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6964, 7292
|
7313, 7906
|
2403, 6940
|
1496, 2385
|
180, 1074
|
1097, 1473
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,753
| 195,435
|
51093
|
Discharge summary
|
report
|
Admission Date: [**2107-11-21**] Discharge Date: [**2107-11-27**]
Date of Birth: [**2029-12-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
77 year oold female admitted with periumbilical abdominal pain,
nausea, vomiting and distention.
Major Surgical or Invasive Procedure:
Status Post Exploratory laparotomy with proximal enterectomy.
History of Present Illness:
The patient is a 77-year-old woman with a 24-36
hour history of periumbilical abdominal pain, nausea,
vomiting and distention. She had a prior history of a total
abdominal hysterectomy long ago. She was tachycardiac with
lactate of 5 and white blood cell count of 15 with a left
shift. A CT scan showed a small bowel obstruction with
transition point in the left lateral slightly lower abdomen
with thickened mesentery. She is now taken to the operating
room for exploratory laparotomy and a probable small bowel
resection. In addition, she has two nonincarcerated
incisional hernias.
Past Medical History:
DM
Nephrolithiasis
Osteoarthritis
HTN
Hypothyroidism
GERD
Social History:
married, daughter and son can be interpreters. Patient's primary
language is Ethiopian.
Family History:
NC
Physical Exam:
Per Dr. [**Last Name (STitle) **] on [**2107-11-21**]
Vital Signs:
Temperature 100.3 HR 118, BP 94/68 97% on RA
Awake but sleepy, in some distress, but fairly comfortable.
Regular Rhythm but tachycardic
Lungs clear bilaterally
Abdomen soft, mildly distended, diffusely tender. Large
incisional hernia in the lower midline, nonreducible. There is
no overt rebound or guarding.
Rectal nontender, heme neg.
No cyanosis, clubbing, or edema
Pertinent Results:
[**2107-11-24**] 03:43AM BLOOD WBC-5.6 RBC-2.88* Hgb-8.7* Hct-25.4*
MCV-88 MCH-30.3 MCHC-34.4 RDW-15.0 Plt Ct-152
[**2107-11-20**] 09:40PM BLOOD WBC-15.6*# RBC-4.44 Hgb-14.0 Hct-40.5
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.4 Plt Ct-365
[**2107-11-21**] 07:26AM BLOOD Neuts-69 Bands-15* Lymphs-9* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2107-11-23**] 01:55AM BLOOD Neuts-75.2* Lymphs-20.8 Monos-3.0 Eos-0.9
Baso-0.1
[**2107-11-20**] 09:40PM BLOOD Plt Smr-HIGH Plt Ct-365
[**2107-11-24**] 03:43AM BLOOD PT-14.4* PTT-26.3 INR(PT)-1.3*
[**2107-11-24**] 03:43AM BLOOD Glucose-105 UreaN-4* Creat-0.6 Na-144
K-3.8 Cl-113* HCO3-26 AnGap-9
[**2107-11-20**] 09:40PM BLOOD Glucose-316* UreaN-14 Creat-0.7 Na-139
K-3.4 Cl-96 HCO3-23 AnGap-23*
[**2107-11-20**] 09:40PM BLOOD ALT-17 AST-22 LD(LDH)-269* CK(CPK)-104
AlkPhos-53 Amylase-102* TotBili-0.4
[**2107-11-23**] 01:55AM BLOOD LD(LDH)-242
[**2107-11-24**] 03:43AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.9
[**2107-11-21**] 07:26AM BLOOD Calcium-7.5* Phos-2.1*# Mg-1.2*
[**2107-11-23**] 04:40AM BLOOD Type-ART pO2-97 pCO2-39 pH-7.36
calTCO2-23 Base XS--2
[**2107-11-21**] 05:33AM BLOOD Type-ART pO2-294* pCO2-29* pH-7.40
calTCO2-19* Base XS--4 Intubat-INTUBATED Vent-CONTROLLED
[**2107-11-21**] 06:32AM BLOOD Glucose-283* Lactate-5.1* Na-135 K-3.5
Cl-112
[**2107-11-23**] 03:44AM BLOOD Lactate-1.2
CT of Abdomen on [**2107-11-21**]:
Findings are consistent with small-bowel obstruction likely
secondary to a closed loop obstruction. Additionally, presence
of abdominal ascites, mesenteric engorgement and differential
enhancement of the wall raise concern for intestinal
ischemia/infarction.
Brief Hospital Course:
The patient is a 77-year-old woman admitted on [**2107-11-21**] with a
24-36
hour history of periumbilical abdominal pain, nausea,
vomiting and distention. CT of the abdomen was shown showing a
large hernia and findings consistent for a small bowel
obstruction.
On [**2107-11-21**] patient underwent a Exploratory laparotomy, small
bowel resection and
repair of incisional hernia. Postoperatively patient was sent to
the SICU.
On [**2107-11-22**] patient was found to have bright red blood per
rectum. Patient recieved 2 units of packed cells and serial
HCT's were drawn. Lowest hct was 22.3.
On [**2107-11-23**] Patient had CXR revealing increased fluid overload,
and Left lower lobe atelectasis.
On [**2107-11-24**] Patient was transferred to the regular floor.
On [**2107-11-25**] Started on clear liquids, had black stool, will
check hct again at 1400.
Restarted on prehospital home medications.
[**11-26**]- [**2107-11-27**] Patient progressed to a regular diet. Last hct.
was 28.8, stable. No complaints of pain. Discharge to home with
family. Follow up with Dr. [**Last Name (STitle) 106111**] in 2 weeks.
Chronic Issues:
1. Diabetes - Patient maintained with sliding scale regular
insulin through most of hospitalization. Now back on previous
diabetic regimen.
2. Hypertension - Initially patient's hypertension maintained
with Intravenous beta blocker, now back on prehospital
medications.
Medications on Admission:
metformin 850mg [**Hospital1 **]
glimerpiride 4mg
synthroid 50 mcg
amlodipine 10mg
lisinopril 20mg
HCTZ 12.5mg
zyrtec 10mg
protonix 40mg
flaxseed oil
MVI
fish oil 1000mg [**Hospital1 **]
citalopram 20mg
Discharge Medications:
1. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily ().
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. 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*
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. medication
Patient may resume upon discharge, zyrtec, MVI, flax seed oil,
and fish oil.
Discharge Disposition:
Home
Discharge Diagnosis:
Status Post Exploratory laparotomy with proximal enterectomy.
Discharge Condition:
Stable
Discharge Instructions:
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.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call Dr.[**Name (NI) 6218**] office for appointment in 2 weeks. Her
office number is [**Telephone/Fax (1) 51009**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2107-11-28**]
|
[
"401.9",
"276.2",
"557.9",
"553.21",
"715.90",
"530.81",
"244.9",
"285.9",
"V45.77",
"250.00",
"560.81",
"789.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.62",
"53.51"
] |
icd9pcs
|
[
[
[]
]
] |
5951, 5957
|
3435, 4555
|
422, 486
|
6063, 6072
|
1780, 3412
|
7467, 7762
|
1303, 1307
|
5097, 5928
|
5978, 6042
|
4869, 5074
|
6097, 7104
|
7119, 7444
|
1322, 1761
|
286, 384
|
514, 1101
|
4571, 4843
|
1123, 1182
|
1198, 1287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,464
| 143,791
|
39419
|
Discharge summary
|
report
|
Admission Date: [**2124-11-2**] Discharge Date: [**2124-11-8**]
Date of Birth: [**2062-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Pre-syncopal episode
Major Surgical or Invasive Procedure:
1. Aortic valve replacement 23-mm St. [**Hospital 923**] Medical
mechanical valve.
2. Ascending aortic replacement and aneurysm resection with
a 28-mm Gelweave ascending aortic tube graft.
History of Present Illness:
This is a 61 year old male with long standing history of heart
murmur who presents with recent presyncopal episode and
worsening dyspnea on exertion over the last 6 months.
Echocardiogram in [**2124-7-20**] revealed possible bicuspid aortic
valve with moderate to severe aortic stenosis. Despite above
symptoms, he remains very active, and performs routine ADL
without difficulty. He currently denies chest pain, syncope,
orthopnea, PND and pedal edema.
Past Medical History:
- Bicuspid Aortic Valve, Aortic Stenosis
- Dilated Ascending Aorta
- Hypertension
- History of Pyelonephritis in [**2096**]
Past Surgical History
- Tonsillectomy
- ORIF, right ankle/leg fracture
- Squamous cell CA, right ear
- Neuroma removal
Social History:
Race: Caucasian
Last Dental Exam: Within one month
Lives with: Wife
Occupation: Hospice chaplain
Tobacco: Quit 32 years ago, prior 1ppd x 10yrs
ETOH: Recovering alcoholic, quit 32 years ago
Recreationa drugs: None
Family History:
Denies premature coronary disease
Physical Exam:
Admission Physical Exam
Pulse: 63 Resp: 16 O2 sat: 100%-RA
BP Right: 145/95 Left: 140/80
Height: 68" Weight: 132 lbs
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 SEM radiating to carotids
Abdomen: Soft[x] non-distended[x] non-tender[x] +bowel sounds
[x]
Extremities: Warm [x], well-perfused [x] Edema: None
Varicosities: None [x]
Neuro: Normal gait. Alert and oriented x3. CN 2-12 grossly
intact. FROM. 5/5 strength in all extremities. No focal
deficits.
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs bilaterall
Pertinent Results:
[**2124-11-8**] 04:40AM BLOOD PT-27.4* PTT-37.6* INR(PT)-2.7*
[**2124-11-7**] 08:30AM BLOOD WBC-11.1* RBC-3.15* Hgb-9.7* Hct-28.2*
MCV-90 MCH-31.0 MCHC-34.5 RDW-12.9 Plt Ct-148*
[**2124-11-2**] 09:15AM BLOOD WBC-6.1 RBC-4.30* Hgb-13.1* Hct-37.4*
MCV-87 MCH-30.5 MCHC-35.2* RDW-13.1 Plt Ct-210
[**2124-11-7**] 08:30AM BLOOD PT-17.1* PTT-27.8 INR(PT)-1.5*
[**2124-11-2**] 09:15AM BLOOD PT-13.0 INR(PT)-1.1
[**2124-11-7**] 08:30AM BLOOD Glucose-154* UreaN-14 Creat-0.9 Na-132*
K-4.0 Cl-95* HCO3-30 AnGap-11
[**2124-11-2**] 09:15AM BLOOD Glucose-121* UreaN-15 Creat-0.8 Na-137
K-3.9 Cl-104 HCO3-28 AnGap-9
Echo: [**2124-11-4**]
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated ascending aorta Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Moderate AS (area
1.0-1.2cm2) Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated.
There are simple atheroma in the descending thoracic aorta.
The aortic valve is bicuspid. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation
is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on no inotropes.
There is a prosthetic aortic valve with trace AI, no leaks.
Residual gradient = 7mmHg.
There is a prosthetic ascending aortic graft. Descending aorta
intact.
Trace - 1+ MR.
Preserved biventricular systolic fxn.
Brief Hospital Course:
On [**2124-11-4**] Mr.[**Known lastname 87120**] was taken to the operating room and
underwent Aortic valve replacement (#23-mm St.[**Hospital 923**] Medical
mechanical valve)/Ascending aortic replacement and aneurysm
resection (#28-mm Gelweave ascending aortic tube graft)with
Dr.[**Last Name (STitle) **]. Please refer to the operative report for further
details. He tolerated the procedure well and was transferred to
the CVICU intubated and sedated in critical but stable
condition. He awoke neurologically intact and was extubated
without difficulty. All lines and drains were discontinued in a
timely fashion. Drips were weaned off and Beta-Blocker and ASA
and diuresis were initiated. POD#1 Anticoagulation was started
with Coumadin for mechanical Aortic valve. INR goal=2.5-3.5 for
mechanical AVR. He remained in the CVICU due to bed
unavailability. POD#2 he was transferred to the step down unit
for further monitoring. A PICC line was placed due to poor
access. Physical Therapy was consulted for evaluation of
strength and mobility. The remainder of his hospital course was
essentially uneventful. POD# 4 Heparin bridge was initiated
until therapeutic INR with Coumadin. On POD#4 INR was 2.7 ([**11-7**]
INR 1.5). He received the following doses of Coumadin
5mg/5mg/7.5 mg. He was instructed to take 2 mg on [**2124-11-8**] and
2 mg on [**2124-11-9**] and VNA is to draw INR (by fingerstick only) on
[**2124-11-10**] and follow up with Dr [**Last Name (STitle) **] for further dosing
instruction. On POD# 4 he was cleared by Dr.[**Last Name (STitle) **] for
discharge to home with VNA. All appointments were advised.
Medications on Admission:
Metoprolol 25mg twice daily
Flexeril 10mg daily
Melatonin 3mg daily
Fish Oil, MV, Vitamin D, Vitamin C
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. tramadol 50 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: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for spasm/pain. Tablet(s)
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: Take
as directed for INR goal 2.5-3.5.
Disp:*30 Tablet(s)* Refills:*2*
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
primary :
Critical aortic stenosis, ascending aortic aneurysm.
- Bicuspid Aortic Valve-
secondary:
- Hypertension
- History of Pyelonephritis in [**2096**]
Past Surgical History
- Tonsillectomy
- ORIF, right ankle/leg fracture
- Squamous cell CA, right ear
- Neuroma removal
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **] #[**Telephone/Fax (1) 170**], an appointment was arranged
for thurs., [**2124-11-30**] at 1:15 pm.
Cardiologist:[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**12-11**] at 3:15pm.
Dr. [**Last Name (STitle) **] to follow INR/Coumadin dosing
***Labs: PT/INR for Coumadin ?????? indication: Mechanical AVR
Goal INR:2.5-3. INR to be drawn by fingerstick only
First draw [**2124-11-10**]
Results to fax [**Telephone/Fax (1) 87121**]
Please call to schedule appointments with your PCP Dr [**Last Name (STitle) **] on
[**2124-11-10**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2124-11-8**]
|
[
"401.9",
"441.4",
"285.9",
"V45.89",
"746.4",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"38.44",
"35.22",
"37.22",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
7801, 7860
|
4633, 6267
|
344, 543
|
8179, 8399
|
2429, 4610
|
9323, 10176
|
1541, 1577
|
6421, 7778
|
7881, 8158
|
6293, 6398
|
8423, 9300
|
1592, 2410
|
283, 306
|
571, 1027
|
1049, 1294
|
1310, 1525
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,346
| 175,880
|
22923
|
Discharge summary
|
report
|
Admission Date: [**2160-12-26**] Discharge Date: [**2160-12-27**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
[**2160-12-26**] - Sigmoidoscopy
History of Present Illness:
88F with PMH signficant for DM2, Afib on coumadin, HTN, SSS
s/p pacer, s/p recent hospitalization with discharge [**2160-12-21**] for
PNA, UTI, and new dx of CHF with MR/TR/AR and cardiomegaly
requring hospitalization for diuresis. Pt now brought to ED from
Nursing facility after mental status change (obtundation) and
desaturation/tachypnia. CXR showed dilated LB and CT A/P showed
sigmoid volvulus at descending colon/sigmoid junction with
partial LBO and contrast from 1 week prior swallow study
proximal
to transition point with decompressed bowel distally. [**Name (NI) 1094**] son
at
bedside, who is HCP. Reportedly, pt did not have n/v, denies
f/c,
and + diarrhea.
Past Medical History:
- Atrial fibrillation, s/p pacemaker placement due to atrial
fibrillation without ventricular response, on coumadin
- Hypertension
- Diabetes mellitus type 2
- Hyperlipidemia
- Peripheral vascular disease
- Peptic ulcer disease
- Sick sinus syndrome status-post pacemaker placement
- Glaucoma
- Urinary incontinence
- Skin cancer
Social History:
Patient lives in lives in [**Hospital3 59217**]
community. At baseline she uses a walker for assistance. She has
never smoked, and drinks alcohol rarely.
Family History:
[**Name (NI) **] mother died sudden death at 85 and MGM died at 75 in
sleep. MGM with angina. No significant past medical history on
paternal side.
Physical Exam:
On Admission
Vitals: 97.6, 105, 106/66, 19, 94% CMV (14, TV 500 PEEP 5, 60%
FIO2)
elderly female, somnolent, responsive to voice, touch but at
baseline still with eyes closed; GCS: 5 motor, 3 eyes, verbal
not
assessed as on ventillator
Dry mucous membranes, NC/AT
tachycardic, irregularly irregular
+ rales b/l lung bases
Abd: markedly distended/tympanitic (per son, at her baseline),
with minimal diffuse TTP. Well healed hysterectomy scar, no
palpable masses/bowel loops
Foley in place
+ venous stasis dermatitis RLE > LLE, b/l pedal edema
Pertinent Results:
[**12-26**] CT Abdomen - IMPRESSION:
1. Partial large bowel obstruction, with an organoaxial volvulus
seen at the junction of the descending and sigmoid colon. No
small bowel dilatation. Retention of oral contrast in the cecum
extending to the point of the volvulus. Small amount of contrast
passage beyond the transition point. 2. Moderate cardiomegaly
with chronically collapsed left lower lobe and mild right-sided
pleural effusion.
Brief Hospital Course:
Pt admitted to [**Hospital1 18**] on [**2160-12-26**] with diagnosis of sigmoid
volvulus. PT was DNR/DNI and surgery was declined by family. Pt
was transferred to the ICU. A sigmoidoscopy was done which
showed the pt had autoreduced the volvulus. Pt was in severe
respiratory distress with mechanical ventilation via a face
mask. Pt was made CMO and transferred to the floor after
ventilatory support was withdrawn. Pt expired at 7:45 Am on
[**2160-12-27**].
Medications on Admission:
coumadin 2 qday, glipizide 5 qday, senna 1 tab [**Hospital1 **], colace
100 [**Hospital1 **], brimonide 0.15 % drops [**Hospital1 **], pantoprazole 40 qday,
tylenol prn, MVI 1 tab qday, lisinopril 20 qday, atenolol 25
qday, lasix 40 po bid, dulcolax 10 po qday, Insulin SS,
Potassium
Chloride 40 meq [**Hospital1 **] while on lasix.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sigmoid Volvulus
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"533.90",
"250.00",
"397.0",
"458.9",
"272.4",
"398.91",
"V45.01",
"401.9",
"799.02",
"443.9",
"365.9",
"486",
"V10.83",
"560.2",
"V58.67",
"V58.61",
"427.31",
"396.3",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.85"
] |
icd9pcs
|
[
[
[]
]
] |
3625, 3634
|
2751, 3211
|
284, 319
|
3695, 3705
|
2290, 2728
|
3761, 3772
|
1563, 1712
|
3596, 3602
|
3655, 3674
|
3237, 3573
|
3729, 3738
|
1727, 2271
|
223, 246
|
347, 1021
|
1043, 1375
|
1391, 1547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,177
| 131,846
|
26971
|
Discharge summary
|
report
|
Admission Date: [**2126-11-14**] Discharge Date: [**2126-11-22**]
Date of Birth: [**2054-11-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening dyspnea
Major Surgical or Invasive Procedure:
[**2126-11-15**] CABGx3
History of Present Illness:
Mr. [**Known lastname **] is a 71-year-old male with worsening anginal symptoms
who underwent cardiac catheterization that showed critical left
main disease and
ostial left anterior descending stenosis with disease involving
the circumflex and his right coronary and particularly the left
ventricular branch. His ejection fraction was diminished. His
anterior wall was hypokinetic. He was transferred to the [**Hospital1 18**]
for suurgical management. He has a heavy alcohol use history and
given his anatomy, he needs urgent surgery realizing the risk of
alcohol withdrawal. However, alcohol withdrawal in the presence
of such coronary disease may also be disastrous. Referred to Dr.
[**Last Name (STitle) **] for urgent CABG.
Past Medical History:
HTN
Gout
Left eye surgery
Melanoma
Prostate Cancer with XRT
Social History:
Very heavy alcohol use. Retired. Lives alone in CT.
Physical Exam:
GEN: NAD
HEENT: NCAT, EOMI, PERRL, EOMI, no JVD, no bruits
HEART: RRR, distant heart sounds
LUNGS: Clear
ABD: Benign
EXT: No edema, no varicosities
Pertinent Results:
[**2126-11-14**] 07:44PM PT-12.8 PTT-21.8* INR(PT)-1.1
[**2126-11-14**] 07:44PM PLT COUNT-354
[**2126-11-14**] 07:44PM WBC-8.1 RBC-3.27* HGB-11.5* HCT-32.5* MCV-99*
MCH-35.3* MCHC-35.5* RDW-13.3
[**2126-11-14**] 07:44PM CALCIUM-11.0* PHOSPHATE-3.1 MAGNESIUM-1.9
[**2126-11-14**] 07:44PM GLUCOSE-124* UREA N-25* CREAT-1.3* SODIUM-144
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-30 ANION GAP-17
[**2126-11-14**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2126-11-14**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2126-11-21**] 07:00AM BLOOD WBC-9.7 RBC-3.28* Hgb-10.6* Hct-30.3*
MCV-93 MCH-32.3* MCHC-35.0 RDW-15.5 Plt Ct-270
[**2126-11-21**] 07:00AM BLOOD Plt Ct-270
[**2126-11-21**] 07:00AM BLOOD Glucose-106* UreaN-40* Creat-1.2 Na-144
K-3.6 Cl-101 HCO3-33* AnGap-14
[**2126-11-14**] CXR
Emphysema. No acute cardiopulmonary abnormality.
[**2126-11-15**] Carotid Duplex Ultrasound
Pending
[**2126-11-17**] ECHO
Left ventricular wall thicknesses and cavity size are normal.
There is
moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the septum, distal half of
the anterior wall, and distal inferior walls. The apex is mildly
dyskinetic with no visible intracavitary thrombus (cannot
exclude due to suboptimal image quality). The remaining segments
contract reasonably well with overalll LVEF of 35%. Minimal
views of the right venrtricle suggest normal cavity size with
good systolic function. Trivial mitral regurgitation is seen.
There is a small (0.8-1.0cm), somewhat echodense pericardial
effusion anterior to the right ventricle c/w with blood,
inflammation or other cellular elements. No right ventricular
diastolic collapse is seen.
[**2126-11-17**] EKG
Sinus rhythm
Prior anterior myocardial infarction
Modest nonspecific low amplitude lateral T waves
Since previous tracing of [**2126-11-15**], precordial T wave amplitude
improved
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2126-11-14**] viua transfer
from [**Hospital6 **] for surgical management of his
coronary artery disease. He was worked-up in the usual
preoperative manner by the cardiac surgical service. Thiamine
and folic acid were started given his history of heavy alchol
use. On [**2126-11-15**], 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 cardiac surgical intensive
care unit for monitoring. On postoperative day one, he remained
intubated and sedated on epinephrine, neo and propofol drips. On
POD #2, epinephrine was weaned off, but he remained on neo and
propofol drips sedated. He was hemodynamically stable and
received ativan for DT prophylaxis. He had tonsillar fossa and
right oropharyngeal bleeding postoperatively and was seen and
evaulated by the ORL service. He remained intubated while the
packing was in place.Chest tubes were removed. He was extubated
on POD #4 and remained in sinus rhythm, alert and oriented. Swan
was also removed.Diuresis, aspirin and beta blockade continued.
He was transferred to the floor on POD #5 to begin increasing
his activity level. Pacing wires were removed on the floor
without incident and his foley was removed on POD #6. He was
cleared for discharge to rehab on POD #7.
HR 88 144/88 RR 20 96% RA sat 94.4 kg (pre- op 93.4 kg) T
98.8
Medications on Admission:
atenolol 50 mg daily
probenecid 500 mg daily
lisinopril 20 mg daily
chlorthalidone 25 mg daily
aspirin 81 mg daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 37.5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Probenecid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
TCU framimgham
Discharge Diagnosis:
hypertension
s/p cabg x3
gout
prostate CA with XRT
CAD
s/p melanoma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain grated then 2 pounds in 24 hours or 5
pounds in one week.
4) Take lasix as directed. Monitor and replete electrolytes
while on lasix.
5) No lotions, creams or powders to wounds.
6) no driving for one month
7) no lifting greater than 10 pounds for 10 weeks.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with your primary care physician and Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 27117**]
in 2 weeks. ([**Telephone/Fax (1) 20259**]
Please call all providers for appointments
follow- up with ENT Dr. [**Last Name (STitle) 3878**] [**Telephone/Fax (1) 2349**] or with ENT in
Conn.
Completed by:[**2126-11-22**]
|
[
"V10.82",
"401.9",
"874.4",
"492.8",
"411.1",
"V10.46",
"E878.2",
"274.9",
"414.01",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6165, 6206
|
3492, 4965
|
342, 368
|
6318, 6325
|
1463, 3469
|
6789, 7223
|
5131, 6142
|
6227, 6297
|
4991, 5108
|
6349, 6766
|
1295, 1444
|
285, 304
|
396, 1127
|
1149, 1211
|
1227, 1280
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,810
| 162,247
|
35569
|
Discharge summary
|
report
|
Admission Date: [**2121-4-8**] Discharge Date: [**2121-4-15**]
Date of Birth: [**2040-10-25**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
OUTPT CARDIOLOGIST: [**First Name5 (NamePattern1) 122**] [**Last Name (NamePattern1) 80965**]
.
Mr. [**Name13 (STitle) 80966**] is an 80yo M with dementia, CAD s/p CABG in [**2105**]
(LIMA-LAD, SVG to OM2, SVG to RPDA), then s/p CABG redo in [**2111**],
then s/p 2 caths this year with patent LIMA, totally occluded
SVG to RPDA, SVG to OM2, s/p BMS to LCX on [**1-28**] who
presented to [**Hospital3 417**] Hospital with increasing chest pain
and nausea over the past few days.
.
Per report, patient has presented several times since last
cathed for recurrent angina. Admitted to [**Hospital3 **] on [**2121-4-5**]
with recurrent chest pain. Ruled out for MI. Last episode of
chest pressure was the morning of transfer, associated with dry
heaves and belching relieved with morphine. Pt was continued on
ASA, Plavix, Statin, BBker, Imdur and placed on Heparin gtt.
.
Cath last [**Month (only) 958**] here at [**Hospital1 18**] showed a patent BMS in LCX and no
new lesions. The plan in conjunction with referring Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] from [**Hospital3 417**] was to optimize medical therapy in
house. If the angina were to continue, the plan was to consider
opening RCA CTO as
well as PCI of a OM2 beyond prior stent. Pt was transfered to
[**Hospital1 18**] for pre-hydration in anticipation of the above procedure.
.
On the floor, pt is agitated, and unwilling to answer questions
about his symptoms. He is threatening to [**Doctor Last Name **] doctors, demanding
to leave the hospital. He states, "my daughters should be
yelling at you to leave me alone." He is adamantly refusing
cath.
Past Medical History:
CAD s/p CABG with re-do X 1
HTN
Dyslipidemia
CRI (Cr 1.8-2.1 at [**Hospital1 18**] [**1-27**])
Dementia
Arthritis
Cholecystectomy
Depression
GERD
Social History:
Lives alone in retirement community. Has 11 children who are
supportive.
No hx of tobacco/etoh/drugs
Family History:
Non-contributory
Physical Exam:
Vitals: 98.6 140/70 73 18 97% RA
Gen: Appears agitated but in NAD.
HEENT: PERRL, EOMI, conjunctiva pink. OP clear.
Neck: No JVP, No Carotid bruit
Lungs: Well-healed scar around the left scapula. Rough crackles
on left lung, dullness on percussion.
CV: S1, S2, PMI nondisplaced
ABD: Soft, NT, ND, + BS's
EXT: 1+ pedal pulses, no edema
Neuro: Refusing to answer orientation questions. CN II-XII
intact, strength 5/5 throughout, sensation intact to light touch
throughout.
Pertinent Results:
Pertinent Results:
Labs:
At OSH:
Hct 30.1, WBC 9.7, plt 161, INR 1.1, K 4.4, NA 144, CR 1.8,
BUN 32
Cardiac enzymes
[**4-7**] 4 am CK 92 CK MB 3.6 Index 3.9 Trop-I 0.02
[**4-7**] 11 am CK 104 MB 4.3 Index 4.1 trop-I 0.06
[**4-7**] 4 pm CK 89 MB 3.8 Index 4.3 trop-I 0.14
.
Radiology Results:
[**2121-4-7**] at OSH
mild prominence of the markings at the right base. The
appearance is of uncertain significance. Post surgical changes
are noted.
.
EKG: Sinus at 77, old inferior infarct. <1mm ST depression in I
and aVL which were previously noted.
.
[**2121-4-6**] OSH ECHO: EF 55%-60%, septal wall hypertrophy. Basal
anterior wall scarring/HK, mild MR, mild AR, mild PR. dilated
LA.
.
[**2121-3-11**] ECHO:
The left atrium is mildly dilated. The left ventricular cavity
size is normal. There is mild regional left ventricular systolic
dysfunction with inferior and inferolateral akinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
The lumen of the descending thoracic aorta appears echodense in
parasternal long-axis views compatible with probable severe
atherosclerotic plaque. EF 45%
.
Cardiac Cath [**2121-3-10**]:
1. Access via 4 F sheath in RFA. We took pictures of the native
left in AP caudal, lao caudal and lao cranial. No other vessels
were engaged in order to save contrast. These views showed the
stent to be widely patent with no new lesions.
2. Hemodynamics with BP 132/70 with HR in sinus at 74 on IV tng.
3. The plan in conjunction with referring Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
[**Hospital3 417**] is medical therapy in house. If he continues to
have angina could have the RCA CTO opened as well as PCI of a
OM2 beyond prior stent.
.
Cardiac Cath [**2121-1-28**]:
1. Selective coronary angiography of this right dominant system
demonstrated native three vessel coronary artery disease. The
LMCA had no obstruction. The LAD was totally occluded at its
mid-portion, with serial focal 80% stensoses proximally; these
stenoses may impair flow to the septals which do supply flow to
the distal RCA. The LCx had a 80% proximal stenosis and a long
tubular 70% lesion in the proximal OM1 which is then occluded
more distally, supplies collaterals to the RCA. The RCA is
totally occluded in its mid-portion, with left to right and
right to left collaterals.
2. Selective angiography of the bypass conduits demonstrated
total occlusion of the SVG-RPDA and SVG-OM2. The LIMA-LAD was
widely
patent.
3. Successful placement of a 2.0x12mm Mini Vision
bare-metal stent was performed in the proximal LCx. Final
angiography showed normal flow, no apparent dissection, and no
residual stenosis. (See PTCA comments.)
4. The right femoral arteriotomy was successfully closed using a
Mynx device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Totally occluded SVG-RPDA and SVG-OM2.
3. Patent LIMA-LAD.
4. Successful BMS placement in the LCx.
.
[**2121-4-13**]
1- Selecive coronary angiography of this right-dominant system
showed
severe diffuse three vessel disease. The LMCA had mild plaquing.
The LAD
was diffusely diseased with serial 80% lesions throughout its
course and
total occlusion at the mid vessel. The KLAD gave collaterals to
the RCA
via its septal branches. The LCX was diffusely diseased with a
long 80%
lesion that starts proximal to the stent and continues as ISRS.
The LCX
gave rise to a major branching OM with long 90% stenosis at the
origin
of the upper pole of the OM. The LCX gave numerous collaterals
to the
distal RCA system. The RCA was chronically occluded proximally
with
essentially no contguous flow channel. Tghe vessel was difusely
diseased
throughout.
2- Limited resting hemodynamic assessment showed moderately
elevated
(171/60 mmHg).
3- Successful POBA of the origin/proximal upper pole of a
branching OM2.
Final angiography showed a nonflow-limiting (TIMI III) stable
dissection
at the angioplasty site with 30-40% residual stenosis and no
distal
emboli.
4- Successful PTCA and stenting of the proximal LCX with a
2.5x18 mm
Cypher DES. Final angiography showed no residual stenosis with
TIMI III
flow and no dissection or distal emboli. Rigorous flow into the
LCX-->RCA collaterals was noted.
5- Successful revascularization of a totally occluded RCA with
POBA of
the entire RCA proper (ostium to bifurcation). Final angiography
showed
30-40% residual stenosis with stable nonflow-limiting (TIMI III)
dissection (proximal third) and no distal emboli.
6- Successful deployment of a Perclose Proglide closure device
to the
RCFA.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Modearts systemic hypertension.
3. Successful POBA of the distal OM.
4. Successful PTCA and stening of the proximal LCX with a Cypher
DES.
5. Successful POBA of the entire RCA proper with
re-establishment of
TIMI III flow to chronically-occluded vessel.
6- Successful deployment of a Perclose Proglide closure device
to the
RCFA.
.
[**4-12**] Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
moderately-to-severely depressed (LVEF= 30%) secondary to severe
hypokinesis/akinesis of the inferior and posterior walls. The
basal inferior septum and inferior free wall are dyskinetic. The
anterior septum is also hypokinetic. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
Labs on discharge:
Brief Hospital Course:
Patient was initially cared for on the cardiac floor while
awaiting cath. He had an uneventful night except for extreme
aggitations, however when he went to the cath lab in the morning
he was agitated and refused cardiac cath. He was then
transferred to the CCU for better monitoring until he could
undergo cath. He did have chest pain and hypoxia on the floor
while aggitated. His EKG had finidngs of ischemia during his
aggitation that resolved when calmer. He was transferred for
the cath and had the interventions. See below for CCU course.
CCU course:
# AMS: Patient was transferred to CCU after refusing cardiac
cath in the setting of AMS in cath lab. HE had a UA which was
positive and thus was started on antibiotics as it was thought
he had AMS in setting of baseline slight dementia with
infection. He also was initially treated with haldol and zyprexa
without change in his AMS and eventually had clearing of his MS
with seroquel and a few days of ABx. Still has nighttime
delerium but no longer has the aggitation that he had
previously. He will continue venlafaxine for now. He can take
seroquel at night as needed.
.
# Angina: Refractory to medical management. Had cardiac cath
that showed severe three vessel CAD but as patient not deemed
good cardiac surgery patient he had POBA of RCA and OM2 and DES
in LCx. Was continued on asa, plavix, statin, imdur, [**Last Name (un) **], beta
blocker. From home meds, his imdur was decreased, and losartan
decreased. His coreg was also increased. After intervention he
remained chest pain free and was feeling well even with the mild
amount of exercise he was doing.
.
# CRI: (Cr 1.8-2.1 in [**2121-1-19**]). Pre- and post-cath hydration
and mucomyst per protocol and [**Last Name (un) **], HCTZ and nsaids were held in
anticipation of cath. Creatinine was stable post cath at
baseline except that two days after cath it went up to 2.3 and
then plateaued, is likely contrast nephropathy and will continue
to monitor. The day of discharge Cr was 2.1.
.
# HTN: Was continued on Imdur and BBker and [**Last Name (un) **] was added
post-cath. See med list for complete list. Was mostly
normotensive except for some hypertension while aggitated early
in his admission.
.
# Dyslipidemia: Was continued on high dose atorvastatin.
.
# UTI: patient with dirty UA and was treated with cipro X 7 days
first dose [**2121-4-11**]. Cipro was stopped due to interaction with
psych meds and he was switched to cefpodoxime and he will finish
his 7 day course with that abx. He has one more day left of
treatment after discharge.
.
# Anemia: Patient had Hct<30 post-cath and was transfused total
of 2uits while in CCU. Hcts after the second transfusion were
stable. He required lasix with the transfusions (40mg IV) with
good effect. His Hct remained stable after discharge from the
CCU.
.
# Fluid overload: had crackles on exam and still had a 3L O2
requirement so was given lasix 40 mg IV daily. For discharge he
was transitioned to 40 mg PO daily which can be reevaluated as
an outpatient.
.
RETURN TO FLOOR COURSE:
Once back to [**Hospital1 1516**] team, patient was doing well. He was
continued to be diuresed and his O2 was weaned slowly. He was
briefly satting well on room air but with movement required
about 1-2L. He worked with PT/OT. He still had some confusion
but was much improved previously.
.
His family agreed to a short rehab stay where his fluid status
will continue to be monitored and he can continue to work with
PT and have nursing care at night in the case of delerium.
Medications on Admission:
Medications at home:
1) ASA 325 Qday
2) Clopidogrel 75 Qday
3) Coreg 12.5 [**Hospital1 **]
4) Imdur 60 Qday
5) Atorvastatin 80 QHS
6) Losartan 100 Qday
7) Ranitidine 150 [**Hospital1 **]
8) Effexor 75 Qday
9) Nitro SL PRN
.
Medications on transfer:
Imdur, plavix, aspirin 325mg, nexium, coreg, cozaar, Lipitor,
norvasc, effexor
Discharge Medications:
1. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours): Please continue for one more day. Last dose should
be [**4-16**].
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
Primary Diagnosis:
1. Coronary Artery Disease
2. NSTEMI
3. Delerium
4. Congestive Heart Failure
Discharge Condition:
stable, walking around, breathing well on room air
Discharge Instructions:
You were admitted to the hospital for chest pain. It was due to
blockages in your heart. It was not well controlled on oral
medicines and you were starting to get worsening shortness of
breath. We did a cardiac catheterization and did two balloon
angioplasties on your vessels and put in one stent. You felt
better and your symptoms improved after the catheterization.
.
You also had some delerium while you were in the hospital. We
treated you with some medicines to help you calm down. You
should not need to continue seroquel at home.
.
Please take the medicines as described in the attached sheet.
We made some changes including increasing your Imdur from 60 mg
daily to 120 mg daily, decreasing your losartan from 100 mg
daily to 25 mg daily, increasing your Coreg from 12.5 twice
daily to 25 twice daily. We added lasix 40 mg daily. We also
added venlafaxine 75 mg daily. You should continue the
antibiotic Cefpodoxime for one more day.
.
Please call your doctor or return to the hospital for worsening
chest pain, shortness of breath, palpitations, fainting,
sweating, nausea, vomitting, fevers, chills, or any other
concerns.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
Please follow up with your primary care doctor Dr. [**Last Name (STitle) **] in
one to two weeks after being discharged from rehab so she can
check your blood pressure and increase your medicines in needed.
Dr.[**Name (NI) 80967**] phone number is [**Telephone/Fax (1) 10381**].
.
Please follow up with your cardiologist Dr. [**Last Name (STitle) **] within two
to three weeks after discharge. Your family can call and make
an appointment which fits into their schedule. His number is
[**Telephone/Fax (1) 8725**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Completed by:[**2121-4-15**]
|
[
"996.72",
"311",
"414.01",
"V45.81",
"410.71",
"V45.82",
"285.21",
"414.12",
"530.81",
"403.90",
"294.8",
"716.90",
"428.0",
"998.2",
"514",
"585.9",
"E879.0",
"599.0",
"272.4",
"293.0",
"414.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.45",
"36.07",
"00.42",
"88.56",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
14043, 14146
|
9153, 12712
|
301, 327
|
14286, 14339
|
2857, 6023
|
15632, 16305
|
2304, 2322
|
13093, 14020
|
14167, 14167
|
12738, 12738
|
7824, 9109
|
14363, 15609
|
12759, 12962
|
2337, 2819
|
251, 263
|
9130, 9130
|
355, 1998
|
14186, 14265
|
12988, 13070
|
2020, 2168
|
2184, 2288
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,680
| 163,438
|
47312
|
Discharge summary
|
report
|
Admission Date: [**2171-7-9**] Discharge Date: [**2171-7-16**]
Date of Birth: Sex: M
Service: NEUROLOGY
CHIEF COMPLAINT: Seeing kids that are not there.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old male with
multiple medical problems including diabetes, hypertension,
coronary artery disease status post coronary artery bypass
of hallucination. He was evaluated by Dr. [**Last Name (STitle) **] in the
Emergency Department and treated in the Neuro Intensive Care
Unit overnight.
Initial evaluation revealed a subdural hematoma on the left
frontal lobe with some mild midline shift. Mr. [**Known lastname 100157**]
story began the afternoon of one day prior to admission when
apartment playing hide and seek and he was the leader. He
thought that they were hiding in the bathroom and so he went
after them. He reports slipping and falling hitting his
buttocks. He did not remember hitting his head or losing
consciousness. Afterwards he was took weak to get up so he
waited for his girlfriend to return home and help him. She
found him unsteady and shaky so she brought him to the ED.
Note, he is a bit unclear of the timing of whether this was
the day after the fall or the day of the fall that he was
brought to the hospital. He has not had any recent illness,
headache, fever, chills, changes in is vision, nausea,
vomiting, chest pain, shortness of breath, abdominal pain or
changes in his GI or GU function, or weight loss. There has
been no weakness or numbness.
In discussion with Mr. [**Known lastname 100157**] primary physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 4036**]
Shans indicates that he has had multiple INR problems in the
past. Furthermore, he is inattentive and has had memory
problems for some time which is not new.
PAST MEDICAL HISTORY:
1. Coronary artery disease with coronary artery bypass graft
in [**2168**].
2. Aortic bileaflet valve.
3. Congestive heart failure with an ejection fraction of 30
to 35%.
4. Diabetes mellitus.
5. Hypertension.
6. Peripheral vascular disease with multiple surgeries.
MEDICATIONS:
1. Atenolol 25 q. day.
2. Lipitor 10 q. day.
3. Mavik 2 q. day.
4. Furosemide 80 b.i.d.
5. Neurontin 400 t.i.d.
6. Celexa 20 q. day.
7. Zantac 150 b.i.d.
8. Klonopin p.r.n.
ALLERGIES: None known.
SOCIAL HISTORY: Retired living with his girlfriend of 30
years. He has an 80 pack year history of smoking. He is now
currently smoking one pack per day since his coronary artery
bypass graft.
FAMILY HISTORY: No stroke or seizures, but has had a
significant history of coronary artery disease, hypertension
and diabetes mellitus.
PHYSICAL EXAMINATION: Vital signs with a T max of 100.9 F
currently 98.7 F, pulse 75 to 90, blood pressure 104/53
ranging to 157/70. Net negative 1.27 liters. General:
Elderly man in no acute distress. Head and neck:
Normocephalic, no lymphadenopathy or bruits. Cardiovascular:
Regular rhythm, normal rate. There is a valvular murmur
during systole, mechanical. Pulmonary: Good air movement,
but wheezy. Abdomen: Positive bowel sounds, soft,
nontender, nondistended. Extremities: Positive pulses.
Neurological: Awake, alert and oriented times four.
Language and comprehension are intact. Attention is poor
with difficulty with months of the year backwards. Memory is
therefore difficult to assess, but he recalls one out four at
five minutes. Cranial nerves: Pupils equal and reactive to
light. Extraocular motions are intact, no nystagmus. Fundi
are normal. Fields are full. There is a mild right facial
droop. The palate elevates symmetrically. Tongue protrudes
midline. Sensation is intact in the face. Motor: There is
a normal tone, but left hand bulk is decreased in an ulnar
distribution. The right deltoid is mildly weak as well as
the left interossea. Left [**Last Name (un) 938**] is also mild to moderately
weak, otherwise motor is full throughout. Toe are downgoing
bilaterally. Sensory: Touch and pinprick is decreased in the
left ulnar distribution, but otherwise intact in the upper
extremity. Sensation to touch, temperature, vibration and
pinprick were decreased from the toes to the knees
bilaterally. Proprioception distally is decreased
bilaterally. Reflexes are 1+ and symmetric. Toes are
downgoing bilaterally. Coordination: Finger to nose is
intact. Heel to shin is intact. Gait: Not tested.
LABORATORY: White count 6.6, hematocrit 31.3, platelets 178,
INR 1.6, sodium 139, potassium 3.7, chloride 97, bicarbonate
34, BUN 26, creatinine 1.2, glucose 202, calcium 8.6,
magnesium 2.5, phosphorus 3.7.
IMAGING: CT Scan of the head reveals a left frontal subdural
hematoma with some mild mass affect.
HOSPITAL COURSE: Mr. [**Known lastname **] was admitted initially to the
Neuro Intensive Care Unit where he had frequent neuro checks.
A repeat head CT Scan was stable and therefore he was
transferred out to the Neurology floor. His initial
presentation is one of hallucination and a left frontal
subdural hematoma in the setting of high INR. It is
difficult to attribute hallucinations to a subdural bleed and
it is likely that hallucinations may be secondary to his
narcotic use. There is also a concern of infectious
etiologies given his asterixis and fever. Work up while in
house revealed a MRSA urinary tract infection and this will
be treated with Vancomycin. Over the following day, his
asterixis improved as well as his mental status.
At the time of discharge, Mr. [**Known lastname **] was clinically stable
and appropriate for discharge. He will stay off Warfarin for
three weeks because of this hemorrhage, but then at that time
he will restart anticoagulation.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: Discharged home with follow up.
DISCHARGE DIAGNOSIS:
1. Left frontal subdural hematoma in setting of high INR.
2. Hallucinations with methicillin-resistant Staphylococcus
aureus urinary tract infection.
3. Coronary artery disease status post coronary artery
bypass graft.
4. AVR requiring Warfarin.
5. Congestive heart failure.
6. Hyperlipidemia.
7. Diabetes.
8. Hypertension.
9. Significant peripheral vascular disease.
DISCHARGE MEDICATIONS:
1. Atenolol 25 q. day.
2. Lipitor 10 q. day.
3. Mavik two q. day.
4. Lasix 80 b.i.d.
5. Neurontin 400 t.i.d.
6. Celexa 20 q.d.
7. Zantac 150 q. day.
8. Klonopin p.r.n.
9. Warfarin to be restarted in two weeks' time.
FOLLOW UP: Mr. [**Known lastname **] will follow up in Stroke [**Hospital 878**]
clinic with Dr. [**Last Name (STitle) **].
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D.
Dept of Neurology-268
Dictated By:[**Name8 (MD) 100158**]
MEDQUIST36
D: [**2171-12-30**] 14:24
T: [**2171-12-30**] 14:29
JOB#: [**Job Number 100159**]
|
[
"357.2",
"852.20",
"428.0",
"V45.81",
"599.0",
"E888.9",
"V43.3",
"250.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2541, 2663
|
6220, 6446
|
5819, 6197
|
4745, 5710
|
6458, 6839
|
2686, 3423
|
153, 186
|
215, 1813
|
3440, 4727
|
1835, 2328
|
2345, 2524
|
5735, 5798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,598
| 128,455
|
29927
|
Discharge summary
|
report
|
Admission Date: [**2164-5-10**] Discharge Date: [**2164-5-15**]
Date of Birth: [**2118-5-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Ms. [**Known lastname 25301**] is a 45-year-old with
hep C cirrhosis and hepatopulmonary syndrome. She is
currently listed for liver transplant
Major Surgical or Invasive Procedure:
Orthotopic Liver Transplant; portocaval shunt, thrombectomy, CBD
anastomosis revision; thrombectomy portal vein, revision of
portal vein anasmosis
History of Present Illness:
Ms. [**Known lastname 25301**] is a 44 year old female who was diagnosed with
hepatitis C in [**2153**]. She received a 48- week course of pegintron
and. She was diagnosed with COPD, and subsequently
hepatopulmonary syndrome and she has been using home oxygen
since [**2162-11-29**] with improvement.
Past Medical History:
Type 2 diabetes mellitus, controlled on glucophage.
History of alcoholism. Quit since [**2162-6-29**].
OPD
Left carpal tunnel release
G4P3, c-section x1
Tubal ligation
Social History:
h/o cocaine and IVDU two decades ago. + cigarettes since she
was sixteen
years old.
Family History:
mother is also HCV positive
Brother has alcoholic cirrhosis.
Sister is anemic with unknown cause.
Physical Exam:
PHYSICAL EXAM
BP: 134/78 mmHg, O2 sat: Supine 86%, standing 86%,
Respirations: 16/min
GENERAL: This is an over wt, well developed appearing 44 year
old. She is alert, oriented, and in no acute distress when
sitting.
SKIN: Anicteric, no rashes, bruising or spider angiomas
HEENT: Normocephalic, sclera anicteric.
NECK: Trachea midline, thyroid non-palpable, no lymphadenopathy
CHEST: Clear to auscultation bilaterally, no wheezing, rhonchi,
or crackles
CARDIAC: S1S2 identified, rate and rhythm regular, no murmurs or
extra sounds.
ABDOMEN: Soft, obese, non-tender, active bowel sounds, no
hepatosplenomegaly, no guarding, rebound, rigidity, masses or
bruits.
EXTREMITIES: No clubbing, cyanosis, pedal edema, palmar erythema
or asterixis
NEURO: CN II-XII grossly intact, gait study.
Pertinent Results:
IMPRESSION:
1. Patent hepatic vasculature.
2. No focal abnormalities seen within the liver and no fluid
collections
identified.
The study and the report were reviewed by the staff radiologist.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2164-5-11**] 1:26 PM
FINDINGS: The liver demonstrates normal echogenicity, without
evidence of a
hepatic fluid collection. No biliary dilatation is seen.
Color Doppler and pulse wave Doppler images were obtained.
Doppler
interrogation of the portal venous system is technically
limited. However,
the main portal vein appears patent with wall- to- wall color
flow, but with
reversal of flow, which is new from [**2164-2-9**].
Appropriate flow is seen within the main, right, and left
hepatic arteries
with sharp systolic upstrokes. Appropriate flow is also seen
within the IVC
and hepatic veins.
IMPRESSION:
1. Hepatic vasculature with wall-to-wall color flow. Doppler
interrogation
of the portal venous system is technically limited; however,
there appears to
be reversal of flow within the main portal vein, new from prior
study.
2. No focal hepatic abnormality or fluid collection identified.
Findings discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71506**] at the time of
dictation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: SUN [**2164-5-13**] 8:19 AM
IMPRESSION:
1. Diffusely small hepatic vasculature, but donor hepatic
artery, portal
vein, and hepatic veins are patent.
2. Relative narrowing of the junction between the donor and
recipient IVC.
3. Nonocclusive thrombus in superior mesenteric vein and
interval development
of nonocclusive thrombus at anterior aspect of the recipient
portal vein,
which does not extend across the anastomosis.
4. Persistent esophageal and splenic varices.
5. Splenic artery pseudoaneurysms (unchanged from prior).
6. Diffuse subcutaneous edema and ascites.
7. Diffuse colonic wall edema.
8. Rectal varices.
Case discussed with Dr. [**Last Name (STitle) **] at the time of imaging.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2164-5-12**] 10:44 PM
IMPRESSION:
1. Intermittent flow in the portal vein, which was more
consistently present
towards the end of the examination, after patient received
intravenous
pressors and fluids.
2. The flow in the intrahepatic main portal vein, left portal
vein and right
portal vein is retrograde (hepatofugal) and of low velocity.
3. Some anterograde flow is demonstrated in the extrahepatic
portal vein in
the region of the portacaval shunt.
4. No flow demonstrated in the hepatic veins.
Findings discussed with Dr. [**Last Name (STitle) 21082**] at the time of imaging.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: MON [**2164-5-14**] 10:06 AM
Brief Hospital Course:
PAtient's liver transplant was unevetful - with the exception
that the transplanted liver was from a 5 y/o donor and therefore
slightly mismatched volume with the patient's body habitus, but
otherwise transplant itself went well. Her immediate
postoperative course was uneventful until she developed
worsening lactic acidosis and worsening and rising bilirubin on
POD2. She underwent an ultrasound 24 hours after the initial
postop ultrasound that demonstrated normal flow. The subsequent
ultrasound demonstrated hepatofugal flow. She underwent a CT
scan with contrast that did not demonstrate any significant
systemic portal venous collaterals, but demonstrated a marked
pruning of the portal venous branches intrahepatically.
Usually this is consistent with hepatic congestion. She was
taken to the operating room for exploration. She underwent
portal vein thrombectomy and construction of portacaval
anastomosis. She initially did well for the first 6 hours postop
but then
began having a rising lactate. A portal vein ultrasound at this
time demonstrated a complete thrombosis of the portal venous
system. She was taken to the operating room for exploration
where a portal vein thrombectomy, redo portal venous
portal-portal anastomosis, takedown of choledochostomy, portal
venogram and temporary
abdominal closure was performed. She was maintained on
prophalactic antibiotics througout. After her third operation
patient remained fairly unstable gradually requiring 3 pressors,
multiple blood product transfusions, and increasing oxygen
requirements on the ventilator. She had been relisted for a
transplant but needed to removed after 48hrs due to instability.
After continued discussions with the fmaily the decision was
finally made to make the pt [**Name (NI) 3225**] and she expired shortly after
withdrawl on [**2164-5-15**] in the late am. Family and attending
physician were notified.
Medications on Admission:
Metformin 1 gm [**Hospital1 **] Multivitamin QD Mycelex 15 x day
Discharge Disposition:
Expired
Discharge Diagnosis:
liver failure
hepatopulmonary syndrome
Discharge Condition:
deceased
Completed by:[**2164-5-15**]
|
[
"458.29",
"496",
"996.74",
"572.3",
"276.6",
"518.5",
"E878.0",
"348.30",
"571.5",
"070.54",
"285.9",
"584.9",
"303.93",
"452",
"276.2",
"518.89",
"V45.89",
"250.00",
"456.21",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.99",
"89.62",
"50.12",
"39.49",
"88.64",
"38.05",
"00.93",
"50.59",
"39.1",
"99.10",
"88.74"
] |
icd9pcs
|
[
[
[]
]
] |
7665, 7674
|
5650, 7550
|
457, 605
|
7756, 7795
|
2166, 5627
|
1245, 1345
|
7695, 7735
|
7576, 7642
|
1360, 2147
|
274, 419
|
633, 935
|
957, 1127
|
1143, 1229
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,819
| 180,730
|
364
|
Discharge summary
|
report
|
Admission Date: [**2181-5-14**] Discharge Date: [**2181-5-20**]
Date of Birth: [**2103-9-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
readmit for mental status changes
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
77 year-old M with chronic liver disease, pulmonary fibrosis,
and CHF who presented with altered mental status. He was
recently discharged (hospitalized from [**Date range (1) 3270**]) from the
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for altered mental status, increased
lethargy and confusion which was attributed to hepatic
encephalopathy and UTI. Prior to his admission on [**2181-5-6**], the
patient was taking Spironolactone, 50 mg daily and Atenolol, 50
mg daily. Ammonia level on prior admission was 114 and total
bilirubin 4.0. RUQ U/S revealed changes c/w chronic liver
disease, patent portal vein and cholelithiasis. EGD revealed e/o
portal gastropathy, varices in the lower and middle thirds of
the esophagus and esophagitis. Also of note, he was
thrombocytopenic which was attributed to chronic liver disease.
Lipid panel revealed high LDL. He also had Guaiac positive
stools. Mental status improved with lactulose. He was started on
nadalol and a PPI. Hepatitis A & B serologies were sent and
unremarkable. A1AT was 72 (83-199), [**Doctor First Name **] titer was 1:40.
Hereditary hemochromatosis mutational analysis was sent.
.
The patient was discharged to rehab on [**2181-5-11**]. On the day of
current admission ([**2181-5-13**]), the NH reports that the patient had
increased lethargy and poor appetite. He was found to be 95% on
2L NC. He complained of indigestion to the staff. Per his
family, he also had chest pain the day PTA. Labs demonstrated a
leukocytosis and worsening LFTs. He received Vancomycin 1 g,
levofloxacin 750 mg, and Flagyl 500 mg in the ED. He was
transferred to the MICU for further management. Cardiology was
consulted for possible STEMI, but did not recommend
catheterization for what is felt to be a recent posterolateral
MI. RUQ U/S was limited by gaseous abdominal distension, but
revealed normal CBD (5mm) and two hypoechoic nodules within the
right liver lobe. Pt denies N/V/orthopnea/platypnea.
Past Medical History:
Interstitial Fibrosis
CHF
Social History:
Lives with wife (with alzheimers), son lives 3 blocks away,
independant own ADLs, was driving up to 1 week ago, DC'd Etoh 5
yrs ago, was told to stop, o/w [**2-3**] drinks/day, quit smoking 25
yrs ago, but o/w 1-2ppd smoker
Family History:
Brother died 40s, CAD
Father died 40s, CAD
1 Sister healthy
Physical Exam:
Vitals: T: 97.3, BP: 114/52 (114-125/39-65), P: 67 (65-73), RR:
16 (14-21), SaO2: 98% 3L NC, I/O: 4267/645 (UOP = 135, Stool
350), LOS +7022
GEN: Confused, NAD.
HEENT: PERRL, EOMI, sclera icterus. MM dry, edentulous
Neck: supple, no JVD appreciated
Pulm: bilateral rales, expiratory wheezes
COR: RRR, [**3-6**] holosystolic murmur radiating to carotids
Abdomen: NABS, firm/NT/distended, liver edge approx 5cm below
costal margin at the mid-clavicular line, splenomegaly, no HJR
or fluid wave appreciated
Rectal (in ED): brown stool, trace guaiac positive.
Ext: trace pitting edema b/t, warm
Skin: scattered ecchymoses (extensive on B/L forearms), fragile
skin, + spider angiomata of upper chest, no palmar erythema.
Neurologic: confused, but able to follow commands, A & O to
person and "[**Hospital1 **]", but not year, + asterixis
Pertinent Results:
EKG: NSR @ 60, LVH, nl axis/intervals. Q waves in III, aVF.
.
LABS (pertinent labs only, see OMR for complete list):
BUN/Cr: 45 --> 50, 1.3 --> 1.5 (40/1.2 on prior admission)
ALT/AST/ALK PHOS: 30/32/129
Albumin: 2.7
T BILI/DIRECT: 7.7 --> 6.2 (peaked at 4.9 on prior admission)
[**Doctor First Name 674**]/LIPASE: 86/281
WBC/HCT/PLT: 27.8/44.6/151 (plt 65-104 on prior admission)
Lactate: 3.1
PT/PTT/INR: 21.6/40/2.1 (1.4-1.6 on prior admission)
Fibrinogen: 100 ([**2181-5-7**])
Haptoglobin: < 20 ([**2181-5-6**])
LDL/HDL/TGL: Pending
Ammonia: 114 ([**2181-5-6**])
TIBC/Vit B12/Iron/Fer/TRF [**Telephone/Fax (1) 3272**]/205/125 ([**2181-5-6**])
.
[**Doctor First Name **]: Pos 1:40 ([**2181-5-6**])
AFP: 1.6 ([**2181-5-6**])
Hereditary Hemochromatosis Mutational Analysis: Pending
A1AT: 72 (NL range: 83-199)
Hep A/B Serologies: negative [**5-7**]
AFP: 1.6 ([**2181-5-8**])
.
IMAGING/STUDIES:
[**2181-5-13**] CXR: A single portable radiograph of the chest
demonstrates no change in the cardiomediastinal contour when
compared with [**2181-5-6**]. There is no change in the appearance of
the lungs. No effusion. Trachea is midline. The aorta is
calcified and tortuous. Calcified gallstones are again noted.
There is retained oral contrast projecting over the left upper
quadrant.
.
[**2181-5-13**] LIVER/GB U/S: 1. Extremely limited study due to gaseous
distention. The gallbladder itself is not visualized. The common
bile duct is not dilated measuring 5 mm. 2. Two hypoechoic
nodules within the right liver lobe require further evaluation
with MRI or multiphasic CT, particularly in the setting of
background liver disease.
.
[**2181-5-13**] CT HEAD: No intracranial hemorrhage or mass effect. No
significant change from [**2181-5-6**].
Brief Hospital Course:
77 year-old M with cirrhosis, pulmonary fibrosis, diastolic
dysfunction and moderate to severe AS presented with delirium,
worsening LFTs, leukocytosis. He ultimated died of cardiac
arrest. His active hospital issues included:
# Encephalopathy: This was felt to be related to liver
dysfunction and possibly an infectious etiology given
leukocytosis on admission. No infectious source found, but pt
responded clinically and with decrease in WBC count on
vancomycin and pip-tazo. Vanc was subsequently d/c'd. His
lactulose was titrated to [**3-4**] BMs per day
# Cirrhosis: Etiology remained unclear. It was felt unlikely to
be related to hereditary hemochromatosis or alpha-1-antitrypsin
deficiency (in the setting of cirrhosis, this level can be low).
Although he did not have a very strong history of alcohol use,
ultimately, it was felt to be more likely is EtOH-induced +/-
NAFLD. Has liver nodules on most recent imaging studies
concerning for HCC, had low AFP on last admission, although
relatively insensitive for HCC. Also could be regenerative
nodules. Albumin 2.6, INR 1.9. He continued nadolol for
variceal prophylaxis. He was initially on spironolactone and
furosemide, but then d/c'ed on admission [**2-2**] ARF.
# ARF: Baseline Cr 1.0-1.2, which likely represents significant
CKD given his cirrhosis and low muscle mass. Cr was 1.3 on
admission, increased to 2.0 this morning. Possible etiologies
include pre-renal vs hepatorenal syndrome vs ATN. In unit,
started on midodrine and octreotide and albumin for possible
HRS. Not responding. Remains non-oliguric. Urine lytes c/w
either prerenal state or HRS. FENA <1%, Na<10. He continued
albumin, midodrine and octreotide, but creatinine continued to
rise. He also developed hyperkalemia with EKG changes requiring
kayexalate.
# Guaiac positive stools: Possible that this is related to
portal gastropathy vs esophagitis vs variceal leak. Hct trending
down still.
# ? STEMI/CAD/CHF: Echo on this admission revealed diastolic
dysfunction, normal systolic function and moderate to severe AS.
No laboratory or clinical evidence of ACS given troponin flat.
Aspirin was stopped given falling Hct and known portal
gastropathy and varices
# ILD: severe and end-stage per recent chest CT. He continued
prednisone 10 daily.
# FEN: low sodium pureed diet, nutrition consult, replete lytes
prn
# PPX: no heparin given thrombocytopenia and ? GI bleed
# Code status: Patient was intially FULL CODE, but after frank
discussion with family about prognosis, he was changed to
DNR/DNI. Family and patient participated in the discussion.
Palliative care and social work were also involved.
Then, on the day of death, his renal function continued to
decline, he became oliguric, increased midodrine to 10 mg tid
for presumed HRS. Checked vanco level which was 41 so vanco
held. Consulted renal who also thought most likely HRS. Renal
had brief discussion with family re: HD, which they would not
recommend as not likely to improve prognosis. Discussed this
with family. He continued to have hyperkalemia [**2-2**] renal
failure, and gave kayexalate. Lactate continued to rise from 5.1
to 6.6. No positive culture data, and he was started on flagyl,
continued zosyn (renally dosed), vanco held given level.
Unfortunately, he became increasing unresponsive overnight,
passed away at 5:30 am.
Medications on Admission:
1. Prednisone 10 mg QD
2. Spironolactone 50 mg QD
3. Nadolol 20 mg [**Hospital1 **]
4. Aspirin 81 mg QD
5. Lactulose 30 ml TID prn 3 BMs
6. Lasix 20 mg Qday
7. Pantoprazole 40 mg [**Hospital1 **]
8. Folic Acid 1 mg QD
9. Levoflox 500 mg QDay for 7 days
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. Cirrhosis, unknown etiology
2. Hepatic encephalopathy
3. Acute renal failure, likely hepatopulmonary syndrome
4. Hyperkalemia due to renal failure
.
Secondary:
1. Pulmonary fibrosis
2. Diastolic congestive heart failure
3. Liver nodules
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
x
|
[
"799.02",
"571.5",
"281.9",
"424.1",
"572.2",
"276.7",
"428.0",
"792.1",
"401.9",
"515",
"573.8",
"584.9",
"428.30",
"572.4",
"287.4",
"599.0",
"456.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
9044, 9053
|
5355, 8701
|
347, 355
|
9346, 9357
|
3591, 5235
|
9414, 9419
|
2660, 2722
|
9005, 9021
|
9074, 9325
|
8727, 8982
|
9381, 9391
|
2737, 3572
|
274, 309
|
383, 2353
|
5244, 5332
|
2375, 2403
|
2419, 2644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,404
| 108,757
|
20580
|
Discharge summary
|
report
|
Admission Date: [**2152-4-11**] Discharge Date: [**2152-4-19**]
Date of Birth: [**2100-10-27**] Sex: F
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient presented to the
[**Hospital6 256**] to have a procedure at
Interventional Radiology with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She is a
woman who has short bowel syndrome requiring TPN and has
hypercoagulable state where there is a clot in most of the
major veins in her body.
Her interventional radiology procedure was complicated by
laceration of the superior vena cava resulting in cardiac
tamponade and cardiogenic shock and hypovolemic shock.
She was rushed to the operating room and underwent a median
sternotomy, multiple blood product resuscitation, and had
repair of her superior vena cava which was avulsed at its
entry into the right atrium with primary repair.
She then stabilized hemodynamically. She was placed in the
Cardiac Surgery Recovery Unit where she was weaned off the
ventilator and subsequently had a right tunneled femoral
venous catheter which enabled her to get ongoing TPN.
She was transferred to the floor where she was seen by
Physical Therapy and continued to have daily TPN and improved
dramatically in her physical activity, more toward although
not completely back to her baseline.
She is to follow-up with her primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], as well as with the transplant surgeon in [**Location (un) 19061**]
per her usual routine.
She is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as needed. She does
not need to come back to [**Location (un) 86**] to follow-up with Dr. [**Last Name (STitle) 952**];
however, she will go home with staples which will need to be
discontinued in two weeks. Her incision is to be followed by
her primary care physician.
PAST MEDICAL HISTORY: History of obesity with gastric bypass
surgery. History of small bowel ischemia and resection
resulting in short gut syndrome. Fatty liver. TPN daily.
Hypercoagulable state. Hysterectomy. Anemia. Low blood
pressure. Occluded superior vena cava in brachiocephalic
vein. Breast reduction surgery.
MEDICATIONS ON ADMISSION: Lactulose, Coumadin, Nexium,
Effexor, TPN, Multivitamin, Vitamin C, Iron, Percocet,
Flagyl, and Vancomycin.
DISCHARGE STATUS: The patient is discharged to home with
services including TPN services and IV services and nursing
for cardiorespiratory check, and Physical Therapy for home
safety.
DISCHARGE DIAGNOSIS: Same as in past medical history in
addition to the following:
1. Partial recannulization of IVC vein system.
2. Lacerated SVC with resultant cardiac tamponade.
3. Median sternotomy, repair of SVC tear, prolonged
intubation with vent dependence.
4. Tunneled right femoral catheter.
5. TPN daily.
6. Hypercoagulable state requiring Coumadin.
7. Poor pain control
8. Ongoing problems with short gut syndrome.
9. Status post blood products resuscitation for cardiogenic
shock due to cardiac tamponade and hypovolemic shock due to
bleeding.
DISCHARGE MEDICATIONS: Percocet p.r.n., Oxycodone p.r.n.,
Coumadin daily dose as before, Venlafaxine 75 two capsules
once a day, Protonix 40 a day, although she takes Nexium at
home which is a fine substitute, Dilaudid p.o. p.r.n. for
breakthrough pain, Colace 1 tab p.o. b.i.d.
CONDITION ON DISCHARGE: Stable to home with services.
FOLLOW-UP: She is the patient follow-up with her primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as instructed, and staples will
need to be discontinued after two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2152-4-19**] 08:22
T: [**2152-4-19**] 08:22
JOB#: [**Job Number 55035**]
|
[
"453.2",
"V45.3",
"459.2",
"785.51",
"423.0",
"579.3",
"998.2",
"571.8",
"998.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.07",
"39.59",
"39.50",
"37.0",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3161, 3418
|
2591, 3137
|
2274, 2569
|
179, 1920
|
1943, 2247
|
3443, 3960
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,302
| 176,952
|
12224
|
Discharge summary
|
report
|
Admission Date: [**2175-4-18**] Discharge Date: [**2175-4-21**]
Date of Birth: [**2098-2-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hyperglycemia, PE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 77yoM with HTN, hypercholesteremia, pancreatic
cancer (s/p bypass) and renal cell carcinoma who was sent in by
his visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] BS into the 400's over the past
few days. In mid-[**Month (only) 958**] he was started on steroid to help
increase his appetite. He did not check blood sugars but
approximately 2 weeks ago he developed chills and shakes and was
brought to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **] where he was found to have a pneumonia
and [**Last Name (NamePattern1) **] blood sugar. He was treated with antibiotics but no
intervention was done for his blood sugars. Since being
discharged his family has been checking his BS and they have
been [**Last Name (NamePattern1) **] and his metformin was increased from 500 [**Hospital1 **] to
850 mg [**Hospital1 **] with 425mg prn by his oncologist Dr. [**Last Name (STitle) **] at [**Hospital1 2025**].
However, he continued to have [**Hospital1 **] BS and was noted to be
more tired with decreased PO intake and dehyration. He was also
sleeping 80% of the time over the last 2 weeks. Last evening his
sugar was in the 500s and this a.m. he was seen by his VNA who
recommended evaluation.
In the ED vitals were 98.8, 75, 150/64, 14, 100% RA. FS 330 and
given 6units SQ insulin and 1L NS. Urine and blood cultures
sent. Received levofloxacin 750 mg IV x 1. EKG with TWI in
inferiolateral leads and cardiac enzymes were sent. The patient
also related some increasing SOB today as well as intermittent
chest discomfort over the past few days, and a CTA was performed
which showed a large pulmonary embolism. Bedside ECHO done by
the ED attending showed some evidence of right heart strain per
the ED resident, but no documentation of this. He was started on
heparin and tranferred to the ICU for monitoring.
Currently the patient has left flank discomfort but no chest
pain or pleuritic pain. Not SOB. + abdominal pain and tenderness
that is chronic for pancreatic cancer. Decreased appetite. No
fevers, chills, nausea, emesis, dysuria, or other symptoms.
Past Medical History:
# Hypertension
# High cholesterol
# GERD on p.m. Zantac
# Status post appendectomy
# Orthostatic hypotension
# Kidney mass - new solid mass in the right kidney concerning
for malignancy, 2.2.3, on [**2174-12-1**]
# DM - increasing BS since [**4-13**] on increasing doses of metformin
# Episode of bright red blood per rectum in [**2169**] requiring
hospitalization at [**Hospital3 **].
# Pancreatic head tumor seen on [**2174-12-1**], pancreatic biopsy
[**2174-12-29**] positive for adenocarcinoma likely of pancreatobiliary
origin. Encases the SMV and SMA and not surgical candidate.
Went to [**Hospital1 2025**] for 2nd opinion who agreed with Dr. [**Last Name (STitle) **].
Admission in [**2-3**] for nausea/emesis and found to have
gastric/small bowel obstruction and underwent surgery (specifics
unclear as history is from son) to relieve obstruction. Had
Gtube for some time but no longer.
# Oncologist [**First Name8 (NamePattern2) 17133**] [**Last Name (NamePattern1) **] at [**Hospital1 2025**]
# ????AFIB ?????? on digoxin
Social History:
Occupation: Worked in construction, retired. Emigrated from
[**Country 38213**] several years ago.
Drugs: denies
Tobacco: 1ppd for 50 yrs, quit [**2171**]
Alcohol: No
Other: Married w/ two sons
Family History:
Brother died of CAD at age 53, sister with diabetes. No colon
cancer, pancreatic, prostate cancer.
Physical Exam:
Tmax: 36.2 ??????C (97.1 ??????F)
Tcurrent: 36.2 ??????C (97.1 ??????F)
HR: 76 (76 - 84) bpm
BP: 137/68(84) {137/68(84) - 148/72(90)} mmHg
RR: 17 (15 - 19) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: Well nourished, No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: RRR, no M/R/G. nl S1, S2
Respiratory / Chest: CTA bilaterally, no wheezes
Abdominal: Soft, Tender: TTP around umbilicus, no rebound or
guarding, no HSM appreciated, scar in midline healed
Extremities: 2+ DP. no calf tenderness
Skin: No rash
Neurologic: A/O x 3
Pertinent Results:
[**2175-4-18**] CTA CHEST:
IMPRESSION:
1. Massive pulmonary embolism with pulmonary emboli noted within
the main, right and left pulmonary artery and their subsegmental
branches. This is associated with the straightening of the
ventricular septum, which suggests increased right heart
pressure.
2. Diffuse panlobular emphysema of both lungs with multiple
bulla.
3. Massive ascites.
4. Enhancing lesion in the liver dome is new compared to prior
abdominal CT and is concerning for metastasis.
Lower ext u/s:[**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, superficial femoral, and popliteal veins were
performed. There is non- occlusive thrombus formation in the
left deep femoral vein with flow detected around the thrombus.
The remaining vessels are patent. In the right lower extremity,
there is non-occlusive thrombus formation in the superficial
femoral vein. The remaining vessels are patent.
IMPRESSION: Bilateral non-occlusive DVT.
ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is borderline
pulmonary artery systolic hypertension. There is a small
pericardial effusion located posterior to the basal
inferolateral segment of the left ventricle. There is a small
amount of fluid anterior to the right ventricle also. There are
no echocardiographic signs of tamponade.
IMPRESSION: Small pericardial effusion located posterior to the
inferolateral wall with some fluid also anterior to the right
ventricle. No echo signs of tamponade. Normal global
biventricular systolic
Brief Hospital Course:
The patient is a 77 y.o.m. with HTN, hypercholesteremia,
pancreatic cancer, renal cell cancer and recent pneumonia who
presents with hyperglycemia and was found to have a pulmonary
embolism.
# Pulmonary embolism ?????? The patient's major risk factor is most
likely malignancy. Given malignancy, large PE, pt was treated
with Lovenox. While awaiting assurance of coverage for long
term lovenox by his insurance, he was started on coumadin, in
the case that the Lovenox was rejected. He received 2 days of
coumadin and had a heightened response to INR 5.3 after only 2
doses of coumadin. When insurance accepted Lovenox treatment,
plan was to discharge on Lovenox [**Hospital1 **], given his supratherapuetic
INR, visting nurses agreed to check his INR at home over then
next 3 days and to start Lovenox only once INR below 3.0.
LENI U/S showed b/l femoral vein thrombus. No IVC filter was
pursued, this was discussed with Dr. [**Last Name (STitle) **], his primary
oncologist.
ECHO showed small pericardial effusions but no tamponade and no
evidence of right heart strain from the PE.
# Hyperglycemia- The was likely in the setting of recent
infection, steroids, worsening pancreatic function. He was on
Lantus while in the ICU with good response. Given the family's
wish to avoid insulin if possible, he was trialed on higher
doses of metformin with good effect. Visiting nurses will
assist family with fsbg checks at home and if persistently
[**Last Name (STitle) **], they understand to discuss with primary care whether
he needs to start Lantus at home.
# Poor appetitie, malnutrition: Steroids were discontinued and
pt given a presription for Megace. Family felt he would eat
better at home and plan to hold off on giving him Megace for
now.
# Pancreatic cancer ?????? Pt will follow up with Dr. [**Last Name (STitle) **] in 5 days.
# HTN ?????? Currently well controlled. Continue home regimen
# Hypercholesteremia ?????? Continued statin
Long term goals: Family decided to transition to DNR/DNI. They
were not prepared to discuss hospice at this time, and felt that
they needed to discuss further with his primary oncologist, Dr.
[**Last Name (STitle) **].
Medications on Admission:
Atenolol 50 mg daily
Norvasc 2.5mg daily
Digoxin 0.125mg daily
Prilosec 20mg daily
Aspirin 81 mg daily
Simvastatin 40 mg daily
Creon 20 mg 2 capsules TID
Lisinopril 5mg daily
Metformin 850mg [**Hospital1 **] and 425 [**Hospital1 **] as needed additional
Zofran 4 mg QID prn
Oxycontin 20 mg [**Hospital1 **]
Oxycodone 1 tab Q4-6H prn
Colace
Senna
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day) as needed.
6. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
7. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*1 box* Refills:*8*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Zofran 8 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
15. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*0*
16. Metformin 850 mg Tablet Sig: One (1) Tablet PO QPM.
17. Megestrol 400 mg/10 mL Suspension Sig: Four Hundred (400) mg
PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
deep vein thrombosis in both legs
pulmonary embolism
diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
Please take the Lovenox shots twice per day, in about 6 weeks
you will need a new prescription, please ask Dr. [**Last Name (STitle) **]. Please
call Dr. [**Last Name (STitle) **] with any shortness of breath, chest pain, bleeding
in your stool, or other concerning symptoms.
Please note the following medication changes:
Restart Metformin twice per day, BUT a new higher dose in the
morning (1000mg, prescription provided) and same dose as prior
at night (850mg).
Start Megace for appetite.
Start Lovenox twice per day.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] within the next 2 weeks.
Please be sure to check finger sticks glucose at least 2 times
per day, if these are persistently over 250, talk to Dr. [**Last Name (STitle) **] at
the upcoming appointment about starting Lantus insulin.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2175-4-24**]
|
[
"V10.52",
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
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[
[
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10940, 11011
|
6800, 8983
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333, 340
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11126, 11135
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,354
| 199,749
|
37762+58168
|
Discharge summary
|
report+addendum
|
Admission Date: [**2196-12-14**] Discharge Date: [**2196-12-21**]
Date of Birth: [**2123-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Status post mitral valvuloplasty
Major Surgical or Invasive Procedure:
valvuloplasty
History of Present Illness:
Mr [**Known lastname 1968**] is a 73 year old man with complicated past medical
history including large B cell non-hodgkins lymphoma, mitral
stenosis, Afib, seizure disorder, electively admitted for
valvuloplasty, transferred to CCU for close monitoring.
.
Briefly, patient was admitted on [**10-14**] with SOB and DOE and was
evaluated for valvuloplasty, however at that time was found to
have a clot in the right atrium and procedure was deferred. He
remained anticoagulated and repeat TEE yesterday revealed
persistent left atrial appendage clot with smoke. Became
hypotensive during the procedure and was given 2L IV fluids,
thought to be multifactorial from poor PO intake, sedation, and
afib with RVR. Today, he underwent planned mitral vavuloplasty
uneventfully with improvement in mitral valve area from 1.2 to
3.7 cm2 (gradient decreased from 10 to 2 mmHg); cardiac index
was 2.5 L/min/m2; mean PCWP 17 mmHg with LVEDP 9 mmHg. He
currently has no complaints.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, cough, hemoptysis, black stools or red stools. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-AAA 4cm
-CVA: Cerebellar artery infarct on MRI
-TIA [**2179**]
-Large B cell non hodgkin's lymphoma treated with diverting
colostomy, chemo, radiation
-Moderate to severe Mitral stenosis wtih MVA of 1cm2
-Chronic atrial fibrillation
-Seizure disorder-last seizure 1.5 yrs ago
-Depressive disorder
-Osteopenia
-Pulmonary hypertension
-? dementia per wife
-Hx Cholecystectomy
-Hard of hearing
Social History:
Currently lives with his wife in an [**Hospital3 4634**] facility. He
is a retired manager. He denies EtOH or drug use, smokes [**4-10**]
cigs/day, has been smoking since age 25.
Family History:
No siblings. Father died in his 80s from emphysema. Mother
died in her early 50s from heart disease.
Physical Exam:
On Admission:
VS: T=not recorded BP=127/71 HR=83 RR=19 O2 sat= 100% 2L
GENERAL: Cachectic 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. MM dry.
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, normal S1, S2, ? S4 vs mid-systolic
click. No m/r/g. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, however poor air
movement.
ABDOMEN: Soft, NTND, decreased bowel sounds. Colostomy bag in
place. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2+ radial pulses
.
On Discharge: VSS, decreased breath sounds in R base, lungs
otherwise clear. Cardiac rhythm remains irregular with no mrg,
mid-systolic click no longer present.
Pertinent Results:
On Admission:
.
[**2196-12-14**] 08:12PM BLOOD WBC-4.2 RBC-3.03* Hgb-10.3* Hct-31.9*
MCV-105* MCH-34.0* MCHC-32.3 RDW-15.0 Plt Ct-188
[**2196-12-14**] 08:12PM BLOOD Neuts-74.1* Lymphs-15.6* Monos-9.6
Eos-0.4 Baso-0.3
[**2196-12-14**] 10:50AM BLOOD PT-20.0* INR(PT)-1.8*
[**2196-12-14**] 08:12PM BLOOD Glucose-69* UreaN-18 Creat-0.7 Na-144
K-5.1 Cl-112* HCO3-26 AnGap-11
[**2196-12-14**] 08:12PM BLOOD Calcium-8.3* Phos-2.8 Mg-1.5*
.
While in-pt:
.
[**2196-12-18**] 05:55AM BLOOD WBC-13.8*# RBC-2.28* Hgb-7.6* Hct-23.8*
MCV-105* MCH-33.5* MCHC-32.0 RDW-15.4 Plt Ct-131*
[**2196-12-20**] 06:35AM BLOOD Neuts-76.8* Lymphs-14.1* Monos-8.2
Eos-0.7 Baso-0.3
[**2196-12-18**] 05:55AM BLOOD CK-MB-2 cTropnT-0.02*
[**2196-12-17**] 04:04AM BLOOD VitB12-741 Folate-9.8
[**2196-12-18**] 05:55AM BLOOD TSH-3.1
[**2196-12-20**] 06:35AM BLOOD Digoxin-1.3
.
On Discharge:
.
[**2196-12-21**] 06:40AM BLOOD WBC-4.8 RBC-2.38* Hgb-8.2* Hct-25.6*
MCV-107* MCH-34.4* MCHC-32.0 RDW-16.3* Plt Ct-128*
[**2196-12-21**] 06:40AM BLOOD Plt Ct-128*
[**2196-12-21**] 06:40AM BLOOD Glucose-77 UreaN-18 Creat-0.8 Na-139
K-4.1 Cl-105 HCO3-29 AnGap-9
[**2196-12-21**] 06:40AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8
.
[**12-24**] ECHO:
The left atrium is severely dilated. Mild to moderate
spontaneous echo contrast is seen in the body of the left
atrium. Moderate to severe spontaneous echo contrast is present
in the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). Definite thrombus is seen in
the left atrial appendage. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium or the right
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is probably
normal (LVEF>55%) (not fully assessed). Right ventricular free
wall motion may be depressed. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly to moderately thickened. The
mitral valve shows characteristic rheumatic deformity. The
mitral stenosis gradient was not assessed. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. A TEE procedure related complication occurred (see
comments for details).
.
IMPRESSION: Left atrial appendage thrombus with prominent
spontaneous echo contrast in the left atrium and left atrial
appendage. Mitral stenosis with rheumatic deformity.
.
Compared with the prior study (images reviewed) of [**2196-10-28**],
the severity of mitral regurgitation is reduced on the current
study. The other findings are similar.
.
[**12-14**] ECG: Atrial fibrillation. Left axis deviation may be due
to left anterior fascicular block. Precordial lead QRS
configuration may be due to
left anterior fascicular block but consider also right
ventricular
overload/hypertrophy. The QTc interval appears prolonged but it
is difficult to measure. ST-T wave changes are non-specific.
Clinical correlation is suggested. Since the previous tracing of
[**2196-10-28**] no significant change.
.
[**12-16**] ECHO (pre-procedure):The left atrium is dilated. Mild
spontaneous echo contrast is seen in the body of the left
atrium. No thrombus/mass is seen in the body of the left atrium.
Overall left ventricular systolic function is normal (LVEF>55%).
There is normal right ventricular free wall contractility. The
mitral valve leaflets are mildly thickened. The mitral valve
shows characteristic rheumatic deformity. There is moderate
valvular mitral stenosis (mean gradient, 8 mmHg). Mild (1+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
[**12-16**] ECHO (post procedure):
.
A catheter is seen traversing the interatrial septum. The left
atrium is dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Mild (1+)
aortic regurgitation is seen. There is mild valvular mitral
stenosis (mean gradient, 3 mmHg). Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
.
IMPRESSION: Mild rheumatic mitral stenosis. Moderate mitral
regurgitation.
.
Compared with the pre-procedure intracardiac echo study of
[**2196-12-16**], the transmitral gradient has decreased significantly,
while severity of mitral regurgitation has slightly increased.
.
[**12-16**] Cardiac Cath:Percutaneous Balloon Valvuloplasty: was
performed on the mitral valve by
a transseptal approach with a maximum balloon diameter of 27 mm.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
.
[**12-17**] ECHO: There is moderate global left ventricular
hypokinesis (LVEF = 35%). The mitral valve leaflets are mildly
thickened. The mitral valve shows characteristic rheumatic
deformity. There is mild valvular mitral stenosis (area
1.5-2.0cm2, mean gradient 5 mmHg). Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
.
IMPRESSION: Rheumatic mitral valve disease with mild stenosis
and mild regurgitation. Moderate global left ventricular
systolic dysfunction.
.
Compared with the prior study (images reviewed) of [**2196-12-16**],
LV systolic function is not as vigorous today. Severity of
mitral regurgitation has decreased, probably in part because a
guidewire/balloon are no longer positioned across the valve.
.
[**12-18**]: CXR Findings concerning for bibasal consolidations
worrisome for infectious process. Part of the consolidation
might be due to superimposed interstitial pulmonary edema and
reevaluation of the patient after diuresis is recommended.
Bilateral pleural effusions, right more than left are small to
moderate.
.
[**12-18**] Abd/Pelvis CT:
1. No evidence of retroperitoneal bleed.
2. Infrarenal abdominal aortic aneurysm measuring up to 4.6 cm
in diameter.
Bilateral iliac artery aneurysms measuring up to 3.4 cm on the
right and 2.5
cm on the left.
3. Right lower lobe consolidation, concerning for pneumonia or
aspiration.
Patchy opacity at the left base also may represent
aspiration.Bilateral
pleural effusions, right greater than left.
4. Compression fracture with burst type component, of vertebral
body L2 of
unknown chronicity, as there are no priors for comparison. Mild
anterior
wedge deformity of vertebral body L1. There is no retropulsion
of the
vertebral bodies.
5. Vague area of hyperdensity within the dependent aspect of the
bladder.
This reflect residual excreted contrast or dependent debris such
as blood.
Please correlate clinically.
.
[**12-20**]: video swallow-final report pending, prelim report showed
some aspiration
Brief Hospital Course:
73 yo gentleman with PMH significant for CVA, B-cell
non-hodgkin's lymphoma, chronic afib on anticoagulation admitted
for elective valvuloplasty for mitral stenosis. Hospital course
was complicated by atrial fibrillation with RVR and pneumonia.
.
#: MITRAL STENOSIS: Patient initially presented for valuloplasty
several months prior however clot was detected in the atrial
appendage therefore he was sent home for further
anticoagulation. He returned this admission and was found to
have persistant clot in the atria, however underwent mitral
valvuloplasty without complication and was found to have a
significantly reduced gradient post-intervention. He was
monitored briefly in the ICU but returned to the floor without
needing intubation or pressor support. Post-valvuloplasty ECHO
showed mild rheumatic MS, moderate regurgitation. Given his
persistent atrial clot, his warfarin dose was increased and he
will be discharged on this increased dose with a goal INR of
2.5-3.5. He has cardiology f/u scheduled and should receive a
repeat ECHO in 6 weeks. He will need monitoring at an
[**Hospital3 **] and will receive repeat INR 2 days after
discharge.
.
# ATRIAL FIBRILLATION: After valvuloplasty, his rate was poorly
controlled with HR in the 100s. Given his hypotension and poor
PO intake, he was inititially managed with fluids with
improvement in HR and BP. Given persistent tachycardia, digoxin
was added to his regimen in the ICU. Additionally, he was
started on metoprolol, which was weaned down from the initial 25
[**Hospital1 **] dosing when pt became bradycardiac with 2 sec pauses on
tele. On discharge HR was well controlled in the 50s-60s on 25
[**Hospital1 **] of metoprolol and digoxin 0.125. He was treated with
heparin bridge until therapeutic on warfarin, which was
increased to 5 mg/day during the hospitalizaton for goal INR of
2.5-3.5. INR was 2.5 on discharge. Pt should f/u with INR
check 2 days post discharge ([**12-23**]). He may also need titration
of BBlocker as an outpatient and should be monitored for
symptoms concerning for bradycardia.
.
# PUMP: Admission ECHO showed normal EF of 50%. Repeat ECHO
showed EF of 35% after procedure, however there was some concern
that this may be rate-related and not representative of his true
EF. Pt was without signs of heart failure. ECG and cardiac
enzymes were drawn at this time out of concern for possible
ischemic event that may have caused worsening EF, however were
not concerning for acute event.
.
# LEUKOCYTOSIS: Pt developed leukocytosis with bandemia and was
found to have RLL infiltrate concerning for pneumonia. He was
asymptomatic from a respiratory standpoint and afebrile. Cdiff
was negative, blood cxs negative x 2. He was initially started
on vancomycin and cefepime, switched to cefepime alone given low
suspicion for MRSA with continued improvement.
.
# Wt Loss: Pt complained of recent 30 lb weight loss which was
concerning for progression of his cancer vs decreased PO intake
in the setting of valvular disease and fatigue. Pt gained wt
during this admission and was taking between [**Telephone/Fax (1) 84561**]
calories/day. Seen by nutrition and speech and swallow who
recommend supplementing meals with ensure. While there was
concern for aspiration given his new pneumonia and trivial
aspiration on video-assisted swallow, speech and swallow felt
that this could be improved with teaching the patient proper
swallowing techniques and recommended no dietary changes given
his poor nutritional status.
.
# Anemia: Pts crit dropped during this admission from 31.9 to
23.2. Macrocytic, initally thought to be secondary to poor
nutritional status vs progression of malignancy. Folate and B12
were normal. Guiac stools were negative, CT abd was checked out
of concern for retroperitoneal bleed s/p cath, however no clear
source of bleed was found. [**Month (only) 116**] also be a dilutional component
given his fluid hydration while in the hospital.
.
# Hx B-cell lymphoma: s/p chemo/radiation/diverting colostomy.
Outside records obtained but remains unclear why pt required
bowel resection. Appears that patient has completed
chemotherapy with CHOP-R and was then lost to follow-up. Given
recent wt loss, anemia and thrombocytopenia, pt was scehduled
for f/u with his primary oncologist.
.
# AAA: 4.6 cm. Will require q6-12 m monitoring with US vs CT.
.
# Skin Lesion: approximately 2 cm pigmented lesions with
irregular borders, pt states has gotten larger over time.
Concerning for squamous cell carcinoma, pt is scheduled for
outpatient f/u with dermatology.
.
# Hx seizures: no recent seizure activity. Depakote was
continued in the hospital.
.
# Depression: fluoxetine was continued
Medications on Admission:
Depakote 500mg [**Hospital1 **]
Lovastatin 40mg 2 tablets in the am
Fluoxetine 40mg daily
Warfarin 3mg last dose Sunday night
Vitamin D 1000 IU daily
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
3. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Outpatient Lab Work
Please check INR, CHEM 7, CBC on Friday [**12-21**]
8. Cefepime 2 gram Recon Soln Sig: One (1) Intravenous twice a
day for 3 days.
Disp:*6 12 g* Refills:*0*
9. Lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
PRIMARY: Mitral stenosis, Left atrial appendage clot
SECONDARY: atrial fibrillation, pnemonia, b cell lymphoma,
anemia, thrombocytopenia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted for mitral valve disease and were treated with
valvuloplasty. You were also treated for your atrial
fibrillation with new medications (metoprolol and digoxin). You
continue to have a blood clot in your left atrium and so your
INR should remain between 2.5 and 3 until the clot resolves.
Your hospital course was complicated by a pneumonia which we
treated with antibiotics. During the hospitalization, you were
also found to have a low red blood cell count and platelent
counts. Please follow up with your primary oncologist.
.
CHANGES TO YOUR MEDICATIONS:
COMPLETE 3 more days of CEFEPIME.
START METOPROLOL 20mg twice daily.
START DIGOXIN 125mcg daily.
.
Please take your medications as prescribed and follow up with
your physicians as outlined below.
Followup Instructions:
Please follow up with your cardiologist as follows. You will
also need a repeat ECHO in 6 wks as the last echo done during
this hospitalization showed that there may have been a decrease
in your hearts pumping function. This finding may, however, be a
result of a fast heart rate during the exam as so, as above,
should be repeated in 6 weeks.
.
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**]
Specialty: Cardiology
Date/ Time: Tuesday, [**1-3**] at 2:45pm
Location: [**Hospital **] MEDICAL GROUP OF [**Location (un) **], [**Hospital1 84562**], [**Location (un) **],[**Numeric Identifier 59599**]
Phone number: [**Telephone/Fax (1) 5879**]
.
MD: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
Specialty: Dermatology
Date/ Time: Wednesday, [**1-12**] at 3:15pm
Location: [**Apartment Address(1) 78489**], [**Location (un) 55**] [**Numeric Identifier 3883**]
Phone number: ([**Telephone/Fax (1) 8132**]
.
Please see Dr [**Last Name (STitle) 15759**] in [**Location (un) 47**] Tueday [**12-27**] 1:30 PM
([**Telephone/Fax (1) 70551**]).
.
You should also follow up with your primary care physician on
discharge from the rehab facility.
Name: [**Known lastname 447**],[**Known firstname 140**] E Unit No: [**Numeric Identifier 13422**]
Admission Date: [**2196-12-14**] Discharge Date: [**2196-12-21**]
Date of Birth: [**2123-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4871**]
Addendum:
Addendum: Pt with moderate-severe malnutrition as evidence by
cachexia, BMI<18, caloric intake <30 kCal/kg/day, recent wt
loss.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 176**] Of [**Location (un) 13063**]
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 4878**] MD [**MD Number(1) 4879**]
Completed by:[**2196-12-21**]
|
[
"287.5",
"V85.0",
"394.2",
"311",
"285.9",
"272.4",
"345.90",
"486",
"V44.3",
"511.9",
"397.0",
"733.90",
"427.32",
"426.2",
"441.4",
"416.8",
"202.80",
"429.89",
"173.9",
"261",
"V12.54",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.28",
"88.72",
"88.56",
"37.23",
"35.96"
] |
icd9pcs
|
[
[
[]
]
] |
19152, 19392
|
10533, 15255
|
350, 366
|
16464, 16464
|
3585, 3585
|
17439, 19129
|
2503, 2605
|
15455, 16182
|
16304, 16443
|
15281, 15432
|
16641, 17190
|
2620, 2620
|
1799, 1867
|
4441, 10510
|
17219, 17416
|
278, 312
|
394, 1689
|
3599, 4427
|
16478, 16617
|
1898, 2291
|
1711, 1779
|
2307, 2487
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,454
| 122,390
|
31066
|
Discharge summary
|
report
|
Admission Date: [**2110-10-31**] Discharge Date: [**2110-11-5**]
Date of Birth: [**2031-11-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Streptomycin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
DOE, palpitations
Major Surgical or Invasive Procedure:
TEE
electrical cardioversion
History of Present Illness:
78-year-old male with history of hypertension, hyperlipidemia,
diabetes and persistent atrial fibrillation s/p PVI [**11/2107**] on
fleicanide. He has not been feeling well for the last 3wks. He
states he has shortness of breath that comes and goes and that
he can feel his heart and it feels like it is working very hard
and fast. He denies shortness of breath when he is laying flat,
but does have difficulty when standing up and has difficulty
walking due to palpitations and shortness of breath. He says
this feeling is similar to an episode he had in [**2105**] when he
developed a. fib. He states that when he eats then he also has
some pain in his chest. He denies cough at present.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
atrial fibrillation s/p pulmonary vein ablation ([**2106**])
hypertension
chronic lung disease likely [**1-7**] smoking
Social History:
-Tobacco history: smoked for a long time, quit in [**2101**]
-ETOH: "and who doesn't drink alcohol"? drinks occasionally on
weekends, did not drink preceding onset of afib
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 13-14 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, distant heart sounds, 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, Crackles throughout.
ABDOMEN: Soft, NTND, obese. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
At discharge: same as above except:
NECK: JVP of 10cm
Pertinent Results:
[**2110-10-31**] 07:25PM GLUCOSE-245* UREA N-32* CREAT-1.4* SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2110-10-31**] 07:25PM estGFR-Using this
[**2110-10-31**] 07:25PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-1.6
[**2110-10-31**] 07:25PM WBC-7.2 RBC-4.43* HGB-12.7* HCT-37.8* MCV-85
MCH-28.6 MCHC-33.5 RDW-14.8
[**2110-10-31**] 07:25PM WBC-7.2 RBC-4.43* HGB-12.7* HCT-37.8* MCV-85
MCH-28.6 MCHC-33.5 RDW-14.8
[**2110-10-31**] 07:25PM PLT COUNT-245
[**2110-10-31**] 07:25PM PT-28.0* INR(PT)-2.8*
EKG: Afib with [**Month/Day/Year 5509**]
.
ECHO [**11-3**]:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal regional and low normal
global systolic function. Normal right ventricular cavity size
with mild free wall hypokinesis. Mild-moderate mitral
regurgitation. Small secundum type atrial septal defect.
Compared with the prior study (images reviewed) of [**2109-12-16**],
biventricular systolic function is less vigorous, a small
secundum type atrial septal defect is now suggested, and the
peak transmitral A wave velocity is more depressed.
.
Labs on Discharge:
[**2110-11-5**] 08:40AM BLOOD WBC-6.6 RBC-4.43* Hgb-12.4* Hct-38.0*
MCV-86 MCH-28.1 MCHC-32.8 RDW-14.6 Plt Ct-256
[**2110-11-5**] 08:40AM BLOOD Plt Ct-256
[**2110-11-5**] 08:40AM BLOOD Glucose-179* UreaN-56* Creat-1.8* Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
[**2110-11-5**] 08:40AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
[**2110-11-3**] 06:45AM BLOOD TSH-1.3
Brief Hospital Course:
78 M with h/o Afib s/p PVI [**11/2107**] on fleicanide, DM, HTN, HL,
who presented in Afib and heart failure with symptoms of DOE and
palpitations x3wks, now s/p DCCV complicated by hypotension.
.
# Afib with [**Name (NI) 5509**] - Pt presented with palpitations and DOE similar
to episode of afib with [**Name (NI) **] in [**2105**]. Pt now presents with Afib
with [**Year (4 digits) **] and clinical evidence of volume overload (bilateral
crackles, elevated jvp). Increased flecainide to 150mg [**Hospital1 **] on
day of admission with PRN metoprolol for further rate control.
HR still not optimally controlled despite increased flecanide
and metoprolol doses and patient continued having episodes of
palpitations and tachycardia. Pt underwent TEE and cardioversion
on [**11-3**]. His Flecainide was discontinued and pt was started on
amiodarone. Home aspirin was continued. After the cardioversion
procedure patient went to the CCU due to hypotension. He
remained asymptomatic throughout his stay in the CCU. His blood
pressure slowly trended into the normal range. The episode of
hypotension (sbp in 80s, with MAP of 60s) was attributed to the
response to medications given while on the medical floor as well
as in the procedure suite.
.
# DOE: On admission pt had clinical evidence of volume overload,
likely due to poor forward flow from Afib. He was diuresed with
IV lasix with some improvement of symptoms. In the CCU he denied
any SOB and was satting well on room air. He had some sleep
apnea at night but continued to sat above 90% on room air.
.
# HTN: Blood pressure well controlled during hospital stay off
Lisinopril and Imdur.
.
# DM: Home metformin was held during hospital stay and at
discharge. Glipizide was restarted at discharge.
.
# Hyperlipidemia: continued home atorvastatin.
.
# Acute on Chronic renal insufficiency: pt with baseline
1.1-1.5. Creatinine increased and peaked at 2.3, [**Month (only) **] to 1.8 on
day of discharge. [**Last Name (un) **] possibly due to poor forward flow from
Afib with [**Last Name (un) 5509**] as well as IV diuresis. Metformin, Lisinopril,
aldactezide and Imdur were held and not restarted at discharge.
Pt should have a chem-7 and INR drawn by the VNA on [**2110-11-6**] with
results to Dr. [**Last Name (STitle) 3357**] on [**11-7**].
Medications on Admission:
MEDICATIONS: confirmed with Sutherland Pharmacy [**2110-11-5**]
atorvastatin 10 mg daily
fenofibrate 48 mg daily
flecainide 100 mg [**Hospital1 **]
glipizide 2.5 mg TID
isosorbide sustained release 30 mg daily
lisinopril 40 mg daily
metformin 500 mg TID
metoprolol succinate 50 mg daily in and and [**12-7**] tablet in the
evening
warfarin 5 mg daily
Ambien 10 mg at HS
ASA 81 mg daily
Vitamin D 50,000 units daily
Nasonex 2 sprays daily
Nitrostat 0.4 mg tab under tongue as directed.
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fenofibrate 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
Please check INR nd Chem-7 on Friday [**2110-11-7**] at Dr.[**Name (NI) 10962**]
office with results to Dr. [**Last Name (STitle) 3357**]
6. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO three times a day.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO every
other week.
10. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
sprays Nasal once a day.
11. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation
Diastolic heart failure exacerbation
Acute on Chronic Kidney disease
Secondary Diagnoses:
Hypertension
Diabetes
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of shortness of
breath. You were found to have atrial fibrillation and excess
fluid in your lungs. You had a procedure called cardiac
cardioversion to convert your irregular rhythm to a normal
rhythm. Your blood pressure dropped after this procedure and
you were monitored in the cardiac intensive care unit overnight.
We did not give you any of your normal antihypertensive
medications. You should not restart these medications at home.
You will see your primary care doctor this week to discuss
restarting them.
STOP taking these medicines for now, Dr. [**Last Name (STitle) 3357**] will restart
them at some point:
Lisinopril
Metoprolol
Metformin
Warfarin (coumadin): you will need less of this medicine because
of the interaction with the amiodarone
Aldactazide
Stop these medications entirely:
Isosorbide mononitrate
Flecainide
START this medication:
Amiodarone: you will need to have your liver, lung and thyroid
function checked frequently while on this medicine.
Continue your other medications as directed. We have confirmed
the medicines with your pharmacy.
.
You will need to have your blood drawn at Dr.[**Name (NI) 10962**] office
on Friday to check your INR and your kidney function.
Followup Instructions:
Please keep the following appointments:
Name: [**Last Name (LF) 3357**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 994**]
Phone: [**Telephone/Fax (1) 4606**]
Appt: [**11-7**] at 11:30am
Please get labs drawn at this appt
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2110-12-2**] at 9:40 AM
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-Pulmonary
When: TUESDAY [**2110-12-2**] at 10:00 AM
With: DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Appt: We are working on an appt for you within the next [**1-8**]
weeks. The office will call you at home with an appt. If you
dont hear from them within 48 hours, please call the office
directly.
|
[
"272.4",
"585.9",
"427.31",
"458.29",
"428.33",
"428.0",
"250.00",
"584.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
8486, 8561
|
4598, 6897
|
308, 338
|
8772, 8772
|
3080, 4203
|
10209, 11669
|
2079, 2194
|
7433, 8463
|
8582, 8582
|
6923, 7410
|
8923, 10186
|
2209, 3005
|
8712, 8751
|
1643, 1701
|
3019, 3061
|
251, 270
|
4222, 4575
|
366, 1539
|
8601, 8691
|
8787, 8899
|
1732, 1853
|
1561, 1623
|
1869, 2063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,342
| 135,660
|
49013
|
Discharge summary
|
report
|
Admission Date: [**2176-7-31**] Discharge Date: [**2176-8-3**]
Date of Birth: [**2130-4-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
- EGD
- TIPS Angioplasty and Embolization of Varices
History of Present Illness:
46 yo F w/ ETOH/HCV cirrhosis, grade 1 varices and portal
gastropathy who presented to the ED yesterday with 1 episode of
hematemesis on [**7-30**], which the patient describes as "dark
clots...just old blood". She subsequently left AMA and returned
the next day with melena x 1. Of note, pt was recently admitted
in [**5-14**] with hematemesis and melena and admitted to the MICU due
to hypotension to SBP 70s. At that time she was treated with NG
lavage, FFP, vitamin K, Levofloxacin 500, Octreotide, PPI and
fluid resucitation along large volume blood transfusions (9
units). Her course was complicated by hypoxia and fluid
overload. She is s/p TIPS in [**6-18**] and since that time has been
doing relatively well. The patient denies the use of NSAIDs,
anti-coagulants, iron supplementation or pepto bismol.
Past Medical History:
Cirrhosis -Heavy ETOH abuse, +HCV (viral load undetectable), c/b
coagulopathy/thrombocytopenia, elevated portal pressures with
varices and portal gastropathy s/p TIPS [**6-13**]
-Celiac sprue dx on Bx EGD [**4-13**] however not on diet since has no
symptoms according to patient
-Chronic LE neuropathy
-Diastolic CHF
a. last echo in [**1-15**], PASP 28, EF >55%
b. ETT/MIBI: [**12-13**], no ischemic regions
-Anemia: Baseline Hct ~30, chronic blood loss, ?sprue
-Asthma
-Depression
-Osteopenia
-Hypothyroidism
-s/p CCY
-TAH for endometrial hyperplasia
Social History:
Lives with husband and 29 y.o son.
Heavy etoh abuse in the past, last drink long time ago according
to patient. Hx of +screens here in the past, tobacco 1 ppd x 30
years. No IVDU.
Family History:
Father died of MI in 80's. Many alcoholics in family. One
cousin with celiac sprue.
Physical Exam:
VS: 98.4 102/53 92 20 99% RA
GEN: looks older than stated age, very aggressive personality
but answers questions appropriately, NAD
HEENT: PERRLA, EOMI, no icterus, dry MM, telangiectasias on
face, poor dentition, neck supple
CV: RRR no m/r/g
LUNGS: CTAB on anterior exam
ABD: soft, NT, ND, +BS, trace of liver edge beneath costal
margin, no rebound or guarding
EXT: no edema, warm, dry skin, tender to touch
SKIN: + spider angiomata
Neuro: no gross deficits
Pertinent Results:
Serum tox negative
Hct 31
INR 1.9
Plts 83
RECENT IMAGING:
EKG [**7-31**]:
SR at 93 bpm, nl axis, QTc slightly prolonged at 450 ms, TWI
V1-3
[**7-30**] U/S:
Patent TIPS stent with no significant change in velocities of
flow compared to [**2176-6-8**].
EGD [**6-18**]:
Varices at the lower third of the esophagus
Erythema and congestion in the stomach body and fundus
compatible with moderate portal gastropathy
Varices at the second part of the duodenum
No gastric varices
[**2176-6-18**]
TIPS
1. Successful placement of a transjugular intrahepatic
portosystemic shunt using three 10-mm bare metallic Wallstents
extending from a right portal vein to the right hepatic vein.
2. Slightly unusual hepatic venous anatomy identified with two
separate right hepatic veins which were small in caliber.
3. Gradient between the portal vein and IVC pre-TIPS placement
was 13 mmHg. Post- TIPS placement the gradient was 9 mmHg.
[**6-4**] EGD:
Grade I varices at the lower third of the esophagus
Grade 1 esophagitis in the gastroesophageal junction
Portal gastropathy
Duodenitis in the proximal bulb
Large duodenal varix
Brief Hospital Course:
Blood loss anemia/GI bleeding:
Pt was transferred from floor to MICU after an episode of
hematemesis and melena. After transfer to MICU, patient was
followed closely by transplant hepatology. Pt was s/p TIPS
placement by IR on [**2176-6-18**] - pt now returns with duodenal
bleeding and had an EGD with cauterization. Hepatic venogram
performed on [**2176-8-1**] revealed a probable umbilical varix, which
was embolized with multiple coils. Pressure gradients across the
TIPS were about 10 mmHg before and after angioplasty of proximal
portion.
Pt's blood count remained stable and patient was discharged to
home from the MICU.
Medications on Admission:
- Gabapentin 900 mg PO Q8H
- Levothyroxine 50 mcg PO DAILY
- Albuterol 1-2 Puffs Inhalation Q6H as needed.
- Levofloxacin 500 mg Tablet PO daily for SBP PPx - NOT TAKING X
1 MONTH
- lactulose prn for constipation >3 days
- Pantoprazole 40 mg Tablet daily
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
2. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper GI Bleed
Secondary:
EtOH Cirrhosis
Discharge Condition:
Good - Patient is ambulating, taking oral intake, and back to
baseline condition.
Discharge Instructions:
Please take all medications as prescribed. If you have any
symptoms of bleeding, change in the color or consistency of your
stool, vomiting, or vomiting any blood, please seek immediate
medical attention.
Followup Instructions:
.Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2176-8-19**] 5:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**], RD Phone:[**Telephone/Fax (1) 3681**]
Date/Time:[**2176-9-10**] 2:00
|
[
"311",
"355.8",
"428.30",
"244.9",
"571.2",
"733.90",
"578.1",
"280.0",
"456.20",
"070.54",
"493.90",
"996.1",
"303.90",
"287.5",
"456.8",
"428.0",
"276.52",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.64",
"38.93",
"45.13",
"99.04",
"00.40",
"44.44",
"39.50",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5133, 5139
|
3696, 4331
|
292, 347
|
5233, 5317
|
2559, 3673
|
5570, 5875
|
1978, 2064
|
4637, 5110
|
5160, 5212
|
4357, 4614
|
5341, 5547
|
2079, 2540
|
241, 254
|
375, 1188
|
1210, 1764
|
1780, 1962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,118
| 113,756
|
44315
|
Discharge summary
|
report
|
Admission Date: [**2186-9-17**] Discharge Date: [**2186-9-21**]
Service: [**Last Name (un) **]/MED Please note that the patient was admitted
on the Orthopedic Service and discharged on the Medicine
Service.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 95026**] is a 79 year old
male with a past medical history significant for a non-small
cell lung carcinoma with metastases to the brain status post
two cycles of chemotherapy with Carboplatin/Taxol, who
experienced a fall on [**9-15**] upon exiting his car and
walking five to six steps. He notes no preceding events
prior to the fall, and notes that it was not mechanical in
etiology. The patient was taken to an outside hospital and
was found to have a left hip subtrochanteric fracture without
neurovascular impairment. At the time, he was found to have
a decreased hematocrit and was transfused. He was
subsequently transferred to [**Hospital1 188**] for an open reduction and internal fixation.
In the Operating Room during this procedure, the patient had
two episodes of supraventricular tachycardia associated with
a decrease in blood pressure ameliorated by cardioversion on
each occasion. The patient was started on an Amiodarone
drip, remained normotensive throughout the rest of the case,
and was transferred to the Surgical Intensive Care Unit.
The patient had a third episode of supraventricular
tachycardia while in the Intensive Care Unit which was
treated successfully with adenosine. Mr. [**Known lastname 95026**] experienced
a fourth episode of supraventricular tachycardia while in the
Intensive Care Unit which converted into normal sinus rhythm
with Lopressor. On subsequent episodes of supraventricular
tachycardia with hypotension, the patient was bolused with
normal saline.
The Cardiology Service was consulted and evaluated the
patient in the Intensive Care Unit. The recommendations per
Cardiology were to continue the Amiodarone intravenously and
continue to use Adenosine as needed for symptomatic
supraventricular tachycardia.
The patient was transferred to the Floor and continued on
intravenous Amiodarone and was started on an oral Amiodarone
load. On [**9-19**], the patient was transferred to the
Medical Service.
PAST MEDICAL HISTORY:
1. Metastatic non-small cell lung carcinoma diagnosed in
[**2186-8-6**], metastatic to the brain. The patient was
noted to have three left frontal lobe metastases, who of
which have regressed after systemic chemotherapy. The
patient is status post two cycles of chemotherapy,
Carboplatin/Taxol. During the last admission, Mr. [**Known lastname 95026**]
was evaluated by the Radiation Oncology Service and was to
have a stereotactic radio surgery for removal of the brain
metastases.
2. Malignant pleural effusions status post pleurodesis.
3. Hypertension.
4. History of supraventricular tachycardia during his last
hospitalization.
5. Benign prostatic hypertrophy.
6. Status post meningioma resection in [**2177**].
7. Status post left inguinal hernia repair in [**2182**].
ALLERGIES: Dilantin (liver toxicity, rash).
MEDICATIONS ON TRANSFER:
1. Amiodarone 400 mg p.o. three times a day.
2. Amiodarone intravenous drip.
3. Ativan p.r.n.
4. Morphine p.r.n.
5. Calcium gluconate p.r.n.
6. Potassium chloride p.r.n.
7. Magnesium sulfate p.r.n.
8. Acetaminophen 325 to 650 mg p.o. q. four to six hours
p.r.n.
9. Lovenox 30 mg subcutaneously q. 12 hours.
10. Colace 100 mg p.o. twice a day.
11. Zofran p.r.n.
12. Percocet one to two tablets p.o. q. four to six hours
p.r.n.
13. Metoprolol 12.5 mg p.o. twice a day.
14. Terazosin 5 mg p.o. q. h.s.
SOCIAL HISTORY: The patient has been married to his wife for
the last 54 years. No children. He is a retired Lieutenant
Colonel in the Air Force and has worked as a defense
contractor. He has no known occupational exposures. He
notes a half pack per day usage of tobacco for 30 years. He
also notes one cocktail imbibed each evening.
FAMILY HISTORY: His mother expired at age 75; she had a
history of hypertension. Father deceased at age 87 secondary
to pneumonia. His brother is 74 years old and in good
health. His sister had passed away from breast cancer.
PHYSICAL EXAMINATION: Temperature 98.0 F.; blood pressure
150/80; heart rate 62; respiratory rate 18; oxygen saturation
95 to 96% on room air. In general, the patient appears in no
acute distress sitting up in a chair. HEENT: Sclerae
anicteric. Normocephalic, atraumatic. Mucous membranes were
moist. Oropharynx is clear. Pupils equally round and
reactive to light and accommodation. Extraocular movements
are intact. Neck is supple with no lymphadenopathy and no
carotid bruits. Chest is symmetric excursion, moderate air
movement, no dullness to percussion. Cardiovascular:
Regular rate and rhythm, S1 and S2; II/VI systolic ejection
murmur with no gallops, no rubs. Abdomen is soft, nontender,
nondistended, normoactive bowel sounds. Extremities: Left
leg was bandaged in an ACE. Right leg had one plus edema.
Neurologic: Cranial nerves II through XII intact. Alert and
oriented times three, appropriate responses with mood and
affect full.
LABORATORY ON TRANSFER: White blood cell count 3.6,
hematocrit 28.1, platelets 162. Sodium 137, potassium 4.2,
chloride 104, bicarbonate 24, BUN 16, creatinine 0.6, glucose
102.
STUDIES: ECG on [**2186-9-18**], demonstrated sinus rhythm,
right bundle branch block, QRS morphology, potential left
atrial abnormality, no significant changes from previous
tracing on [**9-17**].
HOSPITAL COURSE:
1. CARDIOVASCULAR: Mr. [**Known lastname 95026**] has a history of
supraventricular tachycardia present during his last
hospitalization treated with beta blockade. He had
experienced a fall without a clear precipitating factor or
mechanical reason which led to this admission. During his
prior admission, the patient was asymptomatic during his
episodes of supraventricular tachycardia on Telemetry. It is
possible that the patient's supraventricular tachycardia led
to his fall prior to admission. Mr. [**Known lastname 95026**] had experienced
episodes of supraventricular tachycardia during the procedure
and peri-procedure and he was initiated on an Amiodarone drip
after two cardioversions.
The Cardiology Service was following and recommended to
continue an Amiodarone load. Mr. [**Known lastname 95026**] will be continued
on Amiodarone 400 mg p.o. twice a day until [**9-30**]. He
will begin a maintenance dose of 200 mg p.o. q. day starting
on [**10-1**].
Mr. [**Known lastname 95026**] has a history of hypertension and has been on
Lopressor and Terazosin as an outpatient. During this
admission, an ACE inhibitor was initiated and he will be
titrated up on this medication as tolerated.
Mr. [**Known lastname 95026**] will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for his
supraventricular tachycardia on [**10-18**] at 01:00 p.m. in
the [**Hospital Ward Name 23**] Building.
2. ORTHOPEDICS: Mr. [**Known lastname 95026**] was diagnosed with a left
subtrochanteric hip fracture status post fall and transferred
from the outside hospital for open reduction and internal
fixation. This procedure was performed on [**2186-9-17**],
with the complication of supraventricular tachycardia as
described above. The patient remained on the Orthopedic
Service until transfer on [**2186-9-19**]. Physical Therapy
had evaluated the patient and continued to follow while
admitted.
Mr. [**Known lastname 95026**] was changed to a touch-down weight bearing status
to the left lower extremity on postoperative day three.
Recommendations were made to continue daily dressing changes
to the wound sites and the patient was to continue with
thigh-high TEDS stockings to the lower extremities.
3. HEMATOLOGY/ONCOLOGY: Mr. [**Known lastname 95026**] was recently diagnosed
in [**2186-8-6**] with non-small cell lung cancer and has
received two cycles of Carboplatin/Taxol. He is being
followed by Dr. [**Last Name (STitle) **] for his oncologic care. During his
last admission to [**Hospital1 69**] he was
evaluated by Radiation Oncology for the brain metastases and
stereotactic radio surgery was recommended. Mr. [**Known lastname 95026**] was
scheduled to have this SRS on [**9-19**], however, this
therapy was deferred while he is dealing with the acute issue
of his hip fracture. Further decisions regarding his
oncologic care - SRS and chemotherapy - will be determined by
Dr. [**Last Name (STitle) **] as an outpatient.
Mr. [**Known lastname 95026**] was noted to have a significant hematocrit drop
while admitted. Postoperatively the patient received two
units of packed red blood cells. On the day prior to
discharge, Mr. [**Known lastname 95026**] received another two units of packed
red blood cells. Hematocrit is pending at the time of this
discharge.
Secondary to the patient's chemotherapy, last cycle completed
[**9-14**], his cell counts are expected to nadir on [**9-21**].
Secondary to Mr. [**Known lastname 95027**] brain metastases and issue of
anti-coagulation that was raised at his left hip open
reduction and internal fixation, the decision was to
anti-coagulate Mr. [**Known lastname 95026**] with maintenance doses of Lovenox,
30 mg subcutaneously q. 12 hours, for a total of six weeks.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged to [**Location (un) 2716**]
Point in [**Location (un) 55**] for further rehabilitation.
DISCHARGE DIAGNOSES:
1. Left hip open reduction and internal fixation performed
on [**2186-9-17**].
2. Supraventricular tachycardia.
3. Anemia.
4. Non-small cell lung carcinoma.
5. Metastatic lesions to the left frontal lobe of the brain.
6. Anti-coagulation.
7. Hypertension.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg p.o. twice a day, last dose on [**9-30**] in the evening.
2. Amiodarone 200 mg p.o. q.day to be started on [**10-1**].
3. Lorazepam 0.5 mg p.o./IV four times a day p.r.n. - hold
for excessive sedation ( respiratory rate less than 8; oxygen
saturation less than 92%).
4. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n.
5. Lovenox 30 mg subcutaneously q. 12 hours.
6. Colace 100 mg p.o. twice a day.
7. Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
8. Metoprolol 12.5 mg p.o. twice a day - hold for systolic
blood pressure less than 100, heart rate less than 50.
9. Terazosin 7 mg p.o. h.s.
10. Captopril 6.25 mg p.o. three times a day.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname 95026**] is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on
[**10-18**], at 01:00 p.m., office located on the [**Location (un) **]
of the [**Hospital Ward Name 23**] Building.
2. The patient also has a follow-up appointment with Dr.
[**Last Name (STitle) 284**] in the [**Hospital 5498**] Clinic on the [**Location (un) 1773**] of
the [**Hospital Ward Name 23**] Building, appointment scheduled for [**9-28**] at
12:20 p.m.
3. The patient is to have daily dressing changes to the
wound sites.
4. He is currently on touch-down weight bearing status on
the left lower extremity until further directed by Dr.
[**Last Name (STitle) 284**].
5. Mr. [**Known lastname 95026**] is to have thigh high TEDS stockings in
place.
6. Mr. [**Known lastname 95027**] blood counts and electrolytes should be
monitored three times per week.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 44562**]
MEDQUIST36
D: [**2186-9-20**] 16:05
T: [**2186-9-20**] 19:10
JOB#: [**Job Number **]
|
[
"997.1",
"162.9",
"458.2",
"790.01",
"427.1",
"427.5",
"820.22",
"E885.9",
"198.3"
] |
icd9cm
|
[
[
[]
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[
"99.29",
"99.62",
"99.69",
"79.35"
] |
icd9pcs
|
[
[
[]
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3981, 4195
|
9520, 9784
|
9807, 10501
|
5556, 9334
|
10525, 11704
|
4218, 5539
|
9350, 9499
|
249, 2235
|
3114, 3623
|
2257, 3089
|
3640, 3964
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,485
| 119,002
|
7346
|
Discharge summary
|
report
|
Admission Date: [**2181-4-24**] Discharge Date: [**2181-5-6**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
diaphoresis
Major Surgical or Invasive Procedure:
endotracheal intubation
central line placement
History of Present Illness:
Ms. [**Known lastname 4924**] is a [**Age over 90 **]y/o lady with dementia, DM2, HTN on Verapamil,
HLD, and recent hip fracture who presented to the ED with
diaphoresis and is admitted to the CCU due to AV block with
hypotension.
.
Of note, at her recent baseline she is demented with worsening
memory issues. Until 1 week ago, she was in [**Hospital3 **]
receiving help with bathing, cooking, cleaning. Usually walks
with a walker and has fallen in the past with hip fracture that
was non-operatively managed. But then she fell on [**4-18**] and was
admitted [**Date range (1) 27094**] to Ortho for right fully displaced femoral neck
fracture. She underwent right hip arthroplasty on [**4-20**]. She had
a positive UA treated with Cipro [**4-20**] (planned duration 1 week).
No culture data from that admission. She was discharged to
[**Hospital 599**] rehab.
.
On the day of this admission, she was noted to be diaphoretic at
her rehab. She had a new leukocytosis (WBC 15.6 from 9
yesterday), increase in BUN/Cr, and elevated FS blood glucose.
Foley was placed with 200cc obtained. She was noted have
intermittent bradycardia to the 40's with BP 90's/50's. She
reportedly had no chest pain or shortness of breath but seemed
to have labored breathing with RR 28.
.
In the ED, initial vitals were: T 98.6, BP 114/70, HR 32, RR 20.
She was initially alert and conversing. EKG showed AV block
with ventricular rate 30's. Labs significant for WBC 16 (83%N,
1%bands), Hct 28.7 (recent baseline), INR 2, Cr 3.1 (was at
baseline of 1.5 yeterday), bicarb 9, K 5.8, glucose 307. Also
had troponin 5.26, venous lactate 8.3. Toxicology consult was
called in case of CCB overdose but they felt this was unlikely.
Was noted to develop decreased level of consciousness, and
required intubation/sedation with Fentanyl+Midazolam and
transcutaneous pacing temporarily. Dopamine was started and she
recovered her HR and BP. Repeat EKG showed accelerated
idioventricular rhythm vs junctional escape. Another EKG showed
STE in II, III, avF with depressions in the anterior precordial
leads. She received bicarb, CaCl x2, atropine x2. 10U insulin
for FS glucose of 433. Total of 4L NS. A central line was
placed and she was transvenously paced. VS prior to transfer
were: HR 100, BP 122/64, RR 15, POx 96% on 60%FiO2, PEEP 10,
rate 15, TV 550.
.
On arrival to the floor, patient is intubated and sedated,
unable to respond to questions. Her son is at the bedside and
notes that at her baseline she is frequently disoriented, though
she has seemed even more "out of it" since the surgery, slower
to respond to questions. She has seemed more dyspneic over the
past week. Also noted some bilateral arm swelling last week.
.
REVIEW OF SYSTEMS
Patient is intubated and sedated, unable to respond.
Past Medical History:
DM2
dementia
hypertension
hyperlipidemia
right hip fracture (non-operative) [**2-/2180**]
right hip fracture s/p hemi-arthroplasty [**2181-4-20**]
osteoporosis
back pain
depression
hypothyroidism
s/p hysterectomy
Social History:
-Home: Widowed 1.5 years ago. Prior to her recent
hospitalization, she lived in [**Hospital3 **]. Got help with
bathing, dishes, cleaning, and food preparation. She is close
with her son [**Name (NI) **] (HCP) but is estranged from her other
children.
-Tobacco history: Remote history of smoking when she was young
but unsure for how
long.
-ETOH: None
-Illicit drugs: None
Family History:
Two grandsons with diabetes. No known family h/o hypertension or
CAD.
Physical Exam:
ADMISSION EXAM:
VS: T 97.5, HR 75, BP 120/70, POx 97%
Rate 15, TV 550, PEEP 5, FiO2 50%
GENERAL: elderly lady, intubated and sedated.
HEENT: Sclera anicteric. Dry MM.
NECK: No JVD.
CARDIAC: S1 and S2 audible, no murmur
LUNGS: lungs CTA through all fields bilaterally
ABDOMEN: (+)bowel sounds, nondistended
EXTREMITIES: Trace edema to ankles, cool
SKIN: Scattered ecchymoses
PULSES:
1+ DP and PT pulses bilaterally
Pertinent Results:
ADMISSION LABS:
[**2181-4-23**] 05:07AM WBC-9.9 RBC-3.20* HGB-8.3* HCT-26.5* MCV-83
MCH-25.8* MCHC-31.2 RDW-16.0*
[**2181-4-23**] 05:07AM GLUCOSE-136* UREA N-41* CREAT-1.5* SODIUM-137
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
[**2181-4-23**] 05:07AM CALCIUM-7.5* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2181-4-23**] 05:07AM CK-MB-24* MB INDX-3.0 cTropnT-4.47*
[**2181-4-23**] 05:07AM CK(CPK)-808*
[**2181-4-24**] 08:03PM CK-MB-11*
[**2181-4-24**] 08:03PM cTropnT-5.26*
[**2181-4-24**] 08:11PM LACTATE-8.3* K+-6.7*
[**2181-4-24**] 10:16PM LACTATE-4.7*
[**2181-4-24**] 10:16PM TYPE-ART RATES-/15 TIDAL VOL-550 O2-100
PO2-208* PCO2-33* PH-7.26* TOTAL CO2-15* BASE XS--11 AADO2-478
REQ O2-80 -ASSIST/CON
CARDIAC ENZYME TREND: (in addition to blood samples from recent
admission)
[**2181-4-25**] 22:00 Troponin 4.65
[**2181-4-25**] 13:53 CK 621 CK-MB 20 Troponin 5.55
[**2181-4-25**] 00:16 CK 850 CK-MB 14 Troponin 5.00
[**2181-4-24**] 20:03 CK-MB 11 Troponin 5.26
[**2181-4-23**] 05:07 CK 808 CK-MB 24 Troponin 4.47
[**2181-4-22**] 05:15 CK 864 CK-MB 43 Troponin 4.17
[**2181-4-21**] 05:12 CK 579 CK-MB 19 Troponin 0.36
[**2181-4-20**] 11:26 CK 425 CK-MB 9 Troponin 0.13
[**2181-4-19**] 10:45 CK 73 CK-MB 3 Troponin <0.01
Labs [**5-5**] pm:
[**2181-5-5**] 10:27AM BLOOD WBC-13.2* RBC-3.01* Hgb-7.6* Hct-25.9*
MCV-86 MCH-25.3* MCHC-29.4* RDW-20.4* Plt Ct-419
[**2181-5-5**] 10:27AM BLOOD PT-36.5* PTT-35.3 INR(PT)-3.6*
[**2181-5-5**] 09:25PM BLOOD Glucose-124* UreaN-120* Creat-5.4* Na-140
K-5.2* Cl-106 HCO3-12* AnGap-27*
[**2181-5-5**] 09:25PM BLOOD Calcium-8.3* Phos-7.5* Mg-2.4
MICRO DATA:
Blood culture ([**2181-5-1**]): prelim positive for [**Female First Name (un) **] albicans
respiratory culture, sputum ([**2181-4-26**]): yeast
EKG [**2181-4-24**] 7:45:04 PM
Idioventricular rhythm without definite evidence of atrial
electric activity. Compared to the previous tracing of [**2180-2-19**] a
wide complex bradycardia is now seen.
EKG [**2181-4-24**] 8:31:48 PM
Wide complex rhythm with low amplitude P waves suggestive of
complete heart
block with an accelerated subsidiary escape rhythm.
EKG [**2181-4-24**] 9:07:56 PM
Supraventricular rhythm with ventricular premature
depolarizations.
Inferoposterior myocardial infarction, possibly acute. Compared
to the
previous tracing an inferoposterior myocardial infarction
pattern is now
evident.
TTE [**2181-4-25**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with focal severe
hypokinesis to akinesis of the inferior septum, basal to mid
inferolateral and inferior walls. The remaining segments
contract normally (LVEF = 35 %). The right ventricular cavity is
mildly dilated with moderate free wall hypokinesis and sparing
of the apex. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. There is moderate thickening of the
mitral valve chordae. Mild to moderate ([**12-18**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction c/w CAD. Mildly dilated right ventricle with
moderate free wall hypokinesis. Mild-to-moderate mitral
regurgitation. At least mild pulmonary hypertension.
Compared with the prior resting images from the stress echo
study (images reviewed) of [**2181-3-2**], left ventricular function
is now impaired with a reduction in ejection fraction. Estimated
pulmonary artery pressure is now measured and is mildly
elevated.
Renal US [**4-30**]:
FINDINGS: The right kidney measures 10.2 cm and the left kidney
measures 10.5 cm. Both kidneys are normal in size and
echogenicity without hydronephrosis, stone or mass identified.
Two cysts are seen in the right kidney, the larger measuring 1.9
cm at the interpolar region. A smaller cyst in the right renal
interpolar region has a small thin septation without internal
vascularity.
Doppler assessment of the renal arteries was unable to be
performed due to
patient inability to cooperate.
The bladder is decompressed with a Foley catheter in place.
IMPRESSION: No hydronephrosis. Unable to perform Doppler due
to patient
inability to cooperate.
Chest x-ray [**4-30**]:
Increased retrocardiac density and the left lower lung opacity,
which likely represents a combination of atelectasis and/or
consolidation has minimally worsened since [**2181-4-29**]. On
single frontal view, if any of this represents infection cannot
be ruled out and needs further clinical
correlation. Right lung is clear. A right internal jugular line
sheath ends at upper SVC. Heart size is mild-to-moderately
enlarged and unchanged.
Mediastinal and hilar contours are unremarkable.
Chest x-ray [**5-5**]:
The progressive worsening of aeration in the left lung since [**5-2**] was
described on yesterday's chest radiograph and there has been no
change in
appearance. Left lung is still mostly collapsed and there is at
least some left pleural effusion. Whether the consolidation in
the left lung is entirely atelectasis or has a component of
pneumonia is radiographically indeterminate.
Leftward mediastinal shift is unchanged and the left heart
border is still
obscured. Right lung is clear of pneumonia or pulmonary edema.
No
pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 4924**] is a [**Age over 90 **]y/o lady with dementia, DM2, HTN on Verapamil,
HLD, and recent hip fracture s/p operative repair [**4-20**] who
presented from rehab on [**4-24**] with cardiogenic shock in the
setting of bradycardia and AV block, likely from peri-operative
MI, course complicated by new onset afib, [**Last Name (un) **] and the patient
expired from cardiac arrest [**5-6**].
.
# Cardiogenic shock/CHF: Patient with cardiogenic shock on
admission, presumably from perioperative MI (see below). Right
heart failure and impaired left heart pump function as well.
Initially was requiring pressure support (dopamine) but was
weaned off. Transiently was on milrinone, but did not tolerate
it. Had anasarca on admission, but given that she is preload
dependent in setting of RV MI, diuresed gently. Gradually,
developed [**Last Name (un) **] (see below). Patient was not diuresing well with
lasix drip despite addition of metolazone. Per exam and chest
x-ray, was in florid pulmonary edema and on [**5-4**] developed
collapse of right lung. On [**5-6**] at 3am, patient had a 10 second
asystolic episode. She then returned to sinus rhythm in the 40s
for under a minute. She then went into asystole and passed away
peacefully and comfortably, RNs, MD bedside.
.
# MI: peri-operative MI.
Laboratory testing (including add-on labs from prior admission)
notable for elevated cardiac biomarkers with peak MB [**4-22**]
(earlier pending) of 43 and trop continuing to rise to 5.26 on
admission. ECG initially with likely AV block with ventricular
escape though no clear dissociated P waves. Subsequent ECG
(21:07) noted to have junctional rhythm, ST elevation in
inferior leads & STD V2-V4. Appears that patient is > 72hrs
from cardiac event, so no indication for catheterization. Most
likely an inferior-posterior peri-operative infarction.
Significant RV dysfunction. Patient was initially intermittently
requiring transvenous pacing when her rate <70, from complete
heart block, presumably from involvement of both SA and AV node.
The patient was continued on ASA 81mg and held ACE-inhibitor
considering renal dysfunction and beta blocker considering
tenuous blood pressures.
#. Bradycardia and 1st degree AV block: stable.
Peri-operative MI with involvement of conduction system (both SA
and AV node). She initially presented in unstable complete
heart block. Transvenous pacer was removed shortly after
admission. Bradycardia resolved, with intermittent first degree
heart block. The electrophysiology team was consulted and
determined no indication for pacemaker placement at this time.
#. Atrial fibrillation: rate-controlled / rhythm control
Was intermittently in Afib early this admission, but has now
persisted in this rhythm since [**4-27**] at 8AM. Her CHADS2 risk is
4. Continue amiodarone.
-start Heparin gtt today
# PNA: The patient had intermittent fevers, and was initiated on
VAP treatment with Vancomycin/Cefepime (started [**4-27**]). The
patient had blood cultures and a sputum culture that were
positive for yeast. The patient was attempted to increase
mobilization, received nebulizers and had vancomycin renally
dosed secondary to renal dysfunction.
#. [**Last Name (un) **] on CKD: creatinine continued to worsen. The patient most
likely had ATN [**1-18**] cardiogenic shock.
# Delirium: Patient intermittently agitated, complaining of not
being able to breathe. O2 sats OK, but a portion of agitation
may have been from air hunger. Continued lasix. Ischemia could
also be causing chest discomfort and sensation of SOB. The
patient received low-dose morphine for pain or air hunger and
was re-oriented frequently.
Medications on Admission:
verapamil 180 mg ER daily
pravastatin 40 mg daily
pioglitazone 30 mg daily
glipizide 10 mg [**Hospital1 **]
donepezil 10 mg HS
sertraline 25 mg QAM
levothyroxine 25 mcg daily
acetaminophen 325-650 mg Q6H
oxycodone 5-10 mg Q4H PRN
trazodone 50 mg QHS PRN insomnia
alendronate 70 mg PO QMONDAY
cholecalciferol (vitamin D3) 400 unit daily
calcium carbonate 200 mg calcium (500 mg) PO TID
ferrous sulfate 300 mg (60 mg iron) daily
folic acid 1 mg daily
vitamin E 400 unit daily
magnesium oxide 140 mg daily
multivitamin daily
docusate sodium 100 mg [**Hospital1 **]
senna 8.6 mg [**Hospital1 **]
magnesium hydroxide 400 mg/5 mL: 30 mL PO BID PRN constipation
ciprofloxacin 500 mg [**Hospital1 **] (started [**4-20**], planned x1 week)
enoxaparin 30 mg/0.3 mL QPM x 2 weeks from [**4-23**]
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
congestive heart failure secondary to myocardial infarction
acute kidney injury
atrial fibrillation
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,927
| 185,997
|
54050
|
Discharge summary
|
report
|
Admission Date: [**2130-3-9**] Discharge Date: [**2130-3-11**]
Date of Birth: [**2049-5-3**] Sex: M
Service: MEDICINE
Allergies:
morphine / Ambien
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
multiple shocks by ICD
Major Surgical or Invasive Procedure:
ICD revision
Balloon pump placement
History of Present Illness:
80 year-old man with history of ischemic cardiomyopathy, CAD s/p
CABG, AFib, HTN, T2DM, ESRD on HD with ICD admitted for ablation
procedure after frequent firings of his ICD over the past [**12-5**]
days.
.
The patient was living at rehab when his ICD was noted to have
fired. He was sent to an OSH 2d prior to transfer. The patient
was undergoing dialysis, when his ICD fired 4-5 times. This
caused extreme distress for the patient as he was awake during
each firing. His home amiodarone was increased, and the patient
was transferred to [**Hospital1 18**] for EP evaluation and possible
ablation. The patient does not recall having been shocked prior
to [**2-/2130**], though per previous records his device may have fired
in late [**2128**].
.
He does note a mild cough, though this has not been worsening
recently. He denies any other symptoms, including CP, SOB,
fevers, syncope, pre-syncope, palpitations. Currently, his only
complaint is that his ICD firing causes extreme anxiety, pain,
and discomfort.
.
Of note, the patient also has b/l pleural effusions that have
been evaluated by thoracentesis at outside institutions in the
past.
.
The patient has been HD dependent for approximately 3 months,
and he gets his HD through a tunneled central line.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
S/p CABG
-PACING/ICD: AICD
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation
B/l Pleural effusions
Ischemic cardiomyopathy with systolic congestive heart failure
PVD s/p stenting RLE
carotid stenosis
ESRD on HD since ~[**12/2129**]
Depression/anxiety
Gout
hyperparathyroidism
symptomatic orthostatic hypotension on midodrine
multiple pressure ulcers (sacral, toe, heel)
Social History:
-Tobacco history: Quit ~15 yrs previously
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Father with MI in 40s and mother who died in 80s
Physical Exam:
Admission:
VS: 72 117/71 T 98.2 98% on 2L
GENERAL: Pleasant man in NAD
HEENT: MMM
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: Few crackles at the bases b/l with decreased aeration b/l
bases
ABDOMEN: Soft non-tender, non-distended
EXTREMITIES: No c/c/e.
SKIN: Pressure ulcers over sacrum, left middle toe, heel
LINES: Tunneled HD line right chest, no tenderness or
exudates/erythema
Discharge: Expired
Pertinent Results:
ADMISSION LABS
[**2130-3-9**] 04:20PM BLOOD WBC-7.5 RBC-4.17* Hgb-11.0* Hct-36.6*
MCV-88 MCH-26.4* MCHC-30.0* RDW-20.7* Plt Ct-269
[**2130-3-9**] 04:20PM BLOOD PT-22.9* PTT-32.5 INR(PT)-2.2*
[**2130-3-9**] 04:20PM BLOOD Glucose-75 UreaN-39* Creat-3.9* Na-140
K-4.8 Cl-101 HCO3-24 AnGap-20
[**2130-3-9**] 04:20PM BLOOD ALT-25 AST-22 AlkPhos-79 TotBili-0.3
DISCHARGE LABS
[**2130-3-11**] 07:51AM BLOOD WBC-18.2* RBC-3.58* Hgb-9.2* Hct-33.4*
MCV-93 MCH-25.7* MCHC-27.5* RDW-21.6* Plt Ct-194
[**2130-3-11**] 07:51AM BLOOD PT-56.7* PTT-40.4* INR(PT)-5.7*
[**2130-3-11**] 10:52AM BLOOD Glucose-108* Na-135 K-4.3 Cl-98 HCO3-21*
AnGap-20
[**2130-3-11**] 07:51AM BLOOD Glucose-215* UreaN-26* Creat-2.2* Na-135
K-4.2 Cl-98 HCO3-16* AnGap-25*
Brief Hospital Course:
80 yo M with ischemic cardiomyopathy, CAD s/p CABG, AFib, HTN,
T2DM, ESRD on HD with ICD admitted for ablation procedure after
frequent firings of his ICD over the past several days.
# Cardiogenic shock / Ventricular Tachycardia:
He was initially admitted to the CCU after multiple episodes of
VT leading to ICD firings. He was monitored overnight and then
brought to the cath lab for EP study. During the procedure he
developed ventricular tachycardia induced by catheter, and his
blood pressure quickly dropped. He was cardioverted with return
of sinus rhythm, but without a pulse. CPR was performed for PEA
arrest for about 30 minutes with six boluses of epi, 3 amps
bicarb, 2 amps calcium chloride and 100mg lidocaine followed by
initiaion of a drip. Epi, norephi, dopamine and neosynephrine
drips were also initiated for blood pressure support. A balloon
bump was placed at 1:1 and MAPS were maintained >60. He was
shocked a total of 13 times for VT, VF and V flutter. He was
then transferred to the CCU. He was stabilized overnight, but
his MAPS continued to trend down despite aggressive pressor
support. Discussions were held with his family regarding his
poor prognosis, and the decision was made to pursue comfort
based care. His pressors and ventilation was stopped and he
expired.
# End Stage Renal Disease on Hemodialysis for the past 3 months.
On arrival the CCU post-arrest he was placed on CVVH.
Medications on Admission:
Lasix 80mg daily
Metolazone 2.5mg daily
ASA 162mg daily
Carvedilol 3.125mg [**Hospital1 **]
amiodarone
Ativan prn
Remeron 15mg QHS
Wellbutrin 100mg daily
ergocalciferol daily
uloric 40mg daily
omeprazole 20mg daily
crestor 10mg daily
colchicine 0.6mg daily prn
Albuterol/Ipratropium nebs PRN
Nephrocaps 1 tab daily
midodrine 10mg TID HD days; 5mg [**Hospital1 **] non-HD days
Captopril 6.25mg [**Hospital1 **]
Lantus 17u qpm
NovoLog sliding scale
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventricular Tachycardia
End Stage Renal Disease
Ischemic Cardiomyopathy
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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72,538
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41297
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Discharge summary
|
report
|
Admission Date: [**2138-2-12**] Discharge Date: [**2138-3-27**]
Date of Birth: [**2093-4-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
altered mental status, jaundice
Major Surgical or Invasive Procedure:
placement of central lines and hemodialysis line
intubation
History of Present Illness:
44 year old woman with alcoholic cirrhosis, lacunar infarcts
with residual right sided hemiparesis, and hemolytic anemia,
presenting from her first hepatology appointment with altered
mental status and multiple lab abnormalities. The patient lives
and receives her care in [**Location (un) 3844**]. She lives with her
husband who provided her recent history as the patient is unable
to do so. Her husband reports that she was herself (alert and
oriented times 3 but physcially only able to assist with
transfers) until approximately 1 week ago when they noticed that
she was more jaundiced than usual. They went to the patient's
PCP [**Last Name (NamePattern4) **] [**2-9**] at which time labs demonstrated reported Hct ~24 and
normal baseline creatinine. Given complaint of right sided pain
realted to contractures, she was started on a fentanyl patch at
25mcgs. Shortly after starting the patch, her husband noted that
she was more sedated and, over the next 2 days, she became
profoundly sedated such that she was not able to take POs. Her
husband reported that he knew she had an appt at the liver
center today so waited to bring her in for the appt. When they
arrived to the liver center for the patient's 1st appt with Dr
[**Last Name (STitle) 7033**], EMS was called and the patient was sent to the ED.
.
Upon arrival to the ED, her vs were 96.0, 54, 108/75, 16, 88% RA
--> 97% on 5L. She was triggered for nursing concern as she was
minimally responsive. Labs were notable for hct 14.7 --> 11,
creatinine 3.5, plts 117K. CXR and head CT negative for acute
process. She was given 2u emergency release pRBCs, vanc 1g and
zosyn 4.5g and admitted to the MICU for further care.
.
ROS: unable to provide
Past Medical History:
- alcoholic cirrhosis
- cerebral vasculitis with right sided stroke and resultant
hemiparesis
- positive anticardiolipin antibody
- hemolytic anemia
- cryoglobulins
- protein c deficiency
- hypothyroidism
Social History:
Lives with her husband in [**Name (NI) 3844**] who assists her in
activities of daily living.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
General: Eyes open spontaneously, startles but does not follow
any commands or track; moaning nonsensically; markedly jaundiced
HEENT: NCAT, PERRL, EOMI, JVD not elevated
Lungs: clear to auscultation bilaterally
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: firm on R side, + guarding, grimacing with deep
palpation, + bowel sounds
GU: Foley in place with dark urine; right femoral cordis (+
popliteal pulse)
Ext: RLE with distal pitting edema, warm to touch
Back: unstageable sacral decubitus ulcer with necrotic
appearance
.
DISCHARGE EXAM:
Tc: 97.1 BP: 110-125/46-57 HR: 84 RR: 20 O2: 94%RA
BS: 124-213 I: 1300 O: 3300
Gen: Anxious appearing, fatigued, icteric, awake, alert,
oriented x2 (hospital, name)
HEENT: scleral icterus, MMM, EOMI
CV: RRR, 2/6 systolic murmur heard best at upper sternal
borders, +S1, S2
Resp: coarse breath sounds on anterior exam
Abd: Distended, non-tender, +BS
Ext: 3+ pitting edema bilaterally
Neuro: mild asterixis, oriented x2, unable to move right side
Pertinent Results:
ADMISSION LABS:
[**2138-2-12**] 01:30PM BLOOD WBC-12.0* RBC-1.15* Hgb-5.0* Hct-14.1*
MCV-123* MCH-43.1* MCHC-35.2* RDW-17.0* Plt Ct-130*
[**2138-2-12**] 01:30PM BLOOD Neuts-78.6* Lymphs-15.7* Monos-4.5
Eos-0.7 Baso-0.4
[**2138-2-12**] 01:30PM BLOOD PT-28.5* PTT-39.4* INR-2.8*
[**2138-2-12**] 02:45PM BLOOD Fibrino-138*
[**2138-2-12**] 01:30PM BLOOD Glucose-138* UreaN-63* Creat-3.7* Na-130*
K-5.6* Cl-92* HCO3-23 AnGap-21*
[**2138-2-12**] 01:30PM BLOOD ALT-46* AST-145* LDH-559* AlkPhos-131*
TotBili-13.8*
[**2138-2-12**] 01:30PM BLOOD Lipase-70*
[**2138-2-12**] 01:30PM BLOOD Calcium-10.6* Phos-3.5 Mg-4.2*
[**2138-2-12**] 02:45PM BLOOD Hapto-<5*
[**2138-2-12**] 01:30PM BLOOD Ammonia-82*
[**2138-2-12**] 01:30PM BLOOD Lactate-7.6* K-5.8*
[**2138-2-12**] 02:46PM BLOOD Glucose-133* Lactate-6.4* Na-132* K-5.0
Cl-96* calHCO3-24
[**2138-2-12**] 02:46PM BLOOD freeCa-1.19
................................................................
MICROBIOLOGY:
[**2138-2-15**] Sputum Cx:
GRAM STAIN (Final [**2138-2-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2138-2-18**]): Commensal Respiratory
Flora Absent.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. YEAST. MODERATE GROWTH.
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2138-2-15**] HCV Viral Load: not detected
.
[**2138-2-15**] Urine Cx: YEAST >100,000 ORGANISMS/ML
.
[**2138-2-17**] Sputum Cx:
GRAM STAIN (Final [**2138-2-17**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2138-2-19**]):
Commensal Respiratory Flora Absent. YEAST SPARSE GROWTH OF TWO
COLONIAL
MORPHOLOGIES.
LEGIONELLA CULTURE (Final [**2138-2-24**]): NO LEGIONELLA ISOLATED.
.
[**2138-2-17**] CMV IgM Ab negative; CMV IgG Ab positive
.
[**2138-2-17**] EBV VCA-IgG Ab pos; EBNA IgG AB pos; VCA-IgM Ab neg
.
[**2138-2-21**] Sputum Cx:
GRAM STAIN (Final [**2138-2-21**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2138-2-24**]):
Commensal Respiratory Flora Absent.
KLEBSIELLA PNEUMONIAE RARE GROWTH. YEAST SPARSE GROWTH.
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**2138-2-23**] Sputum Cx:
GRAM STAIN (Final [**2138-2-23**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2138-2-25**]):
Commensal Respiratory Flora Absent. KLEBSIELLA PNEUMONIAE RARE
GROWTH. YEAST RARE GROWTH. NO LEGIONELLA ISOLATED.
.
[**2138-2-24**] CMV Viral Load: not detected
.
[**2138-2-24**] Urine Cx: no growth
.
[**2138-2-25**] Sputum Cx: Klebsiella
.
[**2138-2-26**] Urine Cx: no growth
.
[**2138-3-2**] Sputum Cx: pending
................................................................
IMAGING:
[**2138-2-12**] CXR:
1. Mild elevation of the right hemidiaphragm. Subtle left base
retrocardiac opacity may reflect atelectasis, although an
early/mild superimposed consolidation cannot be entirely
excluded.
2. Slight blunting of the right costophrenic angle, trace
effusion cannot be entirely excluded.
.
[**2138-2-12**] CT Head w/o con: Suboptimal scan due to patient motion in
the scanner. With this limitation in mind, no evidence of acute
intracranial hemorrhage or mass effect.
.
[**2138-2-13**] ECHO: The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. Left
ventricular systolic function is hyperdynamic (EF 75-80%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
.
[**2138-2-13**] RUQ U/S:
1. Small amount of perihepatic ascites, containing echogenic
material, which may represent clots.
2. Trace perisplenic and cul-de-sac free fluid.
3. Coarse liver echotexture, compatible with known history of
alcoholic cirrhosis.
4. Splenomegaly.
.
[**2138-2-13**] RLE U/S: Large amount of soft tissue edema overlying the
right thigh. No hematoma or fluid collection seen.
.
[**2138-2-13**] CT Head w/o con:
1. No evidence of acute intracranial hemorrhage or acute large
vascular territorial infarction.
2. Bilateral hypodensities, consistent with lacunes, involving
the corona radiata bilaterally and the left centrum semiovale.
3. Diffuse volume loss likely related to systemic causes.
Correlate clinically.
.
[**2138-2-13**] CT Torso w/o con:
1. Right retroperitoneal hematoma commencing posterior to the
kidney and extending inferiorly along the iliopsoas tendon into
the pelvis.
2. High density fluid in the pelvis dependently consistent with
hemoperitoneum.
3. Large right thigh and axillary hematoma, as described.
4. A nodular liver with splenomegaly and ascites consistent with
known alcoholic liver disease.
5. This CT is severely limited in the evaluation of bowel for
evidence of ischemia. However no portal venous gas or
pneumoperitoneum identified.
.
[**2138-2-13**] RLE Vascular Study: Normal vascular study of the right
groin.
.
[**2138-2-14**] CTA Abdom/Pelvis:
1. Similar intramuscular hematomas in the retroperitoneum and
and right thigh. No definite site of active extravasation
identified.
2. No drainable fluid collection is seen; however, due to the
lack of oral contrast, evaluation is suboptimal.
3. Cirrhotic liver, splenomegaly, ascites and anasarca.
4. Bilateral small pleural effusions and bibasilar atelectasis.
5. Colonic wall edema, predominantly in the descending and
sigmoid could be from third spacing; however, cannot exclude
colitis or ischemic changes ([**Female First Name (un) 899**] territory) if hypotensive. This
finding was discussed with Dr. [**Last Name (STitle) **] in the ICU at 10:30 am,
[**2138-2-15**].
6. Possible small sacral Tarlov cyst.
.
[**2138-2-17**] ECHO: The left atrium is normal in size. Color-flow
imaging of the interatrial septum raises the suspicion of an
atrial septal defect, but this could not be confirmed on the
basis of this study. The right atrial pressure is indeterminate.
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).
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 aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Possible secundum type atrial septal defect.
If the clinical suspicion for a secundum ASD is high and further
information is desired, a TEE is suggested.
Compared with the prior study (images reviewed) of [**2138-2-13**], a
secundum type atrial septal defect is now suggested (subcostal
views were more limited on prior study).
.
[**2138-2-19**] Abdominal X-Ray: Severely limited portable abdominal
radiograph with no evidence for obstruction or ileus.
.
[**2138-2-21**] Abdominal U/S:
1. Nodular hepatic architecture consistent with the patient's
known cirrhosis. No focal liver lesion identified.
2. Small amount of ascites in the abdomen but no pocket large
enough to mark for paracentesis could be identified.
3. Small right pleural effusion.
4. Splenomegaly.
5. No biliary dilatation. The patient is status post
cholecystectomy.
.
[**2138-2-26**] RUQ U/S:
1. Small amount of ascites.
2. Slow to and fro flow in the main portal vein, but no evidence
of thrombus. The flow in the splenic vein is reversed.
3. Echogenic liver with nodular hepatic architecture, consistent
with the patient's known cirrhosis.
.
[**2138-2-26**] CT Abdomen/Pelvis:
1. Marked increase in size of the retroperitoneal hematoma with
a hematocrit level suggestive of recent bleed. Hematoma is
displacing the right kidney superiorly and laterally.
2. Mildly increased right thigh hematoma.
3. Nodular liver with splenomegaly and ascites consistent with
alcoholic liver disease.
.
[**2138-2-26**] CTA Abdomen:
1. Two large hematomas as described, involving the right
retroperitoneum along with the medial musculature of the right
thigh. Overall size and appearance of the hematomas is
unchanged.
2. No evidence of arterial extravasation.
3. Small bilateral pleural effusions.
4. Probable evolving splenic infarcts as described above.
.
[**2138-3-9**] CT Abdomen/Pelvis:
COMPARISON: CT abdomen and pelvis [**2138-2-26**].
FINDINGS:
There is diffuse anasarca. Unchanged right pleural effusion with
associated
compressive atelectasis. There is a small amount of perihepatic
free fluid.
There is a large right retroperitoneal hematoma which has
increased in size
compared to the prior study. The maximum dimensions on the prior
study were
11.2 x 7.8 x 16 cm, on today's study this measures 14.1 x 8.3 x
20 cm. This
hematoma displaces the right kidney anteriorly. The second
hematoma in the
right thigh musculature has also increased in extent, this
previously measured
6 x 6 x 15 cm and now measures 7 x 7.2 x 17 cm.
Lack of intravenous contrast limits the evaluation of the solid
abdominal
viscera. The interventricular septum is prominent on this
non-contrast study
suggesting the presence of anemia. The liver is markedly
heterogenous in
appearance with multifocal areas of abnormally high attenuation,
suggestive of
iron deposition. The spleen measures 13 cm, borderline enlarged.
The right
kidney is displaced anteriorly by the retroperitoneal
hemorrhage, otherwise
both kidneys are unremarkable in appearance. The left adrenal
gland is
normal. The right adrenal gland cannot be visualized due to beam
hardening
artifact from the patient's arms. Mild atherosclerotic
calcification of the
abdominal aorta noted.
There is a Foley catheter in the urinary bladder and a flatus
tube in the
rectum, otherwise these structures are unremarkable in
appearance. Moderate
amount of ascites in the abdomen and pelvis. No appreciable
pelvic
lymphadenopathy. No mesenteric or retroperitoneal
lymphadenopathy.
BONY STRUCTURES: No destructive lytic or sclerotic bony lesions
seen.
IMPRESSION:
There has been interval further increase in size of the right
retroperitoneal
and right thigh hematomas. Active extravasation cannot be
assessed in the
absence of intravenous contrast.
[**2138-3-13**] CTA:
1. Large right retroperitoneal hematoma, stable in size compared
to last CT.
No active extravasation site identified. Hematoma is compressing
the
infrarenal IVC with complete loss of lumen in the infrarenal
IVC. Collaterals
are seen in the anterior abdominal wall, presumably due to IVC
compression.
Please note that protocol used was not designed to evaluate the
veins.
2. Small bilateral pleural effusions, more on the right with
bibasilar
opacities, likely atelectasis; cannot exclude superinfection.
3. Stable similar evolving splenic infarcts.
4. Worsening compression on the right kidney with interval
worsening of
prominence of the right collecting system.
5. Nodular liver contour, in keeping with known cirrhosis.
6. Ascites.
7. Severe anasarca.
Brief Hospital Course:
44F with ETOH cirrhosis, h/o MCA stroke with residual
right-sided deficits, who p/w worsening mental status and
jaundice, found to be severly anemic secondary to spontaneous RP
bleed secondary to consumptive coagulopathy. Treated with blood
product support as well as Amicar IV then PO for fibrinolysis
stabilization. Acute liver failure thought to be secondary to
alcoholic hepatitis and patient was felt not to be a transplant
candidate. Hospital course also complicated by [**Last Name (un) **] requiring
temporary dialysis (resolved) and respiratory failure requiring
temporary intubation (resolved). The patient was in the ICU
twice, once for respiratory and kidney failure and once for
aminocaproic acid (amicar) initiation.
.
# Hypotension/Hemorrhage/Coagulopathy: The patient was admitted
from liver clinic to the ED with altered mental status where she
was found to be severly anemic. Admitted to the MICU where CT
scans revealed a spontaneous abdominal bleed, RP bleed, and
right thigh bleed. Unclear precipitant, though her husband did
report that the patient fell the day prior to admission. She
required frequent blood transfusions (44 PRBC, 31 FFP, 19
platelet, 22 cryo through hospitalization) which was attributed
to a consumptive coagulopathy as well as suspected hemolysis
from liver disease. The patient was eventually transferred to
the floor, however continued to bleed and required frequent
transfusions. She did not respond to steroids for possible
hemolytic anemia. Rheumatologic testing did not return
positive. A workup of her hematologic problems demonstrated low
fibrinogen but normal factor VIII levels, which showed that the
patient was not in disseminated intravascular coagulation. A
repeat CT scan demonstrated enlarging bleeds but no evidence of
extravasation that would have been amenable to interventional
radiologic embolization. Hematology recommended starting Amicar
for stabilization of fibrinolysis, for which she was transferred
back to the MICU. Her Hct stabilized and she no longer required
daily transfusions and was transferred back to the floor. She
was continued on PO amicar with much more stable Hcts. She was
transfused with PRBCs to keep her Hct greater than 21 and
platelets greater than 50 during active bleeding. She received
cryoprecipitate with goal of keeping her fibrinogen greater than
100.
# Decompensated Cirrhosis/alcoholic hepatitis: Most likely
secondary to EtOH. Hepatitis B and C serologies negative.
EBV/CMV IgG positive but IgM nebative. Per hepatology, the
patient is not a transplant candidate considering her history of
CVA, alcohol abuse, and coagulopathy. She was treated with
lactulose and rifaximin and on discharge, was mildly
encephalopathic with intermittent confusion. She did respond
well to extra lactulose when she was encephalopathic. She is
grossly fluid overloaded peripherally for which she is getting
IV lasix, with good reponse.
# Hypercalcemia: Unclear etiology, thought to be secondary to
prolonged immobilization and increased bony resorption. PTH low
normal, though would expect PTH to be undetectable given
persistently elevated Ca levels, and therefore endocrinology
believed that there was some degree of hyperparathyrodism.
SPEP/UPEP negative. She had no overt symptoms of hypercalcemia,
and no EKG changes. Per Endocrine, she was treated with fluids
initially, then diuresis and calcitonin. She was also loaded
with vitamin D in preparation for IV bisphosphonate therapy as
IV bisphosphanates can precipiatate hypocalcemia 3-4 days after
initiation without adequate vitamin D, however as her calcium is
decreasing, may not need IV bisphosphonate. While at the
long-term acute care rehab, she will continue to need frequent
monitoring of her calcium. She was discharged on subcutaneous
calcitonin twice daily, which may be stopped if her calcium
returns to normal or worsens despite its continued
administration, as it may have ceased being effective.
# Respiratory Failure: Sputum culture positive for Klebsiella
pneumonia. Patient was treated with a course of vanc/zosyn/cipro
for HCAP, however repeat sputum cultures continued to be
positive for Klebsiella, so the patient was started on
vancomycin/cefepime as well as micafungin for empiric fungal
coverage. Respiratory failure was also thought to be due to
pulmonary edema in the setting of aggressive fluid resuscitation
(32L positive in the ICU), however this improved with diuresis
and fluid removal with CVVH. She was briefly extubated on [**2-25**],
however was reintubated on [**2-26**] for worsening respiratory
distress. She was subsequently extubated a few days later
without incident.
# [**Last Name (un) **]: Patient with worsening renal function due to ATN from
poor perfusion in the setting of hypotension. A temporary HD
line was placed and the patient was started on CVVH with
normalization of her renal function. Her HD line was pulled on
[**2-24**], however she was again noted to have worsening renal
function with Cr climbing to about 2.0 prior to returning to
baseline by the time of callout. Her creatinine remained stable
once on the floor, the patient was urinating well with
diuretics. At time of discharge, it had returned to baseline.
# Nutrition: The patient was initally on TPN which was then
transitioned to tube feeds once a Dobhoff was placed in
post-pyloric position. Dobhoff was repeatedly pulled out by
patient in ICU or otherwise unable to be placed post-pyloric.
Poor PO intake otherwise. Nutrition consult recommended
encouraging PO, boost glucose control, MV, vitamin C, zinc
supplement. Once her mental status improved, a post-pyloric
Dobhoff tube was placed and bridled and the patient was
continued on tube feeds with PO supplementation (nectar
thickened liquids with soft diet with 1:1 supervision while
feeding).
# Hypothyroidism: Patient was on levothyroxine while taking
Pos, however this was changed to IV formulation when tube feeds
were intitiated over fears of decreased absorption during tube
feeds. At discharge, she was on 100mcg of IV levothyroxine
daily and will need thyroid function tests repeated 1 year post
discharge.
# Hypernatremia: Patient experienced intermittent hypernatremia
requiring free water replacement with tube feed flushes as well
as D5W boluses. Sodium was stable on the floor once tolerating
POs along with tube feeds.
# Diabetes - Sugars controlled on lantus and sliding scale.
#. Goals of Care
Patient was seen by Palliative Care in the MICU [**3-17**] who
followed to give family support because patient is not a
tranpslant candidate. The patient's husband [**Name (NI) 401**] is very
involved and understanding of the issues. The patient was made
DNR but ok to reintubate. Multiple family meetings were held
given the patient's advanced illness, and it was made clear that
should the patient have another complication of her illness, her
prognosis would be extremely poor and a decision on whether to
continue further invasive interventions would have to be made.
In the case of a decompensation, the patient may always return
to [**Hospital3 **] for more aggressive care; however, if the goals
of care switched to comfort then hospice involvement would be
most appropriate.
Transitional Issues
- daily monitoring of Hct, chem 10, fibrinogen
- Transfuse for Hct > 21, platelets > 10, cryo for fibrinogen <
100
- follow up appointments made with Hematology, Hepatology,
Endocrinology.
- If tube feeds held, then her lantus should be stopped
- Please check vitamin D levels in 3 weeks
- Please check thyroid function tests in 1 week's time.
Medications on Admission:
1. thiamine 100mg daily
2. mag oxide 800mg [**Hospital1 **]
3. MVI daily
4. folic acid 1mg daily
5. baclofen 10mg [**Hospital1 **]
6. enteric coated aspirin 325mg daily
7. celexa 20mg daily
8. simvastatin 5mg daily
9. spironolactone 50mg daily
10. nadolol (recently on hold)
11. rifaximin 400mg TID
12. levothyroxine 150mcg qam
13. omeprazole 20mg daily
14. lactulose 30mg [**Hospital1 **]
15. megace
16. procrit
17. lorazepam prn
18. haldol prn
19. tramadol prn
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for throat pain.
4. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for wheezing, SOB.
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. aminocaproic acid 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection
[**Hospital1 **] (2 times a day).
15. levothyroxine 200 mcg Recon Soln Sig: One Hundred (100) mcg
Injection DAILY (Daily).
16. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
17. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale. Injection four times a day: Subcutaneous per attached
sliding scale.
18. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
19. calcitonin (salmon) 200 unit/mL Solution Sig: Two Hundred
Eighty (280) units subcutaneous Injection twice a day.
20. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
21. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 10 days.
22. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 10 days.
23. Outpatient Lab Work
Please check TSH, free T4 in 1 week on [**2138-4-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary: Consumptive coagulopathy, alcoholic hepatitis,
health-care associated pneumonia, acute kidney injury needing
temporary dialysis, hypernatremia, hypercalcemia, hepatic
encephalopathy, retroperitoneal and right thigh hematomas.
Secondary: Hypothyroidism, diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 89919**],
You were admitted to [**Hospital3 **] with altered mental status.
You had a long and difficult hospital course. You were found to
have a very low blood level which was secondary to a spontaneous
bleed you had. This was thought to be due to a bleeding
disorder you acquired from your severe liver disease from
alcohol. You were treated with blood transfusions and a
medication called amicar that helped to stabilize your bleeding.
You were in the intensive care unit for some days intubated due
to a pneumonia. We treated you with antibiotics and were able
to remove the breathing tube. Once you left the intensive care
unit, we watched you on the floor for several days. You blood
level were much more stable on the amicar and your breathing
status was stable as well. You did have high calcium as well
however this was trending down on discharge.
You will be given a new medication regimen while at the
long-term care facility.
You will need to follow up with the Hematologists to continue to
evaluate your bleeding disorder and with the hepatologists to
evaluate your liver disease. You will also need to be seen by
an endocrinologist to take care of your thyroid and calcium
problems.
Followup Instructions:
Department: LIVER CENTER
When: WEDNESDAY [**2138-4-2**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2138-4-18**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30470**], MD [**Telephone/Fax (1) 1803**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2138-5-23**] at 11:00 AM
With: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], 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
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2138-3-28**]
|
[
"707.23",
"249.00",
"438.20",
"E932.0",
"572.2",
"570",
"518.81",
"283.9",
"571.2",
"285.1",
"276.0",
"707.03",
"997.31",
"584.5",
"486",
"453.2",
"289.81",
"303.91",
"287.5",
"459.0",
"785.59",
"275.42",
"572.3",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.23",
"39.95",
"38.95",
"99.15",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
26314, 26414
|
15999, 23613
|
336, 397
|
26739, 26739
|
3567, 3567
|
28141, 29224
|
2487, 2505
|
24126, 26291
|
26435, 26718
|
23639, 24103
|
26878, 28118
|
2520, 3085
|
3101, 3548
|
265, 298
|
425, 2132
|
3583, 15976
|
26754, 26854
|
2154, 2360
|
2376, 2471
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,761
| 155,581
|
48926
|
Discharge summary
|
report
|
Admission Date: [**2193-5-24**] Discharge Date: [**2193-6-18**]
Service:ORTHO
PRINCIPAL DIAGNOSIS:
1. Failure of fixation, thoracic spine
2. Superficial wound infection, thoracic spine
PRINCIPAL PROCEDURE: Revision thoracic fusion
HISTORY AND REASON FOR HOSPITALIZATION: Ms. [**Known lastname 71353**] is an
82-year-old female status post T3 to T12 posterior spinal
fusion on [**2193-3-30**] with Dr. [**Last Name (STitle) 363**]. Her postoperative course
was remarkable for respiratory compromise, requiring
reintubation and extended stay in the Medical Intensive Care
Unit. She was diagnosed with pneumonia and congestive heart
failure, as well as an effusion of unclear etiology. The
returned shortly thereafter to [**Hospital6 1597**] after
reported respiratory arrest. The details of this are
unclear. She was also noted to have a pressure eschar on her
back, and was transferred to Dr.[**Name (NI) 12040**] service at [**Hospital1 1444**] for further evaluation.
PAST MEDICAL HISTORY: Significant for congestive heart
failure, hypertension, diastolic dysfunction, restrictive
lung disease, severe osteoporosis, severe scoliosis and
kyphosis, gastroesophageal reflux disease with hiatal hernia,
question of dementia, history of falls, hard of hearing.
ALLERGIES: Morphine, gastrointestinal upset.
MEDICATIONS ON ADMISSION: Subcutaneous heparin, Captopril,
lasix, Peri-Colace, Risperdal, Zantac, Diamox, Lopressor,
vancomycin and Rifampin, both of which were started at [**Hospital3 **], and Colace.
PHYSICAL EXAMINATION: On admission, the patient was an
elderly female, in no apparent distress, but appearing drowsy
and difficult to arouse. Her heart was regular rate and
rhythm. The lungs had bibasilar crackles as well as
decreased breath sounds, left greater than right.
Examination of her back revealed approximately an 6 x 8 cm
eschar over the mid-portion of her wound on the left side.
There was no surrounding cellulitis. She was neurologically
intact.
HOSPITAL COURSE: The patient was admitted to Dr.[**Name (NI) 12040**]
service. X-rays were obtained. These showed failure of
fixation of her thoracic hardware, presumably due to a fall
prior to admission at [**Hospital3 **].
A Medical consult was obtained, with the plan for revision
thoracic fusion, given the pull-out of her hardware as well
as the question of the depth of her wound infection.
The patient was taken to surgery on [**2193-5-28**]. For details of
the surgery, please see Dr.[**Name (NI) 12040**] operative dictation.
Intraoperatively, the patient did lose approximately 2500 cc
of blood, and was transfused with six units of packed red
cells, four units of fresh frozen plasma, as well as 5 liters
of Crystalloid.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit for ventilator support as well as close
hemodynamic monitoring. The patient's Surgical Intensive
Care Unit course was complicated by several self-extubations,
requiring reintubation. She ultimately underwent
tracheostomy and percutaneous endoscopic gastrostomy
placement as her wean from the ventilator was quite slow, and
her nutrition poor.
Plastic Surgery was asked to consult for evaluation of her
wound. Note that intraoperatively the eschar was seen to be
fairly superficial infection, with no involvement of the
underlying fascia. Plastic Surgery felt that the wound may,
indeed, need a flap, but that the patient's nutrition was too
poor to heal any kind of extensive soft tissue procedure.
Their inclination was to begin Silvadene dressing changes
over the eschar, and to let the wound take its course and
attempt to improve nutrition prior to any procedure.
The patient was maintained on vancomycin throughout her
admission, as she had grown methicillin resistant
staphylococcus aureus from superficial wound cultures, both
at [**Hospital3 **] and at [**Hospital1 69**].
The patient's Surgical Intensive Care Unit course was
otherwise unremarkable.
CONDITION ON DISCHARGE BY SYSTEM:
1. Neurologic: The patient is neurologically intact. She
follows simple commands.
2. Cardiovascular: Her heart rate and blood pressure have
been well controlled.
3. Respiratory: She is on a pressure support ventilator
with pressure support of 12, PEEP of 7.5, at a pressure in
the 40s. Her tidal volumes have been 300, with 24-30
respirations per minute. She does have known bilateral
pleural effusions.
4. Gastrointestinal: She is tolerating tube feeds with
Impact with fiber.
5. Renal: Her BUN and creatinine have been stable.
6. Endocrine: No issues.
7. Hematology: No issues.
8. Infectious Disease: She is currently on vancomycin, day
number 25. She should continue at least a six week course of
vancomycin, currently at 750 mg intravenously every 18 hours.
The wound appears clean, dry and intact, with the exception
of the area along the eschar. This is open and draining
slightly serous/discolored material. We will continue with
Silvadene dressings for the time being. If this wound opens
up further, the patient should be placed on twice a day
wet-to-dry dressing changes.
9. Fluids, electrolytes and nutrition: She is tolerating
tube feeds with Impact with fiber at 50 cc/hour.
10. Prophylaxis: Subcutaneous heparin.
DISCHARGE INSTRUCTIONS:
1. Continue dressing changes twice a day with Silvadene or
wet-to-dries as discussed above.
2. Continue methicillin resistant staphylococcus aureus
precautions.
3. Continue vancomycin for at least six weeks total.
4. Follow up with Dr. [**Last Name (STitle) 363**] when possible.
5. Please follow up with Dr. [**Last Name (STitle) 13797**] from Plastic Surgery
or contact his office with any questions about flap coverage.
Please refer other questions to Dr.[**Name (NI) 12040**] office.
DISCHARGE MEDICATIONS:
1. Niferex 150 mg twice a day
2. Fosamax 10 mg every morning
3. Zinc sulfate 220 mg once daily
4. Reglan 10 mg four times a day
5. Heparin 5000 units subcutaneously once daily
6. Vitamin C 500 mg once daily
7. Vancomycin 750 mg intravenously every 18 hours
8. Epogen 40,000 unit weekly
9. Vitamin E 400 IU once daily
10. Glutamine 5 grams twice a day
11. Nystatin powder three times a day and as needed to
affected areas
12. Albuterol/Atrovent nebulizers every four hours as needed
13. Tylenol 650 mg every six hours as needed
14. Ativan .25 mg every two to fours hours as needed for
agitation
15. Haldol 1 mg every four hours as needed for agitation
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern1) 102751**]
MEDQUIST36
D: [**2193-6-17**] 22:06
T: [**2193-6-18**] 01:06
JOB#: [**Job Number **]
|
[
"996.4",
"998.59",
"486",
"998.3",
"285.1",
"997.3",
"428.0",
"733.00",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.69",
"38.93",
"31.29",
"43.11",
"86.22",
"81.04",
"96.72",
"77.69",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5818, 6756
|
1357, 1534
|
2020, 5277
|
5301, 5795
|
1558, 2001
|
1014, 1329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,821
| 198,454
|
49382
|
Discharge summary
|
report
|
Admission Date: [**2139-7-9**] Discharge Date: [**2139-7-17**]
Date of Birth: [**2073-3-2**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
voice hoarseness
Major Surgical or Invasive Procedure:
s/p tracheostomy & tracheostomy change (on POD7)
History of Present Illness:
Mrs. [**Known lastname **] is a 66 year old woman with metastatic breast cancer,
s/p right modified radical mastectomy ([**2112**]) and chemo/XRT. In
[**2120-5-7**] she had a contralateral axillary mass which was
removed and revealed metastatic breast cancer which was erp
positive. A left simple mastectomy was performed and no tumor
was identified. She took Tamoxifen from [**2120-5-7**] until it was
discontinued in [**2134-5-8**]. In [**2135-5-8**] she developed a
paralyzed vocal cord and a mediastinal mass was identified. This
was positive on biopsy and therapy with Arimidex was begun. The
tumor mass shrunk and her voice improved.
In [**2139-6-7**], patient began experiencing voice hoarseness and
symptoms which had been attributed to GERD. An EGD was suggested
but deferred until after her return. Unfortunately, she had
substantial progression of these symptoms. Her Protonix had been
increased to [**Hospital1 **] and her hoarseness had worsened. More worrisome
was her husband's report that when she sleeps on her back she is
making loud respiratory noises with each breath. This abates if
she
moves on her side. A PET scan done a few days ago shows FDG
avidity in the left axillae and in a large anterior cervical
node as well as in a mass which surrounds and compresses the
trachea. An urgent EGD was performed which showed only mild
gastritis. An ENT examination by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**]
revealed bilateral paralyzed vocal cords and substantial
tracheal narrowing due to external tumor progression.
Past Medical History:
GERD
Breast Ca
s/p b/l mastectomy
Tracheostomy
Social History:
Involved and cooperative family
Lives with husband
Family History:
n/a
Physical Exam:
Afebrile, vitals stable
HEENT: moist mucous membranes, tracheostomy intact
CV: RRR, S1S2 wnl.
Chest: clear bilaterally
Abd: Soft, NTND
Ext: No clubbing, cyanosis, edema; warm/well-perfused
Pertinent Results:
[**2139-7-14**] 06:40AM BLOOD WBC-6.8 RBC-4.07* Hgb-12.6 Hct-35.7*
MCV-88 MCH-31.0 MCHC-35.3* RDW-12.3 Plt Ct-250
[**2139-7-14**] 06:40AM BLOOD PT-12.8 PTT-30.9 INR(PT)-1.1
[**2139-7-14**] 06:40AM BLOOD Plt Ct-250
[**2139-7-14**] 06:40AM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-142
K-5.2* Cl-103 HCO3-27 AnGap-17
Brief Hospital Course:
Patient was admitted to ENT surgery service on [**2139-7-9**] after
undergoing tracheostomy. No concerning intraoperative events
occurred; please see dictated operative note for details. She
was transferred to the ICU for further monitoring and airway
management. She was tolerating trach collar trials without
difficulty. She had adequate pain control and was tolerating
sips on POD1 and was advanced to regular soft diet by POD0. Her
incision was C/D/I, with no evidence of hematoma collection or
infection.
Patient was deemed stable for transfer to the floor on POD2 (but
remained in ICU for bed availability limitations until POD4).
She was evaluated by Speech Therapy and failed initial trials
with speaking (Passy-Muir) valve, but was able to speak with
finger occlusion.
Trach was changed on POD7 in the operating room to a Shiley #6
cuffless/fenestrated trach, which she tolerated well. Speech
Therapy reevaluated the patient on POD8 and fitted the patient
with a Passy-Muir speaking valve.
The patient underwent her initial chemotherapy and radiation
therapy treatments during this admission, which she tolerated
well. She was given explicit instructions for follow-up by the
appropriated services.
The remainder of the hospital course was relatively
unremarkable, and she was discharged in stable condition,
ambulating and voiding independently, and with adequate pain
control. She was given explicit instructions to follow-up in
clinic with Dr. [**Last Name (STitle) 1837**] in [**2-8**] weeks. VNA services were
arranged for tracheostomy care, home teaching, and skilled
nursing for wound evaluation.
Medications on Admission:
Protonix, glucosamine, MVI, Arimidex, [**Last Name (LF) **], [**First Name3 (LF) **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*150 ML(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Tablet, Delayed Release (E.C.)(s)
6. Fexofenadine HCl 60 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Metastatic breast cancer (affecting mediastinum and L axilla)
Tracheal compression (metastatic disease)
Discharge Condition:
Stable
Discharge Instructions:
[**Hospital 16237**] medical attention for chest pain, shortness of breath,
fevers (temp>101.5).
-VNA SERVICES AVAILABLE: SKILLED NURSING, TRACH CARE AND
TEACHING, SPEECH THERAPY AS APPROPRIATE.
-RESUME HOME MEDICATIONS.
Followup Instructions:
-F/u in [**8-16**] days with Dr. [**Last Name (STitle) 1837**].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7732**] Appointment
should be in [**8-16**] days
-Radiation oncology (primary nurse - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @
[**Telephone/Fax (1) 30840**]). NEXT Rad/Onc APPT IS FRIDAY [**2139-7-17**] @
8:30am.
-Follow-up for chemotherapy appointment
Completed by:[**2139-7-17**]
|
[
"478.33",
"196.3",
"197.1",
"530.81",
"198.89",
"494.0",
"V10.3",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"06.12",
"99.25",
"31.42",
"97.23",
"96.71",
"92.29",
"31.41"
] |
icd9pcs
|
[
[
[]
]
] |
5192, 5253
|
2705, 4332
|
336, 387
|
5400, 5408
|
2369, 2682
|
5677, 6165
|
2140, 2145
|
4467, 5169
|
5274, 5379
|
4358, 4444
|
5432, 5654
|
2160, 2350
|
280, 298
|
415, 1986
|
2008, 2056
|
2072, 2124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
433
| 172,593
|
47328
|
Discharge summary
|
report
|
Admission Date: [**2164-3-6**] Discharge Date: [**2164-4-11**]
Date of Birth: [**2112-11-10**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
ICU issue: hypotension
.
PCP: [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**] at [**Hospital1 **] health.
.
HPI:
51F with ESRD on HD, valvular heart disease(4+AR, 3+MR), DVT on
coumadin, now with hypotension on the medical floor starting
this morning. She initially presented with fever and weight gain
from dialysis. She was started on vanc/unasyn empirically to
cover possible line infection or infxn from LE ulcers. In ED,
she had fever to 100.7, WBC 12.2, lactate was 2.0. At dialysis
prior to admission, she had 6L dialyzed off with pre wt 111kg,
post 105. BP [**11/2115**] pre, 128/78 post.
The pt denies fevers, chills, cough, abd pain, she makes no
urine. Over the course of the night bp was trending down. At
11pm it was noted to be 98/47, in the morning rounds was 85/43.
The pt has had no fevers since the ED, WBC down to 9.4 this am
from 12.2. Of note, the pt received lisinopril 20' this am at
0800. Pt was clinically alert and oriented while sitting up in a
chair. Vitals on ICU arrival: T 98.2, 97/38 p92 rr 15 100 on
3L. Her sats were 94% on RA on floor.
.
MICU course:
[**3-8**]: admitted for hypotension. received IVF. BP stable.
.
Abx:
[**2164-3-7**] ceftaxadime
.
ROS:
All systems were reviewed and were negative except for
aforementioned in the HPI.
.
.
Past Medical History:
1. CHF--AR and MR [**First Name (Titles) 767**] [**Last Name (Titles) 100137**] endocardidtis ([**2162**]) with
medical tx, not surgical candidate for valve repair. Echo
[**2162-10-1**] showed LAE, dilated RV/LV, LVEF >60% (intrinsic
depression given regurg). 4+ AR, 3+ MR, 2+ TR. PA systolic
HTN.
2. ESRD on HD qT, R, Sat --due to mixed gent and
contrast-induced nephrotoxicity
3. Chronic PE s/p IVC filter [**11-2**] on lifelong coumadin
4. PVD s/p fem-post tib nonreversed saphenous vein graft [**11-2**]--
c/b wound hematoma --> exploration /evacuation, IVC filter
placed; chronic venous stasis ulcers
5. HBV and HCV
6. Hypothyroidism
7. OA s/p bilateral TKR ([**2157**]) c/b R septic joint --> redo
8. Multiple psych issues including bipolar d/o with psychosis,
narcotic dependence, anxiety d/o
9. Hx of pericardial effusion with tamponade [**2-3**] - resolved
10. MRSA carrier
Other PSH:
1. s/p CCY
2. s/p C-section
Social History:
Lives at home in [**Location (un) 669**] with her husband, who spends his time
taking care of her. She is on SSI. She is not able to walk, is
transported in wheelchair by her husband, whom she cites as a
strong support. No alcohol or drugs. [**1-31**] ppd x 40 years tobacco.
Family History:
NC
Physical Exam:
T 98.2, 97/38 p92 rr 15 100 on 3L. Her sats were 94% on RA on
floor
comfortable at rest.
neck supple, jvd elevated
carotid upstroke nl, no bruit
Heart: rrr, loss of s2 with II/VI systolic murmur as well as
early diastolic murmur.
Chest: coarse BS throughout crackly at bases.
[**Last Name (un) 103**] soft, non tender, nl bs.
extreme: thick, scaly dry cracked skin with multiple ulcers
bilateral LE.
neuro: alert&oriented x 3, maew
Pertinent Results:
.
CXR:
(Prelim read) worsening mild pulmonary edema. R IJ dialysis cath
in good position.
.
ECG: SR at 90 bpm with nl axis/intervals, non-specific TW
changes
.
CT head:
CT OF THE HEAD WITH CONTRAST: The examination is slightly
limited by patient motion, particularly in the posterior fossa.
The presence or absence of acute hemorrhage cannot be assessed
in the presence of contrast, though no gross hemorrhages are
apparent. There is no shift of the normally midline structures.
The ventricles and cisterns are unchanged. The density values of
the brain parenchyma are normal, without definite areas of
pathologic enhancement. There is appropriate opacification of
the intracerebral [**Last Name (un) 1106**] structures. The visualized paranasal
sinuses are well aerated, with a tiny mucus retention cyst
versus polyp in the medial aspect of the left maxillary antrum.
The mastoid air cells are clear. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No areas of pathologic enhancement within the brain
are detected on this limited exam.
Please note that MRI with diffusion weighted imaging and
gadolinium administration is more sensitive for the detection of
intracranial pathology, including infarction.
..
ECHO:
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated. There is mild global right
ventricular free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened. There is a moderate-sized vegetation on
the aortic valve (right coronary cusp). There is no valvular
aortic stenosis. The increased transaortic gradient is likely
related to aortic regurgitation. Severe (4+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened.
No mass or vegetation is seen on the mitral valve. Moderate to
severe (3+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2163-10-27**], no
major change.
[**2164-3-6**] 06:00PM BLOOD WBC-12.2*# RBC-3.57* Hgb-11.2* Hct-35.7*#
MCV-100* MCH-31.3 MCHC-31.3 RDW-18.4* Plt Ct-290#
[**2164-3-6**] 06:00PM BLOOD PT-22.2* PTT-69.7* INR(PT)-2.2*
[**2164-3-10**] 06:35AM BLOOD Fibrino-420*
[**2164-3-6**] 06:00PM BLOOD Glucose-94 UreaN-10 Creat-2.5*# Na-137
K-4.1 Cl-94* HCO3-31 AnGap-16
[**2164-3-6**] 06:00PM BLOOD ALT-11 AST-16 LD(LDH)-218 AlkPhos-243*
TotBili-0.4
[**2164-3-7**] 06:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.5*
[**2164-3-6**] 06:00PM BLOOD Acetone-NEGATIVE
[**2164-3-7**] 06:00AM BLOOD TSH-5.5*
[**2164-3-13**] 06:17AM BLOOD Free T4-0.90*
[**2164-3-6**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-4-10**] 05:52AM BLOOD WBC-7.8 RBC-3.89* Hgb-11.8* Hct-38.4
MCV-99* MCH-30.5 MCHC-30.9* RDW-18.1* Plt Ct-235
[**2164-4-11**] 05:56AM BLOOD PT-23.3* PTT-36.6* INR(PT)-2.3*
[**2164-4-10**] 05:52AM BLOOD Glucose-86 UreaN-23* Creat-6.1* Na-134
K-4.3 Cl-96 HCO3-25 AnGap-17
[**2164-3-7**] 06:00AM BLOOD TSH-5.5*
[**2164-3-31**] 06:30AM BLOOD PTH-103*
Brief Hospital Course:
Assessment/plan:
51F with ESRD on HD, valvular heart disease(4+AR, 3+MR), DVT on
coumadin, with mental status changes.
.
MICU course: Patient initially admitted to [**Hospital Ward Name **] with
volume overload but transferred patient with hypotension and
hypoxia to the MICU. Was treated with IVF as necessary as well
as empiric abx (vancomycin and ceftazadime) for seven days.
Improved without knowing source of infection but also without
pressor need.
.
On floor,
# Mental status- waxed and waned throughout stay, thought to be
better with lightening of narcotics and continued dialysis.
Multiple Ct Heads negative.She did have two episodes of
aspiration PNA associated with starting pos during which her
mental status declined. Her mental status improved, however
with tx. with vanc/ceftazadime/flagyl. Upon discharge, she
still has some transient episodes of confusion +/- myoclonus,
which husband reports she has had longstanding prior to
admission, likely [**3-2**] narcotics, but risks and side effects
explained to pt. and will tolerate given pain needs.
# line infection: [**2-4**] blood cx. now growing staph coag negative,
?contamination, but given h/o endocarditis, indwelling line,
must assume it is real and treated for bacteremia through line X
10d. last day vanc was [**4-6**]. She was afebrile and follow up
cultures negative at time of discharge.
.
# Hypotension: basline BPs in 80s-100s, stable throughout her
stay on the floor
.
# Mild hypoxia: Concern for aspiration initially, temporary mild
o2 requirement, which resolved with reatment of aspiration
pneumonia
.
#. ESRD - second to gent and contrast induced nephropathy.
history of missing dialysis. She received dialysis on TuThSa
cycle. She will receive outpt. dialysis similarly.
.
# tenderness at catheter site: no pus, erythema, but some focal
tenderness along site, which may represent simple pain from line
itself. cx. [**4-4**] off line, which is still NGTD upon discharge.
.
# endocarditis: echo shows a moderate-sized vegetation on the
aortic valve (right coronary cusp). This is old and unchanged
from previous echo in [**10-4**]. Pt is not a surgical candidate and
is on chronic anticoagulation. Blood cultures were all negative
during hospitalization other than 1 coag negative staph, which
was treated as line infection through line. Her INR was labile
given concurrent antibiotic use. She was discharged on 7.5 mg
coumadin with a therapeutic INR, furhter INRs to be drawn at
dialysis.
.
# Leg wounds/PVD
- [**Date Range 1106**]/plastics consulted and patient not a candidate for
surgery. Wound care consulted and appreciate recs.
- dilaudid PRN as needed for severe pain, otherwise will limit
narcotics to improve mental status.
.
# pain control- With improved mental status and activity,
feeling some increased pain overall during day. Transitioning to
pos as pt. will need to be on POs for discharge. stable pain
control on current regimen with occasional episodes of confusion
and myoclonus
- oxycontin to 30, 30, 60 to cover night a bit better.
- 4mg po hydromorphone PRN breakthrough
.
# Psych issues: bipolar d/o with psychosis, narcotic dependence,
anxiety d/o
- continue topirimate, quetiapine
# Hypothyroidism: continue home meds.
# FEN/Code status: Spoke for a long time with family as did Dr.
[**Last Name (STitle) **] (see OMRnote) and pt. is firmly focused on quality of
life, of which food is a big part. Her husband, who is HCP and
she understand risks of aspiration and would still like to eat.
liberalized diet as has been tolerating, and husband was
bringing her food anyways. She and her husband agreed during
these discussions that given her high risk for aspiration and
possibility of needing future intubation should she aspirate,
that she would like to be DNR/DNI and focus on quality of life,
which was to include antibiosis, dialysis and the possibility of
short future hospitalizations, but would also include continued
pos.
She was discharged home with services with outpt. dialysis
Medications on Admission:
Meds:
1. Aspirin 81 mg Tablet QD
2. Docusate Sodium 100 mg [**Hospital1 **]
3. Folic Acid 1 mg Tablet QD
4. Albuterol Sulfate 0.083 % Solution Q6H PRN
5. Pantoprazole 40 mg Tablet QD
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) QD
7. Topiramate 100 mg Tablet QD
8. Warfarin 5 mg Tablet QHS
9. Combivent 1 puff QID PRN
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule QD
11. Gabapentin 300 mg Capsule QD
12. Quetiapine 25 mg Tablet [**Hospital1 **]
14. Levothyroxine 150 mcg Tablet QD
15. Ascorbic acid 500mg QD
16. Thiamine 100mcg QD
17. Lisinopril 20mg Qd
18. Metoprolol 12.5mg [**Hospital1 **]
19. Spiriva 1 puff QD
20. Trazodone 150mg QD
21. Dilaudid 2mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Duloxetine 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. Topiramate 100 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. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 cap* Refills:*2*
11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*60 nebs* Refills:*2*
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Disp:*1 bottle* Refills:*2*
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Disp:*30 Capsule(s)* Refills:*2*
16. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day): to affected area.
Disp:*1 tube* Refills:*2*
17. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QAM AND QPM ().
Disp:*56 Tablet Sustained Release 12HR(s)* Refills:*0*
18. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO QHS (once a day (at bedtime)).
Disp:*56 Tablet Sustained Release 12HR(s)* Refills:*2*
19. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO q3-4h as
needed.
Disp:*90 Tablet(s)* Refills:*0*
20. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*1 bottle* Refills:*2*
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
22. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
23. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
24. OxyContin 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO qAM and qPM: take together with
10mg dose in AM and PM for a total dose of 30mg each qPM and
qAM.
Disp:*56 Tablet Sustained Release 12HR(s)* Refills:*0*
25. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypotension
ESRD
aspiration Pneumonia
.
CHF
Hepatitis
Endocarditis
Chronic anticoagulation
Skin ulcers, non-healing
Discharge Condition:
fair, mental status improved, tolerating pos, satting well on
RA, mobile in wheelchair without assistance
Discharge Instructions:
You were admitted for suspected infection and aspiration
pneumonia. You have gotten dialysis and antibiotics and have
improved. We have also adjusted your pain regimen to optimize
your wakefulness and pain control while minimizing your chances
for aspiration.
.
You should return to the ED if you have any vomiting, fever,
chills, chest pain, shortness of breath, confusion, or any other
concerning symptoms.
Take all medications exactly as prescribed and follow up as
below
Take your coumadin as directed and adjust per your PCP.
Followup Instructions:
You should follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-31**]
weeks by calling [**Telephone/Fax (1) 7976**] (Dr. [**First Name (STitle) 4223**]. You will need to
have your INR checked at that time.
|
[
"070.32",
"507.0",
"424.90",
"585.6",
"403.91",
"996.62",
"790.7",
"428.0",
"707.19",
"349.82",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14591, 14648
|
6810, 10822
|
290, 306
|
14808, 14916
|
3380, 3540
|
15498, 15735
|
2905, 2909
|
11538, 14568
|
14669, 14787
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10848, 11515
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14940, 15475
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2924, 3361
|
229, 252
|
334, 1645
|
3549, 6787
|
1667, 2595
|
2611, 2889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,991
| 109,430
|
11851
|
Discharge summary
|
report
|
Admission Date: [**2183-3-6**] Discharge Date: [**2183-3-10**]
Date of Birth: [**2151-1-20**] Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Sepsis.
Major Surgical or Invasive Procedure:
Central Venous Line Placement.
History of Present Illness:
Mr. [**Known lastname 37404**] is a 32 year-old man with no significant past
medical history who presents with sepsis.
The patient was in his usual state of health until the day of
admission when he began feeling nauseous with vomiting [**3-22**]
times. He also reports a mild headache (all over) and fevers
(none recorded) and rigors. Also with total body aches for
which he has been using tylenol. He visited [**Country 3400**] in
[**Month (only) **], then the [**Country 13622**] Republic in [**Month (only) 404**]. Otherwise no
recent travel.
ROS:
(-) Weight change
(+) Night sweats; chronic for many years
(-) Neck stiffness
(-) Abdominal pain, diarrhea, constipation
In reviewing OMR, there are repeated visits to [**Company 191**] with
diagnosis of viral pharyngitis. His most recent presentation
was in [**2182-11-16**] at which time he had complaints of "sore
throat" which was thought to be of viral origin. He then
presented to [**Company 191**] on [**2182-12-20**] with continued sore throat, along
with left-sided tonsil pain. Per the OMR note, the exam at that
time showed "Oropharynx with large edematous tonsils, left
greater than right, but only slightly erythematous. No
exudate." He was treated empirically with Azithromycin. He
feels that the Azithro helped somewhat.
In the ED, initial vitals showed a T of 101.2, HR 125, BP
109/62, RR 16 and 100%. When his blood pressure fell to 84/49
he was bolused with IVF and a sepsis line was placed. Up to 4
liters of NS were given, along wiht CTX, levaquin and Tamiflu.
Past Medical History:
1. Palpatations with accesory pathway
2. Low back pain
3. Tonsillitis three to four times per year as a child
4. GERD
Social History:
He is an immigrant of Moroccan extraction. He currently owns
his own limousine company. He is married, has a 2-year-old son.
His son, his wife, and his father all lives in his home. He is
a former cigarette smoker, he smoked approximately less than a
pack a day. He would over drink one to two alcoholic beverages
per week, and he has had none in over 4 years.
Family History:
Father with diabetes mellitus.
Physical Exam:
Vitals - T 102.0, BP 143/70, HR 114, RR 18, 100%.
GEN - Overweight man, lying in bed. Ill-appearing, but not
toxic.
HEENT - OP shows left sided tonsil with crypts. Some erythema.
No obvious exudate. No cervical, submandibular LAD. RIJ in
place. Neck is supple. Dry MM.
CV - Tachycardic. No murmurs.
PULM - Clear. No wheeze/rales/rhonchi
ABD - Soft. Non-tender. Non-distended.
EXT - Warm. No edema.
SKIN - Warm to hot. Birthmark on right abdominal wall. No
rash.
NEURO - Alert and oriented. Non-focal.
Pertinent Results:
Lactate: 4.3 --> 2.3 --> 1.7
.
1.004 / 7.0
.
138 99 14
------------ 118
4.4 24 1.3
.
WBC: 18.7
PLT: 267
HCT: 42.2
N:90.9 Band:0 L:6.1 M:2.6 E:0.1 Bas:0.3
.
ABD US ([**2183-3-6**]): 1. Increased liver echogenicity is mostly
consistent with the fatty liver, however, other liver disease
and more advanced liver disease including cirrhosis/fibrosis
cannot be excluded.
2. Normal gallbladder with no evidence of cholecystitis or
cholelithiasis.
.
.
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CT NECK W/CONTRAST (EG:PAROTIDS) [**2183-3-7**] 12:09 AM
FINDINGS: No abscess or fluid collection is noted within the
neck. Multiple pathologically enlarged nodes are noted in the
jugulodigastric regions bilaterally. For example, the large node
in the right jugulodigastric area measures 2.3 x 1 cm. The one
on the left side measures 1.6 x 1.3 cm. The nodes noted in other
stations of the neck are not pathologically enlarged. Mucosal
thickening of both maxillary sinuses is noted.
IMPRESSION: No abscess or fluid collection in the neck.
.
.
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2183-3-8**] 2:54 AM
COMPARISON: [**2183-3-7**].
As compared to the previous radiograph, there is no relevant
change. Known right-sided aortic arch. Central venous access
line in place. Normal size of the cardiac silhouette, no pleural
effusion.
.
.
.
.
.
.
.
.
.
.
................................................................
[**2183-3-10**] 04:55AM BLOOD WBC-8.3 RBC-5.55 Hgb-14.8 Hct-43.3
MCV-78* MCH-26.8* MCHC-34.3 RDW-12.8 Plt Ct-325
[**2183-3-9**] 04:02AM BLOOD WBC-9.2 RBC-5.18 Hgb-13.8* Hct-41.2
MCV-80* MCH-26.7* MCHC-33.6 RDW-12.5 Plt Ct-239
[**2183-3-8**] 04:27AM BLOOD WBC-16.3* RBC-4.39* Hgb-12.0* Hct-34.3*
MCV-78* MCH-27.3 MCHC-34.9 RDW-12.7 Plt Ct-196
[**2183-3-7**] 12:55AM BLOOD WBC-20.3* RBC-4.74 Hgb-12.8* Hct-36.6*
MCV-77* MCH-26.9* MCHC-34.9 RDW-12.1 Plt Ct-229
[**2183-3-6**] 06:35PM BLOOD WBC-18.7*# RBC-5.43 Hgb-14.9 Hct-42.2
MCV-78* MCH-27.4 MCHC-35.2* RDW-12.2 Plt Ct-267
[**2183-3-10**] 04:55AM BLOOD Neuts-51.4 Lymphs-39.5 Monos-5.6 Eos-2.2
Baso-1.4
[**2183-3-9**] 04:02AM BLOOD Neuts-63.8 Lymphs-29.3 Monos-5.2 Eos-1.1
Baso-0.6
[**2183-3-6**] 06:35PM BLOOD Neuts-90.9* Bands-0 Lymphs-6.1* Monos-2.6
Eos-0.1 Baso-0.3
[**2183-3-10**] 04:55AM BLOOD Plt Ct-325
[**2183-3-9**] 04:02AM BLOOD Plt Ct-239
[**2183-3-8**] 04:27AM BLOOD Plt Ct-196
[**2183-3-8**] 04:27AM BLOOD PT-14.7* PTT-27.0 INR(PT)-1.3*
[**2183-3-7**] 12:55AM BLOOD Plt Ct-229
[**2183-3-7**] 12:55AM BLOOD PT-15.1* PTT-27.9 INR(PT)-1.3*
[**2183-3-6**] 06:35PM BLOOD Plt Smr-NORMAL Plt Ct-267
[**2183-3-7**] 12:55AM BLOOD ESR-4
[**2183-3-10**] 04:55AM BLOOD Glucose-111* UreaN-18 Creat-1.1 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
[**2183-3-9**] 04:02AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-140
K-4.1 Cl-102 HCO3-28 AnGap-14
[**2183-3-8**] 06:16PM BLOOD Glucose-111* UreaN-9 Creat-0.9 Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
[**2183-3-8**] 04:27AM BLOOD Glucose-128* UreaN-9 Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-26 AnGap-13
[**2183-3-7**] 12:55AM BLOOD Glucose-147* UreaN-10 Creat-1.0 Na-140
K-3.6 Cl-108 HCO3-21* AnGap-15
[**2183-3-6**] 06:35PM BLOOD Glucose-118* UreaN-14 Creat-1.3* Na-138
K-4.4 Cl-99 HCO3-24 AnGap-19
[**2183-3-7**] 12:55AM BLOOD ALT-38 AST-28 LD(LDH)-132 CK(CPK)-75
AlkPhos-70 Amylase-66 TotBili-0.7
[**2183-3-7**] 12:55AM BLOOD Lipase-20
[**2183-3-7**] 12:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2183-3-10**] 04:55AM BLOOD Calcium-10.0 Phos-5.4* Mg-2.0
[**2183-3-9**] 04:02AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.9
[**2183-3-8**] 06:16PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1
[**2183-3-8**] 04:27AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.7
[**2183-3-7**] 12:55AM BLOOD Albumin-3.9 Calcium-8.5 Phos-1.8* Mg-1.3*
[**2183-3-7**] 10:27AM BLOOD Cortsol-35.9*
[**2183-3-7**] 10:27AM BLOOD Cortsol-32.1*
[**2183-3-7**] 12:55AM BLOOD Cortsol-43.2*
[**2183-3-7**] 12:55AM BLOOD IgG-816 IgA-128 IgM-24*
[**2183-3-9**] 04:02AM BLOOD C3-169 C4-37
[**2183-3-6**] 11:17PM BLOOD Lactate-2.0
[**2183-3-6**] 10:17PM BLOOD Lactate-1.7
[**2183-3-6**] 07:58PM BLOOD Lactate-2.3*
[**2183-3-6**] 06:50PM BLOOD Lactate-4.3*
Brief Hospital Course:
ASSESSMENT/PLAN:
32 man with no past medical history who presents with septic
shock.
.
# Sepsis / Septic shock: Presents with leukoctyosis,
tachycardia and hypotension along with evidence of end-organ
injury (acute renal failure) and mild lactic acidosis. There is
no clear source of infection, though the oropharynx appears a
possible source; CT neck did not show any drainable collection
or abscess. Central line was placed and he received IV fluids
and brief pressor support. Cortisol testing demonstrated an
intact adrenal axis. His ICU course was complicated by an
episode of wide complex tachycardia which was felt to likely
represent atrial tachycardia with bypass tract. ID consultation
was obtained. Although the etiology of his sepsis-like syndrome
was initially unclear despite extensive evaluation, he was
treated empirically with broad-spectrum antibiotics for possible
bacterial source. Laboratory testing failed to confirm a
specific viral pathogen; HIV antibody and HIV viral load tests
returned negative, and influenza testing also returned negative
as well. He improved clinically. Throat culture from [**2183-3-7**]
eventually returned positive for sparse growth of Group A
beta-hemolytic strep. He was discharged on [**3-10**] with a
presumptive diagnosis of GABHS pharyngitis complicated by
sepsis, with instructions to continue antibiotics and follow up
with Dr [**Last Name (STitle) **] in [**Company 191**]. He was also discharged with a
prescription for acyclovir in the setting of newly-developed
herpes labialis.
Medications on Admission:
1. Multivitamin
2. Prilosec 20mg daily
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) for 4 days.
Disp:*22 Capsule(s)* Refills:*0*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 6 days.
Disp:*48 Capsule(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
strep pharyngitis
shock
Secondary:
GERD
WPW
recurrant pharyngitis
Discharge Condition:
good
Discharge Instructions:
You were admitted and treated for your low blood pressure and
presumed infection. You have had many tests sent - some are
still not resulted yet. You also have gotten antibiotics - some
of which you will need to continue for the next several days.
You are much improved and ready for discharge.
You will need to take all medications as instructed.
You have been started on three antibiotics: levaquin,
clindamycin, and acyclovir -> you need to continue taking these.
Please continue all of your home medications.
You will need to keep all of your follow-up appointments as
scheduled.
You need to call your doctor or return to the ED if T>101.5,
chills, nausea, vomiting, rash, or any other concern.
Followup Instructions:
You have a follow-up appointment scheduled on [**2183-3-20**] at
10:20am with Dr.[**Name (NI) 20819**] nurse practitioner. It is very
important that you keep this appointment. Please call to
confirm [**Telephone/Fax (1) 250**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**0-0-0**]
|
[
"584.9",
"427.1",
"034.0",
"054.9",
"038.9",
"995.92",
"785.52",
"276.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9612, 9618
|
7335, 8889
|
343, 375
|
9729, 9736
|
3077, 7312
|
10488, 10875
|
2495, 2527
|
8978, 9589
|
9639, 9708
|
8915, 8955
|
9760, 10465
|
2542, 3058
|
296, 305
|
403, 1954
|
1976, 2096
|
2112, 2479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,687
| 163,956
|
47363
|
Discharge summary
|
report
|
Admission Date: [**2149-6-4**] Discharge Date: [**2149-6-10**]
Date of Birth: [**2087-3-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Nausea, vomiting, diarrhea, hypotension.
Major Surgical or Invasive Procedure:
1. Endotracheal intubation
History of Present Illness:
62 M living at home though recently hospitalized c Type 2 DM,
CHF, PVD, Afib, Alzheimers. Recently hospitalized [**Date range (1) 100252**] for
lightheadedness and falls thought [**3-14**] paroxysmal afib and
[**Date range (1) 6804**] for heel ulcers requiring IV abx. Hx obtained from
wife; pt. on recent d/c from hospital developed nausea,
diarrhea. Minimal PO intake. Discussed with PCP who suggested
compazine suppositery but with minimal effect. Progressed to
vomiting day prior to admission. This morning, evaluated by
visiting nurse and given poor PO intake and concern for heel
ulcer, pt. went to ED at [**Hospital **] Hospital. At [**Name (NI) **] Hospital,
pt. noted to have Cr 2.9 (elevated from baseline 1.0-2.2), BUN
120, WBC 8.0. Concern expressed for CHF and transfered to [**Hospital1 18**].
In ED, noted to be afebrile but hypotensive to 70s/40s c Cr 3.
Treated for septic shock c placement of L subclavian, fluid
resuscitation (3L NS), pressors (dopamine), levofloxacin,
metronidazole.
In ICU, denies any abdominal pain, BRBPR, melena, chest pain,
difficulty breathing, light headedness, palpitations. Does
report some mild orthopnea but states this is normal for him.
Past Medical History:
1. Coronary artery disease
2. Congestive heart disease
- EF 25% to 30% ([**2149-5-27**])
3. Hypertension
4. Hypercholesterolemia (not on statin due to elevated LFTs)
5. Atrial fibrillation
6. Peripherl vascular disease
7. Diabetes mellitus, type 2
- c/b nephropathy, retinopathy and vasculopathy
8. Chronic kidney disease, baseline Cr 1.8-2.2
9. h/o CVA [**2135**]
10. s/p Carotid endarterectomy [**2139**]
11. Left hallux IPJ ulcer
12. Alzheimer's
13. h/o elevated LFTs - unknown etiology
14. Glaucoma (right eye)
Social History:
Lives with wife, but has been at [**Hospital 5481**] rehab since late
[**Month (only) 956**]; more recently has been living at home with VNA and
hospital bed. Remote tob, no etoh/drugs
Family History:
Non-contributory.
Physical Exam:
VS- 96.9, 86-104/51-69, 82-88, [**12-26**], 93-100 NC 4 lpm
HEENT- JVP not elevated, OP dry, skin tenting over forehead
LUNGS- CTA anteriorly, posterior lung fields inaudible
HEART- Irregularly Irregular, normal rate. [**4-15**] SM across
precordium c/w mitral regurgitation
ABD- Obese, non tender, soft, BS+
EXT- Scattered ecchymoses over L arm, L chest. 2+ pitting edema
to b/l thighs. Cool feet, warm ankles. + 3cm diameter ulcer over
R heel with granulation tissue at base but greenish discharge at
perimeter accompanied by foul smell.
NEURO- A*O*3, difficulty with memory.
Pertinent Results:
ADMIT LABS: [**2149-6-3**]
CBC:
WBC-7.8 RBC-3.21* Hgb-9.5* Hct-30.0* MCV-93 MCH-29.6 MCHC-31.8
RDW-19.9* Plt Ct-267
Neuts-75.3* Lymphs-16.9* Monos-6.7 Eos-0.6 Baso-0.5
COAGS:
PT-17.2* PTT-31.4 INR(PT)-1.6*
CHEMISTRIES:
Glucose-67* UreaN-114* Creat-3.0* Na-135 K-5.4* Cl-102 HCO3-20*
AnGap-18
Calcium-8.8 Phos-5.7* Mg-2.8*
LFTS:
ALT-32 AST-47* LD(LDH)-211 CK(CPK)-51 AlkPhos-130* TotBili-1.3
Albumin-3.3*
CARDIAC ENZYMES:
[**2149-6-3**] 10:15PM CK-MB-NotDone cTropnT-0.32* proBNP-[**Numeric Identifier 96431**]*
[**2149-6-4**] 03:32AM CK-MB-12* MB Indx-23.5* cTropnT-0.29*
[**2149-6-4**] 10:19AM CK-MB-NotDone cTropnT-0.29*
[**2149-6-6**] 02:51AM CK-MB-NotDone cTropnT-0.51*
[**2149-6-6**] 11:09AM CK-MB-NotDone cTropnT-0.45*
BLOOD GASES:
[**6-6**] (11:35am) 7.46/24/152 Lactate:4.3
[**6-6**] (5:47am) 7.42/23/127 Lactate:7.3
[**6-6**] (4:20am) 7.43/20/147 Lactate:7.1
[**6-6**] (2:57am) 7.40/22/139 Lactate:7.0
[**6-6**] (12:20am) 7.27/30/42
[**6-6**] (12:08am) 7.23/32/43 Lactate:10.4
[**6-5**] (11:19pm) 7.24/25/118 Lactate:9.0
[**6-5**] (9:55pm) 7.16/32/250 Lactate:10.8
[**6-5**] (7:21pm) 7.22/25/126 Lactate:8.8
[**6-5**] (4:45pm) 7.29/29/111 Lactate:6.7
[**6-5**] (4:00pm) Lactate:6.2
EKG ([**2149-6-3**]):
Atrial fibrillation. Low voltage in the limb leads. Left
bundle-branch block. Occasional ventricular premature beat.
Compared to the previous tracing of [**2149-9-13**] left bundle-branch
block has appeared.
2D-ECHOCARDIOGRAM ([**2149-5-27**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is 16-20
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed with
inferior/inferolateral akinesis and septal hypokinesis. The
right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is moderate thickening of the mitral valve chordae.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
ETT ([**2144-8-14**]):
This is a 57 year old man here for the evaluation of dyspnea.
The
patient received .142mg/kg/min IV Persantine over 4 minutes.
There was no chest, arm, neck or back pain. There were no ECG
changes. The Persantine was reversed with 125mg Aminophylline
IV.
The rhythm was atrial fibrillation. The blood pressure and heart
rate responses were appropriate for the infusion.
No Persantine-induced perfusion abnormalities. Global
hypokinesis suggestive of cardiomyopathy, with EF of 23%. A
follow up rest study may be useful to assess for subtle
myocardial perfusion changes.
Brief Hospital Course:
1. Hypotension:
Likely cardiogenic versus septic. Patient presented with a
history of CHF with low EF; CVPs were elevated with low to
normal SV02 which points more to the former. If this was septic
shock, the most likely source is the heel ulcler, although the
WBC was normal and the patient remained afebrile. In the setting
of diarrhea and recent antibiotics, c.diff colitis was possible,
but, again, the lack of WBC elevations made this less likely
(also did not appear to be having loose stools during
hospitalization time). Aggresively volume resuccitated.
Initially on dopamine alone with dobutamine and levophed added
at 2100 on [**6-4**]. Both dopamine and dobutamine were off two hours
later (2300) with levophed continuing. On [**6-5**] was transitioned
to neosynephrine and vasopressin and the levophed was turned off
(1700). When pressures fell to the 60s systolic, dopamine and
dobutamine were added back (2100). The dobutamine was again on
for just a short time (~3 hours) as his pressures seem to fall
with this inotrope. Neosynpephrine and vasopressin were also
both weaned and the patient remained on dopamine alone until he
was transferred to the CCU. There it was aggressive diuresis
and the patient improved from a cardiovascular and renal
standpoint. Additionally the dopamine was weaned. The patient
remained on pressors as he was hypotensive in their absence.
After discussion with the family, it was determined that all
cardiosupportive medications be withdrawn
For the possible septic shock, vancomycin and zosyn were used.
Culture data were unrevealing, although a call to the OSH showed
that the patient had been given antibiotics without any cultures
having been drawn. The patient remained on empiric antibiotics
throughout the CCU course until it was determined that all
supportive and therapeutic measures be withdrawn.
2. Lactic acidosis:
During the admission, the patient's lactate rose dramatically
(1.5 on admission to 10). A resulting large anion gap acidosis
resulted (pH as low as 7.16 with AG up to 26 with bicarb of 8).
A bicarb drip was started to combat this. Over the subsequent
days, the lactic acidosis resolved and the patient's acid/base
status improved.
3. Code:
On [**6-5**], a potassium was elevated (5.7) and the patient had
short runs of VT. When sustained Vtach occured (9:40p), he was
shocked back into NRS with improved MAPs. Given respiratory
distress (sats dropped to 50%), quickly intubated using
etomidate and succ. An amiodarone drip was started to keep the
patient in NSR. The patient was successfully extubated while in
the CCU and remained on telemetry with occassional PVCs and runs
of what appeared to be VTach vs afib with aberrancy. After
further discussion with the family, it was determined that the
patient would not want heroic measures and all treatments were
withdrawn and comfort measures were initiated.
4. Acute on CKD:
Initially thought to be prerenal; after the patient coded and
was severely hypotensive, ATN was felt more likely. Was
oligo/anuric for one day but put out over 8 liters in 36 hours
in the setting of lasix (initially 100mg IV, then IV gtt and
thiazide). The patient's SCr initially improved, although was
gradually increasing the few days prior to discharge.
5. CHF:
Was initially overloaded after given massive IVF. As above, put
out over 8 liters in the setting of diuretics (may also have
represented post-ATN diuresis). He constantly required pressors
for forward flow and became dramatically hypotensive in the
absence of cardiosupportive medications. He remained on
pressors until it was determined to initiate comfort measures.
6. Elevated INR:
INR appeared elevated (1.3-1.4) at baseline; increased to 2.4
during stay without having gotten any coumadin. LFTs trended up
mildly, but not to levels suggestive of ischemic hepatopathy.
[**Month (only) 116**] have been [**3-14**] antibiotic, poor PO. Got vitamin K x 2 days.
7. LFT abnormalities:
Presents with history of chronically elevated LFTs (which is why
he was not on statin therapy) and elevated amylase/lipase. Is
hepatitis sAg/Ab negative and HCV negative. [**Month (only) 116**] have fatty
liver, but cause of acute increase and increase in amylase
lipase was unclear. Congestive hepatoparthy also on
differential at time of passing.
8. UTI:
Elevated WBC on UA. Antibiotics as above.
9. Nausea/Vomiting/Diarrhea:
Presenting complaints. Differential included viral versus c.diff
colitis. Resolved soon after admission
10. Diabetes:
HISS used.
11. Heel ulcer:
Podiatry consulted with wound care recs used.
12. Anemia:
Baseline hematocrit in the high 20s, low 30s. [**Month (only) 116**] be secondary
to CKD. Hematocrit trended.
.
After discussion with the patient and the family, all were in
agreement that comfort measures be initiated and the patient
passed with family at the bedside.
Medications on Admission:
1. ASA 325mg daily
2. Lasix 80mg daily
3. HCTZ 25mg daily
4. Metoprolol 150mg daily
5. Insulin - NPH 15units at 10pm, 70/30 30units QAM
6. Donepezil 10mg daily
7. Zoloft 50mg daily
8. Miconazole powder
9. Latanoprost eye gtt
10. Ferrous Sulfate 325mg daily
11. OsCal 500 + D
12. Compazine 12.5mg PR qhs
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive Heart Failure
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2149-7-3**]
|
[
"518.81",
"785.52",
"428.20",
"584.9",
"331.0",
"707.14",
"250.40",
"585.9",
"276.2",
"995.92",
"038.9",
"785.51",
"427.31",
"427.1",
"403.90",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11413, 11422
|
6152, 11031
|
363, 391
|
11490, 11500
|
3005, 3414
|
11553, 11587
|
2373, 2392
|
11384, 11390
|
11443, 11469
|
11057, 11361
|
11524, 11530
|
2407, 2986
|
3431, 6129
|
283, 325
|
419, 1609
|
1631, 2155
|
2171, 2357
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,474
| 130,539
|
7497
|
Discharge summary
|
report
|
Admission Date: [**2118-4-26**] Discharge Date: [**2118-5-18**]
Date of Birth: [**2054-3-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Inderal
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2118-4-28**] left heart catheterization , coronary angiogram
[**2118-5-9**] Off pump coronary artery bypass graft surgery x4 (left
internal mammary artery > left anterior descending, saphenous
vein graft > diagonal > obtuse marginal, saphenous vein graft >
posterior descending artery)
History of Present Illness:
This 64 year old Cambodian-speaking female presented with
shortness of breath and wheezing which started as she was on her
way to her cardiology appointment. She was evaluated in
pulmonary clinic where she was advised to increase her dose of
Lasix to 80mg daily because she had lower extremity edema and
persistent shortness of breath. She was unable to do spirometry
but a presumptive diagnosis of asthma/COPD was made. She was
continued on nebulizers and a discussion was had about using a
CPAP or BIPAP machine at home but the patient was not amenable
to this treatment. She was set up with an appointment to follow
up in about a week.
In the meantime lab work drawn revealed a creatinine of 1.6
(baseline over the last year has ranged from 1.2-2.0) and she
was called and told to decrease the Lasix dose back to 40mg
daily because of concern of renal failure. Per her son at home
since discharge in late [**Month (only) 958**] she has been inactive but when she
walks from one room to another in the home she is always short
of breath. When she is sitting she is better. In general when
she goes out it is a big exertion for her and she gets very
short of breath. He notes she has also gained about 10 lbs (her
dry weight is 165lbs) and her leg swelling has gotten worse
since the lasix dose was decreased. In addition she complains of
off and on chest pain which is located in the epigastric region
just below her sternum and lasts for seconds. It feels like a
"punch" and is not worsened with exertion. She has not had
fevers, chills, a cough, or recent travel. There is no one else
sick at home. She denies palpitations. She was not clear about
PND or orthopnea. She has been taking all of her meds regularly,
no missed [**Month (only) 4319**]. she notes her last BM was today however she
does have some abdominal distension and feels full of fluid.
Today she arrived for her scheduled cardiology follow up
appointment with Dr. [**Last Name (STitle) **] and was referred to the emergency
room due to shortness of breath and wheezing.
Past Medical History:
insulin dependent diabetes Mellitus
chronic Hepatitis B
Stage 2 - Chronic kidney disease
hyperparathyroidism
Nephrotic Syndrome
Hypertension
Asthma
Hypertriglyceridemia
h/o stroke
Raynaud's phenomena
Generalized anxiety disordercoronary artery disease
s/p coronary stents
Social History:
The patient lives with her children and her husband. She is
originally from [**Country **]. She struggles ambulating around the
house and is incapable of all IADLs, and only some ADLs (can
toilet, bath, dress). She denies ever smoking cigarettes but
does continue to chew betel. She denies alcohol abuse. She came
to the United States in [**2090**]. She is never left alone due to
history of falls.
Family History:
No history of heart disease in the family. One son has asthma.
Physical Exam:
General: Alert, oriented, no acute distress
[**Year (4 digits) 4459**]: Sclera anicteric, MMM,
Neck: obese and unable to detect JVD
Lungs: Diminished BL with crackles at bases and using abdominal
muscles to breathe. no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: non-tender, distended, bowel sounds present, no rebound
tenderness or guarding
Ext: Warm, 2+ pitting edema to knees
Neuro: A+OX3. Weak RLE with inability to lift it more than an
inch off the bed (per son from old CVA)
Pertinent Results:
EKG: Sinus rhythm at rate of 70bpm with flat TW III, STD V4-V6
(<2mm) STD ~1mm I, II, III, AVF. Unchanged from ED ECGs and
unchanged from prior dated [**2118-3-25**].
TTE [**2118-4-29**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2117-12-3**],
the degree of MR seen appears less.
[**2118-5-17**] 04:38AM BLOOD WBC-9.9 RBC-3.08* Hgb-9.3* Hct-28.4*
MCV-92 MCH-30.1 MCHC-32.6 RDW-15.5 Plt Ct-452*
[**2118-5-16**] 04:35AM BLOOD WBC-9.5 RBC-3.17* Hgb-9.2* Hct-29.3*
MCV-93 MCH-29.2 MCHC-31.6 RDW-15.5 Plt Ct-439
[**2118-4-26**] 11:50AM BLOOD WBC-13.4* RBC-3.92* Hgb-12.6 Hct-37.1
MCV-95 MCH-32.3* MCHC-34.1 RDW-13.6 Plt Ct-339
[**2118-5-18**] 05:42AM BLOOD UreaN-31* Creat-1.1 Na-139 K-4.3 Cl-103
[**2118-5-17**] 04:38AM BLOOD Glucose-158* UreaN-33* Creat-1.2* Na-141
K-4.4 Cl-107 HCO3-31 AnGap-7*
[**2118-5-2**] 07:02AM BLOOD Glucose-112* UreaN-57* Creat-1.9* Na-144
K-4.7 Cl-103 HCO3-32 AnGap-14
[**2118-4-26**] 11:50AM BLOOD Glucose-51* UreaN-28* Creat-1.5* Na-144
K-4.2 Cl-112* HCO3-21* AnGap-15
[**2118-5-16**] 04:35AM BLOOD ALT-28 AST-35 LD(LDH)-334* AlkPhos-59
Amylase-63 TotBili-0.4
[**2118-4-26**] 11:50AM BLOOD ALT-26 AST-23 AlkPhos-80 TotBili-0.2
Brief Hospital Course:
She was admitted after evaluation in The Emergency Department
for shortness of breath. She was treated with steroids and
nebulizers in the Emergency Room, however, due to elevated BNP
was felt to be in acute diastolic heart failure. She was
treated with diuretics. She underwent cardiac catheterization
for evaluation of possible intervention but was found to have
restenosis of the stents placed previously that was not amenable
to PCI. cardiac surgery was consulted for surgical evaluation.
She underwent preoperative workup that include hepatology
consult due to Hepatitis B and was noted as Childs A. The
hepatologists recommended discontinuing the Tenofovir after the
surgery until her creatinine was noted to be stable for a couple
days. Urine culture revealed klebsiella in the urine and she was
treated with ciprofloxacin with a repeat urine culture pending
at the time of surgery. She continued to be diuresed, however,
her creatinine increased and renal was consulted due to history
of chronic kidney disease with evidence of acute injury with
diuresis. Diuretics were then dosed as needed and creatinine
monitored daily. Surgery was delayed until improvement of renal
function. There also was concern for aspiration and a swallow
study was evaluated and she was placed on restriction with 1:1
observation with meals. She also underwent a barium swallow
which ruled out esophagitis but did reveal tertiary dysmotility.
Additionally, [**Last Name (un) **] was consulted preoperatively for diabetes
management as she was on U500 at home to assist with blood
glucose management.
On [**5-9**] she was brought to the Operating Room and underwent off
pump coronary artery bypass graft surgery (see operative report
for further details). She received vancomycin and cefazolin for
perioperative antibiotics and transferred to the intensive care
unit for post operative management.
She was weaned from sedation, however, was resedated due to
dyssynchrony with the ventilator. She remained intubated and
sedated overnight. She continued to fail weaning of sedation and
remained on Propofol and pressure support ventilation. A Lasix
drip was started for gentle diuresis and she progressively
improved. On post operative day two she was weaned off Propofol
and was extubated with anesthesia at the bedside. She required
BiPAP post extubation for ventilation. Her respiratory status
improved and chest tubes and pacing wires were removed per
cardiac surgery protocol.
She was transferred to the floor in stable condition. She
continued to require frequent nebulizer treatments, diuresis and
chest PT for a tenuous respiratory status. Her renal function
was improving while she was on a low dose of Lasix for gentle
diuresis. Lopressor and Lantus were both titrated for better
blood pressure and blood sugar control. She was tolerating a
full diet, ambulating with assistance and her incisions were
healing well by POD#6. Physical Therapy worked with her for
mobility and strength. She was able to progress to self feeding.
A stay at rehabilitation was recommennded prior to her returning
home with family with continued diuresis with intravenous lasix
for a few more days. It was felt that she was safe for discharge
to [**Hospital 100**] Rehab MACU on [**5-18**].
Medications on Admission:
clonazepam 0.5 mg at bedtime as needed for anxiety and related
insomnia
clopidogrel 75 mg DAILY
diltiazem HCl 360 mg Extended Release once a day
ergocalciferol 50,000 unit Capsule every 2 weeks
fluticasone-salmeterol 250 mcg-50 mcg/Dose twice a day
furosemide 40 mg daily
insulin regular hum U-500 per sliding scale with meals
ipratropium bromide 0.2 mg/mL (0.02 %)inhaled every six (6)
hours
levalbuterol HCl [Xopenex] 0.63 mg/3 mL every four (4) hours prn
wheezing/SOB
lisinopril 20 mg Tablet once a day
omeprazole 20 mg twice a day
simvastatin 40 mg Tablet once a day
tenofovir 300 mg every 72 hours with meals
aspirin 325 mg Tablet 1 (One) Tablet(s) by mouth once a day
docusate sodium 100 mg Capsule 1 Capsule(s) by mouth twice a day
ferrous sulfate 325 mg 1 Tablet(s) by mouth daily
loratadine 10 mg Tablet 1 Tablet(s) by mouth daily
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. potassium chloride 20 mEq Packet Sig: One (1) PO once a
day: while on lasix
.
17. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
Three (33) units Subcutaneous once a day.
18. insulin regular human 100 unit/mL Solution Sig: as directed
Injection ac & HS: 120-160:3units ac. 0 HS;161-200:6units ac,3
units HS;201-240:9units ac,6units HS;241-280:12units ac,9units
HS.
19. furosemide 10 mg/mL Solution Sig: Two (2) ml Injection once
a day: please give 20 mg IV daily for 5 days then reevaluate to
transition to oral lasix .
20. Outpatient Lab Work
please check potassium, magnesium and cr twice a week while on
IV lasix
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary artery disease
s/p off pump Coronary artery bypass
s/p coronary stents
Acute on chronic diastolic heart failure
Acute on chronic renal failure (preop)
Urinary tract infection
Hypertension
Diabetes mellitus type 1
Chronic Hepatitis B
Hyperparathyroidism
Nephrotic Syndrome
Asthma
Hypertriglyceridemia
anxiety disorder
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain and left shoulder pain managed with ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg left- healing well, no erythema or drainage.
1+ Edema legs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**5-30**] at 1:45pm
Cardiologist: Dr [**Last Name (STitle) **] [**6-24**] at 9:40am
Please call to schedule appointments with:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] ([**Telephone/Fax (1) 250**]) in [**4-12**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2118-5-18**]
|
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[
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12244, 12310
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281, 572
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4002, 6018
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19,172
| 118,234
|
53349
|
Discharge summary
|
report
|
Admission Date: [**2175-6-5**] Discharge Date: [**2175-6-8**]
Date of Birth: [**2127-7-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: 47-year-old male with history of
HIV and hepatitis C with cirrhosis presents to MICU with
multiple electrolyte abnormalities. The patient was in his
usual state of health until three days prior to admission
when he developed a watery diarrhea. He denied any mucus or
blood. He reported about five bowel movements per day,
denied any fevers, chills, nausea, vomiting or sick contacts.
Denied any recent travel, uncooked foods and no international
visitors. The patient has a history of ascites and
encephalopathy without any history of varices as of 11/00.
His last paracentesis was during an admission in [**2174-12-31**]. The patient recently had started two medications in
the past five days including Ultram and MS Contin. He also
recently increased his Aldactone dose from 100 mg [**Hospital1 **] to 150
mg [**Hospital1 **]. The patient reports no po times 24 hours secondary
to anorexia. He also noted an increase in abdominal girth
and diffuse abdominal discomfort. He presented to the
Emergency Room secondary to abdominal pain and increased
girth.
REVIEW OF SYSTEMS: Significant for bilateral leg pain which
he reports is chronic but worse over the last 10 days. He
also complains of dysuria and a question of urinary
retention. He denies any cough, shortness of breath, chest
pain, palpitations, visual disturbances, headache, bright red
blood per rectum or melena.
In the Emergency Room the patient was found to have a
potassium of 7.3 for which he was given Calcium Gluconate,
Kayexalate, one amp of D50 and 10 units of IV insulin. Also
one amp of bicarb. The patient was given Levo and Flagyl in
addition and also two units of FFP prior to a diagnostic
paracentesis.
PAST MEDICAL HISTORY: 1) Hepatitis C with history of
cirrhosis and ascites. The patient also is status post a
trial of low dose pegylated Interferon without improvement,
no history of varices as of 11/00. 2) HIV, viral load from
[**4-1**] was 67,600 and CD4 was 29. 3) Anemia. 4)
Thrombocytopenia. 5) Leukopenia. 6) Umbilical hernia
repair. 7) Non insulin dependent diabetes. 8) Depression.
9) Aphthous ulcers.
MEDICATIONS: Famvir 250 mg po bid, Epogen 40,000 units subcu
q week, Nystatin cream, Bactrim DS q d, Levaquin 250 mg po q
d, Aldactone 150 mg po bid, Bumex 1-2 mg po q d, Protonix 40
mg po q d, Zithromax 1200 mg po q week, Lactulose, Celexa 10
mg po q d, Fluconazole 100 mg po q d, prn thrush, Flomax 0.4
mg po q d, Chloral Hydrate, Ultram 50 mg po bid and MSIR 10
mg and Quinine 325 mg po q h.s.
SOCIAL HISTORY: The patient is married, with five children.
He has distant history of IV drug abuse, no recent alcohol
times 6 years and a 20 pack year smoking history.
PHYSICAL EXAMINATION: General: Resting in bed in no acute
distress. T 96.0, pulse 64, blood pressure 110/41,
respiratory rate 22 and 99% on room air. HEENT:
Normocephalic, atraumatic, pupils are equal, round, and
reactive to light and accommodation, extraocular movements
intact, dry mucus membranes, dried blood on lips. Neck
supple without lymphadenopathy. Lung, decreased breath
sounds at the bilateral bases with mild crackles, no
wheezes,no spinal or paraspinal tenderness to percussion or
palpation. Cardiovascular, regular rate and rhythm, normal
S1 and S2, [**4-5**] holosystolic murmur throughout the precordium
with radiation to the bilateral carotids, JVP 8 cm. Abdomen,
diffuse mild tenderness, soft, normal abdominal bowel sounds.
Extremities, no clubbing, cyanosis or edema, 2+ DP and PT
pulses. CNS: Alert and oriented times three, strength 5/5
throughout, sensation intact. Rectal, guaiac negative with
good rectal tone.
LABORATORY DATA: Chemistry was significant for sodium of
116, potassium 7.3, 96 chloride, 17 CO2, 49 BUN and 2.5
creatinine, glucose 95. CBC, white count 3.2 with 67%
neutrophils, 23% lymphs and 20 monos. Hematocrit 23.4,
platelet count 72,000, INR 2.1, calcium 7.7, magnesium 2.1,
ALT 31, AST 82, alkaline phosphatase 278,000, total bilirubin
1.5, albumin 2.0, lipase 87. Urinalysis, specific gravity
1.025, negative for signs of infection or hematuria. INR
2.6, PTT 52.6. Abdominal ultrasound showed no evidence for
thrombosis, evidence of ascites consistent with cirrhotic
liver. Abdominal CT showed ascites and a cirrhotic liver
with a 7 mm stone in the gallbladder. There was also diffuse
colonic wall thickening. The spleen, pancreas, adrenals and
kidneys were all normal and there was evidence of mesenteric
retroperitoneal pelvic and inguinal lymphadenopathy. EKG
from the Emergency Room showed normal sinus rhythm at rates
in the low 60's. Of significance were prolonged QRS interval
to .214 milliseconds and flattened T's in 3 and V2.
Peritoneal fluid from diagnostic taps showed 170 whites, 658
reds, 9 neutrophils, 36 lymphs, 33 monos, glucose 133, LDH
40, total protein 1.0 and negative gram stain.
IMPRESSION: 47-year-old HIV positive and hep C cirrhotic
admitted with diarrhea, acute renal failure, decompensated
cirrhosis with significant electrolyte abnormalities with
potassium 7.3 and sodium 116.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit.
1. Fluids, Electrolytes & Nutrition: Patient with
significant hyperkalemia in setting of acute renal failure.
He had received Kayexalate, Calcium Gluconate, Insulin, D50
and bicarb in the Emergency Room. Upon arrival to the floor
his potassium was still elevated at 6.9, therefore he was
given another 60 cc of Kayexalate and more Calcium Gluconate.
Even after 120 cc total of Kayexalate, patient's potassium
still remained elevated to 6.5 the following morning at which
time he was given an additional total of 45 cc of Kayexalate
to finally get his potassium down to 4.8. The patient's EKG
changes resolved completely and he showed no other signs of
ectopy or arrhythmia. It was hypothesized that patient's
potassium remained elevated and was so difficult to control
likely secondary to patient's high Aldactone dosage, that he
had been taking prior to admission along with his acute renal
failure. Patient also with chronic hyponatremia with a
baseline around 124. He presented with a sodium of 116. He
was originally treated with normal saline concurrent with IV
Bumex in order to increase patient's total sodium load.
After one liter patient's sodium slowly corrected during
hospital stay. It was decided to discontinue IV fluid
resuscitation and ultimately due to patient's hematocrit,
increase his intravascular volume with packed red blood cell
infusion. By time of discharge patient's sodium had
corrected to 127.
2. Renal: Patient presented with an increased creatinine to
2.5 from baseline of 1.1 to 1.4. Initially it was believed
to be secondary to prerenal physiology vs hepatorenal
syndrome. Given that patient's urinalysis was negative for
protein, red blood cells or white blood cells, it made
nephritis or nephrotic syndrome unlikely. With volume
resuscitation the patient's creatinine improved to 1.7 at
time of discharge. This will be followed up as an outpatient
to make sure that patient's creatinine continues to correct.
3. GI: Patient with known cirrhosis secondary to hep C with
history of ascites and encephalopathy. Patient had discussed
TIPS during prior admission but did not have a desire for the
procedure. Patient now with decompensated cirrhosis with an
increased INR, increase in ascites, although there was not
significant fluid on abdominal CT for therapeutic
paracentesis. Patient also with new complaint of diarrhea on
chronic Lactulose therapy. GI service was consulted and
patient was taken for sigmoidoscopy with plan for biopsy.
The sigmoidoscopy extended 40 cm up to the flexure of the
descending colon and a biopsy was decided against secondary
to patient's normal looking mucosa. GI service felt that
patient's diffuse colonic thickening most likely was
secondary to his hypoalbuminemia. Therefore, stool cultures
had been sent and on return negative, including for
Cryptosporidia, Isosporidium, Microsporidia. C. diff were
pending. The patient was maintained on Levaquin for SBP
prophylaxis and we held patient's Lactulose during diarrhea.
24 hours prior to discharge patient without any bowel
movements and therefore he was restarted on Lactulose to
prevent hepatic encephalopathy prior to discharge.
4. ID: Patient with HIV, last CD4 29 and viral load of
67,000. Off of heart therapy, only on Famvir. No history of
opportunistic infection. The patient was maintained on his
Bactrim for PCP prophylaxis, Zithromax for [**Doctor First Name **] prophylaxis,
Fluconazole for oral thrush and Famvir for his herpes
labialis. He was also maintained on Levaquin for SBP
prophylaxis. There were no other active issues during
hospital stay.
5. Heme: Patient was chronic pancytopenic,
thrombocytopenic, possibly secondary to chronic splenic
sequestration vs HIV marrow suppression. The patient's
anemia secondary to chronic iron deficiency. He was
maintained on weekly Epogen injections. Additionally,
patient with a question of multiple myeloma per prior
presentation and an abnormal SPEP. The plan was for patient
to have follow-up with hematologist/oncologist as an
outpatient for which patient did not keep his appointment.
On admission patient's hematocrit was 23.4. He received two
units of packed red blood cells with only a bump from 21.1 to
23.2. Therefore, patient was infused with two more units of
packed red blood cells. Hemolysis labs were checked though
not completely accurate secondary to patient recent
transfusion. His LDH, haptoglobin were normal and he was
maintained at his baseline total bilirubin of 1.6. After the
fourth unit of packed red blood cells, the patient's
hematocrit appropriately bumped to 28.6. Patient should
follow-up as an outpatient with oncology for further work-up
of multiple myeloma as previously planned.
Patient's code status is DNR/DNI.
DISPOSITION: After three days in the ICU, the patient's
symptoms resolved and he was able to be discharged right to
home with VNA follow-up.
DISCHARGE DIAGNOSIS:
1. Decompensated cirrhosis.
2. Hyperkalemia.
3. Hyponatremia.
4. Acute renal failure.
5. Diarrhea.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Bumex 1-2 mg po q d, depending on
weight, Aldactone 100 mg po bid, Famvir 250 mg po bid, Epogen
40,000 units subcu q week, Bactrim DS one tablet po q d,
Levaquin 250 mg po q d, Protonix 40 mg po q d, Zithromax 250
mg po q week, Lactulose 30 cc po qid prn to goal 2-3 per day,
Celexa 10 mg po q d, Fluconazole 100 mg po q d prn thrush,
Flomax .4 mg po q d, Ultram 50 mg po bid, MSIR 10 mg po q 6
hours prn pain.
DIET: Low sodium, low potassium diet.
PLAN: Patient should continue daily weights and should
titrate his lactulose to [**3-5**] bowel movements of stool per
day. Patient will follow-up with Dr. [**First Name (STitle) **] at [**Hospital1 **] on [**6-14**]
and a Chem 7 should be rechecked at that time. The patient
will continue to follow-up with GI service as previously
scheduled. Patient did not require physical therapy and will
be followed at home by VNA service.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2175-6-8**] 14:53
T: [**2175-6-8**] 16:41
JOB#: [**Job Number 109745**]
|
[
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icd9cm
|
[
[
[]
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[
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|
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,094
| 153,449
|
21510+57247
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-10-27**] Discharge Date: [**2185-11-24**]
Date of Birth: [**2122-5-26**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man
transferred from an outside hospital with a three day history
of temporal headache getting progressively worse and with a
progressive decline in mental status. The patient was
actually sedated and intubated in transit. He had a
noncontrast head CT scan which showed diffuse subarachnoid
hemorrhage with ventricular dilation. The patient had a
ventricular drain placed by Neurosurgery on admission. He
has had a cerebral angiogram and coiling of a ruptured basilar
artery aneurysm.
PAST MEDICAL HISTORY: Past medical history at the time of
admission was unknown.
MEDICATIONS: His medications were unknown.
LABORATORY DATA: He had a 7 by 5 by 4 millimeter basilar tip
aneurysm which was coiled without complications.
HOSPITAL COURSE: Neurologically, he was sedated, intubated,
moving all four extremities off sedation, not responding to
commands. Pupils were equal and reactive to light and he had
a positive gag. He was admitted to the Intensive Care Unit
for close observation and then was brought to Angio for
coiling.
Repeat head CT scan on [**2185-10-28**] showed increasing edema. A
second ventricular drain was placed at that time.
Neurologically, the patient localized in the left upper
extremity; gaze was conjugate. Pupils were 2.5 down to 2.0.
Localized to 40 percent on the right side. The patient also
spike to 101.3 F., and was pan cultured. Vital signs
otherwise remained stable. Had difficulty ventilating the
patient on [**10-31**]. On [**2185-11-1**], the patient had a CT scan
of his lungs which showed no evidence of embolism and
Doppler's of the lower extremities were negative. Head CT
scan showed no changes. The pain remained intubated and
sedated. Following commands, tracking and moving all
extremities spontaneously. On [**11-2**], the patient was seen by
Infectious Disease for continued fever. They recommended
just checking lab and not starting antibiotics at that time
where there was no clear source of fever. On [**11-4**], the
patient again spiked a temperature to 101.7 F. The patient
was fully cultured. Chest x-ray was clear. Head CT scan
showed question of increasing mass effect. CSF was negative.
The patient was on Vancomycin and Levofloxacin for a fourteen
day course. The patient had an abdominal CT scan and General
Surgery consultation. The abdominal CT scan was questionable
for appendicitis, however, the patient eventually was ruled
out for appendicitis. Followup scans did show
diverticulosis.
With the results of the abdominal CT scan, Infectious Disease
recommended covering the patient with Levofloxacin and Flagyl
for colitis and discontinuing Vancomycin. The patient was
also on triple-H therapy, keeping his blood pressure in the
160 to 180 range and CVP in the 8 to 10 range. The
ventricular drain was raised to 15 centimeters above the
tragus. His blood pressure continued to be kept in the 160
to 180 range. On [**11-8**], the right ventricular drain was
removed. The patient continued to be neurologically stable,
following commands times four, opening his eyes, slightly
confused, wiggling his toes. Temperature was 100.2 F on
[**11-8**]; he continued on Levofloxacin and Flagyl. The patient
had a CT angiogram of the head on [**11-9**] which showed evidence
of basal spasms. The patient continued on triple H therapy.
He was seen by Physical Therapy and Occupational Therapy. On
[**11-11**], the patient had a head CT scan that showed no change.
CT scan of the abdomen at this time showed sigmoid
diverticulitis with no free air and thickened segments. KUB
showed distended loops of bowel. Chest x-ray was clear. The
patient continued on Vancomycin, Levofloxacin and Flagyl for
intravenous antibiotic coverage. On [**11-14**], the patient had
diagnostic angiogram which showed no evidence of vasospasm
and the patient was then backed off on triple H therapy.
Infectious Disease continued to follow for continued fevers.
The patient continued on Vancomycin, Levofloxacin and Flagyl.
Clostridium difficile toxin was negative.
The patient remained neurologically stable. The ventricular
drain was discontinued on [**2185-11-15**] due to the question of
infection and a lumbar drain was placed. The patient
continued to have intermittent fevers, continued on
Levofloxacin, Flagyl and Vancomycin. The patient had a head
CT scan on [**11-13**] which showed no changes. He remained
neurologically stable, awake, alert, following commands, but
somewhat confused. Continued to be followed by Physical
Therapy. He remained in the Intensive Care Unit until
transfer to the Stepdown on [**2185-11-19**] and has remained
neurologically stable. Temperatures have been 99.2 F.
Remains awake, alert and oriented times one. Following
commands. Bilateral lower extremity Dopplers done on
[**2185-11-24**] results of which are pending.
The patient's condition has remained stable. He has been
followed by Physical Therapy and Occupational Therapy. The
patient requires acute rehabilitation stay prior to discharge
to home.
DISCHARGE MEDICATIONS:
1. Lansoprazole 30 p.o. q. Day.
2. Heparin 5000 units subcutaneously three times a day.
3. Insulin sliding scale.
4. Colace 100 mg p.o. twice a day.
5. Albuterol nebulizers, one q. Four hours p.r.n.
6. Ipratropium bromide nebulizer, one q. Six hours.
7. Miconazole powder, two percent topically four times a day
p.r.n.
The patient's condition was stable at the time of discharge.
He will followup with Dr. [**Last Name (STitle) 1132**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2185-11-24**] 12:38:56
T: [**2185-11-24**] 14:08:33
Job#: [**Job Number 56731**]
Name: [**Known lastname 10596**],[**Known firstname **] Unit No: [**Numeric Identifier 10597**]
Admission Date: [**2185-10-27**] Discharge Date: [**2185-11-25**]
Date of Birth: [**2122-5-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10598**]
Chief Complaint:
same as previous
Major Surgical or Invasive Procedure:
same as previous
Brief Hospital Course:
Patient was seen by resident on orthopedic surgery for continued
pain in left shoulder. Although the attending surgeon did not
see the patient, based on the films and history, he beleived the
patient had AC joint arthritis. MRI of his shoulder to rule-out
a rotator cuff injury, NSAIDs and follw-up as outpatient were
recommended.
Discharge Disposition:
Extended Care
Facility:
St [**Hospital **] Hospital Rehabilitation Unit - [**Location (un) 7044**], NH
Discharge Diagnosis:
SAH
right AC joint arthritis
Discharge Condition:
neurologically stable
Discharge Instructions:
continue to monitor neurologic status
Followup Instructions:
follow up with Dr [**Last Name (STitle) 365**] in two weeks call 1-[**Telephone/Fax (1) 8473**] for
appointment
follow up with Dr. [**Last Name (STitle) 10599**] of orthopedics in [**1-21**] weeks for
further work-u po f right shoulder pain, call [**Telephone/Fax (1) 8657**] for
appointment
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 10600**]
Completed by:[**2185-11-25**]
|
[
"518.0",
"729.89",
"430",
"435.9",
"331.4",
"560.1",
"401.9",
"562.11",
"041.84",
"558.9",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.72",
"96.71",
"99.15",
"89.62",
"88.41",
"03.79",
"38.91",
"02.2",
"96.6",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6811, 6916
|
6455, 6788
|
6414, 6432
|
6988, 7011
|
7097, 7530
|
5250, 6341
|
6937, 6967
|
944, 5227
|
7035, 7074
|
6358, 6376
|
167, 686
|
709, 926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,770
| 141,424
|
25927
|
Discharge summary
|
report
|
Admission Date: [**2113-1-27**] Discharge Date: [**2113-2-9**]
Date of Birth: [**2036-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fevers/Fatigue
Major Surgical or Invasive Procedure:
[**2113-2-3**]
Redo sternotomy, Redo Bentall aortic root replacement with a
size 21-mm homograft, Drainage of aortic root abscess.
History of Present Illness:
76 year old man with a history of mechanical aortic valve
replacement ([**2106**])on coumadin, who was transferred to the [**Hospital1 **] on
[**1-27**] from an OSH for further evaluation for recurrent fever,
flank pain, nausea, and vomiting. He was recently in El [**Country 19118**]
where he [**Doctor Last Name 6165**] and was seen in the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 2 occasions over past
6 weeks treated with abx for 4 days then 2 days for bacterial
illness. He returned to the US and saw his PCP that night
developed fever, rigors, myalgias, nausea and back pain. He
presented to [**Location (un) **] [**Location (un) 1459**] where a contrast CT done at the
OSH showed persistent right kidney subcapsular
fluid collecton and left non-obstructing urolithiasis. He was
febrile and started on vancomycin and pip/tazo and oseltamivir.
Blood cultures drawn at the OSH are now growing Group C Strep.
The patient was transferred to [**Hospital1 18**] for further management. A
TTE done here reveals mechanical aortic valve vegetation.
Past Medical History:
Past Medical History:
1. Hypertension
2. AAA s/p repair ([**2106**])-- per OMR but history unclear from
patient, no evidence of graft on CT
3. Right Kidney Stones s/p extracorporeal shockwave lithotripsy
at [**Hospital1 18**]
4. Retroperitoneal hemorrhage
5. CHF? *per patient he does not have this
6. R shoulder Bursitis
7. BPH
Past Surgical History:
1. Aortic valve replacement (mechanical) on coumadin since [**2106**]
2. Cholecystitis s/p cholecystectomy ([**2107**])
Social History:
Travels back and forth between El [**Country 19118**] and here. Wife lives
in El [**Country 19118**]. Has nine kids. Retired, used to be a farmer.
Tobacco - never
Alcohol - not in decades
Drugs - none past or present, no IVDU, no tattoos.
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Hospital1 18**])
Family History:
remarkable for multiple cancers in the family, including stomach
and liver cancer
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right: Left:
Height: 55 inches Weight:147 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []; no costovertebral angle tenderness
Extremities: Warm [x], well-perfused [x] no Edema
no Varicosities; no [**Last Name (un) **] lesions
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2113-2-8**] 04:08AM BLOOD WBC-7.2 RBC-3.20* Hgb-9.9* Hct-29.3*
MCV-92 MCH-31.0 MCHC-33.9 RDW-17.2* Plt Ct-228
[**2113-1-28**] 12:20AM BLOOD Neuts-88.2* Lymphs-7.9* Monos-2.5 Eos-1.0
Baso-0.5
[**2113-2-8**] 04:08AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.7 Mg-2.2
[**2113-2-8**] 04:08AM BLOOD ALT-12 AST-28 LD(LDH)-261* AlkPhos-101
Amylase-45 TotBili-0.7
[**2113-2-8**] 04:08AM BLOOD Glucose-101* UreaN-18 Creat-1.1 Na-136
K-4.5 Cl-96 HCO3-34* AnGap-11
[**2113-2-3**] TEE
PRE-BYPASS:
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%).
The right ventricular cavity is mildly dilated with borderline
normal free wall function. A bileaflet aortic valve prosthesis
is present. The transaortic gradient is normal for this
prosthesis. It appeared as though one of the leaflet was stuck
in the deep transgastric view but with no insufficiency and with
normal gradients. It was noted that previous TEE images from
cardiology had shown normal movements of the leaflets. The
imaging was suboptimal to elucidate further information and was
promptly conveyed to the surgeon. An aortic annular echodensity
of 4cm x 1.6 cm was seen posterior to the aortic root consistent
with abscess is see and was extending to the space between the
aorta and the right PA posteriorly. The abscess is outside the
ascending aortic graft and no cavity filling was seen unlike the
previous TEE images. This does not rule out communication. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
POST-BYPASS:
Patient is on epinephrine 0.02 mcg/kg/min and levophed
0.03mcg/kg/min.
Intact thoracic aorta. There is a circumferential echodensity
with no filling is seen consistent with post surgical state of
aortic root abscesses. The homograft is in situ with functioning
aortic valve and a residual mean gradient of 12 mm of Hg. Mild
MR, TR. Preserved biventricular sytolic function, LVEF 55%
Brief Hospital Course:
This 76-year-old patient who has had a previous aortic root
replacement, Bentall procedure with mechanical composite graft
approximately 6 years ago, presented with signs of sepsis and a
transesophageal echocardiogram showed an aortic root abscess
placed posteriorly with communication into the aortic root. He
had positive blood cultures with group C Streptococci.
Initially he was given antibiotics but he developed signs of
worsening abscess with conduction abnormalities and was taken to
the operating room for urgent redo Bentall operation.
Preoperative coronary angiogram showed no occlusive disease, and
left ventricular function was well-preserved. He was brought to
the operating room on [**2113-2-3**] where the patient underwent redo
sternotomy redo Bentall aortic root replacement with a size
21-mm
homograft and drainage of aortic root abscess. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Infectious disease was consulted and
recommended 6 weeks of PCN G from the date of surgery (aortic
valve gram stain was negative for microorganisms.) Beta blocker
was initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**Hospital 1459**] Nursing and Rehab Center in good condition on post
operative day 6 with appropriate follow up instructions for
appointments and labs.
Medications on Admission:
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
WARFARIN - 2.5 mg Tablet - [**12-25**] Tablet(s) by mouth daily as
directed
NKDA
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 1 week then decrease to 400 mg daily x 2 weeks then
200 mg daily x 1 month then as directed by cardiology.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous every eight (8) hours as needed for line flush.
14. penicillin G potassium 20 million unit Recon Soln Sig: 4
million units Injection every four (4) hours for 6 weeks:
Continue via PICC x 6 weeks from date of surgery.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
16. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO DAILY (Daily) for 7
days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1459**] Care and Rehabilitation Center
Discharge Diagnosis:
Endocarditis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
1+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] on [**2113-2-27**] at 2:00 PM
Cardiologist: Needs referral
[**Hospital **] clinic with Dr [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 2688**] on [**2113-2-27**] at 10:00 AM
[**Hospital **] clinic with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9461**] on [**2113-3-15**] at 11:00 AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-28**] weeks [**Telephone/Fax (1) 1144**]
Please check weekly CBC with diff, Chem 7, LFT's ESR and CRP and
fax results to [**Hospital **] clinic [**Telephone/Fax (1) 1419**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-2-9**]
|
[
"600.00",
"V58.61",
"280.0",
"585.9",
"592.0",
"996.62",
"996.61",
"V43.3",
"421.0",
"E878.2",
"995.91",
"E878.1",
"590.10",
"038.0",
"403.90",
"593.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"39.61",
"39.56",
"38.93",
"88.72",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9456, 9538
|
5409, 7426
|
323, 456
|
9595, 9765
|
3202, 5386
|
10605, 11577
|
2416, 2499
|
7748, 9433
|
9559, 9574
|
7452, 7725
|
9789, 10582
|
1930, 2052
|
2514, 3183
|
269, 285
|
484, 1555
|
1599, 1907
|
2068, 2400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,837
| 123,301
|
3878
|
Discharge summary
|
report
|
Admission Date: [**2177-7-30**] Discharge Date: [**2177-8-6**]
Date of Birth: [**2139-5-20**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 17345**]
Chief Complaint:
Induction of labor @ 34wks GA secondary to breast CA diagnosed
at 22wks, s/p L mastectomy, L axillary dissection, and
chemotherapy x2 cycles.
Major Surgical or Invasive Procedure:
1.Normal vaginal delivery
2.Exam under anesthesia.
3.Ultrasound guided dilation and curettage.
4.Fourth degree peri-urethral laceration.
5. Emergent exploratory laparotomy, total
abdominal hysterectomy, bilateral salpingo-oophorectomy.
History of Present Illness:
38 yo G2P1001 at 33wks 6days GA with recently diagnosed
infiltrating carcinoma with ductal and lobular features admitted
to antepartum service after undergoing a scheduled L total
mastectomy and L axillary dissection. Shortly after her
surgery, she denied abdominal pain, contractions, leaking fluid
or vaginal bleeding. Active fetal movement noted.
Past Medical History:
PNC:
1) [**Last Name (un) **]: [**2177-9-9**]
2) Labs: B pos/Ab neg/RPRNR/RI/HepBsAg neg
3) nl amnio 46 XX
4) U/S on [**2177-5-19**] by Dr. [**MD Number(4) **] [**Name (STitle) **]: EFW 734 gms (86%), TV u/s
3.4 cm
PMH: L breast infiltrating ductal and lobular carcinoma
(diagnosed on breast bx on [**2177-5-12**])
PSH: breast biopsy; L total mastectomy and L axillary dissection
PGYNH: no abnl Pap, no STD
POBH: NSVD x 1, term, female infant, 6 lbs 10 oz
Social History:
She lives with her husband and daughter and
works full time as an accountant in [**Hospital1 392**]. She is a nonsmoker
and does not drink alcohol.
Family History:
No family h/o breast CA.
Physical Exam:
Vitals: 98.6 132/72 110 18
Comfortable
Abd - soft, ND/NT, gravid, vtx, EFW ~5lbs
SVE - [**1-/2121**]/high
Toco - q8min
FHT - 150//moderate variability/+accels/-decels
Pertinent Results:
[**2177-7-31**] 09:56PM BLOOD WBC-12.5* RBC-3.29* Hgb-10.0* Hct-27.0*
MCV-82 MCH-30.5 MCHC-37.2* RDW-15.1 Plt Ct-99*
[**2177-7-31**] 06:32PM BLOOD WBC-19.9* RBC-3.48* Hgb-10.8* Hct-29.2*
MCV-84 MCH-31.1 MCHC-36.9* RDW-14.8 Plt Ct-114*
[**2177-7-31**] 04:19PM BLOOD WBC-22.0* RBC-3.10* Hgb-9.5* Hct-27.7*
MCV-89 MCH-30.6 MCHC-34.2 RDW-15.0 Plt Ct-131*
[**2177-7-31**] 03:06PM BLOOD WBC-17.9*# RBC-2.84*# Hgb-9.0* Hct-25.9*#
MCV-91 MCH-31.8 MCHC-34.8 RDW-14.8 Plt Ct-211
[**2177-7-31**] 01:32AM BLOOD WBC-11.9* RBC-3.87* Hgb-11.8* Hct-35.1*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.4 Plt Ct-333
[**2177-8-1**] 02:13PM BLOOD WBC-16.6* RBC-4.29# Hgb-12.8 Hct-34.9*#
MCV-81* MCH-29.8 MCHC-36.7* RDW-15.7* Plt Ct-96*
[**2177-8-1**] 11:43AM BLOOD WBC-11.2* RBC-3.38* Hgb-10.3* Hct-27.5*
MCV-81* MCH-30.5 MCHC-37.5* RDW-15.5 Plt Ct-67*
[**2177-8-1**] 04:39AM BLOOD WBC-12.1* RBC-2.80* Hgb-8.6* Hct-23.0*
MCV-82 MCH-30.9 MCHC-37.6* RDW-14.8 Plt Ct-93*
[**2177-8-1**] 01:10AM BLOOD WBC-11.0 RBC-2.94* Hgb-9.0* Hct-24.1*
MCV-82 MCH-30.7 MCHC-37.4* RDW-14.8 Plt Ct-97*
[**2177-8-3**] 08:45AM BLOOD Plt Ct-140*
[**2177-8-3**] 08:45AM BLOOD PT-10.6 PTT-20.0* INR(PT)-0.9
[**2177-8-1**] 02:13PM BLOOD Plt Ct-96*
[**2177-8-1**] 11:43AM BLOOD Plt Smr-VERY LOW Plt Ct-67*
[**2177-8-1**] 11:43AM BLOOD PT-11.2 PTT-25.8 INR(PT)-0.9
[**2177-8-1**] 04:39AM BLOOD Plt Ct-93*
[**2177-8-1**] 04:39AM BLOOD PT-11.9 PTT-27.9 INR(PT)-1.0
[**2177-8-1**] 01:10AM BLOOD Plt Ct-97*
[**2177-8-1**] 01:10AM BLOOD PT-13.7* PTT-33.6 INR(PT)-1.2*
[**2177-7-31**] 09:56PM BLOOD PT-13.9* PTT-32.7 INR(PT)-1.2*
[**2177-7-31**] 09:56PM BLOOD Fibrino-177#
[**2177-7-31**] 06:32PM BLOOD Fibrino-85*
[**2177-7-31**] 05:42PM BLOOD Fibrino-63*
[**2177-7-31**] 03:06PM BLOOD Fibrino-122*#
[**2177-7-31**] 01:32AM BLOOD Fibrino-560*
[**2177-7-31**] 06:32PM BLOOD PT-16.5* PTT-46.8* INR(PT)-1.5*
[**2177-7-31**] 05:42PM BLOOD PT-16.6* PTT-57.6* INR(PT)-1.5*
[**2177-7-31**] 03:06PM BLOOD PT-13.0 PTT-32.1 INR(PT)-1.1
[**2177-7-31**] 01:32AM BLOOD PT-10.9 PTT-21.9* INR(PT)-0.9
[**2177-8-1**] 04:39AM BLOOD Fibrino-218
[**2177-8-1**] 11:43AM BLOOD Fibrino-341#
[**2177-8-3**] 08:45AM BLOOD Glucose-110* UreaN-8 Creat-0.8 Na-139
K-4.1 Cl-104 [**2177-8-3**] 08:45AM BLOOD Fibrino-591*#
[**2177-7-31**] 09:56PM BLOOD CK(CPK)-814*
[**2177-7-31**] 09:56PM BLOOD CK-MB-17* MB Indx-2.1 cTropnT-0.32*
[**2177-7-31**] 01:32AM BLOOD ALT-15 AST-30 LD(LDH)-355* AlkPhos-155*
Amylase-73 TotBili-0.2
[**2177-7-31**] 01:32AM BLOOD Lipase-28
[**2177-8-1**] 09:50AM BLOOD Glucose-72 Lactate-1.0 K-7.3*
[**2177-8-1**] 07:27AM BLOOD Glucose-92 Lactate-1.5 K-3.4*
[**2177-8-1**] 01:24AM BLOOD Lactate-1.6
[**2177-7-31**] 06:50PM BLOOD Glucose-180* Lactate-7.5* Na-133* K-4.3
Cl-110
[**2177-7-31**] 05:53PM BLOOD Glucose-164* Lactate-6.5* Na-139 K-6.1*
Cl-110
[**2177-7-31**] 05:22PM BLOOD Glucose-216* Lactate-7.8* Na-130* K-7.0*
Cl-105
[**2177-7-31**] 05:07PM BLOOD Glucose-218* Lactate-9.9* Na-130* K-6.3*
Cl-107
[**2177-8-1**] 07:27AM BLOOD Hgb-11.6* calcHCT-35
[**2177-7-31**] 06:50PM BLOOD Hgb-10.7* calcHCT-32
[**2177-7-31**] 05:53PM BLOOD Hgb-10.3* calcHCT-31
[**2177-7-31**] 05:22PM BLOOD Hgb-12.8 calcHCT-38
[**2177-7-31**] 05:07PM BLOOD Hgb-12.0 calcHCT-36
Brief Hospital Course:
The patient is a 38-year-old gravida 2, para 1 who was scheduled
for induction of labor at 34 weeks. This induction was carried
out to accommodate the patient's
planned chemotherapy for invasive breast cancer diagnosed at
22wks, s/p L mastectomy and L axillary dissection, and
chemotherapy x2 cycles ([**2177-6-12**] and [**2177-7-3**]). On arrival, the
patient had a cervical exam that was unfavorable and was given 1
dose of Pitocin. Following this the patient had a favorable
cervix and was started on Pitocin. Over the course of the day,
she progressed well to full dilation and vaginally delivered a
live born girl that was transferred to the NICU for further
evaluation. At the time of the delivery, the patient had a blood
loss of 450 cc and a small periurethral lac that was repaired
with a 4-0 Vicryl. Good hemostasis was obtained.
15 minutes following delivery, the patient had further vaginal
bleeding. This was estimated to be approximately 300 cc. This
was associated with uterine atony. On exam, the uterus was found
to be atonic and a large amount of clot was found in the lower
uterine segment. The tone improved with bimanual massage as well
as 1 dose of Methergine and 40 units of Pitocin. At this point
in time, the patient was typed and screened and remained on
labor and delivery for further monitoring. 15 minutes later, the
patient had a another episode of the uterine to atony that
resulted in a gush of blood approximately 100 cc in volume. At
this time, a transabdominal ultrasound was performed which
revealed a poorly defined endometrial stripe. The uterus was
found to be atonic and improved with massage. In light of the
persistence of this postpartum hemorrhage with intermittent
atony, the patient was recommended for dilation and curettage as
well as exam under anesthesia to rule out retained products of
conception. The details of the operative procedure are found in
the operative report elsewhere.
During the procedure, as the patient continued to have some
uterine atony, she was given a dose of Methergine and 2 doses of
Hemabate. Following suction, the external genitalia was
inspected and the first degree periurethral laceration appeared
intact. There was a first degree laceration in the posterior
fourchette that was repaired with 3-0 chromic in the usual
fashion. Good hemostasis was obtained. Following this procedure,
as the patient continued to have a small amount of bleeding, she
received a further dose of 1000 mcg of Cytotec.
Having exhausted medical management of postpartum hemorrhage
options, an emergent total abdominal hysterectomy and bilateral
salpingo-oophorectomy was performed to further control bleeding.
Blood products infused at the time of surgery were 7units PRBC,
1 unit PLT, 2 FFPs, 1unit cryo. The details of this procedure
is found in detail in the operative report elsewhere. The pt
remained intubated and was transferred to the intensive care
unit for management on POD#0.
POD#0, pt was noted to have new onset diplopia/nystagmus. MRI
was ordered and was negative for stroke/brainstem injury.
Diplopia/nystagmus resolved spontaneously. Given demand
ischemia in setting of intraoperative tachycardia, EKG was done
and cardiac enzymes were cycled. CK and troponin were found
elevated. Pt was weaned off vent, and hypotension, likely
secondary to PPH, resolved with 3units of additional PRBC in the
ICU over POD#0-2. Pt was transferred to the floor on POD#2.
Pt continued to do well without complications on the floor with
routine postop/postpartum care. On POD#5, given elevated
CK/troponin intraop, pt underwent echo, which was all within
normal limits. Details of the echo results are available in the
echo report.
Pt was discharged home in stable condition on POD#5.
Medications on Admission:
PNV
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p vaginal delivery at 34wks
Postpartum hemorrhage
D&C, total abdominal hysterectomy and bilateral
salpingoophorectomy
Discharge Condition:
Stable
Discharge Instructions:
Given. See below
Followup Instructions:
In 2wks with Dr. [**Last Name (STitle) **] and then in 6wks.
[**Name6 (MD) 8175**] [**Name8 (MD) **] MD [**MD Number(1) 17346**]
Completed by:[**2177-8-14**]
|
[
"648.21",
"174.8",
"665.51",
"666.12",
"648.91",
"659.51",
"V27.0",
"280.0",
"669.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"68.4",
"65.61",
"73.4",
"73.09",
"69.02",
"96.49",
"99.07",
"75.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9198, 9204
|
5215, 8973
|
471, 709
|
9368, 9377
|
1995, 5192
|
9442, 9631
|
1764, 1790
|
9028, 9175
|
9225, 9347
|
8999, 9005
|
9401, 9419
|
1805, 1976
|
290, 433
|
737, 1092
|
1114, 1581
|
1597, 1748
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,168
| 199,734
|
36282
|
Discharge summary
|
report
|
Admission Date: [**2144-4-26**] Discharge Date: [**2144-4-30**]
Date of Birth: [**2114-4-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
bolt [**2144-4-26**]
History of Present Illness:
This is a 30 year old male who was "play fighting" with
friends outside and fell backwards hitting his head on the
cement. No loss of consciousness at the scene, but presented to
outside ED with mental confusion and was electively intubated
for
transfer. On arrival to the ED he seized 30 seconds at that time
was posturing in all four extremities which was witnessed by the
trauma team.
Past Medical History:
None
Social History:
ETOH level 300 on admission
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:300 ETOH level.
O: T: BP: 126/61 HR: 70 R 14 O2Sats 100% ventilated assist
control 100% 550 X 14
Gen: GCS=1/1/3(internal rotation)=5
HEENT: right ear draining blood. Pupils:2.5-2mm sluggish bilat
EOMs Unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: GSC=5
Orientation: not oriented X 3
Recall: none
Language:non verbal/intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2
mm bilaterally. Visual fields not tested
III, IV, VII, V, VII, VIII,IX, X,[**Doctor First Name 81**],XII:exam limited due to poor
mental status- + gag, no corneal
Motor: internal rotation seen during 30 sec seizure on admit to
ED per trauma service, with suctioning pt lifts all extremities
slightly off the bed.On second evaluation in [**Name (NI) **], pt moving all
extremities purposefully and opening eyes.
Sensation: limited exam due to mental status
Toes equivocal bilaterally
Coordination:limited exam due to mental status
Discharge Physical exam:
Oriented x 3. PERRL. EOMS intact. No drift. Face symmetric.
Tongue midline. Full strength and sensation throughout. Has
intermittent blurred vision. Has had right ear drainage but this
has stopped. No gait instability. Staples in place.
Pertinent Results:
[**2144-4-26**] 11:10PM TYPE-ART PO2-379* PCO2-46* PH-7.34* TOTAL
CO2-26 [**2144-4-26**] 09:45PM UREA N-18 CREAT-0.9
[**2144-4-26**] 09:45PM estGFR-Using this
[**2144-4-26**] 09:45PM LIPASE-26
[**2144-4-26**] 09:45PM ASA-NEG ETHANOL-279* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2144-4-26**] 09:45PM URINE HOURS-RANDOM
[**2144-4-26**] 09:45PM URINE HOURS-RANDOM
[**2144-4-26**] 09:45PM URINE GR HOLD-HOLD
[**2144-4-26**] 09:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2144-4-26**] 09:45PM GLUCOSE-97 LACTATE-3.5* NA+-146 K+-3.8
CL--102 TCO2-27
[**2144-4-26**] 09:45PM WBC-13.4* RBC-4.60 HGB-14.1 HCT-41.2 MCV-90
MCH-30.6 MCHC-34.1 RDW-12.3
[**2144-4-26**] 09:45PM PLT COUNT-366
[**2144-4-26**] 09:45PM PT-12.9 PTT-25.1 INR(PT)-1.1
[**2144-4-26**] 09:45PM FIBRINOGE-296
[**2144-4-26**] 09:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2144-4-26**] 09:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2144-4-26**] 09:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
CTA Head [**4-26**]:
FINDINGS: There is evidence of diffuse subarachnoid hemorrhage
along the right frontal and bilateral sylvian fissures, the
subarachnoid hemorrhage extends in the parafalcine region,
tracking inferiorly the suprasellar cistern and anterior to the
pons. There is evidence of effacement of the sulci, likely
consistent with brain edema, the [**Doctor Last Name 352**]-white matter
differentiation is preserved. There is no evidence of
hydrocephalus or intraventricular hemorrhage at the time of this
examination. There is no evidence of transtentorial/subfalcine
or uncal herniations. Right scalp subgaleal hematoma is
visualized with associated underlying fracture through the
petrous portion of the right temporal bone with small depressed
fragment and extension posteriorly to the right occipital bone.
Opacification of the right mastoid air cells, external auditory
canals, middle ear, and two small tiny bubbles are demonstrated
in this area related with pneumocephalus. Mucosal thickening of
the paranasal sinuses with fluid opacifying the nasal cavity,
nasal and oropharynx is visualized. The CTA demonstrates
vascular flow in both internal
carotids and vertebrobasilar system without evidence of flow
stenotic lesion, aneurysm or disection.
IMPRESSION: Diffuse subarachnoid hemorrhage as described in
detail above.
Right scalp subgaleal hematoma with associated underlying
fracture through the petrous portion of the right temporal bone
with a small depressed fragment and with extension posteriorly
to the right occipital bone. Small pneumocephalus is
demonstrated with two small bubbles in the area adjacent to the
fracture.
The carotids and vertebrobasilar system without evidence of flow
stenotic
lesion or disection.
CT C-SPINE [**4-26**]: The skull base through T4 is imaged,
demonstrating no evidence of acute fracture, malalignment, or
paravertebral hematoma along the imaged spine. While CT does not
afford the intrathecal detail as does MR, no abnormality is
detected within the spinal canal.
Images through the skull base show a longitudinal fracture
extending through the petrous portion of the right temporal,
with small dependent fragment, and with extension posteriorly
into the right occipital bone. Tiny pneumocephalus is noted.
There is also overlying subgaleal hematoma. There is
opacification of the mastoid air cells, the external auditory
canal and the middle ear on the right. Mild mucosal thickening
is noted in the left maxillary sinus. The left mastoid air cells
are well aerated.
Limited views through the lung apices show dependent atelectatic
changes.
IMPRESSION:
1. No evidence of traumatic injury seen in the cervical spine.
2. Right temporal bone fractures, more completely evaluated on
the CT
head/CTA head performed subsequently.
3. Incompletely visualized subarachnoid hemorrhage is seen
tracking anterior to the pons, antero and left laterally along
the brainstem and into the upper cervical spinal canal. No mass
effect on the spinal cord seen, however, if there is concern for
cord injury, MRI would be recommended for more sensitive
evaluation.
CT Head [**4-27**]:
FINDINGS: There is a right frontal ICP monitoring device which
is new. There is unchanged diffuse subarachnoid hemorrhage,
particularly in the area of bilateral sylvian fissure more
prominent on the right. No hydrocephalus. No midline shift. In
the inferior frontal lobes (2:11), there are several 5-6 mm
areas of rounded hyperdensity consistent with hemorrhagic
contusions, which are better seen than on the previous study due
to differences in patient positioning. No large areas of
infarction are seen.
There is an unchanged nondisplaced fracture through the right
temporal bone with resulting opacification of the right mastoid
air cells. The fracture also extends into the occipital bone.
There is increased subgaleal hematoma at the right parietal
convexity and decreased right occipital subgaleal hematoma.
There is minimal mucosal thickening in the maxillary sinuses,
sphenoid
sinuses, and ethmoid sinuses. The frontal sinuses are clear.
IMPRESSION:
1. Unchanged diffuse subarachnoid hemorrhage. No hydrocephalus.
2. Bilateral inferior frontal hemorrhagic contusions, better
seen than
before.
3. Unchanged right temporal bone fracture for which a temporal
bone CT is
recommended to further evaluate the middle and inner ear
structures.
4. Decreased right occipital subgaleal hematoma. Increased right
parietal
subgaleal hematoma.
CT Head [**4-29**]:
FINDINGS: Previously noted subarachnoid hemorrhage has decreased
in density. Allowing for the differences in the angle of the
patient's head, previously noted hemorrhagic contusions in the
inferior frontal lobes appear unchanged. No new intracranial
hemorrhage is seen. There is no intraventricular hemorrhage. The
ventricles are stable in size. No new areas of parenchymal edema
or large infarction are seen.
A fracture involving the right temporal and occipital bones is
again seen,
with persistent opacification of the right mastoid air cells.
Right parietal and occipital subgaleal hematomas are again seen.
IMPRESSION:
1. Expected evolution of subarachnoid hemorrhage.
2. Unchanged appearance of bilateral inferior frontal
hemorrhagic contusions, allowing for differences in patient
positioning.
3. Fracture of the right temporal and occipital bones. Dedicated
temporal
bone CT is recommended for evaluation of middle ear and inner
ear structures, as stated previously.
Brief Hospital Course:
The patient was noted to be with a GCS of 5 on admission where
he was intubated electively at the OSH. He was loaded with
dilantin and noted to seize for ~30 seconds with posturing in 4
extremities.
While at [**Hospital1 18**], the patient had his intracranial bolt placed in
the emergency room for presumed increased ICP. His ICPs were
monitored and he was given aggressive mannitol to decrease
intracranial swelling. His sodiums were routinely monitored and
were stable. On [**4-27**], the bolt was removed and the patient was
AOx3 and extubated. His mannitol began to wean on [**4-28**] and he
[**4-29**] his mannitol course. He underwent flexion/extension films
of his cervical spine and this was cleared on [**4-28**] and his
cervical collar removed.
On [**4-29**] he was transferred to the floor after his repeat head CT
was stable. He was AOx3 with an essentially normal exam. ENT was
consulted for persistant small amounts of bloody drainage from
his R ear (he was noted with hemotympanum on admission exam).
They recommended Ciprodex and stict water precautions. He will
follow-up with them as well as with neurosurgery. The patient
was bolused with dilantin on [**4-30**] for a low level and the dose
was increased. He was ambulating, voiding, and eating without
difficulty. He was discharged to home on [**4-30**] with his wife.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: [**2-12**] drops in right
ear Otic twice a day for 10 days.
Disp:*1 bottle* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: No driving while on this medication.
Disp:*30 Tablet(s)* Refills:*0*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diffuse right frontal temporal SAH, along both sylvian fissures,
anterior to pons, fractured right transverse petrous temporal
bones
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
*Because of the bone fractures on the right side of your head;
you must exercise STRICT water precautions to that ear(no
swimming or water to be allowed within the ear, cleaning the
interior of your ear canal, etc) Continue to use the Ciprodex
drops until you are seen in follow up by Dr. [**First Name (STitle) **].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
You also need to follow up with the ENT specialist, Dr. [**First Name (STitle) **].
You will need an audiogram at the time of this appointment.
Please call [**Telephone/Fax (1) 2349**] to schedule your appointment.
Completed by:[**2144-4-30**]
|
[
"801.21",
"305.01",
"780.60",
"801.01",
"385.89",
"E885.9",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.10",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10860, 10866
|
8821, 10164
|
327, 349
|
11043, 11067
|
2163, 8798
|
12648, 13189
|
856, 874
|
10219, 10837
|
10887, 11022
|
10190, 10196
|
11091, 12625
|
903, 1165
|
279, 289
|
377, 767
|
1276, 1880
|
1180, 1260
|
789, 795
|
811, 840
|
1906, 2144
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,080
| 182,585
|
2415
|
Discharge summary
|
report
|
Admission Date: [**2182-2-16**] Discharge Date: [**2182-3-6**]
Date of Birth: [**2098-12-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
EGD
interventional radiology embolization procedure
placement of PICC line
History of Present Illness:
83 yo male with 4 days of BRBPR. The history is obtained mostly
through the niece who is living together with the patient and is
translating. The patient reportedly had about 7 episodes of
diarrhea (unknown amounts) per day since Wednesday. The diarrhea
was watery and bloody. It was bright red blood. The patient went
to dialysis today without mentioning the ongoing BRBPR to his
dialysis team and was dialysed as usual receiving Heparin. He
then after dialysis noticed worsening BRBPR and decided to come
to the ED. The patient is asymptomatic without any
lightheadedness or dizziness. He was also complaining of some
abdominal pain last night, and during the days prior but this
has since improved. The abdominal pain was of crampy character
and mild and it occurred intermittently. It is located in the
LLQ and not radiating. The patient denies hematemesis, nausea or
vomiting.
.
ED course: VS 97.5 77 119/54 18 96% on RA
Pt was found to be hemodynamically stable with a hct drop from
37 five days ago to 23. GI was consulted who did not think a GI
lavage was necessary. A CTA was performed given the possibility
for an aorto-enteric fistula s/p AAA repair in [**2178**]. No
aorto-enteric fistula was found, but diverticulosis without
diverticulitis as well as a moderate right inguinal hernia,
containing loops of non-incarcerated small bowel was found.
Vascular was contact[**Name (NI) **] initially for probablity of aorto-enteric
fistula, but thought that this was very unlikely. On the CT an
incidental finding of a large pleural effusion on the L side was
made which was present on prior studies. GI was contact[**Name (NI) **] and
reportedly is planning to do a non-urgent colonoscopy on Monday,
unless the patient's clinical status changes and more BRBPR is
present. Renal was also notified. 2 U of PRBC were ordered but
were not hung by the time the patient was transferred to the
ICU.
.
ROS: negative for CP, SOB, constipation, f/c/ns, weight loss.
The patient does not produce any urine. Reportedly he has normal
appetite but at times is choking after taking in food.
Past Medical History:
1. ESRD likely d/t HTN
2. HTN
3. AAA repair c/b LLE compartment syndrome
4. BPH
** NOTE: Problem list had contained Liver disease - ?Hep B,
however HepB surface antigen negative in [**2180**]/? NASH - no
evidence supporting this diagnosis. Pt was evaluated in the past
for ascites, but liver ultrasound other wise normal with patent
vasculature. No evidence in our records supporting the diagnosis
of portal HTN and esophageal varices as mentioned on prior dc
summaries.
Social History:
Smoking: no; EthOH: no; drug abuse: no. Cantonese speaking.
Lives with his niece. Ambulatory at baselines with walked.
Independent in washing himself. Food and medications are getting
prepared for him. Not married, no children.
Family History:
no bowel problems, no [**Name2 (NI) 499**] cancer
Physical Exam:
VS T 97.4 BP 122/61 HR 94 RR 20 O2Sat 97 3L
Gen: NAD
HEENT: NC/AT, PERRLA 2>3, dry mm
NECK: no LAD, no JVD, no carotid bruit
COR: mild S1 normal S2, regular rhythm, mild endsystolic murmur
over apex, no r/g
PULM: CTA over R lung field, decreased breath sounds over Left
field about 1/2 up without egophony, no wheezing or rhonchi
ABD: + bowel sounds, soft, mild distended, nt
Skin: warm extremities, no rash, dry skin
EXT: 1+ DP, no edema/c/c,
Neuro: moving all extremities, strength testing limited by
committment, following commands, PERRLA, answering questions
appropriately
Pertinent Results:
EKG: HR 80, left axis, RBBB, left anterior fasicle block,
irrgeular rate, AVB 1st degree, mildly prolonged QT 480. No ST
or TW changes.
.
CT ABDOMEN/PELVIS
.
IMPRESSION:
1. No evidence of aortoenteric fistula.
2. Diverticulosis, without evidence of diverticulitis.
3. Large left pleural effusion, and associated compressive
telectasis. This is incompletely evaluated on this CT of the
abdomen and pelvis only.
4. Moderate right inguinal hernia, containing loops of small
bowel, and fluid, with no evidence of incarceration.
5. Dilated, 12 mm appendix, containing dense material which
appears most consistent with residual contrast from prior
radiological procedure, as dense material is also seen within
several diverticula throughout the [**Name2 (NI) 499**]. No secondary signs of
appendicitis are seen, and clinical context for appendicitis
seems unlikely.
6. Moderate atherosclerotic calcification of the abdominal
aorta, and branches, without focal dilatation or aneurysm.
.
RADIOLOGY Final Report
-59 DISTINCT PROCEDURAL SERVICE [**2182-2-18**] 6:32 PM
IMPRESSION:
1. SMA arteriogram demonstrates an inferior mesenteric artery
with occluded origin and supplied via the middle colic branches
into the left colic artery and superior rectal arteries. No
areas of extravasation of contrast demonstrated at the level of
the splenic flexure, sigmoid and rectum.
2. Active extravasation of contrast at the level of the hepatic
flexure supplied by a branch of the middle colic artery,
successfully embolized with 3 cc of Gelfoam slurry.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2182-2-19**] 3:21 AM
IMPRESSION:
1. Slight decrease in the moderate-to-large left pleural
effusion.
2. Decreased, mild pulmonary edema.
3. Skinfold should not be mistaken for left pneumothorax.
.
RADIOLOGY Final Report
GI BLEEDING STUDY [**2182-2-21**]
IMPRESSION:
No GI bleeding identified.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2182-2-27**] 8:22 AM
COMPARISON: [**2182-2-19**].
As compared to the previous examination, the extent of the
left-sided pleural effusion is minimally decreased. However, the
effusion is also distributed in a different manner given
different patient position. As compared to the previous
examination of [**2182-2-19**], there still is atelectasis of the
left lower lobe and a small right-sided pleural effusion. The
signs of fluid overload have slightly decreased. The visible
parts of the cardiac silhouette are unchanged in size. There are
no parenchymal opacities that have occurred in the meantime.
.
RADIOLOGY Final Report
VIDEO OROPHARYNGEAL SWALLOW [**2182-2-28**] 2:06 PM
VIDEO OROPHARYNGEAL SWALLOW: Study done in conjunction with
speech and swallow division. A teaspoon of honey consistency
barium was administered to the patient under constant video
fluoroscopy. The oral phase was discoordinated with no bolus
propulsion. The pharyngeal phase showed mild delay in swallow
initiation. Laryngeal elevationa nd valve closre were moderately
reduced with severely reduced pharyngeal constrictions. A large
amount of residue was noted in the valleculae and pyriform
sinuses. The pateint aspirated a modereate amount of honey,
which was followed by prolonged coughing and and small amount of
emesis.
IMPRESSION: Aspiration of honey consistency barium.
.
Brief Hospital Course:
LGIB: Pt was hemodynamically stable on admission to th ICU. NG
lavage was deferred in ED. Pt was transfused for goal Hct>30.
Serial hematocrits were trended. Larger bore IVs were placed.
IV PPI [**Hospital1 **] was started. GI was consulted. EGD demonstrated
duodenitis, but no active bleeding. Colonoscopy showed fresh
and clotted blood throughout [**Hospital1 499**] and 10 cm into terminal
ileum. No active bleeding source was identified. GI
recommended tagged RBC scan, which was positive. He was taken
to IR where active extravasation of contrast was seen at the
level of the hepatic flexure supplied by a branch of the middle
colic artery. This was successfully embolized with 3 cc of
Gelfoam slurry. Surgery input was obtained for worry of
ischemia after embolization. Serial lactates remained stable.
Abdominal exam remained reassuring. After embolization, serial
Hcts were followed, and he remained hemodynamically stable. PPI
changed to daily as no UGIB. Pt. transferred to the floor and
3days post embolization had BRBPR --> repeat bleeding scan
negative and hct stable. Pt. had two additional episodes of
~30cc of black liquid stool during the week post embolization.
At present the pt. has had no further evidence of bleeding and
his hematocrit has been stable.
New Atrial Fibrillation: Episode while in ICU. HR in 80-120's.
No history of Afib. Monitored on telemetry. Not anticoagulated
secondary to recent GI bleed. Pt. with episodes of tachy-brady
syndrome [**2182-2-21**] - tachy to 130s and brady to 30s. Cardiology
was contact[**Name (NI) **] - evaluated pt. tele strips and EKGs and it was
felt that his brady episodes occured as the pt. was attempting
to convert back into sinus rhythm. No intervention needed. Pt.
remained HD stable.
ESRD: Renal followed pt throughout hospitalization.
Tues/Thurs/Sat hemodialysis while in hospital.
Coagulopathy: INR increasing initially while in hospital and in
context of NPO. Vitamin K x 1 given. INR has now trended down.
No further intervention needed.
Hypertension: Held antihypertensives in context of GIB. As pt.
not taking POs at present have given prn doses of hydralazine
for SBP>160.
Large pleural effusions: Chronic. Family denied workup in the
past. No respiratory compromise.
Depression/Dementia: Required frequent reorientation. The
patient has been continued on his Zyprexa at 5mg po daily.
? Extrapyramidal disease: patient on Benztropine. No mention in
chart of Parkinsonism or extrapyramidal disease. Pt reports that
it was started for tremor in the context of Zyprexa. Held
Benztropine while in ICU. Have not restarted these medications.
Using Zyprexa sublingual prn.
DELIRIUM: Waxing and [**Doctor Last Name 688**] mental status throughout his
admission, initially with agitation requiring chemical and
physical safety restraint. Was noticed to continually pull at
invasive devices, including pulling out his PICC line. Delirium
slowly improved as sedating medications were weaned.
FEN: Speech and Swallow evaluation completed, and pt failed.
Kept NPO initially. However, after several discussions with
family, the pt was allowed to take po per their request. The
family stated that the patient was eating at his usual baseline
prior to hospitalization, and has never had any documented
episodes of aspiration or aspiration pna. The pt's diet is
pureed solids and honey-thickened liquids, and he should be
assisted with po intake to minimize aspiration risk.
GOALS OF CARE: Multiple meetings were held with the patient's
niece and nephew. They were in agreement that invasive feeding
tube placement was not consistent with what their uncle would
want. Despite multiple speech and swallow evaluations
demonstrating aspiration of oral intake, feeding was attempted
as the patient was able to vocalize that he wanted to eat. He
was able to tolerate pureed solid and thickened liquids, under
supervision, without respiratory compromise or gross aspiration.
Plan was thus to continue oral feeding, with aspiration
precautions, as tolerated.
Code: DNR/DNI, as discussed in detail with the patient's family.
Communication:
[**Name (NI) **] [**Name (NI) 12444**] (Niece and decision maker) [**Telephone/Fax (1) 12445**]
[**Name (NI) **] [**Name (NI) **] (Nephew and decision maker) [**Telephone/Fax (1) 12446**]
Medications on Admission:
Renagel 2400mg tid w/ meals
Renal caps 1 capsule qday
Norvasc 5mg qday
Zyprexa 20mg qday
Benzotropine 0.5-1 qday,
Lorazepam 2mg qam of HD
Docusate prn
Discharge Medications:
1. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Center
Discharge Diagnosis:
lower gastrointestinal bleed
chronic aspiration
Secondary:
- ESRD likely d/t HTN, on dialysis T/T/Sa
- HTN
- AAA repair in [**2178**] c/b LLE compartment syndrome
- Dementia/delirium
- BPH
- Liver disease
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital and treated for your complaint
of blood per rectum. You were seen by the gastroenterology team
as well as the inverventional radiologists. You underwent a
colonscopy and an embolization to control the bleeding from your
[**Year (4 digits) 499**]. You were seen by the nephrology team while here and
underwent your normal course of hemodialysis. The speech and
swallow team were very involved in your care and evaluating your
ability to swallow. Many family meetings were held regarding
your care plan. You are now stable and ready for discharge to a
long term care facility.
You will need to take all medications as instructed.
You will need to keep all follow-up appointments as indicated.
Call your primary care doctor or return to the ED if T>100.5,
chills, nausea, vomiting, chest pain, shortness of breath, blood
per rectum, change in mental status, or any other concern.
Followup Instructions:
You should follow-up with your primary care doctor in the next
1-2 weeks. Please call to arrange an appointment
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"427.31",
"403.91",
"263.9",
"294.8",
"280.0",
"585.6",
"511.9",
"286.9",
"276.0",
"311",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"45.23",
"88.47",
"38.93",
"99.15",
"39.79",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
12057, 12113
|
7286, 11616
|
319, 408
|
12362, 12370
|
3947, 7263
|
13338, 13582
|
3280, 3331
|
11817, 12034
|
12134, 12341
|
11642, 11794
|
12394, 13315
|
3346, 3928
|
274, 281
|
436, 2523
|
2545, 3019
|
3035, 3264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,937
| 104,181
|
20665
|
Discharge summary
|
report
|
Admission Date: [**2198-9-18**] Discharge Date: [**2198-9-20**]
Date of Birth: [**2133-10-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Penicillins / Oxycodone/Apap / Niaspan
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 7677**] is a very pleasant 64 yo woman with CAD s/p recent
CABG ([**7-14**]), PVD (multiple LE stents and CEA), HTN,
hyperlipidemia and hypothyroidism who presented to an OSH with
syncope. She was transferred to [**Hospital1 18**] because of possible
complete heart block noted on EKG.
.
She reports that she awoke with LBP, which is not unusual for
her. After lunch, she became nauseated and diaphoretic and then
vomited. She went to the doctor with her husband, and her
husband's doctor prescribed her a stronger pain medication,
shich she took later in the day. She went to bed early, and then
felt nauseated again, she sat up from bed and then lost
consciousness. When she awoke, she had vomited and been
incontinent of stool. She states 15 minutes passed between when
she had gone to bed and when she woke up, so she could not have
been unconscious for more than a couple of minutes. She called
her sister who lives down the street, and her husband, who was
out bowling. When she awoke, she was not confused, and she had
not bitten her tongue. Her husband then took her to an OSH [**Name (NI) **].
.
In the ED at the OSH, her EKG revealed CHB with a rate in the
30s. She was otherwise hemodynamically stable, with BPs in the
140s-160s/60s-70s. She received a dose of ondansetron in the ED
with good effect. She had a head CT that reportedly did not show
any acute change. She was transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
She denies any chest pain or shortness of breath, but she did
have diaphoresis with her first episode of vomiting after lunch
on the day PTA.
.
On ROS, she has denies any claudicative symptoms. She has a h/o
GI bleed (unknown source requiring 3 units pRBCs) while on
aspirin and clopidogrel ~2 years ago. She denies headache,
cough, hemoptysis, exertional dyspnea, PND, orthopnea, ankle
swelling, palpitations or any prior episodes of syncope.
Carotid U/S [**7-14**]: 40-59% right ICA stenosis. 70-99% left ICA
stenosis
with calcified plaque.
Past Medical History:
OUTPATIENT CARDIOLOGIST: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] [**Telephone/Fax (1) 55203**]
OUTPATIENT PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17369**] [**Telephone/Fax (1) 55204**]
.
CAD 3VD:
CABG, in [**7-14**] anatomy as follows: LIMA to LAD, SVG to DIAG, SVG
to PDA
Coronary angio pre-CABG [**7-14**]: 90% RCA, Diag 70%, and 50% mid LAD
.
PVD s/p lower extremity stents (total of 7)including bilateral
common iliac stenting, right "fem-[**Doctor Last Name **]" bovine patch angioplasty
and stenting
GI Bleed 1.5 year ago with 3 unit transfusion while on Plavix
and ASA- At that time had a normal colonscopy as well as
enteroscopy at [**Hospital1 18**] [**4-12**].
Right carotid endarterectomy [**2193**] at [**Hospital3 **] (note
records from [**Hospital1 **] indicate bilateral CEA's, however patient
denies this)
Carotid angio [**9-/2197**]: 50% subclavian stenosis, 90% carotid
siphon lesion, 60-70% right internal carotid stenosis, less than
50% left internal carotid stenosis, type I aortic arch.
Hyperlipidemia
Hypertension
Recurrent vasovagal syncope
"Lypodystrophy" (decreased fat cell distribution) as a child s/p
plastic surgery with fat flaps transferred from stomach to face
[**Hospital1 756**] and Women??????s)
Peripheral neuropathy
hypothyroidism
bone spurs removed from right arm
total abdominal hysterectomy
hyponatremia
Raynaud's syndrome
Social History:
no history of tobacco use or alcohol abuse
lives with husband
retired [**Name (NI) 22957**] accountant
Family History:
Mother had CHF, brother had MI at age 56 and died of brain
cancer at 58.
Physical Exam:
VS: T 97.6, BP 137/53, HR 41, RR 17, O2 99% on RA
Gen: WDWN woman in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. I-II/VI systolic murmur heard
best at the LUSB
Chest: Well-healed strenal scar. Resp were unlabored, no
accessory muscle use. mild crackles at R base, no wheeze,
rhonchi.
Abd: well-healed infraumbilical scar, soft, NTND, No HSM or
tenderness. + abdominal bruit
Ext: no cyanosis, clubbing or edema, + bilateral femoral bruits.
Pulses:
Right: Carotid 1+ with bruit; Femoral 1+ with bruit; 1+ DP
Left: Carotid 1+ with bruit; Femoral 1+ with bruit; 1+ DP
Pertinent Results:
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] WBC-4.8 RBC-3.92* Hgb-11.5* Hct-33.6*
MCV-86 MCH-29.5 MCHC-34.3 RDW-16.2* Plt Ct-184
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] PT-14.3* PTT-37.3* INR(PT)-1.3*
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] Lupus-NEG
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] Glucose-90 UreaN-17 Creat-0.9 Na-134
K-4.5 Cl-97 HCO3-27 AnGap-15
[**2198-9-18**] 08:55PM [**Month/Day/Year 3143**] CK(CPK)-70
[**2198-9-18**] 08:55PM [**Month/Day/Year 3143**] CK-MB-NotDone cTropnT-<0.01
[**2198-9-18**] 11:19AM [**Month/Day/Year 3143**] CK(CPK)-73
[**2198-9-18**] 11:19AM [**Month/Day/Year 3143**] CK-MB-NotDone cTropnT-<0.01
[**2198-9-18**] 11:19AM [**Month/Day/Year 3143**] TSH-0.24*
.
Lipoprotein a and Anticardiolipin antibody was pending at time
of discharge.
.
EKG from OSH demonstrated junctional bradycardia (? retrograde P
waves on rhythm strip) with a rate in the mid-30s, RBBB, no LVH
or RVH, no ST changes in the lateral, inferior or anterior
leads, normal RWP, early transition.
.
EKG on transfer demonstrated sinus bradycardia at ~42 bpm,
normal axis, normal PR and QTc, wide QRS c/w RBBB, no chamber
abnormalities, no ST segment deviation, isolated TWI in lead II
inferiorly, normal RWP, early transition.
.
Carotid U/S [**7-14**]: 40-59% right ICA stenosis. 70-99% left ICA
stenosis
with calcified plaque.
.
Intra-op TEE [**7-14**]: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
.
CARDIAC CATH performed on [**2198-7-13**] demonstrated:
1. Selective coronary angiography of this right dominant system
revealed diffuse calcification thorughout the coronary arteries.
There was a flow-limiting 90% ostial RCA stenosis as well as
moderate diffuse disease in the dominant rca vessel. There was
diffuse mild disease in a heavily-calcificed left coronary
system. There was a dual LAD with the larger diagonal system
having a 70% lesion at a bifurcation. The LCX had < 50%
proximal disease. There were faint left-->right collaterals
evident.
2. Hemodynamic evaluation revealed normal systolic pressure and
normal LVEDP.
3. Abdominal aortogram with runoff was performed given the
patient's extensive history of PVD and revealed moderate
diffuse, heavily calcified vessels but no evidence of critical
flow-limiting stenosis was apparent. There was evidence of
moderate in-stent restenosis in the right leg.
Brief Hospital Course:
ASSESSMENT: 64 yo woman with CAD s/p recent CABG, PAD s/p
multiple LE stent implantations and R CEA, HTN, hyperlipidemia
presented to OSH ED with syncope with possible complete heart
block. Transferred to [**Hospital1 18**] for pacemaker evaluation.
.
## Cardiac:
- Rhythm: Initial EKG had retrograde P waves in the rhythm
strip and there was a question as to whether she had CHB vs
atrial asystole. Etiology unclear, but most likely is idiopathic
progressive conduction disease. Other possible etiology include
acute ischemia, especially given nausea, diaphoresis, but
without evidence of ischemia on EKG and negative enzymes. The
team also considered hypothyroidism, but her dose of
levothyroxine appears to be appropriate given that her TSH was
at the low end of the normal range. Alternatively, she could
have had increased vagal tone in the setting of nausea and
vomiting. She described taking indomethacin and tramadol for
back pain prior to her episode, and she was advised to avoid
these medications. Metoprolol likely contributed as well.
.
Initially, nodal blocking agents were held and the patient was
monitored on telemetry with transcutaneous pacer pads. Although
she did have some 2 second pauses on telemetry the morning she
was admitted, she continued to be in Normal Sinus Rhythm for >
24 hours prior to discharge. Electrophysiology was consulted
and felt that she had sinus dysfunction. Her beta blocker was
restarted at her home dose, which she tolerated well without any
bradycardic episodes for >24 hours. She was sent home and will
have a Lifewatch cardiac monitor delivered to her house within
24 hours of discharge. She will have follow-up with
electrophysiology (Dr. [**Last Name (STitle) **] at [**Hospital1 18**] on [**10-23**].
.
- Ischemia: Patient had a recent CABG and her EKG did not show
new ischemic changes. Her cardiac enzymes were followed and
remained normal, so it was not felt that her symptoms had
resulted from a new ischemic event.
.
- Pump: normal LV function on intra-op TEE [**7-14**].
.
## Syncope: It was unclear whether the patient had a vasovagal
episode from her nausea or whether this represented symptomatic
bradycardia. She did not have any further episodes of syncope
or presyncope during her hospitalization.
.
## HTN: The team initially held [**Month/Year (2) **] pressure medications given
her recent syncopal episode. After she was restarted on
metoprolol 25 po bid, her [**Month/Year (2) **] pressure was at goal (110s to
120s systolic) without her amlodipine or spironolactone. In
addition, her potassium remained normal. Thus, at the time of
discharge, she was instructed not to continue the amlodipine or
spironolactone unless these were restarted by her outpatient
cardiologist or PCP.
.
## PVD: This was notable for the absence of typical risk
factors, including smoking or diabetes. Lupus anticoagulant was
negative. Lipoprotein a and anticardiolipin antibodies were
sent and were pending at the time of discharge.
Medications on Admission:
ALLERGIES: Iodine / Penicillins / Oxycodone/Apap / Niaspan, IV
dye
.
Metoprolol 25 [**Hospital1 **]
Amlodipine 2.5 daily
Spironolactone 12.5 qTuesday, Thursday
Irbesartan 300 daily
Pravastatin 80 daily
Aspirin 81 daily
Levothyroxine 100 daily
Pantoprazole 40 daily
Ferrous sulfate 325 daily
Vitamin C 500 daily
Risedronate 35 weekly
Cetirizine (Zyrtec) 10 daily
Fluticasone nasal 1 spray daily
Calcium/Vit D
Fish oil
Discharge Medications:
1. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
2. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
spray Nasal once a day.
12. Fish Oil Capsule Sig: [**1-9**] Capsules PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Syncope
Secondary Diagnoses: Sinus dysfunction with bradycardia,
Coronary Artery Disease, Hypertension
Discharge Condition:
Patient was stable, she had been monitored on telemetry without
any bradycardia for > 24 hours. She had no further syncopal
episodes. She was provided with a cardiac 'lifewatch' monitor
that will be delivered to her home within 24 hours.
Discharge Instructions:
You were admitted with a syncopal episode (meaning you fell and
lost consciousness briefly). You were evaluated for a slow
heart rate sometimes referred to as "sick sinus syndrome,"
meaning that the heart's natural pacemaker was firing slowly.
You were monitored closely and had no further events after you
were admitted. Electrophysiology did not advise placing a
pacemaker at this time.
1. Please take all medications as prescribed. Please avoid
taking indomethacin or tramadol as advised by electrophysiology.
Your norvasc (amlodipine) was stopped because your [**Month/Day (2) **]
pressures were at goal without it, and your spironolactone was
stopped because your potassium and [**Month/Day (2) **] pressure were good
without it. Your cardiologist can restart these medications if
appropriate at your follow-up visit.
2. Please attend all follow-up appointments as listed below.
3. Please call your doctor or return to the hospital if you have
chest pain, shortness of breath, palpitations, another episode
when you pass out, or any other concerning symptom.
Followup Instructions:
1. Dr. [**Last Name (STitle) 10543**], your cardiologist, next week.
2. Electrophysiology, Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.
Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2198-10-23**] 3:00. [**Location (un) 436**] of [**Hospital Ward Name 23**]
Center.
3. Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17369**], in early [**Month (only) **].
Completed by:[**2198-9-20**]
|
[
"276.1",
"V12.51",
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"414.00",
"272.4",
"518.81",
"244.9",
"443.9",
"426.0",
"V45.81",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12269, 12275
|
7837, 10838
|
317, 324
|
12441, 12683
|
4886, 7814
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|
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12296, 12296
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10864, 11283
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4044, 4867
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12344, 12420
|
270, 279
|
352, 2380
|
12315, 12323
|
2402, 3818
|
3834, 3939
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,101
| 123,718
|
46126
|
Discharge summary
|
report
|
Admission Date: [**2123-7-29**] Discharge Date: [**2123-9-6**]
Date of Birth: [**2069-5-9**] Sex: M
Service:
CHIEF COMPLAINT: Lower extremity edema and congestive heart
failure.
HISTORY OF PRESENT ILLNESS: This is a 54 year old gentleman
with coronary artery disease, status post inferior myocardial
infarction, congestive heart failure and ejection fraction of
30%. Automatic implanted cardioverter defibrillator,
question of constrictive cardiac physiology, Hodgkin's
disease, status post radiation therapy, hypothyroidism, and
hypercholesterolemia. The patient was also noted to have an
increase in weight of approximately 20 lb over the last month
as well as increasing fatigue and pedal edema. His Lasix was
initially increased to 80 mg from 40 mg q.d. but did not help
with the increasing lower extremity pitting edema.
PAST MEDICAL HISTORY: The patient's past medical history
includes coronary artery disease, status post inferior
myocardial infarct in [**2115**] complicated by left ventricular
thrombus and embolic cerebrovascular accident, status post
stent of the left circumflex coronary artery in [**2123-4-1**],
congestive heart failure with mitral and tricuspid
regurgitation, automatic implanted cardioverter defibrillator
placed in [**2123-4-1**] for inducible ventricular tachycardia,
history of superficial femoral artery thrombosis, Hodgkin's
disease diagnosed at the age of 27, status post mantle
radiation therapy and splenectomy, hypercholesterolemia,
cervical discectomy requiring five days of postoperative
intubation and hypothyroidism.
PREOPERATIVE MEDICATIONS:
1. Synthroid 0.125 mcg q. AM
2. Lasix 80 mg q. AM
3. Captopril 12.5 mg t.i.d.
4. Lipitor 10 mg p. QM
5. Carvedilol .125 mg b.i.d.
ALLERGIES: No known drug allergies
PHYSICAL EXAMINATION: Initial blood pressure was 110/60,
heartrate 70, respiratory rate 16, 98% on room air. General:
He was awake and alert in no acute distress. Head, eyes,
ears, nose and throat: He was pupils are equal, round, and
reactive to light, extraocular muscles intact. Mouth and
oropharynx were clear without exudates or erythema.
Jugulovenous distension to upper jaw. Neck was supple, no
left axis deviation or masses. Heart: Regular rate and
rhythm, normal S1 and S2, 3 to 4 tricuspid regurgitation and
2 to 4 mitral regurgitation radiation to axilla. Pulmonary
clear to auscultation bilaterally. Abdomen was distended,
soft, nontender, good bowel sounds. Scrotal edema and Foley
catheter was in place at the time of physical. Extremities:
+3 pitting edema bilaterally. Neurological was alert and
oriented times three, no focal neurological defects.
LABORATORY DATA: Initial labs included a white blood cell
count of 7.1, hematocrit of 33.9, sodium 128, potassium 4.8,
chloride 92, and carbon dioxide of 28. A BUN was 36,
creatinine .1.
HOSPITAL COURSE: The patient from admission until [**2123-8-9**] was under the care of Cardiology and was managed for
cardiovascular and current heme but also for the other
aspects of this past medical history. On [**8-9**],
cardiothoracic surgery felt that the patient was ready for
surgery and explained to the patient that the surgery would
be high risk. The patient understood and wished to proceed
with the surgery.
On examination for surgery, the patient was found to have
massive edema, lower legs greater than the upper extremities
and was found to have a III to IV systolic murmur and on
transthoracic echocardiogram was found to have +3 mitral
regurgitation and +4 tricuspid regurgitation. At
catheterization the patient was found to have a 35% ejection
fraction, 3+ mitral regurgitation and constrictive
physiology. The surgical plan was to repair the tricuspid
valve and the mitral valve and perform pericardiectomy.
On [**8-10**], the patient was brought to the Operating Room and
a mitral valve replacement and tricuspid valve replacement
was performed using a 31 mm St. Jude valve for the mitral
valve and a 33 mm St. Jude valve for the tricuspid. A
pericardiectomy was also performed. The patient was then
admitted to the Coronary Intensive Care Unit with the
pericardium left open. On [**8-13**], the patient was operated
on to close the chest wall. Anesthesia was general and the
patient tolerated the procedure well. Postoperatively the
patient continued to be intubated and on [**8-14**],
electrophysiology was consulted to manage the heart pacing.
The patient continued postoperatively to be intubated and on
[**8-17**] had a right internal jugular vein cordis changed over
wire to the triple lumen catheter. The patient tolerated the
procedure well with good blood return of all ports and the
line tips of the previous line sent for cultures.
On [**8-18**], the patient had a transesophageal echocardiogram
for atrial tachycardia, atrial flutter, question of atrial
thrombus and findings concluded no atrial thrombus and the
patient wire is seen in the right atrium. On [**8-25**], the
patient returned to the Operating Room for tracheostomy and a
percutaneous endoscopic gastrostomy tube placement. The
patient tolerated the procedures well and was returned back
to the Cardiac Intensive Care Unit. The patient continued to
be intubated and on [**8-31**], was transferred to the Stepdown
Unit on [**Hospital Ward Name 121**] 6. The patient at that point was then switched
from Heparin to Coumadin and the PTT, PT/INR continued to be
monitored. On [**9-1**], the patient was evaluated for
pulmonary congestion in which a culture was sent. On [**9-2**], the patient was evaluated for discharge planning. On
[**9-3**], the sputum cultures came back as
Methicillin-resistant Staphylococcus aureus positive and the
patient was started on a course of Vancomycin 1 mg q.d. On
[**9-5**], the patient was re-evaluated for discharge on
[**9-6**] to [**Hospital1 **] Rehabilitation Center.
The discharge physical were vital signs with temperature
maximum of 96.9, heartrate 79, respiratory rate 20, 100% SAO2
on 30% tracheostomy, blood pressure was 105/58, intakes for
the day were 1800, output included urine output of 1,000 and
chest tube of 280. The patient's physical therapy level was
roughly 1. The patient was alert and oriented with no acute
distress. Cardiovascularly, he was regular rate and rhythm
with no murmurs appreciated. Respiratory rate was clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended with positive bowel sounds. Percutaneous
endoscopic gastrostomy tube was in place. Extremities had no
peripheral edema with slight swelling. Incision for the
chest tube and the percutaneous endoscopic gastrostomy were
intact, clean and dry.
On [**9-5**], he had a PT of 14.2, PTT of 61.2 and INR of 1.3.
DISCHARGE MEDICATIONS:
1. Albuterol metered dose inhaler 2 puffs q. 6 hours prn
2. Coumadin 7.5 mg p.o. q.d. Check PT/PTT q.d.
3. Amiodarone 400 mg per gastrostomy q.d.
4. Miconazole powder to skin folds b.i.d.
5. Nystatin S/S p.o. b.i.d.
6. Synthroid 0.125 mg via percutaneous endoscopic
gastrostomy q.d.
7. Captopril 6.25 mg per percutaneous endoscopic gastrostomy
t.i.d., hold for systemic blood pressure less than 90
8. Fleets enema p.r. q.d. prn
9. Anusol cream t.i.d. prn
10. Bicitra 30 ml per percutaneous endoscopic gastrostomy
t.i.d.
11. Heparin drip titrated for a PTT between 60 and 80 until
the INR is greater than 2.5 and then discontinue. Heparin
levels at discharge were 600 units/hr check PT/PTT q.d.
12. Zantac 150 mg p.o. q.d.
13. Vancomycin 1 gm b.i.d. times ten days
14. Tylenol 650 mg per percutaneous endoscopic gastrostomy q.
6 hours prn
CONDITION ON DISCHARGE: Fair but with tracheostomy,
percutaneous endoscopic gastrostomy tube and
Methicillin-resistant Staphylococcus aureus positive sputum.
Significant events or complications during the stay included
prolonged intubation, percutaneous endoscopic gastrostomy
tube and tracheostomy on [**8-25**], Methicillin-resistant
Staphylococcus aureus sputum on [**9-3**] treated with
Vancomycin.
PRIMARY DISCHARGE DIAGNOSIS:
1. Mitral valve replacement and tricuspid valve replacement
SECONDARY DIAGNOSIS:
1. Coronary artery disease
2. Status post myocardial infarction
3. Congestive heart failure
4. Automatic implanted cardioverter defibrillator placement
in [**2123-4-1**]
5. History of superficial femoral artery thrombosis
6. Hodgkin's disease diagnosed at age 27
7. Hypercholesterolemia
8. Hypothyroidism
DISPOSITION: Staff facility location is [**Hospital1 21979**]. Contact person is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 98131**], Pager #[**Telephone/Fax (1) 98132**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 33068**]
MEDQUIST36
D: [**2123-9-5**] 18:18
T: [**2123-9-5**] 19:30
JOB#: [**Job Number 98133**]
|
[
"041.11",
"V09.0",
"428.0",
"518.5",
"423.2",
"571.5",
"397.0",
"998.11",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"39.61",
"96.6",
"34.79",
"96.72",
"43.11",
"35.28",
"35.24",
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
6767, 7617
|
8051, 8113
|
2877, 6744
|
1618, 1791
|
1814, 2859
|
147, 200
|
229, 853
|
8134, 8906
|
876, 1592
|
7642, 8030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,206
| 193,437
|
12087+56328
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-4-24**] Discharge Date: [**2199-5-23**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
bradycardia, hypothermia
Major Surgical or Invasive Procedure:
.
None
History of Present Illness:
84 yo man with HTN, DM, CVA, COPD, and recent admission for ESBL
Klebsiella UTI treated with ertapenem who presented to [**Hospital 37895**] ED with history of recurrent falls. Patient had been
having recurrent falls for the past 2 days and was found on the
day of admission by the family to have fallen on the floor. He
was brought to [**Hospital 1263**] hospital ED, where he was felt to be
lethargic. Initial vitals at OSH were BP 145/64, P 86, R:16, and
the first noted temperature at 16:45 was 97.0, with a heart rate
of 43 at that time. Given the fall, CT Head and C-spine were
performed and were unremarkable as detailed below. He was then
transferred here because he gets most of his care at [**Hospital1 18**].
.
Patient's daughter accompanies him and provides most of the
history. Daughter's ex-husband had noted patient had been having
increased falls throughout the day. She also reports that
patient had [**4-21**] loose, voluminous bowel movements the day prior
to admission, which was very unusual for him. He had been
running to the bathroom and had been unable to make it on time a
few times. The daughter's ex-husband later heard a thud and
found the patient on the floor and brought him to the hospital.
The diarrhea was not noted to be bloody or contain mucous.
Patient recently completed a course of ertapenem for ESBL
Klebsiella UTI at [**Hospital1 18**]. He denied any fevers or chills, or any
other localizing complaints prior to ED visit.
.
In the ED here, initial vitals were HR 42, BP:119/42, RR:11,
O2Sat 97%. Temperature taken at 19:30 was 32.2. A warming
blanket was placed. Over the next 3 hours, temperature rose to
35.8 and heart rate rose to mid-60s. CT Abdomen was performed
because patient complained of abdmoinal pain and there was
concern for sepsis given hypothermia. This did not reveal any
infectious process. He received 500mg metronidazole empirically.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, 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:
#. Peripheral vascular disease - s/p amputation of 2-4th digit
[**2199-12-29**]:[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **].
#. Diabetes Mellitus
#. Encephalomalacia of the frontal and temporal lobes
#. H/o CVA
#. Hypertension
#. Hypercholesterolemia
#. H/o syncope and near syncope
#. COPD: no on home O2, no PFTs available
#. Penile Prosthesis
#. Chronic Renal Disease: baseline creatinine 1.8-2.1
#. Anemia: for 1 yr, prior HCT 40
#. Homocysteine: 29
#. h/o large axial hernia
Social History:
Denies alcohol, smoking, or illicit drug use. Lives at home with
daughter and son-in-law as well as grandson.
Family History:
Non contributory
Physical Exam:
Vitals: T:96.8 BP:113/49 HR:69 RR:20 O2Sat: 100% on 2LNC
GEN: Well-appearing, NAD
HEENT: EOMI, surgical pupil, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Coarse breath sounds bilaterally
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: Right foot with toe amputations, 1+ peripheral oedema.
NEURO: alert, oriented to "[**Hospital **] hospital", daughter's name,
but not anything else, which per daughter is better than
baseline. CN II ?????? XII grossly intact. Moves all 4 extremities.
SKIN: Stasis dermatitis in lower extremities.
Pertinent Results:
[**2199-4-24**] 06:10PM WBC-5.3 RBC-3.54* HGB-9.4* HCT-30.2* MCV-85
MCH-26.5* MCHC-31.1 RDW-13.8
[**2199-4-24**] 06:10PM TSH-2.8
[**2199-4-24**] 06:10PM GLUCOSE-107* UREA N-86* CREAT-2.5* SODIUM-144
POTASSIUM-5.0 CHLORIDE-112* TOTAL CO2-20* ANION GAP-17
[**2199-4-24**] 06:10PM ALT(SGPT)-37 AST(SGOT)-55* CK(CPK)-320* ALK
PHOS-72 AMYLASE-105* TOT BILI-0.2
[**2199-4-24**] 06:10PM PT-15.7* PTT-34.6 INR(PT)-1.4*
.
ECG: Sinus bradycardiaat 41 bpm, normal axis, first-degree AV
conduction delay, LBBB, ST-segments and T-waves much slower rate
compared to [**2199-4-7**].
.
Imaging:
Head CT on [**2199-4-24**] at [**Hospital3 3383**] Hospital
No intraparenchmal or extraaxial hematoma. Left frontal
encephalomalacia, c/w pervious contusion or infarction.
PRevious left thalamic lacunar infarction. Diffuse ventricular
dilatation and widening of cortical sulci. Periventricular
hypodensity c/w microangiopathy. No acute hemorrhage or
infarction noted.
.
CT C-spine on [**2199-4-24**] at [**Hospital3 3383**]: No acute fracture.
.
[**2199-4-24**] CXR:
FINDINGS: Portable AP upright chest radiograph is obtained. A
large rounded density is again noted overlying the right lung
base which is seen on multiple prior chest radiographs and
thought to represent hiatal hernia. The lungs appear essentially
clear bilaterally and no evidence of pneumonia is appreciated.
No pleural effusions or evidence of CHF. The heart size is
normal. Mediastinal contour is unremarkable. There is no
pneumothorax. The visualized osseous structures are
unremarkable.
.
[**2199-5-9**] EEG:
This is a likely normal routine EEG in the waking and
drowsy states. There were no areas of prominent focal slowing
and there
were no epileptiform features. Of note, portions of the study
were
obscured by electrode or movement artifact and the patient
aborted the
study prematurely.
Brief Hospital Course:
84 year-old male with a history of HTN, DM, CVA, COPD, PVD, and
recent admission for ESBL Klebsiella UTI who initially presented
with bradycardia, hypothermia and abdominal pain. The following
issues were investigated during this hospitalization:
.
# Hypothermic, bradycardiac, unresponsive episodes - Pt's
initial presentation with this symptom constallation was
concerning for sepsis. Because this resolved quickly with
conservative measures, it did not appear that the pt was
infected. Following his initial course in the MICU, the pt' was
called out to the general medical floor where he had two
recurrent episodes (bradycardia, hypothermia, unresponsive, mild
hypotension with SBP to 90s and salivation). Given this, the Ddx
was expanded. An EEG was obtained which did not show evidence of
seizure activity. The pt's antihypertensive regimen was scaled
back significantly. Thyroid studies were unremarkable. It
remains unclear what caused these abnormalities, though they
resolved early into the hospital course and did not recur.
.
# Candidemia: Felt to be nosocomial. Ophthalmologic exam was
unremarkable. CT abdomen to evaluate the spleen and liver for
abscesses were unremarkable. Cultures eventually grew [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**] and patient received a total of 12 days of Caspofungin
prior to discharge from the hospital. This was continued for 2
additional days to complete a 14 day course on discharge.
.
# UTI: Cultures revealed VRE and patient completed a 7 day
course of Linezolid.
.
# Acute on Chronic Renal Failure: Thought most likely pre-renal
secondary to diarrhea. Creatinine remains moderately up from
baseline, but stable.
.
# Question LE vascular insufficieny: The pt was followed by the
vascular service while in house; LE arterial studies showed some
obstruction and he will f/u with vascular as an outpt.
.
# Anemia: Iron studies c/w mixed picture. Fe and B12 repletion
were continued. Consideration was given to epogen, though this
was deferred to a later time given the multiple ongoing medical
issues.
.
# H/o CVA: No acute issues during this hospitalization. ASA
325mg and simvastatin 20mg were continued.
.
# Psych: The pt was continued on his home doses of donepezil and
olanzapine.
.
# DM: Diet controlled, but maintained on Insulin sliding scale
while in-house, given infections.
Medications on Admission:
#. Ertapenem 1 gram from [**0-0-**]
#. Doxycycline 100mg [**Hospital1 **] for 5 days
#. Docusate 100mg [**Hospital1 **]
#. Donepezil 5mg qHS
#. Olanzapine 2.5mg qHS
#. Albuterol Nebs q6H PRN
#. Ipratropium Bromide Nebs q6H PRN
#. Simvastatin 20mg qHS
#. Aspirin 325mg daily
#. Cyanocobalamin 100mcg daily
#. Furosemide 40mg daily
#. Norvasc 10mg daily
#. FerrouSul 325mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
15. Caspofungin 70 mg Recon Soln Sig: 50 mg Intravenous Q24H
(every 24 hours) for 2 days.
16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Twenty (20) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10 mL of NS followed by Heparin flush, daily. .
17. Insulin
Continue Insulin sliding scale per scale provided.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary
#. Junctional Bradycardia
#. Candidemia
#. UTI (VRE)
.
Secondary
#. Peripheral vascular disease - s/p amputation of 2-4th digit
[**2199-12-29**]:[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **].
#. Diabetes Mellitus
#. Encephalomalacia of the frontal and temporal lobes
#. H/o CVA
#. Hypertension
#. Hypercholesterolemia
#. COPD: no on home O2, no PFTs available
#. Penile Prosthesis
#. Chronic Renal Disease: baseline creatinine 1.8-2.1
#. Anemia
Discharge Condition:
Stable
Discharge Instructions:
You were seen and evaluated for multiple medical problems to
include hypothermia (cold body temperature) and bradycardia
(slow heart rate) and later fungal infection in your blood and
recurrent urinary tract infections. These medical issues are now
stable and you are being discharged to a rehabilitation facility
for continued care.
Take all of your medications as directed.
Keep all of your follow-up appointments.
Call your doctor or go to the OR for any of the following: chest
pain, shortness of breath, fevers/chills, nausea/vomiting or any
other concerning symptoms.
Followup Instructions:
Call your primary care physician for [**Name9 (PRE) 702**] in [**5-22**] days.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Name: [**Known lastname 6855**],[**Known firstname 2636**] Unit No: [**Numeric Identifier 6856**]
Admission Date: [**2199-4-24**] Discharge Date: [**2199-5-23**]
Date of Birth: [**2114-6-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4483**]
Addendum:
Correction to patient's Caspofungin regimen: Patient will need
an additional 6 days of Caspofungin upon discharge for a total
of 14 days treatment. Antifungal coverage began on [**5-15**]. [**Hospital 6857**] notified on [**2199-5-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 42**]
[**Name6 (MD) 77**] [**Name8 (MD) **] MD [**MD Number(1) 4484**]
Completed by:[**2199-5-24**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
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8222, 8614
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10828, 11407
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3272, 3933
|
179, 205
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280, 2537
|
2559, 3095
|
3111, 3223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,190
| 149,656
|
5385
|
Discharge summary
|
report
|
Admission Date: [**2107-8-13**] Discharge Date: [**2107-8-26**]
Date of Birth: [**2045-12-2**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
intubation
renal artery angiography
History of Present Illness:
61 yo male with a PMH for Acid reflux, TIIDM, HTN, s/p
nephrectomy following RCC diagnosis, ESRD with dialysis 3x/week,
and s/p cadaveric kidney transplant after lone kidney became
dialysis dependent and stopped functioning well, who comes in
complaining of CP. He was last well 3 days PTA when lifting
heavy trash right after lunch at work when he felt acute chest
pain that was burning in nature in his sternum that radiated to
his back. It was severe in nature and was relieved with rest
after 30 minutes. He did feel some SOB with this episode and
does not remember how long it lasted for.
He had no pain the following day and then 1 day PTA the same
pain returned while watching TV and after eating spicy food.
This time the pain lasted for 30 minutes and was relieved by
burping and drinking gingerale and milk. The pain retuned this
morning without eating and was again relieved by drinking milk.
The pain this morning was not as severe as times before.
Of note, he states that he does not experience any exercise
chest pain and is on his feet and walking all day without
problem. If he walks uphill he does get short of breath but
otherwise does not feel limited by his lung capacity.
.
In the ED, initial vs were: T 98 P 85 BP171/83 R 16 O2 97 sat.on
RA Patient had an EKG that showed no change from previous EKGs
and a normal chest x-ray.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea, dysphagia
or congestion. Denies cough, chest tightness, or palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
DM2
ESRD s/p cadaveric renal transplant in [**8-8**]
renal transplant artery stenosis s/p dilatation/stent in [**8-8**]
hemolysis with unknown etiology ([**1-11**])
ciguatera intoxication ([**4-9**])
Barrett's esophagus ([**12-7**])
asthma
RCC s/p L nephrectomy ('[**93**])
obstructive sleep apnea
s/p AV graft on LUE and AV fistula RLE
hypercalcemia
Social History:
Married with 7 children. Originally born in [**Country **] and moved to
the U.S. in [**2078**]. Currently works as a cook at [**Hospital1 18**] and is
planning on retiring over the next couple of years. Last travel
was in [**Month (only) 1096**] to [**Country **]. Former smoker-quit 20 yrs ago.
Denies alcohol or IVDU.
Family History:
Mother and 3 uncles died of "kidney disease." Otherwise all 8 of
his siblings are healthy.
Physical Exam:
Vitals: T:96.1 BP:146/54 P:82 R:18 O2:98RA
General: Alert and oreinted obese African American male in no
acute distress
HEENT: Scar in right eye from childhood injury, sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, crescendo-decrescendo murmur heard best in the aortic
valve distribution
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, non pitting mild edema
bilaterally in feet, no C/E
Skin: W+M, no rash, petichiae, or echymosis
Neuro:CN II-XII grossly intact
motor: [**5-10**] throughout
Sensation: Intact to light touch throughout
DTR: 2+ biceps bilaterally
Coordination: Intact to rapid alternating movements and
finger-to-nose
Pertinent Results:
[**2107-8-13**] 11:00AM BLOOD WBC-4.2 RBC-3.55* Hgb-9.6* Hct-32.4*
MCV-91 MCH-27.0 MCHC-29.6* RDW-12.7 Plt Ct-177
[**2107-8-14**] 06:05AM BLOOD WBC-4.9 RBC-3.22* Hgb-9.1* Hct-29.0*
MCV-90 MCH-28.3 MCHC-31.4 RDW-13.5 Plt Ct-170
[**2107-8-15**] 05:10AM BLOOD WBC-5.7 RBC-3.19* Hgb-8.8* Hct-29.1*
MCV-91 MCH-27.7 MCHC-30.4* RDW-12.9 Plt Ct-167
[**2107-8-24**] 03:35AM BLOOD WBC-10.2 RBC-3.03* Hgb-8.4* Hct-28.2*
MCV-93 MCH-27.6 MCHC-29.6* RDW-12.5 Plt Ct-179
[**2107-8-25**] 03:35AM BLOOD WBC-6.1 RBC-2.76* Hgb-7.4* Hct-25.6*
MCV-93 MCH-26.8* MCHC-29.0* RDW-13.3 Plt Ct-190
[**2107-8-26**] 05:00AM BLOOD WBC-5.0 RBC-2.87* Hgb-7.7* Hct-26.6*
MCV-93 MCH-26.8* MCHC-28.9* RDW-12.4 Plt Ct-190
[**2107-8-13**] 11:00AM BLOOD Neuts-71.8* Lymphs-20.4 Monos-6.4 Eos-1.2
Baso-0.2
[**2107-8-24**] 03:35AM BLOOD Neuts-82.5* Lymphs-11.8* Monos-3.9
Eos-1.6 Baso-0.2
[**2107-8-13**] 11:00AM BLOOD PT-13.1 PTT-28.5 INR(PT)-1.1
[**2107-8-26**] 05:00AM BLOOD PT-12.6 PTT-27.5 INR(PT)-1.1
[**2107-8-13**] 11:00AM BLOOD Glucose-221* UreaN-59* Creat-4.5*# Na-140
K-3.8 Cl-102 HCO3-27 AnGap-15
[**2107-8-13**] 08:50PM BLOOD Glucose-250* UreaN-60* Creat-4.6* Na-140
K-3.9 Cl-102 HCO3-28 AnGap-14
[**2107-8-14**] 06:05AM BLOOD Glucose-81 UreaN-60* Creat-4.7* Na-144
K-3.6 Cl-107 HCO3-27 AnGap-14
[**2107-8-18**] 06:15AM BLOOD Glucose-137* UreaN-70* Creat-5.5* Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
[**2107-8-19**] 05:15AM BLOOD Glucose-56* UreaN-72* Creat-5.5* Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
[**2107-8-22**] 06:20AM BLOOD Glucose-126* UreaN-51* Creat-3.6* Na-143
K-3.6 Cl-103 HCO3-29 AnGap-15
[**2107-8-23**] 10:21AM BLOOD Glucose-134* UreaN-42* Creat-3.3* Na-143
K-3.6 Cl-105 HCO3-29 AnGap-13
[**2107-8-23**] 05:24PM BLOOD Glucose-126* UreaN-43* Creat-3.4* Na-141
K-4.4 Cl-102 HCO3-31 AnGap-12
[**2107-8-24**] 03:35AM BLOOD Glucose-132* UreaN-46* Creat-3.8* Na-141
K-4.5 Cl-104 HCO3-33* AnGap-9
[**2107-8-25**] 03:35AM BLOOD Glucose-81 UreaN-51* Creat-4.3* Na-142
K-4.4 Cl-104 HCO3-31 AnGap-11
[**2107-8-26**] 05:00AM BLOOD Glucose-58* UreaN-57* Creat-4.1* Na-144
K-4.5 Cl-105 HCO3-30 AnGap-14
[**2107-8-16**] 05:15AM BLOOD ALT-12 AST-13 LD(LDH)-152 AlkPhos-92
TotBili-0.6
[**2107-8-24**] 03:35AM BLOOD LD(LDH)-178 TotBili-0.9
[**2107-8-26**] 05:00AM BLOOD ALT-9 AST-14 AlkPhos-82 TotBili-0.8
[**2107-8-13**] 11:00AM BLOOD cTropnT-0.05*
[**2107-8-13**] 08:50PM BLOOD CK-MB-6 cTropnT-0.03*
[**2107-8-14**] 06:05AM BLOOD CK-MB-6 cTropnT-0.05*
[**2107-8-19**] 06:45PM BLOOD CK-MB-8 cTropnT-0.06*
[**2107-8-15**] 05:10AM BLOOD Calcium-10.0 Phos-3.8# Mg-2.5
[**2107-8-16**] 05:15AM BLOOD Albumin-3.7 Calcium-9.9 Phos-4.5 Mg-2.6
[**2107-8-17**] 05:50AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.6
[**2107-8-23**] 05:24PM BLOOD Calcium-10.5* Phos-3.4 Mg-2.2
[**2107-8-24**] 03:35AM BLOOD Calcium-10.3* Phos-4.6* Mg-2.1
[**2107-8-25**] 03:35AM BLOOD Calcium-10.7* Phos-4.8* Mg-2.4
[**2107-8-26**] 05:00AM BLOOD Calcium-10.7* Phos-3.4 Mg-2.8*
[**2107-8-25**] 12:58PM BLOOD calTIBC-192* Ferritn-572* TRF-148*
[**2107-8-25**] 12:58PM BLOOD PTH-355*
[**2107-8-16**] 11:32PM BLOOD Type-[**Last Name (un) **] pO2-148* pCO2-57* pH-7.30*
calTCO2-29 Base XS-0
[**2107-8-17**] 08:27PM BLOOD Type-[**Last Name (un) **] pO2-232* pCO2-53* pH-7.28*
calTCO2-26 Base XS--2
[**2107-8-23**] 12:20PM BLOOD Type-ART Temp-36.5 Rates-/26 PEEP-5
FiO2-50 pO2-81* pCO2-85* pH-7.22* calTCO2-37* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2107-8-23**] 12:56PM BLOOD Type-ART Temp-36.5 Rates-/28 PEEP-12
FiO2-100 pO2-130* pCO2-104* pH-7.14* calTCO2-38* Base XS-2
AADO2-499 REQ O2-82 Vent-SPONTANEOU
[**2107-8-23**] 01:32PM BLOOD Type-ART pO2-266* pCO2-68* pH-7.26*
calTCO2-32* Base XS-1
[**2107-8-23**] 03:12PM BLOOD Type-ART Temp-36.9 Rates-/12 PEEP-12
pO2-70* pCO2-70* pH-7.27* calTCO2-34* Base XS-2 Intubat-NOT
[**Month/Day/Year **]
[**2107-8-23**] 05:38PM BLOOD Type-ART Temp-37.7 Rates-/30 PEEP-12
pO2-70* pCO2-76* pH-7.25* calTCO2-35* Base XS-2 Intubat-NOT
[**Month/Day/Year **]
[**2107-8-23**] 08:34PM BLOOD Type-ART pO2-88 pCO2-68* pH-7.29*
calTCO2-34* Base XS-3
[**2107-8-24**] 03:18PM BLOOD Type-ART Temp-36.9 Rates-/18 Tidal V-50
pO2-78* pCO2-67* pH-7.29* calTCO2-34* Base XS-2 Intubat-NOT
[**Month/Day/Year **]
[**2107-8-24**] 10:08PM BLOOD Type-ART Temp-37.1 FiO2-40 pO2-73*
pCO2-73* pH-7.25* calTCO2-34* Base XS-1 Intubat-NOT [**Month/Day/Year **]
Comment-NEBULIZER
[**2107-8-25**] 03:59AM BLOOD Type-ART Temp-37.4 pO2-99 pCO2-66*
pH-7.27* calTCO2-32* Base XS-0 Intubat-NOT [**Month/Day/Year **]
[**2107-8-24**] 08:02AM BLOOD Type-ART Temp-36.0 PEEP-12 pO2-104
pCO2-67* pH-7.29* calTCO2-34* Base XS-2 Intubat-NOT [**Month/Day/Year **]
[**2107-8-24**] 06:17AM BLOOD Type-ART pO2-69* pCO2-82* pH-7.22*
calTCO2-35* Base XS-2
[**2107-8-24**] 03:50AM BLOOD Type-ART pO2-102 pCO2-75* pH-7.25*
calTCO2-34* Base XS-2
[**2107-8-16**] 11:32PM BLOOD Lactate-0.7
[**2107-8-17**] 08:27PM BLOOD Lactate-1.0
[**2107-8-23**] 05:38PM BLOOD Lactate-0.6
[**2107-8-24**] 08:02AM BLOOD Lactate-0.6
[**2107-8-23**] 01:32PM BLOOD freeCa-1.27
[**2107-8-24**] 08:02AM BLOOD freeCa-1.36*
[**2107-8-16**] 02:46PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2107-8-14**] 05:31PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2107-8-16**] 02:46PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2107-8-14**] 05:31PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2107-8-16**] 02:46PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2107-8-14**] 05:31PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2107-8-16**] 02:46PM URINE CastHy-8*
[**2107-8-14**] 05:31PM URINE CastHy-3*
[**2107-8-18**] 12:56PM URINE Hours-RANDOM UreaN-621 Creat-182 Na-LESS
THAN
[**2107-8-16**] 02:46PM URINE Hours-RANDOM Creat-184 Na-LESS THAN K-34
Cl-LESS THAN
[**2107-8-16**] 02:46PM URINE Hours-RANDOM
[**2107-8-14**] 05:31PM URINE Hours-RANDOM Creat-177 Na-19 K-28 Cl-14
TotProt-64 Prot/Cr-0.4*
[**2107-8-14**] 05:31PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2107-8-14**] 5:31 pm URINE Source: CVS.
**FINAL REPORT [**2107-8-16**]**
URINE CULTURE (Final [**2107-8-16**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
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
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**Known lastname **],[**Known firstname 21874**] [**Medical Record Number 21875**] M 61 [**2045-12-2**]
Radiology Report CHEST (PA & LAT) Study Date of [**2107-8-13**] 10:19
AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2107-8-13**] 10:19 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 21876**]
Reason: infiltrate?
[**Hospital 93**] MEDICAL CONDITION:
61 year old man chest pain
REASON FOR THIS EXAMINATION:
infiltrate?
Final Report
CLINICAL HISTORY: Chest pain. Renal transplant.
CHEST: Comparison is made with the prior chest x-ray of [**Month (only) 404**]
[**2106**].
Cardiac size is somewhat smaller. No failure is present. The
lung fields are
clear. The costophrenic angles are sharp.
IMPRESSION: Normal chest.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: SAT [**2107-8-13**] 3:40 PM
Imaging Lab
[**Known lastname **],[**Known firstname 21874**] [**Medical Record Number 21875**] M 61 [**2045-12-2**]
Radiology Report RENAL TRANSPLANT U.S. Study Date of [**2107-8-14**]
3:48 PM
[**Last Name (LF) **],[**First Name3 (LF) **] MED CC7A [**2107-8-14**] 3:48 PM
RENAL TRANSPLANT U.S. Clip # [**Clip Number (Radiology) 21877**]
Reason: Please evaluate transplant kidney and evaluate flow in
renal
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with HTN, DM, ESRD s/p right cadaveric
transplant [**2101**] s/p
renal artery re-stenosis [**2105**], now with worsening renal
function.
REASON FOR THIS EXAMINATION:
Please evaluate transplant kidney and evaluate flow in renal
artery with
doppler study.
Provisional Findings Impression: SBNa SUN [**2107-8-14**] 4:43 PM
slightly elevated RIs. No perinephric fluid collection or hydro
Final Report
RENAL TRANSPLANT
COMPARISON: [**2105-11-2**].
HISTORY: Worsening renal function. Evaluate with Doppler.
FINDINGS: The right lower quadrant renal transplant kidney
measures 13.7 cm.
There is no evidence of hydronephrosis or perinephric fluid
collections. There
is normal color flow within the transplanted kidney. The
resistive indices in
the upper, mid and lower pole of the transplant kidney measure
0.78-0.81,
0.81-0.87, and 0.77 respectively. These are slightly elevated
when compared
to most recent prior exam, which had resistive indices measuring
0.77, 0.70
and 0.70 in the upper, mid and lower pole respectively.
There is normal color flow and waveforms within the main renal
artery and
vein. The bladder is unremarkable.
IMPRESSION: Slightly increased resistive indices in the upper,
mid, and lower
pole as described above. No perinephric fluid collection or
hydronephrosis
identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: SUN [**2107-8-14**] 10:34 PM
Imaging Lab
[**Known lastname **],[**Known firstname 21874**] [**Medical Record Number 21875**] M 61 [**2045-12-2**]
Cardiology Report STRESS Study Date of [**2107-8-15**]
EXERCISE RESULTS
RESTING DATA
EKG: SR, NSSTTW, ONE VPB, PROLONGED QT
HEART RATE: 70 BLOOD PRESSURE: 162/68
PROTOCOL MODIFIED [**Doctor First Name 569**] - TREADMILL
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
0 0-3 1.0 8 103 170/68 [**Numeric Identifier 21878**]
1 3-5.5 1.7 10 115 200/70 [**Numeric Identifier **]
TOTAL EXERCISE TIME: 5.5 % MAX HRT RATE ACHIEVED: 72
INTERPRETATION: This 61 yo IDDM man with ESRD s/p transplant '[**01**]
was
referred for evaluation of chest pain. The patient performed 5.5
minutes
of a modified [**Doctor First Name **] protocol(~4.2 METs) and stopped due to
progressive
shortness of breath. This represents a limited exercise
tolerance. The
patient presented with 1/5 dyspnea which he states he has all
the time.
This progressed rapidly to a [**5-10**] by peak exercise. In the
presence of
baseline non-specific ST-T wave changes, there was additional
0.5-1mm of
horizontal/slighlydownsloping ST segment depression
inferolaterally at
peak exercise. These changes became inverted/biphasic T waves in
recovery and returned to baseline by 10 min. Rhythm was sinus
with rare
isolated VPBs. Heart rate response to exercise was blunted(72%
of
predicted maximum) in the presence of beta-blockade therapy.
Baseline
systolic hypertension with an appropriate/slightly exaggerated
exaggerated response to exercise.
IMPRESSION: Limited exercise tolerance due to shortness of
breath.
Possible ischemic EKG changes(although are probably nonspecific)
in the
presence of baseline ST-T abnls. Nuclear report sent separately.
SIGNED: [**Last Name (LF) **],[**First Name3 (LF) 177**] W [**Last Name (LF) **],[**First Name3 (LF) **] A
(04-[**Age over 90 **]M)
[**Known lastname **],[**Known firstname 21874**] [**Medical Record Number 21875**] M 61 [**2045-12-2**]
Radiology Report CARDIAC PERFUSION Study Date of [**2107-8-15**]
[**Last Name (LF) **],[**First Name3 (LF) **] [**2107-8-15**]
CARDIAC PERFUSION Clip # [**Clip Number (Radiology) 21879**]
Reason: ANGINAL CHEST PAIN EVAL FOR ISCHEMIC SIGNS
Final Report
RADIOPHARMACEUTICAL DATA:
2.8 mCi Tl-201 Thallous Chloride ([**2107-8-15**]);
18.4 mCi Tc-[**Age over 90 **]m Tetrofosmin Stress ([**2107-8-15**]);
HISTORY: 61year old male with HTN, DM, presenting with angina
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: modified [**Doctor First Name **]
Resting heart rate: 70
Resting blood pressure: 162/68
Exercise Duration: 5.5 min
Peak heart rate: 115
Percent maximum predicted heart rate obtained: 72%
Peak blood pressure: 200/70
Symptoms during exercise: progressive dyspnea, no chest pain
Reason exercise terminated: progressive dyspnea
ECG findings: 0.5-1 mm horizontal/downsloping inferolaterally
METHOD:
Resting perfusion images were obtained with Thallium-201. Tracer
was injected
approximately 30 minutes prior to obtaining the resting images.
At peak exercise, approximately three times the resting dose of
Tc-[**Age over 90 **]m
tetrofosmin was administered IV. Stress images were obtained
approximately 15
minutes following tracer injection.
Imaging Protocol: Gated SPECT
INTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is slightly increased.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 60%.
Compared with the study of [**2101-7-27**], the left ventricular size
is slightly
increased.
IMPRESSION: 1. Normal myocardial perfusion at the level of
exercise achieved.
2. Slightly dilated left ventricular cavity size, normal left
ventricular
systolic function, LVEF=60%.
[**Name6 (MD) 21880**] [**Name8 (MD) 21881**], M.D.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11925**], M.D.
Approved: TUE [**2107-8-16**] 3:22 PM
Imaging Lab
[**Known lastname **],[**Known firstname 21874**] [**Medical Record Number 21875**] M 61 [**2045-12-2**]
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2107-8-16**]
4:34 PM
[**Last Name (LF) 2106**],[**First Name3 (LF) 2105**] MED CC7A [**2107-8-16**] 4:34 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip #
[**Clip Number (Radiology) 21882**]
Reason: Please evalute for posisble cause of ascites.
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with ESRD s/p right-sided transplant with
re-canalization of
RAS. Now with worsening renal function and possible ascites.
REASON FOR THIS EXAMINATION:
Please evalute for posisble cause of ascites.
CONTRAINDICATIONS FOR IV CONTRAST:
Renal Failure
Provisional Findings Impression: SBNa TUE [**2107-8-16**] 6:13 PM
Mesenteric edema, nonspecific. Causes include third spacing and
vascular
compromise. Clinical correlation is recommended. No significant
amount of
ascites. Small amount of free fluid in the perihepatic and right
paracolic
gutter.
Final Report
CT ABDOMEN AND PELVIS WITHOUT CONTRAST.
COMPARISON: [**2104-2-3**].
HISTORY: 51-year-old male with end-stage renal disease status
post right side
transplant with worsening renal function and possible ascites.
TECHNIQUE: MDCT axially acquired images through the abdomen and
pelvis were
obtained. No IV contrast was administered. Coronal and sagittal
reformats
were performed.
FINDINGS: There are tiny bilateral pleural effusions. There is a
5-mm left
lung base nodule (2, 15) which is stable since [**2104**]. Within the
limitations
of a non-contrast exam, the liver, gallbladder, right adrenal
gland is
unremarkable. The patient is status post left nephrectomy and
left
adrenalectomy. The right kidney is atrophic. The pancreas is
unremarkable.
Just inferior to the pancreas within the root of the mesentery
extending from
the inferior portion of the duodenum is extensive fat stranding
and edema
within the mesentery. This is nonspecific (2, 48). Small bowel
loops are
normal in caliber and without focal wall thickening. There is no
evidence of
free air. Small amount of free fluid is identified within the
perihepatic
space (2, 18) and along the right paracolic gutter (2, 70).
Incidental note
is made of a distal esophageal duplication cyst (2, 21) which
measures
approximately 1.2 x 1.4 cm. Small bowel loops are normal in
caliber and
without focal wall thickening. There is no evidence of
pneumatosis or free
air.
CT OF THE PELVIS: Patient is status post transplanted kidney in
the right
lower quadrant. A stent is identified within the renal artery.
The appendix
is normal. The rectum, sigmoid colon, prostate is unremarkable.
Scattered
calcifications in the prostate gland are noted. A clip within
the bladder is
unchanged (2, 81). There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
Increased diffuse sclerosis of the osseous structures are likely
related to
renal osteodystrophy.
IMPRESSION:
1. Mesenteric edema extending from the root of the mesentry just
inferior to
the pancreas adjacent to the duodenum, nonspecific in etiology.
Differential
diagnosis includes edema secondary to third spacing or vascular
compromise
(SMA/SMV thrombosis?), or possibly bowel pathology although not
abnormalities
are noted in the bowel. It is unlikely that this represents
pancreatitis as
the edema and fat stranding are inferior to the pancreatic bed.
Findings were discussed with Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**] by telephone at
5:30 p.m.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Approved: WED [**2107-8-17**] 2:24 PM
Imaging Lab
[**Known lastname **],[**Known firstname 21874**] [**Medical Record Number 21875**] M 61 [**2045-12-2**]
Radiology Report RENAL TRANSPLANT U.S. RIGHT Study Date of
[**2107-8-17**] 3:48 PM
[**Last Name (LF) 2106**],[**First Name3 (LF) 2105**] MED CC7A [**2107-8-17**] 3:48 PM
RENAL TRANSPLANT U.S. RIGHT Clip # [**Clip Number (Radiology) 21885**]
Reason: Duplex US for possible renal artery stenosis--Please
[**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with history of ESRD s/p rt. renal transplant
and subsequent
rt. renal artery stent
REASON FOR THIS EXAMINATION:
Duplex US for possible renal artery stenosis--Please document
flow velocities
to assess degree of stenosis.
Final Report
TRANSPLANT RENAL ULTRASOUND
CLINICAL HISTORY: Possible renal artery stenosis. Evaluate flow
velocities
and degree of stenosis.
FINDINGS: Transplant Doppler ultrasound was performed. The
transplant kidney
measures 13.2 cm, and appears similar in size when compared to
the prior
examination, without evidence of hydronephrosis or perinephric
collection.
Vascular assessment, including both color and pulse wave Doppler
demonstrates
resistive indices between 0.79 and 0.82 within the parenchyma,
and 0.86 in the
main renal vein. There is no tardus-parvus morphology of the
waveforms or
delayed upstroke to suggest the presence of renal artery
stenosis of the
transplant kidney. The renal vein draining the transplant kidney
also appears
within normal limits.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2107-8-18**] 3:16 AM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 21874**] [**Hospital1 18**] [**Numeric Identifier 21886**]TTE (Complete)
Done [**2107-8-18**] at 11:28:24 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) 2106**], [**First Name3 (LF) 2105**]
[**Hospital1 18**] - Division of Nephrology
[**Location (un) 830**], [**Location 21887**] [**First Name8 (NamePattern2) **]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-12-2**]
Age (years): 61 M Hgt (in): 67
BP (mm Hg): 131/66 Wgt (lb): 237
HR (bpm): 71 BSA (m2): 2.18 m2
Indication: Congestive heart failure.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2107-8-18**] at 11:28 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W052-0:20 Machine: Vivid [**7-11**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness:
*1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
*1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
5.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension:
3.3 cm
Left Ventricle - Fractional Shortening:
0.41 >= 0.29
Left Ventricle - Ejection Fraction:
>= 55% >= 55%
Left Ventricle - Lateral Peak E':
*0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E':
*0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E':
*19 < 15
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity:
*2.4 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 1.18
Mitral Valve - E Wave deceleration time: 244 ms 140-250 ms
[**First Name (Titles) **] [**Last Name (Titles) 21888**] (+ RA = PASP):
*35 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2107-5-19**].
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Moderate symmetric LVH. Top normal/borderline
dilated LV cavity size. Normal regional LV systolic function.
Overall normal LVEF (>55%). TDI E/e' >15, suggesting
PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade II (moderate)
LV diastolic dysfunction. No resting LVOT [**Year (4 digits) **].
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
valvular AS. The increased transaortic velocity is related to
high cardiac output. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No
resting LVOT [**Male First Name (un) **]. Calcified tips of papillary muscles.
Trivial MR. [Due to acoustic shadowing, the severity of MR may
be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is borderline dilated. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with normal
global and regional biventricular systolic function. Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of [**2107-5-19**],
the findings are similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2107-8-18**] 12:45
?????? [**2101**] CareGroup IS. All rights reserved.
OPERATIVE REPORT
[**Last Name (LF) 21889**],[**First Name3 (LF) **] E.
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname 21874**] Unit No: [**Numeric Identifier **]
Service: Date: [**2107-8-23**]
Date of Birth: [**2045-12-2**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 21890**]
PREOPERATIVE DIAGNOSIS: Acute renal failure, status post
renal transplant.
POSTOPERATIVE DIAGNOSIS: Acute renal failure, status post
renal transplant.
OPERATION:
1. Ultrasound-guided puncture of the right common femoral
artery.
2. Catheterization of the right external iliac artery and
the transplanted renal artery.
3. Pelvic angiogram and arteriogram of the transplant renal
artery.
4. Balloon angioplasty of transplant renal artery stent.
ASSISTANT: [**Name6 (MD) 547**] [**Last Name (NamePattern4) 21891**], MD.
TOTAL FLUORO TIME: 21.10 minutes.
TOTAL CONTRAST USED: 10 ml of Visipaque.
INDICATIONS FOR PROCEDURE: This is a 61-year-old male with a
history of end-stage renal disease, who is status post renal
transplant. He has a history of acute renal failure and
renal artery stenosis of the transplanted renal artery. She
had previously undergone stenting of the transplant renal
artery, followed by in-stent angioplasty. He presents again
with acute renal failure and suspected renal artery stenosis.
PROCEDURE IN DETAIL: After informed consent was obtained,
the patient was brought to the angiography suite and placed
in supine on the angiography table. After induction of
anesthesia, both groins were shaved, prepped and draped in
the usual sterile fashion. Using ultrasound the right common
femoral artery was identified. It was patent. Real-time
visualization needle puncture into the right common femoral
artery was achieved with the ultrasound. Hard copies of the
images were stored in the patient's chart for documentation
purposes. Using a micro sheath the right common femoral
artery was accessed. This was followed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire in
the abdominal aorta and a #5 French right tip sheath. A
pelvic angiogram and transplant renal arteriogram were
performed. This showed a patent transplant renal artery.
Given that the patient has repeated history of transplant
renal artery stenosis, we elected to intervene.
Using a Glidewire and an Omni flush catheter, we selected the
renal artery. The catheter was then exchanged for a slip
cath and a spider coil wire was then placed across the stent.
Using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21892**] 6 x 20 mm balloon, we performed an in-stent
angioplasty. No discrete stenoses was noted. As there was
no lesion, we elected to terminate the procedure at this
point. All catheters and wires were withdrawn and the right
common femoral arteriotomy was closed with a Perclose device.
Dr. [**Last Name (STitle) **] was present throughout the entire case.
ANGIOGRAPHIC FINDINGS:
1. The right common iliac artery was widely patent, without
stenosis.
2. The transplant renal artery was widely patent, without
stenosis. The stent was crossed with a combination of
Omniflush catheter and Glidewire. A 6 x 20 mm [**Location (un) 21892**]
balloon was used to angioplasty within the stent,
however no stenosis was noted.
[**Name6 (MD) 547**] [**Last Name (NamePattern4) 21891**], MD
Dictated By:[**Last Name (NamePattern4) 21893**]
MEDQUIST36
D: [**2107-8-23**] 10:10:24
T: [**2107-8-23**] 22:30:59
Job#: [**Job Number 21894**]
Brief Hospital Course:
Patient is a 61 yo male with PMH for GERD/Barretts, HTN, TIIDM,
ESRD, and s/p kidney transplant, who came to the ED complaining
of CP. In the ED he had EKG done and cardiac enzymes started.
His EKG showed no difference to prior EKGs and only Troponin T
was mildly elevated at 0.05. He was admitted to the floor for
observation and to rule out MI.
#Chest pain: Cardiac problems are less likely because his
cardiac enzymes were negative and his second EKG showed no
changes. He underwent stress testing, which was notable for
marked reduction in ability to exercise due to SOB but he had
normal cardiac perfusion and an echo demonstrating LVEF of 60%.
In summary his cardiac workup showed it to be non-contributory
to this process. and second EKG ruled out MI and NSTEMI. His CP
symptoms and history of GERD and Baretts makes relfux the likley
cause of his pain, which brought him to the ED.
#Renal disease:Patient was noted to have elevated creatinine
from baseline elevation (2.5-3.5). Also has history of ESRD in
his cadaveric transplant kidney. His FENA on admission was <1%
which is suggestive of prerenal azotemia. He did not report
being very dry and had this high creatinine in the setting of
high BPs so he was considered also for renal artery stenosis (he
is s/p stenting in transplant kidney renal artery). The team was
also worried about chronic kidney rejection and/or glomerular
nephropathy from diabetes and longstanding HTN. Labs showed
proetinuria of 30, but his baseline is up near 300. Renal
service followed his admission closely and was advising on BP
meds, fluids, and imaging of renal artery. On imaging he had a
renal artery US which showed increased resitance throughout the
transplant but no color flow changes in the renal artery. He
continued to produce adequate urine despite his Lasix being
held. Also, a vascular surgery consult was ordered to assess for
re-stenosis. He was taken to the OR for renal artery angiongram
and possible intervention on 3 different occasions. On the first
two no intervention could be taken as he was unable to lay flat
on the operating table. He was started on lasix and his
orthopnea improved. On [**8-23**] he was taken to the OR for the third
time and was intubated for the procedure. Angiogram revealed
patency of the renal artery, despite this the vessel was
angioplastied. He developed mild respiratory failure after
extubation, had to be put on NIPPV and was transfered to the
MICU. In the MICU he was continued on diuretics and was
successfully weaned off NIPPV. He was transfered to the floor on
[**8-25**] where he was continued on diuretics and his RF improved.
#Orthopnea/Hypercarbic Respiratory Failure/OSA: Patient reported
multiple epsiodes of SOB, once while lying flat. Patient reports
a history of SOB with exertion from childhood (he has asthma
history but no attacks as adult). Of note is he has significant
central obesity that seems to be contributing to this orthopnea.
He also commented on abdominal distension and so CT scan was
ordered to assess for ascites, which would also be a mechanism
for pressure on the diaphragm. It showed mesenteric edema but no
ascitic fluid. His lungs have remained clear on physical exam.
He had an ABG whihc showed chronic respiratory acidosis. He also
had liver panel done to assess for hepatitis reasons for
possible ascites, which showed adequate liver function. His
orthopnea was thought to be due to a combination of dCHF, ARF
and OSA. Once patient was diuresed his orthopnea improved. He
developed mild hypercarbic respiratory failure after extubation
during renal artery angiogram, had to be put on NIPPV and was
transfered to the MICU. In the MICU he was continued on
diuretics and was successfully weaned off non-invasive
ventilation. He was transfered to the floor on [**8-25**] where he was
continued on diuretics and had no more respiratory problems off
O2. The option of nightly use of NIPPV was discussed with the
patient for treatment of OSA but he refused.
#HTN: His HTN was very hard to control while in the hospital,
his medications had to be adjusted on several occasions because
of SBP up to 200s. While in the MICU he was treated with a
labetalol drip that effectively decreased his BP. On transfer he
was transitioned to PO labetalol. His HTN was under better
control on the new regimen.
#TIIDM: His blood sugars fluctuated each day throughout his
stay. He was started on his home dose of NPH but this did not
manage his sugars well and so we switched to 20units AM and 10
units PM and a sliding scale. It is unclear why his home doses
were not effectively managing his sugars. He reported that he
eats differently at home, which could be partially contributing.
He had no more issues with hyper or hypoglycemia after his NPH
adjustment.
#CHF: His last echo showed compensated diastolic heart failure
and the echo during this hospitalization showed LVEF of 60%
demonstrating adequate compensation. In light of these results
and phsyical exam his CHF was thought to not be contributing to
his chest pain. He did have a slight troponin leak on admission
but this was thought to be due to RF.
#Tertiary Hyperparathyroidism: Patient was found to have a
persistently high Ca and a high PTH at 355. This was thought to
be due to tertiary hyperparathyroidism caused by his CRF. He was
started on cinacalcet to treat this condition.
Medications on Admission:
Minoxidil 10mg 1TAB 2xday
Prednisone 5mg 1TAB daily
Clonidine 0.1mg 1TAB 2x daily
Calcitriol 0.25mcg 1capdaily
Furosemide 3TAB 2xday
Mycophenolate 500mg 1TAB 2xday
Lisinopril 10mg 1TAB QHS
Labetalol 200mg 3TAB 2xday
ASA 81 mg
Humalin NPH 20 units AM and 15 in PM
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Ten (10) units Subcutaneous qPM.
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) Units Subcutaneous qAM.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Acute renal failure
- ESRD s/p renal transplant
- HTN
- Diabetes, type 2, insulin dependent
- Renal Cell Carcinoma, s/p nephrectomy
- GERD / Barrett's Esophagus
Secondary:
- s/p AV fistulas
- s/p patella avulsion repair
Discharge Condition:
good
Discharge Instructions:
You were seen in th [**Hospital1 18**] Emergency department for chest pain.
You were admitted and had labwork done to make sure you did not
have a heart attack or some other cardiac reason for your chest
pain. During this workup you had a cardiac stress test that
showed normal heart function and ability. You also had labwork
and tests done to make sure that your chest pain was not caused
by your heart. Your chest pain was most likely caused by your
reflux disease. You did not have any further episodes of pain
during this hospitalization. While in the hospital your kidney
transplant was also being followed because of some elevations in
your labwork. The kidney doctors followed your health throughout
this stay to see if it was still functioning appropriately. You
underwent a test to check the blood supply to your kidney which
did not show a reason for your renal failure. You were
intubated for this procedure and you required a 2 day ICU stay
after extubation. Your renal failure was improving by the time
you were discharged.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**], next week, and your
nephrologist, Dr. [**Last Name (STitle) **], as below.
It is very important to your health to use your CPAP machine at
night. Many of your lung problems are directly or indirectly
related to your obstructive sleep apnea, which is treated with
the CPAP. Please use your CPAP machine. Please discuss with
Dr. [**Last Name (STitle) 5717**] about possibly getting another sleep study to titrate
your CPAP.
Medication Changes:
- your labetalol was increased to 800mg three times a day
- your clonidine was increased to 0.2mg three times a day
- your lasix was decreased to 60mg twice daily
- your calcitriol was changed to cinacalcet 30mg daily
- your nighttime insuline (NPH) was decreased to 10U. Please
discuss your insulin dosing with Dr. [**Last Name (STitle) 5717**].
- your minoxidil was stopped
- your lisinopril was stopped
- your aspirin was stopped. Please discuss restarting with your
PCP and your nephrologist.
- Your NPH evening dose was decreased to 10U. Please follow-up
with [**Last Name (un) **] about titrating this dose.
Please check your blood sugar at least daily. Please call Dr.
[**Last Name (STitle) 5717**] or the [**Last Name (un) **] Center with any blood sugars greater than
300 or less than 75. If your blood sugar is less than 75 or you
feel symptoms of low blood sugar such as shakiness,
lightheadedness, confusion, or nausea, please eat something and
call Dr. [**Last Name (STitle) 5717**], the [**Last Name (un) **] Center, or come to the emergency
department. Please follow-up with the [**Last Name (un) **] Diabetes Center as
soon as possible as below.
If you experience chest pain, shortness of breath, fever >100.4,
weight gain, shakiness, lightheadedness, confusion, nausea,
blood sugar higher than 300 or lower than 75, or any other
symptom that may concern you please contact your primary care
physician or seek help at the nearest emergency room.
Followup Instructions:
Please follow up with your PCP and Dr. [**Last Name (STitle) **] at the following
appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2107-8-30**] 9:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2107-10-31**] 1:20
The [**Last Name (un) **] Diabetes Center will call you to make an appointment
with Dr. [**Last Name (STitle) 978**] as soon as possible to help with your insulin
dosing.
You should discuss the possibility of further testing
(endoscopy) for your reflux disease. You should also make an
appointment with [**Last Name (un) **] to have your diabetes medications
assessed.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
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"584.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.49",
"39.50",
"00.40"
] |
icd9pcs
|
[
[
[]
]
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40719, 42190
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|
1721, 2079
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348, 1703
|
2101, 2454
|
2470, 2791
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,308
| 134,475
|
43987+43988
|
Discharge summary
|
report+report
|
Admission Date: [**2143-11-6**] Discharge Date [**2143-11-28**]:
Date of Birth: [**2077-4-19**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old
female who underwent a descending thoracic aortic aneurysm
repair on [**2143-11-8**]. Preoperatively the aneurysm was thought
to be leaking and thus she went to the Operating Room on a
semiemergent basis. In terms of the aortic repair the
procedure went well, however, her postoperative course was
complicated by lower extremity paraplegia and sepsis.
PAST MEDICAL HISTORY: Infrarenal aortic aneurysm repair
previously by Dr. [**Last Name (STitle) 1391**] at which time she received an
aortobifemoral graft. She has a history of polymyalgia
rheumatica, hypercholesterolemia, reflux. She is status post
L3-L5 laminectomy. She also has a history of hypertension
and chronic renal insufficiency.
PAST SURGICAL HISTORY: Appendectomy and as previously
mentioned a laminectomy.
ALLERGIES: Codeine.
MEDICATIONS: Flexeril and Ativan.
HOSPITAL COURSE: Neurologically, again the patient is status
post a descending aortic aneurysm repair, which was
complicated by lower extremity paraplegia. Postoperatively,
she had all efforts to correct this including a preoperative
cerebral spinal fluid lumbar catheter, which was in place.
However, she has not been able to regain any function. She
has a baseline anxiety state for which she takes Ativan at
home. She has been rather anxious here in the Intensive Care
Unit and has been controlled on Ativan, Morphine, Clonidine
and we are most likely starting Haldol today in order to make
the patient comfortable.
Cardiovascular: The patient is status post an ascending
thoracic aortic aneurysm repair. Her blood pressure has been
somewhat an issue to control. Her blood pressure ranged per
the cardiac service has been preferred to 130 to 150. We
have her on Lopressor 25 mg intravenous q 6 and Hydralazine
25 mg intravenous q 6. She also was noted to have some
postoperative atrial fibrillation for which she was started
on a six week course of amiodarone. She is to continue on
Amiodarone 200 mg per G tube q.d. times four more weeks. Her
blood pressure should be controlled when her anxiety is
controlled, however, a third [**Doctor Last Name 360**] might need to be added.
Pulmonary wise she has failed extubation twice and thus
underwent tracheostomy placement. She is currently on
minimal pressure support ventilation and her arterial blood
gases were good with her last arterial blood gas being 7.39,
38, 112, 24 and -1 on a pressure support ventilation of 10,
PEEP of 5 and FIO2 of 50%. Once she is controlled the
ultimate goal being weaned off to trach collar.
Gastrointestinal wise the patient also underwent placement of
a percutaneous gastrostomy tube. She is tolerating goal tube
feeds atrial fibrillation Impact with fiber at 70 cc an hour.
Genitourinary wise the patient has a Foley. Postoperatively,
she was noted to undergo acute renal failure. Her creatinine
bumps to peak of 5.5. She does have a history of chronic
baseline insufficiency and now her creatinine has stabilized
to 1.9. She is not receiving any Lasix and is self
diuresing on her own per renal recommendations. Also her
creatinine is normalizing on her own. Today she is 1.9.
Infectious disease wise the patient was noted to have E-coli
sepsis. She grew E-Coli from eight out of eight blood
cultures and from her sputum. The exact etiology of this was
unknown as her catheter tip never grew the bacteria, however,
she was maintained on Zosyn for a fifteen day course and now
has been switched to Levaquin per her G tube to be continued
for another four weeks for a total of a six week antibiotic
course as she does have prosthetic graft material in place.
Endocrine wise the patient has been on a sliding scale
regular insulin. Her sugars have not really been an issue.
She does not take any thyroid hormone pills.
FEN wise the patient is receiving tube feeds Impact with
fiber at goal at 70 cc an hour. Her fluids are heplocked and
her electrolytes have been repleted prn.
Tubes, lines and drains, the patient underwent a placement of
a PICC line. All her central lines were out. She currently
has a tracheostomy, percutaneous gastrostomy tube, PICC line
and a Foley catheter.
Disposition wise, the patient is full code.
Hematologically, the patient has had stable hematocrits. She
is on Epogen for her chronic disease and is relatively
stable. Her white count has been stable.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
Status post ascending aortic aneusysm repair complicated by
paraplegia sepsis.
MEDICATIONS ON DISCHARGE: Lopressor 20 mg po q 4,
Hydralazine 25 mg intravenous q six, sliding scale regular
insulin, Albuterol nebulizers prn, Atrovent nebulizers prn,
Amiodarone 200 mg q day times four weeks until [**2142-12-25**]. Lovenox 40 mg subQ b.i.d. for deep venous thrombosis
prophylaxis and Levaquin 250 mg per G tube q.d. times four
weeks until [**2142-12-28**]. Protonix 40 mg per G tube
q.d., Clonidine 0.3 mg transdermal every three days. Reglan
10 mg q 6 hours at tube feeds and Haldol, Ativan and Morphine
prn.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2143-11-28**] 09:08
T: [**2143-11-28**] 10:12
JOB#: [**Job Number 94465**]
Admission Date: [**2143-11-6**] Discharge Date: [**2143-12-3**]
Date of Birth: [**2077-4-19**] Sex: F
Service:
This is an discharge summary addendum.
Patient's clinical status has improved since the last
dictation summary. In terms of her blood pressure
management, her medications have been altered slightly. She
is now on Lopressor 75 mg per G tube t.i.d. and Hydralazine
40 mg per G tube q. six. This regimen has maintained her
blood pressure in the 140 to 150 range which is adequate for
her. Her anxiety has also been well controlled on Ativan and
Clonidine. Her Ativan dose is at 2 mg per G tube q. four to
six hours and Clonidine 0.4 mg per G tube t.i.d. These can
be adjusted accordingly.
Today is Tuesday, [**12-3**]. Her hematocrit was noted to
be 20. This is most likely secondary to chronic disease.
There is no evidence of bleeding. She will receive two units
of blood. The patient has been extremely stable on a trach
collar. She has been removed from the ventilator. The rest
of her discharge planning remains the same. Her medications
are all updated on page one. The patient will be continued
on Lovenox for DVT prophylaxis and tube feeds. Once
appropriate swallowing evaluations have been made, she can be
started on p.o. feeds as per rehabilitation discretion.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2143-12-3**] 10:37
T: [**2143-12-3**] 12:31
JOB#: [**Job Number 94466**]
|
[
"344.1",
"038.42",
"997.5",
"401.9",
"427.31",
"584.9",
"441.1",
"518.81",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.45",
"33.22",
"03.31",
"31.1",
"96.56",
"43.11",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4590, 4670
|
4697, 7064
|
1047, 4535
|
914, 1029
|
160, 544
|
567, 890
|
4560, 4569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,843
| 152,306
|
8349+8350+55933
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2157-11-23**] Discharge Date:
Date of Birth: [**2096-8-11**] Sex: F
Service:
HISTORY: The patient is a 60-year-old female who was found
to have a T2, N2 right upper lobe lung carcinoma. The
patient was admitted for elective surgery, right upper lobe
lobectomy. The patient did well with neoadjuvant treatment.
PAST MEDICAL HISTORY: Included breast cancer on the right
side. Underwent chemotherapy in [**2139**].
PAST SURGICAL HISTORY: Includes right mastectomy,
mediastinoscopy.
ALLERGIES: None.
The patient was taken by Dr. [**Last Name (STitle) 175**] to the operating room on
[**2157-11-23**] for a right upper lobe lobectomy, Stage III-A lung
cancer.
Postoperatively the patient did well however, her recovery
course was complicated by hypotensive episodes in the Post
Anesthesia Care Unit. It was treated with Neo and the
patient was transferred to Intensive Care Unit for several
days because of difficulty weaning off Neo. However on
postoperative day three the patient was able to be
transferred onto the floor. The patient's chest tube was
discontinued without incident. Pain was initially controlled
with an epidural and later switched onto PCA and before
discharge the patient's pain was controlled on p.o. Percocet.
Preoperatively the patient had bilateral wheezing but
postoperatively the patient's wheezing was treated with
Albuterol nebulizer and upon discharge her wheezing improved.
The patient was afebrile.
DISCHARGE MEDICATION:
1. Percocet one to two tabs p.o. q 4 to 6 h p.r.n.
2. Motrin 800 mg p.o. q 8 h times 48 hours then p.r.n.
3. Zantac 150 mg p.o. b.i.d. times one week.
4. Albuterol nebulizer.
CONDITION ON DISCHARGE: Physical examination still had some
diffuse bilateral wheezes. Heart rate was regular. Normal
sinus. Incision is clean, dry, intact. No drainage, no pus.
Pain controlled on p.o. Percocets. Condition was stable,
afebrile.
The patient will be discharged home and told to follow-up
with Dr. [**Last Name (STitle) 175**] in one week.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2157-11-28**] 17:31
T: [**2157-11-28**] 19:50
JOB#: [**Job Number 29545**]
Admission Date: [**2157-11-23**] Discharge Date: [**2157-11-30**]
Date of Birth: [**2096-8-11**] Sex: F
Service: CT Surgery
ADDENDUM: The patient is status post a right upper lobectomy
on [**2157-11-23**]. The patient was due to be discharged
today, however, prior to discharge, the patient was up and
moving about and developed some sinus tachycardia up to a
rate in the 130 to 140 range. The patient, at the time,
complained of pain at the incision site, but the incision was
clean, dry and intact. The patient, when seen by the house
officer, appeared to be in regular sinus rhythm at a rate of
approximately 100 to 110. The case was discussed with Dr.
[**Last Name (STitle) 175**] and the patient will be placed on a low dose beta
blocker, Lopressor 12.5 mg twice a day. The patient is
otherwise stable with stable vital signs, saturating at 95%
with a blood pressure of 120/75.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2157-11-30**] 10:45
T: [**2157-11-30**] 10:48
JOB#: [**Job Number 29546**]
Name: [**Known lastname 5160**], [**Known firstname 1972**] Unit No: [**Numeric Identifier 5161**]
Admission Date: [**2157-11-23**] Discharge Date:
Date of Birth: [**2096-8-11**] Sex: F
Service: Cardiothoracic Surgery
ADDENDUM: Postoperatively the patient did well, was
scheduled for discharge on postoperative day #6, however,
patient's pain was not controlled on po pain medication
overnight. Therefore the pain service was consulted and they
recommended patient have Percocet, be put on Dilaudid 60 mg
po q 4-6 hours prn and Elavil 10 mg po q h.s. prn. The
patient did well on those medications overnight and will be
discharged on [**2157-11-30**].
DISCHARGE MEDICATIONS: Motrin 800 mg po q 8 hours times 48
hours and prn, Zantac 150 mg po bid times one week, Albuterol
nebs prn, Dilaudid 60 mg po q 4-6 hours prn, Elavil 10 mg po
q h.s. prn and also Colace 200 mg po q d.
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 2334**], M.D. [**MD Number(1) 2335**]
Dictated By:[**Name8 (MD) 5162**]
MEDQUIST36
D: [**2157-11-30**] 08:07
T: [**2157-11-30**] 08:52
JOB#: [**Job Number 5163**]
|
[
"162.3",
"458.2",
"427.89",
"196.1",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.4",
"33.48"
] |
icd9pcs
|
[
[
[]
]
] |
4218, 4687
|
481, 1684
|
375, 457
|
1709, 4194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,339
| 100,394
|
45666+58842
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-10-31**] Discharge Date: [**2132-11-7**]
Date of Birth: [**2067-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Right arm pain at rest
Major Surgical or Invasive Procedure:
[**2132-10-31**] Coronary artery bypass graft x3 (Left internal mammary
artery > left anterior descending, saphenous vein graft > R1,
Saphenous vein graft > posterior descending artery)
History of Present Illness:
65 year old male with a known history of CAD s/p PCI in [**2117**]
with a mid LAD stent, hypertension, hyperlipidemia and atrial
fibrillation s/p cardioversion in [**2129**]. He reports exertional
chest pain for the last 3 weeks that radiates down the posterior
side of his right arm. He typically feels the right arm
discomfort at night after walking up stairs. He also notes
occasional dyspnea with activity, but notes he continues to
tolerate his active work schedule without difficulty. He is now
being referred to cardiac surgery for
possible revascularization.
Past Medical History:
Coronary artery disease s/p PCI in [**2117**]-- ACS Multilink stent of
Mid LAD
Atrial Fibrillation s/p Cardioversion [**2129**]
Hypertension
Hyperlipidemia
NIDDM
Sleep Apnea (does not use Cpap)
Arthritis
Social History:
Lives with:wife
Occupation:salesman for car dealership
Tobacco:quit 11 years ago, 1.5 ppd x30 years
ETOH:1-2 drinks/month
Family History:
Family History:His father and brother both died at age 45 from
MI, Mother had stents in 70's
Physical Exam:
Pulse:42 Resp: 12 O2 sat:97/RA
B/P Right:133/62 Left:127/74
Height:6' 3" Weight:276 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft, non-distended, non-tender [x]
Extremities: Warm, well-perfused [x] Edema/Varicosities: None
[x]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2132-11-7**] 04:50AM BLOOD WBC-9.5 RBC-3.84* Hgb-10.8* Hct-31.7*
MCV-83 MCH-28.0 MCHC-33.9 RDW-14.5 Plt Ct-309
[**2132-11-7**] 04:50AM BLOOD PT-14.0* PTT-26.2 INR(PT)-1.2*
[**2132-11-7**] 04:50AM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2132-10-31**]
Echo:Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. There is no aortic
valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is on no pressors. AV-Pacing.
Preserved biventricular systolic fxn.
Trace - 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Aorta intact.
[**2132-11-6**]:
Head CT
CLINICAL INDICATION: 65-year-old male status post fall on the
head and face.
Evaluate for intracranial hemorrhage.
FINDINGS: There is no evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
There is very mild cortical atrophy, likely secondary to
age-related involutional changes. The right lens is absent.
There is no evidence for bony fracture. The visualized portions
of the paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: No evidence for acute intracranial process.
Brief Hospital Course:
Admitted same day admission and was brought to the operating
room for coronary artery bypass graft surgery. See operative
report for further details. He received cefazolin for
perioperative antibiotics and was transferred to the intensive
care unit for post operative management. In the first twenty
four hours he was weaned from sedation, awoke neurologically
intact, and was extubated without complications. He continued
to progress and early am of postoperative day two he went into
rapid atrial fibrillation that was treated with IV Lopressor, IV
Diltiazem, and increased Sotalol and he converted back to sinus
rhythm in afternoon. He had another episode of atrial
fibrillation which converted to sinus rhythm on POD # 4 after
treatment. Chest tubes and pacing wires were removed per caridac
surgery protocol. On POD 6 he was coughing and went to get up
from his chair and fell forward on his face and head. He
remained neurologically intact and his head CT was negative for
intracranial bleed. Plastic surgery was consulted and used
Dermabond for facial laceration closure. He continued to do well
and physical therapy worked with him on strength and mobility.
On POD 7 he was in sinus rhythm and taken off Diltiazem drio and
converted to long acting po Cardizem. It was decided not to
anticoagulate since patient was in sinus rhythm at the time of
discharge. He was ambulating in the halls with assistance,
tolerating a full oral diet and a his incision was healing well.
He was discharged home with VNA services and all appropriate
follow up appointments were made.
Medications on Admission:
AMLODIPINE 2.5 mg once daily
ATORVASTATIN 40 mg once daily
EXENATIDE 5 mcg/0.02 mL per dose 1 sq injection twice per day
before meals
EZETIMIBE 10 mg once daily
FUROSEMIDE 40 mg once daily
LISINOPRIL 10 mg once daily
LORAZEPAM 0.5 mg twice per day as needed
METFORMIN 250 mg once every evening
NITROGLYCERIN SL 0.4 mg as needed for chest pain
POTASSIUM CHLORIDE 10 mEq once daily
SOTALOL 120 mg twice per day
ASPIRIN 81 mg once per day
FOLIC ACID
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal Q12H
(every 12 hours) as needed for dry nares .
Disp:*1 1* Refills:*0*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*1 Tablet(s)* Refills:*2*
8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for anxiety .
Disp:*15 Tablet(s)* Refills:*0*
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for temperature >38.0.
13. sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
14. Cardizem CD 120 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
15. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 1* Refills:*0*
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial Fibrillation
Hypertension
Hyperlipidemia
Diabetes Mellitus type 2
Sleep Apnea
Arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Trace Lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2131-12-5**] at 1:45 PM
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] [**2131-12-9**] at 2:45 PM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 9145**] [**Telephone/Fax (1) 9146**] in [**3-3**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2132-11-7**] Name: [**Known lastname 15520**],[**Known firstname 499**] M Unit No: [**Numeric Identifier 15521**]
Admission Date: [**2132-10-31**] Discharge Date: [**2132-11-7**]
Date of Birth: [**2067-5-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 741**]
Addendum:
Patient with erythema noted surrounding left lower sternal pole.
Erythema with + blanching, not tender to palpation, not warm, no
drainage noted. Sternum stable. Pt afebrile and WBC WNL.
Patient and wife instructed to monitor temperatures daily and
call if temperature >100.4, and call service if erythema
increases, wound becomes warm or tender, drainage occurs or if
sternum feels unstable. Patient is scheduled for follow up
appointment with Dr [**Last Name (STitle) **] [**12-5**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 197**] [**Name (NI) 198**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2132-11-7**]
|
[
"276.52",
"401.9",
"272.4",
"458.29",
"427.31",
"414.01",
"413.9",
"250.00",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
10652, 10844
|
3707, 5287
|
303, 491
|
8115, 8357
|
2149, 3684
|
9198, 10629
|
1487, 1566
|
5785, 7849
|
7964, 8094
|
5313, 5762
|
8381, 9175
|
1581, 2130
|
240, 265
|
519, 1088
|
1110, 1316
|
1332, 1456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,939
| 171,688
|
45722
|
Discharge summary
|
report
|
Admission Date: [**2154-5-3**] Discharge Date: [**2154-5-16**]
Date of Birth: Sex:
Service:
This 69-year-old woman with esophageal cancer status post
neoadjuvant treatment, is admitted for minimally invasive
esophagectomy. The patient presented with dysphagia and a
fairly large tumor, which was treated with neoadjuvant
therapy. She has actually done reasonably well now presents
for surgery.
PAST MEDICAL HISTORY: Notable for type 2 diabetes,
hypertension, COPD and breast cancer. She has had a right
mastectomy in the past.
MEDICATIONS: Fluticasone, salmeterol, Lopressor,
lansoprazole, fentanyl, Colace, albuterol and Ativan.
PHYSICAL EXAMINATION: She is a well-developed woman with a
right mastectomy scar. The abdomen was soft with a
jejunostomy tube in place.
HOSPITAL COURSE: The patient admitted for surgery and
underwent a minimally invasive esophagogastrectomy for her
esophageal cancer. Surgery was uncomplicated. She was
admitted to the ICU for normal postoperative course. She was
started on tube feedings and had an epidural placed for pain
relief. She did have brief hypotension, responding to fluids.
She required some respiratory toilet. She then appeared to be
somewhat volume overloaded and was given a diuretic. The
patient was then transferred to the floor on [**2154-5-6**],
where PCA was started. A barium swallow was performed, which
showed no evidence of leak. She had a low grade fever with a
urinalysis, which was suspicious for a urinary tract
infection and begun on antibiotics. Her fever diminished. She
did require a recatheterization for urinary retention. She
then developed a higher fever on [**2154-5-12**]. She was given
increase in chest PT. An aspiration of the left chest showed
1000 mL of serosanguinous fluid. A preliminary CT of the
chest showed no leak. There was some collapse of the left
lower lobes with atelectasis. The patient underwent a
therapeutic bronchoscopy with improvement. There were 2 small
plugs with no sign of infection. She then seemed to be doing
well and was discharged home on supplemental oxygen.
FINAL DIAGNOSES:
1. Esophageal cancer status post neoadjuvant treatment.
2. Diabetes type 2.
3. Postoperative volume depletion.
4. Postoperative pulmonary collapse with mucous plugging.
5. Urinary tract infection.
SURGICAL PROCEDURES: Minimally invasive esophagectomy, date
[**2154-5-3**].
DISPOSITION: The patient is discharged home with services.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], MD
Dictated By:[**Last Name (NamePattern4) 24987**]
MEDQUIST36
D: [**2154-12-18**] 12:41:45
T: [**2154-12-18**] 13:19:36
Job#: [**Job Number 97439**]
|
[
"401.9",
"496",
"486",
"V10.3",
"197.8",
"250.00",
"150.8",
"196.1",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"42.52",
"96.6",
"42.42"
] |
icd9pcs
|
[
[
[]
]
] |
822, 2103
|
2120, 2712
|
688, 804
|
448, 665
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,865
| 193,988
|
9939
|
Discharge summary
|
report
|
Admission Date: [**2145-5-21**] Discharge Date: [**2145-5-26**]
Date of Birth: [**2096-7-17**] Sex: F
Service: PLASTIC
Allergies:
Morphine / Gadolinium-Containing Agents / Vancomycin
Attending:[**First Name3 (LF) 28638**]
Chief Complaint:
Fever after TRAM flap on [**2145-5-3**].
Major Surgical or Invasive Procedure:
Right breast wound washout of infected hematoma/seroma.
History of Present Illness:
48 y/o f s/p R free tram [**2145-5-3**]. Patient reports fever to
101 and aches x 1 day. Has daughter and husband with strep
throat
at all. Reports some soreness/pressure that has increased in the
lower aspect of her breast and abdomen. Positive HA, no chest
pain, shortness of breath, urinary symptoms, leg swelling, or
cough. Patient saw Dr. [**Last Name (STitle) **] in clinic and she was referred
to
the ED for further management. In ED given vancomycin,
ceftriaxone, and flagyl.
Past Medical History:
-Breast CA with mastectomy and R free tram [**5-3**]
Social History:
Denies smoking, EtOH or drugs
Family History:
non contributory
Physical Exam:
PE: 98.9 106 103/61 18 100
Chest: R flap clean, intact, + doeppler, nl cap refill small amt
of drainage @ 7 oclock, no erythema
Abd: incision c/d/i minimal tenderness no rebound or guarding
Pertinent Results:
[**2145-5-21**] 05:45PM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-[**5-12**]
[**2145-5-21**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2145-5-21**] 05:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2145-5-21**] 06:00PM PLT COUNT-319#
[**2145-5-21**] 06:00PM WBC-22.9*# RBC-4.00* HGB-11.1* HCT-33.3*
MCV-83 MCH-27.7 MCHC-33.3 RDW-14.4
[**2145-5-21**] 06:00PM CALCIUM-9.4 PHOSPHATE-2.5* MAGNESIUM-1.7
[**2145-5-21**] 06:00PM ALT(SGPT)-14 AST(SGOT)-27 LD(LDH)-360* ALK
PHOS-94 TOT BILI-0.6
Brief Hospital Course:
48 y/o female with a history of breast CA s/p mastectomy and
free tram reconstruction who presented with fever to 101 and
tenderness in right breast.
Patient Reported some soreness/pressure that increased in the
lower aspect of her breast and abdomen but denied chest pain,
shortness of breath or urinary symptoms. Given her recent
procedure there was concern for an infected seroma. 200 ccs of
fluid was aspirated from the 7 oclock position and sent for
culture. Cultures showed gram-positive cocci and our patient was
started on broad-spectrum antibiotics. She was admitted to
intensive care unit with a white count 22, blood pressure 80.
She reponded well to fluids and drainage of the seroma cavity.
The morning of [**5-23**] she was feeling better. She was
hemodynamically stable her white count was down to 15.
At this time there still was clinically infected looking fluid
draining from the deep to the TRAM flaps and patient was taken
to the OR to wash out the infected cavity. The wound was packed
open. The patient had dressing changes on the floor for 2 days.
Her white count came down from a high of 22, on admission to 12.
The wound
looked quite clean and we decided to take her back to the
operating room in order to close the wound over a drain. Patient
continued to do well on the floor would dressing changes.
Medications on Admission:
Zoloft, Dilaudid, Motrin
Discharge Medications:
1. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**3-8**]
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
VNA of Eastern MA
Discharge Diagnosis:
right breast reconstruction infected hematoma/seroma.
Discharge Condition:
Stable
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] within 1 week.
|
[
"998.12",
"041.89",
"V10.3",
"998.13",
"V87.41",
"998.51",
"V15.3",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.81",
"85.0",
"96.59"
] |
icd9pcs
|
[
[
[]
]
] |
3592, 3640
|
1943, 3273
|
354, 412
|
3738, 3747
|
1312, 1920
|
4579, 4649
|
1067, 1086
|
3349, 3569
|
3661, 3717
|
3299, 3326
|
3771, 4556
|
1101, 1293
|
274, 316
|
440, 926
|
948, 1003
|
1019, 1051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,813
| 168,693
|
6726
|
Discharge summary
|
report
|
Admission Date: [**2138-10-24**] Discharge Date: [**2138-11-1**]
Date of Birth: [**2057-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Coumadin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
[**2138-10-28**] Mitral valve replacement (33mm St. [**Male First Name (un) 923**] Porcine),
Ligation of left atrial appendage
History of Present Illness:
80 yo M with history of hypertension, hyperlipidemia, and known
moderate to severe mitral regurgitation who presented to ED with
dyspnea, cough, and evidence of heart failure. The patient has
experienced progressive orthopnea, cough with blood tinged
sputum and a low grade fever for 2 days. These symptoms are
believed to be related to his mitral regurgitaion. We are asked
to evaluate for mitral valve replacment.
Past Medical History:
Hypertension
Hyperlipidemia
Diverticulosis
Gastroesophageal reflux disease
Thyromegaly
Raynaud's phenomenon
Prostate Cancer s/p prostatectomy
Osteoarthritis
s/p Right total hip replacement
s/p Left shoulder replacement
s/p Tonsillectomy
s/p Cataract surgery
Social History:
Race:Caucasian
Last Dental Exam:2 months ago
Lives with:wife
Occupation:retired investment manager
Tobacco:quit [**2099**]; 1 ppd x 25 yrs
ETOH:couple of drinks/day
Family History:
Father died of MI age 76
Physical Exam:
Pulse: 115 Resp: 23 O2 sat: 93%RA
B/P Right: 156/62 Left: 159/82
Height:6'0" Weight:150 LBS
General:AAOx3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]SINUS TACH Irregular [] Murmur IV/VII best heard
at apex [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x] Superficial veins B/L thighs with ecchymosis on medial
aspect of left thigh
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**10-24**] Cath: 1. Selective coronary angiography in this right
dominant system
demonstrated single vessel coronary disease. The LMCA, LAD and
Cx had no angiographically significant stenoses. The RCA had a
50% stenosis in the mid-vessel. 2. Resting hemodynamics revealed
mildly elevated right sided pressures with RVEDP of 11mm Hg and
moderately elevated left sided pressures with mean PCW of 25mm
Hg. Cardiac index was preserved at 2.4L/min/m2.
[**10-25**] Chest CT: 1. Perihilar ground-glass opacities, slightly
more prominent on the right, with bilateral small pleural
effusions, likely due to pulmonary edema. 2. Atherosclerotic
calcifications along the aorta and coronary arteries. Also
mitral annular and aortic annulus calcifications.
[**10-27**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%.
[**10-28**] Echo: Pre-bypass: No mass/thrombus is seen in the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
Left [**Month/Year (2) 14965**] wall thicknesses are normal. Overall left
[**Month/Year (2) 14965**] systolic function is low normal (LVEF 50-55%). This
function can grossly overestimate the real LV systolic function
in the presence of severe MR.
[**First Name (Titles) 167**] [**Last Name (Titles) 14965**] chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There may be mild aortic stenosis with AV
area of 1.2 or more. The cardiac output in the presence of
significant MR was around 3. The 2D examination of aortic valve
had shown aortic valve sclerosis. These concerns were conveyed
to the surgeon. The presence of low flow aortic stenosis
(?pseduo aortic stenosis could not be ruled out)> Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is partial mitral leaflet flail. An
eccentric, anteriorly directed jet of Severe (4+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is no pericardial
effusion. Post-bypass: The patient is receiving 0.25 mcg/kg/min
of milrinone for inotropic support post-CPB. Overall LVEF is
40%. There is a septal hypokinesis which was conveyed to the
surgeon. There is a well-seated prosthetic valve in the mitral
position with good leaflet excursion and residual mean gradient
of 2 mm of Hg. There is no paravalvular regurgitation. There is
trace transprosthetic regurgitation. Normal RV systolic
function. The left atrial appendage has been excised with a
minimal appendage stump remaining. Aortic valve area was
estimated to be 1.9cm2 after MV repair with a cardiac out put of
4.5L/min. The aorta is intact post-decannulation. All findings
communicated to the surgeon.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known firstname **] presented to [**Hospital1 18**] with
shortness of breath and acute on chronic heart failure from
severe mitral regurgitation. He was given the appropriate
medical management including antibiotics for possible underlying
pneumonia. He also underwent extensive work-up, including
cardiac cath, echo, carotid u/s and chest CT. He was eventually
stabilized with medical management and brought to the operating
on [**10-28**] where he underwent a mitral valve replacement on
[**2138-10-28**]. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she was transferred to the telemetry floor for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. He was started on betablockers, diuretics
and an Ace inhibitor was added for blood pressure control. He
was evaluated and treated by physical therapy and was cleared
for discharge to home on POD#4 with VNA services.
Medications on Admission:
ASPIRIN 81 mg daily
LOVASTATIN 20 mg daily
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. 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*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every six (6) hours: for pain.
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Mitral regurgitation s/p Mitral valve replacement
Acute on chronic heart failure
Past medical history
Hypertension
Hyperlipidemia
Diverticulosis
Gastroesophageal reflux disease
Thyromegaly
Raynaud's phenomenon
Prostate Cancer s/p prostatectomy
Osteoarthritis
s/p Right total hip replacement
s/p Left shoulder replacement
s/p Tonsillectomy
s/p Cataract surgery
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns
Followup Instructions:
Please call and schedule the following appointments
Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr.[**Doctor Last Name 3733**] in [**3-4**] weeks
Dr. [**Last Name (STitle) **] in [**1-31**] weeks
Completed by:[**2138-11-1**]
|
[
"443.0",
"530.81",
"429.5",
"562.10",
"429.89",
"424.0",
"416.8",
"428.0",
"285.29",
"428.43",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.36",
"88.56",
"35.23",
"39.61",
"37.27",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
7517, 7551
|
5074, 6211
|
303, 431
|
7954, 7960
|
2182, 5051
|
8502, 8757
|
1355, 1381
|
6304, 7494
|
7572, 7933
|
6237, 6281
|
7984, 8479
|
1396, 2163
|
237, 265
|
459, 876
|
898, 1157
|
1173, 1339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,786
| 143,654
|
18523+56963+56964
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2122-10-25**] Discharge Date: [**2122-11-5**]
Date of Birth: [**2068-9-13**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Upper GI bleed.
HISTORY OF THE PRESENT ILLNESS: This is a 54-year-old
gentleman with a history of hepatitis C, cirrhosis, and known
varices, status post recent banding of his varices who
presents with hematemesis. The patient was noted at his
group home to be vomiting blood. EMS was called at that
time. In the field, EMS noted that the patient's blood
pressure was 40/palpable. The patient was transferred
emergently to [**Hospital6 256**] where he
received approximately 8 units of packed red blood cells, 4
units of fresh frozen plasma, and 5-6 liters of normal
saline. Nasogastric lavage revealed bright red blood that
did not clear with 1 liter. At that time, the patient was
intubated for airway protection.
The patient was started on IV Octreotide and IV ciprofloxacin
240 mg q. 12 hours. The patient was admitted to the Medical
Intensive Care Unit for further care.
PAST MEDICAL HISTORY:
1. Hepatitis C.
2. Cirrhosis, Child's A.
3. Varices.
4. Hypertension.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Protonix.
2. Inderal.
SOCIAL HISTORY: The patient currently lives in a group home.
Positive history of IV drug abuse and alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile,
heart rate 100, blood pressure 127/61, respiratory rate 12,
saturating 98%. General: Intubated and paralyzed, assist
control. HEENT: Blood coming out of nares. Active bleeding
out of mouth, NG tube placed. [**Last Name (un) **] tube placed via OG.
Heart: Tachycardiac. Normal S1 and S2. Lungs: Bilateral
breath sounds anteriorly and laterally. Abdomen: Distended,
positive bowel sounds, tympanic. Extremities: No clubbing,
cyanosis or edema.
LABORATORY/RADIOLOGIC DATA: On admission, sodium 138,
potassium 4.0, chloride 106, bicarbonate 25, BUN 13,
creatinine 1.5, glucose 154. White blood cell count 6.6,
hematocrit 28.3, platelets 133,000. INR 1.2. Fibrinogen
123, amylase 92. ABGs on admission 7.33/41/467.
Chest x-ray on admission: Low lung volumes. ET tube in
place, approximately 3 cm above the carina. Perihilar
haziness.
HOSPITAL COURSE: During the ICU course, the patient received
23 units of packed red blood cells, 12 units of FFP, and 3 of
cryo. He underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] procedure on [**2122-10-26**] with
placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube. This resulted in 1 liter of
bloody output. The patient had no further variceal bleeding
since [**2122-10-26**]. He did have positive blood cultures on
[**2122-10-26**] and [**2122-10-27**] resulting in initiation of penicillin
for gram-positive alpha Streptococcus.
The patient was extubated on [**2122-11-1**] and did well on room
air with oxygen saturation in the high 90s. He did have some
mental status changes in the Intensive Care Unit which were
thought to be due to sedation with Fentanyl and possible
hepatic encephalopathy. These quickly resolved after the
patient was weaned off the Fentanyl drip.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2122-11-5**] 03:24
T: [**2122-11-5**] 17:45
JOB#: [**Job Number 50904**]
Name: [**Known lastname 9477**],[**Known firstname **] Unit No: [**Numeric Identifier 9478**]
Admission Date: [**2122-10-25**] Discharge Date: [**2122-11-10**]
Date of Birth: [**2068-9-13**] Sex: M
Service:
ADDENDUM:
SUMMARY OF HOSPITAL COURSE: Since transfer from the Medical
Intensive Care Unit to the floor team on [**2122-11-2**], patient
has done well. Issues have included: 1. Status post
variceal GI bleed: Patient has been stable since his
transfer to the floor. His hematocrit has remained stable
and has continued to be checked periodically. He has had no
more bleeding. Propranolol has been continued to lower his
portal hypertension.
2. Infectious disease: Patient has continued on penicillin-G
for treatment of gram-positive alpha Strep isolated on blood
cultures from [**10-26**] and [**10-27**]. He will continue on these
antibiotics through [**2122-11-12**] to complete a greater than two
week course. We continued to await identification of the
organism from the state laboratory. The patient is not
receiving treatment for a past sputum culture and
methicillin-sensitive Staphylococcus aureus. He has
continued to be afebrile, asymptomatic, and having normal
white blood cell count.
2. Cirrhosis: Patient has not been encephalopathic since his
transfer to the floor. He has continued to have a clear
mental status. He is continued on lactulose with a goal of
three stools per day.
3. Transaminitis status post TIPS procedure: LFTs have been
monitored periodically in this patient since his TIPS
procedure. Although he has had mild elevations with the
LFTs, overall they were within acceptable limits. Most
importantly, his total bilirubin and INR have not been
elevated. On last check on [**2122-11-7**], values included ALT
of 66, AST 93, LD 261, alkaline phosphatase 59, total
bilirubin 1.4.
4. Left eye cloudiness: The patient noted left eye
cloudiness approximately five days after being transferred to
the floor. However, he reported it had been noticeable since
his discharge from the Medical Intensive Care Unit, that he
had simply failed to mention it. It has been then improving
since that time with Artificial Tears. I will have the
patient follow up outpatient Ophthalmology.
5. Fluids, electrolytes, and nutrition: Patient has been
continued on a low sodium house diet. He has been tolerating
this well. Electrolytes have been replaced as needed.
6. Rehabilitation: Patient was seen by both Physical Therapy
and Occupational Therapy. He has made great strides during
his stay on the floor. He has been discharged by both
Physical and Occupational therapy. He is successfully
ambulating around the unit without difficulty.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient will be discharged to [**Hospital 1238**]
Hospital for completion of his IV penicillin.
DISCHARGE DIAGNOSES:
1. Esophageal varices with bleeding.
2. Cirrhosis.
3. Hepatitis B without hepatic carcinoma.
4. Hypertension.
5. Mental status changes now resolved.
6. Bacteremia.
DISCHARGE MEDICATIONS:
1. Combivent 1-2 puffs inhaled q.4h. prn.
2. Spironolactone 50 mg p.o. q.d.
3. Lactulose 30 mL q.8h. prn for a goal of three stools per
day.
4. Propanolol 80 mg p.o. t.i.d.
5. Famotidine 20 mg p.o. b.i.d.
6. Multivitamin tablets one cap p.o. q.d.
7. Zinc sulfate 220 mg p.o. q.d.
8. Ascorbic acid 500 mg one tablet p.o. b.i.d.
9. Artificial Tears prn.
10. Penicillin-G 4 mU IV q.4h. to complete a two week course
through [**2122-11-12**].
FOLLOW-UP INSTRUCTIONS: Patient will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9479**] in [**Location (un) 4887**]. He will
schedule this appointment at his convenience once he is
discharged from rehabilitation. Instructions will be made to
have Dr. [**Last Name (STitle) 9479**] facilitate the patient and seen at outpatient
ophthalmologist once the patient has obtained insurance.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4098**], M.D. [**MD Number(2) 5314**]
Dictated By:[**Name8 (MD) 9480**]
D: [**2122-11-10**] 09:19
T: [**2122-11-10**] 09:18
JOB#: [**Job Number 9481**]
Name: [**Known lastname 9477**],[**Known firstname **] Unit No: [**Numeric Identifier 9478**]
Admission Date: [**2122-10-25**] Discharge Date: [**2122-11-10**]
Date of Birth: [**2068-9-13**] Sex: M
Service:
ADDENDUM:
SUMMARY OF HOSPITAL COURSE: Since transfer from the Medical
Intensive Care Unit to the floor team on [**2122-11-2**], patient
has done well. Issues have included: 1. Status post
variceal GI bleed: Patient has been stable since his
transfer to the floor. His hematocrit has remained stable
and has continued to be checked periodically. He has had no
more bleeding. Propranolol has been continued to lower his
hepatic hypertension.
2. Infectious disease: Patient has continued on penicillin-G
for treatment of gram-positive alpha Strep isolated on blood
cultures from [**10-26**] and [**10-27**]. He will continue on these
antibiotics through [**2122-11-12**] to complete a greater than two
week course. We continued to await identification of the
organism from the state laboratory. The patient is not
receiving treatment for a past sputum culture and
methicillin-sensitive Staphylococcus aureus. He has
continued to be afebrile, asymptomatic, and having normal
white blood cell count.
2. Cirrhosis: Patient has not been encephalopathic since his
transfer to the floor. He has continued to have a clear
mental status. He is continued on lactulose with a goal of
three stools per day.
3. Transaminitis status post TIPS procedure: LFTs have been
monitored periodically in this patient since his TIPS
procedure. Although he has had mild elevations with the
LFTs, overall they were within acceptable limits. Most
importantly, his total bilirubin and INR have not been
elevated. On last check on [**2122-11-7**], values included ALT
of 66, AST 93, LD 261, alkaline phosphatase 59, total
bilirubin 1.4.
4. Left eye cloudiness: The patient noted left eye
cloudiness approximately five days after being transferred to
the floor. However, he reported it had been noticeable since
his discharge from the Medical Intensive Care Unit, that he
had simply failed to mention it. It has been then improving
since that time with Artificial Tears. I will have the
patient follow up outpatient Ophthalmology.
5. Fluids, electrolytes, and nutrition: Patient has been
continued on a low sodium house diet. He has been tolerating
this well. Electrolytes have been replaced as needed.
6. Rehabilitation: Patient was seen by both Physical Therapy
and Occupational Therapy. He has made great strides during
his stay on the floor. He has been discharged by both
Physical and Occupational therapy. He is successfully
ambulating around the unit without difficulty.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient will be discharged to [**Hospital 1238**]
Hospital for completion of his IV penicillin.
DISCHARGE DIAGNOSES:
1. Esophageal varices with bleeding.
2. Cirrhosis.
3. Hepatitis B without hepatic carcinoma.
4. Hypertension.
5. Mental status changes now resolved.
6. Bacteremia.
DISCHARGE MEDICATIONS:
1. Combivent 1-2 puffs inhaled q.4h. prn.
2. Spironolactone 50 mg p.o. q.d.
3. Lactulose 30 mL q.8h. prn for a goal of three stools per
day.
4. Propanolol 80 mg p.o. t.i.d.
5. Famotidine 20 mg p.o. b.i.d.
6. Multivitamin tablets one cap p.o. q.d.
7. Zinc sulfate 220 mg p.o. q.d.
8. Ascorbic acid 500 mg one tablet p.o. b.i.d.
9. Artificial Tears prn.
10. Penicillin-G 4 mU IV q.4h. to complete a two week course
through [**2122-11-12**].
FOLLOW-UP INSTRUCTIONS: Patient will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9479**] in [**Location (un) 4887**]. He will
schedule this appointment at his convenience once he is
discharged from rehabilitation. Instructions will be made to
have Dr. [**Last Name (STitle) 9479**] facilitate the patient and seen at outpatient
ophthalmologist once the patient has obtained insurance.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4098**], M.D. [**MD Number(2) 5314**]
Dictated By:[**Name8 (MD) 9480**]
D: [**2122-11-10**] 09:19
T: [**2122-11-10**] 09:18
JOB#: [**Job Number 9481**]
|
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icd9cm
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[
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45,495
| 162,512
|
42290
|
Discharge summary
|
report
|
Admission Date: [**2163-8-17**] Discharge Date: [**2163-8-22**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central line placement and removal
History of Present Illness:
88 yo M with prior CVA with residual aphasia and right-sided
weakness, CAD, Afib, initially presenting to [**Hospital1 16961**] with right lower extremity edema. He had some leg skin
lesions, starting in [**Month (only) 116**]. He was treated with various topical
treatments, and a prednisone taper. Within the past few days,
the patient was noted to have mottling of his skin on his lower
extremities, particularly on the right. He has had intermittent
RLE edema chronically, but has been more swollen within the past
few weeks. Due to concern about DVT, empiric lovenox was started
for a few days. The patient is not chronically on
anticoagulation.
At [**Hospital1 **], ultrasound was reportedly negative for DVT.
Labs were notable for K 5.4, BUN 77, Cr 1.9. He was sent back to
rehab, then sent to [**Hospital1 18**] for further evaluation.
In the ED at [**Hospital1 18**], initial vital signs were T 97.2, BP 137/70,
HR 70, RR 12, Sat 100%/RA. Right lower extremity ultrasound was
limited due to patient's contractures, but no obvious DVT. The
patient subsequently became tachycardic to the 100s, with SBP
falling to the 90s. Labs were notable for K 6.6, with U/A
suggestive of infection. CXR was unremarkable. He was given
cipro 400 mg IV and 2L NS prior to transfer to the medical
floor.
On arrived to the medical floor, he triggered for BP 86/doppler.
EKG showed Afib/RVR with HR 140s. A secondary peripheral IV was
placed. Normal saline was infused through both IVs, and the
patient was transferred to the MICU.
On arrival to the MICU, the patient was aphasic and unable to
answer questions.
Past Medical History:
CAD s/p MI x2
CVA x2 with residual right sided weakness and aphasia
Baseline mental status: Can say "what is" but little else,
cannot write. Can interact appropriately non-verbally and answer
yes/no questions
CHF
Hypercholesterolemia
Multiple UTI's
Renal failure (baseline creatinine 1.5)
Afib (not on Coumadin)
Depression
Narcolepsy
s/p pacemaker
Social History:
Retired from [**Last Name (un) 91648**] sporting goods where he worked as a
shipper. Former pipe smoker (quit 40 years ago).
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs: T 96.2 HR 106 BP 79/53 RR 17 Sat 98%/RA
General: Sleepy but arousable.
HEENT: Anicteric sclerae. Dry mucous membranes.
Neck: Supple. No JVD.
Resp: Normal respiratory effort. CTAB.
CV: Tachycardia. Irregular rhythm. Normal s1, s2. No M/G/R.
Abd: +BS. Distended. Diffusely tender, with no rebound or
guarding.
Ext: 2+ RLE edema.
Neuro: Alert. Aphasic. Says "no". Does not respond to commands.
PERRL. Moving all extremities.
DISCHARGE PHYSICAL EXAM:
General: NAD, verbal responses are ??????yes?????? or ??????is what it is??????
HEENT: Anicteric sclerae. MMM, PERRL.
Neck: Supple, no JVD
Resp: CTA bilaterally, no murmurs/rubs/[**Last Name (un) 549**]
CV: Irregularly irregular, NlS1S2, I/VI systolic murmur at apex
Abd: +BS, NT/ND, no rebound or guarding.
Ext: Extremities contracted, 2+ BLE edema.
Neuro: Alert, aphasic, repeats "it is what it is, what it is,??????
in response to all questions. Does not respond to commands,
moving all extremities.
Pertinent Results:
Admission Labs:
[**2163-8-17**] 12:45PM WBC-11.4* RBC-4.15* HGB-13.6* HCT-41.9
MCV-101* MCH-32.7* MCHC-32.4 RDW-18.2*
[**2163-8-17**] 12:45PM NEUTS-79* BANDS-0 LYMPHS-15* MONOS-4 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2163-8-17**] 12:45PM GLUCOSE-161* UREA N-93* CREAT-2.5*
SODIUM-128* POTASSIUM-7.5* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-19
[**2163-8-17**] 01:35PM PT-12.9 PTT-25.4 INR(PT)-1.1
[**2163-8-17**] 01:35PM PLT COUNT-203
[**2163-8-17**] 07:37PM CALCIUM-7.8* PHOSPHATE-3.4 MAGNESIUM-2.3
[**2163-8-17**] 07:37PM CK-MB-5 cTropnT-0.02*
[**2163-8-17**] 07:37PM CK(CPK)-80
[**2163-8-17**] 09:04PM LACTATE-2.0
Discharge Labs:
[**2163-8-22**] 02:29AM BLOOD WBC-7.9 RBC-3.19* Hgb-10.4* Hct-31.9*
MCV-100* MCH-32.6* MCHC-32.7 RDW-18.0* Plt Ct-144*
[**2163-8-20**] 02:58AM BLOOD Neuts-87.0* Lymphs-9.1* Monos-3.8 Eos-0.1
Baso-0.1
[**2163-8-22**] 02:29AM BLOOD Glucose-196* UreaN-59* Creat-1.7* Na-139
K-3.0* Cl-109* HCO3-20* AnGap-13
[**2163-8-21**] 01:38AM BLOOD ALT-180* AST-176* LD(LDH)-356*
AlkPhos-127 TotBili-0.3
[**2163-8-22**] 02:29AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
[**2163-8-20**] 02:58AM BLOOD Vanco-18.2
[**2163-8-22**] 02:29AM BLOOD Digoxin-1.7
[**2163-8-21**] 02:04AM BLOOD Lactate-2.0
Microbiology:
[**2163-8-17**] 2:00 pm URINE Site: CATHETER
**FINAL REPORT [**2163-8-22**]**
URINE CULTURE (Final [**2163-8-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SECOND TYPE.
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. 3RD
MORPHOLOGY.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| PROTEUS MIRABILIS
| | PROTEUS
MIRABILIS
| | |
AMPICILLIN------------ <=2 S <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM------------- 0.5 S <=0.25 S <=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
[**2163-8-17**] 1:55 pm BLOOD CULTURE Site: ARM 2ND SET.
Blood Culture, Routine (Pending): PENDING
[**2163-8-17**] 7:15 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2163-8-20**]**
MRSA SCREEN (Final [**2163-8-20**]): No MRSA isolated.
STUDIES:
[**2163-8-21**] KUB: No evidence of obstruction.
[**2163-8-20**] TTE: The left atrium is mildly dilated. The left
ventricular cavity size is top normal/borderline dilated. Global
left ventricular systolic function is probably normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of mitral
regurgitation.] The right ventricle is not well visualized; RV
free wall motion appears grossly preserved in limited views but
intrinsic function may be depressed given the severity of
tricuspid regurgitation. The aortic valve leaflets are mildly
thickened (?#). The aortic valve is not well seen. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is at least mild
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a
trivial/physiologic pericardial effusion.
CXR [**2163-8-18**]: Appropriately positioned right subclavian line.
Worsened
moderate pulmonary edema.
RLE Ultrasound [**2163-8-17**]: Limited study as described above
without DVT in the right common femoral and proximal superficial
femoral vein. The distal right superficial femoral, right
popliteal, and right calf veins could not be assessed.
ECG [**2163-8-17**]: Atrial fibrillation with rapid ventricular
response. Right bundle-branch block. Non-specific ST-T wave
changes. Low voltage in the precordial leads.
Brief Hospital Course:
HOSPITAL COURSE:
88 year old male with h/o CVA with severe aphasia with R-sided
weakness, transferred to MICU with hypotension, treated for
urosepsis with broad spectrum antibiotics.
#. Urosepsis / Hypotension: Patient admitted with hypotension
with SBP 70s, in the setting of atrial fibrillation with RVR and
with UA suggestive of UTI. There were no other focal signs of
infection. Patient was started on vanco/cefepime for broad
coverage given history of recurrent UTIs. Patient had a CVL
placed and received aggressive fluid resuscitation (about 5L).
He was started on pulse dose steroids with hydrocortisone; home
metoprolol and lasix were held. SBP rose to the 90-110s.
Steroids were eventually returned to pre-admission taper. As
urosepsis resolved and rate control was obtained, hypotension
resolved. He did not require pressor support. His urine
culture grew Proteus sensitive to all cephalosporins and his
antibiotics were changed to cefpodoxime for a total 10 day
course.
#. Atrial fibrillation with RVR: He was started on digoxin for
rate control for atrial fibrillation given hypotension. His
rate responded well. His blood pressure remained very sensitive
to beta blockade, and his metoprolol was not restarted. If he
continues to have tachycardia, could restart slowly after
discharge. His HR at discharge was 80-110. Digoxin level was
checkced and was 1.7 on the day of discharge.
#. Acute on chronic renal failure: He was admitted with Cr 2.5
from baseline creatinine of 1.5 which was felt to be pre-renal
in etiology in the setting of urosepsis. Creatinine improved
with IV fluid resuscitation. Lasix was held initially on
admission. Once [**Last Name (un) **] resolved and patient fully fluid
resuscitated, home lasix resumed.
#. Hyperkalemia: Patient had K 7.5 on presentation without EKG
changes. He was treated with calcium gluconate, insulin and
dextrose, and kayexalate (once able to take PO). Etiology
thought to be [**1-26**] renal failure and baseline potassium
supplementation. Once urinary output improved, potassium
returned to [**Location 213**] value.
#. Diabetes mellitus: Continued insulin sliding scale while in
house. His long-acting NPH was held as he did not initially
have oral intake. His blood sugars ranged 80-250 while in the
hospital, although started to trend up to high 100's by the time
of discharge. His NPH will likely need to be restarted slowly
in the next 1-2 days.
#. Hyperlipidemia: Statin resumed once patient stabilized on
admission.
#. RLE swelling: He had LENIs negative for DVT. It was felt
that he likely has chronic venous insufficiency.
#. Other meds. His other medications were held initially in the
setting of lethargy including allopurinol, ASA, citalopram,
cranberry, Os-Cal, omeprazole, tylenol, benadryl, dulcolax,
imodium milk of magnesia, robitussin, vicodin. These can be
restarted after discharge. His home prednisone taper and
simvastatin have already been restarted.
TRANSITIONAL ISSUES:
- Continue cefpodoxime x 5 more days (end date [**2163-8-27**])
- Blood cultures from admission still pending
- Recommend wound care evaluation after discharge for bilateral
lower extremity wounds. Currently wrapped with Adaptic and
Kerlix gauze.
- Monitor blood sugars closely, likely will need to restart NPH
in next 1-2 days
- Follow heart rate, may need metoprolol added back slowly
- Health care proxy [**Name (NI) **] [**Name (NI) 57492**] [**Telephone/Fax (1) 91649**](c), RN [**First Name8 (NamePattern2) **] [**Known lastname **]
at The Stone House ([**Telephone/Fax (1) 91650**]
- Code status: DNR/DNI
Medications on Admission:
allopurinol 100 mg daily
aspirin EC 325 mg daily
citalopram 20 mg daily
cranberry oral tablet 450 mg 2 tablets [**Hospital1 **] (?1 tablet [**Hospital1 **])
furosemide 40 mg daily at 5 p.m.
furosemide 80 mg daily at 8 a.m.
Novolin N 18 units SQ QAM
Novolin R sliding scale
Os-Cal 500+D 500-200 mg-unit [**Unit Number **] tablet PO BID
potassium chloride CR 20 mEq PO daily
prednisone taper (currently on 10 mg daily)
omeprazole 20 mg daily
Toprol XL 50 mg daily
Tylenol
simvastatin 40 mg daily
Benadryl Allergy 25 mg Q6H:PRN itching
Dulcolax 10 mg PR PRN
Fleet enema PRN
Imodium 2 mg Q8H PRN
Milk of magnesia 30 mL PRN
nitro SL 0.4 mg PRN
Robitussin maximum strength 10 mL Q4H:PRN
Vicodin 5-500 1 tablet Q6H PRN
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cranberry Concentrate Capsule Sig: [**12-26**] Capsules PO twice
a day: Take as you were prior to admission.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM.
7. Humalog 100 unit/mL Solution Sig: Per Sliding Scale
Subcutaneous four times a day: Give insulin per sliding scale.
Also was on NPH 18 units QAM prior to admission which was held
during hospitalization.
8. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
10. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please continue pre-hospitalization taper.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for fever or pain.
13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Benadryl Allergy 25 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for allergy symptoms.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
17. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days: Last day [**2163-8-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 5277**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary Diagnosis:
Septic shock due to urinary tract infection
Atrial fibrillation with rapid ventricular response
Secondary Diagnosis:
Chronic congestive heart failure
Chronic kidney disease
Coronary artery disease
Diabetes mellitus
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Aphasia, unable to communicate effectively
Discharge Instructions:
It was a pleasure taking care of you. You were admitted to
[**Hospital1 18**] with a severe infection from your urinary tract and low
blood pressure. You were treated with broad spectrum
antibiotics and your blood pressure stabilized. You also had
kidney failure that improved with treatment of your urinary
infection.
CHANGES TO YOUR MEDICATIONS:
START digoxin 0.125mg every other day
START cefpodoxime 200mg twice daily for 5 more days
STOP metoprolol succinate - this medication can be slowly
restarted after discharge if needed for tachycardia
STOP NPH insulin - can be restarted after discharge if
hyperglycemia
weight increases by more than 3 lbs. We also recommend a wound
care evaluation.
Followup Instructions:
You should follow-up with the physicians at your rehab facility
([**Hospital3 5277**])
|
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icd9cm
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[
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2287, 2413
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2948, 3453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,673
| 152,922
|
5623+55687
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-2-9**] Discharge Date: [**2185-2-21**]
Date of Birth: [**2123-6-24**] Sex: F
Service: MEDICINE
Allergies:
Prevpac / Penicillins
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest [**Hospital 22556**] transfer from [**Hospital1 1516**] for pericardial tamponade,
s/p pericardial drain placement
Major Surgical or Invasive Procedure:
pericardial drain placement
History of Present Illness:
Ms. [**Known lastname 4886**] is a 61 year old woman with hx of ulcerative
colitis/Crohns, recent DVT, who presented with chest discomfort
initially, found to have pericardial effusion increasing in
size, who was transferred from Cardiology service to CCU for
overnight monitoring s/p placement of pericardial drain for
pericardial effusion/ tamponade.
Patient was recently discharged from [**Hospital1 18**] with pneumonia, for
which she was treated with Vancomycin and Ciprofloxacin. Patient
was noted to have small pericardial effusion at that time with a
pulsus paradoxus of <10mmHg, felt to be stable. She was also
diuresed for volume overload, and her TPN volume was decreased.
She was discharged on [**2-5**].
Patient returned to hospital on this admission because of
temperature to 100.1F and was found to have pericardial effusion
markedly incrased in size. On presentation to floor, patient did
complain of tugging sensation in her chest, muscle aches and dry
cough and reported having had these symptoms on discharge from
previous hospitalization. She does report diarrhea but unchanged
from her normal diarrhea associated with her IBD. She was ruled
out for influenza on the floor. She denied chills, sore throat,
runny nose, headache, abdominal pain or SOB. She denied
hematochezia or melena. She admitted to intermittent swelling of
her legs for past two years, which she attributed to her gout
initially.
Echocardiogram this morning was similar to previous Echo
yesterday, showing large free-flowing pericardial effusion with
RV invagination and diastolic collaps, evidence of cardiac
tamponade. Patient was taken to Cath lab for placement of
pericardial drain. Right Heart Cath showed equalization of
pressures in RA, PCWP, and Pericardial Pressure at 20mmHg,
suggesting tamponade physiology. 450cc serosanguinous fluid
drained from pericardiocentesis, fluid sent for studies, drain
left in place, and patient transferred to CCU for further
monitoring.
On transfer to CCU, she appears to be comfortable and stable. No
complaints of chest discomfort, just has mild lower back pain
from positioning in bed.
Past Medical History:
1. Crohn disease diagnosed in [**2159**], in the past she had surgery
due to bowel obstruction requiring a 40-day stay including ICU
management. Colonoscopy last done in [**2184-3-17**]. Currently, on
Remicade infusions every 8 weeks and started on TPN [**12/2184**]
2. Gout. Present in left toes and ankles.
3. Pseudogout.
4. Tubal ligation in the past.
5. Osteoporosis. Recent bone scan shows severe osteoporosis,
not taking bisphosphonate currently.
6. Several abscesses in teeth requiring teeth extraction, likely
secondary to Remicade infusion.
7. Hammertoes.
8. Elbow pain requiring surgery.
9. Asymptomatic kidney stones.
10. Fracture of ribs from coughing.
11. Depression
12. Hypothyroidism
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Retired, worked for election department. Currently lives with
son and son's father (ex-husband). Needs help with almost all
ADLs. States she would probably not be alive without other's
assistance. Diet: Eats what is tolerated. Tobacco, quit last
month. smoked about pack/day for about 40 years. Alcohol,
denies.
Family History:
Positive for diabetes, gout. Negative for inflammatory bowel
disease or GI cancer. Father had heart disease, mother had [**Name (NI) 2320**]
and HTN.
Physical Exam:
VS: T=98.6 BP=112/58 HR=92 RR=18 O2 sat= 100% 2L NC
GENERAL: very thin woman, appears older than stated age, in NAD.
Oriented x3. mildly anxious appearing.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink,
moist mucus membranes.
NECK: JVP not elevated
CARDIAC: RR, normal S1, S2. Rate 90s. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Respirations unlabored, no accessory muscle use. lung
fields clear anteriorly and laterally; limited posterior lung
exam while lying supine post-procedure; no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: Trace lower extremity edema, but has significant
sacral edema. Right groin site clean, dry, no hematomas or
ecchymosis.
SKIN: lower extremities w blanching erythema; nonblanchable
sacral erythema
Pertinent Results:
Admission Labs ([**2185-2-9**]):
134 97 26
------------- 71
4.6 31 1.1
CK: 21 MB: Notdone Trop-T: 0.01
.
TSH:2.0
.
......8.8
13.6 ----- 336
.....27.7
N:87.8 L:8.3 M:3.5 E:0.3 Bas:0.1
.
Lactate:1.2
Serial Echos x 7
ECHO [**2185-2-9**]
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Stranding is visualized within the pericardial
space c/w organization. RV diastolic collapse, c/w impaired
fillling/tamponade physiology.
Conclusions:
The estimated right atrial pressure is 10-15mmHg. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). The right
ventricular cavity is small with borderline normal free wall
function. There is a large pericardial effusion. The effusion
appears circumferential. Stranding is visualized within the
pericardial space c/w organization. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology.
Compared with the findings of the prior study (images reviewed)
of [**2185-2-4**], the size of the pericardial effusion is
markedly increased. Echocardiographic evidence of cardiac
tamponade is now present.
.
Echo [**2185-2-15**]
Overall left ventricular systolic function is normal (LVEF>55%).
RV with normal free wall contractility. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2185-2-14**], the
effusion appears slightly smaller.
Brief Hospital Course:
61yoF with h/o Crohn's disease, recent DVT on Lovenox, bilateral
pleural effusions, large pericardial effusion seen on echo with
echo evidence of tamponade physiology; also with leukocytosis,
low grade fever, paroxysms of AFib seen on telemetry on
presentation.
.
# Pericardial Effusion:
The patient had a recent chest CT and previous echocardiograms
showing evidence of a pericardial effusion. However, the
effusion appeared larger on initial bedside TTE in the ED
(moderate to large in size). Clinically the patient appeared
well with stable bp's and pulses with pulsus paradoxus [**7-26**].
However, given echocardiographic findings suggestive of early
tamponade phsyiology, pt underwent placement of a pericardial
drain. The patient was transferred to the CCU post-procedure
for monitoring with continued significant drainage initially
which tapered off. After the drain was pulled, she had two
serial TTEs which did not show reaccumulation of pericardial
fluid. The pericardial fluid showed WBC 111 (Polys 60, Lymphs
30, Monos 10), Hct 12 with negative cytology and negative
cultures to date (acid fast smear negative but acid fast and
fungal cultures still pending). Rheumatology was consulted for
a high [**Doctor First Name **] titer (1:1280), positive dsDNA. Given tha positive
anti-histone antibody, the most likely cause of the pericardial
effusion is believed to be drug-induced SLE, likely secondary to
infliximab. The patient's GI specialist, Dr. [**Last Name (STitle) 1940**], was
notified that the patient should have her infliximab
discontinued indefinitely. Her pulsus paradoxus was 6 for two
days following transfer from the CCU to the floor. The patient
had a TTE on [**2-21**] ~1 week following her pericardial drain, which
showed continued resolution of the pericardial effusion. She
will need another TTE around [**3-15**] to follow up and ensure the
continued resolution of the pericardial effusion, and was
notified of this prior to discharge.
.
# Deep Venous Thrombosis:
On a past admission, pt was found to have R lower superficial
femoral vein and popliteal vein DVT in [**2184-11-16**] with plan
for 6 month anticoagulation. Initially started on coumadin but
quickly switched to enoxaparin because INR was consistently very
supratherapeutic secondary to poor nutritional status. Most
recently on 40mg enoxaparin [**Hospital1 **], which was switched to heparin
gtt in anticipation of procedure on admission. This was briefly
held in the setting of bloody pericardial effusion in the CCU,
but was re-started on the floor after resolution of pericardial
drainage. LE US showed near-resolution of DVT.
.
# Atrial Fibrillation:
Patient with h/o afib was intermittently in afib throughout her
hospital stay. She was given IV metoprolol, as well as
adenosine in the CCU with conversion back to NSR. The patient
was briefly on admiodarone for anti-arrhythmic effects, but this
was discontinued following pericardial drain when the patient
converted back to NSR. The patient was also briefly on
phenylephrine for MAPs in 40s, SBP in 70 in the CCU, not
responsive to fluids, and was also transfused 1 unit PRBC for
Hct 21. The patient was anticoagulated as above with Heparin
and then Lovenox.
.
# Crohns disease:
Patient with chronic diarrhea [**1-18**] Crohn's disease, guaiac
negative. During these most recent admissions she had a
colonoscopy which was grossly normal up to the ileo-colonic
anastamosis, biopsies also normal at that time, and then had a
follow up MR enterography [**2185-1-14**] showing wall thickening and
hyperemia in the cecum and neoterminal ileum, consistent with
Crohn's disease, which was new from previous study. No evidence
of fistula or abscess formation. She is currently being managed
with daily Mesalamine and Remicade IV q 8wks. Colonoscopy last
done in [**2184-3-17**] did not show evidence of infection or crohn's
flare. Abdominal US during this hospitalization showed only
trace ascites, large b/l pleural effusions, and b/l urolithiasis
and renal cysts. GI was consulted and recommended holding
Mesalamine. Additionally, the patient had been started on
chronic TPN via R PICC about 1 month ago for poor nutritional
status, but TPN was held initially in the setting of pleural
effusions and ?pericardial effusion from fluid overload. The
patient was re-initiated on TPN slowly on the floor and was
cautiously advanced to optimal rate. She should be diuresed
with Spironolactone as needed if she becomes volume overloaded
on TPN. Patient was also continued on Mesalamine, B12, VitD,
iron, Ca carbonate
.
# Lower Extremity Edema/Pleural Effusions/Volume Status:
Patient with a history of lower extremity edema for several
years presented with significant sacral edema, likely [**1-18**] poor
nutritional status and low oncotic pressure [**1-18**] low albumin.
Possibly worsened by acute RV backup secondary to impaired RV
filling in setting of pericardial effusion and tamponade.
However, patient continued to have LE edema following drainage
of pericardial effusion. She was also noted on CXR and
echocardiograms to have b/l pleural effusions which persisted
throughout her hospital stay, and likely also [**1-18**] poor
nutritional status. Her oxygen and respiratory status were
carefully monitored throughout her hospitalization, with a plan
to diurese with Spironolactone as needed for hypoxia or dyspnea,
but the patient did not require diuresis.
.
# Leukocytosis:
Patient with leukocytosis on presentation and was given a dose
of Azithromycin/Ceftriaxone/Vancomycin. Pt had positive UA, but
culture shows <10K organisms, and patient was briefly started on
treatment with cipro/flagyl which were subsequently
discontinued. CXR was negative for infiltrate. Pt was ruled out
for influenza. Blood cultures were negative. Patient remained
afebrile during hospitalization, leukocytosis resolved, and
recent CT abd is without evidence of colitis.
.
# Acute renal insufficiency: Cr elevated and stable at 1.1 from
baseline of 0.7. Improved with fluids back to baseline.
.
# Hypothyroidism: Recently diagnosed; pt was continued on
levothyroxine.
.
# Hx Gout/Pseudogout: Continued allopurinol at renal dose,
continued colchicine.
.
# Depression: not currently on medication. Was seen by social
work in-house.
Medications on Admission:
Budesonide 3 mg capsule sustained-release daily,
Cyanocobalamin 1000 mcg monthly injection
Indomethacin 50 mg twice a day
Infliximab 500 mg infusion every 8 weeks
Mesalamine 400 mg four tablets per mouth 3 times a day,
triamterene/hydrochlorothiazide 50 mg/25 mg one capsule daily
Calcium carbonate 300 mg tablet daily
Ergocalciferol 400-unit tablet twice a day
Ferrous sulfate 325 mg tablet once a day
Magnesium oxide 400 mg tablet once a day
Multivitamin.
Levothyroxine 50mcg QD
Venlafaxine 37.5mg [**12-18**] tablet QD
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
10. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous DAILY (Daily).
11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
12. TPN
Volume(ml/d) 1400 Amino Acid(g/d) 70 Dextrose(g/d) 315
Fat(g/d) 35
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL 30 NaAc 0 NaPO4 40 KCl 10 KAc 30 KPO4 0 MgS04 15
CaGluc 9
Cycle over 12 (hrs.) Start at 1800 Decrease rate to 0 (ml/h) at
600 Stop 600
13. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pericardial effusion secondary to Infliximab-induced Systemic
Lupus Erythematous
Secondary Diagnosis:
Nutrition Deficiency
Chronic Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid ([**Known lastname **]
or cane)
Discharge Instructions:
You presented to the hospital with chest discomfort and you were
found to have a fluid collection around your heart. This was
drained and echocardiograms showed resolution of the fluid after
drainage without reaccumulation subsequently. Your blood tests
indicate the fluid was secondary to a condition triggered by
your Infliximab treatments. Your gastroenterologist was
notified of this, and you should not be treated with Infliximab
in the future.
While in the hospital, your TPN was held initially for a concern
for fluid overload. However, once it was determined that the
fluid around your heart was due to Infliximab, you were
re-started on TPN slowly with close monitoring. You tolerated
the TPN well.
The following changes were made to your medications:
- Furosemide was discontinued
- Heparin drip was discontinued
- Remicade (Infliximab) was discontinued; you should not take
this medication in the future as this caused fluid to accumulate
around your heart
- Enoxaparin was changed to an equivalent once-a-day dose
- Lovenox was started to thin your blood
- Metoprolol was started for your heart
Followup Instructions:
Please call [**Telephone/Fax (1) 62**] to schedule an appointment for a TTE
(trans-thoracic echocardiogram) in 1 month (around [**2185-3-15**]) to
ensure the fluid around your heart has not reaccumulated.
You have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3990**], MD
Phone:[**Telephone/Fax (1) 250**]
Date/Time: [**2185-3-21**] 9:00am
Provider: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 1983**]
Date/Time: [**2185-3-14**] 4:15pm
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2185-3-10**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2185-3-25**] 8:20
Provider: [**Name10 (NameIs) **] STUDY
Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2185-6-1**] 9:00
Name: [**Known lastname 2601**],[**Known firstname **] Unit No: [**Numeric Identifier 3779**]
Admission Date: [**2185-2-9**] Discharge Date: [**2185-2-21**]
Date of Birth: [**2123-6-24**] Sex: F
Service: MEDICINE
Allergies:
Prevpac / Penicillins
Attending:[**First Name3 (LF) 3780**]
Addendum:
Contact[**Name (NI) **] Dr. [**Last Name (STitle) 3781**] and clarified that the patient should be
re-started on Mesalamine on discharge from the hospital. She
will follow-up with Dr. [**Last Name (STitle) 3781**] in 1 month.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**]
Completed by:[**2185-2-21**]
|
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"428.0",
"311",
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"E947.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
401, 430
|
14681, 14681
|
4679, 6172
|
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3706, 3857
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3872, 4660
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|
14605, 14660
|
14696, 14852
|
2602, 3361
|
3377, 3690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,027
| 152,934
|
46942
|
Discharge summary
|
report
|
Admission Date: [**2165-7-19**] Discharge Date: [**2165-7-31**]
Date of Birth: [**2101-3-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Ace Inhibitors /
hydrochlorothiazide / Macrolide Antibiotics / Penicillins
Attending:[**Attending Info 8238**]
Chief Complaint:
fever, malaise
Major Surgical or Invasive Procedure:
Washout with I&D of posterior thoracolumbar incision with
removal and reinstrumentation.
History of Present Illness:
Ms. [**Known lastname 122**] is a 64F with a history of COPD (not on home O2) and
recent spinal fusion with hardware at [**Hospital6 17390**] on [**2165-6-27**] who presented with back pain, fever and
malaise. She had been recovering well from her recent surgery at
rehab ([**Hospital3 **]) until a few days ago when she began to
experience increasing back pain. She did not have bowel or
bladder dysfunction. She did have weakness in her left lower
extremity however she reports this is chronic. She did not
notice any drainage from the surgical site. Because of her
increasing pain she was seen by her orthopedic surgeon in clinic
this morning. Records from that encounter are not available at
this time. The patient reports that she was told that the top of
her wound "looked infected" but she was not given antibiotics.
After she went back to rehab she began to experience fevers and
malaise and therefore she was sent to the [**Hospital1 18**] ED.
In the ED initial VS were 102.7 117 110/47 20 99% 4L. An EKG was
performed which showed sinus tach and right bundle branch block
which is old. CK-MB was negative. Lactate was 1.8. She was given
3 liters of fluid and a right IJ was placed. She was started
empirically on Vancomycin, Levofloxacin, and Flagyl. A CTA of
the chest/abdomen/pelvis was performed which was (prelim)
negative for PE but showed a very large fluid collection
posterior to the thoraco-lumbar fusion hardware. Orthopedics was
consulted in the ED and recommended admission to the MICU for
fever workup.
On arrival to the MICU, the patient immediately spiked to 102.
She was alert and oriented and able to recount details of recent
events. She reported that her back pain was well controlled.
Of note the patient was admitted between [**6-27**] and [**7-4**] to [**Hospital1 **] for a thoracolumbar spinal fusion.
Post-op course was complicated by leukocytosis. Initially a PNA
was suspected and she was treated with levofloxacin. However
cdif subsequently came back positive and levofloxacin was
stopped and she was started on PO vancomycin(course completed
[**2165-7-14**]). She was transferred to rehab after discharge. She has
not had diarrhea in several days.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. Denies chest pain, chest pressure, palpitations.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-CAD
-COPD/Asthma
-Pulmonary HTN
-Bipolar D/O
-T2DM
-Diabetic Neuropathy
-Hypothyroidism
-OSA on CPAP
-HTN
-HLD
-Stress Urinary Incontinence
-Diverticulosis
-IBS
-Osteoarthritis
-Spinal Stenosis
-Chronic Peripheral Edema
-GERD
-3 cm right renal cyst found incidentally [**6-/2165**], needs further
workup
PAST SURGICAL HISTORY:
-L2-3, [**1-20**] laminoforaminotomy [**9-/2164**]
-Spinal Surgery [**2165-6-27**]
----Revision of L3, 4 and 5 laminectomy
----Bilateral T10, T11, T12, L1, L2, L3, L4 and S1 and pelvic
posterolateral instrumentation as well as right-sided L5 pedicle
screw
placement
----Arthrodesis at T10-11, T11-12, T12-L1, L1-2, L2-3, L3-4,
L4-5, L5-S1 and S1 and pelvis
-Bilateral cataracts
-Appendectomy
-left mastoid surgery
-left knee surgery
Social History:
Lives alone. Quit smoking several years ago. No drugs or
alcohol.
Family History:
Mother died at age 70 due to cardiac disease and
complications of diabetes. Father died at age 66 due to
congestive heart failure. Sister died at age 64 due to
emphysema. Brother died of cancer. Numerous other family
members with diabetes and neuropathy.
Physical Exam:
On Admission:
Vitals: T:102.1 BP: 92/52 P: 127 R: 29 O2: 91% 4L NC
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: right IJ
CV: Tachycardic
Lungs: Bibasilar crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema in LE
bilaterally
Neuro: CNII-XII intact, moving all extremities, grossly normal
sensation
Back: there is a midline spinal incision extending down the
thoracic and lumbar spine. There is a large area of erythema,
warmth, and fluctuance surrounding the top part of the incision.
It is tender to palpation. No active drainage.
On Discharge:
Vitals - 97.7 133/83 87 20 97%2L
GENERAL - obese, very pleasant, NAD, comfortable
HEENT - sclerae anicteric, MMM
LUNGS - Good air entry b/l
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - + PICC, WWP, no c/c/e, 2+ peripheral pulses
(radials, DPs). L>R LE edema
BACK - wound vac on and surgical site
Pertinent Results:
Labs on Admission
[**2165-7-19**] 03:15PM BLOOD WBC-15.6* RBC-3.33* Hgb-9.4* Hct-30.3*
MCV-91 MCH-28.4 MCHC-31.2 RDW-16.9* Plt Ct-400
[**2165-7-19**] 03:15PM BLOOD Neuts-90.8* Lymphs-3.7* Monos-4.7 Eos-0.6
Baso-0.3
[**2165-7-20**] 05:01AM BLOOD PT-18.6* PTT-38.1* INR(PT)-1.8*
[**2165-7-20**] 05:01AM BLOOD Fibrino-677*
[**2165-7-19**] 03:15PM BLOOD Glucose-170* UreaN-17 Creat-0.9 Na-139
K-4.8 Cl-104 HCO3-25 AnGap-15
[**2165-7-19**] 03:15PM BLOOD ALT-5 AST-11 LD(LDH)-210 CK(CPK)-30
AlkPhos-161* TotBili-0.2
[**2165-7-20**] 05:01AM BLOOD CK-MB-2 cTropnT-0.08*
[**2165-7-20**] 12:42AM BLOOD Calcium-6.7* Phos-2.7 Mg-0.9*
[**2165-7-19**] 03:15PM BLOOD Albumin-3.3*
[**2165-7-19**] 03:15PM BLOOD CRP-197.0*
[**2165-7-19**] 11:57PM BLOOD Type-MIX Temp-38.9 pO2-41* pCO2-50*
pH-7.30* calTCO2-26 Base XS--1
[**2165-7-19**] 03:37PM BLOOD Lactate-1.8
[**2165-7-19**] 11:57PM BLOOD O2 Sat-65
[**2165-7-20**] 02:43PM BLOOD freeCa-0.99*
Labs on Discharge:
[**2165-7-30**] 05:15AM BLOOD WBC-10.6 RBC-3.19* Hgb-9.3* Hct-28.9*
MCV-91 MCH-29.2 MCHC-32.2 RDW-16.8* Plt Ct-408
[**2165-7-30**] 05:15AM BLOOD Glucose-141* UreaN-6 Creat-0.5 Na-138
K-4.0 Cl-99 HCO3-35* AnGap-8
[**2165-7-29**] 04:32AM BLOOD calTIBC-183* Ferritn-157* TRF-141*
[**2165-7-31**] 04:55AM BLOOD Vanco-17.0
Reports:
CT Abdomen - IMPRESSION: 1. No pulmonary embolism detected to
the proximal segmental levels. More distal evaluation is
limited by patient motion. 2. Very large fluid collection
posterior to thoracolumbar fusion hardware, extending superiorly
to T6. The differential includes, seroma, abscess, and
pseudomenigocele. 3. Widening of the L3-L4 disc space for which
correation with operative note and prior imaging is suggested.
4. Moderate lingular atelectasis.
ECHO - IMPRESSION: Mild symmetric left ventricular hypertrophy
with preserved global systolic function. Right ventricular
dilation and mild global hypokinesis. At least moderate
pulmonary hypertension.
Brief Hospital Course:
Ms. [**Known lastname 122**] is a 64 year-old woman with a history of COPD and
recent spinal fusion with hardware at [**Hospital6 17390**] on [**2165-6-27**] who presented with back pain, fever and
malaise, and found to have a MRSA infecton of surgical site. Now
s/p surgical washout, hardware extraction and replacement on
[**2165-7-20**].
ACTIVE ISSUES
-------------
#. MRSA wound infection: The patient underwent spinal fusion on
[**2165-6-27**] at [**Hospital6 **] and subseqeuntly developed
worsening back pain. Seen in the ED where she was febrile. A CTA
torso was performed which showed a large fluid collection
posterior to the thoraco-lumbar fusion hardware. Patient was
transferred to the MICU for fever work-up. On [**2165-7-20**], the
patient went to the OR for wash-out. During the operation, the
previously placed hardware was found to be unstable and was
replaced. Transferred back to the ICU where the patient was
started on vancomycin with ID following. Initially on pressors
but these were weaned. Remained normotensive and transferred to
the floor. On the floor, the patient did well. Wound vac
remained in place due to poor wound healing. Able to tolerate
physical therapy. Will be discharged to rehab with plans for
continued physical therapy (needs to wear TLSO brace w/ PT) and
IV antibioitics. Will need infectious disease follow-up.
#. Hypoxemia: The patient has a known h/o COPD and OSA. She is
not on home oxygen. In the setting of active infection the
patient was hypoxemic. An echo was done showing moderate pulm
HTN but no loss of LV systolic function. CTA negative for PE>
The patient's respiratory status was stable on the floor. Used
CPAP at night.
#. Anemia: The patient lost ~1L of blood during her operation
here. She required 4 units of PRBCs during her hospital stay.
#. Recent C. diff infection: During her prior hospitalization
the patient developed C. Diff. She underwent therapy with PO
vanc. The patient was initially placed on PO vanc again in the
setting of broad spectrum abx, but this was stopped when her abx
were narrowed to vancomycin only. She remained diahrrea free in
house.
#. Lower Extremity Edema: The patient developed siginificant LE
edema after her surgery. She was treated with IV lasix and
continued on her home PO lasix. Due to some asymetry of the
swelling (L>R), an ultrasound was done showing a possible
ruptured bakers cyst. No DVT was found.
CHRONIC CONDITIONS
------------------
#. COPD/Asthma: Continued spiriva and singulair
#. Diabetes (IDDM): Held oral diabetic medications during
admission. Placed on IHSS. Restarted orals on discharge.
#. Hypothyroidism: Continued on synthroid
#. Hypertension: The patient's home antihypertensives were held
in the setting of active infection. These were restarted over
the course of her hospital stay.
#. Vaginal yeast infection: Received 1 dose of fluconazole
TRANSITIONAL ISSUES:
#. Continue anti-biotics for 4-6 weeks as will be determined by
infectious disease
#. Monitor electrolytes as patient has intermittently required
repletion
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from [**Last Name (un) **]
note.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Omeprazole 40 mg PO BID
4. Gemfibrozil 600 mg PO BID
5. Gabapentin 1200 mg PO TID
6. Simvastatin 20 mg PO DAILY
7. Valsartan 80 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. traZODONE 200 mg PO HS:PRN sleep
12. Levothyroxine Sodium 150 mcg PO DAILY
13. DiCYCLOmine 20 mg PO TID
14. Hydrocodone-Acetaminophen (5mg-500mg [**11-19**] TAB PO Q6H:PRN pain
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Omeprazole 40 mg PO BID
3. Gabapentin 1200 mg PO TID
4. Gemfibrozil 600 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Valsartan 80 mg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. traZODONE 200 mg PO HS:PRN sleep
11. Levothyroxine Sodium 150 mcg PO DAILY
12. DiCYCLOmine 20 mg PO TID
13. Docusate Sodium 100 mg PO BID
14. Senna 1 TAB PO BID:PRN Constipation
15. Vancomycin 1000 mg IV Q 12H
16. Hydrocodone-Acetaminophen (5mg-500mg [**11-19**] TAB PO Q4H:PRN pain
17. Acetaminophen 1000 mg PO Q 8H
18. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing
19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
20. Lorazepam 1 mg PO TID Anxiety
21. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Infected spinal instrumentation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!
In the hospital you were treated for an infection around your
spine. You went to the operating room so that the infection
could be washed out and the hardware replaced. Afterwards, you
were treated with intra-venous antibioitcs and you will need to
continue these after discharge.
New Medications:
- Please START Vancomycin and continue until instructed
otehrwise by infectious disease
- Please START Colace and Senna as you are on higher doses of
opiod medications
- Please START albuterol and ipratropium as needed for wheezing
- Please START Magnesium every other day
- Please START Long acting morphine and reduce the dose as your
pain improves
Please see below for instructions regarding follow-up care.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days. Please call [**Telephone/Fax (1) **] for an
appointment.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2165-8-13**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2165-9-2**] at 9:30 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
Completed by:[**2165-7-31**]
|
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|
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|
[
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11788, 11860
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,433
| 124,391
|
37172
|
Discharge summary
|
report
|
Admission Date: [**2170-11-25**] Discharge Date: [**2170-12-28**]
Date of Birth: [**2120-4-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Bilateral Placement of External Ventricular Drains
History of Present Illness:
The patient is a 64 year-old male with a h/o HTN and
hypercholesterolemia who stopped his medications secondary to
financial difficulties who was transferred from [**Hospital3 **]
for a ICH. Per report, he was at a wedding this evening when he
suddenly became confused and combative complaining of severe
headache. He presented to [**Hospital3 3583**] via EMS and continued
to be combative and confused. He was moving all extremities but
was complaining of severe headache located in the back of his
head.
He was intubated and a head CT there showed, per report, a large
IVH with blood in the 3rd and 4th ventricles possibly coming
from the right caudate head, temporal horns mildly enlarged with
hydrocephalus and cerebral edema. He has elevated blood
pressures with SBPs in the 250s that was non-responsive to
labetalol, but responded to propofol. At this time, he was
transferred to [**Hospital1 18**].
In the [**Hospital1 18**] ED, he was hypertensive on arrival with BP 180s,
intubated and sedated on propofol.
Past Medical History:
HTN
hypercholesterolemia
Social History:
The patient lives alone and has no children. Per sister who was
at the bedside the patient has been estranged from his family
for ~8 years after a dispute over their house after their
parent's death. The sister reports the patient having a history
of isolating himself and holding grudges. He cleaned
homes and worked for himself. He had a number of friends. [**Name (NI) **]
has, per report, no smoking history, occasional etoh use and no
known drug use. There is not an official HCP however there is
next of [**Doctor First Name **] in the greater [**Location (un) 86**] area [**Name (NI) **] [**Name (NI) **], sister
[**Telephone/Fax (1) 83725**]
Family History:
Per sister there is a significant family history of heart
disease. Other family members with DM. Also FH of difficult to
control HTN and ICH.
Physical Exam:
On admission:
O: T: BP: 180/120 HR: 74 AC 1.0/14/500/5
Gen: Intubated and sedated on propofol
HEENT: Pupils: Nonreactive but on propofol.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Obese, soft, BS+
Extrem: Warm and well-perfused.
Neuro: Unable to be assessed at this time.
Cranial Nerves:
I: Not tested
II: Pupils equally round to 2mm bilaterally.
III, IV, VI: Unable to be assessed at this time.
V, VII: Unable to be assessed at this time.
VIII: Unable to be assessed at this time.
IX, X: Unable to be assessed at this time.
[**Doctor First Name 81**]: Unable to be assessed at this time.
XII: Unable to be assessed at this time.
Motor: Unable to be assessed at this time
Sensation: Unable to be assessed at this time.
Reflexes: B T Br Pa Ac
Right
Left
Toes downgoing bilaterally
On discharge:
General: Awake, alert, responsive and appropriate, A+Ox2
HEENT: Sclera anicteric, MMM
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, obese
Ext: Warm, well perfused, 1+ Lower extremity edema L > R
Pertinent Results:
EKG [**2170-11-25**]
Baseline artifact. Sinus rhythm. Delayed R wave progression.
Lateral ST-T wave abnormalities. No previous tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 146 100 414/436 44 -1 69
CT head [**2170-11-25**]:
1. Extensive intraventricular hemorrhage, likely with the right
basal ganglia source making hypertensive hemorrhage most likely.
Underlying mass or vascular lesion are additional causes, and
MRI is more sensitive for the detection.
2. Possible enlargement of the ventricles, although no remote
study is
available for confirmation.
3. Sulci are not well visualized, and this can be seen with
diffusely
elevated intracranial pressure. However, with the exception of
possible right ambient cistern asymmetry, there is no definite
effacement of the basal cisterns. Therefore, determination of
elevated intracranial pressure is somewhat equivocal; correlate
with patient's symptoms and consider followup and when
clinically necessary indicated.
CT C-spine [**2170-11-25**]:
No fracture or malalignment.
CXR [**2170-11-25**]:
1. Satisfactory placement of lines and tubes.
2. Evident moderate CHF
CTA head [**2170-11-25**]:
1. Intraventricular hemorrhage extending from right caudate
head. Bilateral frontal approach ventricular drains as described
above. Decreased size of the ventricles.
2. Except for tortuous vertebrobasilar system, no other
abnormalities are
seen on CT angiography of the head.
CT head [**2170-11-27**]:
1. Significant intraventricular hemorrhage involving the entire
ventricular system, unchanged in appearance from that noted on
most recent prior. Involvement of the right caudate nucleus is
once again noted. 2. Bilateral transfrontal ventriculostomy
catheters are once again noted, unchanged in position from most
recent prior. Slight decrease in size of the left ventricle is
noted.
3. Persistent sulcal effacement and decreased conspicuity of
fissures
consistent with cerebral edema. Correlate clinically/ICP.
CT head [**2170-11-28**]:
1. Hemorrhage involving the entire ventricular system, unchanged
in
appearance from that noted on [**2170-11-27**]. The original
hemorrhage
appears to be centered within the head of the right caudate
nucleus suggesting hypertension as the likely cause of the
intraventricular hemorrhage.
2. Bilateral transfrontal ventriculostomy catheters are once
again noted,
unchanged in position from the most recent prior. The ventricles
are overall unchanged in size compared to the most recent prior.
Renal u/s with Doppler [**2170-12-1**]:
1. Limited study due to the patient's body habitus and portable
technique. No evidence of renal artery stenosis as described
above.
2. Echogenic liver, compatible with fatty infiltration. Please
note types of liver disease such as hepatic fibrosis or
cirrhosis cannot be excluded.
CT head [**2170-12-3**]:
Slight interval decrease in amount of intraventricular
hemorrhage. No new
hemorrhage is seen.
Echo [**2170-12-5**]:
Suboptimal image quality. Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function. No valvular pathology or pathologic flow identified.
Dilated ascending aorta.
LENIS [**2170-12-6**]:
1. Extensive left lower extremity DVT.
2. Technically limited study without definite evidence of DVT in
the right
lower extremity.
EEG [**2170-12-6**]:
Abnormal portable EEG due to the widespread uniform alpha to
beta frequency patterns. This generally represents medication
effect. There were no focal abnormalities (although
encephalopathies can obscure focal findings, as can
medications), and there were no epileptiform features.
Echo [**2170-12-6**]:
Normal right ventricular size and global systolic function. At
least mild left ventricular systolic dysfunction. Small
pericardial effusion.
Chest CTA [**2170-12-6**]:
Acute pulmonary emboli involving the right interlobar pulmonary
artery
extending into the right lower and middle lobar branches,
without evidence of right cardiac strain. Small-to-moderate
pericardial effusion.
RUE u/s [**2170-12-6**]:
Small amount of non-occlusive thrombus around the right PIC
catheter in the cephalic vein. Remainder of right upper
extremity veins are patent.
RUQ u/s [**2170-12-6**]:
No evidence of cholecystitis and no biliary dilatation seen.
Head CT [**2170-12-10**]:
1. Interval decrease in size of frontal and temporal [**Doctor Last Name 534**]
intraventricular
hemorrhage.
2. Unchanged opacification of the right maxillary, ethmoid, and
sphenoid
sinuses as well as the right nasal cavity.
Head CT [**2170-12-11**]:
Unchanged intraventricular hemorrhage status post removal of
ventriculostomy catheters with unchanged dilation of the right
frontal [**Doctor Last Name 534**] of the lateral ventricle, comapred to the most
recent CT study.
Paranasal sinus disease, unchanged from recent but new since
[**2170-11-24**].
Head CT [**2169-12-20**]:
No change in size of right lateral ventricular [**Doctor Last Name 534**] or right
atria/occipital [**Doctor Last Name 534**] intraventricular hemorrhage.
Renal u/s [**2169-12-20**]: No hydronephrosis in either kidney. This is a
very limited study due to the patient's body habitus.
Renal MRI:
Mild proximal luminal irregularity involving only the inferior
accessory right renal artery is unlikely to represent
significant stenosis
given the lack of atherosclerosis and this appearance on only
one series. No definite renal artery stenosis. No adrenal
abnormality.
Admission Labs:
[**2170-11-25**] 12:25AM WBC-14.7* RBC-5.42 HGB-15.4 HCT-47.3 MCV-87
MCH-28.4 MCHC-32.6 RDW-14.6
[**2170-11-25**] 12:25AM PLT COUNT-209
[**2170-11-25**] 12:25AM PT-12.1 PTT-21.1* INR(PT)-1.0
[**2170-11-25**] 12:25AM GLUCOSE-159* UREA N-21* CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2170-11-25**] 12:32AM GLUCOSE-151* LACTATE-3.1* NA+-143 K+-3.8
CL--100 TCO2-26
Brief Hospital Course:
#. Intraventricular hemorrhage and hypertension: Mr. [**Known lastname 83726**] was
admitted to [**Hospital1 18**] on [**2170-11-25**]. He was intubated upon arrival.
Neurosurgical team performed bilateral placement of external
ventricular drains (EVDs). In the surgical intensive care unit,
he was noted to have some bilateral upper extremity tremor,
which was not felt to be seizure activity by Neurosurgery nor
Neurology. His phenytoin level was therapeutic; however,
phenytoin was switched to levetiracetam. On [**12-1**], patient was
extubated. A repeat head CT on [**2170-12-3**] showed improvement with
less blood in the ventricles. On [**2170-12-11**], the EVDs were pulled.
Post-operatively patient experienced delirium, which gradually
improved but he was only oriented x 2 on discharge.
#. Hypertension: His BP required multiple agents to be
well-controlled. He was initially on clonidine, metoprolol, and
lisinopril. The clonidine was gradually weaned off as metoprolol
was titrated up. But his SBP went back up to the 180s, and
clonidine was re-started. Hydralazine and amlodipine were added
and metoprolol was changed to labetolol. He underwent renal MRI
which showed no renal artery stenosis. He would likely benefit
from a full outpatient workup for secondary causes of
hypertension and from seeing a hypertension specialist
(nephrology and cardiology).
#. Ventilator-associated pneumonia: He received a 8-day course
of vancomycin, ceftazadime, and ciprofloxacin. His respiratory
status was back to baseline at discharge.
#. Ventriculitis: He developed altered mental status on
[**2170-12-5**]. CSF showed elevated WBC. The presumed diagnosis was
ventriculitis, and patient was treated empirically with a 12-day
course of vancomycin and ceftazidime. Gram stain and all
cultures were negative.
# DVT/PE: On [**2170-12-5**] patient was noted to be tachypneic and was
found to have a LLE DVT as well as bilateral PE. Vascular was
consulted and placed an IVC filter. He was transferred from the
neurosurgical service to the medical service and a heparin drip
was also started. He was transitioned to Coumadin without
complication and has a goal INR of 2.0 to 2.5 due to his risk of
repeat ICH. He needs Coumadin treatment for three months.
#. Acute renal failure: Prior to discharge, his creatinine
increased to 1.8 from a baseline of 1.0. It was felt that his
renal failure may be related to AIN given peripheral
eosinophilia and recent antibiotic administration. His
antibiotics were stopped and his renal failure remained stable.
His renal failure was not responsive to IV fluids and was felt
to less likely be prerenal. His creatinine was 1.7 at the time
of discharge.
Medications on Admission:
None
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet 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. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection Injection ASDIR (AS DIRECTED): Insulin sliding scale
per protocol.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed for constipation.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
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 Q6H (every 6
hours) as needed for fever, pain.
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Rash: To Groin Rash.
10. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
13. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
14. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Bilateral Intraventricular Hemorrhage
Entrapment of Lateral Ventricle
Hydrocephalus
Uncontrolled Hypertension
Ventilator-associated pneumonia
Ventriculitis/Meningitis
DVT/PE
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you had a bleed in your head.
You had drains placed in your brain because of the bleed, which
have now been removed. The bleed in your brain affected your
breathing and we had to help you breathe with a breathing
machine (ventilator), but you subsequently became able to
breathe by yourself again and the ventilator was no longer
needed. You had two serious infections while you were in the
hospital: a pneumonia and an infection in the ventricles of your
brain (where the drains were), for both you were treated with
antibiotics through your IV. You also had a blood clot in your
leg, part of which broke off and went to your lungs. For that,
you were treated with blood thinners that you will need to
continue for 3 months.
WOUND INSTRUCTIONS
General Instructions
??????Check your incision daily for signs of infection.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????Please continue to take Keppra
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
You also had high blood pressure during your admission and your
medications were adjusted. You also had an acute kidney injury
that was thought to be due to the antibiotics you had been
receiving.
You are being discharged on a blood thinner called Coumadin.
You need to have your INR checked after you leave the hospital
by your rehab facility.
Your kidney function (creatinine) has been at a stable level
prior to discharge. You should have your creatinine checked
weekly. If it remains stable in 1 week (>1.6), you should see a
nephrologist. Please call the nephrology departmet to schedule
an appointment with Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 721**]. If
your creatinine is improved, you should have your creatinine
checked weekly to make sure that it continues to improve.
Followup Instructions:
-When you leave rehab, please call [**Telephone/Fax (1) 250**] to make an
appointment with your primary care doctor. Please ask for an
appointment within 1 week of discharge.
-You have an appointment on [**2171-1-15**] 10:30am to see Dr. [**Last Name (STitle) **] in
the [**Hospital 4695**] Clinic after a Head CT without contrast on
[**2171-1-15**] 10:00am. Please call [**Telephone/Fax (1) 1669**] if you have any
questions.
- You also may need a nephrology (kidney) appointment if your
kidney function does not improve. (Instructions above). You
will also need a follow-up appointment with a hypertension
specialist, either a nephrologist or a cardiologist after
discharge.
|
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icd9cm
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icd9pcs
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13651, 13724
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9501, 12202
|
325, 377
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13942, 13942
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3575, 9054
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16448, 17133
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2166, 2311
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,410
| 121,857
|
52984
|
Discharge summary
|
report
|
Admission Date: [**2190-11-28**] Discharge Date: [**2190-12-8**]
Date of Birth: [**2110-7-9**] Sex: M
Service: MEDICINE
Allergies:
Prozac
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
vomiting, abdominal discomfort
Major Surgical or Invasive Procedure:
upper endoscopy
PICC line
History of Present Illness:
Mr. [**Known lastname **] is an 80 year-old male with multiple sclerosis,
peripheral vascular disease, BL LE ulcers transferred from
[**Last Name (un) 1188**] house with leukocytosis and vomiting for several days.
He denied pain, chest pain, cough, dyspnea, abdominal pain,
dysuria. He had been intermittently feeling nauseated with 2
episodes of vomiting in the two days prior to admission.
Unknown last bowel movement prior to admission.
.
ED course: He was initially afebrile on presentation, and then
spiked to 102.6. His BP was also stable at first. He had a
distended though benign abdominal exam. During his ED course,
he developed more abdominal distension and a CT abd / pelvis was
done which showed a partial SBO and likely bibasilar
infiltrates. His BP was trending down. He received 4 liters of
lactated ringers. He was started on vancomycin, levofloxacin
and flagyl. He had a central line placed. A nasogastric tube
was placed with large output after which time he felt better.
Past Medical History:
Multiple Sclerosis
Neurogenic bladder
Myelodysplastic syndrome
DM
- PVD
- non-healing bilateral ulcers
Social History:
Married with three children. Lives in [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
No etoh, drugs, tobacco.
Family History:
Noncontributory.
Physical Exam:
PHYSICAL EXAM~
Vs- 100.0 111/43 96 16 99 2L nc weight 67kg
Gen- Elderly ill appearing male lying flat in bed, nad
Heent- MMdry, anicteric, poor dentition, EOMI, perrl
Neck- supple, radiating cardiac murmur, no LAD
Cor- Regular, tachy, II/VI SEM at USB to carotids
Chest- Clear anteriorlly
Abd- obese, distended, soft, NT, no palpable masses, decreased
BS in lower quadrants, no surgical scars
Ext- no edema. Open ulcers bilateral heels, no sign of
infection.
Neuro- AAO x 3, no movement of BLE (old), some sensation to
light touch. [**4-15**] motor strength in BUE.
Skin- Ulcers on heels and one pressure ulcer on right lateral
leg
Pertinent Results:
ECG: Sinus tachy vs ectopic atrial rhythm at 116. LAD. LAFB.
NI. PRWP. 0.5mm STD in lateral leads.
.
Studies~
.
CT Abd: 1. Patchy bilateral lower lobe pneumonia with probable
small adjacent pleural effusions and small pericardial effusion.
2. Dilated jejunum measuring 3-4 cm with air-fluid levels and
non-abrupt tapering transition point within the left lower
quadrant. These findings are most suggestive of an early mild
partial small-bowel obstruction, although atypical appearing
ileus is also within the differential. Consider serial
radiographs to assess for change and contrast progression. 3.
Large fusiform infrarenal aortic aneurysm with a large amount of
intramural thrombus as described above. Moderate
atherosclerotic disease involving the intrathoracic aorta and
its branches. 4. Hypoattenuating hepatic lesion, too small to
definitively characterize. Left renal cyst.
.
CXR: No radiographic evidence of pneumonia.
.
Repeat CXR: 1. Appropriately-positioned left subclavian catheter
without evidence of pneumothorax on the supine film.
2. Bilateral lower lobe pneumonia is better appreciated on
concomitantly performed abdominal CT examination.
PICC LINE PLACEMENT
INDICATION: IV access needed for antibiotics.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGISTS: Dr. [**First Name (STitle) 1022**] and Dr. [**Last Name (STitle) 380**] performed the procedure.Dr.
[**Last Name (STitle) 380**], the Attending Radiologist, was present for the entire
procedure.
TECHNIQUE: Using sterile technique and local anesthesia, the
right basilic vein was punctured under direct ultrasound
guidance using a micropuncture set. Hard copies of ultrasound
images were obtained before and immediately after establishing
intravenous access. A peel-away sheath was then placed over a
guidewire and a right double-lumen PICC line measuring 40 cm in
length was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guide wire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French double-lumen PICC line placement via the right basilic
venous approach. Final internal length is 40 cm, with the tip
positioned in SVC. The line is ready to use.
DR. [**First Name8 (NamePattern2) 74613**] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
PreliminaryApproved: TUE [**2190-12-7**] 12:22 PM
Brief Hospital Course:
80 male with history of MS (paraplegia), DM, MDS, chronic anemia
admitted for sepsis and [**Hospital 68385**] transferred to floor after
stabilization and transient pressor needs, then found to have
UGIB, transfer out of MICU after 8 units PRBC, stable on floor.
.
HYPOTENSION AND SEPSIS
Mr. [**Known lastname **] was admitted with a high fever from his nursing home,
and was found to be hypotensive in the ED. The sepsis protocol
was initiated, and he was admitted to the MICU. The differential
diagnosis remained pneumonia or as related to his
gastrointestintal tract, as he was found to have a partial small
bowel obstruction. Patient completed course of Levofloxacin and
Flagyl on [**12-5**]. THe patient had a transient rise in WBC without
clinical signs of infection which resolved after the central
line was removed.
.
SMALL BOWEL OBSTRUCTION, PARTIAL
The patient received NGT placement, as well as decompression via
rectal tube. Surgery was consulted and followed the patient in
house. He was started on TPN, and then diet slowly advanced.
Rectal tube was pulled prior to discharge. TPN was discontinued
prior to discharge. THe patient should be encouraged to take po.
.
UPPER GASTROINTESTINAL BLEED
After sepsis was stabilized in the MICU, the patient was
transferred to the floor, where he was found to have an
increasing heart rate. Suction on the NG tube revealed bloody
return, and the patient was found to have a falling hematocrit.
He was transferred to the MICU for follow-up, and received 8
units of pRBCs while there. After conversation with HCP, a
decision to pursue endoscopy to attempt to identify and stop
bleeding was made. EGD [**12-2**] showed marked friability of the
stomach mucosa with contact bleeding, multiple non-bleeding
ulcers were found in the stomach and a single bleeding ulcer was
found in the cardia near the GE junction s/p electrocautery for
hemostasis. Subsequently, he has been hemodynamically stable
with HR in 90s. Hematocrit remained stable for >96 hours prior
to discharge. He was discharged on Pantoprazole 40mg twice
daily.
.
HYPOXIA
Patient still on oxygen, currently 96% on 2 liters nasal
cannula. Combination of recovery from pneumonia and volume
overload from fluids given in ICU during GIB. Continue with
gentle diuresis and monitor electrolytes.
.
NUTRITION
Due to concern of aspiration patient was evaluated by speech and
swallow on [**12-6**], his diet was advanced to thin liquids and
ground consistency solids. He needs assistance with meals and
should have his pills whole with purees. TPN dicscontinued as
above and PICC line placed prior to discharge.
.
ABDOMINAL AORTIC ANEURYSM
Noted on CT scan was a 4.7 infrarenal AAA in the setting of
profound atherosclerotic disease. Maintain good BP control, will
need serial imaging as an outpatient.
.
DIABETES
Placed on regular insulin sliding scale.
.
CODE STATUS
DNR/DNI, confirmed with patient
Communication: [**Name (NI) **] [**Name (NI) 109228**] (HCP) - nephew [**Telephone/Fax (1) 109229**]
Medications on Admission:
Medications:
- Lasix 20 daily
- MVI
- Verapamil 120 SA daily
- Vitamin C 500 daily
- Simvastatin 80 daily
- Buproprion SR 150 [**Hospital1 **]
- colace
- lorazepam 0.25mg qid (9a, 1p, 5p, 9p)
- Tylenol 325 qid
- risperdal 0.5 q 8p
- senna
- dulcolax
- MOM
- [**Name (NI) **] prn
- compazine prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Verapamil 120 mg Cap,24 hr Sust Release Pellets Sig: One (1)
Cap,24 hr Sust Release Pellets PO once a day.
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
9. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): as indicated.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO four times a
day: as needed for anxiety.
12. [**Name (NI) **] 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
13. Compazine 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
14. Milk of Magnesia 800 mg/5 mL Suspension Sig: One (1) PO
three times a day as needed for constipation.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Sepsis due to pneumonia
Partial small bowel obstruction
Upper gastrointestinal bleed
Abdominal aortic aneurysm
Diabetes mellitus type II
Bilateral heel ulcers
Volume overload with anasarca
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with an infection of your lungs and partial
small bowel obstruction. You also had a bleed in your stomach
which you underwent an upper endoscopy to cauterize the lesion.
You required several units of blood in the intensive care unit.
You were stable afterwards, your diet was advanced after your
evaluation with speech and swallow.
Return to the ER or call you primary care physician if you
experience any chest pain, shortness of breath, bloody or tarry
stools, or any worrisome symptoms.
Take all of your medications as prescribed.
Followup Instructions:
Follow up with your primary care doctor ([**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **])
[**Telephone/Fax (1) 18145**]
|
[
"272.4",
"799.02",
"238.75",
"507.0",
"560.9",
"707.09",
"344.9",
"250.00",
"038.9",
"300.4",
"340",
"782.3",
"531.40",
"285.9",
"596.54",
"995.92",
"707.14",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.07",
"96.07",
"38.93",
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9896, 9969
|
5144, 8150
|
297, 324
|
10203, 10211
|
2339, 5121
|
10813, 10958
|
1646, 1665
|
8495, 9873
|
9990, 10182
|
8176, 8472
|
10235, 10790
|
1680, 2320
|
227, 259
|
352, 1353
|
1375, 1479
|
1495, 1630
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,669
| 177,708
|
12843
|
Discharge summary
|
report
|
Admission Date: [**2178-4-13**] Discharge Date: [**2178-5-7**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
cough, tachycardia
Major Surgical or Invasive Procedure:
[**2178-4-20**] Aortic Valve Replacement (21mm porcine)
.
[**2178-4-18**] Extraction of teeth numbers 13, 14, 22,
24 and 25 prior to cardiac surgery
History of Present Illness:
87 year old male presented to PCP for
cough, and found to have rate in 150s. He was sent to NEBH
ambulatory hospital where EKG was suspicious for aflutter and
troponin was 3.6. He was transferred to [**Hospital1 18**]. Here, he received
lopressor 2.5 mg IV and Cardizem 10 mg IV without improvement.
He
then received 60 mg PO diltiazem, and converted to aflutter with
ventricular rate of 87. He was admitted and sent for cardiac
catheterization and found to have critical aortic stenosis. He
is
now being referred to cardiac surgery for an aortic valve
replacement.
Past Medical History:
Aortic Stenosis
Hypertension
BPH
Past Surgical History:
appendectomy
choleysectomty
?hernia repair (patient does not remember)
Social History:
no current tobacco, never smoker, 1 EtOH drink per day, no drug
use. Wife passed away several years ago leading to mild
depression.
Family History:
non-contributory
Physical Exam:
ADMIT:
VS: 97.9, 122/67, 96, 22, 96% RA
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: tachycardic, nl S1-S2, appears to have grade II
holosystolic murmur heard best at LSB.
LUNGS: rhonchi bilaterally, no wheezing or crackles appreciated,
good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, strength and
gait not assessed.
Pertinent Results:
Cardiovascular Report Cardiac Cath Study Date of [**2178-4-14**]
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate pulmonary hypertension.
3. Biventricular diastolic dysfunction.
4. Critical aortic stenosis.
5. Reduced ejection fraction with anterior wall hypokinesis
CT CHEST W/O CONTRAST Study Date of [**2178-4-16**] 8:29 AM
IMPRESSION:
1. Non-calcified, dilated, fusiform ascending aorta.
2. Diffuse bibasilar ground-glass peribronchial opacity could
represent a
nonspecific interstial pneumonitis or mild CHF.
3. Probable tracheobronchmalacia involving the trachea and
bilateral mainstem
bronchi.
4. Dilated right main pulmonary artery. Consider pulmonary
hypertension.
The study and the report were reviewed by the staff radiologist.
.
[**2178-4-20**] Intra-op TEE:
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is significant
aortic valve stenosis with fixed left and non-crornary cusps.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Biventricular systolic function remains preserved. There is a
well seated, well functioning bioprosthesis in the aortic
position. No aortic regurgitation is seen. The MR remains mild.
.
[**2178-5-7**] 06:08AM BLOOD WBC-9.2 RBC-3.72*# Hgb-8.3*# Hct-26.7*#
MCV-72* MCH-22.4* MCHC-31.1 RDW-21.9* Plt Ct-394
[**2178-5-7**] 08:23AM BLOOD Hct-28.1*
[**2178-5-7**] 06:08AM BLOOD UreaN-25* Creat-1.0 Na-139 K-4.2 Cl-108
[**2178-4-28**] 01:21AM BLOOD ALT-98* AST-147* AlkPhos-132* Amylase-45
TotBili-1.4
[**2178-5-7**] 06:08AM BLOOD Mg-1.8
[**5-6**] PA&Lat:
IMPRESSION: AP chest compared to [**5-2**]:
Previous mild pulmonary edema has cleared, and moderate left
lower lobe
atelectasis and small left pleural effusion have decreased.
There is,
however, a new cluster of nodular opacities in the right mid
lung laterally
(projected over the right first and second ribs), which could be
residual or
organized infection. Findings are consistent with patient's
clinical picture,
CT scanning would be helpful in comparison to the scan on [**4-24**]. It is
useful to note that there were no lung nodules at that time
concerning for
malignancy.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
87 y/o healthy male with HTN and BPH who initially presented to
PCP for cough, found to have rate in 150s, with EKG suspicious
for atrial flutter, and elevated cardiac enzymes suggestive of
NSTEMI. The patient was brought to the Operating Room on [**2178-4-20**]
where the patient underwent Aortic Valve Replacement with Dr.
[**Last Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Initially out
of OR he was hypoxic and extubation was delayed until the
following morning. POD 1 the patient eventually extubated and
was neurologically intact. He developed rapid atrial
fibrillation. Amiodarone was initiated and the patient converted
to SR. Beta blocker was initiated and the patient was diuresed
toward the preoperative weight. He developed respiratory
distress and was re-intubated on POD 2. Bronchoscopy was
performed and large mucus plug removed from RLL. Vancomycin and
Cefepime were started empirically for pneumonia. Dob Hoff was
placed for tube feeds. He remained intubated 2nd to hypoxia
continued agitation and confusion. He eventually extubated on
[**4-26**] but was reintubed 6 hours later due to respiratory distress
and agitation. He was stated on coumadin for a-fib but he became
supratherapeuitic and due to the fact that he remained in SR
coumdain was dc'd. Chest tubes and pacing wires were
discontinued without complications. He eventually extubated
again on [**4-29**] and required aggressive pulmonary toileting. He
completed a course of antibiotics despite negative cultures, his
WBC were elevated during his post-op course but have since
returned to [**Location 39511**]. His current CXR still shows RML density but
clinically he has improved. He will need to be followed closely
while at rehab. Due to his confusion he was started on Seroquel
but this was discontinued due to over sedation, he responded
well to low dose haldol but this was discontinued prior to
discharge. He remains pleasently confused but cooperative. He
was evaluated by speech and swallow and diet was advanced as
indicated. The patient continued to make slow progress and was
transferred to the telemetry floor for further recovery. While
on the floor continued to progress. He has been incontinuent at
times and needs assistance with walking and care. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. He was deemed safe for discharge on
POD#17 to [**Hospital 100**] Rehab.
Medications on Admission:
- nifedipine 30 mg daily
- sertraline 100 mg daily
- flomax 0.4 mg daily
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
Disp:*1 * Refills:*0*
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Disp:*7 Tablet Extended Release(s)* Refills:*0*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*1 ML(s)* Refills:*0*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
Disp:*1 * Refills:*2*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain, fever.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Aortic Stenosis
Hypertension
BPH
Past Surgical History:
appendectomy
choleysectomty
?hernia repair (patient does not remember)
Discharge Condition:
Alert and appropriate
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema-minimal
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**2178-6-10**] 1:45 pma[**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) **] [**2178-5-20**] 1:45pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 11144**] in [**3-5**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2178-5-7**]
|
[
"518.51",
"414.01",
"500",
"934.8",
"427.31",
"490",
"416.8",
"401.9",
"486",
"311",
"396.2",
"997.39",
"521.09",
"E849.7",
"E912",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"37.23",
"23.09",
"38.97",
"33.22",
"96.05",
"96.6",
"35.21",
"96.72",
"31.44",
"39.61",
"38.91",
"88.56",
"96.04",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
9310, 9395
|
4828, 7398
|
275, 426
|
9566, 9727
|
2045, 2111
|
10515, 11073
|
1339, 1357
|
7521, 9287
|
9416, 9449
|
7424, 7498
|
2128, 4805
|
9751, 10492
|
9472, 9545
|
1372, 2026
|
217, 237
|
454, 1022
|
1044, 1077
|
1189, 1323
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,411
| 150,451
|
45480
|
Discharge summary
|
report
|
Admission Date: [**2187-7-25**] Discharge Date: [**2187-7-31**]
Date of Birth: [**2122-3-13**] Sex: F
Service: MED
Allergies:
Dairy
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65F w/ diverticulosis, DMII, HTN, Hyperlipidemia, and h/o
recurrent LGIB (no known etilogy after colonoscopy, EGD, T-RBC
scan) with sudden LGIB at 2pm on DOA. Similar to prev LGIB with
red blood and the stool mixed with blood. Occurred spontaneously
while sitting on couch. No CP, SOB, syncope, presyncope, N/V,
diarrhea. No fevers, chills, wt loss, change in stool caliber.
Past Medical History:
LGIB ([**7-/2183**], [**5-18**], [**4-19**]), Diverticulosis, DMII, HTN,
Hyperlipidemia, DJD (Hip/Knee), GERD.
Social History:
Lives with husband. [**Name (NI) 4084**] smoked or drank. No IVDU or drugs. Has
three kids.
Family History:
Son (age 44) has idiopathic LGIBs. No FHx of colitis, Crohn's,
ulcerative colitis. No bleeding disorders. No CRC. No heart
disease. No congenital disorders. No AVMs.
Brief Hospital Course:
A/P: 65F w/ recurrent and idiopathic LGIB.
1. GIB: Pt likely with lower GIB [**12-18**] diverticulosis. Pt had
one more episode of hematochezia [**7-25**] while drinking go lytely.
HCT 29 [**7-25**] AM. HCT's checked q8 hours and pt put on bowel rest
with PPI. Pt was hemodynamically stable except for tachycardia
to the 120's. ?[**Last Name (un) 97049**]-Jegers (involving S.I.) based on +family
hx (son with multiple episodes GIB of unknown etiology) and
macules over lips and buccal mucosa?
[**7-26**] --> HCT 22 in AM. Recieved 3 units PRBC, hct then 36.6 EGD
revealed small hiatal hernia with short segment of Barrett's
esophagus. Colonoscopy revealed blood throughout the colon
without definite bleeding site. +diverticuli, but none
bleeding. TI seen, but not intubated. TRBC study did not
reveal any active bleeding. Pt moved to [**Hospital Unit Name 153**] [**7-26**] for
hemodynamic monitoring.
[**7-27**] --> HCT 29.8, given 1U PRBC. Hemodynamically stable.
Started on clear liquid diet.
[**7-28**] --> HCT 35.8. No further episodes of bleeding. HD stable.
Scheduled for capsule endoscopy [**7-30**].
[**7-29**] --> 36.1. No bleeding. Awaiting pill endoscopy tomorrow.
[**7-30**] --> 37.6. No bleeding. Tolerated pill endoscopy without
problems. Tolerated full dinner at night. No BM.
[**7-31**] --> 35.7. No bleeding. Will d/c with follow up in [**Hospital **]
clinic [**8-8**].
2. GERD: Pt with Barrett's esophagus on EGD. Put on po
protonix. Likely will need H.pylori eradication with triple
therapy as outpt. Also, may need surveilence EGD's to screen
for dysplasia. Will d/c pt with anti-reflux medications.
3. DM: On RISS.
4. HTN: Holding ACE-I, hctz, nifedipine [**12-18**] GIB. Will d/c pt
on ACE-inhibitor. but will hold hctz and nifedipine until [**Hospital **]
clinic appointment.
5. Hypercholesterolemia: On atarvostatin. Last lipid panel
quite good.
Medications on Admission:
Acetaminophen PRN, Multivitamins 1 CAP PO QD, Moexipril HCl 15
mg PO QD
Pantoprazole 40 mg PO Q24H, Hydrochlorothiazide 12.5 mg PO QD,
HCTZ 12mg PO QD, Glucosamine, Metformin 500mg [**Hospital1 **], Nifedipine
120mg QD, Glyburide 5mg PO QD,
Atorvastatin 10 mg PO QD.
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Moexipril HCl 15 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed of unknown source
Discharge Condition:
Stable
Discharge Instructions:
If you have these symptoms, call your doctor or come to the
emergency room:
1. bloody diarrhea
2. black, tarry stools
3. dizziness
4. blurry vision
5. abdominal pain
6. bloody vomitus
Followup Instructions:
[**Hospital **] clinic: [**8-8**] with
Completed by:[**2187-7-31**]
|
[
"401.9",
"553.3",
"530.85",
"285.1",
"578.1",
"562.10",
"455.0",
"250.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"96.33",
"99.04",
"45.19"
] |
icd9pcs
|
[
[
[]
]
] |
3788, 3794
|
1133, 3053
|
274, 280
|
3871, 3879
|
4119, 4190
|
943, 1110
|
3370, 3765
|
3815, 3850
|
3079, 3347
|
3903, 4096
|
222, 236
|
308, 684
|
706, 818
|
834, 927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,078
| 188,578
|
12910
|
Discharge summary
|
report
|
Admission Date: [**2115-9-19**] Discharge Date: [**2115-9-24**]
Date of Birth: [**2059-1-5**] Sex: M
Service: CCU
CHIEF COMPLAINT: Transferred from [**Hospital6 8283**]
for cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
gentleman with a history of coronary artery disease including
percutaneous transluminal coronary angioplasty of left
circumflex and obtuse marginal in [**2106**] and ramus in [**2108**] who
presented to [**Hospital6 8283**] with a chief
complaint of chest pain and burning in the throat.
Initial electrocardiogram showed a irregular wide complex
tachycardia for which the patient received 20 mg
intravenously of diltiazem. Shortly thereafter, the patient
had a ventricular fibrillation arrest. The patient was
resuscitated with two shocks at 300 joules and intubated.
Electrocardiogram at that time showed atrial fibrillation
with rapid ventricular response and left ventricular
end-diastolic pressure. The patient was given Lopressor and
lidocaine and was started on dopamine 5 mg/kg. The patient
received 10 units of reteplase times two over 30 minutes.
Electrocardiogram showed tombstone elevations and complete
heart block. Dopamine was titrated up to 30. The patient
was stabilized and weaned down to 10, at which time he was
transferred to [**Hospital1 69**] for
cardiac catheterization.
At catheterization, angioplasty showed a 90% proximal right
coronary artery lesion and was intervened upon with a cypher
stent. Hemodynamics during the procedure revealed right
atrial pressure of 18 mm, right ventricular pressure of
130/11, pulmonary artery mean 26, and a pulmonary capillary
wedge pressure of 21.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post percutaneous
transluminal coronary angioplasty in [**2106**] and [**2108**].
2. Hypertension.
3. Dyslipidemia.
4. Atrial fibrillation.
5. Chronic renal failure (with a baseline creatinine of
1.2).
ALLERGIES: Reports dizziness with SUBLINGUAL NITROGLYCERIN.
MEDICATIONS ON ADMISSION:
1. TriCor 54 mg by mouth once per day
2. Toprol-XL 50 mg by mouth once per day.
3. Lipitor 20 mg by mouth once per day.
4. Cardizem-XT 120 mg by mouth once per day.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed the patient was afebrile, her heart rate
was 72, her blood pressure was 153/77, mean was 103, and
pulmonary artery 32/17. In general, the patient was sedated
on ventilator with small conjunctival hemorrhages
bilaterally. There was scant blood around endotracheal tube.
Head, eyes, ears, nose, and throat examination revealed
scattered petechiae around the eyes. The neck was supple.
Cardiovascular examination revealed normal first heart sounds
and second heart sounds. Hard to hear breath sounds due to
coarse breath sounds. Respiratory examination revealed the
lungs were clear to auscultation bilaterally. Laterally
coarse breath sounds. The abdomen was soft, nontender, and
nondistended. Positive bowel sounds. Extremity examination
revealed no edema. Dorsalis pedis pulses were palpable.
Neurologic examination revealed the patient was sedated.
There was a right groin line in place.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data
from outside hospital revealed the patient's white blood cell
count was 7.6. her hematocrit was 46, and her platelets were
216. INR was 1, partial thromboplastin time was 29.5, and
prothrombin time was 12.1. Blood urea nitrogen was 29.
Creatinine was 1.1. AST was 34. Lactate dehydrogenase was
179. Initial creatine kinase was 128. Troponin I level was
0.1.
PERTINENT RADIOLOGY/IMAGING: Electrocardiograms status post
procedure revealed a sinus rhythm at [**Street Address(2) 39674**] elevations
inferiorly in V3 through V6.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Coronary Care Unit status post percutaneous
transluminal coronary angioplasty and proximal right coronary
artery stenosis which was treated with a cypher stent.
1. CARDIOVASCULAR ISSUES: The patient was begun on aspirin
and Plavix. Integrilin was initially started and
discontinued due to bleeding around the endotracheal site.
The patient was continued on Lipitor. Beta blocker and ACE
inhibitor were titrated up as tolerated.
(a) Pump: An echocardiogram was done to assess left
ventricular function. On hospital day one, echocardiogram
revealed an ejection fraction of 30% with hypokinesis of the
inferior wall and 1+ mitral regurgitation.
Beta blocker and ACE inhibitor were titrated up to metoprolol
25 mg by mouth twice per day and captopril 12.5 mg by mouth
three times per day.
(b) Rhythm: The patient was placed on telemetry given her
history of nonsustained ventricular tachycardia and atrial
fibrillation. The patient was started on heparin and was
transitioned to Coumadin. No events on telemetry.
The patient was noted to go into type II heart block and was
started on amiodarone 400 mg by mouth twice per day with a
normal sinus rhythm continuing throughout the duration of her
hospital stay. The patient will need a repeat echocardiogram
in one month to reassess ventricular function as well as
titrating down amiodarone per recommendations of Dr. [**Last Name (STitle) 11679**].
2. PULMONARY ISSUES: The patient was intubated initially
for ventricular fibrillation arrest. The patient was weaned
down. There was a concern of aspiration on hospital day one,
status post emesis. A chest x-ray was negative. The patient
was successfully extubated on the evening of hospital day one
without difficulty. The patient was given Cepacol for a sore
throat. Oxygen saturations on discharge were 99% on room
air.
3. RENAL ISSUES: The patient's creatinine was stable on
admission. The patient was monitored for dye load
nephrotoxicity. The patient had good urine output throughout
her hospital course. The patient was discharged with a
creatinine of 1.1 (at baseline).
MEDICATIONS ON DISCHARGE: (The patient was discharged on)
1. Aspirin 325 mg by mouth once per day.
2. Plavix 75 mg by mouth once per day.
3. Amiodarone 400 mg by mouth twice per day for three days
and then 400 mg by mouth once per day.
4. Lipitor 20 mg by mouth once per day.
5. Toprol-XL 50 mg by mouth once per day.
6. Coumadin 5 mg by mouth once per day (to be titrated for a
goal INR of 2 to 3).
7. Zestril 10 mg by mouth once per day.
8. Lovenox 80 mg subcutaneously twice per day (times seven
days until INR therapeutic).
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with her primary
care physician this [**Name9 (PRE) 2974**] and Monday for an INR check with a
target goal of 2 to 3.
2. The patient was also instructed to follow up in two weeks
with Dr. [**Last Name (STitle) 11679**] with a plan of an echocardiogram in one
month.
3. The patient was to attend cardiac rehabilitation as an
outpatient at [**Hospital6 8283**].
CONDITION AT DISCHARGE: Condition on discharge was stable;
without chest pain or shortness of breath. The patient was
cleared by Physical Therapy.
DISCHARGE STATUS: Discharge status was to home.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Dictator Info 13592**]
MEDQUIST36
D: [**2115-9-24**] 13:14
T: [**2115-9-24**] 19:32
JOB#: [**Job Number 39675**]
|
[
"427.1",
"410.41",
"414.01",
"403.91",
"426.12",
"272.4",
"427.31",
"V45.82",
"478.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.07",
"37.23",
"96.71",
"36.01",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
5988, 6499
|
2047, 3795
|
6532, 6949
|
3824, 5961
|
6964, 7435
|
149, 217
|
246, 1694
|
1716, 2021
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,713
| 140,209
|
47830
|
Discharge summary
|
report
|
Admission Date: [**2189-6-26**] Discharge Date: [**2189-7-7**]
Date of Birth: [**2121-2-12**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
- Pericardiocentesis
- Pericardial drain placement
- Pleurodesis
History of Present Illness:
68 year old male with lung cancer with malignant effusions s/p 4
cycles of gemcitabine and carboplatin who presents with
worsening SOB over the past 5 days. His wife noticed that he was
more SOB and had difficulty walking between rooms and called an
ambulance. Of note, he had a malignant pleural effusion on that
was tapped (Took out 2200 ml of fluid) in [**5-22**] and helped
resolve his sx of SOB. Of note, he had a recent CT scan of the
chest that showed a moderate to large pericardial effusion.
.
Per report in ER his SBPs were in the 150s and his O2 sats were
stable. CXR showed recurrent pleural effusion. Cards was called
but recommended inpatient echo.
.
Upon arrival to the floor the attending physician and fellow
noted the patient to be more confused. He was quickly taken to
echo, and per report from attg ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]), it appeared he had
evidence of tamponade. Cardiology recommended transfer to West
to cath lab for urgent cath for pericardial drain and admission
to the CCU.
Past Medical History:
Non-small-cell lung cancer s/p 4 cycles of carboplatin and
gemcitabine
Diabetes mellitus
Hypertension
Chronic kidney disease, bl creat 1.5
Anemia
Cataracts
Social History:
Mr. [**Known lastname **] has an approximately 15-pack-year tobacco history,
having quit smoking 30 years ago. He denies any alcohol or drug
use. He worked as a blacksmith making springs for cars and
trucks. He reports asbestos exposure for 27 years. Married,
lives with wife, has 5 children, 3 grandchildren.
Family History:
Anemia and diabetes mellitus in his father and diabetes in his
mother. A sister had breast cancer. A brother who had a history
of smoking had throat cancer.
Physical Exam:
On discharge:
97.5 95 145/77 20 99%ra
GENL: WD, WN, NAD
Neuro: A&O x3, mae
CV: RRR, no m/r/g
Lungs: decreased BS on R, clear on L anteriorly
Abd: soft, nt, nd, +Bs
Ext: no edema, 2+ pedal pulses
Pertinent Results:
CXR [**6-26**]:
The lobulated mass lesion in the lateral right upper lobe is
again identified and stable relative to the CT dated [**2189-6-23**]. Again noted is a very large unilateral right pleural
effusion. The cardiac silhouette remains enlarged and globular
particularly on lateral view consistent with underlying
pericardial effusion. The left lung is largely clear. No
pneumothorax is evident.
.
TTE [**6-26**]:
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
large pericardial effusion. There is right atrial collapse and
right ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology. The right ventricle appears
compressed in some views.
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2189-6-30**] 6:25 PM
IMPRESSION: No intracranial hemorrhage or edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name (STitle) **] [**Name (STitle) 12563**]
.
RADIOLOGY Final Report
MR HEAD W/O CONTRAST [**2189-6-30**] 7:46 PM
IMPRESSION:
1. No acute infarction.
2. 1.5-mm aneurysm at the origin of right anterior choroidal
artery. To consider neurosurgery consult.
3. Bilateral mild maxillary sinusitis, right more than left.
4. Sequelae of chronic small vessel occlusive disease in
bilateral cerebral white matter.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 10627**] PERI
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: [**Doctor First Name **] [**2189-7-2**] 9:41 AM
.
Pathology Examination
SPECIMEN SUBMITTED: PERICARDIUM.
Procedure date Tissue received Report Date Diagnosed
by
[**2189-6-30**] [**2189-6-30**] [**2189-7-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/eg??????
DIAGNOSIS:
Pericardium, excision:
Adenosquamous carcinoma involving pericardium. See note.
Note:
The tumor cells are positive for cytokeratin cocktail and are
negative for TTF-1, calretinin and WT-1.
Morphologically, the tumor is compatible with a lung carcinoma
in the appropriate clinical setting. Additional
immunohistochemical stains are pending; once reviewed, an
addendum will be issued.
In addition to being involved by tumor, the pericardium is
chronically inflamed and shows fibrosis, including fibrous
nodules.
Case reviewed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **].
.
[**2189-7-2**] 09:30AM BLOOD WBC-6.6# RBC-4.18*# Hgb-12.1*# Hct-34.7*
MCV-83 MCH-28.9 MCHC-34.8 RDW-18.0* Plt Ct-437
[**2189-6-26**] 10:14PM BLOOD Neuts-63.7 Lymphs-26.8 Monos-8.6 Eos-0.4
Baso-0.5
[**2189-7-2**] 09:30AM BLOOD Plt Ct-437
[**2189-7-2**] 09:30AM BLOOD PT-13.7* PTT-33.5 INR(PT)-1.2*
[**2189-7-5**] 03:10PM BLOOD Glucose-160* UreaN-19 Creat-0.8 Na-138
K-4.6 Cl-100 HCO3-29 AnGap-14
[**2189-7-5**] 03:10PM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
Brief Hospital Course:
Mr [**Known lastname **] is a 68 yo M with h/o NSCL cancer, s/p thoracentesis in
[**2189-5-17**] admitted with cardiac tamponade.
.
1. Pericardial effusion: Patient was admitted with SOB and found
to have a large pericardial effusion. Clinically he was
hemodynamically stable, however echo showed RV collapse and cath
showed equalization of diastolic pressures suggestive of
tamponade physiology. While in the cath lab a
pericardiocentesis was performed with drainage of 450cc of
serosanguinous fluid. A pericardial drain was placed and ~1L of
fluid was drained over the next 24 hours. A repeat ECHO was
done at that time which showed resolution of his effusion. He
remained hemodynamically stable and the drain was pulled after
48 hours once the output had decreased. Thoracic surgery was
consulted and decision was made to perform pericardial window
which was done on [**6-30**] in the OR. The effusion is likely
malignant, however cytology is still pending.
.
2. Hypertension: patient was continued on his outpatient regimen
of Benicar and verapamil with good control of his BP.
.
3. Pleural effusion: Patient is s/p thoracentesis in [**5-23**] and
now with reaccumulation of fluid. It was felt that his SOB was
more likely secondary to his pleural effusion than his
pericardial effusion as his symptoms did not improve
significantly following pericardiocentesis, however he did not
have an oxygen requirement. Given he was symptomatic, a
decision was made among his oncologists, thoracics and
cardiology to perform pleurodesis in addition to pericardial
window. He was taken to the OR on [**6-30**] and underwent both
procedures. Following pleurodesis the patient developed acute
neurologic changes (#4). Postoperative CXR
.
The pt. was seen by the medicine team and admitted for
management of pericardial effusion. The cardiac team placed a
pericardial drain and the pt. was drained for the following 24
hours. The thoracic surgery team was consulted on HD 3 for
management of a recurrant right sided pleural effusion. The pt.
was managed by the medical team as noted above. On HD 6 the pt.
was taken to the OR for flexible bronchoscopy, hematoma
evaluation, pericardial window, and pleurex catheter placement.
While the patient was recovering in the PACU the pt. was noted
to have unequal pupils and stopped following commands - that
he'd been inconsistently following earlier. A code stroke was
called, neurology evaluated the patient, and an emergent CT head
as well as MRI/MRA were performed. The CT showed no evidence of
bleed or mass effect. The MRI/MRA showed some evidence of small
vessel disease but no abnormalities consistent with the pt.
having had a stroke. He was started on anti-seizure medications
and transferred to the SICU for hourly neuro checks and further
recovery. The patient slowly improved through the night of POD
0 and by the morning of POD 1 was back to his baseline. The
neurology team evaluated the patient in the morning and per the
attending, Dr. [**Last Name (STitle) 1693**], it was felt the patient's neuro defecits
as they were the prior evening were related to his recent
surgery and resulting transient metabolic changes. On POD 2 the
pt. was transferred from the SICU to the floor, his chest tube
was removed and daily drainage of the pleurex catheter was
initiated. While in the ICU the patient was also evaluated by
the Neurosurgery team for a 1.5mm aneurysm seen on the MRI ->
the pt. is to get a repeat CTA in 6 months for follow-up.
.
Over the next several days the patient underwent daily pleurex
catheter drainage -> tapering from Q8 hour drainage to q24 hour
drainage. He was also seen by and worked with physical therapy
on a daily basis. His diet was gradually increased to regular
with supplemental nutrition shakes. His foley was removed on
POD 5 and he was voiding without difficulty prior to discharge.
Because of his further need for physical therapy the pt. was
screened for rehab and was ready for discharge on POD 7. Prior
to discharge the pt. was given instructions regarding follow-up
appointments with the interventional pulmonology team, primary
care physician [**Name9 (PRE) 702**], [**Name9 (PRE) 41081**] medications, and
activity levels. He received pleurex catheter care teaching
while in house that shall continue while he is in rehab. The
patient understood these teachings and was ready for discharge.
Medications on Admission:
Aspirin, atenolol, Avandia, Klonopin, glipizide, Glucophage,
simvastatin, verapamil, Benicar, and magnesium.
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO QD ().
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
8. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. finger stick
finger stick qid
12. regular insulin per sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]
Discharge Diagnosis:
recurrent pleural effusion
Discharge Condition:
deconditioned
Discharge Instructions:
- please call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop
chest pain, fever, chills, shortness of breath, redness or
drainage at your incision or catheter site.
- If you have questions re: your pleurex catheter, please call
Interventional Pulmonology [**Telephone/Fax (1) 10084**].
- Pleurex catheter needs to be drained daily at 8am. Call the
interventional pulmonary office [**Telephone/Fax (1) 10084**] when the drainage
is less than 150cc for 2 consecutive days to be evalutaed for
catheter removal.
- you should eat your regular diet as tolerated
- you may take sponge baths while the pleurex catheter is in
place -> no soaking in hot tubs, bath tubs, or swimming pools
Followup Instructions:
- Please follow up with Dr. [**Name (NI) **] when you leave rehab
or if your drainage is less than 150cc for two consecutive days.
[**Telephone/Fax (1) 10084**]
- Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2189-7-14**] 2:00pm
**it is very important that you call to confirm these
appointments**
|
[
"198.89",
"585.9",
"197.2",
"250.00",
"162.8",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"33.23",
"37.12",
"34.09",
"34.21",
"34.91",
"37.0",
"34.92"
] |
icd9pcs
|
[
[
[]
]
] |
11348, 11394
|
5918, 10324
|
295, 362
|
11465, 11481
|
2357, 5895
|
12241, 12600
|
1964, 2122
|
10483, 11325
|
11415, 11444
|
10350, 10460
|
11505, 12218
|
2137, 2137
|
2151, 2338
|
236, 257
|
390, 1440
|
1462, 1620
|
1636, 1948
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,829
| 166,570
|
32798
|
Discharge summary
|
report
|
Admission Date: [**2147-3-23**] Discharge Date: [**2147-3-30**]
Service: MEDICINE
Allergies:
Penicillins / Citrus Derived / Lactulose
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 84 y/o M with PMH of CAD (MI [**1-3**] and [**3-4**])
transferred from rehab for chest pain starting this AM. He notes
that the pain started this AM but denies any associated sx. He
notes that he has not eaten or drank well for some time.
Upon presentation to the [**Hospital1 18**] ED, he was noted to have EKG
w/TWI in V2-V5 in the ED and was hypotensive to 70's/50s in the
ED which was responsive to fluid. Through the ED resident's
discussion with the HCP, the plan was for conservative
management of pt's sx. They did not want cardiac
catheterization. However, they did feel that if pt's hypotension
required pressors or central line, they would be agreeable.
Thus, he was transferred to the CCU.
He was afebrile sating well on RA, his CP resolved w/heparin IV.
.
Currently complains of chest wall pain. Denies SOB,
HA/dizzyness. No cough, fever/chills. + pain in LE bl.
Past Medical History:
Cardiac Risk Factors: negative for Diabetes, Dyslipidemia, and
Hypertension
.
Cardiac History:
STEMI [**1-3**] s/p mid and distal LAD placement of 2 bare metal
stents
anterior STEMI in [**3-4**] - medically managed
h/o LV thrombus - on TTE in [**1-3**], completed 3 wk course of
lovenox
.
Percutaneous coronary intervention [**2147-1-9**] demonstrated:
LAD had total occulsion proximally. RCA no CAD, LCx and LMCA no
CAD mid and distal LAD placement of 2 bare metal stents
.
Other PMH:
- Ulcerative colitis
- Recurrent UTI
- Dysphagia s/p esophageal dilatation
- Bilateral leg ulcers and skin grafts
- h/o C diff
Social History:
Lives at Senior Center. Social history is significant for the
absence of current tobacco use. There is no history of alcohol
abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.6, BP 85/55, HR 62, RR 27, O2 99% on RA
Gen: cachectic elderly gentleman, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, dry MM. No
xanthalesma.
Neck: Supple with flat JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: + scoliosis and kyphosis. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NT + mild distention. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
Rectal: guiac (-)
Ext: No c/c/e. No femoral bruits.
Skin: No rashes, + ulcers on LE bl, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
MEDICAL DECISION MAKING
EKG demonstrated new TWI in V3-V5 compared with prior dated
[**2147-3-11**]
.
2D-ECHOCARDIOGRAM performed on [**2147-3-9**] demonstrated: A moderate
sized apical thrombus in LV. The clot is mural and not mobile.
LV systolic function appears moderately-to-severely depressed
(ejection fraction 30 percent) secondary to akinesis of the
anterior septum and anterior free wall, with extensive apical
dyskinesis. RV WNL. Mild mitral valve prolapse. Mild (1+) MR.
The left ventricular inflow pattern suggests impaired
relaxation.
.
CXR: No acute intrathoracic pathology is noted however the study
is
moderately limited due to patient rotation to the right side.
[**2147-3-23**] 01:23PM BLOOD WBC-3.1* RBC-4.53* Hgb-10.8* Hct-36.1*
MCV-80* MCH-23.9* MCHC-30.0* RDW-14.6 Plt Ct-582*
[**2147-3-25**] 06:05AM BLOOD WBC-4.9# RBC-3.73* Hgb-8.8* Hct-29.4*
MCV-79* MCH-23.5* MCHC-29.8* RDW-15.7* Plt Ct-507*
[**2147-3-23**] 01:23PM BLOOD PT-13.1 PTT-31.3 INR(PT)-1.1
[**2147-3-23**] 07:50PM BLOOD PT-14.7* PTT-93.2* INR(PT)-1.3*
[**2147-3-25**] 06:05AM BLOOD PT-13.7* PTT-67.4* INR(PT)-1.2*
[**2147-3-23**] 01:23PM BLOOD Glucose-87 UreaN-23* Creat-0.7 Na-142
K-4.4 Cl-104 HCO3-31 AnGap-11
[**2147-3-25**] 06:05AM BLOOD Glucose-62* UreaN-13 Creat-0.5 Na-143
K-3.8 Cl-111* HCO3-23 AnGap-13
[**2147-3-23**] 01:23PM BLOOD CK(CPK)-32*
[**2147-3-23**] 07:20PM BLOOD CK(CPK)-28*
[**2147-3-24**] 03:19AM BLOOD ALT-13 AST-17 LD(LDH)-175 CK(CPK)-35*
AlkPhos-72 Amylase-25 TotBili-0.3
[**2147-3-23**] 01:23PM BLOOD cTropnT-0.15*
[**2147-3-23**] 07:20PM BLOOD CK-MB-NotDone
[**2147-3-23**] 07:20PM BLOOD cTropnT-0.13*
[**2147-3-24**] 03:19AM BLOOD CK-MB-5 cTropnT-0.14*
[**2147-3-24**] 03:19AM BLOOD Albumin-2.7* Calcium-7.8* Phos-2.2*
Mg-1.8
Brief Hospital Course:
A/P: 84 yo man with PMH of CAD (MI [**1-3**] and [**3-4**]) admitted with
c/o chest pain in the setting of two recent anterior MI s/p PCI
to LAD and recent medical management.
.
#. CAD - Pt s/p PCI with BMS to mid and distal LAD [**1-3**] and
recent anterior STEMI which was managed medically. Pt is CP free
after IV hydration and improved BPs. Initially with TWI in
V2-V5, trops at BL 0.14, CK-MBs negative. For medical
management of this event (which was not felt to represent
recurrent ACS given low-grade and flat elevations of troponin
alone) he was continued on ASA, statin, and plavix initially,
though plavix was discontinued during his stay for 4 days in
preparation for Gtube placement on [**2147-3-29**]. This was restarted
after his procedure. Metoprolol was held as patient was
hypotensive and bradycardic to high-40s even while awake. He
should follow-up as an outpatient for possible reinitiation of
bblocker.
.
#. Pump - TTE [**3-4**] - EF 30% secondary to akinesis of the
anterior septum and anterior free wall, with extensive apical
dyskinesis consistent with known CAD. His Ace-I was held because
of relative hypotension. [**Name2 (NI) **] should follow-up as outpatient for
possible reinitiation of ace-I.
.
#. Rhythm - h/o atrial fibrillation but in NSR during his stay.
Bblocker was continued as above.
.
#. Hypotension - hypotension improved with IVFs and was thought
to be due to chronic poor PO intake and volume depletion. There
was no evidence of infection. This likely represented volume
depletion as pt has very poor PO intake. Discussed recent
speech and swallow evaluation with speech pathologist at [**Hospital **]
rehab which showed patient aspirated all consistencies (but did
best with honey-consistency). Risks and benefits of enteral
feeding discussed with patient who felt that gastric feeding was
the only Gastric tube was placed by surgery given patient'
.
#. Leukopenia w/relative lymphocytosis and Thrombocytosis -
currently improved
.
#. Anemia - near baseline HCT of 31
.
#. Ulcerative Colitis - continued outpatient regimen
.
#. Severe Malnutrition: aspiration precautions for h/o
dysphagia, spoke with rehab where he had S&S which showed
aspiration of all liquids. Continue honey-thickened liquids,
pureed diet. pt. currently favoring G-tube as longer-term
solution to poor nutrition an PO. spoke with HCP sister as well
sa [**Hospital **] who agree. GI on board for outpatient gtube
placement. Plavix held in preparation, will need to be
restarted after procedure. He was given d51/2NS for calories
during his stay and should continue getting that until he can be
fed enterally.
.
#. Prophylaxis: heparin SC, PPI, bowel regimen
.
#. Code: DNR/DNI
.
#. Communication: Sister, [**Name (NI) 19904**], HCP
[**Name (NI) 53767**]/Family Attorney: [**First Name5 (NamePattern1) 10378**] [**Last Name (NamePattern1) **] home: ([**Telephone/Fax (1) 76373**], cell:
([**Telephone/Fax (1) 76374**]
Medications on Admission:
Aspirin 325 mg daily
Clopidogrel 75 mg daily
Senna 8.6 mg [**Hospital1 **] prn
Bisacodyl 10 daily
Atorvastatin 80 mg daily
omeprazole 40 mg daily
Mesalamine 250 mg TID
Digoxin 125 mcg daily
Metoprolol tartrate 12.5 twice daily
ferrous sulfate 325 mg once daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) tablespoon PO
BID (2 times a day).
4. Aspirin 81 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection 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. Mesalamine 250 mg Capsule, Sustained Release [**Last Name (STitle) **]: One (1)
Capsule, Sustained Release PO TID (3 times a day).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO TID (3 times a day).
11. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Morphine Sulfate 1 mg IV Q2H:PRN
breakthrough pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
failure to thrive
severe malnutrition
chronic systolic congestive heart failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with chest pain. This was
likely caused by low blood pressures from not eating well. You
had a PEG tube placed for your feeds. You should take your food
and medications through this tube from now on.
Please continue to take your medications as prescribed. If you
develop chest pain, shortness of breath, fever, or any other
concerning symptoms please contact a physician [**Name Initial (PRE) 2227**].
Tubefeeding recommendations as below: Monitor lytes including
phosphorus to adjust.
Probalance Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q8h Goal rate: 45
ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 50 ml water q6h
Followup Instructions:
Please follow up with your primary care physician and
cardiologist in [**1-30**] weeks.
Completed by:[**2147-4-2**]
|
[
"V45.82",
"707.13",
"414.01",
"556.9",
"401.9",
"428.22",
"261",
"530.3",
"428.0",
"272.4",
"250.00",
"276.51",
"412",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
9283, 9349
|
4702, 7652
|
259, 265
|
9473, 9482
|
2936, 4679
|
10236, 10354
|
1990, 2072
|
7963, 9260
|
9370, 9452
|
7678, 7940
|
9506, 10213
|
2087, 2917
|
209, 221
|
293, 1186
|
1208, 1824
|
1840, 1973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,798
| 187,310
|
32281
|
Discharge summary
|
report
|
Admission Date: [**2123-11-23**] Discharge Date: [**2123-11-26**]
Date of Birth: [**2079-7-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
bilateral saddle pulmonary emboli
Major Surgical or Invasive Procedure:
percutaneous thrombectomy x2
History of Present Illness:
44 yo F with no previous medical history who is transferred from
an OSH for bilateral saddle pulmonary emboli who is now s/p
percutaneous thrombectomy. She presented to [**Hospital 5279**] Hospital this
am complaining of anxiety with hyperventiliation as well as mid
back pain with leaning forward. The pt was noted to be anxious
on exam and breathing in a paper bag and was given 1 mg IV
ativan. An EKG was significant for sinus tachycardia with a
S1Q3T3 and RV strain. An ABG was 7.12/25/120/8/97.8 on a NRB and
the pt was intubated. This was then followed by HR 32 and the pt
was given atropine with improvement in HR to the 50s. A stat
chest CTA was significant for bilateral saddle pulmonary emboli
with thrombus also seen in the more distal branches of the
bilateral pulmonary arteries. Shortly thereafter, the pt was
started on levophed at 4 mcg/kg/hr which was titrated up to 20
mcg/kg/hr and vasopressin 0.04 units/hr for SBPs in the 40s. A
HCO3 gtt was also started at 200 cc/hr for severe respiratory
acidosis on a rpt ABG. She was given 10 units retaplase IV X 1
prior to being transferred to [**Hospital1 18**].
.
On arrival, labs were significant for Hct 34.2 and ABG
7.03/69/90/20 with lactate of 6.3. The pt was sent immediately
to the OR for percutaneous tPA and thrombectomy. In the OR, a
TEE was significant for massive clot burden in the main PA, R
PA, and L PA with some flow distally. A percutaneous
thrombectomy was performed of the main PA and right PA with
residual clot but flow visualized in the right PA. Levophed and
vasopressin were shut off and she was started on neo at 2
mcg/kg/min and epi gtt at 0.04. She was also given 100 meq HCO3
and was then transferred to the CCU for further management.
.
ROS unable to be performed as pt sedated and intubated. Per her
family, the pt has not had any recent travel and has not
complained recently of shortness of breath, chest pain, or leg
swelling/pain. Of note, the family reports that she is a heavy
smoker and is on OCPs.
Past Medical History:
Anxiety
s/p CCY
Social History:
No alcohol or illicits. 1 PPD X 20 yrs.
Family History:
No family history of blood clots.
Physical Exam:
(on admission)
VS: T 93.5 oral, BP 125/94, HR 114, RR 24, O2 100% on AC FiO2
100%, PEEP 10, TV 600, RR set at 24
Gen: obese female, sedated and intubated. [**Doctor Last Name 13674**] hugger in place.
HEENT: pupils dilated and fixed, NGT in L nare, sanguinous fluid
draining from R nare, ETT tube in place
Neck: RIJ present with area of diffuse ecchymoses and 3X4
palpable hematoma.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. no murmurs appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. No
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Foley draining grossly bloody urine
Neurologic: sedated, pupils dilated and fixed bilaterally, does
not withdraw to pain, does not move extremities spontaneously,
slightly decreased motor tone b/l, unable to perform motor
strength or sensation testing, +1 DTRs b/l, babinski equivocal
b/l, twitch test performed by neurology resident at bedside
negative.
Pertinent Results:
Port CXR [**11-23**] - underinflation with elevation of R diaphragm
and bibasilar atelectasis. Cardiomediastinal silhouette and
pulmonary vascularity are grossly unremarkable. ETT present in
the trachea above the carina.
.
Chest CTA [**11-23**] - large central saddle pulmonary embolism
present with thrombus seen beyond this central saddle embolus in
the central and more distal branches of both pulmonary arteries.
Scatterred areas of ground glass opacification in both lungs
with some pleural thickening on the right. 3 cm long stenotic
semenet of hte R common iliac artery on the order of 70% with
less than 50% segmental stenosis of the L common iliac artery.
.
TEE [**11-23**] - Pre-pulmonary angiography:
1. The left atrium is normal in size.
2. Overall left ventricular systolic function is normal
(LVEF>55%).
3. The right ventricular cavity is moderately dilated. There is
moderate global right ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
5. The mitral valve appears structurally normal with trivial
mitral regurgitation.
6. Moderate [2+] tricuspid regurgitation is seen.
7. Significant pulmonic regurgitation is seen. The main
pulmonary artery is dilated. There is an area of echogenicity in
the right pulmonary artery consistent of pulmonary embolism.
There is limited flow across this area. An area of echogenicity
in the main pulmonary artery cannot be excluded. Unable to
visualize the left pulmonary artery.
8. IVC is dilated.
Post-pulmonary angiography:
1. The area of echogenicity in the right pulmonary artery has
decreased and there is an improvement of flow along the right
pulmonary artery. There is flow along the main pulmonary artery.
The left pulmonary artery remains difficult to visualize.
.
BILATERAL LOWER EXTREMITY ULTRASOUND ([**11-23**]): Thrombus is
identified within the right popliteal vein extending proximally.
However, the superficial femoral vein on the right appears
patent with normal compressibility, waveforms, and augmentation.
Partially occlusive thrombus is identified within the right
common femoral vein. On the left, partially occlusive thrombus
identified within the left popliteal vein. Otherwise, the left
superficial femoral and common femoral veins appear patent with
normal compressibility, waveforms, and augmentation.
IMPRESSION: Thrombus identified within the right popliteal vein
with non-
occlusive thrombus within the right common femoral vein. Likely
thrombus
identified within the left popliteal vein.
.
CTA [**11-24**]: Bilateral pulmonary embolism as described above.
Multifocal opacities/nodular opacities/ and consolidation in the
lungs. Notably, the area of consolidation in the right lower
lobe
appears to have components of ischemia/infarction; less likely
would be a component of pneumonia. Recommend follow up after
clinical treatment to demonstrate resolution of these findings.
Soft tissue stranding in the anterior superior chest,
surrounding the
trachea in the superior mediastinum, and supraclavicular
regions.
.
Echo [**11-24**]: LV unusually small. RV markedly dilated. severe
global RV free wall hypokinesis. abnormal diastolic septal
motion/position consistent with RV volume overload. no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal images due to patient being intubated.
The right ventricle appears markedly dilated and moderately to
severely hypokinetic. Pressure overload of the right ventricle.
LV cavity appears small, probably due to compressive effect of
the large RV. LV function appears normal/hyperdynamic.
Brief Hospital Course:
As mentioned above, on arrival to BIMDC labs were significant
for Hct 34.2 and ABG 7.03/69/90/20 with lactate of 6.3. The pt
was sent immediately to the OR for percutaneous tPA and
thrombectomy. In the OR, a TEE was significant for massive clot
burden in the main PA, R PA, and L PA with some flow distally. A
percutaneous thrombectomy was performed of the main PA and right
PA with residual clot but flow visualized in the right PA. Pt
was brought up to the CCU where she was very tenuous with
hypotension requiring quadruple pressors, and multisystem organ
failure including renal, liver, GI tract, endocrine,
neurological systems [**2-5**] the bilateral saddle pulmonary embolism
and subsequent hypotension (and possibly to to embolisms to
other organs other than lung). Pt had a lactate at 11.1 that
evantually peaked at 17 requiring nuumerous amps of bicarb. She
received blood transfusions for oozing from several sites and
for coffee ground, bloody drainage from upper GI tract throught
the NGT. A STAT CT scan of the head was negative for
intracranial bleed on admission.
Pt had no risk factors for PE other than being on OCPs and
smoker. With signs of RV strain and dilatation on initial EKG
and echos. Once PTT was at goal, the heparin was restarted and
continued. LENIS were positive for bilteral DVTs that were
compressible suggesting fresh clots. Pt was seen by neuro who
thought but had little brain and brain stem fn but given young,
there was still a small hope she would recover some function if
surviving the first 24 hrs.
Pt managed to make it through the first night and then when
weaned off sedation there was a question from neuro about
weather she had recovery of her function to some extent;
therefore she was taken back to have another percutaneous
thrombectomy and placement of an IVC filter. Despite this pt
continued to require 4 pressors with worsening multisystem organ
failure. Her neuro exam was relevant for absent gag reflex,
corneal reflex, with sluggish pupillary response and only
response to pain was decortication. The prognosis was thought
to be exceedingly poor at this time since it had been >72 hrs
since first presenting at the OSH.
After discussion with the family including the HCP [**Name (NI) **] [**Name (NI) 75456**]
on [**2123-11-26**], the decision was made to make the pt cmo. Pt
expired soon thereafter and was pronounced at 17:12 on [**11-26**].
Medications on Admission:
Aspirin 162 mg po daily
Cilostazol 100 mg [**Hospital1 **]
Metoprolol Tartrate 75 mg [**Hospital1 **]
Pantoprazole 40 mg daily
Warfarin 1 mg daily
Nitroglycerin 0.4 mg SL prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Saddle embolus/pulmonary embolism
Multisystem organ failure
Cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"305.1",
"453.41",
"276.2",
"415.19",
"584.9",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"88.55",
"99.10",
"37.21",
"38.05",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10299, 10308
|
7639, 10046
|
359, 389
|
10434, 10443
|
3801, 7616
|
10495, 10501
|
2530, 2565
|
10271, 10276
|
10329, 10413
|
10072, 10248
|
10467, 10472
|
2580, 3782
|
286, 321
|
417, 2418
|
2440, 2457
|
2473, 2514
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,958
| 139,986
|
53550
|
Discharge summary
|
report
|
Admission Date: [**2121-3-20**] Discharge Date: [**2121-3-22**]
Date of Birth: [**2038-7-16**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**Doctor First Name 1402**]
Chief Complaint:
slow ventricular tachycardia
Major Surgical or Invasive Procedure:
Ventricular Tachycardia Ablation
Right Atrial Lead Placement Device Upgrade
History of Present Illness:
Mr. [**Known lastname 30207**] was an 82 year old retired dermatologist with h/o
remote anterior MI with a resultant LV aneurysm/scar with an
LVEF of 25-30%. He has had intermittent symptoms of congestive
heart failure, easily treated with diuretics. He also has a
history of chronic recurrent slow monomorphic ventricular
tachycardia and is s/p ICD implant in [**2106**]. In prior years, his
VT had not caused any syncope and he would experience one or two
ICD firings per year. Over the past several months, he has had
several episodes where he has had syncope or presyncope, with
episodes lasting minutes at a time. In [**1-/2121**] he was admitted to
his local hospital in [**State 108**] for recurrent syncope and ICD
firing. His workup included a cardiac catheterization. His LAD
was found chronically occluded with collaterals from the RCA.
His OM was stented with a bare metal stent.
On [**2121-3-9**] the patient was readmitted to Palm Beach [**Hospital **]
Medical Center with recurrent near syncope that lasted 2
minutes. On arrival he was noted to have mild CHF. He had some
slow VT on the monitor but it did not trigger his ICD. His
Amiodarone was increased to 400mg b.i.d. and Mexiletine dosing
increased to 150mg t.i.d. Since that time he has not had any
further events. His Amiodarone has been cut back to 300mg b.i.d.
He is now being referred for VT ablation.
Pt underwent VT ablation on [**3-20**], which found two circuits
exiting near the rim of the LV aneurysm. Both VTs were
successfully ablated. Upon arrival to the CCU, the patient
denied chest pain or shortness of breath. He was hemodynamically
and electrically stable. I told the family of the benefits of
atrial pacing to improve his hemodynamics and said we could do
an upgrade next week or the week after. The patient and his
family preferred that the upgrade be done the next day, if
possible, since it would be inconvenient to go back and forth
from the hospital.
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p anterior wall MI approximately 40 years ago with LV
aneurysm/scar
s/p bare metal stenting of the OM [**2121-2-6**] (Palm Beach [**Hospital **]
Medical Center)
Ventricular tachycardia with recurrent slow monomorphic VT
Single chamber ICD implant [**2106**], generator replacement in [**2111**]
and [**2116**]
Mitral and tricuspid regurgitation
Pulmonary hypertension
Hx of neurocardiogenic syncope, orthostatic hypotension
Renal insuffiency
Small intracerebral hemorrhage per referring records-Hx unknown
to patient
Abnormal LFT's, possibly from Amiodarone therapy
Hypothyroidism, likely from Amiodarone therapy
Gouty arthritis
Idiopathic thrombocytopenia (runs 95-120's)
Anxiety
Cataract surgery
Asthma (symptomatic with URI)
Small gallstones
Hx of remote PUD. Recent GI series for complaints of abdominal
bloating was found negative.
Social History:
Patient is married. lives half the year in [**State 108**] and half the
year in [**Location (un) 42832**] [**State 531**]. He is a retired dermatologist.
His son in law works as a surgeon at [**Hospital1 18**].
Contact for discharge: [**Name (NI) 4100**] [**Name (NI) 30207**] (wife) [**Telephone/Fax (1) 110068**]
Tobacco: Quit 40 years ago. Patient reports that PFT's one month
ago were "perfect"
ETOH: Denies
Recreational drugs: Denies
Home services: Denies
Family History:
Mother died in her 70's from a stroke. Father dx with CAD at
the age of 60, died in his mid 80's from an MI. No family
history
of sudden cardiac death.
Physical Exam:
Admission Exam:
VS: T=97.4 BP=132/55 HR= 48 RR=14 O2 sat= 98%RA
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: No JVD visualized but pt was supine due to sheath.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Cath sheath in place in R groin. Blood
oozing from multiple sites.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. B/l
toes are violacious and cold to touch, with cap refill.
NEURO: AAOx3, CNII-XII grossly intact.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Discharge Exam:
Pupils Fixed and Dilated.
No Heart Sounds.
No Pulses.
Pertinent Results:
[**2121-3-20**] 02:20PM BLOOD WBC-7.8 RBC-3.98* Hgb-11.6* Hct-36.0*
MCV-91 MCH-29.0 MCHC-32.1 RDW-13.9 Plt Ct-108*
[**2121-3-21**] 04:15PM BLOOD WBC-2.4*# RBC-2.56*# Hgb-7.4*# Hct-23.2*#
MCV-91 MCH-29.0 MCHC-32.0 RDW-14.4 Plt Ct-114*#
[**2121-3-21**] 11:44PM BLOOD WBC-4.2# RBC-3.83* Hgb-11.7* Hct-34.8*
MCV-91 MCH-30.5 MCHC-33.5 RDW-15.0 Plt Ct-73*
[**2121-3-20**] 07:30AM BLOOD PT-12.8* INR(PT)-1.2*
[**2121-3-21**] 01:50PM BLOOD PT-21.0* INR(PT)-2.0*
[**2121-3-21**] 11:44PM BLOOD PT-16.8* PTT-56.3* INR(PT)-1.6*
[**2121-3-20**] 02:20PM BLOOD Glucose-131* UreaN-25* Creat-1.6* Na-137
K-3.9 Cl-104 HCO3-26 AnGap-11
[**2121-3-21**] 06:02PM BLOOD Glucose-146* UreaN-36* Creat-2.4* Na-137
K-4.4 Cl-103 HCO3-22 AnGap-16
[**2121-3-20**] 02:20PM BLOOD ALT-134* AST-134* AlkPhos-59
[**2121-3-21**] 04:15PM BLOOD ALT-375* AST-445* LD(LDH)-507*
AlkPhos-39* TotBili-0.7
[**2121-3-20**] 02:20PM BLOOD CK-MB-24* cTropnT-2.05*
[**2121-3-21**] 04:15PM BLOOD CK-MB-11* cTropnT-1.40*
[**2121-3-22**] 01:36AM BLOOD Type-ART Temp-35.3 pO2-65* pCO2-34*
pH-7.26* calTCO2-16* Base XS--10
[**2121-3-21**] 04:29PM BLOOD Lactate-5.2*
[**2121-3-21**] 06:14PM BLOOD Lactate-3.9*
[**2121-3-22**] 01:36AM BLOOD Lactate-6.1*
Portable TTE (Complete) Done [**2121-3-20**] at 3:15:44 PM FINAL
IMPRESSION: Very small pericardial effusion near the
inferolateral wall of the left ventricle without
echocardiographic evidence of tamponade. Biatrial enlargement.
Severe global and regional left ventricular systolic dysfunction
in the presence of a large apical aneurysm. Mild to moderate
aortic regurgitation. Moderate mitral regurgitation. Tricuspid
regurgitation. Moderate pulmonary artery systolic hypertension.
Portable TTE (Focused views) Done [**2121-3-21**] at 1:22:06 PM
FINAL
There is an apical left ventricular aneurysm. There is no
pericardial effusion. The Impella catheter is seen in the left
ventricle extending to the apical aneurysm, penetrating deeper
into the left ventricular cavity than would be expected to
provide effective circulatory support. Device was pulled back
under fluoroscopic guidance.
Portable TTE (Focused views) Done [**2121-3-21**] at 4:27:40 PM
FINAL
There is an apical left ventricular aneurysm. There is no
pericardial effusion.
Tip of Impella catheter seen at midventricular level, abutting
inferior posterior wall. Brisk Impella outflow seen in proximal
ascending aorta. Left ventricular end diastolic chamber
dimension (4.0 cm) suggests adequate volume unloading.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2121-3-20**] 6:11 PM
IMPRESSION:
1. Small to moderate amount of intrapelvic blood as well as
stranding
surrounding the access site. Moderate amount of blood in the
anterior
pericardial fat space that tracts down to the level of the mid
abdomen on the right.
2. Calcified splenic granulomas.
3. Small non-obstructing renal stone in the right kidney.
4. Small liver cyst and smaller subcentimeter adjacent
hypodensity which is too small to characterize.
CHEST (PORTABLE AP) Study Date of [**2121-3-20**] 1:59 PM
There is moderate cardiomegaly. Left pacemaker lead terminates
in the right ventricle. There is no pneumothorax or large
pleural effusion. There are low lung volumes. There is mild
vascular congestion. There are bibasilar atelectases.
CHEST PORT. LINE PLACEMENT Study Date of [**2121-3-21**] 4:07 PM
FINDINGS: Bilateral, severe pulmonary edema is new since
yesterday. An
orogastric tube courses just below the diaphragm with its side
port still
above the level of GE junction, consider advancing the
orogastric tube by 6 cm for a better seating. Endotracheal tube
tip is 8 cm above the carina ending approximately at the level
of the clavicular head, consider advancing the endotracheal tube
by 2-3 cm for better seating. There is a left pectoral ICD
device with two leads coursing through the left transvenous
approach and right transvenous approach and ending into the
right atrium and right ventricle respectively. There is no
evidence of pneumothorax. An Impella device through the aorta
ends into the left ventricle.
Brief Hospital Course:
Mr. [**Known lastname 30207**] was an 82 year old man with anterior wall MI
approximately 40 years ago with LV aneurysm/scar, s/p bare metal
stenting of the OM [**2121-2-6**], recurrent slow monomorphic VT with
single chamber ICD implant [**2106**], generator replacement in [**2111**]
and [**2116**], MR [**First Name (Titles) **] [**Last Name (Titles) **], pHTN, presented s/p VT ablation on [**3-20**],
which was performed because of recent symptomatic VT and ICD
firings. He was taken back to the EP lab on [**2121-3-21**] for RA lead
placement and device upgrade, during wich he had a cardiac
arrest and prolonged resuscitation resulting in cardiogenic
shock, multisystem organ failure, and eventually to his death.
# Cardiac Arrest
Patient had a PEA arrest in the EP lab on [**2121-3-21**] after RA lead
placement, unclear precipitant. Mechanical and pharmacologic
CPR resulted in VF which was defibrillated twice with a round of
CPR in between. An Impella device was placed by Interventional
Cardiology team to offload the LV. He had increasing pressor
requirement over next several hours, maxed out on three
pressors. Lactate was rising, likely in setting of poor
perfusion and also question of abdominal compartment syndrome,
potentially from intrapelvic bleed post-procedurally. He had
been transfused a total of 6 units of blood, 2 units FFP, 1 unit
platelets, 1 unit cryoglobulin peri-procedurally in setting of
DIC in cath lab, which had resolved by arrival to CCU.
Combination of progressive cardiogenic shock with acute anuric
renal failure resulted in progressive hypoxemic respiratory
failure with increasing difficulty oxygenating on ventilator.
Patient did not respond to IV diuretics and continued to have
worsening hemodynamics with systolic blood pressure in the 70's
despite maximum pressors and impella support. Family was
notified and present at bedside, made decision not to proceed
with CRRT/CVVH due to his deteriorating condition and overall
poor prognosis. Patient was made comfort measures and Impella
device was turned off.
# Slow monomorphic VT:
Patient had single chamber ICD implant from [**2106**], generator
replacement in [**2111**] and [**2116**], and underwent VT ablation on [**3-20**]
because of recent symptomatic VT and ICD firings. Pt was
transiently hypotensive to 70s during VT ablation and received
prophylactic chest compressions (less than 30 sec) but even
though he maintained an adequate pulse. He was noted to have
markedly improved hemodynamics with atrial pacing or sinus
rhythm, which was facilitated by dopamine. Throughout the
remainder of the case he was hemodynamically stable with BPs in
115-145 range. His VTs were non-inducible at the end of the
procedure and he was extubated without complication. Because his
native sinus rhythm was at rates in 40s (due to prior high
dosing with amiodarone), he was started on low dose dopamine
overnight to overdrive underlying slow VT. Per the patient's
and family's wishes, he was taken back to the EP lab [**2121-3-21**] for
RA lead placement and device upgrade, during which he arrested,
as above.
Medications on Admission:
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet -
1.5 Tablet(s) by mouth twice a day
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 0.5 (One half) Tablet(s) by mouth every evening
CARVEDILOL PHOSPHATE [COREG CR] - (Prescribed by Other Provider)
- 80 mg Cap, ER Multiphase 24 hr - 1 Cap(s) by mouth daily (AM)
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth qam
EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every evening
LEVOTHYROXINE [SYNTHROID] - (Prescribed by Other Provider) - 25
mcg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth every evening
MEXILETINE - (Prescribed by Other Provider) - 150 mg Capsule - 1
Capsule(s) by mouth three a day
ONDANSETRON - (Prescribed by Other Provider) - 4 mg Tablet,
Rapid Dissolve - 1 Tablet(s) by mouth as needed
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth twice a day
FUROSEMIDE 20mg PO daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth every morning
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 2 Capsule(s) by mouth every evening
GUAR GUM [BENEFIBER (GUAR GUM)] - (Prescribed by Other Provider)
- Dosage uncertain
VITAMINS A,C,E-ZINC-COPPER [PRESERVISION] - (Prescribed by
Other Provider) - Dosage uncertain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiogenic Shock
Acute on Chronic Heart Failure
Acute on Chronic Renal Failure
Slow Ventricular Tachycardia
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"272.4",
"414.01",
"412",
"997.1",
"427.1",
"996.04",
"428.0",
"584.9",
"E879.8",
"276.2",
"518.51",
"585.9",
"427.5",
"403.90",
"286.6",
"785.51",
"V45.82",
"244.9",
"285.1",
"287.5",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"37.34",
"96.71",
"37.27",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
13678, 13687
|
8993, 12110
|
331, 409
|
13840, 13850
|
4886, 8970
|
13903, 13911
|
3777, 3930
|
13649, 13655
|
13708, 13819
|
12136, 13626
|
13874, 13880
|
3945, 4796
|
4812, 4867
|
263, 293
|
437, 2388
|
2410, 3282
|
3298, 3761
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,516
| 167,606
|
17124
|
Discharge summary
|
report
|
Admission Date: [**2114-12-15**] Discharge Date: [**2114-12-26**]
Date of Birth: [**2064-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfur / Demerol / Amphotericin B / Allopurinol /
Vicodin / Percocet
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Neutropenic fever and Hypotension
Major Surgical or Invasive Procedure:
Peripherally Inserted Central Venous Catheter removal.
Tunneled central venous line insertion.
Nephrostogram and nephrostomy tube replacement/capping.
History of Present Illness:
Ms. [**Known lastname **] is 50 yo F with AML s/p allo-BMT in [**2110**], now with
relapsed AML awaiting repeat SCT, currently s/p high-dose ARA-C
on [**11-29**], who presented to [**Hospital 7188**] Hospital with diarrhea (on
Flagy ~1 week) and fatigue. At the OSH, she was found to be
hypotensive with SBP's 60's-70's and had temp of 100.3. She got
2-3L of IVF, meropenem, vancomycin, and was tran, and was then
transferred to the [**Hospital1 18**] ED. In the ED, she received 1L NS, and
SBP improved from the 70's to low 100's. She was admitted to the
[**Hospital Unit Name 153**]. She was continued on meropenem, vanco, given 2L NS and
started on stress dose steroids. She spiked to 101.7 so blood
cultures were again drawn and she was started on Flagyl for
possible Cdiff. Blood Cx from OSH came back positive for coag
negative staph. Her blood pressures improved and her temperature
curve decreased until prior to transfer to the floor when she
was 101.
She remained HD stable so was transferred.
.
At the time of interview, the patient felt hot, sweaty, and
fatigued. She denied chills. She denied chest pain, shortness of
breath, cough. She noted only 2 episodes of diarrhea with
lomotil. She denied melena, hematochezia. She denied HA, sinus
congestion. She denied dysuria, urinary urgency or frequency.
.
ROS: otherwise negative. no lightheadedness, palpitations. no
mouth pain. no myalgia/arthralgia.
.
ONC HISTORY:
Acute myelogenous leukemia - status post allogenic transplant
[**2110-8-4**]: 5 of 6 matched family member (father) allogenic BMT.
Mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of AML. MEC protocol started [**2114-7-29**]. She
tolerated the chemo well. Of note she was found to have anti HLA
B7 and B27 antibodies so required matched platelet transfusions
during her nadir. She underwent DLI on [**2114-9-4**]. She relapsed with
cytogenetically different AML (monosomy 7). She then underwent
reinduction with MEC in [**10-10**]. She received high-dose ARA-C
starting [**2114-11-29**]. She currently has a matched donor and is
awaiting transplant.
Past Medical History:
- Allergic rhinitis
- Depression
- Right-sided hydronephrosis secondary to fibroid
uterus/retroperitneal fibrosis thought secondary to
paraneoplastic syndrome, status post stent [**6-9**], removed [**8-9**]
- Left-sided hydronephrosis, status post nephrostomy tube
placement [**2114-10-4**]
- History of Lactobacillus bacteremia treated with Meropenem
during admission [**Date range (3) 48091**]
- Gastroesophageal reflux disease
- Chronic fatigue
Social History:
Married, lives with her husband (who is a nurse) and three
children ages 14, 9, 7. Worked as a controller. No tobacco or
alcohol use.
Family History:
Both parents living. Mother with hypertension, myocardial
infarction, systemic lupus. Father (donor) with hypertension,
recently had myocardial infarction. Siblings with hypertension.
Physical Exam:
Vitals: T 99.4 BP 108/68 HR 100 RR 18 O2 99% 1L NC
Gen: Sleepy, nontoxic, flushed
HEENT: PERRL. sclera anicteric. MMM. No oral lesions.
Neck: JVD 7 cm. No LAD.
CV: tachycardic, regular, nl s1, s2, no m/r/g
Resp: CTAB
Abd: soft, NTND, +BS, no rebound/guarding. L nephrostomy tube in
place - no drainage, d/c or tenderness.
Ext: no c/c/e
Skin: no rash
Neuro: A&Ox3
Pertinent Results:
[**2114-12-25**] 12:00AM BLOOD WBC-1.6* RBC-3.46* Hgb-10.5* Hct-30.1*
MCV-87 MCH-30.3 MCHC-34.8 RDW-15.9* Plt Ct-91*
[**2114-12-25**] 12:00AM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-10*
[**2114-12-25**] 07:00AM BLOOD PT-12.8 PTT-89.2* INR(PT)-1.1
[**2114-12-25**] 12:00AM BLOOD Gran Ct-1270*
[**2114-12-24**] 12:05AM BLOOD Gran Ct-1260*
[**2114-12-23**] 12:10AM BLOOD Gran Ct-1090*
[**2114-12-25**] 12:00AM BLOOD Glucose-210* UreaN-16 Creat-0.5 Na-139
K-4.0 Cl-99 HCO3-29 AnGap-15
.
Percutaneous Nephrostogram-
Left-sided nephrostography was performed over-the-guide wire,
which depicted a normal right-sided pelvocaliceal tree. The left
ureter is seen to be patent to the urinary bladder. No
intraluminal filling defect is seen. The caudal third of the
ureter demonstrates a moderate segmental stenosis and lateral
displacement of the course of the ureter seemingly draped along
a mass located medial to the lower third of the ureters course.
The upper two thirds of the ureter appears unremarkable.
Based upon the nephrostogram obtained, decision was made to
exchange the nephrostomy tube. The preexistent tube was then
removed over the guidewire leaving the guidewire in situ in
exchanged for a new 8-French nephrostomy tube. The retention
pigtail was formed within the left renal pelvis and locked in
place. The catheter was secured using an 0-silk retention suture
at the skin entry site, reinforced with an 8-French StatLock
device. The puncture site in the drainage catheter was dressed
with drain sponges, overlaid with Tegaderm transparent
semi-occlusive dressing patches. The estimated blood loss was
minimal. No complications were encountered.
The catheter was capped and left in place.
IMPRESSION.
1. Segmental stenosis of caudal [**2-6**] of left ureter. No
obstruction of the left ureter is observed.
2. Status post over-the-wire exchange of left-sided 8-French
nephrostomy tube, which was left capped.
3. No hydronephrosis.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 50 yo woman with AML who is s/p allogenic BMT
five years ago, and presented recently with a donor cell AML and
is s/p reinduction with MEC and then HIDAC on [**11-29**] who was
admitted with hypotension and gram positive sepsis.
.
#) Hypotension/[**Name (NI) 15305**] Pt was admitted with SBP's in low 80's
responsive to IV fluid boluses. She was admitted to the [**Hospital Ward Name 1826**]
Intensive Care Unit for close monitoring of her volume status.
Given the patient's chronic steroid use and hypotension she was
started on stress dose steroids for relative adrenal
insufficiency. Her symptoms of diarrhea and abdominal pain
raised suspicion for an intrabdominal source, however her R PICC
line was notably painful and erythematous and therefore thought
to be the most likely source of infection. Her right axillary
vein PICC line was removed on admission. And she was started on
Vancomycin IV Serial blood cultures later grew coagulase
positive Staphylococcus sp sensitive to vancomycin. She was
transferred to the BMT floor where an upper extremity doppler
ultrasound revealed total occlusion of the axillary vein
extending into the cephalic vein. The patient was transfused HLA
matched platelets for goal greater than 50,000 and
anticoagulated with heparin gtt. She was continued on vancomycin
IV after reviewing senstivities and speciation data. She
conituned to have fevers to 103 thought secondary to poor
antibiotic penetration into the infected thrombus. Her
antifungal coverage was broadened to voriconazole. TTE was
obtained and did not reveal any valvular vegetations. Once
afebrile for 48hrs she was switched to PO linezolid. She was
changed back to fluconazole for antifungal prophylaxis.
.
#) Nephrostomy-
Extensive discussion between providers of risks and benefits of
nephrostomy tube going into transplant. Etiology of ureteral
obstruction was thought secondary to fibroid uterus vs.
retroperitoneal fibrosis as paraneoplastic syndrome. Urology
consultation recommended leaving the nephrostomy in place. Prior
to discharge, a nephrostogram revealed caudal stenosis, and was
the tube was capped and left in place. Pt tolerated capping of
tube overnight and was discharged with instruction that if she
tolerated the capping that it could be removed in 48-72hrs at
the discretion of her primary oncologist in consultation with
the urology and interventional radiology services.
.
#) Diarrhea-
Thought to be due to chemotherapy. Improved with loperamide. C.
difficile negative x 3. Stool cultures were negative for
cyptococcus, giardia, microsporidia. CT scan revealed
perinephric fat stranding
.
#) AML-
Patient is status post HIDAC on [**11-29**]. Awaiting matched
unrelated donor transplant. Bone marrow aspirate revealed wide
spread infiltration with blast cells and peripheral smear prior
to discharge revealed 10% blast cells. The patient was
discharged with plan for further chemotherapy within a few days
of discharge, with a second attempt at allogenic transplant to
follow.
.
#) Heme- found to have anti-HLA B7 and B27 antibodies and
required matched platelet transfusions. Pt did respond to 1 unit
of unmatched platelets given prior to he central venous catheter
insertion. Pt was transfused with 1 unit HLA matched platelets
prior to discharge.
.
#) Depression: continued celexa
.
#) Chronic fatigue: continued ritalin.
.
#) F/E/N-
Started on TPN during admission + neutropenic diet. Advanced to
regular low bacteria. Given regular IVF's.
.
#) Intravenous [**Name (NI) 12010**]
Pt has very difficult venous access. peripheral IV's only lasted
<24hrs. A repeat PICC line was attempted on the left arm, but
was unsuccessful due to vasospasm. She was later given a left
subclavian triple lumen catheter. Two days prior to discharge
with negative surveillance blood cultures and after being
afebrile for 48hrs a left sided tunneled internal jugular venous
catheter was placed.
.
#) Communication: husband [**Name (NI) **] ([**Name2 (NI) **]) ([**Telephone/Fax (1) 48092**],
([**Telephone/Fax (1) 48093**], Cell ([**Telephone/Fax (1) 48094**]
Medications on Admission:
Fluconazole 200mg q12h
Acyclovir 400mg q12h
Citalopram 20mg qd
Methylphenidate 10mg qam
Loratadine 10mg qd
Olanzapine 5mg [**Hospital1 **] prn
Prednisone 30mg qd
Levoflox 500mg qd (day #[**9-13**])
Beconase AQ 42mcg [**2-5**] sprays prn
Loperamide 2mg q4h prn
Meropenem (reportedly had one dose at OSH)
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
5. Beconase AQ 42 mcg (0.042 %) Aerosol, Spray Sig: One (1)
Nasal [**2-5**] sprays [**Hospital1 **] ().
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Mupirocin Calcium 2 % Cream Sig: One (1) Topical QD ().
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*10 Tablet(s)* Refills:*0*
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
12. Hickman Catheter Care
Central venous catheter care per protocol
13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO PT [**Month (only) **] SELF
DOSE UP TO 12MG PER DAY ().
Discharge Disposition:
Home With Service
Facility:
IV Clinical Network of [**Doctor Last Name **]
Discharge Diagnosis:
Primary: Central Venous Line Infection
Secondary:
Acute Myelogenous leukemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for a central venous line infection following
treatment for acute myelogenous leukemia.
Please take all of your medications as prescribed.
Call Dr. [**First Name (STitle) 1557**] or 911 if you experience any fever, uncontrolled
bleeding, worsening diarrhea or abdominal pain, back pain,
decreased urine output or any other concerning symptoms.
Followup Instructions:
You should follow up with Dr. [**First Name (STitle) 1557**] on Monday. Please call his
office at anytime with any other questions.
|
[
"E933.1",
"787.91",
"996.62",
"276.50",
"593.4",
"995.92",
"255.4",
"453.8",
"038.19",
"996.85",
"785.52",
"996.74",
"205.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.93",
"99.05",
"99.15",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11698, 11775
|
5916, 10020
|
379, 532
|
11897, 11907
|
3900, 5893
|
12319, 12454
|
3316, 3501
|
10374, 11675
|
11796, 11876
|
10046, 10351
|
11931, 12296
|
3516, 3881
|
306, 341
|
560, 2675
|
2697, 3148
|
3164, 3300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,759
| 165,516
|
26642
|
Discharge summary
|
report
|
Admission Date: [**2200-3-19**] Discharge Date: [**2200-3-28**]
Service: CARDIOTHORACIC
Allergies:
Tetracycline / Penicillins / Keflex / Quinidine Hcl
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Transferred from OSH for cardiac cath.
Major Surgical or Invasive Procedure:
cardiac catheterization
CABGx3
History of Present Illness:
Prolonged chest pressure at home x 2 weeks, presented at OSH and
transfered to [**Hospital1 18**] for cardiac cath. Cath revealed Left main
and 2VD with EF 20%. Patient then reffered to cardiac surgery
for bypass grafting.
Past Medical History:
Afib, DVT s/p IVC filter, HTN, hiatal hernia, varicose veins,
Prostate CA s/p XRT and Lupron Tx, GIB,
Social History:
married, lives w/wife. remote [**Name2 (NI) **], no ETOH
Family History:
father CVA
Physical Exam:
Admission
Gen: NAD
Neuro: A+O, nonfocal
Resp: CTA ant
CV: Irreg-irreg, no murmur
Abm: soft/NT/ND/NABS
Ext: RLE scarring and hyperpigmentation +pedal pulses by doppler
Discharge
VS 97.4 73SR 103/55 18 95% RA
Gen: NAD
Neuro: A+Ox3 MAE follows commands
Resp decreased at bases otherwise CTA
CV RRR no murmur. Incision C+D, sternum stable
Abdm: soft NT/ND/NABS
Ext [**2-3**]+ Pedal edema, RLE endoscopic vein harvest site w/steri
strips C+D
Skin macular rash mostly on back and buttocks with some
involvement of chest in areas where tape was applied.
Pertinent Results:
[**2200-3-19**] 05:01AM GLUCOSE-114* UREA N-25* CREAT-1.3* SODIUM-143
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13
[**2200-3-19**] 05:01AM WBC-7.2 RBC-3.73* HGB-12.0* HCT-34.1* MCV-91
MCH-32.3* MCHC-35.3* RDW-13.7
[**2200-3-19**] 05:01AM PT-13.8* PTT-104.8* INR(PT)-1.2*
[**2200-3-28**] 07:45AM BLOOD WBC-11.7* RBC-3.47* Hgb-11.3* Hct-32.5*
MCV-94 MCH-32.4* MCHC-34.6 RDW-14.4 Plt Ct-216
[**2200-3-28**] 07:45AM BLOOD PT-14.7* PTT-24.2 INR(PT)-1.3*
[**2200-3-28**] 07:45AM BLOOD Glucose-110* UreaN-50* Creat-2.2* Na-141
K-3.9 Cl-102 HCO3-30 AnGap-13
Brief Hospital Course:
Pt was admitted for cardiac catheterization found to have
leftmain and #vessel dz. Refferrred to cardiac surgery, brought
to operating room on [**3-21**] (see OR report for details) had
CABG x3 (LIMA->Ramus, SVG->pda->lad). Remained intubated until
POD1 then extubated. Stayed in ICU for 5 days, during that time
all lines and drains were removed. He was weaned off all
vasoactive intravenous medications and gently diuresed. He also
was tx for several eepisodes of Afib with Amiodarone and low
dose Bblockers(causing hypotension). On POD 5 he was transferred
to the floors for continuing care. Over the next 2 days his
activity level was advanced and he continued to be diuresed. The
patient developed a contact dermatitis which was treated with
sarna lotion/ hydrocortisone cream/ benadryl and [**Doctor First Name **]
Medications on Admission:
Amiodarone 200 QD
Norvasc 5 QD
Lupron Q4mo
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week then 400mg QD x 1 week then 200mg QD
.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
8. Warfarin 1 mg Tablet Sig: 5mg today then as directed Tablets
PO DAILY (Daily): target INR 2-2.5
pt to receive 5mg [**3-28**].
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): [**Hospital1 **] x 10 days then QD.
13. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
14. Diphenhydramine HCl 25 mg Capsule Sig: [**2-3**] Capsules PO BID
(2 times a day) as needed.
15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical QID (4
times a day).
17. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) aplication
Topical four times a day as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
s/p cabg x3 (LIMA->Ramus, SVG->PDA->LAD)
PMH: Afib,PVD,hx DVT s/p IVC filter, HTN, Hiatal hernia,
Prostate CA s/p XRT and Lupron tx, GIB
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:
Dr [**Last Name (STitle) **] 4 weeks after d/c from rehab
Dr [**Last Name (STitle) **] 4 weeks
Completed by:[**2200-3-28**]
|
[
"V12.51",
"787.91",
"428.40",
"272.4",
"428.0",
"782.1",
"599.0",
"414.01",
"427.31",
"V15.82",
"410.71",
"V15.3",
"401.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"99.04",
"36.15",
"36.12",
"88.53",
"88.56",
"39.61",
"37.22",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
4606, 4696
|
1997, 2819
|
304, 337
|
4877, 4884
|
1408, 1974
|
5083, 5209
|
805, 817
|
2912, 4583
|
4717, 4856
|
2845, 2889
|
4908, 5060
|
832, 1389
|
226, 266
|
365, 590
|
612, 715
|
731, 789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,954
| 140,995
|
4515
|
Discharge summary
|
report
|
Admission Date: [**2152-3-9**] Discharge Date: [**2152-3-17**]
Date of Birth: [**2088-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Chest Tube placement and removal
Pleurodesis
History of Present Illness:
63 y.o. female with h/o Multiple myeloma and Amyloidosis s/p
auto and allo SCT with complicated medical history including
multiple DVTs, and sponatenous pneumothoraces s/p chest tube
placement now admitted for hypoxia when she was seen in clinic
with an O2 saturation of 86% on RA. The patient states that she
was in clinic today for evaluation when they took her vitals and
noticed her low O2 sat. She does not report feeling more SOB
recently. She also denies any worsening DOE and has been able
to do her activities as she had been doing. She does report
some worsening nausea, and occasional vomiting over the last
week. She also reports having increased fatigue over the last
week. She reports having normal BMs and normal PO intake. She
denies fevers or chills. She denies chest pains. She is
otherwise without complaints.
Past Medical History:
PAST MEDICAL HISTORY
- s/p 3 episodes of epiglottitis/supraglottitis requiring
intubation in [**2145**], [**2149**], [**3-2**]
- Amyloidosis - involvement of lungs, tongue, bladder, heart
- CKD - thought secondary to disease progression
- Diastolic dysfunction- likely secondary amyloid
- h/o multiple DVT's (L IJ, L popliteal, L sup femoral)-IVC
filter, due to R sided DVT propagation; on coumadin
intermittently (due to fluctuating platelet counts on Velcade)
- Osteopenia s/p Zometa infusions
- HTN
- s/p tonsillectomy
- Hx of disseminated herpes in [**2146**]
- Urge incontinence
- Subdural hemorrhages in [**2-/2151**] in the setting of elevated INR
ONCOLOGIC HISTORY
Multiple Myeloma
TREATMENT HISTORY:
1. Initial treatment with melphalan and prednisone, [**2142-2-28**]
followed by VAD [**Month (only) **], [**2142-9-25**] with autologous stem cell
transplant in 01/[**2143**]. With relapse of her myeloma, she received
thalidomide from [**Month (only) **] to [**2143-10-25**].
2. Nonmyeloablative allogeneic stem cell transplant from a
sibling donor in 11/[**2143**].
3. Noted for recurrent disease in the summer of [**2145**] and
received a donor lymphocyte infusion in [**8-/2145**] with relatively
a stable disease after this.
4. Noted for slow progression of her disease in the fall of [**2150**]
and status post a second donor lymphocyte infusion on [**2151-2-5**]
given at a dose of one x10 to the seventh T-cell/kg.
5. Admitted on [**2151-9-13**] due to worsening renal insufficiency
with creatinine of 3.4 and new lung mass causing right lower
lobe collapse. The lung mass was biopsied and thought consistent
with amyloid.
6. Following discharge, she was started on thalidomide for a
short period of time, but was readmitted on [**2151-9-28**] due to
left lower edema and new DVTs.
7. Received Cytoxan [**2151-9-30**] with Decadron 20mg X 4 days with no
change in disease.
8. Received Velcade 1.3mg/m2 D1 and D4, but then admitted due to
worsening lower extremity edema and increased creatinine.
9. Received Cycle 1 Velcade/Cytoxan/Decadron on [**2151-10-22**]. Cycle
2 started on [**2151-11-12**]. Cycle 3 on [**2151-12-3**] with D11 Velcade
held. C 4 started on [**2151-12-24**] but admitted following morning
due to dyspnea. C5 started on [**2152-1-31**] with D8 Cytoxan held and
D11 Velcade held due to low counts. Also on dialysis for renal
failure.
10. Thalidomide to start on [**2152-2-18**]. Coumadin is
anticoagulation.
Social History:
She is married and lives in [**Location 3786**], 2 children, one grandson.
She admits to occasional etoh and denies any h/o tobacco/IVDU.
Family History:
Hypertension, no malignancies
Physical Exam:
Vitals - T: 98.7 BP: 123/72 HR: 84 RR: 20 02 sat: 93-96% on
2L
GENERAL: WD female, NAD, on O2 with some mild difficulty
completing sentences
SKIN: no rash noted
HEENT: right eye with subconjuctival hemorrhage. EOMi. OP clear
CARDIAC: RRR, no murmurs appreciated
LUNG: decreased BS bilaterally posterior lung fields, clear BS
anteriorly. no rhonci or wheezes appreciated
ABDOMEN: soft, NT. normal BS
EXT: 2+ pitting edema BLE to knees.
NEURO: A/O x 3; gross motor function intact.
Pertinent Results:
[**2152-3-17**] 05:04AM BLOOD WBC-2.9* RBC-3.37* Hgb-10.3* Hct-32.8*
MCV-97 MCH-30.5 MCHC-31.5 RDW-14.5 Plt Ct-255
[**2152-3-17**] 05:04AM BLOOD PT-20.8* PTT-46.3* INR(PT)-2.0*
[**2152-3-17**] 05:04AM BLOOD Glucose-87 UreaN-19 Creat-4.7*# Na-141
K-4.6 Cl-103 HCO3-32 AnGap-11
[**2152-3-10**] 06:30PM BLOOD ALT-11 AST-28 LD(LDH)-308* AlkPhos-90
Amylase-37 TotBili-0.5
[**2152-3-17**] 05:04AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0
[**2152-3-9**] 01:10PM BLOOD b2micro-22.8* IgG-827 IgA-75 IgM-111
FREE KAPPA, SERUM 421.0 H 3.3-19.4 MG/L
FREE LAMBDA, SERUM 280.0 H 5.7-26.3 MG/L
FREE KAPPA/LAMBDA RATIO 1.50 0.26-1.65
Blood Culture, Routine (Final [**2152-3-16**]): NO GROWTH
[**2152-3-9**] CT CHEST:
IMPRESSION:
1. Recurrence of a moderate left-sided hydropneumothorax. Small
loculated right hydropneumothorax is seen in the anterior
portion of the right hemithorax adjacent to the mediastinum.
2. Persistent right middle lobe and right lower lobe
atelectasis. Decrease in degree of left lower lobe atelectasis.
3. Moderate-sized bilateral pleural effusions that have
increased in size.
4. Hiatal hernia again seen containing stomach and omentum.
5. Diffuse permeative osseous lesions consistent with multiple
myeloma.
6. Retraction of the right central line is warrented as its tip
lies at the IVC/atrial junction. The information was telephoned
to nurse [**Doctor First Name **] at 5 pm
7. Diffuse septal thickening, which may be due to hydrostatic
edema. Amyloid is an additional consideration given the history
of this
condition.
[**2152-3-10**] CXR:
Small right apical collection of pleural air has appeared
explaining the horizontally oriented right basal fluid level,
reflecting small right pleural effusion. Consolidation at the
right lung base due to chronic atelectasis in the middle and
lower lobes is more pronounced today than it was on [**2-17**].
Large cardiac silhouette is roughly stable, but previously
aerated loops of bowel and a hiatus hernia are no longer
evident. They are probably fluid filled.
Right supraclavicular central venous catheter ends in the right
heart, close to the tricuspid valve.
[**2152-3-10**] CT CHEST:
IMPRESSION:
1. S/p left pigtail catheter palcement with decrease in
hydropneumothorax. Slight increase in size of fluid in right
hydropneumothorax. No significant change in the degree of
atelectasis or right lung air trapping.
2. Right central venous catheter in right atrium likely against
atrial wall and in vicinity of draining cardiac vein. Again
recommend partial withdrawl to reposition.
3. Diffuse permeative osseous lesions again consistent with
multiple myeloma.
4. Large hiatal hernia containing stomach and omentum. The Ge
junction is on the right in the throax with the stomach rotated
180 degrees along its mesentery.
[**2152-3-12**] CXR:
Cardiomediastinal contours are unchanged and partially obscured
by bibasilar parenchymal abnormalities. Moderate bilateral
pleural effusions loculated on the right and with a pig tail on
the left base are unchanged. Bibasilar atelectasis worse on the
right are unchanged. Patient has known chronic right middle lobe
atelectasis. There is no overt CHF. Right supraclavicular
double-lumen catheter is in unchanged position with tip in the
right atrium.
[**2152-3-13**] CXR:
This examination is essentially unchanged. The cardiomediastinal
contours are again obscured by basilar parenchymal abnormality.
The patient has a large hiatal hernia. Moderate bilateral
pleural effusion greater in the left side are unchanged. They
are loculated on the right. Chronic right middle lobe
atelectases and bibasilar atelectases are unchanged. Right
supraclavicular double-lumen catheter with tips in the right
atrium. There is no overt CHF.
Brief Hospital Course:
63 y.o. female with h/o Multiple myeloma and Amyloidosis s/p
auto and allo SCT with complicated medical history including
multiple DVTs, and sponatenous pneumothoraces s/p chest tube
placement now admitted for hypoxia when she was seen in clinic
with an O2 saturation of 86% on RA.
# Hypoxia: The patient's CT scan prior to admission was
consistent with recurrence of pneumothorax on L side with also a
loculated right hydropneumothorax. She also has bilateral
pleural effusions which have increased from prior. On the day
of admission, she had a CT guided pigtail catheter placed and
approximately 700 cc was drained via chest tube. The patient
was seen by thoracic surgery, and the following morning, she
underwent pleurodesis on the left side. Approximately 2-3 hours
later, the patient became acute short of breath, hypoxic to the
high 80s, and required non-rebreather mask to keep her O2 sat
>93%. She also became acutely hypertensive and tachycardic. At
that time, she had a repeat CT scan did not show any new
abnormalities. It was thought that the acute hypoxia was likely
secondary to an acute inflammatory reaction to the pleurodesis.
She was in the ICU for a few days, and was then transferred back
to the BMT service. Of note, while in the ICU, the patient was
hypotensive with pressures down to 58/42. She remained
asymptomatic with clear mental status. Serial lactate levels
remained < 2. She was given gentle IV fluids to support her
pressures without worsening her pulmonary edema and hypoxia. Her
chest tube was removed prior to transfer. She continued to do
well, never requiring intubation. She was weaned off of the
oxygen and was able to maintain her O2 sats 91-96% on RA and
occasionally requiring O2. She does occasionally use home O2.
At the time of discharge, the patient was doing well, and was
discharged home with home O2 as needed. She will followup in
clinic.
# Multiple Myeloma: The patient has a long h/o with
chemo/transplants. She is currently on Thalidomide which she
will continue. She will also continue bactrim prophylaxis.
# ESRD (CKD V): The patient is on Hemodialysis on T/Th/Fr. She
will continue this regimen and followup with nephrology as
scheduled. She will also continue her nephrocaps.
# History of DVTs: The patient was given 2 units FFP prior to
her procedure. She was started on a heparin gtt, and restarted
on her coumadin post procedure. She was bridged for
approximately 48 hours after she had a therapeutic INR. She
will continue coumadin 3 mg daily, with followup of her INR when
she goes to clinic next week.
# Amyloidosis: The patient has multi-organ involvement.
Medications on Admission:
Acetaminophen 325-650 mg po q6 hours prn
Coumadin 3 mg po on days you get dialysis
Imodium A-D 2 mg po q6-8 hours prn for diarrhea
Lorazepam 0.5 mg po q4 hours prn
Protonix 40 mg po daily
Renal Caps 1 mg po daily
Thalidomide 50 mg po qhs start on Friday [**2152-2-18**]
Bactrim 800-160 1 tablet MWF
Warfarin 2 mg po daily on days you don't get dialysis
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Thalidomide 50 mg Capsule Sig: One (1) Capsule PO qhs () as
needed for hem-onc.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*40 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for anxiety.
6. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO
QMON/WED/FRI.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
8. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO every [**7-2**]
hours as needed for diarrhea.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Spontaneous Hydropneumothorax
Hypoxia
Secondary Diagnosis
Multiple Myeloma
Amyloidosis
History of Deep Venous Thrombosis
Discharge Condition:
stable, good O2 sats, afebrile.
Discharge Instructions:
You were admitted because your oxygen saturation was low. You
were found to have a pneumothorax and required a chest tube
placed. You also had pleurodesis, which may have led to a
reaction causing you to drop your oxygen saturations requiring
you to go to the ICU. You did not need intubation, and
eventually, your oxygenation improved. You came back to the BMT
service, and at the time of your discharge, you were able to
tolerate breathing without oxygen.
Please take all medications as prescribed. Please keep all
scheduled appointments. Please keep all scheduled dialysis
appointments.
If you develop any of the following concerning symptoms, please
call your oncologist or go to the ED: shortness of breath, chest
pains, fevers, chills, nausea, vomiting, diarrhea,
lightheadedness, dizziness, or headache.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2152-3-22**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18554**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-3-22**] 1:00
please have your INR checked during your appointment
|
[
"799.02",
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"511.9",
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"511.8",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.04",
"34.92"
] |
icd9pcs
|
[
[
[]
]
] |
12101, 12107
|
8261, 10911
|
330, 377
|
12291, 12325
|
4439, 8238
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12128, 12128
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3932, 4420
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283, 292
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405, 1245
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12147, 12270
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1267, 3714
|
3730, 3870
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,204
| 104,437
|
1187
|
Discharge summary
|
report
|
Admission Date: [**2167-12-11**] Discharge Date: [**2167-12-27**]
Date of Birth: [**2087-5-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Left Internal Iliac artery aneursym
Major Surgical or Invasive Procedure:
-Selective angiography of left internal
iliac artery, coil embolization of 2 outflow vessels from the
internal iliac artery aneurysm. This corresponds to CPT code
[**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 7536**], and [**Numeric Identifier 7536**].
-Endovascular repair of left hypogastric artery
aneurysm with coverage stent graft.
History of Present Illness:
80 M presents to ED c/o constant LLQ pain for 3 days. Pt has
had anorexia over this period of time. Denies fever, chills,
nausea, vomiting, chest pain, SOB, or similar pain in the past.
Last BM was day of admission and was normal.
Past Medical History:
COPD, requiring home O2 (1 liter/min)
CAP in [**2160**], [**2165**]
hypertension
TB in [**2154**], treated for active DZ
thrombocytopenia, mild noted on prior admission
BPH
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7537**] [**Telephone/Fax (1) 7538**]
CRI, unknown etiology
Social History:
denies tobacco and EtOH
Family History:
non-contributory
Physical Exam:
On discharge
99.5 74 114/72 16 94% 3Liters NC
NAD, A&Ox3
RRR
CTAB
soft, NT/ND
Bilateral groin incisions- c/d/i w/o hematoma
No LE CCE
2+ pulses throughout
Pertinent Results:
[**2167-12-27**] 05:30AM BLOOD WBC-6.3 RBC-2.95* Hgb-9.6* Hct-27.8*
MCV-94 MCH-32.4* MCHC-34.4 RDW-14.2 Plt Ct-217
[**2167-12-26**] 03:10AM BLOOD WBC-5.3 RBC-2.97* Hgb-9.4* Hct-27.1*
MCV-92 MCH-31.5 MCHC-34.5 RDW-14.1 Plt Ct-203
[**2167-12-25**] 02:31AM BLOOD WBC-7.3 RBC-3.00* Hgb-9.8* Hct-28.1*
MCV-94 MCH-32.6* MCHC-34.7 RDW-14.4 Plt Ct-218
[**2167-12-27**] 05:30AM BLOOD Plt Ct-217
[**2167-12-27**] 05:30AM BLOOD PT-13.2 PTT-27.6 INR(PT)-1.2
[**2167-12-26**] 03:10AM BLOOD Plt Ct-203
[**2167-12-26**] 03:10AM BLOOD PT-13.5* PTT-30.1 INR(PT)-1.2
[**2167-12-25**] 02:31AM BLOOD Plt Ct-218
[**2167-12-14**] 05:39AM BLOOD D-Dimer-3164*
[**2167-12-27**] 05:30AM BLOOD Glucose-104 UreaN-17 Creat-1.5* Na-140
K-4.5 Cl-104 HCO3-30 AnGap-11
[**2167-12-26**] 03:10AM BLOOD Glucose-99 UreaN-18 Creat-1.4* Na-139
K-4.4 Cl-105 HCO3-29 AnGap-9
[**2167-12-25**] 02:31AM BLOOD Glucose-93 UreaN-21* Creat-1.6* Na-140
K-4.5 Cl-107 HCO3-28 AnGap-10
[**2167-12-24**] 06:35AM BLOOD Glucose-119* UreaN-20 Creat-1.7* Na-143
K-4.5 Cl-109* HCO3-27 AnGap-12
[**2167-12-25**] 10:30AM BLOOD CK(CPK)-132
[**2167-12-25**] 02:31AM BLOOD CK(CPK)-110
[**2167-12-24**] 07:10PM BLOOD CK(CPK)-119
[**2167-12-25**] 10:30AM BLOOD CK-MB-2
[**2167-12-25**] 02:31AM BLOOD CK-MB-2
[**2167-12-24**] 07:10PM BLOOD CK-MB-2 cTropnT-0.02*
[**2167-12-14**] 05:39AM BLOOD CK-MB-7 cTropnT-0.14* proBNP-8388*
[**2167-12-27**] 05:30AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.2
[**2167-12-26**] 03:10AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.9
[**2167-12-25**] 02:31AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.2
[**2167-12-13**] 06:19PM BLOOD TSH-1.4
[**2167-12-15**] 01:50AM BLOOD Type-ART pO2-61* pCO2-44 pH-7.36
calHCO3-26 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2167-12-14**] 04:03PM BLOOD Type-ART pO2-110* pCO2-43 pH-7.35
calHCO3-25 Base XS--1
[**2167-12-14**] 02:25PM BLOOD Type-ART pO2-116* pCO2-42 pH-7.35
calHCO3-24 Base XS--2
Brief Hospital Course:
Pt admitted to Vascular surgery after CT shows:
1. 8-cm left pelvic mass arising from the left internal iliac
artery. Appearances are consistent within an iliac artery
aneurysm. This has a well-demarcated border, and there is no
imaging evidence of continuing extravasation. However, although
varying densities within this mass suggest at least some
components to be chronic, the fact acuity cannot be assessed,
and in this single examination we cannot determine whether this
is an expanding lesion.
2. Mild left hydroureter and hydronephrosis. This is presumably
due to compressive effect from the left pelvic mass.
3. Pulmonary artery hypertension.
4. Emphysema.
Urology was c/s to assess Acute on Chronic renal insufficiency.
It was felt a ureteral stent was not needed, and hydration would
be helpful.
.
HD3 pt had difficulty breathing, like "asmtha attack". Pt
became tachypnic/tachycardic. @ 1755 Code Blue was called for
respiratory distress, w/ BP to 60/30. Pt was intubated,
transferred to SICU on pressors, CVL was placed. EKG shows
RBBB which resolved over a short interval. Cardiology was
consulted; ASA, statin, Beta blocker and heparin drip were
started. Work up was initiated to elucidate the cause of
respiratory failure. Ultimately no definitive cause was found,
though thought to be hypercarbic respiratory arrest.
Echo ([**12-14**]):
Limited views. Overall left ventricular systolic function
appears normal (~60%)
without apparent focal wall motion abnormality. No aortic
regurgitation is
seen. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
.
HD5 pt was extubated, all pressors were off. HD6 pt was
transferred to the floor and CTA to eval anuersym: 1. Large
left internal iliac artery aneurysm as described above which
appears to have increased slightly in size compared to exam of
seven days earlier.
HD8 CVL was removed, pt was diuresed. HD10 pt was started on
mucomyst for renal protection prior to angio study. IV
bicarbonate was also given on call to angio. Pt was consented
for procedure. On HD11 pt taken to angio for coiling of outflow
vessels. Procedure: Selective angiography of left internal
iliac artery, coil embolization of 2 outflow vessels from the
internal iliac artery aneurysm. Pt tolerated well and was
transferred to the floor in stable condition following the
porcedure. HD15 pt taken to OR for second stage of aneurysm
repair. Again mucomyst/bicarb was given prior. Pt and family
wish to proceed. Procedure: Endovascular repair of left
hypogastric artery aneurysm with coverage stent graft. Pt
tolerated procedure well and was taken to the floor in good
condition following the procedure.
.
On HD 17 pt was seen by PT and was cleared for home. The pt.
required 3 Liters O2 by nasal canula to maintain O2 sats above
91%. Pt was sent home on 3 liters O2 and instructed to follow
up with PCP to manage oxygen. Pt was discharged in good
condition. Prior to d/c pt had both groins ultrasounded and was
found to have no evidence of pseudoaneurysm or AV fistula. Pt
remained afebrile throughout stay.
Medications on Admission:
Protonix
Albuterol
Lisinopril
Atenolol
Lasix
Colchicine
Indocin
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H
(every 6 hours) as needed for dbp>90.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left hypogastric artery aneurysm
COPD, requiring home O2 (1 liter/min)
Respitory failure
chronic renal insufficiency
Discharge Condition:
Good
Discharge Instructions:
Please resume taking your regular medications. Take all new
medications as directed. Do not drive while taking narcotic
pain medications.
You may resume your regular activities. No heavy lifting (>20
lbs) for 3-4 weeks. You may shower, keep the wound covered, and
pat dry. Do not soak the wound for 2 weeks.
Please call your physician or return to the hospital if you
experience:
- Increasing pain or swelling at the wound
- Fever (>101.5 F)
- Inability to eat or persistent vomiting
- Foul discharge from the wound.
- Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-14**] weeks. Please call,
([**Telephone/Fax (1) 2867**], to arrange an appointment.
|
[
"V10.46",
"442.2",
"492.8",
"518.81",
"442.84",
"276.51",
"401.9",
"585.9",
"591",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"88.47",
"39.79",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7410, 7467
|
3503, 6597
|
351, 728
|
7628, 7635
|
1581, 3480
|
8239, 8388
|
1364, 1382
|
6711, 7387
|
7488, 7607
|
6623, 6688
|
7659, 8216
|
1397, 1562
|
276, 313
|
756, 990
|
1012, 1307
|
1323, 1348
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,529
| 102,722
|
32857+57822
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-12-26**] Discharge Date: [**2129-1-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
EGD
Colonoscopy
History of Present Illness:
HPI: The patient is a [**Age over 90 **] yo F transferred from an OSH ED for
melena x 24 hours. While at the OSH, the patients initial hct
was 26.2. She was transfused 2 units PRBC without improvement.
She was transfused another 2 units prior to transfer. Per report
was briefly hypotensive at the OSH but has been hemodynamically
stable since arrival.
.
In the ED, initial vitals were HR 51, BP 124/59, RR22, 98%2L.
She remained hemodynamically stable while in the ED. Two 18g
peripheral IV's were placed. She received 2L NS and protonix
40mg IV x 1. Hct drawn here was 38 (s/p a total of 4 units at
OSH). GI was called and will scope in the AM
Past Medical History:
CHF
COPD
Hyperlipidemia
Hypothyroid
Diverticulosis
Osteoporosis
Osteoarthritis
Social History:
Lives in nursing home. Denies smoking. ETOH 2oz daily. No drugs.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals - HR 57 BP 127/62 RR 15 O2 96%
General - elderly female, no acute distress
HEENT - PERRL, EOMI
Neck - supple
Heart - bradycardic, no murmur appreciated
Lungs - CTA B/L
Abdomen - soft, NT/ND, + BS
Ext - trace edema
Rectal - g+ black stool (per ED report)
Pertinent Results:
Hct stable -
[**2128-12-26**] Hct-38.9
[**2128-12-27**] Hct-36.4
[**2128-12-29**] Hct-33.8
nl INR, platelets
[**2128-12-29**] 05:08AM BLOOD WBC-8.1 RBC-3.74* Hgb-11.1* Hct-33.8*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.0 Plt Ct-271
[**2128-12-29**] 05:08AM BLOOD Glucose-90 UreaN-17 Creat-0.5 Na-132*
K-4.1 Cl-98 HCO3-23 AnGap-15
.
EGD:
Findings: Esophagus:
Lumen: A large size hiatal hernia was seen with mild
esophagitis.
Mucosa: Normal mucosa was noted.
Stomach:
Mucosa: Normal mucosa was noted.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
Large hiatal hernia
Recommendations: serial hematocrits
Discuss with family need for colonoscopy. If family/HCP wants to
procede with further workup, prep for colonoscopy.
consult IR for angio if acutely bleeds.
Additional notes: The attending was present for the entire
procedure. Routine post-procedure orders No source of bleeding
seen on this exam. The patient??????s reconciled home medication list
is appended to this report.
.
[**2128-12-31**]
.
COLONOSCOPY.
Showed severe diverticulosis and internal and external
hemorrhoids
Brief Hospital Course:
[**Age over 90 **] yo F presented with melena, but no evidence of UGIB found on
EGD, with stable Hct after 5 unit of PRBCs, only hypotensive at
OSH.
# GI Bleed - Patient with melena x 24 hours. She was briefly
hypotensive. She subsequently received 4 units PRBCS at OSH
with hct 29 --> 38. She was transfered to [**Hospital1 18**]. GI consulted
in the ED. EGD was performed that showed no evidence of current
or recent bleeding. Patient's Hct remained stable at 33-36.
She was continued on IV protonix up until EGD was performed.
She was subsequently transferred to the floor. After adequate
prep, she underwent colonoscopy on [**12-31**] which revealed severe
diverticulosis and internal as well as external hemorrhoids. She
had no further episodes of melena and her blood pressure
remained stable.
.
# CHF/CAD - Patient on toprol/zocor/asa at home. Her BB was
held. Her lasix was held and restarted prior to discharge. Her
statin was continued. Her aspirin was held while in hospital,
she will discuss with her doctor when to restart this as well as
her toprol. She did a prn dose of lasix after her transfusions
with good urinary output.
.
# Hypothyroid - her synthroid dose was kept at 75 micrograms.
.
# COPD - She received nebulizers atrovent and albuterol prn.
.
Code - DNR/DNI
Communication - Son [**Name (NI) **] is HCP - [**Telephone/Fax (1) 76488**]
Medications on Admission:
Toprol XL 50mg daily
Zocor 20mg daily
Prozac 10mg daily
Aspirin 325mg daily
Synthroid 75mg daily
Folic Acid 1mg daily
Nitro Patch 0.2mg/hr daily
Lasix 20mg daily
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Furosemide 20 mg 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.
Discharge Disposition:
Extended Care
Facility:
Our Island Home
Discharge Diagnosis:
Diverticulosis
Internal and External Hemorrhoids
Blood Loss anemia, acute on chronic
Secondary:
Heart Failure, Systolic, Chronic.
COPD
Discharge Condition:
Good. Hematocrit stable.
Discharge Instructions:
Admitted with blood in stool. You had an EGD (camera in your
mouth) which revealed no problems in your stomach. You had a
colonoscopy that revealed diverticulosis and hemorrhoids. Take a
diet with plenty of fiber. For the hemorrhoids, [**First Name8 (NamePattern2) **] [**Last Name (un) **] baths as
often as possible, such as 4 times a day. Do not strain at the
toilet. Drink enough water. Sit on an inflatable doughnut for
relief.
.
Two of your medications, toprol and lasix, were stopped because
of low blood pressure. Now you can [**Last Name (un) 14670**] resume them.
.
Your blood volume remains stable. Please follow up with the
doctor at the nursing home to make sure you do not lose too much
blood. Return to the Emergency Room if you have any concerns.
Followup Instructions:
With the doctor at the nursing home within 3 days of discharge
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Name: [**Known lastname 12475**],[**Known firstname **] L Unit No: [**Numeric Identifier 12476**]
Admission Date: [**2128-12-26**] Discharge Date: [**2129-1-2**]
Date of Birth: [**2037-3-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12246**]
Addendum:
On [**2128-12-27**], after receiving 2u prbc transfusion, pt had a CXR
consistent with acute pulmonary edema, thought to be due to
acute on chronic heart failure. There is documentation that pt
has a hx of chronic heart failure. There is no information in
the [**Hospital1 8**] system to show which type of heart failure the pt has
- diastolic or systolic. She was treated with IV lasix diuresis
with good effect.
Discharge Disposition:
Extended Care
Facility:
Our Island Home
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 12247**]
Completed by:[**2129-2-8**]
|
[
"562.12",
"414.01",
"428.0",
"272.4",
"272.0",
"496",
"285.1",
"280.0",
"455.0",
"455.3",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
6912, 7105
|
2700, 4071
|
271, 293
|
5059, 5086
|
1499, 2677
|
5897, 6889
|
1169, 1187
|
4284, 4814
|
4900, 5038
|
4097, 4261
|
5110, 5874
|
1217, 1480
|
223, 233
|
321, 968
|
990, 1071
|
1087, 1153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,681
| 135,490
|
4961
|
Discharge summary
|
report
|
Admission Date: [**2168-1-26**] Discharge Date: [**2168-1-28**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
VTach, AICD firings
Major Surgical or Invasive Procedure:
ventricular tachycardia ablation
History of Present Illness:
Mr. [**Known lastname **] is an 89 year old gentleman with PMH significant for
HTN,
dyslipidemia, CAD s/p CABG in [**2156**] (LIMA-LAD, SVG-D1, SVG-ramus,
SVG-PDA), remote history of VF arrest in [**2151**] s/p AICD,
hospitalization in CCU in [**7-/2167**], [**Hospital Unit Name 196**] [**8-/2167**] due to multiple
AICD firings, paroxysmal atrial fibrillation, history of
endovascular AAA repair who presented to [**Hospital6 20592**] earlier this AM after his ICD fired 8 times. Patient
states that felt in his usual state this morning, woke up to
make coffee, then after about a minute of standing, felt the
"chest pain" of the ICD firing 8 times. His girlfriend
immediately called 911. He reports no chest pain, SOB, syncope,
dizziness around the time of the firing, although the OSH note
states that he had syncope surrounding one of the ICD firing. On
arrival to the ED, patient was in and out of VT, rates 120s-130s
with stable BPs, pacer terminated. He received IV amiodarone
load, started on an amiodarone gtt, and also IV Lidocaine x 1.
He was subsequently transferred to [**Hospital1 18**] for VTach ablation by
Dr. [**Last Name (STitle) **]. On arrival, patient was in slow VT to 120s, BP
127/59 in NAD, mentating well. He was promtly taken to the lab.
.
Of note, patient states that he was seen in the ED at [**Location (un) **] 2
Sundays ago for diarrhea and dizziness, but states he was
discharged home without intervention. Per Dr.[**Name (NI) 20593**]
last note in [**Month (only) 359**], he was decreased to amiodarone 200-mg/day,
and he remained on mexillitine.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
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:
-CAD s/p CABG in [**2156**] (LIMA-LAD, SVG-D1, SVG-ramus, SVG-PDA)
PACING/ICD:
-Paroxysmal atrial fibrillation
-AICD place in [**2151**] after an episode of VFib arrest
-Recently admitted to CCU for recurrent ventricular tachycardia
successfully terminated by ICD; started on amiodarone
- chronic renal insufficiency (baseline Cr 1.3)
- AAA s/p endovascular repair in [**2163**]
- s/p cholecysectomy
- s/p TURP
- chronic anemia (early myelodysplasia), s/p 2 units of pRBC
about 2 months ago
Social History:
-Live with wife.
-exsmoker, quit about 30 years ago. Smoked for about 20-25
years ago for 1 ppd.
-ETOH: 1 glass of wine about once a month.
-Illicit drugs: denies
Family History:
no history of sudden/early cardiac death
Physical Exam:
ADMISSION EXAM:
VS: T= 97.5 BP= 127/59 HR= 83 NSR RR= 16 O2 sat= 90% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP noted
CARDIAC: S1, S2, irregular, no m/r/g
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND
EXTREMITIES: warm, no edema noted
PULSES: distal 2+ pulses b/l
.
Exam stable throughout admission
Pertinent Results:
ADMISSION LABS
[**2168-1-26**] 02:15PM BLOOD WBC-8.2 RBC-2.80* Hgb-10.6* Hct-31.3*
MCV-112* MCH-37.7* MCHC-33.7 RDW-15.8* Plt Ct-150
[**2168-1-26**] 02:15PM BLOOD PT-32.4* PTT-30.2 INR(PT)-3.3*
[**2168-1-26**] 02:15PM BLOOD Glucose-115* UreaN-43* Creat-1.7* Na-140
K-4.7 Cl-105 HCO3-25 AnGap-15
[**2168-1-26**] 02:15PM BLOOD CK-MB-3 cTropnT-0.02*
[**2168-1-26**] 02:15PM BLOOD Calcium-8.4 Phos-3.5 Mg-2.3
.
DISCHARGE LABS
[**2168-1-28**] 06:00AM BLOOD WBC-5.4 RBC-2.31* Hgb-8.9* Hct-26.1*
MCV-113* MCH-38.6* MCHC-34.2 RDW-15.5 Plt Ct-113*
[**2168-1-28**] 06:00AM BLOOD PT-26.4* PTT-30.6 INR(PT)-2.6*
[**2168-1-28**] 06:00AM BLOOD Glucose-90 UreaN-43* Creat-1.6* Na-139
K-4.1 Cl-106 HCO3-27 AnGap-10
[**2168-1-28**] 06:00AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.2
.
STUDIES:
Admission EKG [**2168-1-26**]: Wide complex tachycardia. Right axis
deviation. Right bundle-branch block. Since the previous tracing
of [**2167-8-20**] the axis is more rightward and right bundle-branch
block pattern configuration is different with prominent R wave
and marked ST-T wave abnormalities. There may be retrograde P
waves in the ST segment. Since the previous tracing the axis is
more rightward. QRS pattern is different in the early precordial
leads and related to the axis. Probable ventricular tachycardia.
Of note on the prior tracing, P wave amplitudes were
low and the ventricular premature beat seen does not appear like
the wide
complex tachycardia on the present tracing. Clinical correlation
is suggested.
.
V-Tach ablation [**2168-1-27**]:
1. The baseline rhythm was v-tach at a TCL 465 ms [**First Name (Titles) 20594**] [**Last Name (Titles) 20595**]
morphology. RS complexes across the precordium and in an
inferiorly directed axis
2. Biosense mapping of the LV performed, after the
administration of IV heparin, via a retrograde aortic approach
using a long sF sheath. A moderate area of decreased voltage
suggestive of scar was present in the inferobasal and
inferoseptal regions.
3. Extensive mapping of the LV and an area with a mid-diastolic
potential and perfect entrainment was found in the basal region
of the LV at 4-5 oclock on the mitral annulus. Ablation was
performed in that area and resulted in termination of the VT. A
total of 3 RF applications were performed. The VT was
subsequently not inducible.
4. Post ablation repeat EPS with double VES were delivered
without induction of VT
.
Conclusion: Successful ablation of V-tach from basal left
ventricle
Brief Hospital Course:
Mr. [**Known lastname **] is an 89 year old gentleman with PMH significant for
HTN, dyslipidemia, CAD s/p CABG in [**2156**] (LIMA-LAD, SVG-D1,
SVG-ramus, SVG-PDA), remote history of VF arrest in [**2151**] s/p
AICD, hospitalization in CCU in [**7-/2167**], [**Hospital Unit Name 196**] [**8-/2167**] due to
multiple AICD firings, paroxysmal atrial fibrillation on
coumadin, history of endovascular AAA repair who presented to
[**Hospital6 17032**] earlier this AM after his ICD
fired 8 times due to Monomorphic VT 120s, now s/p ablation.
# AICD firings/VTach: Pt noted to have ICD firing 8 times [**2-17**]
monomorphic VT to the 120s. Transferred to [**Hospital1 18**] where he
underwent successful ablation of V Tach (see report in pertinent
results). Most likely etiology is structural disease post-MI in
the setting of myocardial scar. He was continued on Metoprolol
25 [**Hospital1 **] (increased from prior Toprol XL dose of 25 mg daily), and
amiodarone 300 mg once daily, which was decreased back to 200mg
daily on discharge. His home mexillitine was d/c'd. He remained
stable in-house without any further episodes of ICD firing or
Vtach. He was set up with follow up with Dr. [**Last Name (STitle) 1911**].
.
# CAD: S/p CABG. No c/o chest pain or SOB. He underwent nuclear
perfusion/stress test on [**2167-8-19**] during which they found LVEF
of 43% with similar finding as prior and no ischemic changes. We
continued home pravastatin, aspirin, and increased beta blocker
dose of 25mg [**Hospital1 **], which was converted to Toprol- XL 50mg daily
on discharge.
.
# AFib: Pt remained rate controlled in-house on with metoprolol
25 mg [**Hospital1 **] (increased from home Toprol XL dose of 25 mg). He was
instructed to continue his higher dose as an outpatient in the
form of Toprol-XL 50mg daily. Coumadin initially held secondary
to supratherapeutic INR of 3.3 which normalized to 2.6 on
discharge. He was instructed to continue his coumadin at his
home dose. He was provided with prescription for an INR check
in 1 week.
.
# Pump: Last EF by perfusion study in [**Month (only) 216**] measured at 43%.
No echo in the [**Hospital1 18**] system. Patient remained euvolemic to dry
on exam throughout admission. Home Lasix was held in-house as Cr
was elevated above baseline, but restarted on discharge. His
Toprolol was increased as above.
.
#. HTN: BPs well controlled in house. Increased metoprolol as
above.
.
#. HL: Continued pravastatin.
.
# CRF: Baseline Cr of 1.3, was 1.7 on this admission. Trended
down slightly to 1.5 then up to 1.6 on discharge. We held his
home lasix in-house, but was instructed to restart at home. He
was given a prescription for electrolyte/creatinine check in 1
week
Medications on Admission:
Amiodorone 200mg daily if SBP > 90
Metoprolol 25 mg XL if SBP > 90
Pravastatin 20mg daily
Coumadin, 5mg Wed 2.5 mg the rest of the wk
Ascorbic acid 500mg [**Hospital1 **]
Folic acid 2.5mg daily
multivitamins 1 tablet daily
Vitamin B6 50mg daily
Lasix 40mg daily
ASA 81mg daily
Mexilitine 150 daily per outpt EP note
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
5. pravastatin 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. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) as needed for pain/sleep.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Tkae 2 tablets on Wednesday.
10. Outpatient Lab Work
Please have Chem-7 and INR checked on Tuesday [**2-2**] at Dr. [**Name (NI) 20596**] office
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. metoprolol succinate 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*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Ventricular Tachycardia s/p ablation
Coronary artery disease
Acute on Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your ICD fired multiple times at home because of ventricular
tachycardia. You were transferred to [**Hospital1 18**] and an ablation was
done that burned the surface of the heart that the ventricular
tachycardia was originating from. This should greatly reduce the
episodes of ventricular tachycardia and possibly prevent the ICD
from firing. You may want to try to eat foods that are high in
potassium and magnesium every day although this may not prevent
ventricular tachycardia. You should continue to call Dr.
[**Last Name (STitle) 1911**] if your ICD fires.
.
We made the following changes in your medicines:
1. Keep your amiodarone at 200 mg
2. Stop taking Mexilitine
3. Increase Metoprolol to 50 mg daily
.
Followup Instructions:
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: TUESDAY [**2168-2-2**] at 10:20 AM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"427.1",
"425.4",
"403.90",
"V45.81",
"414.00",
"585.9",
"414.01",
"272.4",
"V45.02",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
10346, 10414
|
6199, 8923
|
272, 307
|
10551, 10551
|
3704, 6176
|
11440, 11778
|
3122, 3164
|
9289, 10323
|
10435, 10530
|
8949, 9266
|
10702, 11417
|
3179, 3685
|
213, 234
|
335, 2410
|
10566, 10678
|
2432, 2924
|
2940, 3106
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,365
| 167,344
|
54051+59569
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-4-16**] Discharge Date: [**2167-4-23**]
Date of Birth: [**2089-6-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2167-4-18**]
1. Urgent coronary artery bypass graft x4: Left internal
mammary artery to left anterior ascending artery, and
saphenous vein grafts to diagonal, obtuse marginal, and
distal right coronary arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
77 year old female admitted on [**2167-4-14**] to NEBH she had a right
total knee replacement; post op; no complaints. Last night while
on the floor at 11pm sao2 decreased to 80's given o2 NC with
good results, at 4am sao2 dropped to 84%
urine output decreased given 500cc bolus; she was on a 50% venti
mask with sao2 still dropping down to 80's she also complained
of nausea at that time. she was brought to the ICu put on 100%
NRB and sa02 94%. ABG po2 62, 7.39, PCO2 38, HCO3 23, SA02 91%,
BNP 875.1. She was transferred for cardiac cath. This revealed
severe coronary artery disease. IABP was placed. She was
referred for coronary revascularization
Past Medical History:
Coronary Artery Disease
Osteoarthritis
s/p right Total Knee Arthroplasty
Hyperlipidemia
Hypertension
GERD
Hypothyroidism
Depression
Ovarian CA s/p TAHBSO, chemotherapy
right knee partial patellaectomy
Bowel fistula, s/p resection
Past Surgical History:
Ovarian CA s/p TAHBSO
right knee partial patellaectomy
s/p R knee replacement [**2167-4-14**]
s/p resection of bowel fistula
s/p bilateral cataract surgery
Social History:
Lives with: in-law apt, sons live upstairs
Contact: Phone #
Occupation:
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [x] [**2-17**] drinks/week [] >8 drinks/week []
Family History:
non-contributory
Physical Exam:
Pulse:84 Resp:18 O2 sat:98% on 100% NRB
B/P Right: 112/41 Left:
Height: 5'2" Weight: 58.5 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _r knee
ecchymosis and swelling, incision C/D/I____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: cath site, IABP in place, swann in place
Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2167-4-19**] Echo
Conclusions
There is mild to moderate regional left ventricular systolic
dysfunction with EF 40%. The right ventricular cavity is mildly
dilated with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. There is no aortic valve stenosis. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2167-4-22**] 04:20AM BLOOD WBC-13.1* RBC-4.32 Hgb-12.8 Hct-39.7
MCV-92 MCH-29.7 MCHC-32.3 RDW-14.9 Plt Ct-200
[**2167-4-21**] 05:13PM BLOOD WBC-15.2* RBC-4.44 Hgb-13.2 Hct-40.4
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.9 Plt Ct-175
[**2167-4-22**] 04:20AM BLOOD PT-12.4 INR(PT)-1.1
[**2167-4-21**] 05:13PM BLOOD PT-13.0* INR(PT)-1.2*
[**2167-4-22**] 04:20AM BLOOD Glucose-128* UreaN-42* Creat-0.9 Na-138
K-4.1 Cl-96 HCO3-31 AnGap-15
[**2167-4-21**] 05:13PM BLOOD Glucose-113* UreaN-37* Creat-0.8 Na-139
K-3.6 Cl-96 HCO3-33* AnGap-14
Brief Hospital Course:
The patient was brought to the Operating Room urgently on [**2167-4-18**]
where the patient underwent CABG x 4 with Dr. [**First Name (STitle) **]. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring. IABP was removed on POD 1. She was
extubated on POD 2. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Orthopedics was consulted for post knee replacement
recommendations. She will be treated with Lovenox for 3 weeks
and will continue to use the CPM. Beta blocker was initiated
and the patient was gently diuresed. She had continued lower
extremity edema and Lasix was increased to twice a day for 1
week. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. She did initially post op have elevated liver
function tests (Tbili peak 6.4) but these were trending down at
the time of discharge. They are to be rechecked in 1 week at
rehab and if are elevated at that time, the decision to stop
Lipitor should be made. By the time of discharge on POD 5 the
patient was ambulating with assistance. Her wounds were healing
and pain was controlled with oral analgesics. The patient was
discharged to [**Hospital6 **] in [**Location (un) 38**] in good condition
with appropriate follow up instructions.
Medications on Admission:
zofran 4mg
81mg aspirin x2
5 mg sc vitamin K
sublingual Ntg given x2 after c/o chest pressure
coumadin
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing,
sob.
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold if LFT's trending up.
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks: then decrease to 20meq po daily
for one week, then dc.
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 3 weeks.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks: then decrease 40mg po daily for 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Coronary Artery Disease
Osteoarthritis
s/p right total knee arthroplasty
Hyperlipidemia
Hypertension
GERD
Hypothyroidism
Depression
Ovarian CA s/p TAHBSO, chemotherapy
right knee partial patellaectomy
Bowel fistula, s/p resection
Past Surgical History:
Ovarian CA s/p TAHBSO
right knee partial patellaectomy
s/p R knee replacement [**2167-4-14**]
s/p resection of bowel fistula
s/p bilateral cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
gait unsteady, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+, ecchymotic right lower extremity
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**], [**2167-5-19**], 2:30
Cardiologist Dr. [**Last Name (STitle) 11679**] [**2167-5-19**] at 1:30p
Orthopedic Surgeon: Dr. [**Last Name (STitle) **] [**2167-5-21**], 9:45am
[**Last Name (NamePattern1) 14648**]
[**Location (un) 86**], [**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 110798**]
PLEASE CHECK LFT's in 1 WEEK AND MAKE DECISION FOR CONTINUATION
OF LIPITOR AT THAT TIME
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 76503**],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 76504**] in [**4-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2167-4-23**] Name: [**Known lastname 12105**],[**Known firstname **] J Unit No: [**Numeric Identifier 18151**]
Admission Date: [**2167-4-16**] Discharge Date: [**2167-4-23**]
Date of Birth: [**2089-6-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
Note elevated LFT's - to be rechecked at rehab in 1 week and
decision to continue Lipitor to be made at that time.
Pertinent Results:
Labs:
[**2167-4-23**] 05:00AM BLOOD WBC-12.5* RBC-4.27 Hgb-12.7 Hct-39.4
MCV-92 MCH-29.7 MCHC-32.1 RDW-14.7 Plt Ct-271
[**2167-4-23**] 05:00AM BLOOD Glucose-122* UreaN-40* Creat-0.8 Na-137
K-3.8 Cl-97 HCO3-31 AnGap-13
[**2167-4-23**] 05:00AM BLOOD ALT-49* AST-115* LD(LDH)-518*
AlkPhos-135* Amylase-93 TotBili-4.5*
[**2167-4-22**] 04:20AM BLOOD ALT-40 AST-95* LD(LDH)-558* AlkPhos-83
Amylase-70 TotBili-5.8* DirBili-4.1* IndBili-1.7
[**2167-4-21**] 02:16AM BLOOD ALT-34 AST-74* AlkPhos-46 Amylase-42
TotBili-6.4*
LFT's to be rechecked in 1 week at rehab
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2167-4-23**]
|
[
"780.62",
"V43.65",
"428.0",
"401.9",
"424.2",
"V10.43",
"414.01",
"410.71",
"E878.1",
"416.8",
"428.21",
"424.0",
"244.9",
"518.51",
"997.1",
"V88.01",
"530.81",
"785.51",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15",
"88.56",
"37.61",
"37.23",
"97.44",
"88.42",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10774, 10967
|
3945, 5516
|
330, 613
|
7642, 7847
|
10195, 10751
|
8718, 10176
|
2008, 2026
|
5669, 7093
|
7209, 7440
|
5542, 5646
|
7871, 8695
|
7463, 7621
|
2041, 2782
|
270, 292
|
641, 1300
|
1322, 1553
|
1750, 1992
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 134,743
|
13515
|
Discharge summary
|
report
|
Admission Date: [**2142-10-22**] Discharge Date: [**2142-10-25**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
29M h/o Type I Diabetes, c/b gastroparesis, erosive gastritis
with h/o upper GI bleed. Presents with n/v, malaise after an
EtOH binge.
.
Pt states that he was in his USOH until Saturday. He had 4 beers
and 3 rum & Coke. Afterwards, has had nausea & vomiting.
.
He also has since been non-compliant with his insulin, missing
several doses of insulin over the past few days. Last evening,
did not take any NPH or regular insulin.
.
ROS otherwise significant for a cough over the past several
days, minimally productive of scant greenish sputum. Otherwise,
denies f/c/s. No dysuria. No CP, SOB, abd pain.
.
In ED, fingerstick blood sugar 422 and BP 235/104. AG 19,
ketones in urine, but no evidence of UTI. Started on IV insulin
gtt, received 3L NS. Labetalol 5mg IV x 2 with SBP down to 170s
systolic.
Past Medical History:
1. Type I diabetes mellitus, uncontrolled. Last HbA1c 10.8
[**2142-5-3**]. Followed by Dr. [**Last Name (STitle) 9835**] at [**Last Name (un) **]. Complicated by
gastroparesis, nephropathy.
2. Erosive gastritis per EGD [**2137**]. Noncompliant with GI follow
up for EGD after [**2141**] hospitalization/elopement. Noncompliant
with PPI.
3. Hypertension, uncontrolled
4. Chronic renal insufficiency, baseline 1.5
5. Gastroesophageal reflux disease
6. Depression
Social History:
Works at [**Company 2475**] in office services. Lives with girlfriend in
[**Location (un) 686**]. Smokes approx 5 cigarettes/week. Usually rare EtOH,
except this past weekend. Denies illicit drug use.
Family History:
Mr. [**Known lastname 21822**] has 4 brothers and 5 sisters, all with no known Hx
of diabetes or significant medical problems. His [**Name2 (NI) **] are
alive and well. He reports that his grandfather had Diabetes,
but he isn??????t sure what type.
Physical Exam:
Temp 99.7 BP 149/87 HR 88 RR 20 O2 sat 99%
GEN: pt [**Name (NI) **]3, NAD, well nourished
HEENT: PERRLA
CV: RRR
Resp: CTAB no wheezes or crackles
Ab: +BS, soft, NT, ND
EXT: no edema, bruising, or cyanosis
Pertinent Results:
[**2142-10-22**] 08:59AM GLUCOSE-336* UREA N-51* CREAT-2.9* SODIUM-137
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-24*
[**2142-10-25**] 03:39AM BLOOD Glucose-59* UreaN-29* Creat-2.3* Na-140
K-3.6 Cl-106 HCO3-24 AnGap-14
Brief Hospital Course:
29 M with DM1, DKA, hypertensive urgency likely secondary to
noncompliance.
.
DKA - likely [**2-9**] noncompliance.
- No evidence of infection as precipitant. CXR neg, UA with 0-2
wbc, low grade fevers initially which have cleared, no increased
WBC
- CE x2 are nl
- gave fluids and insulin drip
- AG closed by HD 2 however pt continued to have some nausea
- HD 3 pt began taking PO, and was transitioned to [**1-9**] of his
home humalog dose
- HD 4 pt, had good PO intake, without nausea or vomiting
.
# Hypertensive Urgency - also likely [**2-9**] noncompliance, as pt
missed his am's dose of BP medications before admission.
- initially difficult to manage with IV metoprolol and
hydralazine
- Came under control to SBP of 150-170 range with 75 mg tid of
metoprolol and 10 mg of norvasc.
- will discharge on daily metoprolol and norvasc to increase
compliance
- pt likely to have baseline high blood pressures given history
of non-compliance
- Did not restart ACE-I due to worsening of renal function
.
# ARF - currently 2.3 down from Cr 2.9, with baseline ~2, likely
prerenal [**2-9**] DKA
- Gave IV hydration to assist with pre-renal causes, but Cr did
not return completely to baseline.
- Should follow up worsening renal function at [**Hospital **] clinic on
f/u apt as outpatient.
.
# FEN - Pt not tolerating PO's currently initially, but did
increase with time, IV fluid, and reglan.
- emesis initially treated with IV zofran and phenergan.
- pt transitioned to IV reglan and then PO reglan with good
results
- has reported history of gastroparesis and has been on reglan
before
- will give pt outpatient perscription for reglan to assist
with gastroparesis
- pt eating full meal at discharge
- continued home PPI
.
# Proph
- PPI
- pneumoboots and ambulation
- bowel regimen
Medications on Admission:
NPH 40 u [**Hospital1 **]
lisinopril 5 mg po
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. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]:
Twenty (20) units Subcutaneous at bedtime.
Disp:*600 units* Refills:*2*
6. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]:
Twenty (20) units Subcutaneous At breakfast.
Disp:*600 units* Refills:*2*
7. Regular insulin sliding scale
Please see attached regular insulin sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# Diabetic ketoacidosis secondary to diabetes mellitus type 1
# Gastroparesis secondary to diabetes mellitus type 1
# Diabetes mellitus type 1
# Hypertensive urgency
.
Secondary diagnosis:
# Chronic renal insufficiency secondary to diabetes mellitus
type 1
# Diabetic neuropathy
# Gastroesophageal reflux disease
# Erosive gastritis
# Depression
Discharge Condition:
Stable, tolerating PO intake.
Discharge Instructions:
You were admitted to the intensive care unit because you were
hypoglycemic (had very low blood sugar) because of your type 1
diabetes. We started you on an insulin trip. In addition, you
were nauseous and vomiting, probably related to gastroparesis
(slow intestinal movements) related to your type 1 diabetes, and
we gave you medications to help your intestines move. Finally,
we found that you had very high blood pressures, and we gave you
medications to lower your blood pressure.
.
We have started you on some new medications:
.
# For your nausea and vomiting: Metoclopramide 10 mg. Take one
tablet before meals and at bedtime every day.
.
# For your high blood pressure:
1. Toprol XL 200mg daily: Take 200 mg daily in the mornings.
2. Amlodipine 10mg daily: Take 10mg daily in the mornings.
.
# For your insulin: We have written a prescription for an
insulin pen for you to inject your NPH insulin. You should
inject 20 units NPH at every breakfast, and another 20 units NPH
at every bedtime. We have DECREASED your insulin dosage ONLY
BECAUSE YOU ARE NOT EATING A FULL DIET YET. Once you start
eating a full diet, you should return to using your 40 units NPH
at every breakfast, and another 40 units NPH at every bedtime.
.
We have ***STOPPED*** your lisinopril 5mg daily because of your
kidney function. Please follow up with the kidney doctor
mentioned below to determine whether you should restart it.
.
Otherwise, we have not changed your medications.
.
We have made several appointments for you. Please keep these
appointments.
.
If you experience nausea, vomiting, headache, changes in vision,
chest pain, fever, shortness of breath, or any other symptoms
you are concerned about, go immediately to the emergency room
and call your primary care doctor.
Followup Instructions:
Because of your health, we strongly encourage you to follow up
with the doctors [**Name5 (PTitle) 7928**]. We have made the following appointments
for you:
.
[**Hospital 2793**] clinic (for your kidney): Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**], tel.
[**Telephone/Fax (1) 60**], Wednesday, [**10-31**], at 8 am, Medical
Specialties [**Hospital Ward Name 23**] [**Location (un) **]
.
[**Hospital **] clinic (for your diabetes): Dr. [**First Name (STitle) **] [**Name (STitle) 9835**], tel.
[**Telephone/Fax (1) 2384**], Wednesday, [**10-31**], at 1pm, [**Last Name (un) **] Diabetes
Center, [**Location (un) **]. Please check in at front desk.
.
Primary care (for your overall health): Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], tel.
[**Telephone/Fax (1) 250**], Wednesday, [**11-7**], at 1:30 pm, [**Location (un) 3387**], Central 6, [**Hospital Ward Name 23**] Building.
.
Please call if there are any conflicts with your schedule.
|
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icd9cm
|
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[
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[] |
icd9pcs
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[
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2622, 4428
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318, 324
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5988, 6019
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,875
| 145,333
|
8389
|
Discharge summary
|
report
|
Admission Date: [**2155-4-6**] Discharge Date: [**2155-4-16**]
Date of Birth: [**2084-1-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Cardiac catheterization and stent placement to left circumflex
History of Present Illness:
This is a 71 yo F with CAD s/p MI, DM-II, s/p recent infected
plantar ulcer s/p debridement on Friday at NE [**Hospital1 **] admittedw
with fever and early sepsis.
.
She underwent debridement on [**2155-4-4**], and was started on clinda
and cipro following. She developed temps in the 99 range on
Saturdaym and then 102.7 on Sunday early morning, accompanied
with vomiting and nausea. She was taken into the ED for further
evaluation.
.
In the ED her vitals were as follows; T 100.1, HR 90, BP 144/53,
RR 20, O2 sat 97% RA. She received vanc, ceftaz, clindamycin,
and [**Date Range 11958**] in ED. She was noted to have pallor of the foot
and a non-blanching rash ?petechiae on her arms and legs on
exam. Her initial hct was 27. It later fell to 24 after about 3L
of IVF (guaiac neg on exam). She was also felt to be in DIC
based on her exam with petechiae; she had elevated INR to 1.5
but Fibrinogen was high at 818. Her lactate was 2.5.
.
She was also noted to have an elevated Troponin and ST
depressions on EKG. Cardiology was [**Name (NI) 653**], and recommended no
anticoagulation at this time. She was transfused 2u PRBC in ED.
She had abdominal tenderness in the ED on exam, and an abdominal
CT was performed and negative.
.
On admission to the ICU, the patient was initially comfortable
for the initial exam and assessment. She shortly thereafter
developed [**8-7**] chest discomfort, and a drop in her oxygen
saturation to 89-90 on supplemental NC ~ 4L. She was pain free
after 2 SL NTG. Her CXR showed interval opacification c/w fluid
overload.
.
On Review of Systems, she also notes dyspnea on exertion of
recent increasing severity, and a h/o vertigo. No h/o cough, no
dysuria, and no chest pain. All other ROS negative in detail.
Past Medical History:
1) diabetes mellitus Type 2 with neuropathy and foot ulcers
bilaterally (right plantar surface more than 1 year, left great
toe more recently, have grown MSSA, Pseudoman, Klebsiella)
2) hypertension
3) UTI VRE
4) CVA (?x2)
5) CEA [**6-2**]
6) [**6-2**] pMIBI: mild reversible inferior wall defect, EF 52% ;
ETT negative
7) [**5-3**] echo: EF 55-60%, no cardiac embolic source evidence of
left-sided subacute infarcts, chronic small vessel disease
8) diverticulitis
9) Baseline Cr: 1.0
10: Baseline Hct: 30-32
Social History:
She was widowed at age 35 and raised 5 children on her own
working as a teacher??????s aid and housekeeper. Ms [**Known lastname **] spends
most of her days a home, she does not drive to due to diabetic
neuropathy. Her son checks in on her and grocery shops for her.
She quit smoking ten years ago, but smoked approx 10
cigarettes x 40 yrs (20 pack years). She admitted to social use
of alcohol but none recently and no history of alcohol abuse.
She denied IV drug use or supplements/ herbal remedies.
Family History:
Father and identical twin sister died complications of diabetes
and died of heart disease. Mother and sister had diverticulitis
with eventual colectomy/colostomy. Ms [**Known lastname **]??????s husband died of
[**Known lastname 499**] cancer and her daughter died of breast cancer.
Physical Exam:
VS: T 100.8 HR 121 BP 165/69 RR 44 Sat 96% 15L NRB
GEN: Tachypneic
SKIN: petechial rash on dorsum of hands
HEENT: Neck supple
CHEST: Lungs are clear without coarse rales [**3-2**] right>left
CARDIAC: Tachy, regular; no murmurs, rubs, or gallops.
ABDOMEN: peri-umb scar, ruq [**Doctor First Name **] scar.
Non-distended, and soft without tenderness
EXTREMITIES: right foot-charcot with 1+ edema, ulcer of 3cm
diameter, fluctuance of tissue, erythema and warm. left foot
with less deformity, skin intact.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**6-2**], and BLE [**6-2**] both proximally and distally.
.
Pertinent Results:
[**2155-4-6**] 01:30PM WBC-17.7*# RBC-3.41* HGB-9.0* HCT-27.7*
MCV-81* MCH-26.5* MCHC-32.5 RDW-14.3
[**2155-4-6**] 01:30PM NEUTS-92.5* BANDS-0 LYMPHS-4.0* MONOS-3.5
EOS-0 BASOS-0
[**2155-4-6**] 01:30PM PLT SMR-NORMAL PLT COUNT-169
[**2155-4-6**] 01:30PM PT-16.8* PTT-28.6 INR(PT)-1.5*
[**2155-4-6**] 01:30PM FIBRINOGE-818* D-DIMER-762*
[**2155-4-6**] 01:30PM ALBUMIN-3.8
[**2155-4-6**] 01:30PM HAPTOGLOB-382*
[**2155-4-6**] 01:30PM CK-MB-6
[**2155-4-6**] 01:30PM cTropnT-0.12*
[**2155-4-6**] 01:30PM ALT(SGPT)-38 AST(SGOT)-36 LD(LDH)-184
CK(CPK)-175* ALK PHOS-38* TOT BILI-0.8
[**2155-4-6**] 02:58PM LACTATE-2.5*
[**2155-4-6**] 03:10PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2155-4-6**] 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-4-6**] 05:00PM RET AUT-1.5
[**2155-4-6**] 05:00PM %HbA1c-6.1*
[**2155-4-6**] 05:00PM calTIBC-225* FERRITIN-96 TRF-173*
[**2155-4-6**] 05:00PM CK-MB-6
[**2155-4-6**] 05:00PM cTropnT-0.10*
[**2155-4-6**] 05:00PM CK(CPK)-149*
.
.
CT ABDOMEN WITHOUT IV CONTRAST: The lung bases demonstrate
minimal dependent atelectasis. Heart size is normal. There are
no pleural or pericardial effusions.
The liver is diffusely nodular compatible with cirrhosis. No
focal lesion in the liver on this noncontrast study. Prominence
of the common bile duct is again noted which is likely related
to post-cholecystectomy status. Non- contrast evaluation of the
spleen demonstrates no focal lesion with size in the range of
normal The pancreas and left adrenal gland appear normal. There
may be mild nodular thickening of the right adrenal gland though
imaging is quite limited through this region. The kidneys appear
normal in size and are without evidence for stones or
hydronephrosis. There is no lymphadenopathy. Extensive vascular
calcification of the splenic artery is noted.
The large and small bowel are unremakable without evidence of
obstruction. There is no mesenteric or retroperitoneal
lymphadenopathy. Small hiatal hernia is noted. No free fluid,
free air or evidence of fluid collection.
CT PELVIS WITHOUT CONTRAST: The rectum, sigmoid are unremarkable
except for scattered diverticulosis without evidence of
diverticulitis. There is no free fluid or free air.
Calcification in the uterine wall and right ovary noted, stable
from [**2152**].
Bone windows demonstrate no suspicious lytic or blastic lesions.
Moderate multilevel degenerative changes are noted. Subcutaneous
opacities in the anterior abdominal wall likely reflect
medication injection sites.
IMPRESSION:
1. No acute intra-abdominal pathology.
2. Cirrhotic liver.
3. Diverticulosis.
.
FOOT AP/LAT/OBLIQUE
FINDINGS: There has been interval progression of the Charcot
arthropathy with increase in the heterotopic bone formation,
osteopenia, and destructive erosive changes around the joints.
The posterior dislocation of the calcaneus is unchanged. The
subluxation of second through fifth metatarsal bone are
consistent with chronic Lisfranc deformity. There is plantar
soft tissue swelling along the midfoot with defect in the skin
compatible with known ulcer. The underlying bone appears intact.
No subcutaneous gas is identified. No radiopaque foreign body is
noted within the soft tissues.
.
IMPRESSION:
Interval progression of the Charcot deformity. Soft tissue
prominence with skin ulceration along the plantar surface of the
midfoot. No definite evidence of osteomyelitis.
.
ECHO [**2155-4-7**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) The estimated cardiac index is borderline low
(2.0-2.5L/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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Aortic
valve sclerosis.
Compared with the report of the prior study (images unavailable
for review) of [**2152-5-25**], the findings are similar.
.
Cardiac Catheterization [**2155-4-11**]:
PTCA COMMENTS: The initial angiography revealed a 70% mid
LAD lesion
and an 80% proximal LCX lesion. The strategy was to predilate
and stent
both focal lesions with bare metal stents. Bivalirudin was
administered
for anticoagulation. XBLAD 3.5 Guide provided excellent support.
Prowater wire crossed both of the lesions easily. The LAD lesion
was
predilated with a 2.5 X 12 mm Voyager at 8 atms and stented with
a 2.5 X
15 mm Vision stent deployed at 18 atms with no residual stenosis
and
TIMI III flow. The attention was then turned to the LCX. 2.5 X
12 mm
Voyager was used to predilate the lesion at 6 atms and a 3.0 X
15 Vision
stent was deployed at 16 atms with no residual stenosis. the
patient
experienced a brief episode of hypotension that responded to
atropine
and IV fluids after LCX stent deployment. The final angiography
showed
TIMI III flow and no dissection or perforation in either vessel.
the
patient left the cath lab in stable condition.
The left arteriotomy site was closed with a Mynx device given
patient's
severe chronic back pain.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 53 minutes.
Arterial time = 50
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 125
ml
Anesthesia:
1% Lidocaine subq. Versed 0.5 mg IV, Fentanyl 50
micrograms
IV, Cefazolin 1 g IV, Atropine 1 mg IV, Nitro gtt 60 mcg/min
IV, Sodium
bicarbonate 150 mEq/L inf @ 97ml/hr IV
Anticoagulation:
Heparin 0 units IV Plavix 600 mg PO, Bivalirudin bolus
60 mg
IV, Bivalirudin drip 145 mg/hr IV
Cardiac Cath Supplies Used:
.014IN [**Doctor Last Name **], PROWATER 300CM
2.5MM [**Doctor Last Name **], VOYAGER 12MM
4FR CORDIS, MULTIPACK
6FR CORDIS, XBLAD 3.5
6FR ACCESS CLOSURE, MYNX VASCULAR CLOSURE DEVICE
2.5MM [**Doctor Last Name **], MINI VISION 15MM
3.0MM [**Doctor Last Name **], VISION 15MM
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
- [**Doctor Last Name **], PRIORITY PACK 20/30
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. The LMCA had no
angiographically
apparent flow limiting epicardial coronary artery disease. The
LAD had
a 40% proximal and a 70% mid stenosis. The LCx had a proximal
70-80%
lesion. The RCA had mild irregularities.
2. Resting hemodynamics revealed severe systemic arterial
systolic
hypertension with SBP 195 mmHg.
3. Successful stenting of the mid LAD with a 2.5 X 15 mm Vision
bare
metal stent with no residual stenosis (see PTCA comments for
detail).
4. Successful stenting of the proximal LCX with a 3.0 X 15 mm
Vision
bare metal stent with no residual stenosis (see PTCA comments
for
detail).
5. Successful closure of the left femoral arteriotomy with a
Mynx
device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe systemic arterial systolic hypertension.
3. Successful stenting of the mid LAD and proximal LCX with bare
metal stents.
.
MRI FOOT:
MRI OF THE RIGHT FOOT FINDINGS: Comparison with the previous MR
from [**2151-8-27**] shows increased fragmentation and
disorganization of the mid and forefoot. A large soft tissue
defect is identified along the plantar surface of the foot
(series 2, image 16). This soft tissue defect communicates with
the flexor hallucis longus (series 3, image 9). A sinus tract is
seen to extend from this skin defect (series 15, image 27) and
extends approximately to the plantar surface of the neoarthrosis
where it communicates with a fluid collection (series 15, image
32). This fluid collection measures 17 mm in transverse x 6 mm
in craniocaudal x 2.3 cm in AP dimension. There is rim
enhancement and this collection is consistent with an abscess.
No evidence of any significant signal intensity abnormality in
relation to the bones. Some abnormal signal intensity is noted
in relation to the tibial-calcaneal articulation with the
navicular consistent with the Charcot joint.
.
As seen before, the patient is status post arthrodesis with the
tibia fused to the talus. This neoarthrosis articulates with the
navicular bone and some fluid is seen in relation to this joint.
.
Diffuse edema is noted in the subcutaneous tissues of the
plantar aspect of the foot. The inflammation and the skin defect
extend up as far as the bone. This may be concerning for
progression to osteomyelitis at a later stage.
.
IMPRESSION:
1. Sinus tract extending from skin at soft tissue defect in
plantar aspect of the foot to plantar surface of neoarthrosis of
tibia fused to calcaneus.
2. Sinus tract extends to 2.3 cm collection inferior to
neoarthrosis.
3. Increased fragmentation and disorganization of mid foot and
forefoot since previous study.
4. No definite evidence of osteomyelitis but a soft tissue
defect and abscess extend to plantar surface of neoarthrosis and
is concerning for progression to osteomyelitis.
.
Brief Hospital Course:
1. Sepsis/Charcot foot:
Underwent debridement fo plantar ulcer and was started on
clindamycin and cipro. She developed fevers to 102.7 associated
with nausea and vomiting and was admitted. Patient was found to
be bacteremic with staph aureus [**1-31**] culture bottles consistent
with wound cultures from Right Charcot foot. She was covered
with broad abx including vancomycin and cefepime until
sensitivities revealed MSSA and antibiotics were tailored to
nafcillin. Patient was seen by ID who recommended a 6 week
course of antibiotics.
2. Hypoxia / Pulmonary Edema:
The patient was admitted initially to the medical intensive care
unit for concern for sepsis, and was transfused 2 units of
packed red cells and given 3L of IVF in the emergency
department. After arrival to the MICU, the patient became
acutely dyspneic. ECG showed tachycardia with exaggeration of
lateral and interior ST depressions, and CXR had fluffy
bilateral infiltrates. BNP 8300. Felt she had acute diastolic
heart failure and flash pulmonary edema, and she was diuresed
with good effect. She did have a transient elevation in her CK
to 175 with troponin leak to 0.14.
3. Cardiac/CAD:She developed 7/10 chest pain, and she was given
SL NTG for CP Pt with exaggeration of pre-existing ECG changes,
suggestive of ischemia. Did have troponin leak of 0.14 and
clinical picture was felt to be consistent with NSTEMI.
Underwent cardiac catheterization notable for LAD with 40%
proximal and a 70% mid stenosis. The LCx had a proximal 70-80%
lesion. The RCA had mild irregularities. Underwent stenting of
the mid LAD with a 2.5 X 15 mm bare metal stent and proximal LCX
with a 3.0 X 15 mm bare metal stent with no residual stenosis.
Patient remained chest pain free post procedure.
4. C.Difficile Associated Diarrhea
The patient was found to be C. difficile A toxin positive,
checked given diarrhea. She was started on flagyl 500mg TID. She
should continue flagyl for duration of nafcillin as well as 2
weeks after competion of nafcillin.
5. DM: Labile finger sticks with both hypoglycemic episodes and
hyperglycemia requiring short term insulin gtt while in unit.
Upon transfer to the floor, patient had symptomatic hypoglycemia
with FS in 40s. Decreased 70/30 dinner dose to 60 units.
Continued AM dose at 90 units. Decreased sliding scale--see
attached.
.
6. Anemia: Borderline microcytic anemia (MCV 84) with
inappropriate marrow response. Received 2U PRBCS but no evidence
of active bleeding. Stool OBs were negative. Continued on iron
supplements and started folic acid. Patient should have
colonoscopy scheduled as outpatient.
.
7. Acute on Chronic Renal Failure: Baseline cr of 1.0. Admitted
with creatinine of 1.6. ARF likely pre-renal. Improved with IVF.
Meds were renally dosed and lisinopril was initially held.
Creatinine improved to 1.1 upon discharge.
.
8. Petechiae: Noted on exam raising concern for [**Doctor Last Name **] but lab
studies revealed elevated fibrinogen as well as elevated Ddimer.
As these are acute phase reactants, consistent with response to
sepsis. INR also elevated. This was felt to be due to
nutritional deficiency.
.
9. HTN: patient had elevated blood pressures despite increasing
medical regimen. On day of discharge BP had ranged from 130-170
overnight. Therefore lisinopril was increased from 5 to 7.5mg
daily.
Medications on Admission:
Ferrous Sulfate 325mg daily
Diltiazem 240mg daily
Lisinopril 2.5mg daily
Metformin 1000mg daily?[**Hospital1 **]
Simvastatin 40mg daily
EC ASA 325mg daily
MVI
Niacin 500mg daily
NPH/R 70/30 90 U daily
NPH/R 70/30 70 U daily
Clindamycin 150mg QID
Ciprofloxacin 500mg [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC with differential, BUN, creatinine, AST, ALT,
Alk. Phos, Total bilirubin drawn once per week and faxed to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at Fax:[**Telephone/Fax (1) 1419**]
2. Outpatient Lab Work
Please draw CBC with differential, BUN, creatinine, AST, ALT,
Alk. Phos, Total bilirubin, ESR, and CRP on [**2155-5-9**] and
fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at Fax:[**Telephone/Fax (1) 1419**]
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours) for 5 weeks: Last day: [**5-22**], [**2155**].
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Prochlorperazine 5-10 mg IV Q6H:PRN
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
19. 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.
20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 weeks: Last day [**2155-6-4**].
22. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Ninety (90) units Subcutaneous qAM.
23. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Sixty (60) units Subcutaneous qPM.
24. Insulin
See attached sliding scale
25. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Non-ST elevation myocardial infarction
C. difficile colitis
Methicillin- sensitive S. aureus bacteremia/deep wound infection
Acute diastolic heart failure
Secondary:
Diabetes mellitus
Chronic kidney disease
Discharge Condition:
Good, vital signs stable, afebrile, chest pain free
Discharge Instructions:
You were admitted to the hospital with a foot infection that
spread to the blood. You also had an infection in your gut
called C. difficile colitis. You were treated with two separate
antibiotics to treat this. You will need to continue antibiotics
for several weeks. You also had a heart attack and had a stent
placed in your coronary artery to open up the blockage.
.
Please contact your doctor or return to the emergency room if
you develop worrisome symptoms such as chest pain, shortness of
breath, fever, chills, etc.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5193**] on [**5-5**] at 1:40pm PHONE:
[**Telephone/Fax (1) 5194**]. You need to have your blood pressure and diabetes
followed up at that time.
You should follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] in infectious diseases
clinic in [**Hospital Unit Name **] on [**5-12**] at 10AM. You should have
your blood drawn the Friday before the appointment and the
information will be faxed to Dr. [**Last Name (STitle) 7443**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2155-5-12**] 10:00
|
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"995.92",
"357.2",
"713.5",
"280.9",
"428.0",
"250.62",
"428.31",
"410.71",
"585.9",
"403.90",
"571.5",
"250.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"86.04",
"00.41",
"88.52",
"37.22",
"88.55",
"36.06",
"99.20",
"00.46",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
19904, 19976
|
13576, 16910
|
279, 344
|
20237, 20291
|
4143, 9650
|
20863, 21534
|
3191, 3477
|
17244, 19881
|
19997, 20216
|
16936, 17221
|
11471, 13552
|
20315, 20840
|
3492, 4124
|
9669, 11454
|
233, 241
|
372, 2118
|
2140, 2652
|
2668, 3175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,412
| 159,910
|
27989
|
Discharge summary
|
report
|
Admission Date: [**2159-4-12**] Discharge Date: [**2159-4-28**]
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Ace Inhibitors
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
left sided shaking, left gaze preference
Major Surgical or Invasive Procedure:
tracheal intubation and mechanical ventilation
arterial line placement
central venous line placement
lumbar puncture
History of Present Illness:
85yo woman with PMH significant for atrial fibrillation on
coumadin, h/o stroke in [**10-15**] with residual left sided weakness
and dysarthria, hyperlipidemia presented with left sided
shaking. She was was last seen well at 8pm the evening of
admission and was then found on the floor of the bathroom around
midnight. Her daughter heard her call out that she couldn't get
up; she was lodged between the toilet and the wall. She was
unable to stand without assistance; she did not answer queries
to where she was. She was "looking off to her left" according to
her daughter and was not saying much. She then started shaking
on her left side (beginning with curling of her left side). The
daughter's vantage point was behind the patient and she is
unsure of which side was shaking or if both were.
Per history, EMS found her awake but with R-sided weakness and
"+GTC seizure activity (eyes deviated towards the right) lasting
<1minute at a time". She received two rounds of ativan 3mg and
another two doses of valium 5mg and was intubated at the scene
by EMS for airway protection.
She presented to [**Hospital1 18**] and a code stroke was called.
Review of systems per her daughter: +malaise, for which she
presented to her PCP one week prior. No neck pain, headache,
cough, fever, chest pain, nausea, vomiting, diarrhea.
Past Medical History:
Stroke, as above; required her to walk with a walker
Recent urinary tract infection, treated with ciprofloxacin from
[**Date range (1) 23742**]
Hypertension
Hyperlipidemia
Social History:
Quit smoking 10yrs ago. No etoh since [**Month (only) 404**] per her daughter;
previous etoh abuse. No other drug use. Lives with her daughter.
In [**Name2 (NI) 404**], was falling and drinking heavily.
Family History:
Mother with HTN, stroke
Physical Exam:
VS 98.7/98.7 77-97 afib 96-164/37-87 15-17 80/900
Genl: Lying in bed in NAD
Neck: supple
CV: irreg no bruits
Pulm: ctab
Abd: soft benign
Ext: no edema
NEURO
MS: Intubated, examined off sedation x 10min. Moving right side
spontaneously more than the left. Not following commands or
opening her eyes.
CN:
CN I: not tested
CN II: Pupils 4->2 b/l.
CN III, IV, VI: EOMI no nystagmus
CN V: +corneal reflexes b/l
CN VII: full facial symmetry
Motor: Tone increased in legs, R>L. Moving all limbs
spontaneously and antigravity.
Sensory: withdraws to pain in all limbs.
Reflexes: brisker on the right, toes up b/l
Coordination and gait were not able to be assessed.
Pertinent Results:
Labs:
.
On admission [**2159-4-12**] 12:30AM:
WBC-13.1* RBC-3.38* Hgb-10.9* Hct-32.2* MCV-95 MCH-32.1*
MCHC-33.7 RDW-14.5 Plt Ct-366
Neuts-92.1* Bands-0 Lymphs-3.6* Monos-3.8 Eos-0.4 Baso-0.1
PT-21.4* PTT-35.5* INR(PT)-2.1*
Glucose-213* UreaN-13 Creat-1.1 Na-138 K-4.1 Cl-100 HCO3-19*
AnGap-23*
ALT-19 AST-29 LD(LDH)-374* CK(CPK)-98 AlkPhos-124* Amylase-79
TotBili-0.6
Calcium-8.1* Phos-3.9 Mg-1.3*
Albumin-3.7
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Cardiac enzymes negative x 2
.
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 Blood-TR
Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG RBC-[**2-12**]* WBC-0-2 Bacteri-OCC
Yeast-NONE Epi-0
.
Other pertinent labs:
Free T4-0.83* TSH-0.45
[**2159-4-23**] Ammonia-40
.
.
Studies:
.
CXR ([**4-12**]): Mild hydrostatic edema presumably cardiogenic in
etiology.
Retrocardiac opacity likely reflects atelectasis, although an
underlying
infection cannot be entirely excluded.
.
Head CT ([**4-12**]): No CT evidence of acute cortical stroke. Chronic
ischemic
changes and age-appropriate atrophy as above
.
CTA/CTP ([**4-12**]):
1. Small, 3 mm focal dilatation at the origin of the posterior
communicating artery and the internal carotid artery on the left
could represent an aneurysm.
2. 50% stenoses of the left common carotid artery at the level
of the bulb and the origin of the left internal carotid artery,
respectively.
3. 60% stenosis of the right internal carotid artery in the
neck.
4. Diffuse. vascular atherosclerotic, calcific disease.
.
MRI/A ([**4-12**]):
1. No evidence of acute infarction by diffusion-weighted
imaging.
2. Subacute versus chronic, likely chronic right posterior
cerebral artery territory infarct in the occipital lobe.
3. Evidence of small vessel ischemia.
4. Three-mm aneurysm extending posteriorly of the left
supraclinoid portion of the internal carotid artery.
.
Head CT ([**4-16**]): Stable appearance of the brain.
.
CT c-spine ([**4-12**]): Severe degenerative changes throughout the
cervical spine somewhat limiting assessment. Possible fractures
identified at the left anterior arch of C1, as well as within
the dens. MRI is recommended for further evaluation.
.
MR [**Name13 (STitle) **] ([**4-14**]): 1. The changes seen on CT at C1-2 level
appear to be due to advanced degenerative change with thickening
of the transverse ligament and degenerative pannus formation.
No evidence of fracture of the odontoid process or lateral
masses of C1 or C2 identified. 2. Changes of cervical
spondylosis predominantly from C3-4 to C6-7. 3. No evidence of
intrinsic spinal cord signal abnormalities or extrinsic
spinal cord compression. 4. No evidence of ligamentous
disruption.
.
Abd u/s ([**4-23**]): 1. Distended gallbladder with asymmetric edema
within the gallbladder wall, indeterminate for the presence or
absence of acute cholecystitis. Recommend further
characterization with a HIDA scan. 2. Prominent CBD, measuring
0.96 cm in size. The distal CBD and head of the pancreas are
not well seen- recommend further visualization with contrast
enhanced CT of the Abdomen. 3. Pedunculated cystic lesion
projecting between the lateral left lobe of the liver and the
pancreas. The origin of this cystic lesion is incompletely
resolved with the current study and further characterization
with a CT scan is recommended.
.
RUQ US [**4-25**]:
1. Limited evaluation of the liver, without focal mass lesions.
Normal hepatic vasculature.
2. Minimal gallbladder wall edema and sludge are identified. The
edema would be consistent with third spacing of fluid related to
the patient's underlying hepatic disease.
.
ECHO: The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is borderline
pulmonary artery systolic hypertension.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate mitral regurgitation with mildly thickened leaflets and
supporting structures.
.
EEG ([**4-12**]): Markedly abnormal portable EEG due to the very low
voltage
slow background and with bursts of generalized slowing. There
were some
periods with a markedly suppressed background. These findings
indicate
a widespread encephalopathy.
.
EEG ([**4-16**]): : This 24-hour EEG telemetry captured no
electrographic
seizures. No interictal epileptiform discharges were seen. The
background was slow and disorganized throughout much of the
recording
indicating a mild to moderate encephalopathy.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the neurology ICU after being
intubated for airway protection after receiving several rounds
of ativan for seizure activity. Hospital course was complicated
and is reviewed below by problem.
1. seizure: The episode prior to presentation was concerning for
a seizure. She had no prior seizure history, but she had had a
stroke, which could act as seizure focus. For further
evaluation, she underwent CTA, MRA, and EEG. The CTA and MRI
were negative for infarction or stenosis, but showed a 3mm
aneurysm extending posteriorly of the left supraclinoid portion
of the internal carotid artery, which will need to be followed
as an outpatient. EEG initially showed very low voltage slow
background and with bursts of generalized slowing, consistent
with encephalopathy. Repeat showed some improvement but
persistent findings of a mild to moderate encephalopathy. It was
thought that she had a symptomatic seizure secondary to
infection. She was not put on any antiepileptic medications and
had no further evidence of seizures.
2. encephalopathy: This was initially thought to be secondary to
infection. Tox screen was negative. She was treated for presumed
PNA for 7 days and seemed to improve, but then her mental status
began to decline after extubation ([**4-19**], [**4-20**]) with worsening
over the next several days. Lumbar puncture had initially been
considered, but given her improvement it was thought to be low
yield. With decreased responsiveness, the lumbar puncture was
again considered. However, she initially had some respiratory
difficulties making a lumbar puncture high risk (she would have
needed ativan for agitation, with concern for reintubation), and
then she had an elevated INR which did not come down to 1.5 even
after several units of FFP. She was considered to have a low
suspicion for meningitis, but was started on ceftriaxone,
vancomycin, and ampicillin on [**4-23**] for empiric coverage, as the
lumbar puncture could not be performed. On transfer to the
Medical ICU, lumbar puncture was attempted, but was unsucessful.
3. respiratory distress: Mrs. [**Known lastname **] required intubation twice
for respiratory failure and once for concerns of decreased
responsiveness with an episode of apnea. On [**4-20**] the pulmonary
service was consulted as the patient was wheezing and was noted
to have increased work of breathing (using accessory muscles,
tachypneic). A transthoracic echocardiogram was performed (see
above). She was started on budesonide and diuresed with
improvement of the wheezing.
4. atrial fibrillation: Anticoagulation was established with
heparin gtt whenever coumadin needed to be stopped for
procedures. She was treated with beta-blockers or IVF as needed
for tachycardia.
5. acute renal failure: Her creatinine acutely rose on [**4-19**].
FeNa was low, and she was thought to be total body overloaded
but intravascularly dry. She was given albumin and lasix with
stabilization of the Cr.
6. fever: She was initially treated with ceftriaxone and
vancomycin for 7 days, but all cultures were negative and the
antibiotics were discontinued. They were restarted, with
ampicillin, at meningitic doses on [**4-23**] after the patient
decompensated with a temperature of 104. Upon transfer to the
medical ICU, broad antibiotic coverage with vancomycin,
ceftriaxone, and zosyn were started.
7. transaminitis: She was noted to have an acute rise in ALT and
AST on [**4-23**]. RUQ u/s showed gall bladder wall edema without
stones or sludge. Due to concern for cholangitis, she was
transferred to the Medical ICU team. Hepatology and General
Surgery consulted and recommended repeat US. A second US was
obtained and showed minimal gall bladder wall edema with minimal
sludge. ERCP was recommended when she was more clinically
stable.
8. anemia: She had a slow Hct drop and was given a unit of
PRBCs. Rectal guaiac was negative and her Hct stabilized.
9. hypotension: upon transfer to the Medical ICU she was noted
to have fevers and hypotension. Upon discussion with her
family, they brought in evidence of a living will, which
outlined her preference for no resuscitation. Her blood
pressure was supported with IV fluid boluses, per her family's
request to not use vasopressors. The subsequent day, she showed
evidence of worsened liver and renal function, periods of apnea
on the ventilator, and continued cardiovascular compromise. A
family meeting was held with her son, [**Name (NI) **] (Health Care Proxy),
and daughter, [**Name (NI) **]. The decision was made to change the
goals of care to comfort only, according to the patient's
predetermined wishes. She was extubated and started on a
morphine drip, titrated to comfort. The patient passed away
comfortably and was pronounced dead at 8:15pm on [**2159-4-28**].
Commun: HCP son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 68156**](H), [**Telephone/Fax (1) 68157**](C)
Medications on Admission:
diovan 80
zocor 40
coumadin 5 qod
atenolol 50
protonix 40
prozac 20
thiamine
folate
cipro [**Date range (1) 23742**]
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia, TIA
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"518.81",
"433.10",
"584.9",
"780.39",
"428.0",
"435.9",
"V58.61",
"486",
"427.31",
"272.4",
"348.30",
"491.21",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.71",
"38.91",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13115, 13124
|
7969, 12916
|
285, 403
|
13183, 13193
|
2910, 3633
|
13249, 13260
|
2188, 2213
|
13083, 13092
|
13145, 13162
|
12942, 13060
|
13217, 13226
|
2228, 2891
|
205, 247
|
431, 1757
|
3655, 7946
|
1779, 1952
|
1968, 2172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,442
| 156,638
|
40639
|
Discharge summary
|
report
|
Admission Date: [**2150-8-12**] Discharge Date: [**2150-8-16**]
Date of Birth: [**2108-7-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing fatigue
Major Surgical or Invasive Procedure:
[**2150-8-12**] Mitral valve repair
History of Present Illness:
41 year old gentleman with a known history of mitral valve
prolapse followed by serial echocardiograms. His most recent
echocardiogram revealed moderate mitral valve prolapse with
severe regurgitation. He is mildy symptomatic with fatigue. As
his mitral regurgitation is now severe, it has been recommended
that he proceed with surgical repair versus replacement prior to
developing left ventricular dysfunction. He has thus been
referred to Dr. [**Last Name (STitle) **] for surgical evaluation.
Past Medical History:
Mitral valve prolapse with mitral regurgitation
Hyperlipidemia
Left hand cellulitis occurred 15 years ago
Right arm fracture
Eczema/dermatitis - face and scalp
Debridement of L 4th infected finger - 15 years ago
Social History:
Mr. [**Known lastname 63724**] lives with his wife. [**Name (NI) **] works as a Technology
Consultant. He denies tobacco use and drinks 4 alcoholic
beverages weekly.
Family History:
one sibling with MVP.
Physical Exam:
Pulse:66 Resp:16 O2 sat: 98%
B/P Right: 137/78 Left:148/86
Height: 72" Weight: 173
General:NAD, tall, thin
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera,OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- [**5-20**] hars systolic murmur
heard loudest at apex
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
Neuro: Grossly intact, MAE [**6-18**] strengths, nonfocal exam
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit : murmur radiates to carotids
Pertinent Results:
[**2150-8-12**] Echo: Pre bypass: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the [**Month/Day/Year 8813**]
arch. There are simple atheroma in the descending thoracic
aorta. The [**Month/Day/Year 8813**] valve leaflets (3) appear structurally normal
with good leaflet excursion and no [**Month/Day/Year 8813**] stenosis or [**Month/Day/Year 8813**]
regurgitation. The mitral valve leaflets are myxomatous. The
mitral valve leaflets are elongated. There is moderate/severe
bileaflet mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. There is no pericardial effusion. Post
bypass: Preserved biventricular funciton. Initial regurgiation
secondary to systolic anterior motion of mitral valve resolved
with volume and rate control, no residual MR [**First Name (Titles) **] [**Last Name (Titles) 35494**] filling.
No MS. [**First Name (Titles) **] [**Last Name (Titles) 86554**] intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
[**2150-8-15**] 06:41AM BLOOD WBC-11.0 RBC-3.84* Hgb-12.5* Hct-35.8*
MCV-93 MCH-32.5* MCHC-34.9 RDW-13.6 Plt Ct-161
[**2150-8-15**] 06:41AM BLOOD Glucose-96 UreaN-11 Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-31 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 63724**] was a same day admit and on [**8-12**] he was brought to
the operating room where he underwent a mitral valve repair.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later that day he was weaned from sedation,
awoke neurologically intact and extubated. On post-op day to he
was started on beta-blockers and diuretics and diuresed towards
his pre-op weight. Later this day he was transferred to the step
down floor for further care. Chest tubes and epicardial pacing
wires were removed per protocol. He worked with physical therapy
for strength and mobility. By post-operative day four he was
ready for discharge to home with services. All follow-up
appointments were advised.
Medications on Admission:
Amoxicillin prn dental
Lisinopril 2.5mg daily
[**Last Name (un) 88909**] or another topical cream daily to face and scalp
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. 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*
5. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*2*
7. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Mitral valve prolapse with mitral regurgitation s/p Mitral Valve
Repair
Past medical history:
Hyperlipidemia
Left hand cellulitis occurred 15 years ago
Right arm fracture
Eczema/dermatitis - face and scalp
Debridement of L 4th infected finger - 15 years ago
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check cardiac surgery office on [**8-25**] at 10:30am
Surgeon: Dr. [**Last Name (STitle) **] on [**9-3**] at 1:30pm
Cardiologist: Dr. [**Last Name (STitle) 2912**] on [**9-10**] at 2:00pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 11427**] in [**5-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2150-8-16**]
|
[
"429.5",
"424.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.33",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5537, 5586
|
3643, 4450
|
328, 365
|
5887, 6104
|
2175, 3620
|
7027, 7579
|
1326, 1349
|
4622, 5514
|
5607, 5679
|
4476, 4599
|
6128, 7004
|
1364, 2156
|
270, 290
|
393, 891
|
5701, 5866
|
1142, 1310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,301
| 123,703
|
7483
|
Discharge summary
|
report
|
Admission Date: [**2141-2-7**] Discharge Date: [**2141-2-23**]
Date of Birth: [**2097-10-3**] Sex: F
Service: Thoracic Surgery
CHIEF COMPLAINT: Left lower lobe lung mass.
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old
female first seen by the Cardiothoracic Surgery Service in
[**2140-6-7**]. The patient had presented in the Emergency
Department with confusion, word-finding difficulty, and
cognitive slowing. Computerized axial tomography scan of her
head as well as an magnetic resonance imaging scan performed
in [**Month (only) 216**] showed a 3 cm left frontal and a left parietal
metastases. There was some extensive surrounding edema at
the time with some compression of the body of the left
lateral ventricle. Both of these metastases were
subsequently removed on [**2140-7-28**]. Pathology was
consistent with adenocarcinoma. A computerized axial
tomography scan of the chest performed on [**2140-7-27**]
showed a mass in the left lower lobe. She had stereotactic
radiosurgery to the left frontal and left parietal surgical
bed in [**2140-9-7**]. She has subsequently underwent four
cycles of Gemcitabine and Carboplatin chemotherapy. The
patient was followed following these procedures and was
neurologically and psychiatrically stable at the beginning of
[**2141-2-6**]. Following further workup there was no evidence
of further metastatic disease and given the patient's young
age, the Oncology Division as well as the Thoracic Surgery
staff felt that the patient's survival may benefit from
surgical resection of the lung mass.
PAST MEDICAL HISTORY: 1. Metastatic lung cancer as
mentioned above. 2. Left foot drop. 3. Osteomyelitis of
the left lower extremity. 4. Bilateral lower extremity
edema times approximately nine months (etiology unclear. The
patient has required Lasix for control. The patient has also
required increasing doses of narcotic medications to control
lower extremity pain believed related to that edema.) 5.
Traumatic splenectomy, effusion of the right wrist,
straightening of the left great toe subsequent to
osteomyelitis. 6. Right breast duct excision.
MEDICATIONS ON ADMISSION: Senna b.i.d., Aldactone 50 mg p.o.
q.d., Neurontin 600 mg p.o. t.i.d., Compazine prn, Fentanyl
patch 75, Pepcid 20 mg p.o. b.i.d., Effexor 37.5 mg p.o.
b.i.d., Lasix 100 mg p.o. q.d., Aleve prn, Dilaudid prn,
Klonopin.
SOCIAL HISTORY: The patient is married and has a large
involved family. The patient worked as a manager at a [**Company 15428**]. The patient has been a heavy smoker in the past.
The patient also has a history of alcohol abuse.
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: The patient was admitted to [**Hospital6 1760**] on [**2141-2-7**], and taken
to the Operating Room where she underwent a left lower
lobectomy, mediastinal lymph node dissection and lysis of
adhesions. The procedure was uncomplicated with an estimated
blood loss of 150 cc.
In a postoperative area the patient was noted to have a new
left hemiparesis. The patient was also somnolent. An
emergent computerized axial tomography scan of her head was
obtained which revealed a large area of hemorrhage in the
right temporal and parietal region. There was also over 1 cm
right to left some sloughing herniation. A Neurosurgery
consultation was requested and the patient was emergently
taken to the Operating Room for evacuation of the hematoma.
The patient was then transferred to the Intensive Care Unit
while intubated and sedated. On postoperative day #1, the
patient was able to open her eyes to noxious stimuli but was
not following commands. She was moving all four extremities
spontaneously but with the right being significantly stronger
than the left extremities. The patient was on Dilantin and
Decadron as well as the Nitroprusside drip for blood pressure
control. The patient was extubated on postoperative day #1.
On postoperative day #2, the patient required reintubation
for extreme agitation where the patient attempted to get out
of bed, pulling her line and flashing on her bed. Following
intubation, the patient had a bronchoscopy performed for
copious secretions. The bronchoscopy revealed that her left
lower lobectomy stump site was intact with no bleeding.
There was copious clear sputum on the right. A
bronchoalveolar lavage was performed and specimens were sent
for cultures. The sample ultimately grew Serratia. The
patient had been started on Levofloxacin postoperatively and
subsequently completed a 14 day course. Over the following
few days, in the Intensive Care Unit the patient's
medications were titrated to minimize her agitation. Her
neurologic status remained largely stable.
On postoperative day #5, the patient pulled out one of her
chest tubes. The site was immediately dressed appropriately
and a chest x-ray performed which revealed no evidence of
pneumothorax. The patient's second chest tube on the right
side was removed later that day by the thoracic surgery team.
Following the removal of the chest tubes, the patient had a
chest x-ray which revealed a significant pneumothorax. A
pigtail catheter was placed into the pneumothorax for
decompression on postoperative day #6. At this time, the
patient remained disoriented, confused and mildly agitated.
On postoperative day #7 the patient was started on tube feeds
and her Decadron was ultimately weaned off. On postoperative
day #9, the patient had a bedside swallow evaluation.
However, the patient did not cooperate much with the
examination and it was believed that she could tolerate thin
liquids and pureed foods under strict supervision while
upright. Over the following few days, the patient made some
slight improvement, but on the morning of postoperative day
#13 was noted to be significantly improved. The patient
remained confused but easily reoriented. She was moving all
extremities spontaneously and purposefully. She was
following some simple commands, although inconsistently. She
remained intermittently agitated but could be calmed down
with the family present. The patient's Ativan drip was
weaned off and her Decadron was discontinued. On
postoperative day #14, the patient was transferred to the
regular floor. She was maintained on 1:1 observation. She
appeared somewhat sleepy. The Neurology Team which had
followed the progress of the patient recommended that her
Ativan be slowly weaned. This was initiated. The patient at
that time was beginning to take more regular food by mouth.
On postoperative day #15, the patient pulled out her
nasogastric feeding tube. Given that the patient was
beginning to eat more, the decision was made not to replace
the tube. By the evening of postoperative day #15 the
patient was clearly eating much better. She was calmer,
responding appropriately to questions, moving all extremities
and still had some slight weakness on the left.
Discharge planning had been initiated following the [**Hospital 228**]
transfer to the floor. By postoperative day #16, the patient
was deemed ready for discharge. By that day the patient was
able to converse somewhat fluently, although requiring
frequent prompting to recall some details. Her pain was well
controlled. The patient had a very good appetite and was
tolerating her food with no problems. The patient was able
to ambulate a short distance out of her room with a walker
although she would drift to one side with ambulation and
required guidance. The patient's pigtail catheter into the
chest had been removed without complications. The patient's
laboratory data were essentially normal. Her white count had
been stable in the 14 to 15 range during the four days prior
to discharge but on [**2-23**], her white count had dropped to
10.3. The patient had been afebrile essentially throughout
her admission. The patient was to be discharged for
neurological rehabilitation when a bed became available.
DISCHARGE CONDITION: Stable from a thoracic surgery
standpoint and improving from a neurological standpoint.
DISCHARGE DIAGNOSIS:
1. Adenocarcinoma of the lung, left lower lobe.
2. Hemorrhagic stroke, right parietal area.
FOLLOW UP:
1. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**], her
thoracic surgeon, in clinic one week following discharge.
2. The patient is to follow up with the Neurology Service.
The patient should make an appointment in the [**Hospital 878**]
Clinic by calling phone #[**Telephone/Fax (1) 1690**] for an appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
3. The patient is to follow up with her primary care
physician within one to two weeks following discharge.
4. The patient will need to follow up with the Neurosurgical
Service following discharge.
5. The patient will need to follow up with her oncologist
following discharge.
DISCHARGE MEDICATIONS:
1. Albuterol 1 to 2 puffs q. 4 hours prn
2. Dulcolax 10 mg p.o./q.d. prn
3. Clonidine TTS one patch to skin every Saturday (deliver
0.1 mg daily)
4. Fentanyl 75 mcg/hr patch changed every three days.
5. Neurontin 600 mg p.o. t.i.d.
6. Dilaudid 2 mg p.o. q. 4 hours
7. Ativan taper
8. Nicotrol 10 mg inhaler q. 4 hours
9. Protonix 40 mg p.o. q. day
10. Dilantin 100 mg p.o. t.i.d.
11. Seroquel 50 mg p.o. q. AM, 75 mg p.o. q. PM
12. Senna one tablet p.o. b.i.d. prn
13. Spironolactone 50 mg p.o. q.d.
14. Venlafaxine 37.5 mg p.o. b.i.d.
15. Trazodone 75 mg p.o. q.h.s.
16. Lasix 100 mg p.o. q.d.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2141-2-23**] 09:37
T: [**2141-2-23**] 09:56
JOB#: [**Job Number 27383**]
|
[
"518.0",
"511.0",
"997.3",
"V10.85",
"512.1",
"196.1",
"997.02",
"276.0",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"34.04",
"33.24",
"01.39",
"38.93",
"32.4",
"96.04",
"96.6",
"38.91",
"33.39",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
7975, 8064
|
8942, 9811
|
8085, 8180
|
2178, 2398
|
2702, 7953
|
8191, 8919
|
166, 194
|
223, 1587
|
1610, 2151
|
2415, 2684
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,698
| 149,531
|
10885
|
Discharge summary
|
report
|
Admission Date: [**2183-3-12**] Discharge Date: [**2183-3-15**]
Date of Birth: [**2121-9-5**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a 61- year- old female
with a history of right ICA stenosis 75-80% and left ICA
stenosis 65-70% stenosis and a [**Doctor Last Name **] aneurysm 3.5 mm from the
anterior communicating artery. This patient is admitted for
coiling of the ACOM aneurysm.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CAD with CABG in [**2179**].
3. Dyspnea.
4. COPD.
5. Reflux.
6. Patient also has a history of schizophrenia.
MEDICATIONS:
1. Haldol 3 mg q.8 a.m., 2 mg q.2 p.m., and 3 mg q.8 p.m.
2. Cogentin 1 mg p.o. b.i.d.
3. Atenolol 100 q.d.
4. Lipitor 20 q.d.
5. Zestril 40 q.d.
6. Cartia XT 180 q.d.
7. Aspirin 325 q.d.
8. Serax 15 b.i.d.
9. Zantac 150 b.i.d.
10. Plavix 75 mg q.d.
11. Trazodone 200 q.h.s.
PAST SURGICAL HISTORY:
1. CABG x3 in [**2179**].
2. Hysterectomy.
3. Appendectomy.
PHYSICAL EXAM: In general, the patient was in no acute
distress. Mental status: Pleasant, cooperative, attentive.
Cardiac: S1, S2 slow rate, 3+ carotid bruit on the right.
Chest was clear to auscultation with fine crackles at the
bases, clear with cough. Abdomen is soft and nontender.
Extremities: No edema, 1+ right radial pulse, left radial
pulse. Dopplerable DP pulses in the lower extremities.
Pupils are equal, round, and reactive to light. Face
symmetric. Right lip decreases with smile. Tongue midline.
Patient was admitted status post a coil embolization of an
ACOM aneurysm without interprocedure complications. She was
monitored in the recovery room overnight. Her sheaths were
removed. There was no hematoma to her right groin. Her
pedal pulses remained intact. She was awake, alert, and
oriented times three. EOMs full. Visual fields were full to
confrontation. Her smile was symmetric. Her extremities
were full strength and equally bilaterally.
She was transferred to the regular floor on postoperative day
one. Her Foley was D/C'd. She was voiding spontaneously,
tolerating a regular diet. Was assessed by Physical Therapy
and found to be safe for discharge home. She was discharged
on [**2183-3-15**] in stable condition with followup with Dr.
[**Last Name (STitle) 1132**] in two weeks.
MEDICATIONS ON DISCHARGE:
1. Haldol 2 mg p.o. q2 p.m., Haldol 3 mg p.o. b.i.d.
2. Trazodone 200 mg p.o. q.h.s.
3. Zantac 150 mg p.o. b.i.d.
4. Lisinopril 40 mg p.o. q.d.
5. Atorvastatin 20 mg p.o. q.d.
6. Atenolol 100 mg p.o. q.d.
7. Colace 100 mg p.o. b.i.d.
8. Aspirin 325 p.o. q.d.
9. Plavix 75 mg p.o. q.d.
10. Percocet 1-2 tablets p.o. q.4h. prn.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**Last Name (STitle) 1132**] in two
weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2183-3-14**] 16:02
T: [**2183-3-18**] 05:17
JOB#: [**Job Number 35426**]
|
[
"414.00",
"496",
"V45.81",
"437.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2313, 2640
|
895, 956
|
972, 1023
|
168, 431
|
1039, 2287
|
2748, 3066
|
453, 872
|
2665, 2723
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,487
| 186,887
|
51044
|
Discharge summary
|
report
|
Admission Date: [**2142-12-13**] Discharge Date: [**2142-12-21**]
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Pedestrian struck by car
Major Surgical or Invasive Procedure:
ORIF Left tibial plateau [**2142-12-14**]
History of Present Illness:
88 yo man who while walking across the street was struck by a
car at low speed. No reported LOC. He was taken to [**Hospital1 18**] for
trauma evaluation. He was noted to have left knee pain and
swelling.
Past Medical History:
Orthostatic hypotension
Alzheimers
CABG x [**3-30**] year ago
Thrombocytopenia - followed in Heme/[**Hospital **] clinic
Allergy: Aspirin - patient has low platelets.
Social History:
Lives with wife; 136 pack year smoking history; denies
current alcohol use. Uses a cane to help to ambulate. Can climb
stairs.
Family History:
Sister died of unknown cancer; father died of stomach
cancer.
Physical Exam:
afebrile 134/68 55 16 100%RA FS=50
Appears comfortable, NAD
Head atraumatic
PERRLA, EOMI.
Chest: symmetric rise, no crepitus. CTAB.
CV: RRR, S1S2
Abd: soft, NTND
Pelvis: stable
Pectal: guaiac neg, tone nl
Ext: moving all extremities. LLE w/ swelling and ecchymosis over
knee
Pertinent Results:
[**2142-12-13**] 12:30PM PT-12.5 PTT-23.5 INR(PT)-1.0
[**2142-12-13**] 12:30PM FIBRINOGE-245#
[**2142-12-13**] 12:30PM WBC-5.8 RBC-3.95* HGB-13.3* HCT-38.8* PLT
COUNT-41*
[**2142-12-13**] 12:30PM GLUCOSE-51* LACTATE-1.3 NA+-146 K+-4.2
CL--106 TCO2-27 UREA N-24* CREAT-1.1 AMYLASE-90
[**2142-12-13**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2142-12-13**] 02:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG RBC-[**3-31**]* WBC-0-2
BACTERIA-OCC YEAST-NONE EPI-<1
CT RECONSTRUCTION [**2142-12-13**] 12:36 PM
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
Reason: eval for fx
[**Hospital 93**] MEDICAL CONDITION:
88 year old man s/p ped struck
REASON FOR THIS EXAMINATION:
eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pedestrian struck by vehicle, currently not
complaining of neck pain.
COMPARISON: None.
TECHNIQUE: Non-contrast CT of the cervical spine was performed
with the coronal and sagittal reformations.
NON-CONTRAST CT OF THE SPINE: No fractures are identified. The
vertebral body heights are well maintained. There is mild
narrowing of multiple disc spaces as well as small anterior and
posterior osteophyte formation. The cervical spine is diffusely
demineralized. There is moderate left foraminal stenosis at the
C5-C6 level and mild right foraminal stenosis at the C6-C7
level. There is no significant spinal canal stenosis. In the
right lung apex, there is an area of consolidation measuring
approximately 8x20mm, with a post-inflammatory appearance. The
prevertebral soft tissue structures appear unremarkable.
IMPRESSION:
1. No evidence of fracture or dislocation. Degenerative disease
of the cervical spine with left foraminal stenosis at the C5- C6
level and right foraminal stenosis at the C6- C7 level.
2. Small peripheral opacity in the right lung apex of uncertain
clinical significance, but likely post infectious in nature.
Preliminary read was given to Dr. [**Last Name (STitle) **] at approximately 1:30
p.m. on [**2142-12-13**].
RADIOLOGY Final Report
CT RECONSTRUCTION [**2142-12-13**] 3:10 PM
CT LOW EXT W/O C LEFT; CT RECONSTRUCTION
FINDINGS:
There is a vertical fracture through the lateral aspect of the
tibial plateau with approximately 2-mm depression of the
fracture fragment relative to the remainder of the tibial
plateau on the coronal images. There is an associated
moderate-sized lipohemarthrosis. No other fractures are
identified. Degenerative changes are seen along the superior
aspect of the patella with mild enthesopathy.
The patellar and quadriceps tendons appear intact. Soft tissues
demonstrate mild edematous changes around the fracture site.
Vascular calcifications are seen within the superficial femoral
and popliteal arteries.
IMPRESSION:
Minimally depressed (2 mm) fracture of the lateral aspect of the
tibial plateau with an associated lipohemarthrosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: [**Doctor First Name **] [**2142-12-13**] 5:18 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2142-12-13**] 12:35 PM
FINDINGS: No intra or extraaxial hemorrhage is identified. There
are no mass lesions, shift of normally midline structures,
evidence of major vascular territorial infarction. There are
prominent ventricles and sulci consistent with age-appropriate
involutional change. There is diffuse hypodensity of the
periventricular white matter consistent with chronic
small-vessel infarction which is unchanged since the prior
study. The [**Doctor Last Name 352**]-white matter differentiation is well preserved.
No fractures are identified. Note is made of vascular
calcifications in the cavernous portions of the internal carotid
arteries. The visualized paranasal sinuses and mastoid air cells
are well pneumatized. The soft tissues structures appear
unremarkable.
IMPRESSION: No intracranial hemorrhage or mass lesion.
These findings were discussed with Dr. [**Last Name (STitle) **] at 1:30 p.m. on
[**2142-12-13**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: [**Doctor First Name **] [**2142-12-13**] 9:11 PM
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION
NON-CONTRAST CT OF THE SPINE: No fractures are identified. The
vertebral body heights are well maintained. There is mild
narrowing of multiple disc spaces as well as small anterior and
posterior osteophyte formation. The cervical spine is diffusely
demineralized. There is moderate left foraminal stenosis at the
C5-C6 level and mild right foraminal stenosis at the C6-C7
level. There is no significant spinal canal stenosis. In the
right lung apex, there is an area of consolidation measuring
approximately 8x20mm, with a post-inflammatory appearance. The
prevertebral soft tissue structures appear unremarkable.
IMPRESSION:
1. No evidence of fracture or dislocation. Degenerative disease
of the cervical spine with left foraminal stenosis at the C5- C6
level and right foraminal stenosis at the C6- C7 level.
2. Small peripheral opacity in the right lung apex of uncertain
clinical significance, but likely post infectious in nature.
Preliminary read was given to Dr. [**Last Name (STitle) **] at approximately 1:30
p.m. on [**2142-12-13**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: [**Doctor First Name **] [**2142-12-13**] 9:11 PM
Brief Hospital Course:
Pt was evaluated in the trauma bay by ER and trauma surgery
teams. He was admitted to the trauma service. Xrays and CT scans
were obtained, see results section for details. He was found to
have a left tibial plateau fracture. Orthopedic Service was
consulted. On [**12-14**] he underwent ORIF of his left tibial
plateau. He tolerated the procedure well. He was transfused 2
units of platelets perioperatively for platelet counts in
30s-40s (within his normal range, h/o thrombocytopenia).
Orthopedics is recommending that patient remain on Lovenox for a
total of 3 weeks, Geriatrics Service also followed patient
during his hospital. His home meds were resumed. physical
therapy was also consulted and have recommended that patient go
to a rehabilitation facility for improving his functional
abilities.
Medications on Admission:
Aricept 5mg [**Hospital1 **]
Effexor XR 150mg QD
Fludrocortisone 0.1mg [**Hospital1 **]
Midodrine 10mg TID
Topamax 25mg QHS
Zocor 40mg QD
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
2. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours): Continue for a total of 3
weeks.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone 5 mg Tablet Sig: [**1-28**] - 1 Tablet PO every 4-6 hours
as needed for pain: [**1-28**] tab for mild pain
1 tab for mod-severe pain.
8. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day as needed for
constipation.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
10. Donepezil 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Midodrine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
s/p pedestrian struck by car
L lateral tibial plateau fracture
Discharge Condition:
stable
Discharge Instructions:
Keep all follow-up appointments.
A small peripheral opacity of the right lung apex was seen on a
CT scan of your cervical spine. This is most likely residual
from a prior infection, but you should follow up with your
primary care doctor.
Do not bear any weight on your left lower extremity.
Followup Instructions:
Follow-up with the orthopaedic trauma clinic 2 weeks after
discharge. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow-up with your primary care doctor [**First Name8 (NamePattern2) 712**] [**Last Name (Titles) 713**] regarding
the lung opacity seen on chest CT. Call [**Telephone/Fax (1) 719**] for an
appoinment.
Follow-up with the orthopaedic trauma clinic 2 weeks after
discharge. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow-up with your primary care doctor [**First Name8 (NamePattern2) 712**] [**Last Name (Titles) 713**] regarding
the lung opacity seen on chest CT. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2143-1-22**] 10:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2143-1-15**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2143-3-5**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2142-12-18**]
|
[
"458.0",
"414.00",
"331.0",
"823.00",
"780.52",
"294.10",
"V12.59",
"287.31",
"311",
"V45.81",
"E814.7",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"79.36",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9374, 9447
|
7280, 8085
|
241, 285
|
9554, 9563
|
1246, 1999
|
9904, 11112
|
872, 936
|
8273, 9351
|
2036, 2067
|
9468, 9533
|
8111, 8250
|
9587, 9881
|
951, 1227
|
177, 203
|
2096, 7257
|
313, 519
|
541, 710
|
726, 856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,936
| 144,288
|
888
|
Discharge summary
|
report
|
Admission Date: [**2165-10-6**] Discharge Date: [**2165-10-11**]
Date of Birth: [**2095-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old man with severe CHF (EF <20%), HTN, DM
2 presenting with increasing shortness of breath and pedal edema
for the past 7 days. Family reports that he stopped taking all
of his medications approximately 5 days PTA because he could no
longer taste anything and was concerned that one of his meds was
causing this. He came to the ED because he could no longer walk
around the house without becoming short of breath and he had to
sleep sitting straight up. In addition he reported a dry cough
productive of grey sputum, lightheadedness/dizziness. He denied
fever and chest pain.
Past Medical History:
CHF, EF 20% in [**2164**]
Chronic renal insufficiency
DM2
HTN
Hypercholesterolemia
Obesity
Benign prostatic hypertrophy.
Bronchitis.
Possible obstructive sleep apnea
Multifocal Atrial Tachycardia
Social History:
Rare ETOH. Quit tobacco 12 years ago. The patient lives with
girlfriend, and cats. Was working in a steel mill in [**State 4260**] from
[**Month (only) 958**] to [**2164-8-11**]. Close to son.
Family History:
FAMILY HISTORY: Noncontributory
Physical Exam:
Initial CCU Exam
VS: BP's 102-128/80-90, HR 70-80's T95.6 O2 92%on 6L VM
Gen: [**Last Name (un) 6055**] [**Doctor Last Name 6056**] respirations, somnolent, apparent respiratory
distress
HEENT: JVP elevated
CV: distant heart sounds, RRR no murmur audible
ABD: obese, soft, nontender, nondistended BS +
Lungs: Anterior lung fields with crackles bilaterally
Extremities: cool with 2+pitting edema bilaterally
Pertinent Results:
[**2165-10-6**] 11:30AM WBC-10.5 RBC-5.95 HGB-16.7 HCT-49.2 MCV-83
MCH-28.0 MCHC-33.9 RDW-16.0*
[**2165-10-6**] 11:30AM NEUTS-74.2* LYMPHS-16.2* MONOS-8.0 EOS-1.4
BASOS-0.2
[**2165-10-6**] 11:30AM GLUCOSE-206* UREA N-20 CREAT-1.3* SODIUM-143
POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-26 ANION GAP-14
[**2165-10-6**] 11:30AM PLT COUNT-371#
[**2165-10-6**] 11:30AM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-2.2
[**2165-10-6**] 11:30AM CK-MB-NotDone proBNP-7209*
[**2165-10-6**] 11:30AM cTropnT-0.05*
[**2165-10-6**] 11:30AM CK(CPK)-69
.
EKG demonstrated atrial fibrillation,rate 90bpm, normal
intervals, normal axis, PVC, <1mm ST segment elevation in V1,
V2. No significant change compared with prior.
.
HEMODYNAMICS on arrival to CCU
CVP 12 PA 56/28 PCWP 27 CO 5.8 CI 2.22 SVR 690
.
OTHER TESTING:
CXR [**2165-10-6**]-
1. Slight perimediastinal vascular haze, increased interstitial
markings, and bilateral lower lung field haze, all suggestive of
mild fluid overload with probable layering posterior effusion.
2. Left lower lobe/retrocardiac density is nonspecific and may
represent underlying atelectasis or consolidation
.
TTE [**2165-10-7**]
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
There is severe global left ventricular hypokinesis (LVEF <20
%). No masses or thrombi are seen in the left ventricle. The
right ventricular cavity is mildly dilated with severe global
free wall hypokinesis. The aortic valve leaflets appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2164-12-10**],
the findings are similar (left ventricular dysfunction was also
global on review of the prior study and right ventricular free
wall hypokinesis was also present. Borderline pulmonary artery
systolic hypertension is now suggested.
Brief Hospital Course:
1. Dyspnea/CHF: The patient's worsened dyspnea was thought to be
due to a CHF exacerbation in the setting of medication
non-compliance and pneumonia. Upon arrival to the CCU, the
patient was exhibiting [**Last Name (un) 6055**] [**Doctor Last Name **] respirations, and due to
somnolence and increasing hypercapnia required intubation. A PA
catheter was placed, and he was started on dobutamine, and
responded well to diuresis with lasix and diuril. He was
extubated on [**10-7**], and his respiratory status improved with
continued diuresis. He will be discharged on lasix 80 [**Hospital1 **] as he
remains volume overloaded; diuretics will be titrated at his
followup heart failure clinic visit in the next week. He
continued his home beta blocker and ACEI. Spironolactone was
started, and he will continue this as an outpatient. His
electrolytes and renal function should be reassessed at his next
clinic visit on [**2165-9-14**].
.
2. MAT/Tachycardia: Mr. [**Known lastname **] had a run of tachycardia to the
150's in the ED that responded well to lopressor by report. On
the floor, he continued to have brief episodes of NSVT and PVCs
on telemetry.
.
3. CAD: Patient continued on aspirin, betablocker, statin, and
ACEI.
.
4. Pneumonia: The patient was initially treated with
azithromycin and ceftriaxone and in the ED, subsequently on
levofloxacin and flagyl. He will complete a 7d course of
levofloxacin to end on [**2165-9-12**].
.
5. Diabetes: The patient was treated with insulin while in the
CCU, with resumption of his metformin subsequently. Given his
baseline elevated creatinine, an alternative oral [**Doctor Last Name 360**] than
metformin may be preferable. This can be readdressed at his next
outpatient followup appointment.
.
5. Sleep apnea: CPAP continued
.
6. Traumatic foley insertion: Urology was consulted for
hematuria, per urology balloon inflated in the prostatic fossa,
foley repositioned and irrigated with good urine output and
resolution of hematuria.
.
#Code Status - Full
.
#Contact - long time girlfriend [**Name (NI) **] [**Name (NI) 6057**]
Medications on Admission:
lipitor 80mg po daily
ASA 325mg po daily
Toprol XL 200mg po daily
lisinopril 40mg po daily
metformin 850mg po bid
lasix 40mg po bid
Discharge Medications:
1. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
12. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses: take Sunday [**2165-9-12**].
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. CHF exacerbation
2. pneumonia
Discharge Condition:
fair
Discharge Instructions:
You came into the hospital due to shortness of breath. Your
symptoms were due to worsening of your congestive heart failure
in the setting of stopping your heart failure medications.
Please take your medications every day as directed. If you
believe you are having side effects from the medications or
other problems taking them please call your doctor before
stopping the medications.
You have one more dose of antibiotics (levofloxacin) to take to
complete the course of treatment for your pneumonia. Please take
the levofloxacin on Sunday [**10-13**], even if you are
feeling well before then.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Call your doctor and seek medical attention at once if you
develop:
** worsening shortness of breath, chest discomfort, fevers,
chills, or sweats, worsening cough, or other symptoms that worry
you
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4451**] on Tuesday
[**10-15**] at 1pm
|
[
"414.01",
"427.1",
"428.0",
"413.9",
"486",
"250.00",
"599.7",
"585.9",
"403.90",
"327.23",
"V15.81",
"996.76",
"428.40",
"427.89",
"518.81",
"V45.02",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.61",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7503, 7561
|
4055, 6137
|
324, 331
|
7638, 7645
|
1910, 4032
|
8589, 8739
|
1446, 1463
|
6319, 7480
|
7582, 7617
|
6163, 6296
|
7669, 8566
|
1478, 1891
|
277, 286
|
359, 981
|
1003, 1200
|
1216, 1413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,802
| 122,524
|
50158
|
Discharge summary
|
report
|
Admission Date: [**2129-11-5**] Discharge Date: [**2129-11-10**]
Date of Birth: [**2085-2-22**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Shortness of breath and pleuritic chest pain
Major Surgical or Invasive Procedure:
Subclavian line placement
History of Present Illness:
44 yo F w/ history of diabetes type 1 presenting with three days
of non-productive cough, subjective fevers, chills and right
sided pleuritc chest discomfort. In the ED, was found to have
RML and RLL pna, wbc 29.8, glucose 397. Initially she was kept
in obs and later became hypotensive with SBP 70-280's, and sats
91-92%.
Past Medical History:
* asthma (FEV1 1.26, FVC 1.9)
* recurrent bronchitis and sinusitis
* dm1 (last HbA1c 11.8)
* hypertension
* hypercholesterolemia
* anxiety
Social History:
Married, works as waitress, prior 40pkyr smoking history.
Recently traveled to [**Country **] in [**Month (only) **], two children (adopted),
+PPD/-CXR and is on INH therapy.
Family History:
coronary artery disease, diabeted and breast cancer run in her
family.
Physical Exam:
T 98.6 BP 107/53 HR 114 RR 26 Sat 92-94%
Gen: sleepy, oriented, arousale.
HEENT: anicteric, OP clear, EOMI, PERLL, MMM
Neck: no JVD, no accessory muscle use, L Subclavian line
CV: Reg rhythm, tachycardic, nl S1/S2, no m/r/g
Pul: bilateral rhonchi, crackles [**2-11**] way up R>L, mild exp
wheezes on right.
Abd: obese, soft, non-tender, non-distended, NABCS
Ext: 1+ DP b/l, trace edema, no cords.
Pertinent Results:
[**2129-11-5**] 08:35AM BLOOD WBC-29.8*# RBC-4.44 Hgb-12.9 Hct-37.4
MCV-84 MCH-29.0 MCHC-34.3 RDW-14.3 Plt Ct-264#
[**2129-11-5**] 08:35AM NEUTS-88* BANDS-4 LYMPHS-3* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2129-11-5**] 08:35AM PLT SMR-NORMAL PLT COUNT-264#
[**2129-11-5**] 08:35AM GLUCOSE-352* UREA N-12 CREAT-0.7 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-20* ANION GAP-14
[**2129-11-5**] 05:05PM PT-15.1* PTT-28.9 INR(PT)-1.4
[**2129-11-5**] 03:48PM LACTATE-2.2*
[**2129-11-5**] 06:52PM TYPE-ART TEMP-35.8 RATES-/24 O2-100 PO2-78*
PCO2-35 PH-7.33* TOTAL CO2-19* BASE XS--6 AADO2-604 REQ O2-98
INTUBATED-NOT INTUBA
[**2129-11-9**] 04:32AM BLOOD WBC-10.4 RBC-3.38* Hgb-9.5* Hct-28.8*
MCV-85 MCH-28.0 MCHC-32.9 RDW-14.9 Plt Ct-272
[**2129-11-9**] 04:32AM BLOOD Glucose-219* UreaN-12 Creat-0.5 Na-141
K-4.3 Cl-106 HCO3-25 AnGap-14
[**2129-11-5**] 05:05PM BLOOD CRP-20.29*
[**2129-11-5**] 05:05PM BLOOD Cortsol-31.2*
Legionella Urinary Antigen (Final [**2129-11-8**]): NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
CXR [**11-5**] (final): New consolidation within anterior segment of
right upper lobe with minimal involvement in right middle lobe.
These findings are consistent with pneumonia in the appropriate
clinical setting. Followup radiographs after completion of
antibiotic therapy are recommended to insure complete resolution
and to exclude other process.
Brief Hospital Course:
Mrs. [**Known lastname 104678**] has a history of asthma, hypertension,
hyperlipidemia and presented with pleuritic chest pain, cough
and in the emergency department, had progressive hypoxia and
hypotension. Her CXR showed evidency of right lower lobe and
right middle lobe pneumonia.
For her sepsis, likely due to her pneumonia given the positive
chest x-ray and absence of other symptoms, the sepsis protocol
was initiated. Ceftriaxone 1g IV q24 and Levaquin 500 mg qd
were given. A left subclavian line was placed and she was given
4 liters of normal saline in the emergency department. She was
admitted to the [**Hospital Unit Name 153**] for monitoring. Her blood pressure
remained stable while in the [**Hospital Unit Name 153**].
For her multilobar pneumonia, which was believed to be community
acquired, she was changed from levaquin to azithromycin 500mg qd
(to complete a 10 day course) and was continued on ceftriaxone
for a total of four days. Urinary Legionella antigen was
negative. Her lung exam improved signficantly by the day of
discharge to the point that her rhonchi cleared.
For her asthma, her advair was continued and she was given
albuterol-ipratroprium nebs. In addition, she was given
prednisone 40mg qd for two days followed by a one week taper
(40-30-30-20-20-10-10-off).
For her pleuritic pain, she was given toradol which kept her
pain under good control. The pain improved signficantly once
the prednisone was initiated.
For her diabetes mellitus, type 1, she was initially placed on
an insulin gtt. In the [**Hospital Unit Name 153**], she was placed on her home regimen
of regular insulin, sliding scale plus a PM dose of lantus. Her
sugars were relatively well controlled until steroids were added
and they improved once the steroids were tapered down.
For her anxiety, she was given ativan 0.5mg qPM.
For access, her subclavian line was discontinued on [**9-7**].
Communication was with her and her husband.
She was discharged home directly from the MICU in good condition
and will followup with Dr. [**Last Name (STitle) 575**] in [**2-11**] weeks.
Medications on Admission:
Lipitor 20 qHS
Cozaar 25mg qd
Advair diskus 50/500
[**Doctor First Name **] 120mg qd
Albuterol MDI / neb
Lantus 26u qPM
Regular insulin
Nasonex
Discharge Medications:
1. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
2. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
5. Prednisone 10 mg Tablet Sig: taper Tablet PO once a day for 4
days: Two tabs by mouth once a day for two days followed by one
tab by mouth once daily for two days.
Disp:*6 Tablet(s)* Refills:*0*
6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Disk Inhalation twice a day.
Disp:*60 disks* Refills:*2*
7. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: 1-2 mg NEB
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*20 doses* Refills:*1*
8. Motrin 800 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
9. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety for 15 days.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Sepsis
Discharge Condition:
Good, afebrile.
Discharge Instructions:
Please seek medical attention if you have fevers>101, shortness
of breath, chest pain or anything else medically concerning.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 575**] in the next two weeks to followup.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2130-1-24**] 9:15
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2130-1-24**] 9:30
|
[
"038.9",
"995.91",
"401.9",
"486",
"250.01",
"300.00",
"272.0",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6467, 6473
|
3033, 5138
|
354, 382
|
6534, 6551
|
1611, 3010
|
6724, 7184
|
1106, 1178
|
5333, 6444
|
6494, 6513
|
5164, 5310
|
6575, 6701
|
1193, 1592
|
270, 316
|
410, 736
|
758, 898
|
914, 1090
|
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