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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11,842
| 197,912
|
6657
|
Discharge summary
|
report
|
Admission Date: [**2144-7-22**] Discharge Date: [**2144-8-4**]
Date of Birth: [**2072-1-7**] Sex: F
Service: MEDICINE
Allergies:
Dicloxacillin / Keflex / Bactrim
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
Left Subclavian central Line
History of Present Illness:
72 yo woman with lung CA, COPD, CAD who presented to [**Hospital1 2025**] ED with
worsening SOB. Patient initially diagnosed with squamous cell
lung CA in [**4-18**] with RUL mass. S/p XRT and chemo with
Taxol/[**Doctor Last Name **] with substantial improvement in RUL mass therefore
patient underwent RUL lobectomy with improvement of symptoms.
Patient then returned to clinic with increased SOB in [**5-18**] and
found to have extensive mediastinal tumor encasing her trachea
and with narrowing of her esophagus. She had a tracheal stent
placed by Dr. [**Last Name (STitle) **] on [**2143-5-16**]. Bronchial washings showed
recurrence of squamous cell Ca and the patient was started on
low dose Taxol/[**Doctor Last Name **]. Patient found to have progression of
disease afer this therapy and was last seen by Dr. [**Last Name (STitle) 3274**] on
[**2144-5-21**] who felt that the patient would not tolerate further
chemotherapy. No further oncologic treatment has been offered.
.
Patient presented to [**Hospital1 2025**] ED c/o sudden onset of SOB. Recently
had low grade fevers at home and mildly increased SOB from
baseline over past 3-4 days. On presentation patient was "dusky"
and NRB was placed with O2 sats 100%. Patient also had
increased work of breathing and attempt was made to intubate x 2
in the ED. This was unsuccessful due to stenosis of the trachea
and therefore the patietn was taken to the OR for intubation.
CXR showed RUL consolidation felt to be a pneumonia and
therefore patietn received Azithromycin, Vanco and Gent. EKG
showed [**Street Address(2) 4793**] elevation in lead III in one QRS complex with TWI
in V1-V2. Patient was bolused with Heparin and started on drip.
Otherwise VSS per report and patient transfered for further care
at request of daughter. [**Name (NI) **] spoke with PCP who then spoke with
daughter and decided no cardiac cath, but wanted medical
management with hope to wean from vent quickly.
Past Medical History:
-lung cancer in right upper lobe, ~4 years ago, treated with
chemotherapy and surgery
-neuropathy around lung cancer surgery scar
-diabetes, diagnosed in '[**29**], followed at [**Hospital **] Clinic
-COPD: [**9-18**] FVC 64% prediceted, FEV1 59% predicted and Ratio:
91%
-osteoarthritis of knees, hips
-polymyalgia rheumatica, 8-9 years
-macular degeneration, recently diagnosed
-s/p right cataract surgery
-hypertension, controlled with medication
- Mult ED admissions for hypoglycemia.
Social History:
lives with daughter, [**Location (un) 442**] subsidized housing, 2 ppd long
term smoker, quit for 6mth on own, now smoking again.
Family History:
non-contributory
Physical Exam:
VS: 95.6 (ax) 91/54 20 94% (AC 400/18 Peep 5 FiO2 100)
Gen: Intubated and sedated, minimally responsive on no sedation.
HEENT: PERRL, no scleral injection or icterus, elevated JVP to
mandible, neck supple
CVS: Distan HS, regular, unable to appreciate any murmurs but
exam imited by BS
Chest: coarse bronchial BS throughout, NO R anterior BS, lat
[**Last Name (un) 8434**] with mild wheeze
ABd: mild distention, NABS, soft, no masses
Ext: cool to touch, no mottling, pulses + by doppler
Neuro: arousable to voice, following commands
Pertinent Results:
CT Chest [**2144-6-23**]: Impression:
1. Interval increase in the mediastinal soft tissue extending up
to the hilum
and causing narrowing of the right and left main bronchi. There
is slight
improvement in the narrowing of the right middle lobe and right
lower lobe
bronchi.
2. Interval development of bilateral pleural effusions, very
minimal on the
right and moderate on the left.
3. New right lower lobe pneumonia, likely to aspiration.
4. Stable left upper lobe spiculated nodular lesion.
5. Stable post-radiation changes in the right lung.
Brief Hospital Course:
A/P: 72 yo woman with NSCLC s/p chemo, s/p R upper lobectomy
with recurrence of mass surrounding trachea s/p tracheal stent.
Patient admitted with respiratory failure [**12-18**] COPD exacerbation/
progressive [**Hospital 4699**] transferred to MICU from OSH hypotensive and
intubated.
.
# Respiratory Failure: Likely secondary to COPD exacerbation and
progressive Lung CA now encasing her trachea. Most recent PFTs
indicate FEV1/FVC = 90 suggestive of concomitant restrictive
disease likely [**12-18**] to chest wall disease/infiltrative CA.
Patient with tracheal stent but now required intubation after
becoming cyanotic with increased work of breathing. Also CXR at
OSH showed R sided infiltrate, ?PNA vs. infiltrative CA vs. post
obstructive. Pt has elevated WBC with left shift suggestive of
infectious process. Sputum positive for coag + staph aureus,
likely MRSA. Patient still on AC but weaned O2 down to 40%.
Sedation was weaned with patient tolerating ET tube without
difficulty. However, careful ET tube care required since patient
very difficulty to intubate given tracheal constriction -
required surgical placement at OSH. Bronchoscopy performed in
the MICU showed obstruction of the L main stem bronchus which is
odd considering the patient's CA is on the right.
Atrovent/Albuterol MID continued via ET tube q 6 hrs.
Solu-Medrol for COPD exacerbation for 72 hrs. Patient was
treated with Levaquin initially, now only Vancomycin since
sputum growing gram positive cocci, coag positive, likely MRSA
given patient's history. Vancomycin dosed at 750 mg IV daily. CT
of the chest was performed to evaluate for interval change
regarding her lung CA and new infiltrate on CXR. This showed
interval increase in the mediastinal soft tissue extending up to
the hilum and causing narrowing of the right and left main
bronchi, slight
improvement in the narrowing of the right middle lobe and right
lower lobe
bronchi. Interval development of bilateral pleural effusions,
very minimal on the
right and moderate on the left. New right lower lobe pneumonia,
likely to aspiration. Stable left upper lobe spiculated nodular
lesion. Stable post-radiation changes in the right lung. Sputum
cultures also came back positive for MRSA and sparse GNR growth.
Patient was continued on Vancomycin with goal trough >15,
measured at 16. On [**2144-7-27**] patient went to the OR on the [**Hospital Ward Name **] for removal of her tracheal stents with placement of a
Y-shaped stent covering both her left and right main stem
bronchi. This was performed successfully and patient was noted
to be easily intubated. Patient returned to the ICU and
continued on mechanical ventilation. She underwent several
spontaneous breathing trials on pressure support of [**3-19**] without
any difficulty. The decision to extubate her was pending
discussing with the patient and her daughter regarding her
re-intubation should she fail extubation. The final decision was
that the patient wished to be DNR/DNI and did not want a
tracheostomy. The patient's status was optimized for extubation.
She was diuresed to 1.8 L and weaned off sedation with a good
cough reflex. She was successfully extubated on [**2144-7-30**]. She
continued to saturate well with shuvel mask and then NC and then
on room air. She was diuresed further post extubation and then
started on her home regimen of 20 mg Lasix daily.
.
# CAD: Patient with 1 mm elevation in III, TWI in V1-V2 new
compared to EKG [**4-7**] and q waves in anteroseptal leads likely
representing an old anteroseptal MI but does not meet criteria
for acute STEMI. Cardiac enzymes negative x 3. Patient arrived
on heparin gtt later discontinued given lack of evidence for
acute MI. Patient hypotensive with BP 70s/40s requiring dopamine
with improvement in SBP to 100-120/50-60. s/p L subclavian line
placement upon arrival. Patient weaned off dopamine after first
day of admission with maintenance of BP with IVF. Goals to
maintain CVP >8, MAP >65. IVF NS bolus were given liberally to
maintain BP. Patient also restarted on Lisinopril once her BP
was stable. Beta blockers were held due to her severe COPD. ASA
and Lipitor were continued.
.
# DM: Patient with history of hypoglycemic episodes in past.
Patient was monitored closely on insulin gtt with excellent
sugar control, requiring increased doses after initiation of
steroids. After extubation, patient was transferred to RISS with
advancing diet with good control.
.
# PPx - Heparin SC, pneumaboots, PPI, FS with Insulin gtt, OG
feeds then PO intake after extubation.
.
# FEN - OG feeds running as per nutrition recs, diet later
advanced slowly after extubation, bolus IVF as needed, monitor
electrolytes with repletion.
.
# Comm - Daughter.
.
# Code: Confirmed DNR/DNI during this admission after lengthy
conversations with both patient and daughter.
-------------
After her ICU course, she was transferred to the floor and plans
were made to transition her to hospice care. On the floor, her
care was geared towards comfort measures. Her code status was
discussed with her daughter. The pain and palliative care who
agreed with morphine for pain control/resp distress. She was
discharged to hospice.
Medications on Admission:
Advair diskus
Ativan 0.5mg [**Hospital1 **]
Fosamax Qweek
Lasix 20mg QD
Humalog SS
Lipitor 10 QD
Lidoderm patch
Lisinopril 20mg QD
Megace 40mg QD
Nortriptyline 20mg Qhs
Spririva 18mcg QD
Lopid 600mg QD
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*2*
2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*35 Tablet Sustained Release(s)* Refills:*2*
3. 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*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
Disp:*60 ampules* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*20 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO
hourly as needed for pain: Please place under tongue. Can give
hourly as needed.
Disp:*150 mL* Refills:*0*
10. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch
Transdermal every seventy-two (72) hours as needed for increased
upper airway secretions.
Disp:*1 box* Refills:*0*
11. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) 0.5-1mL
PO every 4-6 hours as needed for anxiety: Do not exceed 8mg in
24 hours.
Disp:*30 mL* Refills:*0*
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours).
Disp:*60 ampules* Refills:*2*
13. Levsin 0.125 mg/mL Drops Sig: [**11-17**] mL PO every 4-6 hours: To
decrease upper airway secretions
.
Disp:*10 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
non small cell lung cancer s/p tracheal stent
Discharge Condition:
stable
Discharge Instructions:
Please take medications that make you comfortable. There is no
need to take all your other medications. Please call Dr. [**Last Name (STitle) 5263**]
if there is anything to make you more comfortable.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5263**] within 2 weeks of discharge
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2144-9-2**] 10:20
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2144-10-15**] 10:00
Completed by:[**2145-3-21**]
|
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"162.8",
"996.59",
"715.95",
"401.9",
"715.96",
"482.41",
"491.21",
"250.00",
"507.0",
"729.1",
"V09.0",
"519.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72",
"96.05",
"33.22",
"98.15"
] |
icd9pcs
|
[
[
[]
]
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11368, 11419
|
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|
311, 380
|
11509, 11518
|
3621, 4167
|
11768, 12334
|
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3066, 3602
|
252, 273
|
408, 2356
|
2378, 2869
|
2885, 3017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,236
| 151,904
|
28799
|
Discharge summary
|
report
|
Admission Date: [**2136-5-16**] Discharge Date: [**2136-5-22**]
Date of Birth: [**2090-5-12**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Seizure and intubated
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
46 yo man with history of cervical spinal cord injury, s/p C3-6
ACDF and remaining quadriplegia, indwelling suprapubic
catheter/recurrent UTIs, baclofen pump, COPD, OSA who presented
to OSH with after his wife noted seizure like activity with
subsequent unresponsiveness.
.
Per wife and pt. over the past 10 days, they noted several
episodes they thought were seizures. These are described as
head turning to the right, facial grimacing, gutteral sounds,
lasting 1-2 mins at a time with subsequent impaired ability to
respond to her which resolved within 5-10 mins. He has had a
total of four events of similar nature, although on one
occasion, patient states that he actually recalled having these
symptoms. She notes that on that occasion, patient was actually
yawning. The night prior to evaluation, while going to sleep,
wife noted another episode similar to above, however this time,
after 2 mins of these events, patient did not return respond to
her at all. Wife noted that his eyes rolled backwards and this
was followed by tremmors of b/l UEs. Wife also notes that ~ 1mo
ago he was admitted to [**Hospital **] Rehab, where multiple medication
changes were made, which she can not recall.
.
EMS arrived and VS were 132/P, 88, RR 8, irregular, 2mm pupils
and was unresponsive. Was placed on NRB, 1mg Narcan was given
and reported to be last seen at baseline 3hrs prior by wire.
After a few mins, was responsive to noxious stimuli. "No obvious
signs of seizure activity noted."
.
While at OSH ([**Hospital3 26615**]), initial VS were 96.6F 150/p 12 88
100% NRB and HR varied 80-140s. He was noted to have pinpoint
pupils and given a total of 4 mg of Narcan without effect,
followed by intubation for airway protection in setting of
unresponsiveness to vocal or noxious stimuli purposefully, but
only with h/n movements. CT head was negative for ICH, with nl
electrolytes, troponins, WBC of 7K and HCT of 46, INR 3.1, Ca
[**34**].8, Trop < 0.03, . Utox was positive for opiates/methadone
(on methadone/vicod) and benzodiazepines (valium), UA postive
for Nitrites. ECG was SR w/ Twf in III and IVCD.
.
On arrival to the ED at [**Hospital1 18**], VS were "Afebrile," 65 20 106/66
100% on 450/16/40%/5. Per neurology c/s, bedside EEG was
obtained (read pending) who were concerned re: sz from baclofen
toxicity. Anesthesia interrogated the baclofen pump working
appropriately and also obtained history of intermittent
benzodiazepine use, gabapentin use. Patient's ECG was SR, CXR
w/o acute process. Laboratory values were notable for ABG of
7.51/48/84/40, with Chem 7 notable for Cl 97 and HCO3 of 39 and
Na 142 with Cr 0.5. WBC 10K w/ HCT of 46% and MCV of 103, PT
37.3, PTT: 65.7, INR: 3.6. He received a 1g Vancomycin, and 1g
of CFTX. Was maintained on midazolam gtt.
.
On transfer, VS were 65 108/65 24 100% on 450/16/40%/5 and is
intermittently responding to verbal commands (do you have
pain?).
.
On arrival to the MICU, patient's VS were wnl. Patient opened
eyes and followed simple 2 step commands.
.
Per d/w Dr.[**Last Name (STitle) **], no recent changes to baclofen pump, 8wks
ago, increased by 15% w/o effect (~ 1000mcg daily), last month
also had a myelogram that showed normal function for the pump
but tone has increased significantly over the past [**1-23**] year.
.
Review of systems:
(+) Per HPI as well as fatigue and anorexia, chrohic LE edema
and recent malodorous and discolored urine from foley catheter,
nasal congestion. BMs EOD.
.
(-) Denies fever, chills, headache, neck stiffness.. Denies
shortness of breath, cough, dyspnea or wheezing. Denies chest
pain, chest pressure, palpitations. No abdominal pain, diarrhea,
dark or bloody stools. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias.
Past Medical History:
- Anterior Cervical Diskectomy and Fusion C3-6 for cord edema in
setting of fall (8ft from ladder) and subsequent quadriplegia,
C6 level clinically
- indwelling suprapubic catheter
- Cervical syrinx
- s/p IVC filter [**2130**]
- s/p baclofen pump
- COPD
- OSA
Social History:
Lives in [**Location 32944**] MA with his wife and son. Currently
unemployed.
Tobacco: 1ppd
EtOH: denies
Drug use: MJ occasionally
Family History:
Denies hx of Sz, brain cancer, early MI.
Physical Exam:
Admission Physical Exam:
Vitals: 88 120/68 16 100% at AC 450/16/5/40%
General: Alert, oriented x3, no acute distress, DOWb intact
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 10cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly and
laterally
Abdomen: distended, + BS, LLQ SC pump in place, no erythema or
tenderness.
GU: suprapubic foley, no erythema or purulent drainage.
Ext: Cool, contracted, LE edema to mid thigh, 1+ pulses, no
clubbing.
.
Pertinent Results:
Admission Labs [**2136-5-16**] 06:10AM:
WBC-10.1 RBC-4.29* Hgb-14.1 Hct-44.4 MCV-103* MCH-32.8*
MCHC-31.7 RDW-12.3 Plt Ct-175
Neuts-84.5* Lymphs-13.4* Monos-1.5* Eos-0.5 Baso-0.2
PT-37.3* PTT-65.7* INR(PT)-3.6*
Glucose-100 UreaN-15 Creat-0.5 Na-142 K-3.5 Cl-97 HCO3-39*
AnGap-10
Albumin-4.1 Calcium-9.6 Phos-2.8 Mg-1.8
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG
Tricycl-NEG
Type-ART pO2-84* pCO2-48* pH-7.51* calTCO2-40* Base XS-12
.
.
Imaging:
EEG [**2136-5-16**]: This is an abnormal EEG because of the presence of
infrequent epileptic discharges in the occipital regions as well
as
nearly continuous slowing in these regions. These findings are
indicative of potential bioccipital epileptogenic foci with
underlying
subcortical dysfunction. In addition, background showed diffuse
slowing
suggestive of a mild encephalopathy of non-specific etiology. No
electrographic seizures are present.
.
CXR [**2136-5-16**]: Supine portable view of the chest demonstrates ET
tube terminating 2.5 cm above the carina. A nasogastric tube is
positioned in the stomach. Low lung volumes. Retrocardiac
opacity obscures the left hemidiaphragm. Right lung base opacity
is also noted. No large pleural effusion or pneumothorax. Hilar
and mediastinal silhouettes are unremarkable. Heart size is
normal. There is no pulmonary edema. Partially imaged upper
abdomen is notable for air-filled prominent stomach and bowel
loops.
.
EEG [**2136-5-18**]: This is an abnormal portable EEG, because of mild
diffuse
background slowing with intermittent bursts of further slowing
indicative of a mild diffuse encephalopathy of nonspecific
etiology. No
epileptiform discharges or electrographic seizures are present.
Note is
made of a slower than average cardiac rate.
.
MR C spine with and without contrast [**2136-5-19**] (PRELIM REPORT!!!):
1. Diffuse cervical spinal cord atrophy with cystic myelomalacia
at C4-5 at the site of prior contusion. No abnormal enhancement
is seen.
2. Post-surgical changes from anterior cervical fusion and
instrumentation at C3-C5 levels and C3-C6 laminectomies.
3. Multilevel degenerative changes in the cervical spine, most
prominent at C4-C5 and C5-C6 as described above.
Brief Hospital Course:
46 yo man with history of cervical spinal cord injury, s/p C3-6
ACDF and remaining quadriplegia, indwelling suprapubic
catheter/recurrent UTIs, baclofen pump, COPD, OSA who presented
to OSH with after his wife noted seizure like activity with
subsequent unresponsiveness, s/p 1 day intubation. Admission
complicated by hypotension, bradycardia, hypoventillation.
.
# Hypotension, bradycardia, hypopnea: Patient presented
hypotensive to SBP high 70-80 without reflex tachycardia (HRs as
low as 40s). Hypotension was not responsive to extensive volume
challenge (given 7.5 L NS in 24 hours). The etiology appears to
be a combination of increased vagal tone and medication effect.
The HR and BP responded to atropine challenge, indicating
increased vagal tone from some offending process. Started on
scopalomine patch. He was later also started on midodrine for
further pressure support. The etiology of the increased vagal
tone was most likely related to the UTI. The other major
factors contributing was probably excess benzodiazepine and
opioid. He had pinpoint pupils when he first came in. On his
home doses of medications the patient had a low respiratory
rate, and retained CO2 on ABG. The chronic hypopnea may lead to
increased bradycardia. The patient's diazepam and methadone
doses were decreased as below.
.
# Complicated UTI (enterococcus and serratia): Patient presented
with foul smelling urine which is consistent with prior UTIs. He
never had a fever, but he may have been unable to mount fever
due to level of spinal cord lesion. Patient was initially on
broad spectrum antibiotics but was narrowed based upon OSH
culture data. Following 4 days of IV antibiotics, the patient
was narrowed to PO amoxicillin for enterococcus plus cipro for
serratia. Will receive a total of 14 days of abx for complicated
UTI. Last dose of Abx to be given on [**2136-5-31**].
.
# Toxic/metabolic encephalopathy. The patient was admitted
following sustained altered mental status after an episode of
clonic movements, thought by wife to represent seizure activity.
Resolved per wife on admission to the ICU, but patient
continued to be sedated with flat affect. Now much improved
once decreased opiates, likely medication effect, as well as
encephalopathy related to the UTI. Methadone dose was
decreased. Diazepam dose was decreased. EEG was negative for
seizure activity. Unclear if patient actually had seizure
leading up to original presentation but no evidence during this
hospitalization. More likely patient had toxic/metabolic
derangements described above. Of note, the patient's wife was
very concerned that the movements she saw (eyes rolling back in
head, patient becoming confused) had happened a previous time
when the patient received cymbalta. Cymbalta was stopped.
.
# ? Syringx: Patient had been recently diagnosed with cervical
syringx per OSH records. However repeat MRI here did not show
syringx but did show diffuse cervical spinal cord atrophy with
cystic myelomalacia at C4-5 at the site of prior contusion. This
was conveyed to one of the patient's primary neurologists, Dr.
[**First Name (STitle) 27598**].
.
# COPD. On albuterol at home. Chronically retaining CO2.
Decreased diazepam and methadone to increase respiratory drive.
Continue albuterol PRN.
.
# DVT. After discussion with patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 61384**], it does
not appear that any documentation of DVT exists. The patient had
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] IVC filter placed at the time of his spinal cord
injury, and has been on anticoagulation since then. Current
recommendations are that patients with IVF filters be
anticoagulated if there are no contraindications (since IVC
thrombi can develop). Given absence of contraindications, the
patient's coumadin was continued.
.
# OSA: Patient has previous diagnosis of OSA however he has
declined CPAP at home and here due to discomfort. Nasal cannula
at night to maintain O2 sats
# Chronic PAIN: Pain medications decreased, as above, for
respiratory suppression and sedation. Patient remained with
controlled pain on decreased methadone to 10mg qid. Patient
also started on lidocaine patch.
.
Medications on Admission:
- Valium 10 mg TID
- Gabapentin 1200 mg TID
- Vitamin C 1g QAM
- Vitamin D [**2124**] units QAM
- Stool softeners (Miralax)
- Mucinex 1200 mg [**Hospital1 **]
- Coumadin 7.5mg W/F/[**Doctor First Name **], other days as 5mg (last dose 2.5mg)
- Lasix 40 mg three times per week
- Spironolactone 50mg 3/wk
- Vicodin 7.5/750 PRN TID (90 pills per mo)
- Ketoconazole topical
- Nystatin topical [**Hospital1 **]
- Clobetasol topical [**Hospital1 **]
- Cymbalta 60 mg QD (recently stopped and changed to citalopram
40mg daily, which patient did not tolerate- Methadone 20mg Q6H
and 5mg TID prn
- Albuterol neb prn
- Famotidine 20mg
- Methadone 20mg QID
Discharge Medications:
1. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
2. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. warfarin 5 mg Tablet Sig: 1.5 Tablets PO DAYS ([**Doctor First Name **],WE,FR).
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
(MO,TU,TH,SA).
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a week.
8. spironolactone 50 mg Tablet Sig: One (1) Tablet PO three
times a week.
9. Vicodin 5-500 mg Tablet Sig: 1.5 Tablets PO every eight (8)
hours as needed for pain.
10. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze.
14. methadone 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
16. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 10 days.
Disp:*60 Capsule(s)* Refills:*0*
17. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
19. diazepam 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
20. midodrine 2.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
21. baclofen 2,000 mcg/mL Solution Sig: refilled by the pain
service Intrathecal ASDIR (AS DIRECTED).
22. Outpatient Lab Work
Check INR on [**5-23**] and fax to Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital 69564**] MEDICAL ASSOCIATES
Fax: [**Telephone/Fax (1) 69565**]
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Complicated urinary tract infection, bacterial
Metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with evidence of seizure activity and
somnolence. You were found to have a UTI. Your wife was also
concerned that cymbalta may have caused these symptoms. Your
cymbalta was stopped. You are receiving antibiotics for the UTI.
Your baclofen pump was refilled on [**2136-5-22**].
MEDICATION CHANGES:
start midodrine, scopolamine
stop cymbalta
stop mucinex
changed dose of methadone, valium
Followup Instructions:
Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52932**], NP
Specialty: Priamry Care
Location: [**Hospital 69564**] MEDICAL ASSOCIATES
Address: 1 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69566**] JR WAY, STE#[**2126**], [**Location (un) **],[**Numeric Identifier 69567**]
Phone: [**Telephone/Fax (1) 69568**]
When: [**Last Name (LF) 766**], [**5-28**] at 10:30am
Name:Dr [**First Name (STitle) 27598**] and Dr [**Last Name (STitle) **]
Location: [**Location (un) 4480**] [**Hospital **] Hospital
Address: [**Doctor Last Name 51227**], [**Hospital1 3597**] [**Location (un) 3844**]
Phone: [**Telephone/Fax (1) 69569**]
When: Office is working on an appoitment for the next 2-3 weeks
at the above address with both of these physicians. You will be
called at home with an appointment. If you have not heard,
please call above number for status.
[**2136-5-24**], 1:30pm
Baclofen pump refill
|
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20,536
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11488
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Discharge summary
|
report
|
Admission Date: [**2157-2-26**] Discharge Date: [**2157-3-1**]
Service: MEDICINE
Allergies:
Penicillins / Warfarin
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
87F h/o hypertension, hyperlipidemia, atrial fibrillation, and
CAD s/p CABG who was recently discharged from [**Hospital1 18**] with
hypokalemia, pAFIB, and is re-admitted after an episode of
weakness.
.
Per pt, she was feeling well until the night PTA, when she
developed a nonproductive cough, denies fevers, chills, sweats,
chest pain, shortness of breath, n/v, abdominal pain. She awoke
on teh morning of admission and felt "unwell", as a result she
did not take her AM dose of Toprol. She walked to the kitchen
to make coffee. She reached up to get a mug and felt that her
arms were weak, prompting her to [**Last Name (un) 5511**] the living room and active
EMS. She denied lightheadedness, dizziness, nausea, vomiting,
palpitations, chest pain or feelings of presyncope.
.
Upon arrival in the ED, temp 98, HR 93, BP 160/90, RR 18, and
pulse ox 100% on room air. Labs were notable for K 5.8
(confirmed on repeat) and UA with 11-20 WBCs and few bacteria.
She received ciprofloxacin for treatment of UTI, kayexalate for
treatment of hyperkalemia, and aspirin.
.
On admission to the floor, was feeling well. She walked around
the floor and felt palpitations then triggered for HR of 150-200
on the telemetry and the EKG machine. Her HR on the O2 monitor
was 100-130s. She denied chest pain, shortness of breath,
lightheadedness, dizziness, further palpitations, LE edema. She
received 30mg PO diltiazem and 10 mg IV diltiazem. Her SBP went
from 140s to 100s with manual BP cuff. She was given a bolus of
500cc of NS, with improvement in SBP back to 140s, however she
was then transferred to the ICU for rate control.
.
Review of systems:
(+) Per HPI.
(-) Denies pain, fever, chills, night sweats, weight loss,
headache, sinus tenderness, rhinorrhea, congestion, cough,
shortness of breath, chest pain or tightness, palpitations,
nausea, vomiting, constipation, abdominal pain, change in
bladder habits, dysuria, arthralgias, or myalgias.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Coronary Artery Disease s/p CABG in2006
4. Paroxysmal atrial fibrillation
5. Right common iliac stenosis with retrograde dissection
6. Abdominal aortic aneurysm (4.5 x 4.7 cm)
7. h/o hyperthyroidism
8. Cataracts
9. Vitamin B12 deficiency
10. history of Gallstone pancreatitis
11. Hearing Loss
12. s/p appendectomy
13. Uterine prolapse s/p pessary placement (none now)
14. s/p Spinal infarct 10 yrs ago. Patient now has partial
numbness in both leg, vagina and perineum.
Social History:
Home: lives alone; widowed; has a daughter in [**Name (NI) 531**]
([**Female First Name (un) **])
and son [**Doctor First Name 4884**] in [**State 4565**]
EtOH: Denies
Drugs: Denies
Tobacco: 60-80 PPY history, quit > 10 years ago
Family History:
Father - died at age 77 with bleeding PUD
Mother - died in 90s with history of HTN
Sister - died at age 59 with colon cancer
Physical Exam:
Vitals: AF 97.7, /90, HR 90s-160s, 100RA
Gen: lying in bed, NAD, no respiratory distress
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: tachycardic, too fast to assess for mrg. JVP not elevated.
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 4-/5 in L hip flexor, 4+/5 in R hip
flexor. 5/5 strength throughout. 2+ reflexes, equal BL. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
STUDIES:
None
.
EKG:
ED - NSR
on the Floor - AF with rapid ventricular rate to 150s, ST
depressions laterally.
.
Cardiology Report ECG Study Date of [**2157-2-26**] 8:30:54 AM
Sinus rhythm. Prior inferior myocardial infarction. Left
ventricular
hypertrophy. Compared to the previous tracing of [**2157-2-15**] there
is no
significant change.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 140 82 362/425 36 -14 -22
.
.
LABS:
[**2157-2-26**] 09:10AM BLOOD WBC-5.9 RBC-4.54 Hgb-12.1 Hct-35.9*
MCV-79* MCH-26.7* MCHC-33.8 RDW-15.0 Plt Ct-274
[**2157-2-26**] 05:40PM BLOOD WBC-4.9 RBC-4.19* Hgb-11.7* Hct-34.0*
MCV-81* MCH-27.9 MCHC-34.4 RDW-14.6 Plt Ct-245
[**2157-2-27**] 05:25AM BLOOD WBC-5.1 RBC-4.43 Hgb-11.8* Hct-37.5
MCV-85 MCH-26.6* MCHC-31.4 RDW-14.8 Plt Ct-269
[**2157-2-28**] 06:50AM BLOOD WBC-5.0 RBC-4.16* Hgb-11.3* Hct-34.2*
MCV-82 MCH-27.3 MCHC-33.2 RDW-14.7 Plt Ct-246
[**2157-2-26**] 09:10AM BLOOD Neuts-76.9* Lymphs-16.9* Monos-4.7
Eos-0.8 Baso-0.7
[**2157-2-26**] 09:10AM BLOOD PT-12.5 PTT-26.7 INR(PT)-1.1
[**2157-2-28**] 06:50AM BLOOD Plt Ct-246
[**2157-2-26**] 09:10AM BLOOD Glucose-100 UreaN-18 Creat-1.0 Na-135
K-5.8* Cl-100 HCO3-27 AnGap-14
[**2157-2-28**] 06:50AM BLOOD Glucose-93 UreaN-19 Creat-1.0 Na-137
K-3.5 Cl-101 HCO3-28 AnGap-12
[**2157-2-26**] 05:40PM BLOOD Glucose-100 UreaN-17 Creat-1.0 Na-141
K-3.4 Cl-104 HCO3-27 AnGap-13
[**2157-2-26**] 09:10AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0
[**2157-2-26**] 05:40PM BLOOD Calcium-8.3* Phos-2.4* Mg-1.8
[**2157-2-27**] 05:25AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.0
[**2157-2-27**] 05:25AM BLOOD T3-114 Free T4-1.3
[**2157-2-26**] 09:24AM BLOOD freeCa-1.01*
.
MICRO:
[**2157-2-28**] 06:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2157-2-26**] 10:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2157-2-28**] 06:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2157-2-26**] 10:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2157-2-26**] 10:10AM URINE RBC-0 WBC-[**10-8**]* Bacteri-FEW Yeast-NONE
Epi-0 RenalEp-0-2
[**2157-2-28**] 06:28PM URINE RBC-2 WBC-23* Bacteri-FEW Yeast-NONE
Epi-1
[**2157-2-28**] 06:28PM URINE Mucous-RARE
.
.
[**2157-2-26**] 2:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
.
.
Time Taken Not Noted Log-In Date/Time: [**2157-2-26**] 3:32 pm
URINE Site: NOT SPECIFIED
**FINAL REPORT [**2157-2-27**]**
URINE CULTURE (Final [**2157-2-27**]):
MIXED BACTERIAL [**Year/Month/Day **] ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
.
[**2157-2-28**] 6:28 pm URINE Source: CVS.
URINE CULTURE (Pending):
Brief Hospital Course:
87f with history of paroxysmal atrial fibrillation admitted
after an episode of weakness, found upon arrival to the medical
floor to be in AFIB with RVR.
.
# paroxysmal atrial fibrillation - pt with h/o pAFIB, and was
recently discharged on toprol 50mg qdaily, and aspirin 325mg
qdaily. she did not take her AM dose of toprol [**12-21**] feeling
unwell. she was in NSR in ED on ECG, but converted into AFIB
with RVR upon arrival to the medical floor. she received 30mg
oral diltiazem then 10mg IV diltiazem without improvement in
heart rate, with SBP decline from 140 to 100s, prompting ICU
transfer. SBP improved to 140s with 500cc IVF, and she was
given 5mg IV lopressor, and rapidly converted into sinus rythym
shortly after arival to ICU. She was continued on metoprol 25mg
[**Hospital1 **] and returned to the medical floor. she has a h/o
hyperthyroidism (pt denies), TSH was low normal, FT4, T3 WNL.
.
Upon arrival back to the floor, HR 90s-100s, with increase to
140s with ambulation, thus Toprol was increased 75mg QDAILY.
Extensive discussion was conducted between patient and her
daughter regarding benefits of coumadin based upon CHADs=2 (age,
HTN, has h/o "spinal stroke" but no CVA). Pt had been placed on
coumadin at the time of her bypass, with subsequent rectal
bleeding, thus strongly preferred aspirin. She will continue to
discuss this with her PCP and cardiologist at her f/u
appointments within the next week. On the day of discharge, her
HR ranged 60-80s, without significant rise with ambulation, she
was in sinus rythym.
.
# bacterial urinary tract infection - pt was asymptomatic,
denied dysuria or frequency, mental status changes. she
received ciprofloxacin x4d. UCx was contaminated by [**Last Name (LF) **], [**First Name3 (LF) **]
was repeated, and is pending at discharge, however given she is
asymptomatic, she was discharged without additional antibiotics.
she will follow-up with her PCP [**Name Initial (PRE) 176**] 1 week of discharge, and
was instructed to discuss urology referal given her history of
recurrent UTIs.
.
# hyperkalemia - likely secondary to her potassium repletion, pt
strongly preferred to discontinue this medication. her
potassium level ranged ~3.5 during this admission, and given her
GFR, she was discharged off of potassium with instructions to
follow-up with her PCP [**Name Initial (PRE) 176**] 1 week, at which time, if labs
suggested significant hypokalemia, she could resume potassium
repletion.
.
# hypertension, [**Last Name (un) 17066**] - SBPs ranged from 160-200s upon arrival
(completely asymptomatic). per pt and her daughter, she has had
elevated BPs in past. she was continued on HCTZ, and her toprol
was titrated up to 75mg qdaily as above. her SBP improved to
150s upon discharge.
.
# hyperlipidemia - continued aspirin and statin.
.
# weakness / ? failure to thrive - pt with h/o "spinal stroke"
"years ago" resulting in some weakness of left leg, prompting
her to walk with cane. she is otherwise extremely independent,
and well informed of her home medication regimen. neurologic
exam on admission was unremarkable. she ambulated with physical
therapy, who ultimately recommended home physical therapy. she
initially declined home VNA, however, ultimately accepted. her
admission and functioning at home was discussed with her
daughter, [**Name (NI) 36662**], who agreed with home VNA and PT if the pt
would accept these interventions, but admitted that her mother
is fiercely independent.
.
# CAD s/p CABG - pt without chest pain, dyspnea, orthopnea,
lower extremity edema. she was continued on aspirin, statin,
and beta blocker was increased as above to Toprol 75mg po
qdaily. Cardiac enzymes were apparently checked in ICU, and
revealed mild troponin leak of 0.02 in the setting of AFIB 200s,
likely demand.
.
She is awaiting cardiology follow-up for her atrial fibrillation
after her recent admission, at which time she will discuss
outpatient TTE as needed.
.
# vitamin B12 deficiency - continue vitamin B12 for repletion
.
# comm - Patient (attempted to call daughter [**Name (NI) **] -
[**Telephone/Fax (1) 36663**].
Medications on Admission:
1. Acetaminophen 325-650mg PO q6h prn
2. Hydrochlorothiazide 25mg PO daily
3. Aspirin 325 mg PO daily
4. Cyanocobalamin 50mcg PO daily
5. Pyridoxine 50mg PO daily
6. Toprol XL 50 mg PO daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cyanocobalamin 250 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary:
paroxysmal atrial fibrillation
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
you were admitted to the hospital with weakness while reaching
for a coffee mug, you were found to have a rapid irregular heart
beat, in the setting of not having taken your morning dose of
Toprol. You were breifly treated with IV medication for heart
rate in the ICU, and returned to the floor, your Toprol dose was
increased to 75mg daily.
.
we discussed extensively your risk for stroke, and recommended
that you take coumadin to reduce this risk, however you
preferred to stay on a regular aspirin, as you had had some
rectal bleeding with coumadin in the past (at the time of your
bypass surgery).
.
you were also treated for a urinary tract infection for 3 days.
you have a history of frequent urinary tract infections, and
should discuss with your primary care physician [**Name9 (PRE) 36664**] to the
urology clinic.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2157-3-4**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2157-3-8**] 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
|
[
"244.9",
"414.00",
"729.89",
"599.0",
"427.31",
"276.7",
"272.4",
"266.2",
"276.8",
"441.4",
"366.9",
"V45.89",
"V45.81",
"401.9",
"389.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11435, 11493
|
6582, 10710
|
238, 246
|
11601, 11601
|
3786, 6107
|
12634, 13229
|
3023, 3149
|
10951, 11412
|
11514, 11580
|
10736, 10928
|
11784, 12611
|
3164, 3767
|
6141, 6559
|
1926, 2227
|
190, 200
|
274, 1907
|
11616, 11760
|
2249, 2758
|
2774, 3007
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,597
| 126,216
|
54431
|
Discharge summary
|
report
|
Admission Date: [**2169-6-7**] Discharge Date: [**2169-6-13**]
Date of Birth: [**2104-1-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x 5 (LIMA>LAD, SVG>Ramus>OM1, SVG>OM3, SVG>RCA) [**6-7**]
History of Present Illness:
65 yo M with complaints of chest pain and + ETT, referred for
cardiac cath which showed 3VD. He was referred for surgery.
Past Medical History:
htn, hyperlipidemia, chronic angina, nephrolithiasis
Social History:
works at [**Company 111418**]
-tobacco, quit 10 years ago
1 beer/day
Family History:
NC
Physical Exam:
Admission
VS HR 70 RR 18 BP 160/80
Gen NAD
Lungs CTAB
Heart RRR
Abdomen soft/NT/ND
Extrem warm, no edema
Discharge
VS T 98.7 HR 82 SR BP 116/58 RR 18 O2sat 95%-RA
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm CTA-bilat
CV RRR, no murmur. Sternum stable, incicion CDI
Abdm soft, NT/+BS
ext warm, 2+ pedal edema bilat. SVG harvest site w/steris CDI
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-6-8**] 05:20PM 18.1* 4.77# 11.8*# 36.7*# 77* 24.7* 32.1
13.1 143*
[**2169-6-8**] 04:49PM 14.7*# 2.76*# 6.3*# 21.1*# 77* 22.9*
29.9* 12.3 136*#
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2169-6-8**] 05:20PM 143*
[**2169-6-8**] 05:20PM 14.7* 36.5* 1.3*
[**2169-6-8**] 04:49PM 136*#
[**2169-6-8**] 04:49PM 16.5* 42.9* 1.5*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2169-6-8**] 04:49PM 113*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-6-8**] 05:20PM 11 0.7 116* 22
[**2169-6-12**] 06:11AM BLOOD WBC-9.1 RBC-3.35* Hgb-8.3* Hct-26.3*
MCV-79* MCH-24.7* MCHC-31.5 RDW-14.0 Plt Ct-203
[**2169-6-12**] 06:11AM BLOOD Plt Ct-203
[**2169-6-8**] 05:20PM BLOOD PT-14.7* PTT-36.5* INR(PT)-1.3*
[**2169-6-12**] 06:11AM BLOOD Glucose-119* UreaN-19 Creat-1.0 Na-138
K-4.2 Cl-102 HCO3-31 AnGap-9
RADIOLOGY Final Report
CHEST (PA & LAT) [**2169-6-12**] 11:18 AM
CHEST (PA & LAT)
Reason: evaluate for effusion
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for effusion
INDICATION: Status post CABG, evaluate for effusion.
COMPARISON: [**2169-6-10**].
FRONTAL AND LATERAL CHEST RADIOGRAPH: Cardiac and mediastinal
contours appear stable. Median sternotomy wires are again seen.
Persistent retrocardiac opacity seen. Small to moderate pleural
effusion is seen on the lateral view, however, it is not well
lateralized.
IMPRESSION:
1. Small-to-moderate pleural effusion definitely seen on lateral
view, not clearly lateralized.
2. Retrocardiac opacity, possibly representing combination of
atelectasis and effusion, although focal consolidation cannot be
excluded.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
[**Known lastname 111419**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 111420**] (Complete)
Done [**2169-6-8**] at 2:31:54 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-1-2**]
Age (years): 65 M Hgt (in): 62
BP (mm Hg): 140/70 Wgt (lb): 140
HR (bpm): 74 BSA (m2): 1.64 m2
Indication: CABG
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2169-6-8**] at 14:31 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 3.8 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname **], J.
POST-BYPASS:
Preserved biventricular systolic function.
Mild AI.
Intact thoracic aorta.
LVEF 55%
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2169-6-9**] 08:44
Brief Hospital Course:
He was admitted to [**Hospital Ward Name 121**] 6 after his OR time was cancelled
secondary to an emergency case. He was taken to the operating
room on [**6-8**] where he underwent a CABG x 5, please see OR report
for details. In summarry he had CABGx5 with LIMA-LAD,
SVG-Ramus-OM1, SVG-OM3, SVG-RCA. His bypass time was 104 minutes
with a crossclamp of 92 minutes. He tolerated the operation well
and was transferred to the cardiac surgery ICU in stable
condition. He remained hemodynamically stable in the immediate
post-op period and was extubated without incident. He was
transferred to the floor on POD #1. His chest tubes and wires
were discontinued on POD #2 without incident. He continued to
progress in his activities of daily living and was ready for
discharge home on POD 5.
Medications on Admission:
nitro sl prn, asa 325', atenolol 50', lipitor 80'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABGx 5 (LIMA>LAD, SVG>Ramus>OM1, SVG>OM3, SVG>RCA) [**6-7**]
htn, hyperlipidemia, chronic angina, nephrolithiasis
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] [**Telephone/Fax (1) 250**] 2 weeks
Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] [**Telephone/Fax (1) 4022**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2169-6-13**]
|
[
"401.9",
"272.4",
"V45.82",
"413.9",
"414.01",
"V15.82",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"36.15",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
9106, 9164
|
7048, 7836
|
329, 394
|
9331, 9339
|
1108, 2197
|
9652, 10025
|
723, 727
|
7936, 9083
|
2234, 2264
|
9185, 9310
|
7862, 7913
|
9363, 9629
|
742, 1089
|
279, 291
|
2293, 7025
|
422, 545
|
567, 621
|
637, 707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,864
| 197,793
|
40440+58373
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-5-16**] Discharge Date: [**2173-6-8**]
Date of Birth: [**2105-4-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2173-5-16**]: Left craniectomy and evacuation of hematoma
[**2173-5-21**]: Trach placement
[**2173-5-25**]: EGD w/ gastric biopsy
History of Present Illness:
68F who was camping in [**Location (un) 3844**] and went to bed around
1230am and was fine at that time. At approximately 230am she
awoke with a severe sudden onset headache and informed her
husband. She was nauseous and diaphoretic at that time but did
not vomit. She was taken to [**Hospital 8641**] Hospital where she became
altered and was intubated for declining mental status and sirway
protection. She underwent a CT scan of the head which showed a
large left occipital IPH with intraventricular extension. While
at the OSH she was also noted to develop hypothermia and an
enlarging left pupil. She received mannitol, lasix, and decadron
and was transported to [**Hospital1 18**] for further care. She arrives
intubated and not sedated. Her left pupil was reported as 4mm
and NR upon arrival. Unable to obtain review of systems
Past Medical History:
seasonal allergies
Social History:
lives with husband normally in [**Name (NI) 108**] but camps each summer in
[**Location (un) **] in a trailer which is where she currently was. No
tobacco
Family History:
CVA in mother, father, and grandmother
Physical Exam:
Gen: intubated, not sedated
HEENT: Pupils: R 3mm and minimally reacts. L 6mm and NR
EOMs: unable to assess
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: no response to commands, not sedated
Orientation, language, Recall: unable to assess secodnary to
clinic status
Cranial Nerves:
I: Not tested
II: R 3mm minimally reacts L 6mm NR
III-XII: unable to assess
Motor: localizes with RUE, no mvmt LUE, w/d bilateral lower
extremities
Sensation: unable to assess
Toes mute bilaterally
Coordination: unable to assess
PHYSICAL EXAM UPON DISCHARGE:
EO to noxious stimuli
PERRL
+ flinch to threat
MAE's spontaneously (L UE > R UE)
R UE does not withdraw to stimuli but moves spont.
Incision- well healing except small area, mid incision that was
moist and minimally opening on [**6-7**] but this dry and closed on
[**6-8**].
Pertinent Results:
[**5-16**] CTA Head: FINDINGS: I concur with Dr.[**Name (NI) 88617**]
analysis, but also there is substantial expansion of the
hemorrhage, consisting of multiple new foci within the more
anterior aspect of the left temporal lobe, completely effacing
the left temporal [**Doctor Last Name 534**], likely accounting for her observation of
increasing mass effect.
CT angiography of the head reveals no area of hemodynamically
significant
stenosis or within the limitations of this technique, an
aneurysm or other
vascular malformation. There does not appear to be any
observable
pathological vascularity in the area of the hemorrhage. However,
it is to be acknowledged that the mass effect associated with
the hemorrhage could obscure pathological vessels, by reason of
compression of these structures.
[**5-16**] CT Head: Findings: There has been interval performance of a
left frontal-temporal crainectomy, resulting in reduction in the
extent of right sided subfalcine herniation.
There also appears to have been partial removal of the
hemorrhage, with
contiguous gas bubbles likely reflecting surgery in the left
parietal
component of the hemorrhage. No change in ventricular size is
seen, nor the extent of the intraventricular hemorrhage.
[**5-16**] CT Head: IMPRESSION:
1. Slight decrease of the midline shift to the right.
2. Slight increase of the extracranial fluid collection
overlying the
craniectomy site containing air and hemorrhage.
3. No acute territorial infarction, significant transtentorial
herniation or new foci of intracranial hemorrhage.
[**5-18**] Chest CTA:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Smooth interlobular septal thickening with ground-glass
opacities of
aerated lungs, compatible with pulmonary edema. Neurogenic
pulmonary edema is considered, given the patient's clinical
history of recent intracranial
hemorrhage.
3. Large dependent right upper lobe and bilateral lower lobe
consolidations could reflect dependent edema, but coexisting
aspiration pneumonia should be considered.
4. Small bilateral pleural effusions.
[**5-19**] Head CT:
IMPRESSION:
1. No change in appearance of large left parietal and occipital
intraparenchymal hematomas, blood layering along the tentorial
leaflets, with an intraventricular extension. There is no
evidence of new hemorrhage or new large vascular territorial
infarction.
2. Minimal transgaleal herniation in the posterior aspect of the
craniectomy site.
3. Slight increase in rightward shift of midline structures.
[**5-21**] Gastric biopsy pathology:
Acute, ulcerative gastritis with numerous broad, ribbon-like,
non-septate hyphal forms morphologically compatible with
zygomycosis. PAS-D and GMS stains demonstrate the ribbon-like
fungal hyphal forms previously seen on H&E-stained sections.
[**5-22**] MRI Cspine:
Multilevel degenerative disease.
At C4-5, minimal retrolisthesis and a posterior endplate
osteophyte ridge
result in flattening of the ventral spinal cord and moderate
spinal canal
narrowing. Uncovertebral and facet arthropathy results in
approximately
moderate bilateral neural foraminal narrowing.
At C5-6, there is a posterior endplate osteophyte ridge, greater
on the left, with flattening of the left ventral spinal cord and
moderate narrowing of the left aspect of the spinal canal. There
are uncovertebral osteophytes resulting in approximately
moderate neural foraminal narrowing, worse on the left.
[**5-23**] EEG:
IMPRESSION: This is an abnormal video EEG due to the presence of
a slow
background with bursts of generalized slowing which represents a
moderate encephalopathy and a left frontal breach rhythm due to
skull
defect. There were frequent left frontal central epileptiform
discharges, often appeared as prolonged PLEDs at 1 Hz for the
majority
of the recording, indicative of highly epileptogenic cortex.
However,
there was evolution of these discharges to suggest discrete
electrographic seizures.
[**5-24**] CT Abd/Pelvis:
IMPRESSION:
1. No other sites of infection identified within the abdomen and
pelvis.
Possible gastric wall thickening in the fundus vs. retained food
should be
correlated with recent EGD.
2. Improved bibasilar atelectasis with increased moderate-sized
bilateral
pleural effusions and persistent mild pulmonary edema.
[**5-24**] MRI Brain:
IMPRESSION:
1. Acute/sub-acute infarct involving the splenium of corpus
callosum
secondary to posterior pericallosal vascular compromise from
herniation.
Punctate focus of possible slow diffusion in the right parietal
white matter suggesting a tiny infarct.
1. Slight interval increase in the size of fluid overlying the
craniectomy
site. No interval change in the shift of midline structures.
2. Large left parietal and occipital hematomas are
redemonstrated with blood overlying the tentorium and blood in
the lateral ventricles.
3. Interval increase in mucosal thickening and fluid in the left
mastoid air cells and new mild inflammatory changes in the right
mastoid air cells, sphenoid sinuses, and maxillary sinuses.
[**5-24**] CT abd/pelvis:
IMPRESSION:
1. No other sites of infection identified within the abdomen and
pelvis.
Possible gastric wall thickening in the fundus vs. retained food
should be
correlated with recent EGD.
2. Improved bibasilar atelectasis with increased moderate-sized
bilateral
pleural effusions and persistent mild pulmonary edema.
[**5-24**] EEG:
IMPRESSION: This is an abnormal video EEG due to the presence of
a slow
background which represents a moderate encephalopathy and
generalized
delta frequency slowing which represents deep midline
dysfunction. The
left hemisphere showed persistently increased amplitude and
sharper
contours indicative of a breach rhythm such as can be seen in
skull
defect. Additionally, there was focal left frontal or diffuse
left
hemisphere delta frequency slowing which represents focal
subcortical
dysfunction. There were frequent left frontal central sharp
discharges
and there were long periods of left hemisphere periodic
lateralized
epileptiform discharges (PLEDs) occurring at 1 Hz frequency
which
represents highly epileptogenic cortex, without any clear
clinical
change. No clear electrographic seizures were seen.
[**5-25**] Gastric bx pathology:
Gastric body type mucosa with focal active inflammation and
fibrin deposition. Numerous aggregates of fungal organisms with
the same morphology as described in previous biopsies
(S11-24004G) are present. PAS and GMS stains examined.
[**5-25**] EEG:
IMPRESSION: This is an abnormal video EEG due to the presence of
a slow
background which represents a moderate to severe encephalopathy,
along
with a left frontal breach rhythm due to skull defect. It is
also
abnormal due to the presence of left frontal and left hemisphere
epileptiform discharges, which occurred as left hemisphere
periodic
lateralized epileptiform discharges, or PLEDs, at 1 Hz frequency
for the
majority of the recording. These finding indicates highly
epileptogenic
cortex, but no clear evolution of the discharges were seen to
suggest
electrographic seizures. This pattern alternated with left
hemisphere
rhythmic delta and theta frequency activity with embedded left
frontal
spikes. Of note, there was significant electrical artifact in
the left
hemisphere which obscured some portions of the study.
[**5-26**] EEG:
IMPRESSION: This is an abnormal video EEG due to the presence of
frequent left frontocentral or left hemisphere epileptiform
discharges,
which occurred as prolonged runs of PLEDs at 1Hz, indicatve of
epileptogenic cortex. However, no clear electrographic seizures
were
seen. Focal mixed delta and theta frequency slowing was also
seen in the
left hemisphere indicative of subcortical dysfunction. There
were six
pushbutton activations without any clear clinical change
concerning for
seizure activity and without any change on EEG. The background
was slow
and disorganized, consistent with a moderate encephalopathy.
[**5-27**] EEG:
IMPRESSION: This is an abnormal video EEG due to the presence of
frequent and nearly continuous left hemisphere periodic
lateralized
epileptiform discharges, or PLEDs, occurring at 1 Hz frequency
which
represents highly epileptogenic cortex. Alternating with this
pattern
were brief periods of delta and theta mixed frequency slowing
with some
continued left hemisphere sharp wave discharges notably between
12:15
and 12:30 as well as 17:30 and 19:30. The focal slowing reflect
subcortical dysfunction. There was left posterior quadrant
increased
amplitude and faster activity which represents a breach rhythm
such as
due to skull defect. There were no electrographic seizures seen
in this
recording.
[**5-30**] CT Head:
IMPRESSION: Interval evolution of intracranial hemorrhage with
stable
rightward mass effect, and fluid collection in the
hemicraniectomy bed.
[**5-30**] LENIS:
IMPRESSION: No evidence of DVT in the left lower extremity.
[**5-30**] CXR:
A tracheostomy tube is present. Compared with [**2173-5-29**], 5:19 a.m.
and allowing for differences in technique, I doubt significant
interval change. Again seen is a tracheostomy tube,
cardiomegaly, and diffuse opacities in both lungs, with
increased retrocardiac density and obscuration of the left
hemidiaphragm. The appearance would be compatible with pulmonary
edema, with or without associated pneumonia.
Brief Hospital Course:
Pt was taken emergently from the emergency room to the OR for
emergent neurosurgical intervention. She underwent a craniotomy
and evacuation of the hematoma. She tolerated the procedure
well, remained intubated and was transferred to the ICU.
On POD#1 her mannitol was weaned and she was extubated. She
initially remained stable but in the early morning on [**5-18**] she
developed desaturations and respiratory distress which required
reintubation. CXR revealed bilateral consolidations therefore a
bronchoscopy was performed by the SICU team. She was also noted
to be hypernatremic so she was started on free water boluses. On
[**5-19**], neurology consult was obtained who thought there may be
decreased movement on one side, so a repeat head CT was
obtained, which was stable. On [**5-20**], the patient's family met
with the SICU team and NSURG team and agreed to proceed with
tracheostomy and PEG. Additionally, she remained intermittently
febrile and so was started on vancomycin, cefepime, and
tobramycin for VAP. On [**5-21**], a tracheostomy was performed but
the PEG was aborted due to a large gastric ulcer in the body of
the stomach, at the proposed site for the PEG. An H.pylori was
sent which was negative. A gastric biopsy was positive for
invasive zygomycosis. ID was consulted.
On [**5-19**], she had an MRI of the Cspine done for a question
of upper extremity weakness, no major spinal etiology was noted.
She was febrile on [**5-23**] and was pancultured. She was bolused
with Dilantin for a low therapeutic level. On [**5-24**] she was once
again bolused with Dilantin. An ab/pelvic CT was obtained per ID
recommendations. EEG from [**Date range (1) 70311**] showed some seizure
activity. She was also started on Ambisome for presumed
zygomycosis infection.
On [**5-25**], patient recieved another dilantin bolus and keppra was
added to her medications. Neurology is concerned that patient
continues to seize. On [**5-26**], her dilantin goal was increased to
20-25. Her corrected level was currently 15.2, so a 500mg bolus
of dilantin was administered. On examination, patient remained
unchanged. ID recommends vancomycin, ambisome, and cefepime for
her treatment of zygomycosis. On [**5-27**], patient was seen to be 5
liters positive, question if extra fluid in IV antibiotics.
Pharmacy was consulted to help reduce amount of fluid mixed with
antibiotics. Dilantin was changed to IV for better absorption
and an additional 100mg IV was given. Her current level
corrected was found to be 18.0.
On [**5-28**], a CT chest shows worsening plueral effusion, BAL done,
spiked temp. 300mg bolus dilantin and standing dose increased to
150mg TID.
On [**5-29**], dilantin level was 16.5 corrected, reloaded with 350 mg
dilantin, febrile - fever w/u ordered. She was started n a 2
week course of Linezolid for a blood culture with
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ON [**5-30**], febrile, UA neg, lasix given for pulm edema seen on
CXR, informal bedside echo showed good function
On [**5-31**] her dilantin goal was changed to 10-20 and she remained
stable
On [**6-1**] she again was stable in the ICU
On [**6-2**] her Dilantin level was 6.0 and per the epilepsy team her
Dilantin elvels were no longer being chased.
On [**6-3**] she remained stable an has been afebrile since the
evening of [**5-31**]
On [**6-1**] she was awaiting a rehab bed and remained
neurologically stable.
On [**6-8**] a bed was offered and she was cleared for rehab.
Medications on Admission:
zyrtec, colace, MVI, other vitamins
Discharge Medications:
1. senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2
times a day).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 650 mg/20.3 mL Solution [**Month/Year (2) **]: [**12-13**] PO Q6H (every
6 hours) as needed for pain.
5. glucagon (human recombinant) 1 mg Recon Soln [**Month/Day (2) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day (2) **]: Fifteen (15) ML
Mucous membrane TID (3 times a day).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
8. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
9. nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
10. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) ml
Injection TID (3 times a day).
11. levetiracetam 100 mg/mL Solution [**Month/Day (2) **]: Twenty (20) mL PO BID
(2 times a day).
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
14. linezolid 600 mg/300 mL Parenteral Solution [**Last Name (STitle) **]: Three
Hundred (300) mL Intravenous Q12H (every 12 hours): Continue for
2 weeks Day 1=[**5-29**].
15. amphotericin b liposome 50 mg Suspension for Reconstitution
[**Month/Year (2) **]: Three [**Age over 90 1230**]y (350) mg Intravenous Q24H (every 24
hours): Continue for 1 month (day 1= [**5-24**])will decide in ID f/u
whether to change to PO.
16. fosphenytoin 50 mg PE/mL Solution [**Month/Year (2) **]: Four (4) mL Injection
Q8H (every 8 hours).
17. insulin regular human 100 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Intracranial Hemorrhage s/p craniotomy
Cerebral edema
Gastric Ulcer
Dysphagia
Respiratory failure
Pneumonia
Zygomycosis
Pulmonary edema
Fever
Seizure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
General 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.
?????? Your wound closure uses dissolvable sutures.
?????? You may shower.
?????? 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.
?????? 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**]. You
have also 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.
Followup Instructions:
Neurosurgery:
??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI of the brain with gadolinium contrast.
GI:
?????? You need a repeat EGD in [**2-12**] weeks. They will see you
in clinic prior to this to reevaluate you. They will call you
with the date and time of this appointment with Dr. [**Last Name (STitle) **]. If
you do not hear about this appointment, please call ([**Telephone/Fax (1) 667**]. Until this time you will continue to be fed via NG/NJ
tube.
Infectious Disease:
?????? You are to continue with Linezolid for a total of 2
weeks (Day 1= [**5-29**]). You are to continue with Ambisome for 1
month. After your repeat EGD they will decide whether this can
be changed to PO. You will follow up in the [**Hospital **] clinic after your
repeat EGD. They will call you with the date and time of this
appointment with Dr [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **]. If you do not hear from them
please call ([**Telephone/Fax (1) 4170**] to check on the scheduling process.
Completed by:[**2173-6-8**] Name: [**Known lastname 14073**],[**Known firstname **] Unit No: [**Numeric Identifier 14074**]
Admission Date: [**2173-5-16**] Discharge Date: [**2173-6-8**]
Date of Birth: [**2105-4-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 599**]
Addendum:
VAP was ruled out as a diagnosis during the patient's
hospitalization.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2173-6-22**]
|
[
"432.1",
"348.5",
"518.81",
"117.7",
"787.20",
"486",
"276.0",
"431",
"277.39",
"E879.8",
"401.9",
"531.30",
"V64.1",
"E849.7",
"437.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"45.16",
"38.93",
"00.14",
"96.6",
"33.23",
"96.71",
"96.04",
"89.19",
"01.25",
"96.72",
"02.12",
"31.1",
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
20905, 21108
|
11845, 15309
|
280, 415
|
17863, 17863
|
2491, 3303
|
19295, 20882
|
1512, 1553
|
15396, 17580
|
17690, 17842
|
15335, 15373
|
17999, 19272
|
1568, 1788
|
232, 242
|
2195, 2472
|
443, 1280
|
1932, 2165
|
11169, 11822
|
4584, 11160
|
17878, 17975
|
1302, 1323
|
1339, 1496
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,298
| 176,520
|
26517+57502
|
Discharge summary
|
report+addendum
|
Admission Date: [**2135-2-16**] Discharge Date: [**2135-3-10**]
Date of Birth: [**2086-8-2**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Erythromycin Base
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Transfer to Medicine for antibiotic management after abscess
decompression and T1-8 laminectomy.
Major Surgical or Invasive Procedure:
Emergent thoracic laminectomies T1-T8 on [**2135-2-16**].
Aspiration of seroma on [**3-1**] and [**3-7**].
History of Present Illness:
This is a 48 year-old female with a history of DM type 2 who
presnted with progressively worsening thoracic pain following a
steroid epidural injection on [**2-7**]. She was seen at an OSH on
[**2-14**], where an MRI was reportedly done and without
abnormalities. An LP performed that day showed 21 WBC and 1.7 gm
of protein. She apparently left AMA despite the LP results. She
returned to the OSH on [**2-15**] with progressive bilateral LE
weakness. Labs at that time were remarkable for WBC of 12.5, and
blood cultures returned positive for MRSA. She was transferred
to [**Hospital1 18**] for further care, where Vancomycin and Ceftriaxone
(meningitis doses) were started. A T-spine MRI was limited [**2-10**]
to the patient's body habitus, but ultimately read as T2-8
epidural abscess. A repeat LP showed WBC 128, TP 350. She
underwent emergent decompression on [**2135-2-16**] with T1-T8
laminectomies and incision and drainage.
Past Medical History:
1. DM type 2
2. Hyperlipidemia
3. Chronic back pain
4. Colitis with frequent diarrhea
5. Hypertension
6. Nephrolithiasis
7. Diverticulosis with prior diverticulitis
Social History:
She lives with her sister, + tobacco history 30-40 pack-year. No
EtOH, no illicit drug use.
Family History:
Non-contributory.
Physical Exam:
Physical examination on admission:
BP 95/60 HR 82 T 98.6 SpO2 96% RA
Gen: obese woman , falling asleep while I speak
HEENT: no scleral icterus
Neck: no jvp
Chest: cta bl
CV: rrr no m/g /r
Abdomen: nt, nd
Ext : no edema
Pertinent Results:
Relevant laboratory on admission:
WBC-15.6* RBC-3.73* HGB-11.4* HCT-33.6* MCV-90 MCH-30.5
MCHC-33.9 RDW-14.5
NEUTS-86.4* LYMPHS-9.6* MONOS-3.8 EOS-0.1 BASOS-0.1
PLT COUNT-259
PT-11.8 PTT-23.1 INR(PT)-1.0
GLUCOSE-195* UREA N-15 CREAT-0.6 SODIUM-134 POTASSIUM-5.0
CHLORIDE-99 TOTAL CO2-22 ANION GAP-18
LACTATE-0.8
LP:
WBC-77 RBC-6580* POLYS-85 LYMPHS-8 MONOS-7
WBC-128 RBC-314* POLYS-92 LYMPHS-4 MONOS-4
ALBUMIN-186.3
PROTEIN-350* GLUCOSE-115 LD(LDH)-54
AMYLASE-3
Lyme negative
GS negative, 3+PMNs, culture negative
Micro:
[**2135-3-7**] FLUID ASPIRATE negative
[**2135-3-1**] FLUID ASPIRATE negative
[**2135-2-18**] Blood cultures X2 negative
[**2135-2-17**] Blood cultures X2 negative
[**2135-2-16**] TISSUE MRSA
[**2135-2-16**] Wound culture MRSA
[**2135-2-16**] Blood cultures 1/4 bottles with MRSA
[**2135-2-16**] CSF negative
[**2135-2-15**] SEROLOGY/BLOOD LYME negative
Imaging:
[**2135-2-16**] MRI T-spine: Dorsal epidural collection extending
throughout a large portion of the upper thoracic spine (roughly
T1 to T8). There is impingement on the spinal cord. The
collection may represent blood products in an epidural hematoma,
given its signal characteristics and absence of enhancement.
Post-op MRI: 1) Extensive interval upper thoracic laminectomy
whose full extent is not included in the image field-of-view,
with extensive post-surgical changes, but no evidence of
residual epidural fluid collection, abscess or hematoma in the
cervical, upper thoracic (to the T3 level), or lumbar spine. 2)
No evidence of vertebral osteomyelitis, discitis or anterior
paraspinal fluid collection, with abundant, presumably
post-surgical, fluid collections with air in the deep dorsal
soft tissues and surgical bed. 3) Cervical and lumbar disc
desiccation, without focal herniation or canal compromise. 4)
Layering right more than left pleural effusions (or thickening).
[**2135-2-17**] ECHO: 1. Left ventricular wall thickness, cavity size,
and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. 2. No obvious vegetations
seen.
Brief Hospital Course:
48 year-old woman with DM type 2 admitted with an extensive
thoracic epidural abscess. Her hospital course will be reviewed
by problems.
1) Epidural abscess/MRSA bacteremia: As noted above, an MRI on
admission was remarkable for an extensive thoracic epidural
abscess extending from T2-T8. Blood cultures also returned
positive for MRSA with 1/4 bottles on admission (with 2 days of
positive cultures at an OSH prior to transfer). She went to the
OR on [**2135-2-16**] for emergent I&D, decompression and T1-T8
laminectomies. Tissue cultures grew MRSA. A post-op MRI showed
no residual abscess, no discitis or osteomyelitis. She was
continued on Vancomycin IV, with dosing adjusted to keep level
15-20. The ID service was consulted, and followed the patient in
house.
Given her MRSA bacteremia, she underwent further studies to rule
out other seeding sites. A TTE was negative for vegetations on
[**2-17**]. Given that she will receive 6 weeks of abx regardless, a
TEE was not performed. Surveillance blood cultures have been
negative, and her inflammatory markers have trended down in the
hospital. A PICC line was placed on [**2-21**]. She developed redness
along the wound site post-operatively, with some serosanguinous
drainage. Aspiration was performed on [**2-25**], and repeated again
on [**3-1**] and on [**3-7**]. GS and culture of the aspirated fluid
returned negative. Staples were removed on [**2135-3-6**].
She was followed by neurology and PT during her hospital stay,
with a significant improvement in her mobility. She continues to
report bilateral lower extremity weakness, but much improved
versus admission. She will need ongoing PT at discharge. She
will follow-up with Dr. [**Last Name (STitle) 2716**] in ID and Dr. [**Last Name (STitle) **] in
Neurology. She will continue Vancomycin 1 gm IV BID, with last
doses on [**2135-3-31**] (total 6 weeks)
2) Anemia: Nadir Hct 21.8 in hospital. Studies consistent with
anemia of chronic disease, with normal iron/TIBC, normal
ferritin, negative hemolysis labs, stools guaiac negative. Her
reticulocyte % was slowly rising in the week prior to discharge,
suggestive of some marrow recovery. She did not require a blood
transfusion.
Of note, despite iron studies consistent with anemia of chronic
disease, we elected to initiate iron supplementation therapy
with FeSO4 325 mg PO BID.
3) DM type 2: She was continued on Metformin and Glipizide in
house. She was also covered with a RISS, with fair glycemic
control.
4) Pain: Pain control was an issue during this hospital stay.
Oxycontin and Oxycodone were both titrated up, and she required
small doses Dilaudid around the clock until the day prior to
discharge. The pain service was consulted, with recommendation
to discharge on Oxycontin 60 mg PO QAM, 40 mg PO BID (1600 and
midnight), and to increase Topamax to 100 mg PO QHS. She will
follow-up with the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center as an out-patient. A
15-day supply of medications was provided.
5) Urinary retention: Following the surgery, she had a foley
catheter left in place for a prolonged period of time. She
failed a voiding trial, and the foley was replaced. Neurology
followed her throughout the admission, with an impression of
narcotic-induced urinary retention, possibly on a background of
some bladder atony. Per neuro, a spinal bladder is most commonly
spastic. It is of note, however, that she reportedly began
having symptoms of urinary retention prior to the initiation of
narcotic therapy (3 days PTA), still raising cord damage
(secondary to the abscess) as a possibility. She failed multiple
voiding trials, and straight cath was performed for a period of
time. Urology was curbsided, and recommended out-patient
follow-up with urology. We would have preferred to continue
straight cath prn, but unfortunately she was unable to do self
straight cath, and a foley with leg bag was replaced on [**3-7**] in
anticipation for discharge. She will follow-up with urology (Dr.
[**Last Name (STitle) 770**] as an out-patient.
6) Pulmonary: Suspect OSA given body habitus. Would recommend
out-patient sleep study.
She was discharged home with home IV antibiotics and home PT.
Medications on Admission:
Glucophage
Lisinopril
Crestor
Trazodone
Glucotrol
Dilaudid
Discharge Medications:
1. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO every eight
(8) hours as needed for constipation: Titrate to 1 bowel
movement per day.
Disp:*qs qs* Refills:*1*
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous every twelve (12) hours: Please chekc weekly CBC,
BUN, creatinine, and trough vancomycin level and fax results to
[**Hospital **] clinic at [**Telephone/Fax (1) 1419**]. .
7. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*15 Tablet(s)* Refills:*1*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed: Per protocol.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. OxyContin 20 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO QAM: Please take 60 mg in the
morning. Tablet Sustained Release 12HR(s)
12. OxyContin 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO twice a day: Please take 40 mg
at 1600 and midnight. .
Disp:*105 Tablet Sustained Release 12HR(s)* Refills:*0*
13. Oxycodone 15 mg Tablet Sig: One (1) Tablet PO every [**4-14**]
hours as needed for pain: For breakthrough.
Disp:*90 Tablet(s)* Refills:*0*
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Topiramate 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
16. Glipizide 10 mg Tablet Sig: 1.5 Tablets PO twice a day.
17. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Thoracic epidural abscess
Status post emergent T1-T8 laminectomies on [**2135-2-16**]
Diabetes mellitus type 2
Anemia of chronic disease
Urinary retention
Hypertension
Discharge Condition:
Patient discharged home in stable condition, independent with
ADLs.
Discharge Instructions:
Please note that we have started an antibiotic called Vancomycin
to treat your infection. You need to take 1 gm intravenously
every 12 hours, last doses on [**2135-3-31**].
You will need to have weekly lab tests (CBC, BUN, Creatinine,
and Vancomycin trough level). These results should be faxed to
the Infectious Disease Clinic at [**Telephone/Fax (1) 1419**].
You need to follow-up with Dr. [**Last Name (STitle) 363**] in 1 week. Please call his
office to schedule an appointment. See below for his clinic
number.
You will need to follow-up with Dr. [**Last Name (STitle) 65500**] in Neurology and
Dr. [**Last Name (STitle) 2716**] in Infectious Disease. Please see below for your
scheduled appointments.
You have a scheduled appointment in the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center on .
Please see below for details.
The [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center will call you to arrange for a follow-up
appointment.
Finally, you will need to follow-up with Urology (Dr. [**Last Name (STitle) 770**].
Please call his clinic at [**Telephone/Fax (1) 2906**] to schedule an
appointment.
Please return to the ED or call your PCP if you experience
recurrent fever, chills, or if you notice pus coming out of your
neck wound.
Followup Instructions:
1. Please call Dr.[**Name (NI) 12040**] office at [**Telephone/Fax (1) 3573**] and schedule
an appointment to see him in 1 week.
2. You have a scheduled appointment with Dr. [**Last Name (STitle) 65501**] in
Neurology on [**3-22**] at 1300. Please see below.
- Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 540**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2135-3-22**] 1:00
3. You also have a scheduled appointment with Dr. [**Last Name (STitle) 2716**] on
[**3-28**] at 0900. Please see below. It is important that you go
to this appointment.
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2135-3-28**] 9:00
4. You need to follow-up with Dr. [**Last Name (STitle) 770**] in Urology regarging
your difficulty to urinate. Please call the urology clinic on
thursday, and schedule an appointment to see him in the next
week. The clinic phone number is [**Telephone/Fax (1) 2906**].
Completed by:[**2135-3-9**] Name: [**Known lastname 11512**],[**Known firstname 11513**] A Unit No: [**Numeric Identifier 11514**]
Admission Date: [**2135-2-16**] Discharge Date: [**2135-3-10**]
Date of Birth: [**2086-8-2**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Erythromycin Base
Attending:[**First Name3 (LF) 211**]
Addendum:
Please note that Ms. [**Known lastname **] was discharged home with home IV
antibiotics and home PT.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 413**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2135-3-10**]
|
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"327.23",
"324.1",
"272.0",
"289.9",
"E935.8",
"250.00",
"041.11",
"564.00",
"788.20",
"344.9",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"57.95",
"03.09",
"03.31",
"86.01",
"57.94"
] |
icd9pcs
|
[
[
[]
]
] |
13861, 14070
|
4137, 8358
|
383, 492
|
10930, 11000
|
2044, 2064
|
12361, 13838
|
1769, 1788
|
8467, 10598
|
10739, 10909
|
8384, 8444
|
11024, 12338
|
1803, 1824
|
246, 345
|
520, 1455
|
2078, 4114
|
1477, 1644
|
1660, 1753
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,072
| 167,779
|
45748
|
Discharge summary
|
report
|
Admission Date: [**2186-7-29**] Discharge Date: [**2186-8-2**]
Date of Birth: [**2106-11-12**] Sex: F
Service: MEDICINE
Allergies:
Dopamine / Mirapex / Demerol
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Tachycardia, hypotension, altered mental status
Major Surgical or Invasive Procedure:
[**7-30**]: Left open reduction and intramedullary nailing of
a left intertrochanteric hip fracture
History of Present Illness:
Ms. [**Known lastname 1557**] is 79yo female with Parkinson's, AF not
anticoagulated [**2-6**] h/o recurrent falls and osteoporosis
initially admitted after unwitnessed fall, found to have L
intertrochanteric femur fx POD#1 s/p open reduction and IM rod
placement yesterday who is transferred to MICU in setting of AF
with RVR associated with hypotension in setting of witnessed
aspiration event and untreated UTI. This am, pt was found to be
in AF with RVR with SBPs 60s when seen by PT. She was given 2L
IVF with improvement in BP to 90s, also received Diltiazem 10mg
IV x 2 and metoprolol 5mg IV x 3 once BP was improved and HR
improved to 90s. Of note, she also had positive urine cx which
had not yet been treated and had witnessed aspiration event in
setting of altered mental status this am.
.
Regarding presenting fall, husband heard pt fall in bathroom and
found wife on ground, crying in pain. There was no reported
history of seiure activity, bladder or bowel incontinence and he
felt this was typical for her given her recurrent falls.
.
In ED, vitals 98.4 185/103 74 16 99% RA. She had one set of
negative cardiac enzymes. EKG with Q waves in V5 V6 and LAD. CT
head negative for hemorrhage. CT neck without fracture but with
canal stenosis C4-C7, seen previously. Hip plain films with
displaced left hip intertrochanteric fracture.
.
On arrival, HR 80s-90s, SBP 90s/60s, improved to 110s with IVF.
Past Medical History:
1. Parkinson's disease.
2. Mitral valve replacement.
3. Atrial fibrillation - not on coumadin [**2-6**] balance issues
4. Dysarthria.
5. History of colitis [**2181**] - ?ischemic
6. Hypertension.
7. Hypothyroidism.
8. s/p appendectomy.
9. s/p TAH BSO
10. s/p thyroidectomy.
11. s/p left lumpectomy in [**2174**] (Dr. [**Last Name (STitle) 3100**] & XRT
12. s/p Right mastectomy in [**2140**]
13. GERD
14. osteoporosis
15. chronic constipation
Social History:
Lives with husband at home, with aids to help around the house.
She never used tobacco or alcohol. She lives with husband in
[**Name (NI) 745**] and is retired. Needs assistance with all ADLs including
dressing, cleaning.
Family History:
Mother with hypertension died at age [**Age over 90 **]. Father died at age
77. Brother with [**Name2 (NI) **] in 60s. No diabetes mellitus.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, not oriented to place, oriented to self and
husband, no acute distress, interacts appropriately with husband
and son
[**Name (NI) 4459**]: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP 7-8cm, no LAD
Lungs: Bibasilar rales, no wheezes, rhonchi
CV: Regular rate and rhythm, 3/6 systolic murmur LLSB radiating
to apex with no respirophasic variation, normal S1, prominent
S2, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema, Left thigh with dsg C/D/I, edema, mild tension,
ecchymoses
Pertinent Results:
Labs on Admission: [**2186-7-29**]
WBC-7.0 RBC-4.34 Hgb-12.8 Hct-40.6 MCV-93 MCH-29.4 RDW-13.6 Plt
Ct-238
Neuts-56.5 Lymphs-35.9 Monos-5.2 Eos-1.8 Baso-0.8
PT-12.4 PTT-25.3 INR(PT)-1.0
Glucose-102 UreaN-27* Creat-1.0 Na-141 K-4.6 Cl-106 HCO3-26
AnGap-14
Calcium-9.0 Phos-3.8 Mg-1.8
.
Cardiac Enzymes:
[**2186-7-31**] 01:27PM BLOOD CK(CPK)-243*
[**2186-7-31**] 04:02PM BLOOD CK(CPK)-590*
[**2186-7-31**] 11:22PM BLOOD CK(CPK)-579*
[**2186-8-1**] 03:50AM BLOOD CK(CPK)-374*
[**2186-8-1**] 07:00AM BLOOD CK(CPK)-681*
[**2186-7-29**] 08:45AM BLOOD cTropnT-<0.01
[**2186-7-31**] 01:27PM BLOOD CK-MB-7 cTropnT-0.13*
[**2186-7-31**] 04:02PM BLOOD CK-MB-15* MB Indx-2.5 cTropnT-0.33*
[**2186-7-31**] 11:22PM BLOOD CK-MB-10 MB Indx-1.7 cTropnT-0.24*
[**2186-8-1**] 03:50AM BLOOD CK-MB-7 cTropnT-0.13*
[**2186-8-1**] 07:00AM BLOOD cTropnT-0.25*
.
Other Labs
[**2186-7-31**] WBC-7.6 RBC-2.89* Hgb-8.9* Hct-27.6* MCV-96 RDW-13.8
Plt Ct-184
[**2186-8-1**] WBC-9.0 RBC-3.93* Hgb-11.4 Hct-34.7* MCV-88 RDW-15.8
Plt Ct-156
[**2186-8-1**] Lactate-0.9
.
Micro:
URINE CULTURE (Final [**2186-7-31**]):
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
.
Other Studies:
[**2186-7-29**] EKG: Normal sinus rhythm, rate 74. Left axis deviation.
Left ventricular hypertrophy. Compared to the previous tracing
of [**2183-8-5**] septal repolarization abnormalities have resolved.
[**7-29**]/O9 CT head w/o: No evidence of hemorrhage
[**2186-7-29**] CT spine w/o: No acute fracture or dislocation.
Extensive multilevel degenerative changes, as detailed on prior
report from [**11-10**] with mild central canal stenosis at the levels
of C4-C7. Grade 1 anterolisthesis of C3 on C4 vertebral bodies.
[**2186-7-29**] Hip X-ray: Displaced left hip intertrochanteric fracture
[**2186-7-30**] Hip X-ray: Eight films from the OR demonstrate interval
placement of an intramedullary rod spanning the femoral
fracture. At the end of the
procedure, the alignment is near anatomic.
[**2186-7-30**] Echo: The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. A mitral valve
annuloplasty ring is present. The mitral annular ring appears
well seated with normal gradient. Mild to moderate ([**1-6**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. Compared with the report of the prior study (images
unavailable for review) of [**2180-3-24**], mild pulmonary artery
systolic hypertension is now present and the severity of mitral
regurgitation is slightly increased.
[**2186-7-31**] CTA: No evidence of central PE. Small pleural effusions
with
subsequent atelectasis. No other parenchymal opacities. Healed
rib
fractures.
.
Brief Hospital Course:
This is a 79 woman transferred to MICU for hypotension and
tachycardia initially admitted s/p fall treated with open
reduction and IM rod placement.
# Hypotension: Likely multifactorial triggered by AF with RVR
with poor perfusion in setting of NPO status and decreased PO
intake. BP now improved after IVF and with rate control as
below. We ruled out PE with a negative CTA. Her UTI likely did
not cause sepsis related hypotension given her clinical picture.
However, her UTI was treated with ceftriaxone and blood cultures
were drawn. We obtained an Echo to make sure she had adequte
EF. Also, we obtained serial cardiac enzymes to confirm that she
was not having an acute MI. He was transfused 3 units of pRBC
while in the MICU for anemia. This coupled with IVF, resolved
that patient's hypotension. Her hematocrit and vitals were
stable upon discharge.
# AF: Pt has history of AF and had episode of AF with RVR this
am, possibly triggered by anemia/hypotension. Cardiology has
been following and recommended rate control with Metoprolol 25mg
po BID in addition to Norpase 100 TID. Her rate was well
controlled upon discharge.
.
# Anemia: Patient's hematocrits have been stable after the blood
transfusion.
.
# Intertrochanteric fx: S/P surgery for L intertrochanteric fx,
started on Lovenox today. Receieved Cefazolin x1 for the
operation. Her pain has been controlled with Tylenol and
Oxycodone prn. She will require further physical rehabilitation
at rehab.
.
#. s/p fall-- Most likely consistent with mechanical fall versus
brief episode of afib with RBR. Head CT neagtive for acute
process on admission. Likely related to Parkinsons and gait
disturbance given recurrent falls.
.
#. Parkinson's- Continued Sinemet, discharged on Azilect per
home regimen
.
#. HTN--Restart on quapril, norvasc upon discharge.
.
#. Hypothyroidism-- Continue home Levothyroxyl.
.
#. Osteoporosis--Ca and VitD.
.
# FEN: Speach and swallow saw the patient and recommended nectar
thick liquids, with ground founds. Will require further speech
and swallow evaluation with video study as outpatient.
.
# Prophylaxis: Lovenox 40mg SC daily and home PPI
.
# Code: DNR/DNI confirmed with husband [**Name (NI) 6339**]
.
# Communication: Patient and husband [**Name (NI) **] [**Telephone/Fax (5) 97477**]
C[**Telephone/Fax (5) 97478**]
Son [**Name (NI) **] [**Numeric Identifier 97479**]
Medications on Admission:
Sinemet CR 50/200 TID, Sinemet 25/100 half tab TID, Levoxyl
112mcg QD, Prevacid 30mg [**Hospital1 **], Norpace 100mg TID, Micro-K 6pills
but dose unknown per day TID, MVI, Toprol XL 25 QD, Norvasc 5
[**Hospital1 **], Azilect 1mg QD, Quinapril 20 QD, Evista 60 [**Last Name (LF) 244**], [**First Name3 (LF) **] 325 QD,
Coenzyme 1200mg Q10 qday
Discharge Medications:
1. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO TID (3 times a day).
2. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO TID (3 times a day).
3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours).
8. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Oxycodone 5 mg Tablet Sig: .5 to 1 Tablet PO Q6H (every 6
hours) as needed for pain.
11. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Azilect 1mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Left intertrochanteric hip fracture, 3-part.
Atrial fibrillation with rapid ventricular response
Urinary tract infection.
Discharge Condition:
vital signs stable. Good condition
Discharge Instructions:
You were admitted with a fall. You had your hip replaced and
during your stay you had rapid heart beat that required
treatment in the ICU. Your heart rate was stabilized and you
are being discharged to a rehab for further physical therapy and
care.
Continue to be weight bearing as tolerated on your left leg
Continue your lovenox injections for a total of 4 weeks after
surgery
Please resume all your medications as prescribed by your doctor.
You were given new medications; please take them as instructed.
.
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: Out of bed w/ assist
Left lower extremity: Touchdown weight bearing
Treatments Frequency:
Staples/sutures out 14 days after surgery
Dry sterile dressing daily or as needed for drainage or comfort
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 1942**]
Date/Time:[**2186-8-8**] 3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2186-8-28**] 9:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2186-10-25**] 2:30
Completed by:[**2186-10-9**]
|
[
"276.52",
"V45.71",
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"781.2",
"820.21",
"V10.3",
"V42.2",
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"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"79.05"
] |
icd9pcs
|
[
[
[]
]
] |
11133, 11218
|
7010, 9385
|
336, 439
|
11384, 11421
|
3475, 3480
|
12595, 13271
|
2601, 2745
|
9778, 11110
|
11239, 11363
|
9411, 9755
|
11445, 12126
|
2760, 3456
|
12144, 12225
|
12247, 12355
|
3776, 6987
|
249, 298
|
467, 1879
|
3494, 3759
|
1901, 2345
|
2361, 2584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,642
| 170,515
|
38847+38848
|
Discharge summary
|
report+report
|
Admission Date: [**2176-3-11**] Discharge Date: [**2176-3-20**]
Date of Birth: [**2112-4-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Transfer for GPC sepsis
Major Surgical or Invasive Procedure:
PICC Placement
Central Line placement at [**Hospital1 **] [**Location (un) 620**]
Intubation at [**Hospital1 **] [**Location (un) 620**]
History of Present Illness:
63 yo M with PMH of HTN and [**Hospital 86233**] transferred from [**Location (un) 620**] ICU for
GPC sepsis. Patient presented to [**Location (un) 620**] ED with AMS on [**3-10**]
per his wife. On [**Name2 (NI) 1017**] morning was in normal state of health
and went to run an errand for a 15 minutes. When he returned he
was rigoring and c/o feeling poorly. That afternoon he [**2-20**]
episodes of nausea/vomiting/diarrhea with yellow liquid stool
and became altered. EMS was called and he was brought to
[**Location (un) 620**] ER.
.
In the ED at [**Location (un) 620**], he was febrile to 103.7--->104 after
tylenol. Admitted to ICu. Received total of 8L NS after
dropping pressures to 70's and sinus tach to 100's. He was
started on levophed with recovery of pressures to 100's. A L SC
CVL was placed. Labs remarkable for WBC of 24, Cr of 1.5, and
blood cultures grew out GPC in chains in [**12-19**] bottles. UA
negative. UOP was poor at 75cc over several hours. Treated with
CTX, vanco, Zofran and Tylenol.
.
Upon arrival to the unit here patient is intubated and sedation
and appears comfortable.
.
Review of systems: unable to 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:
S/p splenectomy after ruptured spleen at age 16 [**12-19**] mono
HTN
Vertigo
Social History:
Works in desk job, lives with wife.
- Tobacco: None
- Alcohol: 1 drink/month
- Illicits: none
Family History:
Unable to obtain at the time of admission.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, 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:
[**2176-3-11**] 05:44AM BLOOD WBC-34.6* RBC-3.93* Hgb-12.6* Hct-37.7*
MCV-96 MCH-32.1* MCHC-33.4 RDW-13.5 Plt Ct-211
[**2176-3-20**] 05:46AM BLOOD WBC-23.2* RBC-3.51* Hgb-10.9* Hct-32.9*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.8 Plt Ct-290
[**2176-3-12**] 01:58AM BLOOD Neuts-82* Bands-9* Lymphs-4* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2176-3-15**] 04:56AM BLOOD Neuts-85* Bands-0 Lymphs-7* Monos-3 Eos-0
Baso-0 Atyps-3* Metas-2* Myelos-0 NRBC-1*
[**2176-3-11**] 02:39PM BLOOD PT-19.9* PTT-50.0* INR(PT)-1.8*
[**2176-3-14**] 02:31AM BLOOD PT-14.1* PTT-25.6 INR(PT)-1.2*
[**2176-3-11**] 02:39PM BLOOD Fibrino-463*
[**2176-3-11**] 05:44AM BLOOD Glucose-102* UreaN-34* Creat-1.5* Na-142
K-3.7 Cl-112* HCO3-17* AnGap-17
[**2176-3-20**] 05:46AM BLOOD Glucose-102* UreaN-19 Creat-0.7 Na-137
K-4.1 Cl-107 HCO3-21* AnGap-13
[**2176-3-11**] 02:39PM BLOOD CK(CPK)-3263*
[**2176-3-12**] 01:58AM BLOOD CK(CPK)-5664*
[**2176-3-12**] 09:17AM BLOOD CK(CPK)-4502*
[**2176-3-11**] 02:39PM BLOOD CK-MB-20* MB Indx-0.6 cTropnT-0.14*
[**2176-3-12**] 01:58AM BLOOD CK-MB-18* MB Indx-0.3 cTropnT-0.14*
[**2176-3-12**] 09:17AM BLOOD CK-MB-14* MB Indx-0.3 cTropnT-0.08*
[**2176-3-15**] 04:56AM BLOOD CK-MB-3 cTropnT-0.04*
[**2176-3-11**] 05:44AM BLOOD Calcium-6.7* Phos-3.7 Mg-1.1*
[**2176-3-20**] 05:46AM BLOOD Calcium-7.2* Phos-2.4* Mg-1.9
[**2176-3-11**] 02:39PM BLOOD D-Dimer-[**Numeric Identifier **]*
[**2176-3-11**] 05:44AM BLOOD Osmolal-301
[**2176-3-11**] 06:38AM BLOOD Lactate-3.8*
[**2176-3-13**] 03:54AM BLOOD Lactate-2.0
[**2176-3-15**] 03:47PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.027
[**2176-3-11**] 11:26AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2176-3-15**] 03:47PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2176-3-11**] 11:26AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2176-3-15**] 03:47PM URINE RBC-19* WBC-8* Bacteri-NONE Yeast-NONE
Epi-0
[**2176-3-11**] 11:26AM URINE RBC-49* WBC-11* Bacteri-NONE Yeast-FEW
Epi-0 TransE-1
[**2176-3-11**] 11:26AM URINE CastGr-2*
[**2176-3-11**] 11:26AM URINE Hours-RANDOM Creat-144 Na-48
[**2176-3-11**] 11:26AM URINE Osmolal-749
[**2176-3-12**] 10:35PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-24
Lymphs-32 Monos-44
[**2176-3-12**] 10:35PM CEREBROSPINAL FLUID (CSF) TotProt-44
Glucose-109
[**2176-3-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2176-3-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2176-3-15**] URINE URINE CULTURE-FINAL INPATIENT
[**2176-3-12**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL INPATIENT
[**2176-3-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2176-3-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2176-3-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2176-3-12**] URINE URINE CULTURE-FINAL {GRAM POSITIVE
RODS} INPATIENT
[**2176-3-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2176-3-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2176-3-11**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2176-3-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: *0.21 >= 0.29
Left Ventricle - Ejection Fraction: 45% >= 55%
Left Ventricle - Stroke Volume: 38 ml/beat
Left Ventricle - Cardiac Output: 3.58 L/min
Left Ventricle - Cardiac Index: *1.71 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 12
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.80
Mitral Valve - E Wave deceleration time: 163 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
global LV hypokinesis. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
mass or vegetation on mitral valve. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve. Indeterminate PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. There
is mild global left ventricular hypokinesis (LVEF = 45 %). There
is no ventricular septal defect. RV with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
If clincally indicated, a TEE is suggested to exclude a small
valve vegetation.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2176-3-11**] 7:45
AM
Final Report
INDICATION: ETT, nasogastric tube placement.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The tip of the endotracheal tube projects 4 cm above
the carina. The course of the nasogastric tube is unremarkable,
there is no evidence of complications, the tip is not visualized
on the image. Left-sided central venous access line placed over
the subclavian vein. The tip of the line projects over the mid
SVC. Again, no complications and notably no pneumothorax is
seen. Mild retrocardiac atelectasis. Mild crowding of the right
basal vascular structures. Borderline size of the cardiac
silhouette without evidence of pulmonary edema.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2176-3-12**]
12:22 AM
FINDINGS: There is no acute intracranial hemorrhage or cerebral
edema. There is preservation of normal [**Doctor Last Name 352**]-white matter
differentiation. All four ventricles are moderately enlarged.
However, the sulci are normal in size. No evidence of
transependymal CSF flow is seen. There is no abnormal extraaxial
collection.
There is mild mucosal thickening of the maxillary sinuses with a
mucus
retention cyst of the left maxillary sinus. There is extensive
opacification of the ethmoid air cells. There is mild mucosal
thickening in the sphenoid sinuses. The mastoid air cells are
clear.
IMPRESSION: Diffuse moderate ventriculomegaly without sulcal
enlargement to suggest underlying atrophy. The chronicity of
this finding is unknown in the absence of the previous studies.
In the current clinical setting, this appearance is concerning
for ventriculitis. MRI with gadolinium is
recommended for further evaluation. Neurosurgical consultation
should be
considered if there are any clinical signs of increased
intracranial pressure.
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS W/O
CONTRAST
FINDINGS:
CHEST:
There is a left-sided central venous catheter with tip at the
distal
brachiocephalic vein. Chest wall is unremarkable. There is an
endotracheal
tube in place. There is a nasogastric tube in place with tip in
the stomach. There are bilateral small pleural effusions. The
bilateral airspace consolidation at the lung bases are most
likely related to passive atelectasis. Aorta and pulmonary
vasculature are within normal limits. Heart is grossly normal
with no evidence of pericardial effusion. No significant
lymphadenopathy. The tracheobronchial tree is patent.
ABDOMEN:
No free intraperitoneal air. Liver, pancreas, gallbladder,
biliary tree,
adrenals, and kidneys show no abnormalities. There are splenules
in the left upper quadrant. Visualized gastrointestinal tract
shows no abnormalities.
CT OF THE PELVIS:
There is a rectal tube in place and a Foley catheter in place,
in good
position. Visualized gastrointestinal tract is unremarkable. No
pelvic free fluid is seen. No significant lymphadenopathy.
Urinary bladder and prostate show no abnormalities.
BONE WINDOWS:
No suspicious osseous lesions.
IMPRESSION:
1. No evidence of abdominal collections and no acute
intra-abdominal
abnormalities.
2. Bilateral small pleural effusions with adjacent atelectasis.
3. Splenules in the left upper quadrant.
Radiology Report MRV HEAD W/O CONTRAST Study Date of [**2176-3-12**]
5:02 PM
FINDINGS:
MRI HEAD: There is focal T2 signal hyperintensity in the left
subinsular white matter and anterior limb of the left internal
capsule, likely due to chronic microvascular infarction. The
ventricles are enlarged for the patient's age of 63 years, out
of proportion to sulcal size. There is no evidence of
transependymal CSF flow. There is no edema or mass effect. There
is no slow diffusion to suggest acute ischemia. Following
administration of intravenous gadolinium, there is no evidence
of abnormal enhancement.
There is mucosal thickening with probable mucus retention cysts
in both
maxillary sinuses, the sphenoid sinuses, frontal sinuses, and
opacification of multiple bilateral ethmoid air cells, without
fluid levels to suggest acute sinusitis. There is opacification
of the mastoid air cells bilaterally. Fluid is also noted in the
nasopharynx, a nonspecific finding.
MRV HEAD: There is asymmetry of the transverse sinuses, left
smaller than
right, a normal variant. There is no evidence of a filling
defect within the dural venous sinuses on the postcontrast
MPRAGE images to suggest thrombosis.
IMPRESSION:
1. No evidence of intracranial infection or acute infarction.
2. Ventricular enlargement out of proportion to sulcal size,
without evidence of subependymal migration of cerebrospinal
fluid. While there are no signs of vetriculitis, this appearance
may represent communicating hydrocephalus (including, but not
limited to, normal-pressure hydrocephalus). Alternatively, this
appearance could be secondary to predominantly central cerebral
atrophy. Recommend clinical correlation for further evaluation.
3. Bilateral mastoid air cell opacification. Please correlate
clinically to exclude infection.
4. No evidence of dural venous sinus thrombosis.
Neurophysiology Report EEG Study Date of [**2176-3-13**]
FINDINGS:
ABNORMALITY #1: Throughout the recording, the background rhythm
consisted of a low voltage mixed theta/delta activity.
BACKGROUND: As above. There are technician notes of a head
tremor
which is seen on EEG to be a 3.5-4 Hz movement artifact in the
bioccipital leads without apparent epileptiform features. There
is no
evidence of electrographic seizures associated with these
movements.
HYPERVENTILATION: Could not be performed due to the patient
being
intubated.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: No normal waking or sleep morphologies were seen during
this
recording.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 72 bpm.
IMPRESSION: This is an abnormal extended routine EEG due to
slowing and
disorganization of the background rhythm suggestive of a
moderate to
severe encephalopathy. Medications, toxic/metabolic disturbances
and
infections are common causes. No epileptiform discharges or
electrographic seizures were seen during this recording.
Brief Hospital Course:
# Strep Pneumo Sepsis: Initially thought to be due to lung
source, given small infiltrate seen on CXR at [**Location (un) 620**], and with
since he had had a splenectomy when he was younger he was at
increased risk of bacteremia. However, on arrival to [**Hospital1 18**]
imaging did not show any sign of pneumonia, and prior to his
becoming ill did not have any localizing symptoms other than
some nasal congestion, no tooth pain, shortness of breath or
abdominal pain. He arrived from [**Location 620**] intubated, sedated, on
pressors and on broad spectrum antibiotic coverage pending
speciation results from his blood cultures. Once his blood
cultures grew out Strep pneumo his antibiotic coverage was
changed to ceftriaxone. During his ICU in attempt to discern
the source of the bacteremia, and due to his initial
presentation with altered mental status a CT of his head was
done, which showed enlarged ventricles, which was concerning for
an intracranial process or possible meningitis. A lumbar
puncture was done, two days after presentation due to DIC, with
an opening pressure of 26, neurology and neurosurgery were both
consulted, and an MRI was done which showed enlarged ventricles
but no other concerning findings other than diffuse sinus
disease. A CT of the torso and a TTE were done to further
evaluate source of infection were done but these were normal.
LP cultures were negative, but it was decided that he would
complete a 14 day course of meningitis dosing of ceftriaxone
given altered mental status on admission. Although, it was
thought that due to the large amount of sinus disease that his
sinuses were likely the source of infection. He remained
intubated in the ICU until [**2176-3-14**] when he self extubated, did
very well post extubation and was soon transferred to the
medicine service. His condition continued to improve while on
the medicine service. Meningitis dose ceftriaxone was continued
and the patient remained afebrile. He was discharged with PICC
line and services to complete a 14 day course of ceftriaxone at
home.
.
#. AMS: Patient presented with altered mental status. This was
thought to be due to acute delirium in the setting of
bactermia/sepsis. Neurology was consulted for further evaluation
of this, CT scan findings of dilated ventricles and tremulous
movements that the patient was found to be exhibiting. An EEG
was done and it ruled out seizure activity. His mental status
improved with treatment of his septic shock and it returned to
baseline prior to transferring to the medical service.
.
# Acute Kidney Injury: Cr 1.5 on admission and on repeat,
thought to be due to ATN in setting of sepsis. His creatinine
improved during his stay as his underlying infection and blood
pressures improved, making ATN the likely diagnosis. His renal
function was within normal limits upon discharge.
.
# Atrial Fibrillation: Patient went into A.fib with RVR while he
was intubated and on pressors during transport for a CT scan.
He underwent the initial loading of amiodarone, and converted to
a bradycardic sinus rhythm. He was not continued on amiodarone
and was not started on anti-coagulation. His bradycardia
improved throughout his hosptitalization.
.
# DIC: Patient's MICU course was complicated by DIC as he was
found to have elevated markers on admission. FFP transfusion was
attempted but had to be stopped because the patient became
febrile. Supportive therapy was continued and this subsequently
resolved.
Medications on Admission:
Pravachol
Aldactozide
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q12H (every 12 hours) for 7 days.
Disp:*28 grams* Refills:*0*
3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours as needed for fever: take if you develop
fevers but only after your IV ceftriaxone course has finished.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
Pneumococcal bacteremia
Secondary diagnosis:
HTN
DL
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 transfered to the [**Hospital1 18**] for management of your serious
infection. You intially went to the medical intensive care unit
were you required fluids and medications to maintain your blood
pressure and a ventilator for assistance with breathing. You
were treated with antibiotics and your condition improved. While
on this medication to maintain the blood pressure you developed
an abnormal heart rhythm called atrial fibrillation. You were
treated with medications and this resolved but you subsequently
had a slow heart rate. Once you were not requiring medication to
maintain your blood pressure and a ventilator for assistance
breathing you were transfered to the medical floor. Your
condition continued to improve and your slow heart rate improved
as well. You will need to finsh a 14 day course of the
antibiotic ceftriaxone for your infection the last day being
[**2176-3-25**]. You will also need to be vaccinated with the
pneumonia, meningitis and H-influenza vaccines as an outpatient.
Medication changes:
CONTINUE: Ceftriaxone for 5 more days to complete a 14 day
course, the last day is [**2176-3-25**]
STOP: Aldactazide and discuss re-strating this medication with
your PCP
[**Name Initial (PRE) **]: Augmentin every 12 hours take if you develop fevers but
only after your IV ceftriaxone course has finished
Followup Instructions:
Name:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD
Address: [**Street Address(2) 86234**], [**Location (un) **],[**Numeric Identifier 45899**]
Phone: [**Telephone/Fax (1) 86235**]
When: [**Last Name (LF) 766**], [**3-25**] at 10am
**Please request a referral to see Dr. [**Last Name (STitle) **] from Dr. [**Last Name (STitle) 30175**].
Fax referral to [**Telephone/Fax (1) 86236**].
**Please discuss appropriate vaccinations after splenectomy with
your PCP
Department: NEUROLOGY
When: TUESDAY [**2176-4-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22438**], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Admission Date: [**2176-3-23**] Discharge Date: [**2176-3-29**]
Date of Birth: [**2112-4-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Rigors
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
History of Present Illness:
Patient is well known to the team as he was discharged on
[**2176-3-20**]. Briefly, 63 yo M with PMH of HTN, BPV and s/p
splenectomy in his 20[**Hospital **] transferred from [**Location (un) 620**] ICU on [**3-10**] for
management of pan-sensitve strep pneumo sepsis. He was initially
admitted to the MICU where he was treated with CTX and his
infectious work up was only revealed sinusitis on brain MRI. On
HD2 he was weaned off pressors and on HD4 he self extubated. he
was subsequently transfered to the medical floor where he was
continued on CTX and remained afebrile. He was discharged with a
PICC line and infusion company assistance to finish a 14 day
course of IV CTX 2 g [**Hospital1 **] which he would have finished on [**3-25**].
He had been doing well since he was discharged until the day of
admission when he developed rigors at around 12:30 pm. He stated
that they were the same type of rigors that he had prior to his
previous hospitalization. He took is temperature and it was 97.
He continued to rigor for ~ 1 hour. He denied LOC or seizure
activity and this was witnessed by his daughter.
In the ED, his vital he was febrile to 100.8 and had a CXR done
which revealed RLL atelectasis and could not exclude PNA. He was
given vancomycin 1 g x 1 and levofloxacin 750 mg IV x 1.
Review of systems:
(+) Per HPI. Mild cough that he has had since self extubating
but has been improving. Lower neck pain and R flank pain (both
of which he has had since discharge and are improving). Also
had right chest pain in lower rib area
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias.
Past Medical History:
S/p splenectomy after ruptured spleen at age 16 [**12-19**] mono
HTN
S/p pan-sensitive Streptococcus Pneumonia sepsis [**2176-3-10**]
Vertigo
Social History:
Works in desk job, lives with wife.
- Tobacco: None
- Alcohol: 1 drink/month
- Illicits: none
Family History:
Not obtained
Physical Exam:
Physical Exam:
Vitals: T: 98.4 BP: 120/74 P: 54 R: 18 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: supple, FROM, JVP not elevated, no LAD
Lungs: mild crackles at R base, otherwise CTA
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, 1+ edema
Pertinent Results:
Labs on Admission:
[**2176-3-23**] 02:00PM BLOOD WBC-14.3* RBC-3.43* Hgb-10.7* Hct-32.0*
MCV-93 MCH-31.3 MCHC-33.6 RDW-14.3 Plt Ct-472*#
[**2176-3-23**] 02:00PM BLOOD Neuts-74* Bands-0 Lymphs-9* Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2176-3-23**] 02:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Target-OCCASIONAL
Burr-1+ Acantho-OCCASIONAL
[**2176-3-23**] 02:00PM BLOOD Plt Smr-HIGH Plt Ct-472*#
[**2176-3-23**] 02:00PM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-137
K-4.6 Cl-104 HCO3-24 AnGap-14
[**2176-3-23**] 02:12PM BLOOD Lactate-1.6
Pertinent Labs:
[**2176-3-24**] 05:09AM BLOOD calTIBC-202* Ferritn-687* TRF-155*
[**2176-3-26**] 05:32AM BLOOD PEP-NO SPECIFI IgG-1267 IgA-715* IgM-52
IFE-NO MONOCLO
[**2176-3-25**] 06:36 IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 595 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 489 241-700 mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 109 22-178 mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 63.8 4.0-86.0 mg/dL
IMMUNOGLOBULIN G, SERUM 1[**Telephone/Fax (1) 86237**] mg/dL
[**2176-3-23**] 04:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2176-3-23**] 04:05PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2176-3-23**] 04:05PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2176-3-26**] 06:03PM URINE U-PEP-NEGATIVE F
[**2176-3-26**] 06:03PM URINE Hours-RANDOM TotProt-10
[**2176-3-27**] CATHETER TIP-IV WOUND CULTURE-PRELIMINARY
INPATIENT
[**2176-3-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2176-3-23**] URINE URINE CULTURE-FINAL INPATIENT
[**2176-3-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2176-3-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Discharge Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2176-3-29**] 06:55 8.8 3.32* 9.9* 31.4* 95 29.8 31.5 13.9 622*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2176-3-29**] 06:55 891 20 0.9 137 4.6 104 26 12
UPRIGHT PA AND LATERAL VIEWS OF THE CHEST [**2176-3-23**]:
IMPRESSION: Moderate atelectasis of the right lower lobe with a
right pleural effusion. An underlying consolidative process
cannot be excluded. trace left pleural effusion.
CT OF THE CHEST WITHOUT IV CONTRAST [**2176-3-23**]:
IMPRESSION: Somewhat increased bilateral pleural effusions, but
decreased
associated parenchymal opacities, which are compatible with
compressive
atelectasis although slightly improved pneumonic consolidations
are not
excluded.
MR HEAD W & W/O CONTRAST [**2176-3-26**] 11:01 AM
IMPRESSION: There is no evidence of acute intracranial
pathology. There is
no evidence of abnormal enhancement. Interval decrease in the
pattern of
mucosal thickening involving the ethmoidal and maxillary
sinuses, there is
also mild decrease in the amount of mucosal thickening in the
mastoid air
cells, however, there are residual opacities, more significant
on the left. Unchanged subinsular T2 and FLAIR
hyperintensities, possibly consistent with chronic microvascular
ischemic changes.
ECHOCARDIOGRAPHY REPORT TEE (Complete) [**2176-3-27**] at 3:15:01 PM
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a mass in the right ventricle that appears
to be a calcified, torn chord associated with the tricuspid
valve. No tricuspid valve vegetation is seen, and no significant
tricuspid regurgitation is present. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. There is a
very small filamentous mass associated with the right coronary
cusp of the aortic valve that could represent a Lambl's
excrescence versus a small vegetation. No aortic valve abscess
is seen. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is mild mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**11-18**]+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve.
IMPRESSION: Possible aortic valve endocarditis.
CXR PA/LAT [**2176-3-28**]
IMPRESSION: Persistent bilateral plate atelectasis and mild
degree of pleural effusions. Cause of process is unknown.
Further followup and clinical evaluation is recommended.
Brief Hospital Course:
# Fevers/rigors: Mr. [**Known lastname **] presented to the [**Hospital1 18**] ED on [**3-23**] with
rigors, fever, and an elevated white count. A chest x-ray and CT
showed bilateral pleural effusions R>L. Ceftriaxone was
discontinued and he was started on vancomycin and cefepime. For
the remainder of the hospitalization, Mr. [**Known lastname **] remained
afebrile with a normal white count. To further evaluate the
source of infection, Interventional Pulmonology attempted
thoracentesis, but determined the effusion was too small to
drain. Infectious Disease recommended an MRI of the head since a
previous MRI study on [**2176-3-12**] showed enlarged ventricles and
sinusitis, but there was no evidence of intracranial pathology.
A TEE showed no overt evidence of endocarditis. At this time,
Infectious Disease recommended stopping all antibiotics,
removing and culturing his PICC line, and monitoring for signs
of infection for over 48 hours. PICC line and blood cultures
both showed no growth. He remained afebrile at time of discharge
on Friday [**2176-3-29**]. Haemophilus B, meninogococcal, and
pneumococcal vaccines were given during hospitalization.
#Normocytic Anemia: Mr. [**Known lastname **] presented with a normocytic anemia
upon admission. Immunoglobulin & SPEP/UPEP laboratory tests were
negative for indicators of Multiple Myeloma. He was guaiac
negative. The etiology of his anemia is most likely anemia of
chronic disease, but we strongly recommend an outpatient
colonoscopy and continued monitoring.
#Chest Discomfort: Mr. [**Known lastname **] developed significant right-sided
chest discomfort during his hospital course. This pain was most
likely caused by his pleural effusion and musculoskeletal
deconditioning. Lidocaine patches, heat packs, and ibuprofen
were effective, but he should follow-up with an outpatient
provider if the pain continues.
#HTN: We continued to hold BP meds. Consider restarting as an
outpatient if develops hypertension.
#Patient was full code during this admission.
Medications on Admission:
Pravastatin 20 mg daily
Aldactoside 25/25 mg daily (has been held since [**3-10**])
Ceftriaxone 2 g [**Hospital1 **] [**Date range (1) 86238**] course
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**11-18**] Adhesive Patch, Medicateds Topical DAILY (Daily) for 14
doses: to affected area.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 doses: at first sign of fever. Then contact your PCP or go
to the ER for evaluation.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Care Network
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Fevers and rigors, unspecified
- Small right pleural effusion, too small to tap
SECONDARY DIAGNOSES:
- Pneumococcal bacteremia
- Hypertension
- Asplenia [**12-19**] complication of mononucleosis at age 16
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] because you had rigors and had a
low grade fever on presentation to the emergency room. At CT
scan of your chest showed a fluid collection around your lung
and this prompted us to change your antibiotics. We did a brain
MRI and this showed resolving sinusitis. We did a
transesophageal echocardiogram to look for a potential source
but this was normal. Your PICC line was then taken out and
antibiotics stopped. You did not have rigors or fevers even
after stopping antibiotics. You received the pneumococcal,
meningococcal and haemophilus influenza vaccines while in the
hospital. Your iron level was low and we started you on iron
supplementation. Please have your PCP [**Name9 (PRE) 32385**] this in 3 months
to see if continued iron therapy is necessary.
Medication Changes:
START: Levofloxacin 750 mg daily if you have a fever and then
contact your PCP or go to the emergency room for further
evaluation.
START: Iron 325 mg daily
START: Lidocaine patches to affected site for pain
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2176-4-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22438**], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2176-4-17**] at 10:30 AM
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
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792
| 197,891
|
50624
|
Discharge summary
|
report
|
Admission Date: [**2186-4-6**] Discharge Date: [**2159-2-19**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
female with a past medical history of bilateral carotid
stenosis, coronary artery disease, status post left anterior
descending percutaneous intervention, hypertension,
hypercholesterolemia, who was admitted to the CCU for
monitoring following elective right internal carotid artery
percutaneous intervention. The patient has initially been
evaluated in [**7-22**], for word finding difficulty and a left
facial droop and was found to have bilateral internal carotid
artery stenosis. The patient has a history of significant
coronary artery disease, multiple medical problems and her
age. She was referred for elective stent intervention of her
carotids as opposed to endarterectomy. She had a magnetic
resonance scan - MRA of head and neck on [**2186-2-22**], which
showed a two right hemispheric microhemorrhages and right
subcortical small vessel ischemic disease. During the stent
procedure, the patient required a Neo-Synephrine drip for
decreased blood pressure and Atropine times two for decreased
heart rate. During the procedure, the patient was noted to
have an right posterior carotid AV fistula.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Carotid stenosis bilaterally, ultrasound [**2-20**], bilateral
internal carotid artery stenosis of 70 to 90%.
3. Cerebrovascular accident with small vessel disease. Known
facial droop, right hemispheric microhemorrhages.
4. Coronary artery disease, [**11-20**], catheterization with a
left main 20% ostial stenosis, left anterior descending 80%
midstenosis, status post stent, diagonal 90% stenosis status
post stent, left circumflex 40% lesion at the OM1. Ejection
fraction estimated to be 67% on a MUGA, ETT MIBI, that she
had in [**12-23**]. There was no nuclear defect, perfusion
defects, during the test.
5. Hypertension.
6. Hypercholesterolemia.
7. Osteoporosis.
8. Status post cataract surgery.
9. Status post Zenker's diverticular repair.
10. Questionable history of dementia.
ALLERGIES: Intravenous pyelogram dye causes her to have
anaphylaxis.
MEDICATIONS ON ADMISSION:
1. Lopressor 12.5 mg p.o. twice a day.
2. Aspirin 81 mg once daily.
3. Univasc 7.5 mg one once daily and 15 mg q.p.m.
4. Dyazide 12.5 mg once daily.
5. Lipitor 10 mg once daily.
6. Plavix 75 mg once daily.
7. Fosamax 70 mg q.week.
8. Multivitamin one once daily.
9. Lactulose.
SOCIAL HISTORY: She lives alone. No tobacco use and rare
ETOH use.
PHYSICAL EXAMINATION: At the time of presentation, she was
afebrile with a heart rate of 63, blood pressure 120/50 to
160/60, respiratory rate 16, oxygen saturation 99% on two
liters. She is in no acute distress lying in bed.
Extraocular movements are intact. The pupils are equal,
round, and reactive to light and accommodation. Anicteric.
No bruit or jugular venous distention appreciated. Heart is
regular rate and rhythm, S1 and S2, no murmurs, rubs or
gallops. Her lungs are clear to auscultation bilaterally
posteriorly. Abdomen with normoactive bowel sounds, soft,
nontender, nondistended. Extremities - no cyanosis, clubbing
or edema. Right leg immobilizer placed. Her dorsalis pedis
were [**1-22**]. Her neurologic examination revealed cranial nerves
with the exception of her facial nerve were intact. She has
flat nasolabial fold on the left side. Normal upper and
lower extremity strength.
LABORATORY DATA: On the day of admission, white blood cell
count 6.6, hematocrit 32.6, platelet count 291,000. Total
cholesterol was 173, HDL 45, LDL 109.
ASSESSMENT: This is an 81 year old female with a history of
coronary artery disease, peripheral vascular disease, carotid
artery stenosis, bilaterally, hypertension,
hypercholesterolemia, admitted to the CCU status post right
internal carotid artery stent.
1. Neurology - The patient had stent, status post right
internal carotid artery stent. She initially was on
Neo-Synephrine to maintain a blood pressure goal between 110
and 150. She had q1hour neurological checks and then q2hour
neurological checks. Initially, her Neo-Synephrine was
weaned off and the patient's blood pressure gradually rose to
approximately 160 to 170. As a result, some very low dose
Nitroglycerin drip was started to try to keep her blood
pressure between 150 and 110. The patient had hypotension
with blood pressure down to 70. The Nitroglycerin drip was
stopped and Neo-Synephrine drip was started with blood
pressure up to as high as 200s. When all drips were stopped,
her blood pressure gradually came down to 120 to 130
systolic. This was fairly soon after the stent had been
placed and the patient arriving in the CCU. Overnight the
first hospital night, the patient was placed on a low dose of
Neo-Synephrine 0.1 to maintain her blood pressure between 110
to 120 with gradually being able to be weaned off the drip
and on the second hospital day, the Neo-Synephrine drip was
turned off. The patient did not require any Atropine in the
CCU, however, she did have a symptomatic bradycardia going
down to mid 30s while she is sleeping, coming up to mid 40s
to 50s when being awakened. On the neurologic examination,
there was no focality or any change in her examination from
her baseline which had the left nasolabial fold flattening.
However, the patient did seem to be confused the evening
status post the procedure and on day two on the [**2186-4-6**], the
patient had a CT of the head without contrast which showed no
definite hemorrhage. The results were reviewed with the
neurologist following along with the team, Dr. [**Last Name (STitle) 1774**]. On the
second day postprocedure, the patient was acting more
oriented and less confused. Her confusion seemed to coincide
with the onset of night fall and possible disturbance of her
sleep/wake cycle. The rest of her stay the patient had blood
pressure near goal being consistently in the 120s to 130s.
She was transferred to the floor and Step-Down Unit on [**Hospital Ward Name 121**]
Two for further monitoring. The patient was seen by physical
therapy who felt the patient was a fall risk and recommended
for both feet physical therapy and occupational therapy and a
short term rehabilitation to optimize her functional capacity
before returning to living alone at home.
2. Hematology - The night after the procedure the patient
had a right arterial and venous sheath in place for her
arterial line that was monitoring her blood pressure. The
patient, despite having a leg immobilizer and numerous
discussions and explanations and exhortations to stay in bed,
attempted to get out of bed on the first night of her
admission, and was seen by house staff. House staff and
nursing staff got the patient into bed. Her groin
examination was stable with no bruit or hematoma, however, on
the next day, her hematocrit dropped to 26.3. The patient
had two units of packed red blood cells transfused with her
hematocrit being 34.9 on the day of discharge. Her CT of her
abdomen and pelvis showed no retroperitoneal hematoma. This
examination was done on [**2186-4-7**].
3. Blood pressure control - The patient will be discharged
on Univasc 7.5 mg twice a day and will follow-up with Dr.
[**First Name (STitle) **] in four to six weeks to have her blood pressure
medications adjusted possibly placing her back on her beta
blocker as well.
4. Coronary artery disease - The patient was continued on
her Aspirin and now will be on Plavix for life long therapy.
5. Infectious disease - The patient had a low grade
temperature maximizing at 100.5 on the day prior to
discharge. She had urine and blood cultures sent, all of
which are no growth at the time of discharge. As well, her
urinalysis was unremarkable. She had no localizing symptoms
of temperature or fever. Her temperature is 100 temperature
maximum on the day of discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Bilateral carotid artery stenosis, status post right
internal carotid artery stenting.
2. Significant coronary artery disease, status post left
anterior descending stenting.
3. Hypertension.
4. Hypercholesterolemia.
5. Peripheral vascular disease.
6. Mild dementia.
7. Right facial droop seemingly due to an old stroke.
PROCEDURE: Right internal carotid artery stent.
MEDICATIONS ON DISCHARGE:
1. Univasc 7.5 mg p.o. twice a day.
2. Artificial Tears one to two drops O.U. p.rn.
3. Lactulose.
4. Multivitamin.
5. Lipitor 10 mg p.o. once daily.
6. Plavix 75 mg p.o. once daily.
7. Aspirin 325 mg p.o. once daily.
8. Fosamax 70 mg q.week.
FOLLOW-UP: The patient is to see Dr. [**First Name (STitle) **] in approximately
four weeks in follow-up appointment for this procedure and at
the same time to see her primary care physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2186-4-9**] 12:07
T: [**2186-4-9**] 13:27
JOB#: [**Job Number 105355**]
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|
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28,397
| 135,398
|
32553
|
Discharge summary
|
report
|
Admission Date: [**2188-10-11**] Discharge Date: [**2188-10-22**]
Date of Birth: [**2149-11-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
L1 Corpectomy T12-L2 Fusion
Posterior Laminectomy and Fusion T10-L3.
History of Present Illness:
38 RHD M masonry contractor who was deer hunting [**10-11**] and fell
@08:30 20 feet from his stand, no LOC, unable to walk, GCS 15,
HD stable, transferred from [**Hospital 8641**] Hospital.
Past Medical History:
Lyme Dx
Left leg 1.5 cm short s/p pediatric injury
Social History:
Denies
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
RUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis; LUE with obvious wrist deformity and pain with
wrist flesxion and extension; deltoid, triceps and biceps intact
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes intact at biceps, triceps and brachioradialis
+ midline tenderness at thoracolumbar junction
Pertinent Results:
[**2188-10-20**] 07:31AM BLOOD WBC-10.1 RBC-3.68* Hgb-11.0* Hct-31.7*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.5 Plt Ct-513*#
[**2188-10-17**] 05:51AM BLOOD WBC-9.5 RBC-3.45* Hgb-10.3* Hct-29.9*
MCV-87 MCH-29.9 MCHC-34.5 RDW-13.8 Plt Ct-267
[**2188-10-16**] 03:37AM BLOOD WBC-8.0 RBC-3.35* Hgb-10.1* Hct-29.0*
MCV-87 MCH-30.1 MCHC-34.8 RDW-13.8 Plt Ct-207
[**2188-10-15**] 04:28AM BLOOD WBC-7.6 RBC-3.00* Hgb-9.1* Hct-25.5*
MCV-85 MCH-30.3 MCHC-35.5* RDW-13.5 Plt Ct-179
[**2188-10-14**] 05:12AM BLOOD WBC-6.1 RBC-2.85*# Hgb-8.6*# Hct-24.9*
MCV-87 MCH-30.2 MCHC-34.6 RDW-12.9 Plt Ct-165
[**2188-10-13**] 03:34AM BLOOD WBC-6.8 RBC-4.10* Hgb-12.7* Hct-35.5*
MCV-87 MCH-31.0 MCHC-35.8* RDW-13.3 Plt Ct-148*
[**2188-10-17**] 05:51AM BLOOD Glucose-141* UreaN-10 Creat-0.5 Na-138
K-4.2 Cl-102 HCO3-29 AnGap-11
[**2188-10-14**] 05:12AM BLOOD Glucose-125* UreaN-10 Creat-0.7 Na-137
K-4.2 Cl-103 HCO3-29 AnGap-9
[**2188-10-12**] 01:45AM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-139
K-4.1 Cl-102 HCO3-29 AnGap-12
[**2188-10-17**] 05:51AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.2
[**2188-10-13**] 10:23PM BLOOD Calcium-7.7* Phos-3.1 Mg-1.7
[**2188-10-12**] 01:45AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 75903**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
thoracolumbar fusion with instrumentation for his L1 burst
fracture. He was informed and consented for the procedure and
elected to proceed. Please see Operative Note for procedure in
detail. His cervical fracture was treated non-operatively in a
hard collar.
Post-operatively he was administered antibiotics and pain
medication. His catheter and drain were removed POD 3 and he
was able to take PO's. His pain was well controlled and he
remained afebrile throughout his hosptial course. He will
return to clinic in ten days. He was discharged in good
condition.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
L1 burst fracture
Left wrist fracture
Post-op anemia
C2 spinous process distraction injury
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Followup Instructions:
Please follow up in the Orthopaedic Spine clinic. Please call
[**Telephone/Fax (1) 11061**] for an appointment.
Please follow up in the Hand clinic with Dr. [**Last Name (STitle) 64927**]. Please
call [**Telephone/Fax (1) 2007**].
Completed by:[**2188-10-20**]
|
[
"250.00",
"354.0",
"806.04",
"806.4",
"807.01",
"285.9",
"813.42",
"E884.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"99.04",
"81.05",
"78.13",
"04.43",
"84.51",
"79.02",
"81.62",
"77.99",
"81.04",
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
4085, 4132
|
2618, 3331
|
332, 403
|
4267, 4274
|
1420, 2595
|
4529, 4795
|
737, 742
|
3386, 4062
|
4153, 4246
|
3357, 3363
|
4298, 4506
|
757, 1401
|
283, 294
|
431, 623
|
645, 697
|
713, 721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,995
| 152,964
|
33603
|
Discharge summary
|
report
|
Admission Date: [**2200-5-16**] Discharge Date: [**2200-5-20**]
Date of Birth: [**2136-12-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2200-5-16**]: Coronary artery bypass grafting x4:
Left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the marginal
branch, diagonal branch, and posterior descending artery.
History of Present Illness:
63 year old male has been experiencing symptoms of shortness of
breath and bilateral leg heaviness while jogging and walking for
the last few months. Over the last few weeks, he has started to
experience chest discomfort and bilateral arm pain while
running. His symptoms resolve with rest and he denies any
symptoms occurring unrelated to exertion. He was referred to Dr.
[**Last Name (STitle) **] and seen in the office on Friday [**2200-5-2**]. An echo was done
at that time which revealed
basilar inferior, inferolateral hypo to akinesis with no
definite scar. Mild mitral regurgitation noted with borderline
anterior leaflet MVP. EF 50-55%. He has referred him for cardiac
catheterization and found to have three vessel disease and is
now being referred to cardiac surgery for revascularization.
Past Medical History:
Dyslipidemia
Varicose veins
Hypothyroid
Gastric ulcer mid [**2178**]/GI bleed
Social History:
Race: Caucasain
Last Dental Exam: 4 months ago
Lives with: wife
Occupation: Superintendent of schools in [**Location (un) 5176**], due to retire
this week.
Tobacco: quit 30 years ago
ETOH:denies
Family History:
father had an MI at age 65. Brother has atrial fibrillation
Physical Exam:
Physical Exam
Pulse:54 Resp:18 O2 sat:100/RA
B/P Right:107/66 Left:119/74
Height:6' Weight:225 lbs
General: awake alert oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur: none
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x]
no Edema dense area of Varicosities right calf; none on the left
calf.
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: very soft bruit
Pertinent Results:
Preop:
[**2200-5-16**] 10:13AM HGB-13.6* calcHCT-41
[**2200-5-16**] 10:13AM GLUCOSE-88 LACTATE-1.8 NA+-138 K+-4.0 CL--106
[**2200-5-16**] 01:29PM FIBRINOGE-170
[**2200-5-16**] 01:29PM PT-14.2* PTT-22.0 INR(PT)-1.2*
[**2200-5-16**] 01:29PM WBC-8.5 RBC-3.22* HGB-10.5* HCT-29.4* MCV-91
MCH-32.7* MCHC-35.8* RDW-12.7
[**2200-5-16**] 03:30PM UREA N-16 CREAT-0.8 SODIUM-141 POTASSIUM-4.3
CHLORIDE-111* TOTAL CO2-24 ANION GAP-10
Discharge:
[**2200-5-20**] 05:08AM BLOOD WBC-4.5 RBC-3.15* Hgb-10.0* Hct-28.6*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.3 Plt Ct-190
[**2200-5-20**] 05:08AM BLOOD Plt Ct-190
[**2200-5-20**] 05:08AM BLOOD Glucose-95 UreaN-15 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-27 AnGap-13
[**2200-5-20**] 05:08AM BLOOD Mg-2.2
Radiology Report CHEST (PORTABLE AP) Study Date of [**2200-5-18**]
11:40 AM
Final Report CHEST ON [**5-18**].
FINDINGS: The endotracheal tube, chest tube and mediastinal
drains have been removed. Right IJ line tip is in the lower SVC.
There are compressive
changes at both bases. There is a small left apical
pneumothorax.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40 cm
from the incisors.
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. No mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname 59353**]
before surgical incision.
Post_Bypass:
Preserved biventricular systolic function. LVEF 55%.
No valvular issues. Intact thoracic aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2200-5-16**] 15:32
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] for cardiac catheterization, which
revealed patient had 3 vessel coronary artery disease. Cardiac
surgery was consulted and the following day the patient was
brought to the operating room for coronary bypass grafting.
Please see the operative report for details, in summary he had:
Coronary artery bypass grafting x4 with Left internal mammary
artery graft to left anterior
descending, reverse saphenous vein graft to the marginal branch,
diagonal branch, and posterior descending artery. His bypass
time was 77 minutes with a crossclamp time of 64 minutes. He
tolerated the operation well and post-operatively was
transferred to the cardiac surgery ICU for recovery in stable
condition on Neosynephrine infusion The patient woke
neurologically intact, was weaned from the ventilator and
extubated without difficulty. On POD1 the patient was weaned
from his Neosynephrine infusion. The remainder of his post-op
course was uneventful. All tubes, lines and drains were removed
per cardiac surgery protocol. On POD2 he was transferred to the
stepdown floor for continued recovery. Over the next few days he
worked with physical therapy and the nursing staff to improve
his strength and conditioning. On POD4 he was discharged home
with visiting nurses.
He is to follow up in wound clinic in 1 week and with Dr [**Last Name (STitle) **]
in 4 weeks
Medications on Admission:
LEVOTHYROXINE - Dosage uncertain
METOPROLOL TARTRATE -25 mg twice a day
NITROGLYCERIN - Dosage uncertain
SIMVASTATIN -20 mg daily
ASPIRIN 325 mg once a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 2 weeks.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever or pain.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every [**2-26**]
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p Coronary bypass grafting x4
PMH: Dyslipidemia
Varicose veins
Hypothyroid
Gastric ulcer mid [**2178**]/GI bleed
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating independently with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- trace bilat 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) **] Date/Time:[**2200-6-12**] 1:00 [**Telephone/Fax (1) 170**]
Cardiologist: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on ????
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 1447**],[**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8324**] in [**2-25**]
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:[**2200-5-20**]
|
[
"285.1",
"E878.2",
"411.1",
"272.4",
"414.01",
"458.29",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
9052, 9101
|
6278, 7667
|
332, 554
|
9260, 9513
|
2512, 6255
|
10354, 10999
|
1716, 1778
|
7874, 9029
|
9122, 9239
|
7693, 7851
|
9537, 10331
|
1793, 2493
|
272, 294
|
582, 1385
|
1407, 1487
|
1503, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,672
| 159,612
|
1569
|
Discharge summary
|
report
|
Admission Date: [**2189-3-18**] Discharge Date: [**2189-3-20**]
Date of Birth: [**2155-9-3**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath, chest tightness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 33 year old woman with a past medical history
significant for asthma presents to the hospital complaining of
SOB and chest tightness x 1 week. She states that her symptoms
began approximately 2 days after moving into her grandmother??????s
attic. She started to wake up in the middle of the night
feeling SOB which was quickly relieved with her inhaler. The
day before presentation to the hospital, she not only had
symptoms at night, she also started to experience SOB, chest
tightness and wheezing throughout the day. She used her inhaler
approximately 10 times but experienced no relief, she then used
her cousin??????s albuterol nebulizer because she was too weak to go
through her un-packed moving boxes to find her own. She gave
herself 2 treatments with no relief of symptoms. Her aunt,
concerned about her lack of improvement called 911.
At baseline, Ms. [**Known lastname **] uses her inhaler approximately twice per
day and states that she normally does not have to use it at
night. She states that for the past 3-4 years she feels that
her asthma has been under control. She reports that she had to
be intubated approximately 2-3 times and averages [**12-7**] emergency
room visits a year. Her triggers include: cold, URIs, mental
stress, cats, pollen, flowers, perfume and possibly exercise.
In her new home she needs to go through a common hallway to get
to her room. She has also been w/o her allergy pillows since the
move.
In the [**Name (NI) **] pt received IV Solumedrol and ATC albuterol nebs with
improvement in her symptoms. She was changed to 60 mg of
prednisone today. Currently she denies SOB. She continues to
note minimal chest tightness.
Denies N/V/D/belly pain/dysuria/F/C
Past Medical History:
1. Asthma
-Diagnosis at 3-4 years old
2. Depression
-Diagnosis at 26-27 years old
-Two hospitalizations due to suicidal ideation. Patient feels
that suicidal thoughts were due to family stressors in
combination with her asthma exacerbations (she had to be
intubated twice during her acute depressive episodes).
3. Eczema
-Diagnosis at 3-4 years old
-Well-controlled with Eucerin or hydrocortisone valerate
4. Allergic Sinusitis
-Patient states that she has base-line post-nasal drip, cough
and sneezing due to sinusitis
-Well-controlled with [**Doctor First Name **]
Social History:
Tobacco: A half a pack a day for the past 3-4 years. Patient
states that she is trying to quit due to the urging her
boyfriend.
EtOH: Occasionally
Cocaine, Heroine, Marijuana: Patient states that she has used
marijuana, but not currently. She denies past or present
cocaine or heroine use.
Sexual History: Not assessed.
Education level: Not assessed.
Employment: Ms. [**Known lastname **] works as a conductor for the ??????T??????, Green
line
Ms. [**Known lastname **] has two children. She currently lives in [**Location 9137**] in
grandmother??????s attic. She was recently granted custody of her
brother and sister who also live with her.
Family History:
Mother and father are in their 50s and still alive. She has a
sibling and cousin with asthma. No family history of CAD, DM or
hypertension.
Physical Exam:
T 97.7, 118/67, 92, 22, 98% RA, I/O: 1340/625
General : Well developed, well nourished, pleasant woman lying
down in bed, in no apparent respiratory distress
HEENT: Normocephalic, atraumatic. Moist mucus membranes, good
dentation, no sores appreciated in mouth, no lymphadenopathy.
Ears and eyes were not assessed.
Cardio: RRR, nl s1 and s2 with no extra heart sounds or
murmurs. Dorsalis pedial pulses palpated bilaterally; brisk
capillary refill
Lungs: Decrease breathe sounds bilaterally, no wheezes or
crackles appreciated
ABD: Active bowel sounds; soft, non-tender, non-distended; no
hepatospleenomegaly
Musculoskeletal: no calf-pain, no lower extremity edema
Neuro: A&Ox3; CNII-XII intact; 5/5 strength in both upper and
lower extremities, gross sensory intact, reflexes not assessed
Pertinent Results:
[**2189-3-18**]
GLUCOSE-96 UREA N-17 CREAT-0.9 SODIUM-141 POTASSIUM-4.0
CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2189-3-18**]
WBC-7.5 RBC-4.29 HGB-14.0 HCT-40.4# MCV-94# MCH-32.7* MCHC-34.7
RDW-12.0
PLT COUNT-136*
[**2189-3-18**]
NEUTS-41.1* LYMPHS-44.2* MONOS-4.1 EOS-8.8* BASOS-1.9
CXR 4/1305
IMPRESSION: Normal radiographic appearance of the chest.
Brief Hospital Course:
In the ED Ms. [**Known lastname **] was noted to be afebrile and in acute,
severe respiratory distress. She was given IV Mg, continuous
albuterol nebulization and subcutaneous epinephrine with some
improvement of symptoms. It was felt that Ms. [**Known lastname **] needed to
be closely observed so she was admitted to the MICU.
Ms. [**Known lastname **]??????s stayed in the MICU overnight. She remained afebrile
and her symptoms of dyspnea and air hunger improved. She was
then admitted to the Medicine service.
Asthma. Peak flow on day of discharge 350 cc (baseline),
Ambulatory O2 sat 98%.
-Albuterol nebs as needed
-Ipratropium Bromide nebs as needed
-Salmeterol 250/500 inhaler [**Hospital1 **]
-Prednisone 40mg qd
-Patient recieved counseling regarding removal of environmental
tiggers from her new home in order to decrease her risk of
having another acute asthma attack.
-Patient was scheduled for 2 outpatient appointments as
follow-up: one with her PCP [**Name9 (PRE) **] [**Name9 (PRE) 9138**] and with her
pulmonolgist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for the following week.
Eczema
-Continue Eucerin PRN
Allergic Sinusitis
-Beclomethasone nasal spray [**Hospital1 **]
Smoking
-Received smoking cessation counseling
-Continue Nicotine Patch 14mg
-Patient was given Wellbutrin to take 150 mg daily x3 days and
then [**Hospital1 **], she will follow up with her PCP.
Medications on Admission:
[**Doctor First Name **]
Adivir 500/50 one puff [**Hospital1 **]
Albuterol neb PRN
Ortho Evra birth control patch
Discharge Medications:
1. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
2. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
3. Prednisone 10 mg tabs
Please take 4 tabs for 2 days, then 3 tabs for 3 days, then 2
tabs for 3 days, then 1 tab for 3 days, and then stop.
Disp: 26 tabs
4. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*3 Patch 24HR(s)* Refills:*2*
5. Wellbutrin 75 mg Tablet Sig: Two (2) Tablet PO once a day:
for three days, and then increase to 2 tabs twice a day. .
Disp:*120 Tablet(s)* Refills:*2*
6. Nebulizer Machine
Please dispense one nebulizer machine.
7. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*QS * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Asthma Attack
Discharge Condition:
Good.
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening shortness of breath, chest
tightness, or have any other concerns.
You should try to avoid cats, dust and other known substances
that triggers your asthma attacks.
Followup Instructions:
You have the following appointments scheduled:
1. Provider: [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-3-26**]
11:30
2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2189-3-26**] 2:30
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-4-7**] 1:30
|
[
"493.02",
"305.1",
"311",
"692.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7222, 7228
|
4735, 6157
|
314, 320
|
7291, 7298
|
4354, 4712
|
7604, 8272
|
3375, 3518
|
6322, 7199
|
7249, 7270
|
6183, 6299
|
7322, 7581
|
3533, 4335
|
238, 276
|
348, 2094
|
2116, 2692
|
2708, 3359
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,093
| 193,845
|
45606
|
Discharge summary
|
report
|
Admission Date: [**2119-8-10**] Discharge Date: [**2119-8-14**]
Date of Birth: [**2038-1-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Fall and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 97258**] is an 81M with a h/o myelofibrosis, zencker's
diverticulum s/p surgery, blindness, hypothyroidism, hearing
loss, and recent shortness of breath who presented today after a
fall. This morning the patient went to see his PCP for his
shortness of breath. His PCP was concerned that he may have CHF,
pneumonia, or aspiration and ordered a CXR which showed possible
CHF and left base PNA. While walking back from the CXR he
apparently lost consciousness and fell. He does not remember the
details leading up to the fall. He was then brought to the ED
for further evaluation.
With regards to his shortness of breath, it has been going on
for the past month. He is concerned that he is aspirating again
since he had similar symptoms prior to his zenker's diverticulum
repair in [**2116**]. He denies fevers and night sweats but has noted
some chills over the same period. He has chronic swelling in his
lower extremities R> L which he thinks may be worse lately. He
was previously on lasix 20mg daily but his hematologist had him
stop taking it two weeks ago because he appeared to be dry per
their note. He endorses 1 pillow orthopnea and PND which are
both worse over the past few weeks.
On arrival to the ED his vitals were 98.1, 110, 183/83, 22,
90%RA. While in the ED he desaturated to 70% on RA and he was
placed on a 100% non-rebreather. EKG showed no ST changes, old
RBB and LAFB and PAC's. CXR from PCP's office before the fall
showed likely CHF and L lower lobe PNA, patient refused repeat
CXR. CT head/ cspine showed no acute process. Hand and knee
injuries were not imaged. Given his history of aspiration he was
treated with IV Zosyn. He was also given 20mg IV lasix and put
out 700cc's urine. While in the ED he spiked a temperature to
102. Labs were notable for a WBC of 14. He was then admitted to
the MICU for further management.
On arrival to the MICU, patient is saturated in the high 90s on
60% Non-re-breather. He is A+OX3 and able to give a complete
history without respiratory distress.
Past Medical History:
Past Medical History:
1. Myelofibrosis (JAK2 positive) followed by Dr. [**Last Name (STitle) 3638**]
2. Hypertension.
3. Hearing loss.
4. Legaly Blind from macular degeneration
5. Hypothyroidism.
6. Leg edema, right more than left.
7. Fracture of the superior and inferior rami
and sacrum in 12/[**2117**].
8. Diverticulitis
9. Zencker's diverticulum surgically repaired at [**Hospital 97259**] in [**2117-2-22**].
10. Hypothyroidism
11. Aspiration PNA ([**4-/2116**]) with hypoxemic respiratory failure
requiring intubation
12. Aspiration PNA ([**11/2118**]) requiring hospitalization
.
PAST SURGICAL HISTORY:
1. History of bone marrow biopsy.
2. Surgical treatment of fractures.
Social History:
The patient is single and does not have any
children. He lives alone in an apartment. He worked as an
English professor [**First Name (Titles) **] [**Hospital3 **] [**Location (un) **], but he is now
retired. He denies any domestic violence. He does not drink and
does not smoke. He feels mildly depressed due to his current
lack of companionship and decreased physical activity. He
exercises on a regular basis and currently is enrolled in
physical therapy. He eats well.
Family History:
The patient's mother died of lung cancer and the
patient's father had some type of bone lesion. His one brother
has type 2 diabetes at older age.
Physical Exam:
ADMISSION PE:
General: Alert, oriented. Conversant
HEENT: Non-rebreather in place. Dried blood in the mouth, lacs
to lower lip and chin.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: basilar crackles Left > right
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: 1+ pitting edema bilaterally. Echymoses and swelling over
dorsum of L hand. Skin breakdown over right hand, backside from
fall. Effusion of left knee.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation,
DISCHARGE PE:
VS - T 97.6 BP 161/52 HR 72 RR 20 SO2 96%/2L
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PER, sclerae anicteric, poor dentition
LUNGS - Inspiratory crackles in right base, good air movement,
resp unlabored, no accessory muscle use
HEART - Distant heart tones. Bigeminy, no murmurs.
ABDOMEN - NABS, soft/NT, distended, hepatomegaly, ?splenomegaly,
no masses, no rebound/guarding
EXTREMITIES - WWP, bilateral 1+ pitting pedal edema
SKIN - large eccymosis on chin.
NEURO - awake, A&Ox3, sensation grossly intact throughout,
Pertinent Results:
ADMISSION LABS
[**2119-8-10**] 03:35PM BLOOD WBC-14.5*# RBC-2.95* Hgb-8.9* Hct-29.0*
MCV-98 MCH-30.2 MCHC-30.6* RDW-20.7* Plt Ct-561*
[**2119-8-10**] 03:35PM BLOOD Neuts-90.9* Lymphs-6.2* Monos-2.3 Eos-0.3
Baso-0.4
[**2119-8-10**] 03:35PM BLOOD PT-13.2* PTT-36.7* INR(PT)-1.2*
[**2119-8-10**] 03:35PM BLOOD Glucose-99 UreaN-38* Creat-1.3* Na-146*
K-4.7 Cl-111* HCO3-25 AnGap-15
[**2119-8-10**] 03:35PM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
[**2119-8-10**] 03:35PM BLOOD TSH-5.9*
CBC TREND
[**2119-8-10**] 03:35PM BLOOD WBC-14.5*# RBC-2.95* Hgb-8.9* Hct-29.0*
MCV-98 MCH-30.2 MCHC-30.6* RDW-20.7* Plt Ct-561*
[**2119-8-11**] 04:35AM BLOOD WBC-18.3* RBC-2.34* Hgb-7.1* Hct-23.0*
MCV-98 MCH-30.2 MCHC-30.7* RDW-20.6* Plt Ct-329
[**2119-8-12**] 01:52AM BLOOD WBC-12.4* RBC-2.20* Hgb-6.7* Hct-21.7*
MCV-99* MCH-30.3 MCHC-30.7* RDW-20.8* Plt Ct-331
[**2119-8-12**] 09:20AM BLOOD WBC-9.0 RBC-2.11* Hgb-6.3* Hct-20.7*
MCV-98 MCH-29.7 MCHC-30.2* RDW-20.6* Plt Ct-296
LFT/HEMOLYSIS
[**2119-8-11**] 04:35AM BLOOD ALT-9 AST-12 LD(LDH)-382* CK(CPK)-27*
AlkPhos-52 TotBili-0.6
[**2119-8-11**] 04:35AM BLOOD Hapto-10*
[**2119-8-12**] 01:52AM BLOOD Ret Aut-2.9
[**2119-8-12**] 01:52AM BLOOD Coombs neg.
CARDIAC ENZYME TREND
[**2119-8-10**] 03:35PM BLOOD CK-MB-6 cTropnT-0.05*
[**2119-8-11**] 04:35AM BLOOD CK-MB-3 cTropnT-0.05*
ABG
[**2119-8-10**] 11:02PM BLOOD Type-ART pO2-142* pCO2-38 pH-7.43
calTCO2-26 Base XS-1
[**2119-8-10**] 11:02PM BLOOD Lactate-0.7
DISCHARGE LABS
[**2119-8-14**] 06:10AM BLOOD WBC-8.3 RBC-2.68* Hgb-7.9* Hct-25.4*
MCV-95 MCH-29.4 MCHC-31.1 RDW-21.1* Plt Ct-336
[**2119-8-14**] 06:10AM BLOOD Glucose-82 UreaN-48* Creat-1.3* Na-142
K-4.4 Cl-110* HCO3-27 AnGap-9
[**2119-8-14**] 06:10AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.1
STUDIES:
[**8-10**] PA + LAT CXR
IMPRESSION: CHF as well as new pulmonary parenchymal
infiltrates on the left base suspicious for pneumonic infection.
Followup examination is recommended.
[**8-10**] CT Head w/o Contrast
IMPRESSION:
1. No acute intracranial process.
2. Chronic small vessel ischemic disease and atrophy.
3. Lucent lesion within the right calvarium, likely hemangioma.
4. Opacification of the right mastoid air cells, likely due to
inflammation.
[**8-10**] CT spine w/o Contrast
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Rotation of C1 on C2 may be positional, correlate with
patient's pain to
exclude rotatory subluxation.
3. Multilevel degenerative changes.
4. Large enker's diverticulum.
5. Likely mild pulmonary edema.
[**8-11**] Hand(AP+LAT) XR:
IMPRESSION:
1. Acute, non-comminuted, non-displaced fracture of the head of
the fourth metacarpal.
2. Acute, non-comminuted, laterally displaced fracture of the
base of the fifth metacarpal.
3. Moderate degenerative changes in the first carpometacarpal
joint.
[**8-11**] ECHO
IMPRESSION: At least moderate pulmonary hypertension. Dilated
right ventricle with borderline-normal systolic function and
evidence of pressure overload. Symmetric LVH with normal global
and regional biventricular systolic function.
[**8-11**] LENI US
IMPRESSION:
No evidence of deep vein thrombosis in the lower extremities.
Relatively stable soft tissue edema.
[**8-11**] CXR AP
There is increased opacity in the left lower lobe, consistent
with increasing pleural effusion and atelectasis, superimposed
infection cannot be excluded. A small right pleural effusion is
less conspicuous than before, is associated with adjacent
atelectasis. Moderate cardiomegaly is stable. There is no
pneumothorax. There is mild vascular congestion.
Brief Hospital Course:
Mr. [**Known lastname 97258**] is an 81M with a h/o myelofibrosis, Zencker's
diverticulum, and blindness who presents with shortness of
breath and a fall.
ACTIVE ISSUES
#) Hypoxemia: CXR showed new left lower and middle lobe opacity.
On arrival to the MICU, amp/sulbactam and azithromycin were
started to cover atypicals and anaerobes as pt has significant
aspiration risk with Zenker's diverticulum. He had been off of
his lasix for 4weeks and he appeared slightly volume up on exam
and chest x-ray showed vascular congestion. He received 20 mg
IV lasix and put out 1 L overnight in the MICU. Dry weight was
unclear, but highest weight in past 2 years was during
hospitalization at 115 lbs, normally ranges 100-113 in OMR. By
the morning of [**8-11**], he was weaned to 2 L NC. ABG nml. Echo on
[**8-11**] did not show evidence of CHF. On the medical floor, he was
placed on 4L NC initially and weaned on [**8-12**] to 2L. His
anitbiotics were switched to PO augmentin and PO azithromycin
and he was given 20 mg PO lasix for his SOB. The medical team
touched base with his PCP who agreed to keep pt on Lasix 20mg PO
daily. He had been afebrile since ED. In regards to oxygen
supplementation, pt desaturated to mid 80s on room air when
weaning attempted on day of discharge and was then placed back
on 2L NC where he continued to saturate in the mid to high 90s.
Pt is to continue augmentin for a 7 day course, and azithromycin
5 day course was completed on [**2119-8-14**].
#) Anemia: He has a normocytic anemia worsening from
myelofibrosis and was admitted with 29.0. Hct trended and
dropped to 20.7 on [**8-12**]. Acute drop in Hct could be due to
hemolysis secondary to infection/DIC. DIC unlikely based on INR
not changed from baseline, baseline LDH, and normal billirubin.
Haptoglobin was low at 10, but Coombs was negative and
reticulocyte count was low. He was transfused 1u of RBCs on [**8-12**]
for hct of 20.7 and was also started on home dose Lasix to
prevent fluid overload. Pt's initial hct of 29 on admission was
most likely related to hemoconcentration as pt was not taking in
good PO at home and was dehydrated. After speaking to pt's outpt
hematologist, pt's baseline hct falls between 20-22. He was
continued on home B12/folate and was discharged with stable hct
at 25.
#) Syncope/Fall: Patient does not remember fall so he likely
lost consciousness beforehand. Syncope may have been related to
acute illness as above or dehydration/orthostatic hypotension as
pt admits to not have been taking in good PO in past week
(possibly related to pneumonia vs disabled vs depression). With
pt's recent swelling of bilateral feet due to not taking Lasix,
may have been a mechanical fall and with pt's head trauma
(ecchymosis on chin), did lose consciousness with subsequent
concussion. Hypoxia was another possibility as pt has pulmonary
hypertension seen on echocardiography with pneumonia, and thus
pt required high amounts of O2 supplementation in the MICU. ECG
and troponins ruled out MI, but arrhythmia is a possible
etiology given RBBB and bigeminy found on telemetry. Head
/c-spine CT showed no fracture. XRay hand revealed fracture,
which was splinted by plastics. Telemetry on floor [**8-11**] shows
bigeminy, but appeared stable, so telemetry DC'ed on [**8-12**]. Pt's
pain in chin and L hand was controlled with acetaminophen 650 mg
Q6h PRN. PT evaluated pt and found that pt's risk for future
falls was significant and recommended rehab dispo. Pt is to work
on balance and lower extremity exercises at rehab facility. Pt
also should see PCP and consider cardiology referral as RBBB was
found on EKG along with atrial bigeminy on telemetry and at risk
for complete heart block.
#) Left Hand Fracture of 4th and 5th metacarpals: Pt fell on day
of admission and found to have fractures of L 4th and 5th
metacarpals. Pt was seen by plastic surgery hand team and had
hand placed in ulnar gutter + thumb spica short arm cast. Pt is
to follow-up with orthopedic hand team in clinic on [**8-23**].
Pain was manageable with PRN Tylenol and was no longer needed on
day of discharge.
#) Hypothyroidism: TSH high at 5.9 on [**8-10**]. Synthroid increased
to 100 mcg while pt was in the MICU. With pt living alone at
home and legally blind, personal hygiene and medication
compliance are issues. Pt may have not been adherent with
medications and will need TSH followed up on in near future.
#) Zencker's Diverticulum: He complains of episodes of N/V and
chronic cough, which initially improved following surgical
repair of diverticulum, but has now worsened; pt endorses having
food particles regurgitation intermittently. Aspiration was a
concern and pt was seen by speech and swallow while in MICU;
video study deferred as pt's bedside swallowing trials were
acceptable. Pt's intermittent nausea and cough (may also be
related to pneumonia) may suggest possible worsening of zencker
diverticulum and thus outpatient barium swallow is recommended
to evaluate chronic aspiration and diverticulum. He wants to
follow-up with his prior surgeon at [**Hospital1 2025**].
#) Depression: Pt endorses worsening depression during
hospitalization and feels extremely lonesome. He denies active
suicidal ideation or any intent on hurting himself, but does
have some passive suicidal ideation, and expresses desire to
"give up". Social work was consulted and recommended follow-up
with social work and psychiatry as outpatient. We recommended
outpatient psychiatry appointment (pt has specific preferences
on who not to see) for psychotherapy and pharmacotherapy if
needed.
TRANSITIONAL ISSUES
#Conduction disease of the heart:
-Pt is to followup with PCP for cardiology referral to
investigate RBBB and atrial bigeminy.
#Pneumonia:
- continue PO augmentin 500 mg [**Hospital1 **] for 7 days (started [**8-10**], end
on [**2119-8-16**])
#Anemia:
- f/u w/ Dr. [**Last Name (STitle) 3638**] on [**9-27**]
- monitor CBC
- continue Vitamin B12 100 mcg PO daily
- continue folic acid 1 mg PO daily
#Left hand fracture:
- Keep hand elevated
- Patient will FU in ortho hand clinic in one week following
discharge or re-evaluated in one week
#Hypothyroidism
- continue synthroid 100 mcg PO daily
- check TSH and titrate synthroid accordingly
#Zencker Diverticulum
- We recommend pt have an outpatient barium swallow to further
investigate chronic aspiration
#Depression:
- Pt requests outpatient psychiatry appointment for depression
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Acetaminophen 1000 mg PO Q6H:PRN pain
5. Amoxicillin-Clavulanic Acid 500 mg PO Q12H Duration: 2 Days
stop on Day 7 ([**2119-8-16**])
6. Furosemide 20 mg PO DAILY
7. Nystatin Oral Suspension 5 mL PO TID
8. Sodium Chloride Nasal [**12-26**] SPRY NU [**Hospital1 **]:PRN congestion
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Syncope, Fall
Left hand fracture
Community Acquired Pneumonia
Secondary
Zenker's diverticulum
Anemia, Myelofibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 97258**],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to hospital after falling and losing
consciousness. We found that you did have fluid in your lungs
and a pneumonia and you did well in the ICU before being
transferred to the medical floor for continued treatment of your
pneumonia. Your red blood cell count was low and we gave you a
blood transfusion after getting approval from your PCP and
hematologist. Your doctors recommended [**Name5 (PTitle) **] continue taking Lasix
to help with your breathing and leg swelling. You finished a 5
day course of azithromycin for your pneumonia but you are to
continue taking Augmentin for another two days to fully treat
your pneumonia. In addition, please follow up with your primary
care physician in regards to possible cardiology (heart
specialist) referral as we saw some abnormalities on your EKG
and heart tracings. This may or may not have been related to
your fall.
We recommend you have a barium swallow study to evaluate how
well you swallow food. Your history of Zenker's diverticulum
puts you at risk for aspiration and future recurrent lung
infections.
You are to follow up in orthopedic hand clinic on [**8-23**]
for further management of the fractures in your left hand.
Followup Instructions:
You are to followup in hand clinic for further treatment of the
fractures in your hand.
Department: ORTHOPEDICS
When: WEDNESDAY [**2119-8-23**] at 10:10 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2119-8-23**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**],MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please discuss with your primary care physician to establish [**Name Initial (PRE) **]
psychiatrist to talk to about your depression. Also, ask them
to refer you to a cardiologist.
Department: GERONTOLOGY
When: MONDAY [**2119-9-11**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2119-9-27**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 11223**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2119-9-27**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) 3014**], NP [**Telephone/Fax (1) 9645**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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[
[
[]
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,704
| 126,228
|
41274
|
Discharge summary
|
report
|
Admission Date: [**2150-4-26**] Discharge Date: [**2150-5-10**]
Date of Birth: [**2092-10-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
seizure, ?s/p arrest
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
57 year old male with past history of obstructive
hydrocephalus,hypertension, [**Hospital 88414**] nursing home resident. Was in
usual state of health today when he fell out of chair,
Tonic-clonic seizure like activity was also noted and was found
to be pulseless by nursing staff. CPR was started and AED
advised a shock and it was administered. Of note, blood glucose
was 68 2 minutes prior to event and patient was administered
[**Location (un) 2452**] juice. When EMS arrived, he was noted to have pulses and
were unable to intubate in the field due to trissmus, possible
decortication. Initial rhythm noted to be sinuts tach and he was
unresponsive with "snoring respirations". Blood glucose reported
to initially 140. He was transported to [**Hospital3 **] for
evaluation. On exam there, pupils noted to be 2-3mm bilateraly
and reactive, no gag, rigid extremities. There, he was
intubated. CT Head showed no acute bleed, mild hydrocephalus. He
was noted to have left sided tremulousness and was given 10 mg
ativan + 2mg versed and loaded with fosphenytoin. Labs at [**Hospital **] showed normal BMP, slight elevation of AST/ALT to 73/69,
respectively. CBC with 14.1 WBC's, normal diff.
Lifeflight to [**Hospital1 18**] for neuro eval/cooling. Enroute, he recieved
rocuronium, propofol, fentanyl, 2L Cold NS with vent settings at
450x12, PEEP 5, FiO2 100%.
In the ED, initial vitals were 98.1 101 197/114 18 100% on vent.
CT Neck was performed and noted to be negative.
Vitals prior to transfer were 98.1 101 194/114 18 100% 550x18
PEEP.
Past Medical History:
Obstructive Hydrocephalus
NIDDM (recent blood sugars 71-83 fasting am, 78-174 afternoon)
ETOH Abuse
Hypertension
Known paralysis of Left UE
Social History:
Lives in nursing home, rest unavailable - patient sedeated.
Family History:
unable to obtain, patient sedated
Physical Exam:
On Admission:
VS: Temp: BP: 156/86 HR: 82 RR: 18 O2sat: 100%on CMV 550x18,
PEEP 5, FiO2 40%
GEN: intubate, unresponsive
HEENT: pupils equal at 2-3 mm, non-reactive, MMM, ETT in place,
no JVD
RESP: CTA b/l anteriorally
CV: RRR, no m/g/r
ABD: soft, non-distended, +BS, no HSM
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: sedated, withdraws to pain, left arm with increased
tonicity - appears chronic contraction. Babinski's
indeterminant. no facial droop.
.
On Discharge:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, fixed downward gaze
Head, Ears, Nose, Throat: Normocephalic, Poor dentition,
Endotracheal tube, OG tube
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, No(t) Distended
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, rue edematous
Skin: Warm
Neurologic: fixed downward gaze, upgoing toes, no response to
voice or sternal rub.
Pertinent Results:
On admission:
[**2150-4-26**] 10:25PM BLOOD WBC-21.9* RBC-5.20 Hgb-14.8 Hct-42.7
MCV-82 MCH-28.5 MCHC-34.7 RDW-15.5 Plt Ct-409
[**2150-4-26**] 10:25PM BLOOD PT-12.1 PTT-26.4 INR(PT)-1.0
[**2150-4-27**] 01:16AM BLOOD Glucose-287* UreaN-17 Creat-0.7 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2150-4-27**] 01:16AM BLOOD ALT-63* AST-55* CK(CPK)-502* AlkPhos-82
TotBili-0.3
[**2150-4-27**] 01:16AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.4*
.
Imaging:
CXR on admission: As compared to the previous radiograph, the
endotracheal tube and the nasogastric tube are in unchanged
position. The tip of the endotracheal tube projects
approximately 4.5 cm above the carina. The course of the
nasogastric tube is unchanged. No safe evidence of pneumothorax.
No pleural effusions. No focal parenchymal opacities. Normal
size of the cardiac silhouette.
.
[**2150-4-26**] C-Spine: There is no evidence of fracture or
subluxation. Multilevel degenerative changes are noted, most
prominent at C4-C5. The thecal sac cannot be completely
evaluated on CT scan. There is no evidence of traumatic
dislocation. The prevertebral soft tissue is maintained. There
is evidence of an ET tube as well as a nasogastric tube. The
visualized lung apices clear.
.
ECHO [**2150-4-27**]: Symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mildly dilated descending thoracic aorta.
.
CT Head contrast [**2150-5-2**]:
1. Subtle areas of increased conspicuity of periventricular and
subcortical white matter hypoattenuation that may be technical,
though areas of subacute infarction are not excluded and
recommend correlation with MRI if clinically feasible.
2. Mildly increased prominence of the ventricular system,
particularly
involving the temporal horns. Continued followup is recommended.
3. No intracranial hemorrhage.
.
MRI [**2150-5-3**]: Again seen are extensive periventricular white
matter abnormalities suggesting small vessel ischemia. These are
best seen on the FLAIR images. However, the diffusion images
demonstrate numerous areas of slow diffusion also in the deep
white matter, suggesting innumerable deep infarctions. There is
no evidence of hemorrhage. The FLAIR images demonstrate
extensive signal intensity abnormality involving the pons, and
there is evidence of mild slow diffusion within this area, also
suggesting infarction.
CONCLUSION: Extensive deep white matter infarction including
cerebellar
hemispheres and probable involvement of the pons.
.
Ultrasound [**2150-5-3**]:
1. DVT in right subclavian, axillary (2 veins noted), and
brachial veins.
Proximal extent of DVT not evaluated.
2. Thrombus in the right basilic vein.
3. Cephalic vein patent.
.
Microbiology:
GRAM STAIN (Final [**2150-4-29**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
Brief Hospital Course:
57 year old male with history of obstructive hydrocephalus who
had a fall at his nursing home with subsequent seizure like
activity. He was admitted here intubated for post cardiac arrest
cooling. Neurology followed. He was treated with dilantin based
on history but there was no evidence of seizure on EEG. After
rewarming, he remained non-responsive. On [**4-28**] he was started on
antibiotics for ventilator-associated pneumonia for fever and
increased secretions. When his respiratory barriers to
extubation were improved with fewer secretions and diuresis, and
tolerating minimal settings, more attention was focused on his
failure to improve neurologically. He was off of sedation for
several days. He had a CT which was concerning for watershed
infarcts. This was followed by an MRI which showed innumerable
deep infarctions including cerebellar hemispheres and probable
involvement of the pons. Additionally, his exam was notable for
a downward gaze which has been associated with progression to a
persistent vegetative state in post arrest patients. His health
care proxy is a social worker who has known him only since
[**Name (NI) 1096**]. She agreed to be his HCP so that he would be accepted
at a nursing home. She relayed the patient had clearly stated
that he would not want to be kept alive on machines or have his
life extended if he were not able to have meaningful quality of
life. He was visited by his sister from whom he had been
estranged for seven years. On [**5-4**], goals of care were changed
to CMO. He was extubated and non-comfort-oriented medications
were stopped. The NEOB was called and they declined his organs.
He was transferred to the floor on [**2150-5-5**]. He was continued on
a Morphine drip and Scopolamine patch. He developed persistent
fevers on [**2150-5-6**] and was given Acetaminophen 650 mg PR Q4H PRN.
He was admitted to inpatient hospice on [**2150-5-7**]. His central
line was discontinued on [**2150-5-8**] and a PIV was placed. He
developed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6055**]-[**Doctor Last Name **] breathing pattern with occasional
apneic pauses. He had respiratory failure in the early morning
of [**2150-5-10**]. Autopsy was declined by his next of [**Doctor First Name **].
Medications on Admission:
amlodpine 10 daily
glipizide 10 daily
vitamin b12 1000mcg daily
crestor 5mg once daily
thiamine 100mg daily
lisinopril 40mg [**Hospital1 **]
metoprolol 25mg 1.5 tablets (37.5mg) [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
paroxetine 40mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Chief: hypoxic brain injury
Immediate: respiratory failure
Discharge Condition:
Expired
|
[
"348.30",
"E884.2",
"401.1",
"780.03",
"276.2",
"427.1",
"453.85",
"780.39",
"348.1",
"453.82",
"453.84",
"331.4",
"E879.8",
"518.81",
"427.41",
"250.00",
"599.0",
"294.10",
"342.90",
"434.91",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8948, 8957
|
6372, 8647
|
326, 337
|
9060, 9070
|
3431, 3431
|
2167, 2202
|
8978, 9039
|
8673, 8925
|
2217, 2217
|
2691, 3412
|
266, 288
|
365, 1910
|
3887, 6349
|
1932, 2074
|
2090, 2151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,899
| 145,848
|
9034+55994
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-9-23**] Discharge Date: [**2140-9-26**]
Date of Birth: [**2081-1-10**] Sex: M
Service:
ADMITTING DIAGNOSIS:
1. Attempted suicide drug overdose.
2. Depression.
3. Herniated disk.
Russian gentleman with a past medical history significant for
prior depression with multiple suicide attempts in the past
who was subsequently brought to the [**Hospital6 649**] Emergency Room on [**9-23**] with a chief
complaint of unresponsiveness after being discovered by EMTs.
The patient was found in the hotel room unresponsive to
stimuli and painful stimulation. He was discovered with
Diphenhydramine 32 tab x 3, with a total 4800 mg total
OxyContin, 20 mg 13 pills Tylenol #3 36 pills.
White in the ambulance prior to arrival to the Emergency
Room, the patient was given Narcan and was subsequently
evaluated in the Emergency Room and was found to have [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma scale of 3 at which time the patient was
intubated for airway protection and was given charcoal lavage
times one. The patient was then toxicology screened for his
urine and was negative for any illicit drug use. The patient
was subsequently transferred to the Medical Intensive Care
Unit where he was monitored closely for acute respiratory
failure secondary to attempted overdose with Benadryl and
OxyContin.
The patient was subsequently extubated on [**9-25**] without
complications and was found to be awake and responsive and to
tolerate a regular diet. On [**9-25**], the patient was found
to be .................. most likely secondary to aspiration
and was started on Levofloxacin and Flagyl. Sputum and blood
cultures were sent. The patient denied any suicidal ideation
or depression.
He gave a history of recent separation with his spouse as the
precipitant for his suicide attempt. He noted that he
had a depressed mood for about one year, and he had been
treated with Prozac in the past which had helped his
depression, but it was complicated with sexual dysfunction,
and so he was changed to Wellbutrin. He had only been on
Wellbutrin for one week prior to the suicide attempt. The
patient gives a reasonable willingness to pursue medical
assistance for his psychiatric illness.
He denied any chest pain, shortness of breath, abdominal
pain, nausea, vomiting, or diarrhea at the time.
PAST MEDICAL HISTORY: Depression. Suicide attempt in [**2115**]
in which he cut his arm. He had no hospitalization at that
time. Second suicide overdose attempt in [**2124**] for which he
was hospitalized. He had a third suicide attempt overdose in
[**2138**]. He was hospitalized. He has a history of herniated
disk. Prostate cancer.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: He is in a third marriage of five years
duration. He is an immigrant from [**Country 532**]. He is a professor
[**First Name8 (NamePattern2) **] [**Last Name (Titles) 26749**] language at [**University/College **]. He admits to occasional
tobacco and alcohol use. No illicit drug use except for
overdose.
FAMILY HISTORY: No known family psychiatric history to date
but a questionable history of depression in his mother.
MEDICATIONS: He was on Zantac, subcue Heparin, Levofloxacin,
Flagyl, Reglan, Ativan.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: Vitals signs: He had a T-max of 101??????,
a Tc 99.5??????, oxygen saturation 99% on room air,
respirations 25, blood pressure 108/55. General: He was in
no acute distress. He was alert and oriented. He had a
moderate to flat affect. Chest: Clear with good breath
sounds. There were basilar crackles heard on the right.
Heart: Regular, rate and rhythm. No murmurs, rubs or
gallops heard. Abdomen: Soft, nontender, nondistended.
Positive bowel sounds. Extremities: No clubbing, cyanosis
or edema. Pulses 2+. Warm. Full range of motion.
LABORATORY DATA: He had a chest x-ray performed which showed
no evidence of infiltrate or an infected process.
White count 8.6; blood cultures, urine culture, and sputum
cultures were negative to date.
HOSPITAL COURSE: This was a 59-year-old man admitted to the
[**Hospital6 256**] on [**9-23**] for
attempted overdose with Benadryl, Tylenol #3, and OxyContin.
He was subsequently successfully extubated in the Intensive
Care Unit and medically cleared for an acute myocardial
infarction by enzymes. He was transferred to the medical
floor for ultimate treatment of questionable aspiration
pneumonia and for psychiatric placement.
Pulmonary: Status post extubation on [**9-24**], the patient
had a good oxygen saturation on room air. Currently he is no
need of supportive oxygen. Chest x-ray was negative for any
infiltrative process or infectious process. Most likely
fever was due to either aspiration pneumonia or chemical
pneumonitis. The patient will be continued on Levofloxacin
and Flagyl for a 10-day course.
Infectious disease: The patient was with fevers of
questionable etiology. Chest x-ray was negative. The
patient will continue on Levofloxacin and Flagyl. The
patient was afebrile for discharge.
Cardiovascular: The patient ruled out for myocardial
infarction by enzymes times three and was subsequently
cleared of any cardiac issues.
Heme: The patient had a low hematocrit to 30.5 on the
morning of [**9-25**]. Subsequent repeat hematocrit showed a
hematocrit of 33.5 and 32.5 respectively. The patient was
with no active bleeding and no signs or symptoms of
hemorrhage.
GI: The patient was tolerating a regular diet with no nausea
or vomiting. LFTs were all within normal limits.
Psychiatry: The patient is with a history of depression and
status post recent suicide attempt with overdose. The
patient was medically cleared and is now awaiting psychiatric
placement. He is currently followed by Psychiatry. He is on
a 1:1 sitter, and he is covered with Ativan 0.5 to 1.0 mg
p.o. p.r.n. for agitation.
DISPOSITION: The patient is medically stable and cleared for
psychiatric placement.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 31245**]
MEDQUIST36
D: [**2140-9-26**] 16:12
T: [**2140-9-26**] 16:01
JOB#: [**Job Number 31246**]
Name: [**Known lastname **], [**Known firstname 4794**] Unit No: [**Numeric Identifier 5441**]
Admission Date: [**2140-9-24**] Discharge Date:
Date of Birth: [**2081-1-10**] Sex: M
Service: Medicine
ADDENDUM: The patient was not discharged on [**9-26**], he is
being discharged on [**9-27**] t [**Hospital1 **] 4 which is [**Hospital6 5442**] Psychiatric Inpatient [**Hospital1 **].
The patient was stable and medically cleared.
[**Name6 (MD) 1662**] [**Last Name (NamePattern4) 4337**], M.D. [**MD Number(1) 4338**]
Dictated By:[**Name8 (MD) 5443**]
MEDQUIST36
D: [**2140-9-27**] 13:25
T: [**2140-9-27**] 13:38
JOB#: [**Job Number 5444**]
|
[
"722.10",
"507.0",
"296.33",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3092, 3318
|
4117, 7004
|
2741, 2748
|
3341, 4099
|
151, 2373
|
2396, 2717
|
2765, 3075
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,695
| 113,348
|
25840
|
Discharge summary
|
report
|
Admission Date: [**2133-6-12**] Discharge Date: [**2133-7-1**]
Date of Birth: [**2073-11-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Lower Back Pain with LE weakness beginning [**2133-6-8**]
Major Surgical or Invasive Procedure:
Laminectomy T12-L2
Single wire pacemaker placed
History of Present Illness:
Pt is a 59 y/o Cantonese female with a h/o Atrial fibrillation
and mechanical MVR (Bjork-Shiley) secondary to RHD experienced
low back pain and LE weakness beginning on [**2133-6-8**]. MRI of the
lumbar spine revealed a cystic mass at the T12-L2, which was
found to be a hematoma upon surgical exploration on [**2133-6-12**] and
was subsequently evacuated. Pt has been on Coumadin and digoxin
due to her cardiac hx and initially her INR was 3.5. During the
operation the pt experienced episodes of bradycardia with right
neck manipulation and swan-ganz catheter placement c/w vagal
etiology, however bradycardia and pauses continued for following
the surgery. Permanent v-lead pacemaker was placed on [**2133-6-14**]. Pt
demonstrated NSVT believed to be d/t digoxin toxicity (1.1).
Currently pt c/o pain in right leg from the buttock down to the
ankle on the lateral calf, diminishing distally. No c/o CP other
than at the incision site for the pacemaker, no SOB, no LH.
Difficulty with using bedside commode due to pain and reports no
BM, but positive flatus.
Past Medical History:
MVR secondary to RHD with Bjork-Shiley valve in [**3-/2108**]
Atrial fibrillation
HTN
Social History:
Visiting brother in US, lives in [**Name (NI) 651**], speaks predominantly
Cantonese and some English. No tobacco, alcohol, or recreational
drugs.
Family History:
Mother with HTN.
Physical Exam:
VS: HR - 103 RR - 20 T - 98.8 BP - 124/78
O2 sat - 95% on RA Pain - [**4-21**]
Gen: WN, WD thin woman who appears her age. Appears to be
uncomfortable and is diaphoretic.
HEENT: EOMI
NECK: JVP noted b/l, no JVD
CV: Irregularly irregular, tachycardic; Loud S1, S2, no M/R/G/C
noted; heart beat noted visibly across the chest and by
palpation. No carotid bruits.
Resp: CTA b/l A/P, no W/R/R
Abd: +BSx4, soft, NT/ND, no HSM
Ext: PP present and symmetric, except dorsalis pedis R>L. Ext
warm, with no cyanosis or edema. No right leg tenderness.
Neuro: AOx3; observed exam by Dr. [**First Name (STitle) 1022**] (ortho) - weakness in
right hallux extension; left LE weakness improving, left knee
extension at 2/5 strength.
Pertinent Results:
[**2133-6-12**] 12:20AM DIGOXIN-1.1
[**2133-6-12**] 12:20AM PT-23.0* PTT-31.6 INR(PT)-3.5
[**2133-6-12**] 12:20AM WBC-8.8 RBC-4.13* HGB-13.6 HCT-39.2 MCV-95
MCH-33.0* MCHC-34.8 RDW-13.4
[**2133-6-12**] 12:20AM GLUCOSE-137* UREA N-18 CREAT-0.6 SODIUM-135
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
MRI L-Spine [**2133-6-12**]:
IMPRESSION: Extramedullary hematoma, which may be intradural or
epidural, compressing the conus and cauda equina from T11/12
through L1/2. Associated large veins are suggestive of a
vascular malformation. If the hematoma is intradural, a spinal
cord arteriovenous malformation is likely. A conventional
angiogram is recommended for assessment of vascular
malformation. Follow-up lumbar spine MRI is also recommended to
evaluate the surgical decompression.
MRI L-Spine [**2133-6-13**]:
IMPRESSION: Status post decompression of a large dorsal epidural
hematoma, there is soft tissue swelling which continues to
impress the distal cord and proximal cauda equina.
CXR [**2133-6-15**]:
IMPRESSION:
1. Pacing leads in the expected position of the right ventricle.
No evidence of pneumothorax. 2. Massive enlargement of the left
atrium
Echo [**2133-6-16**]:
IMPRESSION: Normal functioning mitral valve prosthesis. Mild
aortic stenosis. Mild aortic regurgitation. Severe biatrial
enlargement. Preserved biventricular systolic function.
Pulmonary artery hypertension.
PM Interrogation [**2133-6-24**]:
PM functioning properly
Brief Hospital Course:
59 yo Cantonese F with history of Atrial fibrillation, Mitral
valve replacement presented with epidural hematoma and lower
extremity weakness. Patient is s/p epidural hematoma evacuation
on [**2133-6-12**] and s/p single wire pacer placement on [**2133-6-14**]
sceondary to periop brady/pause. Patient was found to have
NSVT/?junctional tachycardia likely secondary to digoxin
toxicity.
.
The patient p/w spontaneous epidural hematoma and LE weakness on
[**2133-6-12**]. Following diagnositic evaluation, the patient was taken
to surgery for a T12-L2 laminectomy and subsequent evacuation of
the hematoma. At the time of admission the patient's INR was 3.5
as she was taking 3.5mg coumadin PO Qhs for prophylactic
anticoagulation due to her h/o afib and MVR. Her coumadin was
held and her INR monitored following surgery. She was placed on
coumadin 3.0mg Qhs once her INR dropped below 2.0 and she was
bridged with a heparin drip. Coumadin was increased to 4.0mg on
[**2133-6-17**] and as her INR rose to 2.8 on [**6-22**], decreased to 3.0mg.
Subsequent to her INR dropping from 2.5 to 2.1 on [**6-25**] and then
to 1.9 on [**6-26**] the coumadin dose was increased to 4.0mg and
5.0mg repectively. Coumadin continued to be titrated to a dose
of 3.5mg (her dose PTA) giving an INR of 2.4 at discharge.
In the perioperative period the patient began having episodes of
bradycardia and pauses for which a single wire pacemaker was
placed on [**2133-6-14**], with confirmation of proper lead placement by
CXR. The PM was interrogated on [**2133-6-24**] and found to be
functioning properly. Additionally in this time she developed
mild anemia likely due to the spontaneous hematoma and surgical
blood loss for which she received a total of 2 units of PRBCs
and has since resolved.
During this time the patient was continued on Lanoxin for her
atrial fibrillation and developed a NSVT/? junctional
tachycardia likely due to digoxin toxicity. Her digoxin was
discontinued and per EP's recommendations was not restarted and
will be held indefinitely. In order to maintain K levels above
4.0 to avoid potential dysrhytmias from hypokalemia,
spironolactone 25mg PO daily was started. On this regimen the
patient required 40mEq of KCl PO daily to maintain her K levels
and this was reduced to 20mEq daily as the K level on the day
prior to discharge was 4.5. On discharge the K level was 4.3.
For heartrate control metoprolol was increased over time to an
eventual dose of 75mg PO BID the day prior to discharge, during
which time the patient's BP was stable at SBP=110s to 130s. On
the day of discharge metoprolol 75mg [**Hospital1 **] was increased to Toprol
XL 200mg to help control SBP that were in the upper 120s.
Following evacuation of her epidural hematoma she developed
right LE pain, which was attributed to a radiculpathy and was
successfully treated with Neurontin 100mg TID. Due to
predominately left LE weakness, PT was consulted and recommended
that the pt be discharged to an extended care factility where
she could receive further care from PT. The patient continued to
improve during the course of her stay, but was it was still
considered necessary that the pt receive rehab upon d/c. Prior
to discharge the patient was prescribed an AFO left foot splint.
In addition she spiked a temperature to 100.3, for which an
infection work-up was began. Urine Cx showed Proteus Mirabilis,
Bld Cx negative. She was treated impirically on Vacnomycin,
which was d/c after the Bld Cx came back negative, and
Ciprofloxacin. P. mirabilis was found to be intermediately
sensitive to ciprofloxacin and Tx was switched to a sensitive
antibiotic, Ceftriaxone 500mg po Q12H for 10 days. Ceftriaxone
was stopped on [**2133-6-29**] and the patient remained afebrile and
asymptomatic. Both incisions healed well without current
drainage, erythema, edema, or tenderness.
Lastly during her hospital course she developed some bladder
irritation/spasms and hematuria likely due to foley catheter
trauma. The catheter was d/c'ed and she was treated with Detrol
for a couple of days. She has since been asymmptomatic and
without hematuria.
Medications on Admission:
Lanoxin 0.25mg po daily
Coumadin
Flexeril
Vicodin
Mehtylprednislone dose back
Apo-amilizide 50/5 mg po daily
Tensiomin (Chinese med) 25 mg po daily
Take chinese herbs and teas
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Warfarin Sodium 1 mg Tablet Sig: 3.5 Tablets PO HS (at
bedtime).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
6. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
7. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Epidural hematoma s/p evacuation, periop brady/pause s/p single
wire pacemaker placement, non-sustained ventricular tachycardia
secondary to digoxin toxicity
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed. Contact primary care
physician or return to hospital if experience chest pain,
shortness of breath, palpitations, worsening lower extremity
weakness, or other concerns.
Followup Instructions:
The following appointments have been scheduled for you:
1. [**Company 191**] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name12 (NameIs) **], MD Where: [**Hospital 273**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2133-7-24**] 3:00
2.
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2133-8-10**] 11:30
Completed by:[**2133-7-1**]
|
[
"427.31",
"276.8",
"997.1",
"E942.1",
"285.9",
"398.91",
"V43.3",
"599.0",
"867.0",
"336.1",
"599.7",
"401.9",
"724.4",
"041.6",
"344.60",
"E879.6",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.81",
"03.09",
"89.45",
"99.04",
"37.71",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9056, 9126
|
4071, 8199
|
373, 423
|
9328, 9336
|
2581, 4048
|
9596, 10094
|
1802, 1820
|
8425, 9033
|
9147, 9307
|
8225, 8402
|
9360, 9573
|
1835, 2562
|
276, 335
|
451, 1513
|
1535, 1622
|
1638, 1786
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,841
| 177,580
|
17985
|
Discharge summary
|
report
|
Admission Date: [**2132-5-20**] Discharge Date: [**2132-5-25**]
Date of Birth: [**2068-8-6**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old male
with known right coronary artery disease, status post
inferior myocardial infarction in [**2122**], who has demonstrated
recurrent angina over the past month treated with TPA
beginning on [**2132-4-3**]. The patient underwent a direct
stenting of the left circumflex artery on [**2132-4-7**], and
was subsequently recommended for repeat cardiac
catheterization on [**2132-5-20**]. Repeat catheterization
demonstrated left main and right coronary artery disease with
50% stenosis at the bifurcation of the LAD and the left
circumflex artery and total occlusion of the right coronary
artery immediately distal to the RV marginal branch. The
patient's calculated left ventricular ejection fraction was
56%. The patient was subsequently admitted to the [**Hospital Unit Name 196**]
Service on [**2132-5-20**] for further evaluation and
management.
PAST MEDICAL HISTORY: Inferior myocardial infarction in
[**2122**], status post cataract surgery.
ADMISSION MEDICATIONS:
1. Enteric coated aspirin.
2. Zocor 40 mg p.o. q.d.
3. Toprol XL 50 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Altace 5 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 29789**] and is retired,
the patient is married. The patient denied any history of
tobacco or alcohol use. The patient reportedly golfs and
exercises four times a week for at least an hour a day.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2132-5-20**] for further evaluation of his cardiac
pathology. Following a discussion with the patient regarding
the relative risks and benefits of cardiac surgery, the
patient consented to undergo a coronary artery bypass graft
procedure to be scheduled on [**2132-5-21**].
On [**2132-5-21**], the patient, therefore, underwent a
quadruple coronary artery bypass graft procedure.
Anastomosis included from the LIMA to the LAD, saphenous vein
graft to the distal RCA and saphenous vein graft to the OM1,
OM3. The patient had a bypass time of 78 minutes and a cross
clamp time of 51 minutes. The patient's pericardium was left
open; lines placed included an arterial line and CVP; both
ventricular and atrial wires were placed; both mediastinal
and bilateral pleural tubes were placed intraoperatively.
The patient was subsequently transferred to the Cardiac
Surgery Recovery Unit, intubated, for further evaluation and
management. Shortly upon arrival in the CSRU, the patient
was successfully weaned and extubated without complication
and was noted, thereafter, to be tolerant of oral intake.
On postoperative day number one, the patient was successfully
weaned from all pressors and was noted to have his pain well
controlled via oral pain medications.
On postoperative day number two, the patient was cleared for
transfer to the regular floor and was subsequently admitted
to the Cardiothoracic Service under the direction of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**]. On the floor, the patient progressed well
clinically through the time of his discharge.
The patient was evaluated by Physical Therapy, who cleared
him for discharge to home following resolution of his acute
medical issues.
On postoperative day number three, the patient's chest tubes
and pacing wires were removed without complication. The
patient's Foley catheter was subsequently removed without
complication. The patient was thereafter noted to be
independently productive of adequate amounts of urine for the
duration of his stay. The patient subsequently cleared level
V PT certification on postoperative day number four, [**2132-5-25**], and was subsequently cleared for discharge to home with
instructions for follow-up.
CONDITION ON DISCHARGE: The patient is to be discharged to
home with instructions for follow-up.
STATUS AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. times ten days.
3. Colace 100 mg p.o. b.i.d.
4. Potassium chloride 20 mg p.o. b.i.d. times ten days.
5. Enteric coated aspirin 325 mg p.o. q.d.
6. Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
7. Lipitor 40 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: The patient is to maintain his
incisions clean and dry at all times. The patient may shower
but should pat dry incisions afterwards; no bathing or
swimming until further notice. The patient may resume a
regular diet. The patient has been advised to limit physical
activity; no heavy exertion, no driving while taking
prescription pain medications. The patient is to follow-up
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1275**] in one to two weeks; the patient is to
call [**Telephone/Fax (1) 3658**] to schedule an appointment. The patient is
to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in six weeks; the
patient is to call [**Telephone/Fax (1) 170**] to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 49788**]
MEDQUIST36
D: [**2132-5-24**] 05:16
T: [**2132-5-24**] 17:44
JOB#: [**Job Number 49789**]
|
[
"414.01",
"V45.82",
"272.0",
"412",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.22",
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
4116, 4425
|
1645, 3964
|
4450, 5515
|
1186, 1378
|
4084, 4093
|
1086, 1163
|
1395, 1627
|
3988, 4069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,584
| 138,652
|
41012
|
Discharge summary
|
report
|
Admission Date: [**2145-11-16**] Discharge Date: [**2145-12-9**]
Date of Birth: [**2071-4-17**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Nonverbal, altered mental status (from rehab)
Major Surgical or Invasive Procedure:
-Failed attempts at internal jugular and subclavian central line
placement
-Right femoral central line placement
History of Present Illness:
74 year old female with history of ESRD [**1-20**] lithium toxicity on
HD with recent AVF thromboses and procedures, bipolar disorder,
?AF on amiodarone, HTN/HL, CAD s/p LAD stent in [**2142**], L3/L4
discitis on 8-week IV abx therapy, and goiter s/p thyroidectomy,
presenting to ED from longterm rehab ([**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **]) with an
acute change in mental status (lethargy, nonverbal) with
baseline of full orientation, and glucose of < 20. En route to
ED, she was given 1 amp of D50 by EMS with sugar improving to 90
but without complete return to normal baseline. She started to
speak again in the ED and reports that she just did not feel
right after her HD session yesterday. No CP/SOB/abd pain.
She was last admitted to [**Hospital1 18**] on [**2145-11-3**] for a fistula
placement, which failed and resulted in a small hematoma. She
was monitored overnight and sent back to [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] continue
HD through her existing temporary line. She had a prior
admission in [**Month (only) **] and [**Month (only) 359**] for AVG thrombus. Initial
thrombectomy was successful, but it re-thrombosed and during her
admission in [**Month (only) 359**], the procedure failed, prompting the
initiation of the temporary line. During a prior admission this
[**Month (only) **] for chest pain (elevated troponins [**1-20**] ESRD, flat
CK-MB and no ACS), she was noted to have altered mental status
and this was attributed to multiple etiologies including uremia,
subacute encephalopathy with global cerebral dysfunction (Neuro
eval), but not due to myxedema with her elevated TSH. Of note,
she has taught college classes as recently as this [**Month (only) 547**].
In the ED, initial VS were: HR 150, SBP 60s-70s/40s, nl RR and
O2. She was found to be in paroxysmal AF with HRs 150s-160s and
hypotensive with SBPs in the 50s-60s. Attempts at a-line
placement were unsuccessful. Central line placed in groin after
attempts at IJ and subclavian. She was given 5L NS then 2 more
after looking at collapsed IJ on U/S. She was started on
phenylephrine and self-converted to sinus in 90s, with
improvement of hypotension. EKG was notable for ST depressions,
felt to be rate-related vs. demand ischemia per cards after a
TTE negative for any new wall motion abnormalities; given ASA
PR. Due to persistent hypoglycemia, she was started on
maintenance D5-1/2NS with KCl + D10. Broad antibiotic coverage
with Vanc/Cefepime/Flagyl due to concern for sepsis with a temp
of 97.8, bair hugger placed. She was also given hydrocortisone
100mg x1 due to concern for adrenal insufficiency with
hypotension and electrolyte abnormalities. Vitals on transfer:
97.4 (will transfer on Bair Hugger), 100s/80s, RR 18-20, O2
98-100% on 2L
On arrival to the MICU, patient on a Bair hugger and BPs have
been consistent in left forearm, quickly weaned off
phenylephrine. She is alert and oriented x3, but is somewhat
somnolent. She wants a McDonald's hamburger.
Past Medical History:
Bipolar disorder
Hypertension
HLD
?Atrial fibrillation
Gastritis
GERD
GI bleed [**5-/2145**], EGD showed erosive esophagitis & duodenal
ulcers
ESRD [**1-20**] lithium, on HD
AV graft thrombosis on left
"cardiac arrhythmia with bradycardia" in [**State 108**]
CAD, LAD stent [**1-/2143**]
Ascending aortic aneurysm s/p repair [**1-/2143**], + ectasia of
descending thoracic aorta (largest diameter 4.8cm)
L3/L4 discitis s/p 8 weeks of IV antibiotics
Goiter, s/p thyroidectomy [**2128**]
Osteoarthritis, s/p L total knee replacement
Restless legs syndrome
Social History:
Currently resides at [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **], Married, retired professor
at [**Hospital1 3278**] (retired in [**2145-3-19**]). No smoking history. No EtOH
or illicits. Her sister is healthy and is considering donating
kidney to her. Patient ambulates with a walker and needs help
getting out of bed.
Family History:
Father had "heart problems." Otherwise non-contributory.
Physical Exam:
On admission:
Vitals: T: 34.5C BP: 130/57 P:70 R: 18 O2: 100% on 2L ; FSBG 187
General: Alert, oriented, obese female in mild respiratory
distress on Bair hugger
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
(3->2mm)
Neck: supple, JVP not elevated but difficult to assess given
obesity, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ?soft RUSB systolic
murmur, no rubs or gallops
Lungs: Clear to auscultation on inspiration, some rhonchi on
expiration likely upper airway, no wheezes or rales.
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Mental status clear, CNII-XII intact, 5/5 strength
upper/lower extremities, grossly normal sensation, gait
deferred.
Pertinent Results:
On admission:
[**2145-11-16**] 08:30AM BLOOD WBC-6.5 RBC-2.75* Hgb-8.4* Hct-27.4*
MCV-100* MCH-30.7 MCHC-30.8* RDW-16.7* Plt Ct-331
[**2145-11-16**] 08:30AM BLOOD Neuts-72.4* Lymphs-20.5 Monos-5.3 Eos-1.6
Baso-0.3
[**2145-11-16**] 08:30AM BLOOD Plt Ct-331
[**2145-11-16**] 08:50AM BLOOD PT-11.6 PTT-28.8 INR(PT)-1.1
[**2145-11-16**] 08:30AM BLOOD Glucose-119* UreaN-24* Creat-4.3*#
Na-146* K-2.7* Cl-109* HCO3-25 AnGap-15
[**2145-11-16**] 09:10AM BLOOD ALT-19 AST-29 CK(CPK)-23* TotBili-0.1
[**2145-11-16**] 09:10AM BLOOD Calcium-4.5* Phos-1.8*# Mg-1.1*
[**2145-11-23**] 10:50AM BLOOD Phenyto-12.8
[**2145-11-16**] 08:40AM BLOOD Glucose-108* Lactate-3.8* K-2.6*
Imaging:
Echo [**11-16**]
The estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size is normal.
with normal free wall contractility. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CT head [**11-21**]
NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass,
mass effect, or infarction. Moderate proportional enlargement of
the ventricles and sulci is consistent with age-related cortical
atrophy. Areas of hypoattenuation in the corona radiata and
periventricular white matter correlate with areas of FLAIR
hyperintensity on prior MRI and suggest chronic small vessel
ischemic changes. There is no shift of the usually midline
structures. The suprasellar and basilar cisterns are widely
patent. No scalp hematoma or acute skull fracture is identified.
The visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: No acute intracranial process.
EEG [**11-22**]
IMPRESSION: This EEG gives evidence at the beginning for what
would be
considered electrographic status epilepticus that seemed to
respond
positively to the infusion of Ativan and then later to the
infusion of
phosphenytoin. The epileptiform activity resolved and the
background at
the end of the study remained in the mild to moderate
encephalopathic
range. There were still occasional generalized and a few
multifocal
discharges of an epileptic nature near the end. The cardiogram
rhythm
was felt to be secondary to the use of beta blockade that was
present
prior to the treatment of the status and it, too, seemed to
resolve as
the evening wore on.
MRA head [**11-22**]
IMPRESSION:
1. No evidence of acute infarction.
2. Stable age-related involutional changes and small vessel
ischemic disease with one focus of old microhemorrhage.
3. Almost certainly artifactual attenuation of the bilateral M2
branches of the MCA. If there is concern for severe global
cerebral ischemia, the MRA may be repeated with 3D
time-of-flight acquisition begun more superiorly in the neck to
demonstrate contiguous flow through the MCA.
EEG [**11-27**]
IMPRESSION: This EEG continues to show mild to, at times,
moderate
encephalopathy without clear focality or laterality. There are
also
multifocal as well as generalized interictal epileptiform
discharges.
The record appears to be about the same as the previous 24-hour
record.
No sustained either clinical or electrographic seizures were
seen or
identified.
CXR [**12-1**]
IMPRESSION: AP chest compared to [**11-25**]:
Feeding tube ends in the upper stomach, with the proximal end of
the weighted tip at or just beyond the gastroesophageal
junction.
Previous pulmonary vascular congestion and mild edema have
resolved. Heart is top normal size. Angulation of the
dual-channel central venous line suggests that it may cannulate
the azygos vein, in the same position since [**11-16**]. There
is no pneumothorax or appreciable pleural effusion.
Brief Hospital Course:
74 year old female with history of ESRD [**1-20**] lithium toxicity on
HD with recent AV fistula thromboses and failed placement of
right AV fistula, bipolar disorder, likely AF, HTN/HL, CAD s/p
LAD stent in [**2142**], L3/L4 discitis on 8-week IV abx therapy, and
hypothyroidism s/p thyroidectomy, initially presenting with
hypothermia, hypogylcemia, altered mental status, and atrial
fibrillation with hypotension, consistent with septic shock
along with numerous electrolyte abnormalities.
# Septic shock: Initially found to be in AF with RVR to
150s-160s and rate-related ST depressions with hypotension that
persisted once she spontaneously converted to sinus. Her
hypothermia, tachycardia, altered mental status, and persistent
hypoglycemia indicated a septic picture. After numerous failed
attempts at IJ and subclavian central access, a right femoral
line was placed. Upon admission to the ICU, she was continued
on phenylephrine. Investigation of an infectious source came up
empty, with a normal LP, clear CXR, unimpressive urinalysis and
no GI symptoms. Her dialysis line did not look erythematous.
Without any back pain, an epidural abscess related to her
discitis seemed unlikely. Blood and urine cultures were sent
and did not grow anything. She was monitored on a Bair hugger
for 1 day until her temperatures returned to [**Location 213**]. Antibiotic
coverage was initially CNS coverage with Vanc/CTX/Acyclovir,
then switched to Vancomycin and Cefepime with her chronic
doxycycline. Her pressor was weaned and she seemed to improve
on broad antibiotic coverage despite not uncovering a source.
She was then transferred to the floor and continued on
vancomycin dosed renally for dialysis, and cefepime. The patient
remained afebrile and never showed any signs of infection. A
chest xray demonstrated right sided effusions on atelectasis,
but were not thought to be infectious. However, despite these
findings, the patient was kept on antibiotics since her clinical
picture did not improve and an infectious etiology remained on
the differential.
# ESRD on HD per temporary line: Patient was a chronic dialysis
patient who received dialysis throughout the majority of her
stay. During her dialysis sessions, the patietn would exhibit
severe hypotension and afib with RVR. As the [**Hospital 228**] medical
status deteriorated, the decision was made with the team and the
family to discontinue hemodialysis. At this point, comfort
measures only were initiated. Her mantal status never recovered,
and the patient eventually passed from ESRD.
# Seizures: After initial MICU stay while on the medical floor,
the patient developed odd behavior that was difficult to
explain. The patient would complain of odd feelings all over her
body, but was unable to verbalize what it felt like and would
seem strange or inappropriate. Then she developed clear
localizing symptoms with weakness on one side in the context of
one of these episodes during HD. Neurology was consulted and a
code stroke was called. The patient's CT scan and MRI of her
head were both negative. An EEG was ordered, which showed status
epilepticus. The patient was given 1mg ativan which broke the
seizure, but the patient then developed bradycardia to the 20s.
The patient was subsequently transfered to the unit for closer
monitoring. The patient was kept seizure free in the unit and
was hemodynamically stabilized for several days. It remains
slightly unclear why the patient developed seizure disorder but
strong suspicion of hypoperfusion and some degree of anoxic
brain injury during the hypotension preceding admission formed a
source for epilepsy. Unfortunately, her mental status improved
at best to wakefullness and partial orientation but she remained
without insight into the cause of her hospitalization. It is
unclear if this was due to persistent seizures (though she was
noted to have further seizures on the floor after her care was
deescalated), ESRD (as HD discontinued), or new/continued
infectious course and sepsis. Her mental status slowly declined
after discontinuation of HD.
# Atrial fibrillation: RVR on admission to ED. It appears that
she had been taken off amiodarone prior to admission. There was
initially concern for unstable AF on admission, but she
spontaneous conversion to sinus. ST depressions seen in I, II,
aVL, V3-V6 resolved once rate controlled. Troponins checked and
were actually lower than previous admission. Infection was the
likely etiology of AF here. Her beta-blockade was initially held
due to concern for septic shock, but were restarted after went
back into AF with RVR. TSH was checked and normal.
Anticoagulation was not started given her history of bleeding.
While on the floor, the patient was initially given oral
metoprolol up to 50 TID for control of her A fib. However, this
control was poor so the patient was switched to IV lopressor. On
transfer back to the ICU, the patient was on IV lopressor 5 mg
Q4H:PRN and was using all the PRN doses. Unfortunately, her AFIB
was poorly controlled despite the lopressor use. Once the
decision was made to make the patient CMO, we stopped monitoring
her Afib and she did not receive treatment for it. She was
removed from Telemetry.
# Bipolar disorder: Continued on zyprexa, mirtazapine,
clonazepam. However, once the patient developed seizures,
neurology requested that all psych meds [**Doctor First Name **] stopped in order to
give a clear EEG picture of [**Last Name **] problem. Upon conferring with
her husband, her psych meds were held. Once the patient was made
CMO, the decision was made to continue olanzapine, but none of
her other psych meds were re-started.
# Goals of care: During patient's second MICU stay (induced by
status epilepticus and bradycardia in the context of treating
this)decision was made between the MICU team and her family and
proxy (her husband) to not further escalate care, intubate, or
use other aggressive measures given strong suspicion of some
degree of anoxic brain injury, very poor quality of life with
repeated hospitalizations since initiating HD, and poor
prospects for reasonable recovery to patient's baseline (very
intelligent and independent professor). After transfer to floor
decision was made given these same reasons to discontinue HD (as
patient had already considered this prior to that
hospitalization) and focus care on comfort. She became
progressively more encephalopathic after discontinuation of HD
and passed away on [**2145-12-9**] with her sister at her side.
Medications on Admission:
simvastatin 20 mg Tablet daily
- levothyroxine 125 mcg daily
- sevelamer carbonate 800 mg TID
- metoprolol succinate 25mg ER daily
- nephrocaps 1 tab daily
- MVI
- vitamin D 50,000 IU qweek
- vitamin D 1000 units daily
- olanzapine 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
- senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
- cinacalcet 30 mg Tablet daily
- omeprazole 20 mg daily
- hydromorphone 2mg qdaily (for chronic pain)
- aspirin 81mg
- trazadone 50mg qhs
- doxycycline 100mg [**Hospital1 **] (lifelong for discitis, per ID)
- pramipexole 0.75 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Medications:
none- pt expired
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
none- pt expired
Discharge Condition:
none-pt expired
Discharge Instructions:
none- pt expired
Followup Instructions:
none- pt expired
Completed by:[**2145-12-9**]
|
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icd9pcs
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16687, 16757
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9443, 15977
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334, 448
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,619
| 187,012
|
37404
|
Discharge summary
|
report
|
Admission Date: [**2142-12-7**] Discharge Date: [**2142-12-10**]
Date of Birth: [**2072-2-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2142-12-8**]:
1. Rigid bronchoscopy using the black Dumon bronchoscope.
2. Flexible bronchoscopy.
3. Endobronchial biopsy and tumor debridement of the left
main stem.
4. Placement of covered metal stent [**44**] x 40 mm in the left
main stem.
History of Present Illness:
70M who presented to [**Hospital 1727**] Medical Center earlier today with
complaints of shortness of breath and chest pain. The chest pain
began last night and was relieved temporarily by sublingual
nitroglycerin, but recurred this morning. He also felt very
short
of breath this morning. He was coincidentally scheduled for a CT
scan of the chest today and when he arrived at the radiology
scanner, 911 was called because of his severe dyspnea. EMS
arrived and found that the patient was in atrial fibrillation
with rapid ventricular rate and he was taken to the ED. He was
briefly on a diltiazem gtt for rate control but converted back
to
NSR (which he remains in) prior to transfer to [**Hospital1 18**].
The patient reports 2 months of intermittent chest pain, general
malaise, and non-productive cough. The cough was empirically
treated with cipro in [**Month (only) 359**] without improvement. He also
endorses a 30lb weight loss and loss of appetite over the past
2-3 months and has drenching night sweats most nights.
Past Medical History:
NIDDM, HTN, Hyperlipidemia, Rheumatoid arthritis, Obesity,
Chest pain s/p cardiac cath [**10-29**] with 50% occlusion of obtuse
marginal and 50% occlusion of RCA
Social History:
Retired from [**Company **]. Former smoker, approx 40
pack year history of smoking, no alcohol, no drugs, endorses
asbestos exposure
Family History:
Mother died of GI bleed, father of unidentified cancer
Physical Exam:
VS: T 98.5, BP 113/71, pulse 81, RR 20, 88% RA, 98% on 2LNC
Physical Exam:
Gen: pleasant in NAD
Lungs: diminshed t/o
CV: RRR S1, S2, no MRG
Abd: soft, NT, ND
Ext: warm, no edema.
Pertinent Results:
[**2142-12-9**] 08:00AM BLOOD WBC-9.8 RBC-3.70* Hgb-8.9* Hct-28.5*
MCV-77* MCH-24.2* MCHC-31.4 RDW-19.3* Plt Ct-350
[**2142-12-9**] 08:00AM BLOOD Glucose-159* UreaN-14 Creat-1.0 Na-137
K-4.0 Cl-99 HCO3-28 AnGap-14
[**2142-12-8**] 01:12AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] rigid bronchoscopy, flexible
bronchoscopy, endobronchial biopsy and tumor debridement of the
left main stem, and placement of covered metal stent [**44**] x 40 mm
in the left main stem on [**2142-12-8**] by Dr. [**Last Name (STitle) **] for a large
mediastinal mass with left main stem obstruction. The patient
was observed over the weekend, and discharged home on [**2142-12-11**],
after deemed safe by PT. His home medications were resumed and
needs follow up with medical oncology, which the patient and
family are aware of and will set up locally. His oxygen
saturations dropped to 88% on RA with ambulation, so he was set
up with portable home oxygen. He was sent home with a 7 day
course of levaquin for post obstructive pneumonia.
The frozen section performed in the operating room revealed the
possibility of small-cell carcinoma versus lymphoma. We will
await the final analysis by the pathologist
to determine the next step in treatment.
Medications on Admission:
Metformin 500 QID, Metoprolol 100 [**Hospital1 **], Furosemide 20 [**Hospital1 **],
Glipizide 20 QAM, Enalapril 2.5 QD, Folic acid 1 QD, Zetia 10
QD,
Lipitor 80 QHS, Trilipix 135 QD, Methotrexate 17.5 [**Last Name (LF) **], [**First Name3 (LF) **] QD,
Diovan 320 QD, Oxycodone 5 PRN
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*0 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*0 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*0 Tablet(s)* Refills:*0*
7. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)): hold this med until you are done taking
levaquin. Monitor your blood sugar and talk to your primary care
about resuming.
Disp:*0 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
9. Enalapril Maleate 2.5 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day.
11. Methotrexate Sodium 10 mg Tablet Sig: One (1) Tablet PO once
a week.
12. Methotrexate Sodium 7.5 mg Tablet Sig: One (1) Tablet PO
once a week.
13. Trilipix 135 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
14. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day: take while stent
is in place.
Disp:*60 Tab, Multiphasic Release 12 hr(s)* Refills:*0*
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
16. home oxygen
2 liters/min continous oxygen for portability pulse dose system
17. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] health care
Discharge Diagnosis:
left mediastinal mass
Discharge Condition:
Mental status: good
Ambulation: with assistance
Voiding to toilet
Tolerating diabetic diet
Pain controlled with PO pain medications
Discharge Instructions:
Please call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 10084**] if you develop
increased shortness of breath, cough or sputum production,
fevers more than 101.5, shakes, chills.
You may resume all of your home medications, and take all new
medications as prescribed. Follow the instructions provided to
you regarding your diet and activity. You may shower and bathe
today.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks; Call on Monday for an
appointment.
Followup Instructions:
1) local radiation oncology as outpatient- see your local
oncologist within the next week.
2) Dr. [**Last Name (STitle) **] - please follow-up in 2 weeks. Please call his
office for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2142-12-10**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,815
| 147,292
|
49399
|
Discharge summary
|
report
|
Admission Date: [**2197-8-23**] Discharge Date: [**2197-8-27**]
Date of Birth: [**2143-5-24**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Methotrexate / Ceftazidime
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 54yo M with Crohn's disease s/p multiple surgeries
with resultant short gut syndrome [**12-22**] to colectomy and ileostomy
and TPN dependency who was recently admitted to [**Hospital1 18**] for
evaluation of low grade fevers, history of multiple line
infections, MV endocarditis and osteomyelitis for which the pt
is on chronic vancomycin for last 4 years, hickman for TPN, now
present w/ fever and hypotension.
.
At home he became febrile (24 hr nursing care) w/ to 103.4. His
nurse called Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (ID)on [**8-23**] who was notified
that he developed fever to 101 but subsequently deferveced. He
was instructed to call back if recurrent fever. Dr. [**First Name (STitle) **] was
called back later that his temp was 103 and she instructed him
to go to the ED. He also had +fatigue. He had decreased activity
and appetite. + Dyspnea w/any exertion.
.
He was recently admit to [**Hospital1 **] 2 weeks ([**Date range (1) 8403**]) ago for fever -
work up for etiology neg. Durint that admission, he had no
leukocytosis. CXR was negative for pneumonia. All blood cultures
were negative to date, including cultures for yeast, mycolytic
infections and for M. furfur. Urine culture was negative. TEE
was negative for endocarditis. CT of the cspine and bone scan
were negative for osteomyelitis. MRI showed subtle signal
changes which may suggest chronic osteomyelitis but no prior MRI
was available for comparision( last one was in [**2193**], when he did
not have osteo).His Hickman was felt to be free of infection, so
it was not pulled.
.
He denies any headache, neck pain, CP, chills, lightheadedness,
headache, cough/sputum production, or change in bowel or urinary
habits (burning, frequency, etc.). He also has noticed no
erythema, tenderness, or swelling around his Hickman line (last
changed [**2196-7-21**]), though he notes that his previous line
infections have also been without external/visible changes. He
has no sick contacts or recent travel.
.
In the ED, he had bld cultures sent. Vanco and zosyn was given
(pt was already on vanco qod). ID was notified. CXR no evidence
no focal infiltrate or change from prior CXR. BP 70s/40s. 2L NS.
BP improved to 80-90s/40s.He did not have any signs of distress
and was mentating within his normal range Small rim of erythema
around Hickman, but obvious pus. Stoma was WNL.
.
He was transferred to the ICU for closer monitoring for
hypotension.
Past Medical History:
1. Crohn's disease s/p multiple surgeries with resultant
ileostomy and shortgut syndrome dependent on TPN with chronic
hypocalcemia, vitamin D deficiency.
2. Infectious: Staph epidermidis C4-C5 Osteomyelitis (on
Chronic Vancomycin), Endocarditis with Mitral Valve Vegetation,
Recurrent Polymicrobial Line Sepsis, Previous RLL PNA, LE
Cellulits
3. Respiratory - COPD (Baseline PaCO2 of 48), H/O ARDS x 2 with
Intubations/Tracheostomy ([**2192**] and [**2193**]), Klebsiella bacteremia.
4. Severe MR
5. CKD (Baseline Cr 1.3 to 1.4)
6. Anemia of Chronic Inflammation (on EPO)
7. Mild Dementia
8. Chronic Pain (Fentanyl 50 mcg Patch)
9. Restless Leg Syndrome
10. Steroid-Induced Osteoporosis
11. Multiple Spinal Compression Fx
12. Peripheral Neuropathy
13. UGIB/Duodenal Ulcer ([**2193**])
14. Depression
15. Bilateral SVC Thrombi.
Social History:
Lives alone; 24[**Hospital 8018**] nursing care with multiple nurses; fully
intact ADLs; ambulates without assistance; never married; has no
children; has worked many odd jobs; he has five brothers and one
sister that are very supportive.
His brother [**Name (NI) **] [**Name (NI) **] is his health care proxy.
[**Name (NI) **] has a 60-pack-year history of smoking. He reports minimal
alcohol use and previous use of marijuana but denies any IVDU.
Family History:
F: Crohn's disease
M: TIA in her 70s
GF: DM
Physical Exam:
On Admission:
VS BP 98/65 P 60 RR 14 O2 98% RA
Gen:NAD, tired appearing male in NAD
HEENT:PERRL, dry MM, oral pharynx clear
Neck:Supple, flat JVP
CV:RRR, III/VI SEM over LLSB
Resp:good inspiratory effort w/ occasional wheezing
Abd:Soft, non-tender, non-distended, stoma intact
Ext:warm, +2 distal pulses
Neuro:A +Ox3, CN II-XII intact, motor and sensory grossly intact
Pertinent Results:
[**2197-8-23**] 07:00PM BLOOD WBC-10.0# RBC-3.92* Hgb-12.4* Hct-35.4*
MCV-90 MCH-31.5 MCHC-34.9 RDW-15.3 Plt Ct-180
[**2197-8-25**] 05:37AM BLOOD WBC-3.4* RBC-3.40* Hgb-10.4* Hct-30.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.2 Plt Ct-162
[**2197-8-23**] 07:00PM BLOOD Neuts-83* Bands-10* Lymphs-2* Monos-2
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-8-25**] 05:37AM BLOOD Plt Ct-162
[**2197-8-25**] 05:37AM BLOOD PT-12.9 PTT-33.2 INR(PT)-1.1
[**2197-8-25**] 05:37AM BLOOD Glucose-116* UreaN-33* Creat-2.0* Na-137
K-3.9 Cl-107 HCO3-23 AnGap-11
[**2197-8-24**] 07:45AM BLOOD Glucose-98 UreaN-33* Creat-2.0* Na-140
K-4.2 Cl-109* HCO3-22 AnGap-13
[**2197-8-23**] 07:00PM BLOOD ALT-21 AST-17 AlkPhos-848* TotBili-3.1*
[**2197-8-25**] 05:37AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.4
[**2197-8-24**] 07:45AM BLOOD calTIBC-178* Ferritn-463* TRF-137*
[**2197-8-23**] 07:18PM BLOOD Lactate-1.3
Retic 2.4, hapto 207, LDH 165, FENa 5.6%, bili 3.1->1.8, alk
phos 848->763, ALT 21, AST 17, vanco 12.5
.
Microbiology:
TPN fungal culture: pending
Blood cultures: pending
Urine culture: negative
Fungal blood cultures: pending
Stool c diff negative x 1
.
RUQ U/S:
FINDINGS: The patient is status post cholecystectomy. There is
no intra- or extra-hepatic biliary ductal dilatation. The common
duct measures 6 mm in diameter, which is not significantly
changed, allowing for differences in technique. The main portal
vein shows appropriate hepatopetal flow. No focal liver lesions
are identified, and the echotexture of the liver appears normal.
IMPRESSION: No evidence of biliary obstruction.
.
FRONTAL CHEST: Cardiac and mediastinal contours appear stable,
with mild cardiomegaly. No focal consolidations are identified
within the lungs. No evidence of pleural effusion. Multiple
right-sided rib fractures again seen. Right-sided central venous
line with tip overlying the distal SVC. Cervical fusion hardware
again noted.
IMPRESSION: No evidence of acute cardiopulmonary process or
significant change from prior study.
Brief Hospital Course:
Fever: Blood culture and urine cultures were sent. CXR on
admission did not show focal infiltrate. He was started on vanco
(increased from chronic qod to qd) and zosyn (per discussion w/
ID). His recent hosp admission record [**7-26**] was reviewed and
showed extensive infectious workup which was unrevealing
(including MRI c-spine, which revealed no significant new
changes; neg bone scan; negative blood cultures; negative TEE).
GI and ID were concerned that his line (hickman placed in [**7-25**])
was the source of his fever. He has never had anything cultured
from the line and his cultures are again negative, though his
chronic vancomycin may be suppressing the organism. ID
recommended his home TPN be cultured (including M furfur).
Given negative cultures, the zosyn was discontinued and his
vancomycin was returned to [**Location **] dosing. The patient remained
afebrile x 24 hours and was thus discharged home with
instructions to continue checking his temperature at least 2
times per day.
Hypotension-Pt was initially hypotensive to SBP 70s in the ED.
He responded quickly to a number of 500cc IVF boluses over the
initial 48 hrs. His BP meds were initially held. He will
follow-up with his primary care doctor for a repeat blood
pressure check to consider restarting his lisinopril given his
history of MR. His norvasc and lasix are also being held.
Hyperbilirubinemia/Elevated ALk Phos- His alk phos and bili were
elevated on admission (rest of his LFTs was relatively stable).
He did not complain of pain. RUQ u/s recommended by GI was
unremarkable. Labs were improving at the time of discharge
Anemia-He has baseline anemia in the range of 35-37. His hct
slowly drifted down to low 30s on admission. Hemolysis labs were
sent but were normal. Iron studies suggest anemia of chronic
disease. Folate and B12 were normal.
Nutrition-Pt was initially given standard TPN as his home
formula was not available. Dr. [**Name (NI) 79**] (pt 's own GI specialist)
came by on [**8-25**] and gave specific instruction on the
non-standard TPN formulation.
Medications on Admission:
1. Polysaccharide Iron Complex 150 mg [**Hospital1 **]
2. Pantoprazole 40 mg q 24
3. Ascorbic Acid 500 mg daily
4. Calcium Carbonate 1500 mg daily
5. Calcitriol 0.25 mcg daily
6. Ergocalciferol (Vitamin D2) 50,000 unit q wk
7. Lisinopril 20 mg daily
8. Furosemide 20 mg daily
9. Zolpidem 5 mg qhs
10. Risperidone 0.25 mg [**Hospital1 **]
11. Dronabinol 5 mg tid
12. Glutamine 10 g tid
13. Amlodipine 2.5 mg q 2pm
14. Ursodiol 600 mg [**Hospital1 **]
15. Acetaminophen 325 mg prn
16. Clonazepam 0.5 mg tid prn
17. Albuterol inhal q6 prn
18. Lorazepam 1 mg qhs prn
19. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q4-6H
prn
20. Vancomycin HCl 1000 mg IV Q48H
21. Zofran *NF* 8 mg IV Q8H:PRN PRN
22. Epoetin Alfa 10,000 unit/mL qwk
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Glutamine 10 g Packet Sig: One (1) Packet PO TID (3 times a
day).
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours.
12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for anxiety: hold for rr < 8 or oversedation.
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours).
15. Epogen 10,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapy
Discharge Diagnosis:
hypotension
fever
acute renal failure
hyperbilirubinemia
anemia of chronic disease
history of short gut syndrome on TPN
history of cervical osteomyelitis on chronic vancomycin
Discharge Condition:
good: afebrile, wbc down, creatinine back to baseline
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] or go to the emergency room for
temperature > 101, low blood pressure, decreased urine output,
weight gain > 3 pounds, chest pain, back/neck pain, or other
concerning symptoms.
Please store your TPN in a separate mini-refrigerator that you
should bleach one time per week to prevent TPN contamination.
Please continue your home TPN, as previously prescribed. No
changes have been made.
Please stop taking supplemental IVF each day.
Please follow-up with your primary care doctor or his nurse
practitioner within 1 week for a blood pressure check and labs
including kidney function (creatinine) to consider restarting
your lisinopril. For now, please do not take that medication.
Please also defer starting your amlodipine and lasix for now.
If your weight increases > 3 pounds, please call your doctor to
discuss restarting the lasix.
Please continue getting weekly labs each Monday, which are faxed
to Dr. [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**].
You were hospitalized for fever of concern for infection. You
were given zosyn (antibiotics) in addition to vancomycin. Blood
and urine cultures were drawn and your TPN was being cultured
for possible source of infection. Infectious disease was
consulted. Dr. [**Last Name (STitle) 79**] also came by to evaluate you. A right upper
quadrant ultrasound showed no dilation of your bile ducts,
despite elevated bilirubin which has since improved. Your blood
count is stable.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2197-8-29**] 11:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2197-9-27**] 11:15. PLEASE CALL HER OFFICE ON TUESDAY
MORNING TO SCHEDULE AN EARLIER APPOINTMENT (1-2 WEEKS)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2197-10-16**]
11:30
Please call Tuesday to schedule follow-up with Dr. [**Last Name (STitle) 5717**] in [**11-21**]
weeks. Phone: [**Telephone/Fax (1) 250**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,295
| 131,054
|
49879
|
Discharge summary
|
report
|
Admission Date: [**2163-6-21**] Discharge Date: [**2163-6-30**]
Date of Birth: [**2108-11-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2643**] is a 55 year-old woman with ESLD [**1-27**] EtOH cirrhosis
complicated by encephalopathy, ascites, and and hyponatremia,
currently undergoing transplant evaluation presenting with
hyponatremia. Patient was recently discharged from [**Hospital 24356**]
hospital on [**6-16**] - [**2163-6-18**] following recent admission for
failure to thrive and inability to ambulate. She was discharged
to a rehab facility for [**Hospital 3058**] rehab to gain strength.
Patient had another recent admission prior to the last one for
hepatic encephalopathy (discharged [**6-15**]). During admission at
[**Hospital 24356**] Hospital, patient had Na of 130 prior to discharge. As
per rehab records patient received "gentle hydration" for
hyponatremia, but there is not record of how much fluid she
received. Today patient had labs checked at rehab and was found
to have Na of 117. Given the new hyponatremia, patient was
transferred to [**Hospital1 18**] ED.
In the ED, initial VS were: 97.0 72 119/59 16 100%. Patient had
labs showing Na of 118 and had blood cultures drawn. She was
complaining of abdominal pain and had a bedside ultrasound that
showed no ascites to tap. She received morphine 5 mg IV x1 for
pain. She was started on NS 100 mL/hr and received 300 cc NS
prior to arrival to the floor. Urine lytes were not sent from
the ED prior to starting IVF as patient did not urinate.
On arrival to the MICU, patient complains of RLQ abdominal pain,
which is consistent with her chronic abdominal pain. She feels
tired and mildly weak, but denies headache, nausea, seizures,
confusion. No fevers or chills. Patient feels thirsty. She
endorses a 25 pound weight gain "over a little while" she is not
sure how long.
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. Denies nausea, vomiting, diarrhea, constipation,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- ETOH cirrhosis complicated by gastroesophageal varices,
ascites, and encephalopathy
- Choledocholithiasis s/p ERCP & CBD stent placement [**2161-11-6**]
- GERD
- s/p hysterectomy for excessive bleeding in [**2157**]
- s/p exploratory laparotomy [**2-3**]
- Chronic tremor
Social History:
Married with 2 sons. [**Name (NI) 3003**] alcoholism, last drink in [**2-3**]. Prior
20 pack-year smoker. Quit 15 yrs ago. Remote marijuana use.
Lives on [**Location (un) 448**] of house.
Family History:
Mother and father had alcoholic liver disease. Father with CAD.
Physical Exam:
Admission:
General: Alert, oriented, chronically ill appearing, jaundiced,
no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild diffuse tenderness, distended, shifting
dullness, no rebound/guarding
GU: no foley
Ext: warm, well perfused,no clubbing, cyanosis, 2+ lower
extremity edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact,
patient with tremor
Discharge:
VS - 99.3; 109/56; 103 (100-120s); 20; 98RA
Tele: Sinus tachycardia >120s
General: Alert, oriented, chronically ill appearing, jaundiced,
no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, spider angioma
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, decreased tenderness to palpation, mildly
distended, no rebound/guarding
Ext: warm, well perfused,no clubbing, cyanosis, 2+ lower
extremity edema, bilateral hand tremors, but no asterixis
appreciated
Neuro: CNII-XII intact, patient with tremor
Skin: no caput medusae, +spider angiomas on chest and forehead
Mental Status:
A&O: name, [**Hospital1 **], correct date, [**Last Name (un) 2753**]
Attention: world backwards correctly
Recall: [**2-26**], [**1-28**] then [**2-26**] with prompt at 5 min
Calculations 5 quarters = 1.25
Task: able to point to floor after pointing to ceiling
Praxis: able to show how she would comb her hair
Abstraction: "don't cry over spilled milk" = "better drink your
milk fast!"
*Overall, patient is less tangential, more direct in
questioning, and more coherent.
Pertinent Results:
Blood Counts:
[**2163-6-21**] 02:01PM BLOOD WBC-6.0# RBC-2.71* Hgb-9.3* Hct-28.2*
MCV-104* MCH-34.2* MCHC-32.8 RDW-17.6* Plt Ct-71*
[**2163-6-23**] 02:16PM BLOOD WBC-2.7* RBC-1.94* Hgb-6.6* Hct-20.5*
MCV-105* MCH-34.1* MCHC-32.4 RDW-17.5* Plt Ct-52*
[**2163-6-27**] 07:11AM BLOOD WBC-2.7* RBC-2.91* Hgb-9.5* Hct-28.2*
MCV-97 MCH-32.7* MCHC-33.8 RDW-21.0* Plt Ct-34*
[**2163-6-30**] 03:18AM BLOOD WBC-3.2* RBC-2.65* Hgb-8.7* Hct-26.9*
MCV-101* MCH-32.8* MCHC-32.3 RDW-21.2* Plt Ct-35*
Coags:
[**2163-6-21**] 02:01PM BLOOD PT-22.9* PTT-47.1* INR(PT)-2.2*
[**2163-6-29**] 03:27AM BLOOD PT-31.1* PTT-71.9* INR(PT)-3.0*
Chemistry:
[**2163-6-21**] 02:01PM BLOOD Glucose-88 UreaN-17 Creat-0.5 Na-118*
K-4.8 Cl-87* HCO3-24 AnGap-12
[**2163-6-22**] 11:15AM BLOOD Glucose-93 UreaN-20 Creat-0.4 Na-115*
K-4.8 Cl-88* HCO3-24 AnGap-8
[**2163-6-23**] 10:06AM BLOOD Glucose-76 UreaN-15 Creat-0.3* Na-120*
K-5.7* Cl-96 HCO3-23 AnGap-7*
[**2163-6-25**] 07:29AM BLOOD Glucose-117* UreaN-9 Creat-0.1* Na-131*
K-4.2 Cl-100 HCO3-23 AnGap-12
[**2163-6-30**] 03:18AM BLOOD Glucose-93 UreaN-10 Creat-0.3* Na-132*
K-4.4 Cl-98 HCO3-30 AnGap-8
Liver:
[**2163-6-21**] 02:01PM BLOOD ALT-59* AST-60* AlkPhos-159* TotBili-7.4*
[**2163-6-24**] 09:59AM BLOOD ALT-44* AST-58* LD(LDH)-285* AlkPhos-72
TotBili-11.3* DirBili-2.9* IndBili-8.4
[**2163-6-25**] 07:29AM BLOOD LD(LDH)-264* TotBili-14.1* DirBili-2.7*
IndBili-11.4
[**2163-6-29**] 03:27AM BLOOD ALT-27 AST-35 AlkPhos-97 TotBili-6.1*
URINE CULTURE (Final [**2163-6-26**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES PERFORMED ON CULTURE # 349-6679D [**2163-6-22**].
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Abd U/S [**2163-6-23**]
1. Large amount of ascites.
2. Limited visualization of the liver with no focal liver
lesion identified
and no biliary dilatation seen.
3. Limited Doppler examination cannot confirm flow within the
portal veins
(low vs no flow). If confirmation is desired, an MRI could be
performed if
the patient is compatible.
4. Cholelithiasis.
5. Splenomegaly.
Brief Hospital Course:
This is a 54yo woman PMHx ESLD [**1-27**] EtOH cirrhosis complicated by
encephalopathy, ascites, and hyponatremia, currently undergoing
transplant evaluation, who presented with hypervolemic
hyponatremia and metabolic/hepatic encephalopathy, who improved
with hypertonic saline and subsequent fluid restriction, now at
baseline and ready for discharge to a rehab.
Active Issues:
# Hyponatremia - Patient was admitted to the MICU w hyponatremia
of 118, felt to be of hypervolemic etiology. Patient received
hypertonic saline w Na improving to 128; patient was
subsequently fluid restricted, with stabilization of Na. At
time of discharge Na was 132. At discharge she was maintained
on a 1.5L free water restriction.
# Encephalopathy - Patient was admitted with notable confusion,
thought to be secondary to her metabolic abnormalities. With
improvement in her serum sodium and uptitration of her lactulose
her mental status improved to baseline (see discharge exam).
Additionally, mental status altering medications were stopped
(gabapentin, methocarbamol, oxycodone, tramadol, zolpidem,
zonisamide) without negative effect.
# Acute Anemia / Thrombocytopenia - Patient's was admitted with
Hct 28.2, which trended down to to 20 over several days.
Platelets also trended down concurrently from 50 to 20s. She
remained guaiac negative with indeterminate hemolysis studies,
making DIC unlikely. She was transfused with 3 units pRBCs over
2 days, with eventual response in her Hct to 27-28. At
discharge, Hct had remained stable for >3 days. Discharge Hct
was 26.9, platlets were 35. Above events were attributed to
fluid shifts during acute illness.
#Nutrition: Patient evaluated by nutrition service, who
reccomended NG FT. FT placed on [**6-27**] without complications with
isosource feeds per nutrition reccommendations (Isosource 1.5 @
20 ml/hr advance q 6 hours by 20 ml/hr to goal of 45 ml/hr =
1620 kcals/73 g protein). Encouraged to PO as well, which she
was able to do. Patient discharged with FT. Continued Vitamin D,
calcium
#UTI: On admission, patient was found to have a positive Ucx
growing E. coli. She completed a 5 day course of ceftriaxone.
Patient discharged without urinary symptoms.
# ESLD: Patient with known ESLD [**1-27**] EtOH cirrhosis. Presented
with increased ascited c/w decompensated cirrhosis.
Spironolactone and lasix were continued and patient's ascites
improved to baseline. Encephalopathy treated effectively with
lactulose and rifixamin as above. Continued folic acid, added
thiamine.
Inactive
# Chronic Abdominal pain: Patient w chronic mild abdominal pain,
diffuse and stable during this admission. Ultrasound was
unchanged from prior.
# Tremor: Patient has bilateral hand tremor. In consultation
with outpatient neurologist, her zonisomide was discontinued due
to rare side effects of anemia and hyponatremia. Tremor did not
recur with cessation of medication and at discharge patient was
able to feed herself, hold a spoon, and walk (activities she was
unable to do prior to admission). Patient was instructed to
follow-up with neurologist regarding this issue.
# GERD: Continued omeprazole
# Chronic leg pain: As above, discontinued gabapentin,
methocarbamol, and tramadol without worsening of chronic pain.
TRANSITIONAL
- Code status: full code
- Follow-up scheduled in Liver [**Hospital 1326**] Clinic with Dr [**Last Name (STitle) 497**]
- On [**2163-7-4**], please check CBC, Chem10, ALT/AST, Tbili, AlkPhos
and PT/PTT and fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], [**Hospital1 18**] Liver Center,
([**Telephone/Fax (1) 4409**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ICU admission.
1. Furosemide 20 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. HydrOXYzine 10 mg PO QHS:PRN itching
4. Lactulose 45 mL PO QID
titrate to [**1-28**] BMs
5. Methocarbamol 750 mg PO Q8H:PRN pain
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO BID
8. TraMADOL (Ultram) 50 mg PO Q12H
9. Ziprasidone Hydrochloride 20 mg PO DAILY
10. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
11. Omeprazole 40 mg PO BID
12. FoLIC Acid 1 mg PO DAILY
13. Vitamin D 1000 UNIT PO BID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. HydrOXYzine 10 mg PO QHS:PRN itching
4. Lactulose 45 mL PO TID
titrate to [**2-27**] BM per day
5. Omeprazole 40 mg PO BID
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO BID
8. Vitamin D 1000 UNIT PO BID
9. Thiamine 100 mg PO DAILY
10. Simethicone 40-80 mg PO QID:PRN abd cramping
11. Senna 1 TAB PO BID:PRN Constipation
12. Ondansetron 4 mg IV Q8H:PRN nausea
13. Docusate Sodium (Liquid) 100 mg PO BID
14. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
15. Calcium Carbonate 500 mg PO QID:PRN abd pain
16. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN abd
pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY
- Hyponatremia
- Hepatic encephalopathy
- Urinary tract infection
SECONDARY
- Cirrhosis complicated by varices, ascites, encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 2643**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were hospitalized for confusion and low
sodium. You were treated in the ICU and your sodium improved.
For your confusion, you received lactulose and rifixamin and
your mental status improved to your baseline. Given that your
nutrition was so poor, you had a feeding tube placed. You were
ready for discharge to a rehabilitation facility.
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: [**Street Address(2) 9646**] [**Hospital Unit Name **], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 3183**]
Department: TRANSPLANT
When: WEDNESDAY [**2163-7-13**] at 3:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
Completed by:[**2163-6-30**]
|
[
"427.89",
"338.29",
"456.21",
"456.8",
"788.20",
"303.93",
"287.5",
"571.2",
"276.52",
"789.00",
"041.04",
"276.1",
"V15.82",
"572.2",
"729.5",
"285.9",
"789.59",
"530.81",
"599.0",
"781.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12369, 12451
|
7464, 7829
|
327, 333
|
12640, 12640
|
4979, 7441
|
13287, 14009
|
3024, 3089
|
11710, 12346
|
12472, 12619
|
11120, 11687
|
12825, 13264
|
3104, 4474
|
2115, 2506
|
266, 289
|
7844, 11094
|
361, 2096
|
12655, 12801
|
2528, 2803
|
2819, 3008
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,686
| 123,608
|
14270
|
Discharge summary
|
report
|
Admission Date: [**2133-9-23**] Discharge Date: [**2133-10-2**]
Date of Birth: [**2081-6-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
52M with a h/o IDDM and ESRD who was found to have 3 vessel CAD
on a work up for renal and pancreas transplants.
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->OM, PDA) [**2133-9-25**]
History of Present Illness:
This patient has a h/o type 1 DM, ESRD and HTN and was being
worked up for renal and pancreas transplants and had a +ETT. He
underwent cardiac cath which revealed: 50% LM [**Last Name (un) 2435**]., 50% LAD
[**Last Name (un) 2435**]., 90% mid RCA, and an EF of 60%. He is now admitted for
CABG.
Past Medical History:
HTN
ESRD on HD x 5 yrs.
Type 1 DM
s/p mult. toe amps.
Legally blind
s/p L AV fistula
Social History:
Lives in nursing home.
Cigs: none
ETOH: none
Family History:
Unremarkable
Physical Exam:
WDWNWM in NAD
AVSS
HEENT: NC/AT, EOMI, PERLA, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: + BS, soft, nontender, without masses or hepatosplenomegaly
Ext: L AV fistula, without C/C/E, toe amps
Neuro: nonfocal
Pertinent Results:
[**2133-10-1**] 06:00AM BLOOD WBC-10.1 RBC-3.47* Hgb-9.9* Hct-30.3*
MCV-87 MCH-28.6 MCHC-32.8 RDW-17.3* Plt Ct-197
[**2133-9-28**] 02:37PM BLOOD PT-12.5 PTT-26.9 INR(PT)-1.1
[**2133-10-2**] 06:05AM BLOOD Glucose-187* UreaN-23* Creat-5.1*# Na-142
K-4.3 Cl-99 HCO3-34* AnGap-13
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2133-9-28**] 2:54 PM
CHEST (PORTABLE AP)
Reason: pneumothorax?
[**Hospital 93**] MEDICAL CONDITION:
52 year old man with CAD s/p CABG
REASON FOR THIS EXAMINATION:
pneumothorax?
CLINICAL HISTORY: Coronary artery disease status post CABG.
CHEST: Since the prior chest x-ray, the mediastinal endotracheal
tube, left chest tube, and Swan-Ganz catheter have all been
removed. The heart is enlarged and some atelectasis is present.
No evidence of pneumonia, pneumothorax or failure is seen.
IMPRESSION: Cardiomegaly, no failure, atelectasis only.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Cardiology Report ECHO Study Date of [**2133-9-25**]
PATIENT/TEST INFORMATION:
Indication: Chest pain. Coronary artery disease. Intra-op TEE
for CABG
Status: Inpatient
Date/Time: [**2133-9-25**] at 14:25
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW002-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.3 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: 2.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aorta - Arch: 2.4 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.0 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 8 mm Hg
Aortic Valve - Mean Gradient: 4 mm Hg
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.50
Mitral Valve - E Wave Deceleration Time: 310 msec
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color
Doppler. Prominent Eustachian valve (normal variant).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
Normal ascending aorta diameter. There are complex (>4mm)
atheroma in the
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. The rhythm
appears to be
A-V paced. The patient is in a ventricularly paced rhythm.
Results were
Conclusions for
post-bypass data
Conclusions:
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the aortic arch. There
are complex
(>4mm) atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is
seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
POST-BYPASS: Pt is AV paced and is receiving an infusion of
phenylephrine
1. Biventricular systolic function is preserved.
2. Aorta contour is intact
3. Other findings are unchanged
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2133-9-25**] 17:20.
Brief Hospital Course:
The patient was transferred from [**Hospital6 3105**] on
[**2133-9-23**] for CABG. He had a renal consult and carotid studies
which were negative. He underwent CABGx3(LIMA->LAD< SVG->OM,
PDA) on [**2133-9-25**]. Cross clamp time was 64 mins. and total bypass
time was 87 mins. He was transferred to the CSRU on Neo,
Propofol, and Lidocaine. He was extubated on the post op night
and had his chest tubes d/c'd on POD#2. He was transferred to
the floor on POD#4 and continued to improve. His epicardial
pacing wires were d/c'd on POD#6. He was dialyzed on [**10-1**] and
was discharged to his nursing home on POD#7.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Humalog 4U daily
Lantus 8U daily
pepcid 20 mg PO daily
Renagel 800 mg PO daily
Novalog 70/30 5U daily
Nephrocaps
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily ().
7. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: as directed units Subcutaneous twice a day: 6 units QAM
8 units QPM.
8. Insulin Aspart 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Omeprazole 20 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*
Discharge Disposition:
Extended Care
Facility:
Healthrehab
Discharge Diagnosis:
s/p CABG x3(LIMA-LAD,SVG-OM,SVG-
PMH:IDDM, HTN, ESRD on HD, retinopathy, Multiple toe amputations
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) 42392**] [**Name (STitle) 42393**] in [**1-26**] weeks
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] in [**2-27**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2133-10-2**]
|
[
"585.6",
"362.01",
"285.21",
"V49.72",
"276.0",
"403.91",
"369.4",
"250.51",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7741, 7779
|
5839, 6461
|
433, 483
|
7921, 7928
|
1377, 1768
|
8129, 8374
|
995, 1009
|
6668, 7718
|
1805, 1839
|
7800, 7900
|
6487, 6645
|
7952, 8106
|
2442, 5816
|
1024, 1358
|
281, 395
|
1868, 2416
|
511, 809
|
831, 917
|
933, 979
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,184
| 135,755
|
44358
|
Discharge summary
|
report
|
Admission Date: [**2146-12-5**] Discharge Date: [**2146-12-9**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Acute change in mental status and reported right sided facial
droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
On [**12-5**], she was at her nursing home, [**Hospital3 537**], when she
was
noted to be drowsy by nursing staff. She was taking a shower
around 9:20-9:40AM when her aide noticed that the patient became
progressively weak. She "slumped over" and was helped back to
bed. She was reportedly falling to the right and had a right
facial droop. She was minimally verbal and generally weak. EMS
was called and found the patient with right facial droop,
slurred
speech, and weak right hand.
She arrived in the [**Hospital1 18**] ER on at 10:20AM. Her vitals at that
time were: BP142/114, HR 64 RR12 O2Sat 99%. She was emergently
intubated, paralyzed and sedated for ariway protection. On
intial evaluation by stroke fellow, she was unresponsive, not
moving extremities and had NIH stroke scale of 23. Her initial
head CT showed possible early infart signs in the left insular
cortex, but no hemorrhage. She was given labetalol 15mg IVP x2
for BP control. IV t-PA was administered at 11:30AM with 4.5mg
IV bolus and 40.5mg over one hour. She also rec'd one unit of
PRBCs in the ER for a Hct of 27.8.
Past Medical History:
1. HTN
2. History of colon polyp
3. Chronic renal insufficiency
4. Hypothyroidism
Social History:
Lives in a NH. She is married-her husband is in the Rehab
facility at [**Hospital3 537**] after being treated for PNA. She has
one son who lives in [**Name (NI) 4565**]. At baseline, is alert and
mobile, but confused
Physical Exam:
T: 98.6 BP:178/72 HR: 55
Vent AC 550x12, not overbreathing, with Fi02 50%, Sp02 100%.
Gen: WD/WN, intubated, comfortable on vent, NAD.
HEENT: Dried blood around nares, in oral cavity. Anicteric. MM
dry. +ETT.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Coarse breath sounds anterolaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Grimaces to noxious stimuli. Not following
commands.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. No blink to threat.
III, IV, VI: Oculocephalic reflex intact.
V, VII: Bilateral corneal reflexes intact.
VIII: Unable to assess.
IX, X: Gag reflex intact.
[**Doctor First Name 81**]: Unable to assess.
XII: Unable to assess with presence of ETT.
Motor: Postures RUE to noxious stimuli. Withdraws RLE, left
side to noxious stimuli.
Sensation: Postures RUE to noxious stimuli. Withdraws RLE, left
side to noxious stimuli.
Reflexes: Present and symmetric. Grasp reflex absent. Toes
downgoing bilaterally.
Coordination: Unable to assess.
Gait: Unable to assess
Pertinent Results:
[**2146-12-9**] 05:05AM BLOOD WBC-6.7 RBC-4.87 Hgb-12.8 Hct-39.7 MCV-82
MCH-26.2* MCHC-32.2 RDW-17.5* Plt Ct-126*
[**2146-12-5**] 10:50AM BLOOD WBC-6.2 RBC-3.68* Hgb-8.5*# Hct-27.8*#
MCV-76*# MCH-23.0*# MCHC-30.4*# RDW-14.7 Plt Ct-193
[**2146-12-9**] 05:05AM BLOOD Plt Ct-126*
[**2146-12-5**] 10:50AM BLOOD PT-13.2 PTT-23.6 INR(PT)-1.1
[**2146-12-5**] 10:50AM BLOOD Plt Ct-193
[**2146-12-9**] 05:05AM BLOOD Glucose-83 UreaN-35* Creat-1.5* Na-142
K-3.9 Cl-109* HCO3-23 AnGap-14
[**2146-12-5**] 10:50AM BLOOD Glucose-124* UreaN-39* Creat-1.4* Na-149*
K-4.1 Cl-112* HCO3-26 AnGap-15
[**2146-12-5**] 10:50AM BLOOD CK-MB-NotDone cTropnT-0.54*
[**2146-12-5**] 10:43PM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2146-12-6**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.51*
[**2146-12-9**] 05:05AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.9
[**2146-12-6**] 03:40AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.6 Cholest-125
[**2146-12-8**] 04:45AM BLOOD calTIBC-283 Ferritn-74 TRF-218
[**2146-12-6**] 03:40AM BLOOD %HbA1c-6.2*
[**2146-12-6**] 03:40AM BLOOD Triglyc-77 HDL-42 CHOL/HD-3.0 LDLcalc-68
Brief Hospital Course:
1. NEURO-
After IV t-PA was given, the patient was noted to be moving her
extremities left greater than right. An MRI was done (although
no diffusion imaging could be obtained due to problem with MRI
machine) which did not show evidence of new stroke, but did
reveal periventricular T2 hyperintensities c/w chronic small
vessel disease. An old, right cerebellar infarct was also seen.
Multiple areas of susceptibility were seen bilaterally in the
basal ganglia and thalami. A repeat CT scan was done on [**12-6**]
which was negative for acute infarct or bleed. Anti-platelets
were held due to fluctuations in Hct. An EEG showed slow
background and occasional generalized theta and delta slowing
c/w
drowsiness or mild encephalopathy. She had carotid US which
showed mild, <40% bilateral proximal ICA stenosis. During her
course, her mental status improved. Neuro exam has shown
decreased attention, dysarthria and mild right facial droop. She
was started on aspirin, lipitor and ACEI for secondary stroke
prevention.
2. PULM:
Initially intubated and sedated, but extubated [**12-6**] without
complications. CXR has shown mild CHF and LLL atelectasis vs
infiltrate. She was treated with Levofloxacin for PNA. Rpt CXR
showed bilateral pleural effusions and mild CHF. Her
respiratory status improved after lasix. She was started on
atrovent and albuterol nebs with resolution of wheezing and SOB.
3. CV:
Her inital EKG showed non-specific anterolateral ST changes.
Cardiac enzymes were positive with peak troponin of 0.54. Echo
showed EF 35%, mildly dilated LA, mild left ventricular hypo
(inferior wall), mild-moderate AR, MR [**First Name (Titles) **] [**Last Name (Titles) **] HTN. Cardiology
consult saw her and felt that the elevated troponin and
decreased
EF were likley indicative of CAD. They recommended medical
management with beta blocker and anti-platelet (ASA). If
patient
becomes symptomatic, they suggest evaluation with persantine
stress test. Her lipid profile showed HDL 42, LDL 68, and TG
77.
She was started on a statin and ACEI. She should have an
outpatient persantine stress test if she develops cardiac
symptoms.
4. GI:
Initially fed with NGT. Now able to tolerate oral feeding per
swallow eval today. Continue GI ppx. Stool guiac has been
negative.
5. RENAL/LYTES:
Elevated BUN/Cre-do not know baseline Cre. Now also with
hypernatremia-started on free water hydration today. Started on
ACEI-need to follow up lytes and BUN/Cre as an outpatient.
6. ID:
Pt had postitive UA on admission and was started on
Levofloxacin. Also has LLL infiltrate on CXR. Will cont abx
for 7 day course. She has been afebrile and her
7. Heme:
On admission, Hct was 27.8. She rec'd 2 U PRBCs in the unit
with
poor Hct response. Yesterday, rec'd an additional 2 U PRBCs,
Hct
rose to 40. She was started on ASA 325mg as her Hct was stable
post transfusion. She should have follow up iron studies and
B12 level as an outpatient.
8. Endocrine:
Her HbA1C was mildly elevated. She should adhere to a diabetic
diet. Synthroid was continued at pre-admission dose
9. Rehab:
PT/OT evaluated the patient and she will be discharged for
continued PT.
Medications on Admission:
1. Atenolol 50 mg po qd
2. Synthroid 75 mcg po qd
3. Vitamin B12 SC qMonth
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Atenolol 50 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: 0.5 Tablet PO HS (at bedtime)
as needed for insomnia.
10. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
13. Atrovent 0.02 % Solution Sig: One (1) Inhalation every six
(6) hours.
14. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
1. Acute stroke: s/p IV t-PA
2. Non ST elevation MI
3. Chronic renal insufficiency
4. Anemia-s/p 4U PRBC transfusion
5. Pnuemonia
Discharge Condition:
Improved-mild right facial weakness and right UE weakness.
Discharge Instructions:
Please continue to take your medications as prescribed. If you
develop chest pain, SOB, new weakness, numbness, dizziness,
difficulty with speech or swallowing, please return to the ER
for evaluation.
Followup Instructions:
1. Dr. [**Last Name (STitle) 2903**]: Friday [**12-16**] at 11:15AM. Please have Dr.
[**Last Name (STitle) 2903**] check your BUN/Cre and potassium as you have just been
started on Lisinopril. You should also have a PA and lateral
CXR to follow up on LLL pneumonia and bilateral pleural
effusions. Please have your liver function tests checked in one
month as you have been started on lipitor.
2. Dr. [**Last Name (STitle) **]: [**2146-2-6**] at 1:00pm [**Hospital 878**] Clinic [**Hospital Ward Name 23**] Bldg
[**Location (un) **]. [**Telephone/Fax (1) 657**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"274.9",
"401.9",
"436",
"486",
"593.9",
"410.71",
"599.0",
"244.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"96.71",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8756, 8827
|
4157, 7336
|
331, 338
|
9002, 9062
|
3076, 4134
|
9312, 9977
|
7461, 8733
|
8848, 8981
|
7362, 7438
|
9086, 9289
|
1831, 2325
|
223, 293
|
366, 1472
|
2410, 3057
|
2340, 2394
|
1494, 1578
|
1594, 1816
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,347
| 138,131
|
29039
|
Discharge summary
|
report
|
Admission Date: [**2128-8-12**] Discharge Date: [**2128-8-14**]
Date of Birth: [**2048-11-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
sepsis, altered mental status, renal failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yo female with pmhx significant for paranoid schizophrenia,
dementia, a-fib, diabetes, who was brought to the ED from her
nursing home for worsening renal failure, increased confusion,
and a supratherapeutic INR of 6.8. In the ED the patient was
found to be febrile to 101 with systolic bp's in the 60's, heart
rate ranging from 120's up to 140's. Rhythm consistent with
a-fib with [**First Name3 (LF) 5509**]. She was given 4 liters of IVF with improvement
of her blood pressure to systolic 100-110's, however her heart
rate decreased to only 120's. Her code status was confirmed by
her PCP to be DNR/DNI, guardian was unable to be reached. A UA
was suggestive of infection with >50 WBCs, many bacteria.
Lactate wnl. Blood and urine cultures were drawn and the pt was
given a dose of Vanc, Levo, and Flagyl for empiric coverage.
CXR showed atlectasis, no consolidation. She was admitted to
the [**Hospital Unit Name 153**] for further management given her uncontrolled a-fib
with [**Hospital Unit Name 5509**].
.
Currently the patient is awake, moaning in bed. Not responsive
to questions.
Past Medical History:
Afib - on coumadin
Hypertension
Hypothyroidism
NIDDM
psychotic senile dementia
paranoid schizophrenia
cataracts OU
B12 deficiency
Knee effusion
Social History:
babbles at baseline, feeds self
Family History:
Non contributory
Physical Exam:
vitals: temp 97.3/ bp 86/46/ 128/ 21/ 96% on 2L
GEN: awake, moaning, non-verbal, obese
HEENT: atraumatic, anicteric, dry mucosa
NECK: no JVD, no LAD, no carotid bruits
CV: tachy, irregular, no murmurs appreciated
LUNGS: rhonchi B/L at bases, no crackles, no wheeze, no
accessory muscle use
ABD: distended, soft, no rebound, no guarding, hypoactive BS
EXT: warm, dry. DP pulses faint but palpable B/L. R knee with
displaced patella, effusion. No erythema or increased warmth.
Trace LE edema.
SKIN: Multiple ecchymoses, chronic venous stasis changes on LE
B/L
NEURO: awake, non-verbal. Tracks, doesn't follow commands,
answer to questions. Moves all extremities spontaneously. Toes
downgoing B/L, reflexes diminished B/L, no myoclonus.
Pertinent Results:
[**2128-8-12**] 02:55PM PT-39.5* PTT-36.4* INR(PT)-4.4*
[**2128-8-12**] 02:55PM WBC-18.9*# RBC-3.33* HGB-9.8* HCT-29.2*
MCV-88 MCH-29.5 MCHC-33.6 RDW-16.3*
[**2128-8-12**] 02:55PM cTropnT-0.10*
[**2128-8-12**] 02:55PM LIPASE-98*
[**2128-8-12**] 02:55PM ALT(SGPT)-78* AST(SGOT)-149* LD(LDH)-810*
CK(CPK)-86 ALK PHOS-412* AMYLASE-49 TOT BILI-2.4*
[**2128-8-12**] 02:55PM GLUCOSE-60* UREA N-196* CREAT-4.8*#
SODIUM-130* POTASSIUM-7.3* CHLORIDE-94* TOTAL CO2-22 ANION
GAP-21*
[**2128-8-12**] 03:45PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2128-8-12**] 03:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2128-8-12**] 03:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2128-8-12**] 08:55PM CK-MB-NotDone cTropnT-0.07*
[**2128-8-12**] 08:55PM CK(CPK)-24* TOT BILI-3.0* DIR BILI-3.0* INDIR
BIL-0.0
[**2128-8-12**] CXR: There has been interval removal of a right PICC.
The heart size remains moderate to severely enlarged and rotated
to the right. Linear opacity at the lung bases consistent with
scarring or atelectasis. No consolidation is seen. Pulmonary
vasculature is not congested.
.
[**8-12**] KUB: There is massive dilation of the stomach and some of
the small
bowel loops also appear dilated. There is inspissated material
noted in the rectosigmoid region. This is unchanged from
previous radiograph on [**2127-12-22**]. Diffusely distended
air-filled bowel loops are noted, which appear chronic and
nonspecific in character. There is no definitive evidence of
acute obstruction or ileus.
.
[**8-13**] RUQ US: Cholelithiasis with ultrasound findings suggestive
of acute cholecystitis.
Brief Hospital Course:
A/P: 79 yo female with multiple medical problems admitted to
[**Name (NI) 153**] for presumed sepsis, uncontrolled a-fib with [**Name (NI) 5509**], increased
confusion. Hospital course is listed by problem as follows:
.
# Sepsis - the patient initially presented with hypotension and
met SIRS criteria, with most likely source of infection being
the urine on admission; however, diagnostic imaging on HD2
revealed eviwith evidence of cholecystitis. The patient was
started on Vanc/ Zosyn for broad spectrum coverage on admission.
Bcx subsequently grew GNR.
# Hypotension - BP was initially somewhat responsive to IVFs
although tachycardia did not improve. UOP was adequate and
stable; however was also thought be secondary to increased BUN.
The patient was given fluid boluses prn for resuscitation. As
per guardian, no [**Name (NI) 14938**] was placed and pressors were not used.
.
# abdominal distension: pt had evidence of increasing abdominal
distension with somewhat localizing pain in the RUQ (difficult
to assess per pt's mental status) with KUB showing evidence of
dilated loops of bowel. Admission labs with evidence of elevated
transaminases, bilirubins, amylase and lipase. On HD 2 RUQ US
showed multiple gallstones and evidence of cholecystis, not
ammenable to percutaneous drainage. Obstructive gallstones were
believed to explain elevated pancreatic and liver enzymes, and
possible SBO as well.
.
# Acute renal failure- patient with baseline creatinine 1.1 6
months ago, most recent creatinine 1.28 in [**Month (only) 547**]. Renal failure
was thought to be pre-renal with possible ATN component given
hypotension in ED. [**8-12**] renal US with e/o minimal hydronephrosis.
IVF resuscitation was continued, nephrotoxins were avoided, and
electrolytes were monitored regularly.
.
# Altered mental status- per nursing home, pt has had increased
confusion from baseline dementia/schizophrenia. Differential
diagnosis includes infection, uremia, possibly medication
related, cerebral vascular event. Through her hospital course,
the infection and renal failure were treated as above. Standard
toxic metabolic w/u with Vit B12/ Folate, TSH, RPR were sent.
.
# A-fib with [**Month/Day (2) 5509**]- Patient with known a-fib, on AC with coumadin,
rate controlled with lopressor. Coumadin was held in the setting
of supratherapeutic INR. Esmolol drip was started briefly on HD2
at low-dose to treat tachycardia for concern for demand
ischemia; however, the patient did not tolerate this well with
subsequent drop in BP so this was discontinued.
.
# Metabolic acidosis- with elevated anion gap. Likely secondary
to uremia as pt with normal lactate, no ketones on UA, no known
ingestions.
.
# Hyponatremia- likely hypovolemic hyponatremia by exam. Feurea
= 66.8 (nml). hyponatremia was resolved by HD2 with IVF
administration.
.
# Supratherapeutic INR- secondary to coumadin for a-fib,
trending down from 11 to 4.4 with 2.5 mg Vitamin K given at NH.
.
# Anemia- normocytic, baseline hct 31-34. Guaiac negative in
the ED, no iron studies or colonoscopy/EGD on record. There was
no active signs of bleeding. During hospital course, hct was
monitored. Given likely demand ischemia, there was a plan to
transfuse if <25.
.
# Elevated troponin- pt poor historian but flat CK less
suggestive of ACS. Likely troponin leak from demand ischemia
related to a-fib with [**Name (NI) 5509**], pt has had elevated troponin to .07
in the past. No known CAD. CEs were trending downwards during
course. baseline EKG was not able to be obtained per [**Name (NI) 5509**].
.
The patient was agressively rescusitated with IVFs during her
course. Pneumoboots and PPI were used to prophylaxis.
.
# Code- DNR/DNI with no [**Name (NI) 14938**] or pressors. Per discussion with the
patient's guardian on [**2128-8-13**] it was decided to discontinue
aggressive measures and opt for comfort measures only. The
patient was started on a morphine drip. She passed away on
[**2128-8-14**] at 9:45am. The patient's guardian was notified.
.
HCP/ guardian is [**Name (NI) 2411**] [**Name (NI) 69962**] [**Telephone/Fax (1) 69963**]- in NY until
Saturday, cell # is [**Telephone/Fax (1) 69964**], sister is [**Name (NI) 4115**] [**Name (NI) **]
[**Telephone/Fax (1) 69965**]- does not make any health care decisions. PCP is
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] [**Telephone/Fax (1) 608**]
Medications on Admission:
lasix 20 mg
aspirin
colace
levoxyl 175 mcg
lisinopril 5 mg
omeprazole
risperdal .5 mg [**Hospital1 **]
senna
Vitamin C
lopressor 50 mg [**Hospital1 **]
novolin N 36 units qam
novolin R sliding scale
coumadin 5 mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis, hypotension, cholecystitis, afib, dementia
Discharge Condition:
expired
|
[
"427.31",
"276.2",
"276.52",
"574.00",
"244.9",
"250.00",
"290.0",
"584.9",
"995.92",
"790.92",
"295.32",
"560.9",
"038.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8936, 8945
|
4269, 8667
|
360, 366
|
9039, 9049
|
2524, 4246
|
1729, 1747
|
8966, 9018
|
8693, 8913
|
1762, 2505
|
276, 322
|
394, 1497
|
1519, 1664
|
1680, 1713
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,716
| 143,898
|
34225
|
Discharge summary
|
report
|
Admission Date: [**2122-5-2**] Discharge Date: [**2122-5-13**]
Date of Birth: [**2076-5-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Portal Vein Thrombosis
Major Surgical or Invasive Procedure:
PICC line placement, removed on day of d/c [**5-13**]
History of Present Illness:
45 year old Male without no known past medical history presents
with portal vein thrombosis. The patient presented to the
[**Hospital 8**] Hospital ED on [**4-30**] with complaints of marked
abdominal pain. He reports that the pain began approximately 5
days prior to admission here as a dull ache in his lower back
with diffuse pain in the abdomen that was sharper in nature. He
reports it was constant, not worse with eating or movement. He
reports nausea, but no vomiting. He notes he had chills, but
denies fevers. He reports constipation, no other changes in his
stools. He was initially seen on [**2122-4-26**] PM in the ED at which
time he received IVFs and was discharged with percocet for pain.
His condition worsened, and he went to his PCP [**Last Name (NamePattern4) **] [**2122-4-28**] who
believed that this might be viral hepatitis and thus sent
hepatitis serologies and additional labs, which were significant
for mild transaminitis. His PCP ordered [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 78830**] for further
evaluation which, per the admit note to [**Hospital 8**] Hospital,
revealed mild edema and infiltration in the mesentery and the
retroperitoneum with pericolic gutter ascites suggestive of
pancreatitis (he does not come with official report). Also noted
on CT were splenic varices suggestive of portal hypertension
with a question on CT of portal vein thrombosis. He was
scheduled for an outpatient RUQ Ultrasound to further evaluate
the portal vein flow, but his pain became too severe so he
presented to [**Hospital 8**] Hospital ED for further evaluation.
At [**Hospital 8**] hospital, RUQ ultrasound doppler revealed main
portal vein, right and left branch portal vein thromboses.
Although not explicitly noted in the ultrasound report, it is
noted on the [**Hospital 8**] Hospital admission note that there was
concern for SMV thrombosis, although further information was not
available and the physician requesting transfer did not state
this concern. He received 100mg SC lovenox. He had progressive
difficulty eating/drinking due to worsening nausea along with
gastric distension. A Nasogastric tube was placed for with
relief; initial output was 500cc and admission notes
greenish/brown fluid which was GUAIAC positive, although he was
GUAIAC negative from below. His abdominal pain remained
significant so he was started on a Dilaudid PCA with some mild
improvement in his pain. Vascular surgery was consulted and
recommended transfer to [**Hospital1 18**] for IR portal vein thrombolysis
procedure along with hepatology consultation.
Past Medical History:
ADHD
Depression
Anxiety
Low testosterone
Obesity
Social History:
He is the director of economic development for [**Hospital1 3494**] and
lives with his partner. [**Name (NI) **] is a nonsmoker and denies EtOH and
other illicits. Over 20 years ago, he would drink EtOH heavily
on weekends, but none since. No h/o IVDU.
Family History:
No family history of liver disease. No history of autoimmune
disease or IBD. No history of thromboses. Mother did not have
miscarriages. Father and [**Name2 (NI) 9876**] with MIs in their 50s, mother with
Type 2 DM
Physical Exam:
ROS:
GEN: - fevers, + Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, - Vomitting, - Diarhea, + Abdominal Pain, +
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.5, 147/85, 100, 18, 96%
GEN: Uncomfortable
Pain: [**5-26**]
HEENT: EOMI, Dry MM, - OP Lesions
PUL: CTA B/L
COR: Tachycardic, RRR, S1/S2, - MRG
ABD: Tender to deep palpation (greatest in RUQ), - Rebound, -
Guarding, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
DERM: - telangectasia, - Spider Angiomata, - Jaundice, - Rash
Pertinent Results:
ADMISSION LABS: [**2122-5-2**]
WBC-11.1* RBC-4.93 Hgb-14.4 Hct-42.7 MCV-87 MCH-29.1 MCHC-33.6
RDW-13.7 Plt Ct-176 Neuts-84.8* Lymphs-9.9* Monos-4.8 Eos-0.3
Baso-0.1
PT-14.7* PTT-25.0 INR(PT)-1.3*
Glucose-120* UreaN-16 Creat-0.6 Na-141 K-3.9 Cl-106 HCO3-25
AnGap-14
ALT-56* AST-21 AlkPhos-53 Amylase-61 TotBili-1.1
Lipase-145* Albumin-3.4 Calcium-7.9* Phos-2.0* Mg-2.0
Lactate-1.4
On Discharge: [**2122-5-13**]
WBC-3.8* RBC-4.05* Hgb-12.3* Hct-35.6* MCV-88 MCH-30.5 MCHC-34.7
RDW-14.6 Plt Ct-174
PT-14.8* PTT-65.5* INR(PT)-1.3*
Glucose-104 UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-105 HCO3-28
AnGap-10
.
IMAGING
RUQ U/S:
1. Limited ultrasound examination given poor acoustic window and
habitus. The main portal vein is thrombosed, with extent into
the superior mesenteric vein difficult given overlying bowel
gas. A CTA abdomen [**Known lastname **] be performed for further evaluation.
2. Diffusely echogenic liver consistent with fatty infiltration.
However, other forms of diffuse fibrosis/cirrhosis cannot be
excluded.
3. Splenomegaly.
4. Small-to-moderate amount of ascitic fluid in the right upper
quadrant.
.
CT Abdomen/Pelvis:
.
1. Chronic portal vein occlusion with cavernous transformation,
extending to
SMV, most notably in the left mid abdomen, where there is venous
and
mesenteric edema and a focally thick-walled segment of jejunum
in keeping with mesenteric ischemia.
2. Heterogeneous perfusion of the liver without focal lesion.
Early changes of cirrhotic liver disease are present including
ascites, splenomegaly, and left hepatic atrophy.
.
Repeat CT a/p on [**5-4**]:
1. Portal, splenic, and superior mesenteric venous thrombosis,
as on prior examination. Cavernous transformation as noted.
2. Multiple mildly dilated loops of small bowel. Given the
aforementioned venous thrombosis, likely differential
considerations do include mesenteric ischemia.
3. Heterogeneous attenuation of the liver suggesting abnormality
in perfusion related to portal venous thrombosis.
4. Moderate ascites.
5. Right-sided pleural effusion.
Brief Hospital Course:
A/P: 45yo previously healthy man presented to OSH with abdominal
pain, found to have portal vein thrombosis, transferred to [**Hospital1 18**]
for potential intervention, Hct was trending down with blood in
[**Hospital 78831**] transferred to the ICU for closer monitoring, now s/p EGD
with no significant findings, retransferred to floor.
.
#) Portal vein thrombosis: Etiology not entirely clear.
Differential includes hypercoagulability, malignancy,
pancreatitis, cirrhosis. Appears to be acute on chronic given
splenomegaly and collaterals seen on imaging. CT showed chronic
protal vein occlusion extending into SMV with thickened jejunum
suggesting mesenteric ischemia. Extensive liver workup negative
thus far. Lipase trended down.
#) UGIB- Patient initially had BRB and coffee grounds in NGT.
Hematocrit dropped from 43.8--> 38 but remained stable
thereafter. Patient remained HD stable. Pt used NSAIDs
occasionally once per week and no EtOH to suggest PUB. No
vomiting to suggest Boerhaves or [**Doctor First Name 329**] [**Doctor Last Name **] tear. Not brisk
enough to suggest variceal bleed. EGD on [**5-3**] without any
significant findings, also no portal gastropathy.
#) Depression/Anxiety: Patient currently NPO and NGT to
intermittent suction so will not be able to administer PO
antidepressant.
Patient was transferred to the surgical service and followed
with abdominal exams.
He was started on a heparin drip for the PV thrombus and began
Coumadin on [**5-10**].
Despite having to reinsert the NGT following a large meal, he
remained stable and without indication that this was indeed a
small bowel obstruction. He was passing flatus and had several
BMs. In addition after removal of the NGT the second time and
very cautious reinstatement of clears and then low residue diet,
he tolerated this very well withour further nausea or vomiting.
In the interim he received several days of TPN for nutritional
support.
No surgical intervention was performed.
In response to the finding of Portal Vein Thrombus he will
bridge as an outpatient on Lovenox and Coumadin until INR
therapeutic in the 2-3 range.
INR and Coumadin dosing will be followed by patients PCP Dr
[**Last Name (STitle) **] at his primary clinic in [**Hospital1 8**].
Medications on Admission:
Home MEDS:
Percocet 2 tabs PO q6h prn pain
Zoloft 100mg PO daily
Ritalin 10mg PO bid
Androgel
Pseudoephedrine prn
MEDS on transfer:
Dilaudid PCA (continuous rate of 0.1mg with 5min lockout, total
1.2mg/hour)
Protonix 40mg IV daily
Zofran 4mg IV q6h
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal Q24H (every 24 hours).
4. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **]
(2 times a day).
Disp:*10 syringes* Refills:*1*
5. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO PRN
as needed for allergy symptoms.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day: Do
not get a tablet with iron.
7. Outpatient Lab Work
Draw PT/INR on Friday [**5-15**] and fax results to [**Telephone/Fax (1) 78832**] Attn
Dr [**Last Name (STitle) **]
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Take
as directed.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Portal Vein Thrombus
Discharge Condition:
Good
Discharge Instructions:
Please call Dr [**Last Name (STitle) 15283**] office at [**Telephone/Fax (1) 673**] if you develop fever
> 101, chills, nausea, vomiting, diarrhea or have no stool for
more than 2 days. Call or return to ER if you develop abdominal
pain.
Watch for signs of bleeding to include nosebleed, rectal
bleeding or easy bruising.
Have PT/INR checked on Friday [**5-15**] and have results faxed to
[**Telephone/Fax (1) 697**].
Lovenox injections to continue until Coumadin level is
therapeutic
Continue low residue diet
Goal INR [**1-18**]
Followup Instructions:
Call Dr [**Last Name (STitle) 15283**] office at [**Telephone/Fax (1) 673**] to arrange follow up
appointment
Follow Up with Dr [**Last Name (STitle) 78833**]. He will be monitoring Coumadin
dosing as an outpatient.
Completed by:[**2122-5-13**]
|
[
"300.4",
"578.9",
"790.4",
"452",
"314.01",
"278.00",
"557.0",
"259.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
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|
6530, 8779
|
336, 392
|
10068, 10075
|
4473, 4473
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3374, 3591
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|
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274, 298
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420, 3015
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4489, 4853
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3037, 3088
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3104, 3358
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8938, 9056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,954
| 126,990
|
4514
|
Discharge summary
|
report
|
Admission Date: [**2151-12-25**] Discharge Date: [**2152-1-29**]
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, pneumothorax
Major Surgical or Invasive Procedure:
bilateral chest tube placement
endotracheal intubation
History of Present Illness:
This is a 63 y/o female with a complicated medical history,
including progressive multiple myeloma, amyloidosis (pulmonary,
bladder, tongue, cardiac), CKD on HD, h/o multiple DVTs, who
presented with acute left-sided back pain with dyspnea beginning
last night. She describes the pain as sharp and constant,
located over the left mid-lower back, which kept awakening her
from her sleep yesterday. This morning, she began having
dyspnea with exertion, no orthopnea or PND. No chest pain. No
recent f/c/s, cough, viral symptoms. No n/v/abd pain/diarrhea.
+chronic LE edema, which has worsened over the last 2 weeks.
.
In the ED, initial VS were Tc 98.3, BP 142/77 (baseline SBP's
90's), HR 102, RR 26, SaO2 high 80's/RA -> 98%/NRB. Stat CXR
demonstrated a left-sided apical PTX, confirmed by CT of the
chest. EKG was notable for low-voltage, however bedside echo
done in the ED did not show a pericardial effusion/tamponade
physiology. While in the ED, her BP decreased transiently to
78/44 after receiving 0.5 mg IV dilaudid (given for back pain),
increased to 90's systolic with 2 L NS. Another CXR
demonstrated a new right-sided PTX compared to the previous CXR
taken 4-5 hours ago. Both CT surgery and IP were consulted and
bilateral chest tubes were placed in the ED by CT surgery. The
patient is now admitted to the MICU for further management.
Past Medical History:
- Multiple myeloma stage III with amyloidosis dx'd in [**2142**], s/p
melphalan, and prednisone and then VAD x 4 cycles followed by
auto BMT and subsequent Thalidomide. Then mini-allo-BMT in 99
and again with recurrence had donor lymphocyte infusion from
brother in [**2145**], and 1/[**2151**]. Has had disease recurrence sinc
that time period. Endobronchial bx on [**9-15**] showed amyloid in
lungs. Treated with cytoxan x1, dexamethasone x4 days.
[**2151-9-20**] marrow biopsy showing maturing trilineage hematopoiesis
and lambda light chain restricted plasmacytosis c/w multiple
myeloma, amyloid also present [**2151-9-29**] free serum kappa/lambda
ratio 0.03. Currently on 4th cycle of Velcade, Cytoxan and
Decadron.
- 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
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:
Tc 96.1, BP 105/57, HR 90, RR 19, SaO2 96%/NRB (15 L O2), pulsus
approximately [**3-28**]
General: older female in mild respiratory distress, able to
complete full sentences, +NRB in place
HEENT: NC/AT, PERRL, EOMI. +NRB mask
Neck: supple, flat JVP
Chest: shallow, decreased BS throughout with scattered rhonchi.
+crepitus over posterior axillae b/l. b/l chest tubes in place.
CV: RRR no m/g/r, good heart sounds
Abd: soft, NT/ND, NABS
Ext: 1+ pitting edema b/l
Pertinent Results:
CT chest [**12-25**]:
1. Large left pneumothorax and small right apical pneumothorax
are new since [**2151-10-3**].
2. Moderate bilateral lung colapse, moderately worse since
9/[**2151**].
3. Small bilateral pleural effusions, slightly increased since
9/[**2151**].
4. Unchanged pulmonary arterry hypertension.
5. Widespread skeletal involvment of multiple myeloma, unchanged
since 9/[**2151**].
Findings were discussed with ICU nurse Romi at 7 PM on
[**2151-12-25**].
.
[**12-25**] EKG - Low voltage, lower compared to prior EKG [**10-1**]. NSR,
nl axis and intervals. No other acute changes.
.
[**12-25**] CXR #1 -
FINDINGS: There is a new left-sided pneumothorax seen in the
left upper lobe compared to the previous examinations. A
right-sided hemodialysis catheter is in place with tip
projecting over the right atrium. A large right hilar opacity
is consistent with the previously seen hilar mass as reported on
the previous CT. Bilateral pleural effusions are slightly
increased in size compared to the most recent chest x-ray.
There is bibasilar atelectasis.
.
[**12-25**] CXR # 2 - There is essentially no change in the left-sided
pneumothorax. This is approximately 15-20%. Since the previous
chest x-ray, there is a new linear opacity in the right
hemithorax of unclear etiology. It appears to represent a
pneumothorax on the right. No discernible lung markings are
identified outside this linear opacity. No pneumothorax was
present on the chest CT. There are large bilateral pleural
effusions. The effusion on the right
appears to be loculated. Fluid tracks in the major fissure on
the right. There is bibasilar atelectasis. Heart is top normal
in size. Mediastinum is within normal limits.
.
[**12-30**]: CXR Interval decrease in right pneumothorax is
demonstrated, which is almost invisible on the current study.
There is no change in the position of the two central lines on
the right, with the double lumen catheter tip terminating in the
right atrium about 5.5 cm below the cavoatrial junction. The
right PICC line tip is in the mid SVC.
The known hiatal hernia is again demonstrated projecting over
the heart
silhouette. The atelectasis of the part of the right lower lobe
is noted. There is overall no change in the appearance of the
cardiac silhouette and the rest of the lungs including the
patchy opacities in the left base.
Extensive involvement of the skeletal structures by multiple
myeloma is again noted. Small bilateral pleural effusion is
demonstrated slightly improved compared to the previous study.
.
[**1-4**]: CXR In comparison with the study of [**1-1**], there is no
significant
change. Again, there is enlargement of the cardiac silhouette
with bilateral pleural effusions, more marked on the right.
What appears to be a huge hiatal hernia is seen. Catheters
remain in position.
.
[**1-7**]: CXR Interval development of a moderate-sized right
hydropneumothorax. Ill-defined linear opacity in the right mid
lung field
likely reflects atelectasis secondary to the hydropneumothorax.
Left small pleural effusion is unchanged. Cardiomediastinal
silhouette and retrocardiac air-fluid structure likely
representing hiatal hernia are both unchanged. Right central
venous catheter position unchanged. IMPRESSION: Moderate-sized
right hydropneumothorax, new.
.
CTA [**1-3**]
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Increased atelectasis involving bilateral lower lobes, and
worsening hyperinflation of the right upper lobe. No
endobronchial lesion is identified.
3. Small right anteroapical pneumothorax. Resolution of
previously identified left pneumothorax.
4. Bilateral pleural effusion. The right decreased, the left
increased compared to prior exam.
5. Stable large hiatal hernia containing stomach, large bowel
and omentum.
6. Diffuse permeative lesion within the osseous structures with
areas of cortical destruction consistent with multiple myeloma.
.
Chest CT [**1-17**]
IMPRESSION:
1. Interval decrease in left-sided pneumothorax, which is now
tiny.
2. Stable collapse with subsequent hyperinflation of a portion
of the right lower lobe. No evidence of right-sided
pneumothorax.
3. Moderate-sized bilateral pleural effusions.
4. Large hiatal hernia containing stomach, bowel, and omentum,
which may contribute to the significant bibasilar atelectasis.
Superimposed infection cannot be excluded at the lung bases.
5. Diffuse permeative osseous lesions consistent with multiple
myeloma.
.
CT abdomen/pelvis [**1-18**]
IMPRESSION:
1. Findings suggestive of the possibility of chronic colitis.
Clinical correlation is recommended.
2. Findings suggestive of chronic cystitis. Clinical correlation
is recommended.
3. Bibasilar atelectasis and pleural effusions. A large hiatal
hernia containing the entirety of the stomach as noted above.
.
colonoscopy [**1-28**]
Findings:
Mucosa: The colonic mucosa was hyperemic with increased
vascularity throughout but with a predominance on the left.
Cold forceps biopsies were performed for histology at the
ascending colon and descending colon.
Protruding Lesions Medium non-bleeding internal hemorrhoids
were noted.
Impression: Abnormal vascularity in the colon (biopsy)
Internal hemorrhoids
Otherwise normal colonoscopy to terminal ileum
Recommendations: Return to hospital [**Hospital1 **].
Follow-up biopsies.
Please wait 24 hours before beginning anticoagulation because
biopsies were taken.
Additional notes: Although the colon was hypervascular as noted
above, there was no evidence of colitis or obvious source of
bleeding identified.
Brief Hospital Course:
This is a 63 y/o female with progressive MM, systemic
amyloidosis, CKD on HD, p/w spontaneous b/l pneumothoraces and
respiratory distress.
.
# Respiratory distress - both hypoxic and hypercarbic, [**2-26**]
secondary spontaneous PTX. Etiology of the pneumothorax unclear
but included PCP, [**Name10 (NameIs) **] pulmonary amyloid, TB, or other
infectious processes. She had bilateral chest tubes placed by
CT surgery on admission. She was also covered with broad
spectrum antibiotics(vanco/zosyn), and was treated with IV
bactrim and steroids for PCP. [**Name10 (NameIs) **] was intubated upon arrival to
the MICU and had a BAL performed which showed no evidence of PCP
or bacterial infection. Subsequently her Bactrim was decreased
to prophylaxis dose and her steroids were discontinued. Her
antibiotics were discontinued on [**12-28**] after her BAL cultures
returned negative. She was extubated without incident on [**12-27**].
She had her L chest tube removed on [**12-28**] and her R chest tube
removed on [**12-29**]. Her respiratory status remained stable
throughout the remainder of her MICU course. She was transferred
to the floor and her respiratory status continued to improve.
She no longer required O2 and was satting 93% with ambulation.
She subsequently received a four day course of chemotherapy and
on [**1-7**] developed worsening shortness of breath and desats to
mid 80s with ambulation. A chest X-ray was obtained and showed
a R hydropneumothorax. The thoracic surgery team was called and
placed a chest tube the same day with over 600cc of initial
drainage. Pleural cultures was negative for bacterial or fungal
infection. She did initially improve with chest tube in place
and had a talc pleurodesis performed on [**1-10**]. However over the
course of the evening had an increasing O2 requirement and
hypotension with systolics to the 70s and she was transferred to
the ICU. While there she was never intubated, but maintained on
O2. She was started on IV Vancomycin and Cefepime for
presumptive treatment of pneumonia. No evidence of PE on CTA.
Upon return to the floor, she continued to have an O2
requirement of 4-5L to maintain O2 sats as well as dyspnea on
exertion. On [**1-16**] she again developed acute shortness of
breath and hypotension and was sent back to the [**Hospital Unit Name 153**] where she
was found to have another pneumothorax. She was again evaluated
by thoracics who declined to place a chest tube as the PTX
naturally reabsorbed over the next 48 hours. The patient was
stabilized and returned to the BMT service for further
management. Pulmonary consult team was following her and signed
off on [**1-11**], a possible cause of her blebs and emphysematous
changes that lead to her pneumothoraces is oligemic changes
secondary to multiple pulmonary emboli. She was discharged on
coumadin for anticoagulation for her history of multiple DVTs
and anticipation of thalidomide treatment.
.
# ID/hypotension/?sepsis: The initial fever had an unclear cause
. She was treated for presumed sepsis in the setting of
hypotension with the antibiotics noted above which were
discontinued without obvious source of infection. Patient was
initially treated with levophed for low BPs. However, it was
discovered with placement of an a-line that patient's invasive
BP readings were ~10-20 mmHg higher than her noninvasive cuff
readings. It was also reported by her nephrologist that she
typically has SBPs in the 80s or lower while on dialysis but
always mentates without evidence of hypoperfusion. Given this,
her levophed was discontinued and MAPs of >50 were tolerated.
She continued to mentate throughout. She had an ECHO performed
which showed preserved systolic function and evidence of
diastolic dysfunction and elevated filling pressures as
previously documented and likely secondary to her cardiac
amyloid or her history of poorly controlled hypertension. After
admission she had no further recurrence of her fever.
.
# CKD on HD - on HD T/Th/Sa, followed by Dr. [**Last Name (STitle) 1366**]. She was
dialyzed once in the MICU on [**12-28**] without incident. She
received 10 mg of po midodrine prior to HD for relative
hypotension and tolerated ultrafiltration well. She was
continued on nephrocaps. She was intially treated with sevelamer
which was changed to phoslo given relatively low serum calcium.
Phoslo was subsequently discontinued as she had low phos levels.
She received HD on Tues,Thurs,Sat while on the floor. Upons
discharge she will continue to had HD as her usual schedule.
.
# Anemia: Patient was found to have significant Hct drop on
[**2151-12-28**] which was verified on repeat. Hemolysis labs were
negative. She had no evidence of bleeding. She was guiaic
negative. It was thought that this drop was potentially
secondary to decreased production from marrow suppression and
dilution in the setting of volume expansion. She received 2
units PRBCs with an appropriate response in her Hct. Her Hct
remained stable for the remainder of her MICU course following
transfusion until [**1-23**]. She had two large, grossly bloody
bowel movements but was hemodynamically stable. She reported
crampy abdominal pain the day before but denied nausea, vomiting
or epigastric pain. Her hematocrit dropped 4 points and she
received 2 units of blood. An intravenous PPI was started and
she received DDAVP. Her anticoagulation was discontinued. No
further episodes occured and GI deferred her colonoscopy. It
was felt that her lower GI bleed was due to ischemic colitis as
she had some episodes of hypotension. However, in light of
necessity of anticoagulation
colonoscopy was performed and showed hypervascularity in parts
of the colon but no obvious source of bleeding. Biopsies were
taken and anticoagulation was started the following day.
# Multiple Myeloma w/amyloidosis - s/p cycle 4 of
velcade/cytoxan/decadron the day prior to admission. Received
pentamidine on the same day for PCP [**Name Initial (PRE) 1102**]. As above, her
prophylaxis was changed to bactrim during hospitalization. She
was called out of the MICU to the Hematology/Oncology floor.
There she received a four day course of
velcade/decadron/cytoxan. She tolerated this well.
.
# h/o multiple DVTs - has been on and off coumadin
intermittently due to fluctuating platelet counts while on
Velcade. She was restarted on coumadin 1 day prior to admission
but this was held in the setting of chest tube placements. Upon
transfer to the Heme/Onc floor, so was soon restarted on
Coumadin but then held again with chest tube placement on [**1-7**].
Once stabilized in the ICU she underwent CTA which showed no
evidence of PE. She was started on IV heparin. She remained on
IV heparin until her lower GI bleed. At that time her recently
started coumadin and the IV heparin were discontinued. After
colonoscopy the anticoagulation was re-started with coumadin.
She will follow up with Dr. [**First Name (STitle) **] one day after discharge for
INR monitoring.
.
# HTN - Her anti-hypertensives were held due to relative
hypotension
.
# F/E/N -She was given tube feeds while intubated. Upon
extubation she had some swallowing difficulties which gradually
resolved. On call out from the MICU she was tolerating a
dysphagia diet. Upon arrival to the floor she did well with a
regular, low sodium diet
.
# Access - PICC line, HD catheter, 20-g PIV
Medications on Admission:
1. Renal caps 1 tablet daily
2. Immodium prn
3. Ativan 0.5 mg q4 hours prn
4. Toprol 12.5 mg daily
5. Protonix 40 mg daily
6. Pentamidine 300 mg inhaled qmonth (last dose [**2151-12-24**])
7. Compazine prn
8. Coumadin 2 mg daily - restarted [**2151-12-24**]
Discharge Medications:
1. Sliding tub bench
Dispense: 1 (one)
2. Raised toilet seat
Dispense: 1 (one)
3. 3-in-1 commode
Dispense: 1 (one)
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Pentamidine 300 mg Recon Soln Sig: One (1) inhalation
Inhalation once a month.
8. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for nausea.
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for insomnia/anxiety/nausea.
11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
12. Home oxygen
with associated equipment. Continuous at 2L.
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1.) Bilateral pneumothoraces
2.) Lower Gastrointestinal bleed
Secondary:
3.) Chronic renal failure
4.) Multiple myeloma
5.) Amyloidosis
Discharge Condition:
afebrile, displaying normal vital signs, 95% ambulatory O2 sat
improved >90% with rest, tolerating po.
Discharge Instructions:
You were admitted to the hospital because of shortness of breath
and you were found to have pneumothoraces of both lungs (air
between the lung and chest wall). You had chest tubes placed on
both sides and were treated in the intensive care unit until
these tubes could be removed. Repeated chest X-rays showed that
your lungs had expanded back to normal. You were then
transferred to the oncology service. Because of diarrhea you had
samples tested for infection - which were negative. You then
underwent a cycle of chemotherapy with velcade/cytoxan/decadron.
While you were on the heme/onc service you developed a lower GI
tract bleed. This is felt to be due to ischemic colitis. You
had a colonoscopy that showed an increased number of blood
vessels in part of your colon but no obvious source of bleeding.
.
When you leave the hospital you should take all medications as
prescribed. Please wait to take your Toprol XL until instructed
to do so by your doctor.
.
Because you had chest tubes recently removed it is very
important that you do not take a bath or immerse in water for at
least 2 more weeks. It is fine to shower; simply keep the sites
clean with mild soap and water and cover as needed with a clean
dry gauze daily. If you have any concerns that there is
increased redness, swelling, or drainage from these sites,
please seek medical attention.
.
You should continue to receive dialysis on Tues, Thurs, Sat as
previously scheduled and follow-up with Dr. [**Last Name (STitle) 118**]. Be sure to
confirm with him your medications that you take for your
kidneys.
.
You have a follow-up appointment with Dr. [**First Name (STitle) **] on Monday. You
may call to reschedule if this time does not work for you:
[**Telephone/Fax (1) 3237**].
Followup Instructions:
You have the following scheduled appointments:
.
Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2152-1-31**] 2:30
You will resume hemodialysis as scheduled.
Completed by:[**2152-1-31**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,377
| 177,842
|
32300
|
Discharge summary
|
report
|
Admission Date: [**2129-8-22**] Discharge Date: [**2129-8-25**]
Date of Birth: [**2051-4-30**] Sex: F
Service: MEDICINE
Allergies:
Diltiazem / Lisinopril
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 year-old Mandarin-speaking female with history of atrial
fibrillation on coumadin, amiodarone induced pulmonary fibrosis
and CHF (EF on [**First Name3 (LF) **] 55% with apical hypokinesis and 2+ MR in
[**2-16**]) who presented to the ED with diarrhea for 8 days. She
noted a sudden onset of the diarrhea with no inciting events.
She made no recent dietary changes and had no recent sick
contacts. She had no nausea, vomiting, fevers or chills. She
noted blood on the toilet tissue but none in the bowl. Her VNA
found her to be hypotensive and sent her to the ED.
.
In the ED, initial vital signs were T 98.3, HR 76, BP 94/57, RR
18, O2 Sat99. She received 3L of NS. A CT scan revealed mild
colitis. She received Flagyl and Ciprofloxacin in the ED. (*Of
note, an incidental pulmonary nodule was detected at the right
lung base.*) A reaction developed at the site of Ciprofloxacin
infusion and she was switched to Ceftriaxone upon transfer to
the MICU. She was still hypotensive in the MICU and received
further IVF.
.
The patient was transfered to the medicine team the following
day ([**8-23**]). On transfer, the vital signs were T:97.0, HR:95,
BP:108/60, RR:18, SO2:96% on RA.
.
Review of systems:
(+) Per HPI
(-) Denies: vomting, melena, changes in diet, fast-food intake,
history of travel, sick contacts, family history of bowel
disease inc. colon cancer.
Past Medical History:
CHF with EF 55% 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] [**2-16**]
Amiodarone induced pulmonary fibrosis
Paroxysmal atrial fibrillation, now status post AVJ ablation
and permanent pacemaker implantation in [**2126-10-7**]. The
pacemaker had previously been placed for tachybrady syndrome. On
coumadin.
Hypertension
Hemorrhoids
Gastritis
Osteoarthritis
Hypothyroidism
Hyperlipidemia
GERD
Depression
Tachy-bradycardia Syndrome s/p Pacemaker placement ([**2125**])
Social History:
1. Living: Lives alone and has VNA
2. Occupation: Used to work as a cook for an elderly woman.
3. Smoking: Used to smoke 1.5 packs per day but stopped
approximately 1 year ago
4. Alcohol: None
Family History:
No family history of bowel disease or colon cancer
Physical Exam:
Vitals: T:98.6, BP:118/60, P:65, R:18, SO2: 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moist mucus membranes, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: Minimal crackles at the bases but otherwise clear
CV: RRR (paced), normal S1, S2, no murmurs, rubs, gallops
Abdomen: soft, minimal TTP in lower abdomen
Ext: warm, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CN II-XII grossly intact
Pertinent Results:
Labs:
[**2129-8-22**] 03:00PM BLOOD WBC-9.7 RBC-3.85* Hgb-11.2* Hct-34.2*
MCV-89 MCH-29.1 MCHC-32.7 RDW-14.0 Plt Ct-310
[**2129-8-22**] 03:00PM BLOOD Neuts-77.2* Lymphs-16.5* Monos-3.1
Eos-2.8 Baso-0.4
[**2129-8-23**] 06:26AM BLOOD WBC-6.2 RBC-3.41* Hgb-10.4* Hct-29.8*
MCV-87 MCH-30.3 MCHC-34.8 RDW-13.9 Plt Ct-220
[**2129-8-25**] 07:44AM BLOOD WBC-7.9# RBC-3.50* Hgb-10.7* Hct-31.1*
MCV-89 MCH-30.5 MCHC-34.3 RDW-14.3 Plt Ct-239
[**2129-8-22**] 08:26PM BLOOD PT-33.5* INR(PT)-3.4*
[**2129-8-23**] 06:26AM BLOOD PT-30.0* PTT-31.9 INR(PT)-3.0*
[**2129-8-25**] 07:44AM BLOOD PT-20.5* PTT-28.2 INR(PT)-1.9*
[**2129-8-22**] 03:00PM BLOOD Glucose-85 UreaN-39* Creat-2.1* Na-135
K-4.0 Cl-100 HCO3-25 AnGap-14
[**2129-8-23**] 06:26AM BLOOD Glucose-81 UreaN-31* Creat-1.4* Na-142
K-4.1 Cl-112* HCO3-22 AnGap-12
[**2129-8-25**] 07:44AM BLOOD Glucose-108* UreaN-11 Creat-1.0 Na-138
K-4.2 Cl-108 HCO3-24 AnGap-10
[**2129-8-22**] 03:00PM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.7* Mg-2.0
[**2129-8-25**] 07:44AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.8
.
Micro:
1. UA negative
2. Blood cultures pending at discharge
3. C. diff toxin negative x one, repeat pending at discharge
4. Stool cultures pending at discharge
.
Images:
CT Abdomen/Pelvis ([**8-22**]):
1. Mild stranding and minimal thickening of the ascending colon
concerning for mild infectious/inflamatory colitis.
2. Cholelithiasis without cholecystitis.
3. 5mm pulmonary nodule in the right lung; if no risk factors
follow up in 12 months. If risk factors 6-12 months.
.
Brief Hospital Course:
78 year old Mandarin-speaking female with CHF,
amiodarone-induced pulmonary fibrosis, and AF on coumadin
admitted with colitis and hypotension.
.
1. Colitis: A bacterial etiology was assumed on admission given
the duration of the diarrhea. Empirirc antibiotics, Ceftriaxone
and Metronidazole, were initated with coverage for C. diff.
Blood, urine and stool cultures (including C. diff toxin) were
sent. Patient was C. diff toxin negative. In the initial course
of her illness she reported close to 10 bowel movements per day.
On admission she was only have 3 per day. Antibiotics were not
continued upon transfer from the MICU to the medicine floor. The
patient had one bowel movement per day while on the medicine
service but no further diarrhea. ** A repeat C. diff toxin and
stool cultures were pending at the time of discharge. Blood
cultures were negative to date. Patient has GI follow-up as she
has never had a colonoscopy.**
.
2. Hypotension: Patient received approximately 3.6L NS in the ED
and MICU. Patient was normotensive on transfer to the medicine
service and required no further intravenous fluid resuscitation.
.
3. Acute Kidney Injury: Cr 2.1 on admission but returned to
baseline of 1.0 following intravenous fluid resuscitation. No
urine studies were pursued given fluid response and likelihood
of prerenal etiology in the face of severe volume depletion.
.
4. Heart Failure with Preserved EF: EF 55% in [**2-16**]. Patient's
Furosemide, Metoprolol and Valsartan were held in the setting of
hypotension and acute kidney injury. Patient was euvolemic at
discharge and restarted on home medications.
.
5. Anemia: Baseline hematocrit mid- to high-30s in months prior
to admission. Patient has never received colonoscopy. No
evaluation pursued during this admission but patient was
scheduled with gastroenterology follow-up.
.
6. Atrial Fibrillation: Patient on Coumadin for anticoagulation
and Metoprolol tartrate for rate control. Metoprolol was
initially held in the setting of hypovolemia and rate remained
within normal limits. Metoprolol was restarted once euvolemic.
INR 3.4 on admission. Coumadin was held until INR less than 3
and was reinitiated. Patient followed by [**Hospital 197**] clinic as an
outpatient.
.
7. Solitary Pulmonary Nodule: 5-mm pulmonary nodule in the right
lung base detected on abdominal CT. Patient was a smoker at one
point in her life but reported different pack-year histories. Of
note, patient was reported to have Amiodarone-induced pulmonary
fibrosis. ** Patient will need follow-up as an outpatient. [**First Name8 (NamePattern2) **]
[**Last Name (un) 8773**] guidelines, a followup chest CT at 12 months is
recommended if there are no risk factors. If there are risk
factors, then initial followup CT at 6 to 12 months is
recommended. **
Medications on Admission:
Medications - Prescription
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth every week on
Wednesday
CLONAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a
day
FLUOXETINE - 20 mg Capsule - 1 Capsule(s) by mouth once a day
Folate 1mg daily
FUROSEMIDE [LASIX] - 20 mg daily
LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth Twice a day
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth Every morning and every night before dinner Take 30
minutes before breakfast, take 30 minutes before dinner
PRAMIPEXOLE - 0.125 mg Tablet - 1 Tablet(s) by mouth hs
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
TIOTROPIUM BROMIDE - 18 mcg Capsule, w/Inhalation Device - 1
puff
inh once a day
WARFARIN - 1 mg Tablet - Take up to 5 tablets daily or as
directed by coumadin clinic
Trazodone 25mg daily at night
.
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth daily
CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by
mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit Capsule -
1
Capsule(s) by mouth once a day - No Substitution
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by
mouth daily
GLUCOSAMINE HCL-MSM-CHONDROITN - 500 mg-167 mg-400 mg Tablet - 1
Tablet(s) by mouth Three times a day
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO Every Week on
Wednesday.
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ASDIR: Take up to
5 tablets daily, as directed by your coumadin clinic. .
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
11. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO at
bedtime.
13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: **
Do NOT take this medication until you see your primary care
physician.**.
15. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day: No Substitution.
17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
18. Glucosamine HCl-MSM-Chondroitn [**Telephone/Fax (3) 75495**] mg Tablet Sig:
One (1) Tablet PO three times a day.
19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
20. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
21. Outpatient Lab Work
Please have your INR, CBC and Chem-10 checked in 4 days (Monday,
[**2129-8-29**]). Please have the results sent to your PCP.
[**Name Initial (NameIs) **]: [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
Diarrhea
Secondary Diagnoses:
Incidental Pulmonary Nodule
Congestive Heart Failure
Pulmonary Fibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 1255**]:
You were recently admitted to the hospital for severe diarrhea
and low blood pressure. You received intravenous fluids and a
short-course of antibiotics. Both your diarrhea and your blood
pressure improved. It is likely that the cause of your diarrhea
was a virus. You should follow up with your primary care
physician as described below.
No changes were made to your home medications with one
exception. You should not take your Aspirin 81 mg until you see
your new primary care physician in [**Name9 (PRE) **].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: RADIOLOGY
When: TUESDAY [**2129-8-30**] at 1:30 PM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GASTROENTEROLOGY
When: THURSDAY [**2129-9-8**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2129-9-14**] at 3:50 PM
With: [**Doctor First Name 5147**] [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You were incidentally found to have a nodule in your right lung.
You should have a repeat CT-scan in [**6-18**] months to ensure that
it is stable.
Completed by:[**2129-8-28**]
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3,127
| 144,842
|
23149
|
Discharge summary
|
report
|
Admission Date: [**2115-3-7**] Discharge Date: [**2115-3-13**]
Date of Birth: [**2062-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation and extubation
History of Present Illness:
This is a 52 yo male with PMH of Hep C cirrhosis with grade III
varices, HCC s/p RF ablation [**7-15**], h/o seizure disorder, who was
found down and uresponsive today by his mother. [**Name (NI) **] was brought
in by ambulance. In addtion, there was question of urinary
incontinence by EMS and he was noted to have a chipped front
tooth, raising concern for seizures.
.
In the ED, his vitals were: T 97 HR 72 BP 119/80 RR 22 Sat 98%
on NRB. Head CT was negative for acute process. Abd ultrasound
showed insufficient ascites for tap. CT of the abdomen revealed
unchanged RF ablation site of HCC and non-occlusive portal vein
thrombus. CT of the C spine was negative for cervical trauma.
Blood cultures were drawn. His ammonia level was elevated at
118. Lactate was 2.5. Serum and urine tox screens were negative.
Due to altered mental status and GCS score of 7, he was
intubated. He received CTX/Vanc/Clinda in the ED.
Past Medical History:
1. Cirrhosis - HCV, grade III esophageal varices,
2. HCV - diagnosed [**2099**], s/p 2 incomplete trials of PEG
IFN/ribavirin, d/c'd for depression and noncompliance, diagnosed
with hepatocellular carcinoma, approximately 4-cm mass. He
underwent radiofrequency ablation of this lesion on [**2114-7-11**].
Repeat CT without lesions.
3. Thrombocytopenia
4. H/o seizure disorder - on Keppra
5. s/p R mastoidectomy - for GSW to head, deaf in R ear
6. H/o PTSD - s/p GSW
7. Depression/anxiety
8. IV drug use from [**2081**] to [**2109**]
9. History of hepatitis B in [**2085**]
Social History:
Lives in [**Location 1268**] by himself in his own apartment. He is
divorced and has an 8-year-old daughter. Currently unemployed,
on [**Social Security Number 59562**]social security. Volunteers at VA. H/o heavy alcohol abuse
[**2078**]-[**2107**], during which he drank a pint to a quart of vodka per
day, sober x 4 yrs. H/o IV heroin use, last use 4yrs ago. +
Tobacco use, 1 ppd x ~40y. H/o incarceration for domestic abuse.
Presently uses <1pp day.
Family History:
Father died at age 62, had a history of emphysema, asthma, COPD,
lung cancer, stroke, alcoholism, hypertension, type 2 diabetes.
Mother and sister with breast cancer. Sister recently passed
away from breast CA.
Physical Exam:
V: afebrile, BP 146/82 P 77 RR 99% R 15
Gen: No distress
HEENT: PERRL, NCAT, broken front tooth.
Resp: clear bilaterally
CV: RRR nl s1s2 no MGR
Abd: soft, NTND no appreciable ascites
Ext: 2+ edema, venous stasis changes and chronic dermatitis
bilaterally
Neuro: alert and oriented
Pertinent Results:
[**2115-3-7**] 08:41PM TYPE-ART TEMP-36.4 PO2-108* PCO2-30* PH-7.46*
TOTAL CO2-22 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED
[**2115-3-7**] 08:41PM LACTATE-1.4
[**2115-3-7**] 08:41PM O2 SAT-98
[**2115-3-7**] 06:18PM TYPE-ART PO2-113* PCO2-31* PH-7.44 TOTAL
CO2-22 BASE XS--1
[**2115-3-7**] 04:59PM GLUCOSE-124* UREA N-22* CREAT-1.2 SODIUM-140
POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-19* ANION GAP-15
[**2115-3-7**] 04:59PM ALT(SGPT)-43* AST(SGOT)-72* CK(CPK)-169 ALK
PHOS-82 AMYLASE-83 TOT BILI-2.9*
[**2115-3-7**] 04:59PM LIPASE-55
[**2115-3-7**] 04:59PM CK-MB-5
[**2115-3-7**] 04:59PM ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-3.8
MAGNESIUM-2.2
[**2115-3-7**] 04:59PM AMMONIA-118*
[**2115-3-7**] 04:59PM OSMOLAL-300
[**2115-3-7**] 04:59PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2115-3-7**] 04:59PM URINE HOURS-RANDOM
[**2115-3-7**] 04:59PM URINE HOURS-RANDOM
[**2115-3-7**] 04:59PM URINE GR HOLD-HOLD
[**2115-3-7**] 04:59PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2115-3-7**] 04:59PM LACTATE-2.5*
[**2115-3-7**] 04:59PM WBC-9.8# RBC-4.46* HGB-13.4* HCT-39.5* MCV-89
MCH-30.2 MCHC-34.1 RDW-19.0*
[**2115-3-7**] 04:59PM NEUTS-79.2* LYMPHS-11.2* MONOS-7.0 EOS-1.9
BASOS-0.7
[**2115-3-7**] 04:59PM ANISOCYT-2+ MICROCYT-1+
[**2115-3-7**] 04:59PM PLT COUNT-46*
[**2115-3-7**] 04:59PM PT-20.4* PTT-43.4* INR(PT)-2.0*
[**2115-3-7**] 04:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2115-3-7**] 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
AT DISCHARGE
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-3-13**] 03:40PM 4.0 3.29* 10.2* 29.4* 89 30.9 34.7 19.8*
17*1
1 VERIFIED BY SMEAR
[**2115-3-13**] 05:10AM 3.4* 3.11* 9.5* 27.3* 88 30.6 34.8 19.4*
15*
CT Head: IMPRESSION: Stable head CT with no acute interval
change. MRI with gadolinium would be more sensitive to detect
subtle small metastases or other mass lesions, however, there
are no secondary signs (such as vasogenic edema) to suggest an
underlying mass.
.
CT C Spine: IMPRESSION: No traumatic injury to the cervical
spine. The orogastric tube is coiled in the posterior oropharynx
but extends inferiorly into the esophagus. The endotracheal tube
balloon is inflated over the vocal cords and needs to bee
positioned distally.
.
CT abdomen/pelvis: No ascites and no acute intra-abdominal
process.
Unchanged RF ablation site of HCC and non-occlusive portal vein
thrombus. Cholelithiasis with no pericholecystic inflammatory
changes.
Brief Hospital Course:
#AMS: Given the pts asterixis on exam and elevated ammonia
levels, the underlying etiology was thought to be acute
encephalopathy. In the ED, NG lavage cleared w/ 50cc. His portal
vein thrombus is stable on CT as well. His sensorium improved
with an aggressive regimen of lactulose. The patient stated that
he had been compliant with lactulose, but this is in doubt. Abx
were held in unit and he continued to improve w/ lactulose.
Extubated on [**3-9**]. He continued to do well off antibiotics and
on lactulose. MS now at baseline.
.
# Hep C cirrhosis: Pt has h/o varices as well. Diuretics were
held but propanolol was continued. Lasix and aldactone were
resumed upon discharge at lower doses, with follow up in clinic.
.
# Thrombocytopenia: His platelets were consistently very low and
<20. A hematology consult was obtained prior to discharge. Their
recommendation was to have the patient follow up as an
outpatient.
.
# Seizure Disorder: Continued on his outpatient medications.
# Mild [**Doctor First Name 48**]: On admit, Cr was 1.2 with baseline of 0.9 to 1.1.
Suspected prerenal etiology, given IVF w/ improvement in Cr. Now
back to 0.8. He had non-gap metabolic acidosis, probably due to
diarrhea (from excessive lactulose) and IVF resuscitation.
.
# FEN: Regular diet. No IVF. Checked lytes daily, repleted prn.
.
# PPX: Hep SC, lactulose, PPI
.
# FULL CODE
.
# Dispo: To home w/ services
Medications on Admission:
Levetiracetam
Lactulose 30cc qid
Propranolol 40 mg [**Hospital1 **]
Spironolactone 100 mg daily
Furosemide 40 mg daily
Protonix 40 mg Tablet [**Hospital1 **]
Aluminum-Magnesium Hydroxide 225-200 mg/5 mL qid
Zonisamide 1 tab in AM and 2 tab in PM
Discharge Medications:
1. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO four times
a day.
4. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
5. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Hepatic encephalopathy
.
Secondary diagnosis:
ESLD due to HCV and cirrhosis
HCC
h/o seizure disorder
h/o GSW to head and resultant PTSD
Depression/anxiety
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for altered mental status. A
full infectious and trauma workup was negative in the ER. You
were intubated for airway protection and started on empiric
antibiotics. Your mental status began to clear with the
administration of lactulose. Your antibiotics were held and once
your mental status cleared, you were extubated without
complication and sent to the regular medicine floor. You
continued to improve on the floor and you were able to work with
PT and OT. You were discharged home with plans for close
follow-up in Liver Clinic.
.
Please continue to take all your medications as prescribed.
1) Your LASIX and ALDACTONE were restarted at lower doses.
Please continue to take these medications at the lower dose
until you follow up with Dr. [**Last Name (STitle) 497**].
2) Continue taking your KEPPRA and ZONISAMIDE at your outpatient
doses.
.
Please keep all your follow-up appointments.
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
difficulty breathing, chest pain, abdominal pain and distension,
weakness, change in your mental status, seizures, or any other
worrisome symptoms.
Followup Instructions:
Please keep all of the following appointments:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-3-20**] 9:40
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-3-20**] 11:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2115-5-2**] 11:30
.
You should also schedule a follow-up appointment with your PCP
in the next 4-8 weeks.
|
[
"571.5",
"276.51",
"572.2",
"276.2",
"287.5",
"070.54",
"593.9",
"345.90",
"V10.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8126, 8184
|
5579, 6984
|
334, 362
|
8402, 8409
|
2926, 4815
|
9660, 10102
|
2394, 2608
|
7281, 8103
|
8205, 8205
|
7010, 7258
|
8433, 9637
|
2623, 2907
|
273, 296
|
390, 1311
|
4824, 5556
|
8270, 8381
|
8224, 8249
|
1333, 1907
|
1923, 2378
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,787
| 168,392
|
2414
|
Discharge summary
|
report
|
Admission Date: [**2106-7-8**] Discharge Date: [**2106-7-11**]
Date of Birth: [**2045-9-16**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with a history of renal cell cancer with metastasis of
the long bone status post recent removal of right
endobronchial lesion and prolonged hospital course secondary
to postobstructive pneumonia requiring intubation. The
patient presents for photodynamic treatment to the right
middle lobe, right lower lobe lesions.
PAST MEDICAL HISTORY: Renal cell cancer diagnosed in [**2104-5-5**] status post right nephrectomy, status post XRT and
steroids for T5 lytic lesion, status post a lung mass
resection.
Hypertension.
Rosacea.
Status post vasectomy.
MEDICATIONS:
1. Trazodone.
2. Oxycodone.
3. Protonix.
4. Lexapro.
5. Megace.
6. Ambien.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, blood pressure
117/68, pulse 127, respiratory rate 26, and 95 percent on
room air. GENERAL: The patient was in no acute distress,
ill-appearing. HEENT: Extraocular motion intact, anicteric.
Slightly dry mucous membranes. HEART: Tachycardic. LUNGS:
Decreased breath sounds, half-way up in the right. ABDOMEN:
Soft, nontender, and nondistended. Positive bowel sounds.
EXTREMITIES: No edema. NEUROLOGIC: Cranial nerves II
through XII intact, moving all four extremities.
HOSPITAL COURSE BY PROBLEM: Metastatic renal cell cancer and
right endobronchial mass. The patient underwent photodynamic
therapy on [**2106-7-8**]. The following day, the patient
underwent a bronchoscopy to remove obstruction and necrotic
tumor debris. Following the bronchoscopy, the patient
required intubation for respiratory distress, respiratory
alkalosis. Additionally, the patient became hypertensive and
tachycardiac requiring transfer to the MICU. The patient
initially needed pressor support. It was felt that he likely
became bacteremic secondary to the opening up of a
postobstructive pneumonia.
It was noted on his bronchoscopy, a large amount of pus
released when the obstruction was removed. The patient was
treated with broad spectrum antibiotics and aggressive IV
fluid hydration. He underwent repeat bronchoscopy where a
large amount of tumor debris was removed and once again
following the bronchoscopy, worsened with worsening hypoxia
despite ventilatory support. On the afternoon of [**2106-7-11**],
the patient's wife requested a meeting with the house staff.
She expressed her husband's and her wish that he not suffer
any longer with this disease. She reported that he did not
wish to undergo a prolonged intubation and expressed his
desire not to again be in ICU care as he had during his last
long hospitalization. Instead, the patient and family wish
to focus on the patient's comfort. Therefore, after awaiting
other family members to arrive, a morphine drip was started
and the patient was removed from the ventilator. Mr. [**Known lastname 7168**]
[**Last Name (Titles) **] on 7:07 p.m. on [**2106-7-11**] due to respiratory failure
from metastatic renal cell carcinoma. His immediate family
were present and primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9022**], was
notified.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 2019**]
Dictated By:[**Last Name (NamePattern1) 12327**]
MEDQUIST36
D: [**2106-7-11**] 20:39:43
T: [**2106-7-12**] 08:59:41
Job#: [**Job Number 12443**]
|
[
"786.3",
"V10.52",
"518.89",
"401.9",
"198.5",
"519.1",
"518.5",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"32.28",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
903, 1408
|
1437, 3503
|
164, 517
|
540, 880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,418
| 197,799
|
4980
|
Discharge summary
|
report
|
Admission Date: [**2112-5-25**] Discharge Date: [**2112-5-27**]
Date of Birth: [**2036-12-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Lyrica / Ace Inhibitors / Metformin /
Dofetilide / Quinidine / Fentanyl
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
shortness of breath, hypotension
Major Surgical or Invasive Procedure:
Non-invasive ventilation
History of Present Illness:
This is a 75 yo M with a history of past MI, [**First Name3 (LF) 7921**] with EF 15%,
afib on coumadin, s/p pacer placement, who was transferred from
[**Hospital1 1501**] today after being diagnosed there with RLL pna on CXR after
lung exam was suspicious for consolidative process. Per
patient's daughter, he was coughing for 3 weeks and was
intermittently having altered mental status. Multiple CXR's up
until today did not show any evidence of acute cardiopulmonary
process. He was satting 87% on room air prior to transfer. With
3L O2 by NC, sats came up to 95%. Vitals prior to transfer
96.2ax 72 118/78 24.
.
On arrival to our ED, he was started on bipap after his DNR/DNI
status was confirmed with patient and HCP. His [**Name2 (NI) **] were notable
for a leukocytosis and ARF (no priors for comparison). Once
Bipap was initiated, his sats responded well, however, he became
hypotensive (100/50 -> 80 with starting bipap). He was given 2L
NS, then levophed was started through peripheral line in lieu of
IVF given unknown EF. He was also given aspirin, vanco, CTX and
levofloxacin for his pneumonia. Blood cultures were drawn. On
transfer, his pulse 70, BP 99/70, RR 20, satting 100% on bipap.
.
He is transferred to the MICU for further management. Currently,
the patient is comfortable on bipap, moving extremities, but not
quite alert.
Past Medical History:
congestive heart failure with cardiomyopathy,EF 15%
prior MI
atrial fibrillation and ventricular ectopy with a pacemaker
diabetes with associated neuropathy
hypertension
history of lower extremity ulcers
left vestibular schwannoma
Social History:
lives in [**Hospital1 1501**]. Daughter is HCP.
Family History:
Non-contributory
Physical Exam:
General: Alert, oriented, mild respiratory distress on bipap
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi with bronchial breath sounds in RLL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused except for right hand which is cool to
touch, 2+ pulses, no clubbing, cyanosis. 1+ pitting edema.
Pertinent Results:
Admission [**Hospital1 **]:
[**2112-5-25**] 10:28PM WBC-15.1* RBC-4.19* HGB-12.3* HCT-38.1*
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.8
[**2112-5-25**] 10:28PM NEUTS-90.1* LYMPHS-4.1* MONOS-5.3 EOS-0.5
BASOS-0.1
[**2112-5-25**] 10:28PM GLUCOSE-104 UREA N-32* CREAT-1.8* SODIUM-133
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2112-5-25**] 10:44PM LACTATE-2.1*
[**2112-5-25**] 10:28PM cTropnT-0.03*
[**2112-5-25**] 10:28PM CK(CPK)-55
.
[**2112-5-25**]
AP UPRIGHT CHEST: The right costophrenic angle is not imaged.
Well definied right lower lobe opacity and ill defined left
lower lobe opacities likely represents pneumonia. There is
moderate cardiomegaly. A single- lead pacemaker overlies the
left ventricle. The imaged osseous structures are unremarkable.
.
IMPRESSION:
1. Right and left lower lobe pneumonia.
2. Moderate cardiomegaly.
.
[**2112-5-25**] UA Culture - negative
.
[**2112-5-26**] Blood Cx x1 - NGTD, pending at time of discharge.
[**2112-5-25**] Blood Cx x2 - NGTD, pending at time of discharge.
Brief Hospital Course:
This is a 75 yo M with [**Last Name (LF) 7921**], [**First Name3 (LF) **] 15%, afib on coumadin, s/p pacer
placement, admitted from [**Hospital1 1501**] with RLL pna and respiratory
distress.
.
#. Respiratory distress: felt most consistent with HCAP, with
leukocytosis to 20, for which he was initially treated with
vanc/ceftriaxone/levaquin and BiPaP starting [**5-25**]. He was
quickly weaned down to nasal canula by 12PM on [**5-26**], and
switched to vancomycin (dosed by level, 12 on [**5-26**]), and zosyn
for HCAP starting [**5-27**]. His WBC came down to 10. He was gently
diuresed with lasix drip on [**5-26**], and repeat CXR appeared
euvolemic, thus he was switched back to his oral regimen of
lasix on [**5-27**]. He is being discharged back to rehab with plan
to complete a 7 day course of antibiotics, and resume his home
regimen of diuretics.
.
#. Hypotension: pt was transiently noted to be hypotensive at
the same time bipap was placed which was felt most likely [**1-4**]
reduced venous return with peep. He improved modestly with
500cc IVF bolus, but transiently required levophed for ~3 hrs,
which was discontinued at 4AM on [**5-26**]. He maintained SBP 100s
off pressors since that time, and was restarted on his home
lopressor at the time of discharge. He should have the
remainder of his home antihypertensives restarted at rehab
(diovan, spirionlactone) given his significant heart failure at
baseline. He has 2 sets of blood cultures, [**5-25**] and [**5-26**] which
are still pending at the time of discharge and will need to be
followed by after her arrival to rehab (by calling our
microbiology lab, [**Telephone/Fax (1) **]).
.
#. Cardiology - pt had a mild troponin elevation, with negative
CK, and MB, consistent with his mild renal failure. From a
volume standpoint, he was initially felt to be slightly volume
overloaded, and he was treated with a lasix drip given his
transient hypotension, and transitioned back to his usual home
regimen of lasix on [**5-27**]. His diovan and spirinolactone were
held [**1-4**] initial hypotension, but should be restarted as his
blood pressure stabilizes. His aspirin and metoprolol were
restarted prior to his discharge.
.
Regarding his rythym , he remained paced, and was continued on
amio. Digoxin was held initially pending his level, and
restarted once his level returned normal. He was on coumadin
previously, but had been getting this held at [**Hospital1 1501**]. His INR was
supratherapeutic during this hospitalization (4.4) on [**5-27**], so
this continued to be held, but should be restarted once his INR
< 3.0.
.
# HTN - as above, his anti-hypertensives were held given initial
hypotension. his metoprolol was restarted prior to discharge.
He should have his spironolactone and diovan started if his
blood pressure is stable at rehab.
.
# ARF - baseline unknown, but per [**Hospital1 18**] [**Location (un) 620**] records, his
creatinine was 2.0 in [**2109**] [**1-4**] CHF exacerbation. Upon arrival,
CRE 1.8, and trended down to 1.5 with lasix drip. His diovan
and spironolactone were held, but should be restarted at rehab.
He was discharged home on his home regimen of lasix orally.
.
# DM2 - he was continued on insulin sliding scale.
.
# PSYCH - he was continued on cymbalta and risperdal.
.
# Code: code status was discussed, and the pt is DNR/DNI
confirmed with patient in ED and HCP's here in MICU.
Medications on Admission:
Medications per [**Hospital1 1501**] notes:
Amiodarone 200mg once daily
Aspirin 81mg daily
Coumadin 2.5mg daily (d/c'd?)
Digoxin 125mcg every other day
Diovan 10mg daily
Novolin 70/30 24 units SQ QD
Humalog sliding scale
Lasix 40mg daily
Metoprolol succinate 100mg daily
Spironolactone 12.5 mg daily
Duonebs
guaifenisin
allopurinol 300 qd
cymbalta 20mg
risperdal 0.5mg hs
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
8. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 5 Days
9. Vancomycin 1000 mg IV Q 12H Duration: 5 Days
10. Outpatient Lab Work
vancomycin level at 8am on [**2112-5-28**], please adjust vanco dosing
based on level
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for diarrhea.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day: hold
for diarrhea.
13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet
PO once a day as needed for constipation.
14. insulin
please take insulin as per attached sliding scale. you are
prescribed 70/30 24 UNITS QDAILy and humalog sliding scale.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
17. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
18. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
19. Risperdal 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Health-Care Associated Pneumonia
2. Acute on chronic congestive heart failure with
cardiomyopathy, EF 15%
3. Mixed cardiogenic/septic shock
4. Acute on chronic renal failure
Discharge Condition:
Hemodianymically stable, improved oxygenation on 2L NC
Discharge Instructions:
You were evaluated and treated for your shortness of breath and
found to have a pneumonia and heart failure.
.
You were started on IV antibiotics and gentle diuresis and your
shortness of breath improved.
.
The following changes were made to your medication regimen:
1. your coumadin is being held because your INR > 3. This
should be restarted once INR < 3.
2. you were started on antibiotics for pneumonia, you should
complete 5 more days of vancomycin and zosyn. you should have
vancomycin dosed according to daily vancomycin levels given your
poor renal function.
3. your digoxin was held initially, but restarted upon discharge
because your digoxin level was normal (1.2), this level should
be rechecked if your kidney function continues to worsen.
4. your spironolactone, diovan were held because of low blood
pressures, this can be restarted as your blood pressure
increases.
.
.
If you develop worsening symptoms, such as chest pain or
shortness of breath, please seek medical attention.
Followup Instructions:
Please contact your primary care physician and schedule [**Name Initial (PRE) **] follow
up after you are discharged from rehab.
|
[
"357.2",
"785.51",
"486",
"518.82",
"V58.67",
"425.4",
"427.31",
"403.90",
"V45.01",
"995.92",
"V58.61",
"585.9",
"584.9",
"785.52",
"250.60",
"412",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9300, 9372
|
3752, 7162
|
389, 416
|
9593, 9650
|
2701, 3729
|
10697, 10829
|
2129, 2147
|
7585, 9277
|
9393, 9572
|
7188, 7562
|
9674, 10674
|
2162, 2682
|
317, 351
|
444, 1793
|
1815, 2048
|
2064, 2113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,575
| 132,757
|
13878
|
Discharge summary
|
report
|
Admission Date: [**2121-2-17**] Discharge Date: [**2121-2-22**]
Date of Birth: [**2070-4-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal Pain/ Nausea/Vomiting
Major Surgical or Invasive Procedure:
Central Venous Line
Arterial Line
History of Present Illness:
50M schizophrenic NH resident (poor historian) who presents with
nausea, vomiting, and abdominal pain. Pt is DNR/DNI.
Past Medical History:
1. Schizophrenia
2. Alcohol related dementia
3. Seizure disorder
4. Thyroid disorder
5. History of tachycardia
6. GERD - EGD [**6-/2120**] showed grade III esophagitis, mild
gastritis
Social History:
lives at [**Hospital **] Rehab and [**Hospital **] Care Center
works in construction at a factory
Tob: 1ppd x 34yrs
EtOH: occasional
Illicits: denies use
Family History:
Non-contributory
Physical Exam:
Admission Exam
----------------
[**2121-2-17**]
99.9 150s 95/47 18 96% 4L
AOX1, pale, diaphoretic, MM Dry
Tachy
CTAB
Abd distended, (+) lower abdominal tenderness
No rebound. Guaiac (-)
No CCE
Pertinent Results:
Admission Labs
------------------
[**2121-2-16**] 05:48PM BLOOD WBC-14.2*# RBC-5.73# Hgb-15.6# Hct-46.0#
MCV-80* MCH-27.2 MCHC-33.8 RDW-15.7* Plt Ct-313
[**2121-2-16**] 05:48PM BLOOD Neuts-42* Bands-32* Lymphs-11* Monos-10
Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0
[**2121-2-16**] 05:48PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Envelop-1+
[**2121-2-16**] 05:48PM BLOOD Plt Ct-313
[**2121-2-16**] 05:48PM BLOOD Glucose-143* UreaN-46* Creat-1.1 Na-132*
K-4.8 Cl-87* HCO3-29 AnGap-21*
[**2121-2-16**] 05:48PM BLOOD ALT-24 AST-26 Amylase-18 TotBili-0.6
[**2121-2-16**] 05:48PM BLOOD Lipase-15
[**2121-2-16**] 05:48PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-2-17**] 01:43AM BLOOD CK-MB-NotDone
[**2121-2-17**] 01:45AM BLOOD cTropnT-<0.01
[**2121-2-18**] 03:35AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-2-16**] 05:48PM BLOOD Albumin-4.2 Calcium-9.9 Phos-5.7*#
Mg-3.7*
[**2121-2-16**] 05:57PM BLOOD Lactate-3.0*
Discharge Labs
-----------------
[**2121-2-19**] 03:59AM BLOOD WBC-6.2 RBC-3.77* Hgb-10.7* Hct-30.6*
MCV-81* MCH-28.4 MCHC-35.0 RDW-15.4 Plt Ct-197
[**2121-2-19**] 03:59AM BLOOD Plt Ct-197
[**2121-2-19**] 03:59AM BLOOD Glucose-93 UreaN-5* Creat-0.6 Na-139
K-3.5 Cl-103 HCO3-28 AnGap-12
[**2121-2-18**] 03:35AM BLOOD CK(CPK)-34*
[**2121-2-19**] 03:59AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.1
[**2121-2-18**] 03:57AM BLOOD Glucose-95 Lactate-0.8
CT ABDOMEN W/CONTRAST [**2121-2-16**] 11:27 PM
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
Reason: please do torso PO and IV contrast; r/o PE, mesentenric
[**Last Name (un) **]
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with schizophrenia, ETOH dementia p/w hypoxia,
N/V/D/crampy abd pain; CXR unremarkable; KUB showed ?dilated
loops of small bowel.
REASON FOR THIS EXAMINATION:
please do torso PO and IV contrast; r/o PE, mesentenric
ischemia, obstruction
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 50-year-old with schizophrenia, presenting with
hypoxia, nausea, vomiting and diarrhea with abdominal pain,
evaluate for obstruction or ischemia. Also evaluate for PE.
COMPARISONS: CT abdomen and pelvis of [**2120-11-3**] and CT chest of
[**2120-4-30**].
TECHNIQUE: Axial MDCT images of the chest, abdomen, and pelvis
with CTA protocol through the chest, followed by delayed imaging
through the abdomen and pelvis with oral prep. Coronal and
sagittal reformats were performed.
CT CHEST WITH AND WITHOUT IV CONTRAST: Study was not optimally
timed to evaluate the pulmonary arteries, however allowing for
this, there is no central pulmonary embolus. The subsegmental
branches are not well evaluated. There is upper lobe emphysema.
Several large bullae in the right upper lobe. There are
ill-defined alveolar and ground-glass opacities most prominent
in the right lower lobe, but also in the left lower lobe and
lingula which may relate to aspiration or multifocal pneumonia.
Borderline tracheomalacia. The esophagus is moderately dilated.
CT ABDOMEN WITH IV AND ORAL CONTRAST: The liver, spleen,
kidneys, adrenal glands, and pancreas are normal. Incidental
note is made of a small axial hiatal hernia. Bladder is normal.
No free fluid or free air in the abdomen.
CT PELVIS WITH IV AND ORAL CONTRAST: There is marked dilatation
of the proximal small bowel loops greater than 4 cm, with
decompression of the distal small bowel loops. The transition
point is not directly visualized but likely somewhere in the
right lower quadrant. There is no ascites nor pneumatosis. No
free air or free fluid in the pelvis. There is some stool and
air within the colon, but no passage of contrast past the
proximal small bowel. No abnormal lymphadenopathy is
appreciated. Atherosclerotic disease is noted throughout.
BONE WINDOWS: No focal osseous abnormalities are appreciated.
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images
confirm the above findings.
IMPRESSION:
1) Small-bowel obstruction, transition point not directly
visualized but within the right lower quadrant.
2) Multifocal ground-glass and alveolar opacities in the RLL,
LLL, and lingula indicating aspiration versus multifocal
pneumonia.
3) Suboptimal study for evaluation of PE, however no central
embolus is appreciated.
4) Upper lobe emphysema and bullae.
5) Dilated esophagus.
CT ABDOMEN W/CONTRAST [**2121-2-18**] 2:05 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: looking for resolution of bowel obstruction
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with nausea and vomiting. please use iv contrast
REASON FOR THIS EXAMINATION:
looking for resolution of bowel obstruction
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 50-year-old male with nausea and vomiting. Plain
film suspicious for partial small-bowel obstruction versus
ileus.
COMPARISON: Abdominal plain films from [**2-16**] and 2, [**2120**].
TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis
was performed after oral and intravenous contrast. Coronal and
sagittal reformations were obtained.
CT OF THE ABDOMEN: Patchy opacities in the right lower lobe in
particular, but also to a lesser extent in the left lower lobe
are [**Known lastname **] seen. There is small bilateral pleural effusions. A NG
tube is seen entering the stomach. The visualized heart and
pericardium appear unremarkable.
The liver, adrenal glands, spleen, pancreas, and kidneys appear
unremarkable. There is high-density material within the
nondistended gallbladder consistent with sludge. Contrast
reaches the mid colon. The mid-small bowel demonstrates mild
dilation, without wall thickening or pneumatosis. The more
distal small bowel is relatively decompressed. The colon has a
moderate amount of air, stool, and contrast within it. There is
a mild stranding in the anterior mesentery on the right with
small lymph nodes in this region. There is a small amount of
ascites tracking into the pelvis. The abdominal aorta is of
normal caliber with mild atherosclerotic changes.
CT OF THE PELVIS: A Foley catheter is within the bladder lumen.
The prostate, seminal vesicles, and rectum appear unremarkable.
No pathologic pelvic or inguinal lymphadenopathy is appreciated.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
lesions.
IMPRESSION:
1. Findings consistent with partial small-bowel obstruction with
dilated loops of mid-small bowel, and relative distal
decompression, but without obstruction of contrast flow. Small
amount of ascites.
2. Small bilateral pleural effusions and a small amount of
ascites.
3. Bilateral lower lobe atelectasis; however in the right lower
lobe, additional patchy opacities are suggestive of aspiration
or possible infection.
Brief Hospital Course:
[**Known firstname 11312**] [**Known lastname **] was evaluated in the emergency department at [**Hospital1 18**]
on [**2121-2-16**]. WBC count was 14.2; BUN 46; Creat 1.1; lactate 3.0.
KUB was (+) dilated small bowel loops. Abdominal/pelvic CT scan
showed SBO with transition point in RLQ. It also showed
multifocal ground-glass and alveolar opacities in the RLL, LLL,
and lingula indicating aspiration versus multifocal pneumonia.
He was admitted to the surgery service under the care of Dr.
[**First Name (STitle) 2819**]. He was made NPO. IV fluids were continued. An NGT and
urinary catheter were placed. IV antibiotics were started for
possible aspiration PNA. He was taken to the ICU for
resuscitation and monitoring of rapid afib. IV amiodarone was
started. Cardiology was consulted. ECHO was completed which
showed mild symmetric left ventricular hypertrophy with LVEF
>50%. At HD 1 he was cardioverted to NSR. At HD 3 he was
afebrile. He had return of bowel function. WBC count was 6.2.
At HD 4 the NGT was removed and he was transferred to the floor.
At HD 5 he was tolerating clear liquids. Home medications were
restarted. Foley catheter and central line were discontinued.
Medications on Admission:
Dulcolax
Omeprazole
Clozaril
Depakote
Colace
Miralax
Zocor
Carafate
Inderal Isosorbide
Haldol
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4657**] - [**Location 1268**]
Discharge Diagnosis:
Small Bowel Obstruction
Atrial Fibrillation
Aspiration Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please contact or return for:
* Fever (>101 F or chills)
* Abdominal Pain
* Nausea or vomiting
* Inability to pass gas or stool
* Shortness or breath
* Chest pain or irregular heart beat
* Any other concerns
You may continue your home medications as prescribed.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in clinic in [**11-19**] weeks. Please
call for an appointment. The number is ([**Telephone/Fax (1) 6347**].
Completed by:[**2121-3-10**]
|
[
"295.92",
"530.81",
"511.9",
"507.0",
"291.2",
"401.9",
"305.00",
"560.9",
"789.5",
"780.39",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"38.93",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9275, 9344
|
7938, 9131
|
346, 381
|
9453, 9460
|
1175, 2797
|
9773, 9970
|
923, 941
|
5713, 5779
|
9365, 9432
|
9157, 9252
|
9484, 9750
|
956, 1156
|
275, 308
|
5808, 7915
|
409, 528
|
550, 735
|
751, 907
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,420
| 114,387
|
8208
|
Discharge summary
|
report
|
Admission Date: [**2190-10-8**] Discharge Date: [**2190-10-10**]
Date of Birth: [**2123-7-4**] Sex: F
Service: MEDICINE
Allergies:
Paxil / Benadryl / Buspar / Levaquin / Adhesive Tape
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Pericardial effusion s/p SVT ablation
Major Surgical or Invasive Procedure:
electrophysiology study with incomplete ablation
History of Present Illness:
66-year-old lady with history of breast and bladder cancers was
admitted for elective EPS with ablation for SVT. She first
noted palpitations approximately 16 years ago in the setting of
high emotional distress when her son was killed while in the
service. Since then, she has had palpitations in the setting of
chemotherapy, and over the past years has had no more than [**3-2**]
episodes per year. However, on the day of her most recent
cystoscopy on [**3-5**] at [**Hospital1 69**], she
experienced a tachycardia, which was terminated after she
received intravenous Lopressor. The same tachycardia occurred on
[**3-9**] for which she presented to [**Hospital6 17032**]
Emergency Room, where the tachycardia was terminated with
intravenous adenosine. The tracings of the tachycardia were
reviewed by her Electrophysiologist, Dr.[**Last Name (STitle) 1911**], and
thought be a narrow complex tachycardia at 150 beats/minute with
an RP interval of 100-120 msec. However, immediately post
adenosine, there was evidence of sinus rhythm with a fully
pre-excited QRS complex consistent with a left lateral bypass
tract. Since the Emergency Room visit, she has been on low-dose
atenolol without further recurrences of the arrhythmia.
Dr.[**Last Name (STitle) 26676**] recommended EPS with ablation and the patient
was admitted today for the procedure.
.
During the procedure she developed hypotension to SBP of 77 mm
HG. This responded to IVF and dopamine infusion to SBP of 130s.
Patient was mentating appropriately. Focal views of TTE showed
noncircumferential pericardial effusion with mild RA collapse
without RV collapse. Her heparin was reversed with protamine.
PA catheterization showed preserved CO, no equalization of
filling pressures, and preserved Y descent on RA tracing. This
suggested nonhemodynamically significant effusion. Patient was
admitted to CCU with PA catheter for close hemodynamic
monitoring.
.
On arrival patient complained of stable pleuritic chest pain
which she had since the cath lab. She denied any shortness of
breath. No other complaints.
.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
- Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t
endometriosis
- Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and
radiation therapy
- Papillary bladder cancer diagnosed [**2180**] s/p multiple
resections
and chemotherapy, finished [**2190-4-28**]
- [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer
of
the right ureteral orifice
- Anxiety
.
Social History:
Lives with: husband
Occupation: retired
ETOH: no
Tobacco: 35 years/ 1ppd, quit in [**2180**]
Contact person upon discharge: Husband and son: [**Telephone/Fax (1) 29176**]
Home Services: NO
.
Family History:
Unremarkable for any cardiac disease
.
Physical Exam:
VS: T=96 BP=103/58 HR=97 RR=17O2 sat= 98% 2LNC
GENERAL: Pleasant lady, in NAD. Lying down flat, Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Unable to assess JVP appropriately given the patient's
position.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB in
anterior lung fields, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis.
PULSES:
Right: DP 2+ Left: DP 2+
.
Pertinent Results:
[**2190-10-10**] 08:50AM BLOOD WBC-14.1* RBC-3.54* Hgb-9.5* Hct-30.5*
MCV-86 MCH-27.0 MCHC-31.3 RDW-14.7 Plt Ct-156
[**2190-10-10**] 08:50AM BLOOD Glucose-120* UreaN-11 Creat-0.8 Na-135
K-4.3 Cl-101 HCO3-26 AnGap-12
[**2190-10-10**] 08:50AM BLOOD Calcium-8.6 Phos-1.6* Mg-2.5
.
ECG: [**2190-10-8**] at 7:23 AM
NSR, rate in 70s, nl axis, early R wave transition in precordial
leads, no acute ST-T changes compared to
.
ECG: [**2190-10-8**] at 11:58 AM
Narrow complex tachycardia, rate in 140s, early R wave
transition. No acute ST-T wave changes.
.
2D-ECHOCARDIOGRAM [**2190-10-8**] Focused Views:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. There is a small
to moderate sized pericardial effusion primarily around the
right atrium and right ventricle with minimal around the apex
and inferolateral wall. There is mild right ventricular
diastolic collapse.
IMPRESSION: Mild-moderate loculated anterior pericardial
effusion with echocardiographic evidence for increased
pericardial pressure.
.
2D-ECHOCARDIOGRAM [**2190-10-9**]
The left ventricular cavity is unusually small. The inferior and
posterior walls are hypokinetic. The rest of the left ventricle
is hyperdynamic. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is a small
to moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2190-10-8**], the pericardial effusion appears similar
in size.
.
HEMODYNAMICS:
RAP 20, PCWP 17, Arterial oxygen 98%, RV oxygen sat 71%
.
EPS [**2190-10-8**]:
Left lateral ventricular pre-excitation. Retrograde VA block
via BT at 350 msec. Anterograde BT block at 300 msec. Atypical
Induced orthodromic AVRT, CL 400 msec via left lateral BT.
Difficulty crossing AV. Ablations were performed primarily at
the entrent atrial acitivation site during Vpacing. Also slow
pathway ablation were performed to prevent initiation of the
AVRT. Ablation procedure was incomplete given hypotension as
above.
.
CT ABDOMEN/PELVIS [**2190-10-9**]:
1. No retroperitoneal bleed.
2. Mild to moderate sized pericardial effusion with
indeterminate density
measurements suggesting proteinaceous fluid or blood. No obvious
right atrial compression. Recommend echocardiogram
3. Right femoral line with tip located at the cavoatrial
junction.
4. Left lobe hepatic cyst; could consider outpatient ultrasound
for further
characterization.
5. No large hematoma at right femoral entry site.
6. Stranding in mesentery, nonspecific finding.
Brief Hospital Course:
66 y/o lady with history of SVT now with pericardial effusion
s/p attempted EP ablation.
.
# Pericardial Effusion/PUMP: Patient was found to have a 1.4 cm
anterior pericardial effusion after she became hypotensive
during SVT ablation procedure on [**2190-10-8**]. TTE also showed mild
RA collapse without any RV collapse. Emergently, patient
received a right heart cath that was consistent with a
non-hemodynamically signicant effusion w/o tamponade physiology,
so pericardiocentesis was not felt to be indicated. (Cardiac
output was preserved and there was no equalization of filling
pressures.) Swan-ganz was initially left in place to monitor for
development of tamponade physiology. Arterial line was also
placed for blood pressure monitoring. Patient was initially
hypotensive, but her blood pressure was responsive to IV fluid
hydration and dopamine. Her blood pressure remained stable over
the next 24 hours, and a repeat TTE on [**10-9**] did not show
worsening of the pericardial effusion. Chest pain secondary to
the pericardial effusion was well-controlled with Toradol and
patient was discharged on ibuprofen prn for pain.
.
# RHYTHM: Prior to admission, SVT was thought be a narrow
complex tachycardia at 150 beats/minute with an RP interval of
100-120 msec. However, immediately post adenosine, there was
evidence of sinus rhythm with a fully pre-excited QRS complex
consistent with a left lateral bypass tract. In EP lab,
monitors showed left lateral ventricular pre-excitation,
retrograde VA block via BT at 350 msec, anterograde BT block
at 300 msec, and atypical induced orthodromic AVRT, CL 400 msec
via left lateral BT. During the procedure, it was difficult
crossing the AV, and ablations were performed primarily at the
entrent atrial acitivation site during Vpacing. Also slow
pathway ablation was performed to prevent initiation of the
AVRT. The ablation procedure was incomplete given hypotension
as above. Rhythm was monitored on telemetry and showed
predominantly sinus rhythm.
.
# CORONARIES: Patient has no known CAD. Chest pain while
inpatient was pleuritic in nature and attributed to
hemopericardium. ASA was continued.
.
# Extensive groin manipulation: Due to extensive groin
manipulation during cardiac procedures on [**2190-10-8**], patient was
monitored closely for evidence of retroperitoneal bleed. In the
cath lab, heparin was reversed with protamine, post cath checks
were unremarkable, and a CT scan of abdomen and pelvis was
negative for a retroperitoneal bleed. Hemoglobin and hematocrit
remained stable throughout hospital stay.
.
# H/o breast CA and papillary bladder CA: Stable. Patient
advised to continue outpatient follow-up per primary oncologist.
.
FEN: Patient was maintained on cardiac prudent diet.
Electrolytes were repleted as necessary.
.
PROPHYLAXIS: SCD's were used for DVT prophylaxis.
.
CODE: FULL
Medications on Admission:
Atenolol 25mg daily, last dose [**2190-10-3**]
Lunesta 2mg qhs
Alprazolam 0.25mg daily in the am, [**1-29**] tablet at noon, 1 tablet
at night PRN
Simvastatin 30mg daily
MVI daily
Vitamin D daily
Vitamin B12 500mcg daily
Calcium, magnesium daily
Fish oil 1000mg daily
Asa 81mg daily
.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain: please take with food.
10. Lunesta 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Supraventricular tachycardia, AVRT
Pericardial effusion
Secondary Diagnoses:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
- Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t
endometriosis
- Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and
radiation therapy
- Papillary bladder cancer diagnosed [**2180**] s/p multiple
resections
and chemotherapy, finished [**2190-4-28**]
- [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer
of
the right ureteral orifice
- Anxiety
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital for a procedure to fix an
abnormal rhythm in your heart. The procedure was unable to be
finished because of concern for build up of fluid around your
heart. Ultrasounds of your heart showed that the fluid around
your heart was not getting worse. You were discharged on
[**2190-10-10**], and will have close follow up with Dr. [**Last Name (STitle) **].
Please follow up in 6 weeks for liver ultrasound to follow up
liver cyst.
No changes were made to your medications.
Please see below for your follow up appointment with Dr.
[**Last Name (STitle) 1911**].
Please call your physician [**Last Name (NamePattern4) **] 911 if you develop chest pain,
shortness of breath, worsening palpitations,
dizziness/lightheadedness, fevers, chills, or any other
concerning medical symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1911**] tomorrow, [**2190-10-11**].
Please call [**Telephone/Fax (1) 11767**]. You have another appointment with Dr.
[**Last Name (STitle) 11649**] on [**2190-10-26**], see below.
[**Last Name (un) 1918**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-10-26**] 10:40
|
[
"V10.51",
"423.9",
"V45.89",
"573.8",
"997.1",
"V10.3",
"300.00",
"458.29",
"272.4",
"427.89",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"38.91",
"37.34",
"88.72",
"37.26",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
11063, 11069
|
7092, 9968
|
350, 401
|
11794, 11816
|
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|
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|
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|
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|
11090, 11090
|
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|
3398, 4076
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11187, 11255
|
11275, 11348
|
273, 312
|
3259, 3327
|
429, 2510
|
11109, 11166
|
11379, 11773
|
2532, 2600
|
3135, 3243
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,936
| 166,430
|
20896
|
Discharge summary
|
report
|
Admission Date: [**2157-1-6**] Discharge Date: [**2157-2-8**]
Date of Birth: [**2099-11-5**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
pulled out IJ catheter
Major Surgical or Invasive Procedure:
R chest tube
Hemodialysis
Tunneling of Hemodialysis Catheter
Endotracheal intubation
History of Present Illness:
57 yo man with CAD s/p CABG in [**2137**], low EF, DM, CKD here after
recent 44 day stay at [**Hospital 7145**] hospital initially there for reversal
of colostomy on [**11-12**] after emergent Hartmann's with left
colectomy for sigmoid diverticular bleed in [**2156-6-16**]. Post op
course complicated by NSTEMI in setting of hypoTN from
anesthesia, respiratory distress for which he was reintubated,
ARF on CRF and post-op sepsis. He was bronched and bilateral
pleural effusions that were tapped twice. ECHO showed 40% EF
with global HK. He was started on HD for his worsening kidney
disease. He had to be taken back to the OR for anastomotic
breakdown with peritonitis post anastomosis of the transverse
and sigmoid colon done on [**2156-11-25**]. He was started on
[**Last Name (LF) **], [**First Name3 (LF) **] and flagyl per ID. He was also on TPN for
nutrition over this course and had episodes of postop delerium.
Eventually on [**12-24**] was d/c'd to rehab [**Hospital1 **] with cont'd
drainage of JP drains, good colostomy output and reasonable
urine output while on HD on antibiotics. Cultures at OSH most
notable for pseudomonas aeroginosa growing out of abd wound site
which is sensitive to [**Hospital1 **] and cipro. He had [**Female First Name (un) **] grow out
of JP fluid cultures and enterocccas type D that is not VRE,
wound cultures also grew out [**Female First Name (un) **] and coag negative staph.
.
Course at rehab appears to have been uneventful except
completion of [**Female First Name (un) **] and flagyl, until night of [**12-6**] when
pulled out a right IJ tunneled line and was found at 1:30
bleeding from site and sent into [**Hospital1 18**] for evaluation. Exam with
decreased BS on Right and CXR then showed white out of right
lung, with concern for hemothorax given line removal, thoracics
was called and chest tube placed with 2L serous-sanguinous fluid
drainage. In setting of chest tube, pt's BP dropped to 79/12
which responded to a 250NS bolus. Follow up CXR with small
apical pneumothorax and CT in fissure, but pt's resp status
stable on 4LNC.
.
He admits to pain at tube site and in back, but no shortness of
breath or other complaitns. He does not know why he pulled the
HD catheter. Denies any preceeding cough, SOb or other symptoms.
Past Medical History:
CAd s/p CABG in [**2137**](LIMA-LAD, SVG-RCA), s/p 2 stents RCA [**6-/2155**]
with 3VD with occluded SVG grafts and patent LIMA, NSTEMI [**11-20**],
last cath at [**Hospital1 2025**] Summer [**2156**]: 60% lesion in diag, 50% lesion in
the ostial right and no significant disease in the remainder of
the vessels
CHF with EF 40% on [**2156-12-21**] echo with: Mod LV dysfunction, EF 40%
with mildly dilated RV and mild pulm htn, global HK, 2+MR [**First Name (Titles) **] [**Last Name (Titles) **]R.
Hypertension
Hyperlipidemia
Insulin-dependent diabetes mellitus
morbid obesity
hypothyroidism
s/p Hartmann's procedure for diverticular bleed
recurrent bilateral pleural effusions R>L-- last tapped under
USG guidance [**12-24**]
depression
Social History:
forty-five pack year history, quit 15 years ago. No EtOH in 3
years, never a heavy drinker.
Family History:
two brothers with DM. Mother died at age 5 of a stroke. Father
died at 55 of an MI.
Physical Exam:
PE: 96.7 BP 91-102/67-79, HR 74-82, RR 12-20, O2sat: 100% on 4L
NC
VS: GEN sedated, nad, moving all extremities
HEENT PERRL, 2mm, MMM, anicteric
CHESt CTAB with decreased BS on left
CV RRR no murmurs
ABd soft, NT/ND, +BS, guiaic + with brown formed stool
EXT +large ecchymosis of right forearm near site of brachial PIV
attempt, cool extremities, with palpable DP, radial and femoral
pulses bilateral, no LE edema
Neuro nonfocal 2+reflexes
Pertinent Results:
[**2157-1-6**] 08:59PM CK(CPK)-33*
[**2157-1-6**] 08:59PM CK-MB-NotDone cTropnT-0.66*
[**2157-1-6**] 01:40PM PLEURAL TOT PROT-3.3 GLUCOSE-94 LD(LDH)-296
ALBUMIN-1.4
[**2157-1-6**] 01:40PM PLEURAL WBC-2125* RBC-1000* POLYS-72*
LYMPHS-17* MONOS-10* EOS-1*
.
[**2157-1-6**] 09:30AM GLUCOSE-100 UREA N-28* CREAT-3.4* SODIUM-135
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
[**2157-1-6**] 09:30AM LD(LDH)-255* CK(CPK)-30*
[**2157-1-6**] 09:30AM CK-MB-3 cTropnT-0.70*
[**2157-1-6**] 09:30AM TOT PROT-6.5 ALBUMIN-2.9* GLOBULIN-3.6
.
[**2157-1-6**] 09:30AM TSH-6.9*
.
[**2157-1-6**] 09:30AM WBC-10.3 RBC-3.04* HGB-9.3* HCT-29.8* MCV-98
MCH-30.6 MCHC-31.2 RDW-21.0*
[**2157-1-6**] 09:30AM NEUTS-82.8* BANDS-0 LYMPHS-9.8* MONOS-2.8
EOS-4.4* BASOS-0.2
[**2157-1-6**] 09:30AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+
[**2157-1-6**] 09:30AM PLT SMR-NORMAL PLT COUNT-421
.
[**2157-1-6**] 03:20AM GLUCOSE-121* UREA N-27* CREAT-3.4*#
SODIUM-134 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
.
[**2157-1-6**] 03:20AM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-156*
AMYLASE-26 TOT BILI-0.6
[**2157-1-6**] 03:20AM LIPASE-22
[**2157-1-6**] 03:20AM CALCIUM-8.5 PHOSPHATE-4.8* MAGNESIUM-1.9
.
[**2157-1-6**] 03:20AM WBC-9.0 RBC-2.98*# HGB-9.1* HCT-29.7*
MCV-100*# MCH-30.5 MCHC-30.6* RDW-21.3*
[**2157-1-6**] 03:20AM NEUTS-82.1* LYMPHS-10.1* MONOS-3.0 EOS-4.3*
BASOS-0.5
[**2157-1-6**] 03:20AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+
[**2157-1-6**] 03:20AM PLT COUNT-436
[**2157-1-6**] 03:20AM PT-15.0* PTT-30.1 INR(PT)-1.5
.
ECHO: LVEF 25% to 30% (nl >=55%)The left atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is severe
regional left ventricular systolic dysfunction. Overall left
ventricular systolic function is severely depressed. Resting
regional wall motion abnormalities include inferior and
inferolateral akinesis/hypokinesis and basal anteroseptal
akinesis with mild to moderate hypokinesis elsewhere. Right
ventricular chamber size is normal. The aortic root is
moderately dilated. The aortic valve leaflets are moderately
thickened. The mitral valve leaflets are moderately thickened.
Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is eccentric. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
.
[**2157-1-7**] CTA:
1. No evidence of thoracic aortic dissection. The mediastinum
likely appears widened on chest radiograph due to mediastinal
lipomatosis.
2. Small anterior right pneumothorax, with right chest tube in
place posteriorly as described.
3. Small bilateral pleural effusions.
4. Ground-glass within both lungs, which may be related to
atelectasis plus or minus superimposed edema or infiltrate.
Please correlate clinically.
5. Borderline mediastinal lymph nodes.
6. Coronary artery calcifications.
.
ECHO ([**2157-1-20**]):
The left ventricular cavity is dilated. There is severe regional
left
ventricular systolic dysfunction. Overall left ventricular
systolic function is severely depressed. Resting regional wall
motion abnormalities include thinned and akinetic inferior and
inferolateral segments with hypokinesis elsewhere. There is mild
pulmonary artery systolic hypertension. No left ventricular
thrombus is visualized.
.
Bilateral LE US ([**2157-1-25**]):
[**Doctor Last Name **] scale and color son[**Name (NI) 493**] examination of both lower
extremity venous systems was performed. Normal compressibility,
waveform, color flow, and augmentation is present within both
common femoral veins, superficial femoral veins, and popliteal
veins. No intraluminal thrombus is identified.
.
SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2157-1-24**]**
GRAM STAIN (Final [**2157-1-24**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2157-1-22**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
[**2157-1-27**] 1:09 pm BLOOD CULTURE Site: A LINE
**FINAL REPORT [**2157-2-2**]**
AEROBIC BOTTLE (Final [**2157-2-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2157-1-30**]):
REPORTED BY PHONE TO [**Last Name (un) 55602**],[**Doctor Last Name **] -CC6D- @ 10:50
[**2157-1-28**].
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- 0.5 S
PENICILLIN------------ 2 S
VANCOMYCIN------------ <=1 S
[**2157-1-27**] 1:09 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2157-1-27**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2157-1-31**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ENTEROBACTER SAKAZAKII. SPARSE GROWTH.
CLINICAL SIGNIFICANCE UNCERTAIN. POSSIBLE
OROPHARYNGEAL FLORA.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER SAKAZAKII
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
.
[**2157-1-28**] 3:22 pm BLOOD CULTURE
**FINAL REPORT [**2157-2-3**]**
AEROBIC BOTTLE (Final [**2157-2-3**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2157-2-3**]): NO GROWTH.
.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2157-1-30**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
1. Hypotension: He was initially admitted to [**Hospital1 18**] MICU on [**1-6**]
w/ hypotension. Patient initially hypotensive, but largely
resolved by the time patient transferred to the floor. Was
likely intra-vascularly depleted as grossly fluid volume
overloaded given prolonged hospitalization with sepsis and low
albumin. Drop in BP was in setting of foley cath placement and 2
L output and likley was secondary to rapid fluid shifts. Felt
not likely sepsis given no white count, fevers or localizing
source, and surveillance BCx were negative. After demonstrating
hemodynamic stability, he was transferred to Med floor on [**1-7**].
He did well on the Med floor until [**1-12**], when he had HD w/
3.5L fluid removal, followed by hypoTN requiring dopamine gtt
and transfer to the MICU. It was thought that this episode was
[**2-17**] fluid shifts after dialysis. In the MICU he was treated w/
IV fluids and dopamine was weaned, allowing transfer back to the
Medicine floor on [**1-13**]. On [**1-19**], he developed recurrent hypoTN
w/ SBP in the 70s, requiring readmission to the MICU and
dopamine gtt. This episode of hypotension was unexplained,
though there was some contribution from adrenal insufficiency as
proven by cortisol stim test on [**1-30**]. He was treated w/ stress
dose steroids and IV fluids, and dopamine was again weaned off.
He then remained hemodynamically stable w/ SBP 90s to 100
throughout his stay.
.
2. Effusion: he had a hemothorax on admission, likely [**2-17**]
trauma from self-d/c his HD catheter at rehab. This effusion
was exudative by lytes criteria. He was treated w/ chest tube
placement and drainage of the effusion. The effusion was
drained easily, but was complicated by a PTX that persisted
despite indwelling chest tube fixed to water seal. CT surgery
and the IP service considered pleuridesis, but believed that it
was not indicated. The pt's PTX eventually resolved, and the
chest tube was d/c on [**1-28**] w/ no evidence of recurrent PTX
during his admission.
.
3. Atrial fibrillation: On [**1-19**], the pt developed afib w/ RVR
that converted to NSR after diltiazem 10mg IV. In the MICU, he
demonstrated recurrent afib and was treated w/ digoxin for rate
control. He was also treated w/ amiodarone for chemical
cardioversion, resulting in conversion to sinus rhythm. In the
setting of PAF, heparin gtt was started for anticoagulation, and
was transitioned to coumadin therapy. At d/c, INR is
supratherapeutic at 4.4. He will need to hold coumadin on
evening of [**2157-2-8**], and should not resume coumadin treatment
until [**2157-2-9**]. After d/c, he will need lab monitoring of his
INR q 2-3 days until INR stabilized; he should continue coumadin
w/ goal INR [**2-18**] for anticoagulation.
.
4. ESRD: Pt was oliguric on admission w/ <100cc urine output per
day. On HD #12, pt noted to have very little output over the
past several days. A tunneled HD catheter was placed on
[**2157-1-11**]. He was treated w/ HD M/W/F per the Renal team, which
was complicated by fluid shifts and hypotension on at least one
occasion, as above. Patient was also maintained on Nephrocaps
and Sevelamer, as well as EPO at dialysis. After d/c, tunneled
HD catheter will remain in place for continued HD on a M/W/F
schedule. He should return in [**3-21**] weeks as an outpt for
creation of a surgical fistula for ongoing HD.
.
5. CAD: Patient initially denied chest pain and EKG was
unchanged. Trops were positive, but pt in renal failure. CK was
flat. However, throughout his hospitalization, patient had
multiple episodes of CP that occurred in the evening and early
morning. Patient's EKG remained at baseline with exception of
1mm ST elevations in lead III. Cardiology notified and reviewed
history and EKG. Felt that ST changes in 1 lead hard to
interpret and did not signify undergoing ischemia. Patient
subsequently ruled out for MI with negative cardiac enzymes 3
times. Patient's chest pain felt likely secondary to anxiety and
gas pain. Patient did have rare episodes of NSVT- 7-10 beats and
remained asymptomatic.
.
6. CHF: upon his transfer to the MICU on [**1-19**], he was tachypnic
and hypoxic, and was intubated for resp distress. ECHO
demonstrated EF 25% w/ LV anterior akinesis requiring
anticoagulation. He was dx w/ CHF exacerbation and was treated
w/ fluid removal at dialysis. His pulmonary edema improved w/
repeated HD sessions, which were limited by low-normal blood
pressure throughout his admission. Treatment was also initiated
w/ digoxin. He was anticoagulated w/ heparin and then coumadin
due to the risk of ventricular thrombus formation in the setting
of anterior ventricular akinesis. He should continue coumadin
after d/c for goal INR [**2-18**].
.
7. Mental Status/Psych: Patient initially somnolent and ALL
sedating medications were held. Patient with suidical ideation
on [**1-10**], when he stated that he wanted to kill himself. Patient
placed on 1:1 sitter. Patient evaluated by psychiatry, and
sertraline dose increased from 25 to 50mg. He had a paradoxical
reaction to benzodiazepines so patient was maintained on PRN
haldol for agitation. QT interval followed and stable given
that patient was on Fluconazole as well. At d/c, he has good
mood w/ no agitation or SI. He will continue treatment w/
sertraline and standing haldol after d/c.
.
8. Abdominal Wound: he has colostomy placed for treatment of
diverticular bleed by Dr. [**Last Name (STitle) **] at NEBH. Retention sutures were
in place initially following his exploratory laparotomy for
peritonitis following reversal of his colostomy. At the adivce
of Dr. [**Last Name (STitle) **], the surgery service was consulted and removed his
JP drains and tension sutures during the admission. At d/c, the
wound is well healed.
.
9. Hypothyroidism: slightly elevated TSH at rehab, but remains
on same replacement dose. Repeat THS elevated and FT4 low, felt
likely due to current medical illness and patient continued on
Levothyroxine 50mcg. TSH must be repeated after resolution of
his medical illness in [**4-21**] weeks.
.
10. DM2: blood glucose well controlled w/ his home dose of NPH
insulin during admission. He will continue NPH insulin after
d/c.
.
11. Pneumonia: while intubated for CHF, he developed ventilator
associated PNA w/ MSSA and Enterobacter on sputum cx. He was
treated w/ 2 week course of IV vancomycin and with zosyn. His
PNA gradually resolved w/ abx as indicated by resolution of
fever and ability to wean off the ventilator. He was extubated
1 week before d/c, and was weaned off oxygen 3 days before d/c.
He will need to continue zosyn therapy until [**2157-2-10**] (2 weeks
after his last positive blood culture.) At d/c, there are no
signs of active infection.
.
12. Code status was full code during this admission
Medications on Admission:
Heparin 5000 UNIT SC TID
SSI and nph 25am/20pm
Levothyroxine Sodium 50 mcg PO DAILY
Loperamide HCl 2 mg PO TID:PRN
Albuterol-Ipratropium [**1-17**] PUFF IH Q6H:PRN
Nephrocaps 1 CAP PO DAILY
Amiodarone HCl 200 mg PO DAILY
Pantoprazole 40 mg PO Q12H
Aspirin 325 mg PO DAILY
Benzonatate 100 mg PO TID
Sertraline HCl 50 mg PO DAILY
Cholestyramine 4 gm PO BID
Simethicone 40-80 mg PO QID:PRN
Clopidogrel Bisulfate 75 mg PO DAILY
Fluconazole 200 mg PO QHD
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-17**]
Puffs Inhalation Q6H (every 6 hours) as needed.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed.
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
15. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
20. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
21. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
22. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
hold dose on [**2157-2-8**], do not begin until [**2157-2-9**].
23. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 3 days.
24. Haloperidol 0.5 mg IV HS
hold for sedation
25. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
1. R Pneumothorax/Hemothorax
2. ESRD on HD
3. NSVT
4. Chest Pain
Secondary Diagnoses:
1. CAD
2. HTN
3. Chronic Kidney Disease
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as perscribed.
Please return to the ED with any chest pain, nausea, vomiting,
chest pain, palpitations, fevers, chills, night sweats.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge.
PLEASE have your primary care physician check your Thyroid
Function Tests and Liver Function Tests in 4 weeks.
|
[
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"244.9",
"707.05",
"414.01",
"403.91",
"780.52",
"512.1",
"998.11",
"486",
"428.0",
"427.1",
"255.4",
"511.8",
"458.29",
"V55.3",
"458.21",
"585.6",
"518.81",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"34.09",
"96.72",
"96.04",
"00.17",
"38.93",
"99.04",
"34.04",
"99.10",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
21306, 21385
|
11685, 18509
|
294, 381
|
21575, 21584
|
4144, 11662
|
21795, 22010
|
3583, 3668
|
19010, 21283
|
21406, 21491
|
18535, 18987
|
21608, 21772
|
3683, 4125
|
21512, 21554
|
232, 256
|
409, 2695
|
2717, 3458
|
3474, 3567
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,540
| 194,217
|
17878
|
Discharge summary
|
report
|
Admission Date: [**2194-11-4**] Discharge Date: [**2194-11-22**]
Date of Birth: [**2127-4-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Increased output from colostomy bag and intermittent fever,
chills, and mild intermittent diffuse abdominal discomfort over
the past few days.
Major Surgical or Invasive Procedure:
IR placed pigtail catheter placed in deep pelvic collection.
History of Present Illness:
History of Present Illness: 67M with colon CA s/p colostomy and
recurrent enterocutaneous fistula admitted with 2 days of
copious rectal drainage. Recent admission [**Date range (1) 49563**] for septic
shock from ascending cholangitis, E. Coli bacteremia c/b liver
abscesses s/p IR drainage [**9-16**], HAP, hypoxemic resp failure, ATN
requiring CVVH, rapid afib/flutter s/p DCCV and GI bleed.
Underwent ERCP and CBD stent [**9-16**] to treat obstruction in the
lower third of the biliary tree felt to be from stone or
stricture. EGD and C-scope [**10-10**] showed gastritis, duodenitis,
and a small erosion/ulceration of the skin at the anal
anastamosis with evidence of oozing. He was discharged to rehab
to complete an additional 5 weeks of Augmentin.
Presented to [**Hospital3 5097**] with 2 days of a report of increased rectal
output. CT there showed ECF. Transferred here. In the ED, triage
V/S 100.5 132 106/61 18 94%4l. Labs notable for WBC# 5.5 88%PMN
Hct 29.9 CO2 18 AG 15 lactate 2.0 Cr 2.1 (baseline ~1.6). At
0420 hypotensive to 79/50 (HR 134) despite 500 cc bolus, given
2nd liter bolus and L IJ placed. Neo gtt started. Given vanco 1
g, zosyn 4.5g IV, flagyl 500 mg IV, and tylenol. Surgery
compared OSH CT to our prior images and felt that anastamotic
leak was old with just increased output now, and recommended
conservative management given his poor surgical candidacy. V/S
prior to transfer 97.6 127 105/44 (neo 0.85 mcg/kg/min) 98%2L.
On the floor, patient has no complaints. He does endorse
intermittent fever, chills, and mild intermittent diffuse
abdominal discomfort over the past few days. He does not think
that his ostomy output or rectal drainage has changed in
quantity. He states that he was told he has a viral infection
but that a cause could not be found. He denies dizziness,
lightheadedness, chest pain, palpitations, cough, shortness of
breath, nausea, hematochezia, or melena.
.
Past Medical History:
- Rectal Cancer s/p pelvic exenteration, cystectomy, formation
of a ileal conduit, and colostomy
- ECF s/p enterectomy, enteroenterostomy for enterocutaneous
fistula
in [**3-6**] with urostomy and colostomy placement
- new ECF '[**93**] from rectal recurrence
- Clear cell RCC s/p partial R nephrectomy [**2-11**]
- CKD b/l Cr ~1.6
- COPD
- Atrial flutter s/p DCCV
- Hypertension
- Asthma
- Depression
- h/o C diff. colitis
Social History:
-Lives at [**Location (un) 169**] [**Hospital1 1501**], reports no relatives
-Retired truck driver
-Divorced w/ no children
-20 pack yr smoking history, currently smokes 10 cigarettes/day
Family History:
-brother w/ renal cancer who died in his 60's
-brother w/ lung CA who died in his 60's
-family history of heart disease
Physical Exam:
GEN: Awake, alert, appears comfortable
HEENT: OP clear dry MM
NECK: L IJ site c/d/i
LUNGS: bibasilar rales clear with coughing no wheeze/rhonchi
CV: reg tachy nl S1S2 no m/r/g
ABD: soft NTND normoactive bowel sounds, pink ostomy with
air and stool in bag, and pink urostomy with clear yellow urine,
evidence of rectal ECF with yellow discharge, surround
excoriation
EXT: warm, dry tr pedal edema; L PICC site c/d/i no
erythema/drainage
SKIN: 3x4 cm punctate blanching macular erythema R ant thigh,
macerated tinea cruris
NEURO: AAOx3, conversing appropriately
Pertinent Results:
[**2194-11-4**] 03:15AM BLOOD WBC-5.5# RBC-3.51* Hgb-9.9* Hct-29.9*
MCV-85 MCH-28.3 MCHC-33.2 RDW-17.0* Plt Ct-88*
[**2194-11-11**] 09:17AM BLOOD WBC-12.2*# RBC-3.85* Hgb-10.7* Hct-32.2*
MCV-84 MCH-27.8 MCHC-33.3 RDW-17.4* Plt Ct-191
[**2194-11-15**] 05:48AM BLOOD WBC-5.2 RBC-3.37* Hgb-9.5* Hct-28.3*
MCV-84 MCH-28.3 MCHC-33.7 RDW-17.3* Plt Ct-216
[**2194-11-4**] 03:15AM BLOOD Glucose-94 UreaN-48* Creat-2.1* Na-133
K-3.6 Cl-100 HCO3-18* AnGap-19
[**2194-11-13**] 06:15AM BLOOD Glucose-90 UreaN-16 Creat-1.5* Na-135
K-4.5 Cl-109* HCO3-17* AnGap-14
[**2194-11-4**] 03:15AM BLOOD ALT-87* AST-76* AlkPhos-471* TotBili-1.4
[**2194-11-6**] 04:34AM BLOOD ALT-36 AST-14 LD(LDH)-118 AlkPhos-330*
TotBili-0.8
[**2194-11-4**] 12:53PM BLOOD calTIBC-146* Ferritn-1237* TRF-112*
[**2194-11-4**] 08:42PM BLOOD Hapto-216*
[**2194-11-5**] 01:50AM BLOOD CEA-2.6
U/A - Negative
[**2194-11-11**] Blood Culture, Routine-PENDING INPATIENT
[**2194-11-11**] Blood Culture, Routine-PENDING INPATIENT
_______________________________________________________
[**2194-11-7**] ABSCESS GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{ESCHERICHIA COLI, GRAM NEGATIVE ROD #2}; ANAEROBIC
CULTURE-FINAL INPATIENT
ESCHERICHIA COLI. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI
|
AMIKACIN-------------- 8 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
_____________________________________________
[**2194-11-8**] Blood Culture, Routine- Negative
[**2194-11-7**] Blood Culture, Routine- Negative
[**2194-11-6**] Blood Culture, Routine- Negative
[**2194-11-5**] Blood Culture, Routine- Negative
[**2194-11-5**] Blood Culture, Routine- Negative
[**2194-11-6**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- Negative
[**2194-11-5**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- Negative
[**2194-11-4**] CATHETER TIP-IV -FINAL {YEAST, PRESUMPTIVELY NOT C.
alBICANS}
[**2194-11-4**] Blood Culture, Routine-FINAL {[**Female First Name (un) **] (TORULOPSIS)
GLABRATA}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle
Gram Stain-FINAL
[**2194-11-4**] Blood Culture, Routine-FINAL {[**Female First Name (un) **] (TORULOPSIS)
GLABRATA}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle
Gram Stain-FINAL
[**2194-11-4**] Blood Culture, Routine-FINAL {[**Female First Name (un) **] (TORULOPSIS)
GLABRATA}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle
Gram Stain-FINAL
________________________________________________
Cardiac Echo Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are complex (>4mm) atheroma
with ulceration in the descending thoracic aorta to 35 cm. The
aortic valve is functionally bicuspid with fusion of the
noncoronary and left coronary cusps; the fused cusps are not
mobile. The aortic valve leaflets are moderately thickened. No
masses or vegetations are seen on the aortic valve. Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No valvular vegetations seen. Functionally bicuspid
aortic valve with moderate aortic regurgitation. Ulcerated
non-mobile complex atheroma in the descending aorta at the
esophageal level of 35 cm from the gum line
CT GUIDANCE DRAINAGE [**2194-11-7**]
Following this, an 8 French catheter was then introduced into
the collection under CT fluoroscopic guidance using via trocar
technique. Purulent aspirate containing stool contents was again
obtained, and the pigtail catheter was formed. CT fluoroscopic
imaging confirmed successful placement of the catheter. At the
time the catheter deployment, total of 200 ml of fluid drainage
was removed revealing a mixture of stool and blood, of note
blood clot was seen on the preprocedure scan in the collection.
Specimens were collected for microbiology analysis.
IMPRESSION:
Technically successful pigtail drainage catheter placement in
the midline
pelvic collection using CT fluoroscopic guidance.
[**11-14**] CT ABD/Pelvis - report pending
Brief Hospital Course:
67 yo male with complicated history including hx of metastatic
rectal cancer s/p multiple surgeries including colostomy, and
probable neoadjuvant chemo and XRT, and multiple rounds of
chemotherapy, recurrent enterocutaneous fistula, and clear cell
RCC (s/p partial nephrectomy), was recently admitted to [**Hospital1 18**]
for cholangitis c/b liver abscesses (drained last admission),
septic shock, respiratory failure (intubated). Pt presented 12
days later with complaints of copius rectal drainage,
hypotension, and sepsis which appears to be due fungemia.
During this admission, pt was also noted to have a signficant
fluid collection in the pelvis, which is now s/p IR drainage.
.
#Sepsis/fungemia:
Pt presented with increased amounts of output from his
colostomy, with history of severe C. diff and was on chronic Abx
therapy. He also had noted recent hepatic abscess as well as
PICC line in place (concern for line sepsis) and multiple
ostomys and enterocutaneous fistula as sources of possible
infection. He was also residing at a facility putting him at
increased risk of infectious processes. He was intially started
on daptomycin (history of VRE rectal abscess) and zosyn for
empiric coverage of intra-abdominal process. In addition, he
was started on IV flagyl and PO Vancomycin for empiric coverage
of C. diff. ERCP was consulted for possible cholangitis
secondary to elevated LFT's in setting of recent procedure and
septic picture. Pt ERCP was delayed secondary to tachycardia,
and in the intervening days his LFT's trended down and it seemed
unlikely that this infectious picture was related to a biliary
process as the patient grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 40140**] from his blood Cx
on [**2194-11-4**]. ERCP was not done. Pt was started on Micafungin
and PICC catheter tip was sent for culture and also grew yeast.
ID was consulted for fungemia, and TTE was done to look for
endocarditis. TTE had worsening aortic regurge and concern for
valvular vegetation so TEE was done, which was negative for
vegetations. TEE revealed large deep ulceration of an aortic
plaque. Pt was treated for glabrata fungemia with micafungin
for two weeks
.
# Cholangitis/Liver abscess/Presacral fluid collection:
Pt was known to have liver abscesses from cholangitis from his
previous hospitalization. Per ID discussion with Radiology,
these original liver abscesses have resolved. During the
hospitalization, pt had been started on Pip/Tazo for empiric
broad-spectrum coverage during his period of sepsis.
Considering the resolution of his liver abscesses, and the
chronic and incurable nature of his pelvic fluid collection, ID
recommended discontinuation of the Pip/tazo. However, after
discontinuation, pt developed increased temperature and
clinical instability (HR to 130's). Therefore Pip/Tazo was
resumed.
The micro from the pelvic fluid collection shows ESBL e.coli,
[**Last Name (un) 36**] to pip/tazo.
Discussed pt's presacral abscess with ID attending at length,
and it appears that this pocket may pose significant challenges.
It appears that this infected area likely communicates with
bowel, and thus there is likely no endpoint to antibiotic
therapy, however, antibiotics obviously can not be continued
indefinately. JP drain for pelvic abscess now with no outpt
since [**11-11**]. It was unclear if pocket resolved or if drain no
longer accessing pocket, so another CT scan was obtained which
showed enlarged peri=rectal fluid collection. Case was
re-discussed with surgery - who felt that the fluid collection
represented stool output from fistula to small or large
bowel,and that patient was not a surgical candidate for
correction of this. Pip/tazo was discontinued on [**11-17**], and
patient did not have any fevers off antibiotics. The drain was
replaced on 11/2o to ensure on going drainage of the peri-rectal
fluid collection (it had become partially dislodged and was no
longer draining). Patient also with brown discharge from
urethra, and this, too, is felt to represent fluid from the
per-rectal fluid collection.
..
#Atrial flutter with [**Name (NI) 5509**] -
Pt developed aflutter with [**Name (NI) 5509**] while in the ICU, which was
initially difficult to control. He required an esmolol and
diltiazem drip to achieve adequate rate control. This was
subsequently converted to oral metoprolol and diltiazem. Pt
later became tachycardic on the floor after discontinuation of
Pip/Tazo, and his diltiazem was uptitrated with improvement in
his HR. Patient's HR remained well controlled on high dose
diltiazem and metorpolol.
.
# ? chronic cholecystitis: Ab ct showed large fluid collection
in the liver, so patient was initially scheduled for IR drainage
of this collection. However, re-examination of the images
revealed that patient had markedly appearing gallbladder.
Gallbladder has appeared abnormal in many past radiological
images over the years, but now appeared even worse, raising
suspicion for necrotic gallbladder or chronic cholecystitis.
However, there was no clinical correlation to this radiological
finding. Patient without RUQ pain whatsoever, no fevers, normal
wbc count - all off zosyn. He was watched for 72 hours off abx,
and had no symptoms. Case discussed with surgery, who felt that
he should not have a cholecystectomy or drain placed in the
gallbladder. The gallbladder abnormality may represent
gallbladder CA or adenomyosis of the gallbladder.
#Acute on chronic renal failure - appeared pre-renal; resolved
with fluids.
.
#Microcytic anemia - hct at baseline, but pt was guaiac positive
so there was concern that there may be some bleeding for
gastritis or duodenitis noticed on previous EGD. GI was
consulted, but they felt that EGD was not indicated at this
time. HCT stable on PPI.
.
#COPD, chronic stable -
- continued ipratropium prn
.
#Ulcerated aortic ulcer/plaque -
During TEE, pt was incidentally noted to have an ulcerated
plaque on his aorta. The cardiology service recommended
treating with a statin.
.
# GOALS OF CARE: During patient ICU course there were lengthy
conversations with SW and with multiple medical teams. Pt was
made DNR/DNI during this admission per ICU discussion with
patient. Palliative care consulted via ICU, and had multiple
meetings with the patient. Patient feels that he has had
multiple medical challenges over the years, and has overcome all
of them. He wishes to continue full medical care and treatment
for his conditions. He was counselled that the gallbladder may
still represent occult infection and cancer, and that the
peri-rectal fluid collection of stool may also become
problem[**Name (NI) 115**]. We reviewed that he has had multiple infections
and complications of treatment. Yet, Mr [**Name13 (STitle) 4027**] was very clear
in his wishes to continue hospitalization for his conditions
when necessary.
# DVT Prophylaxis: heparin SQ TID
Medications on Admission:
1. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 weeks.
2. heparin, porcine (PF) 10 unit/mL Syringe Sig: daily and prn
ML Intravenous PRN (as needed) as needed for line flush.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
5. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q2hr as needed for shortness of breath or
wheezing.
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for sleep.
7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO once a day.
8. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO twice a day:
hold if sys BP < 90 or HR < 60.
11. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
12. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for watery stools in ostomy.
13. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for loose stools in ostomy.
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Discharge Medications:
1. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze, SOB.
5. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**] [**Location (un) 1411**]
Discharge Diagnosis:
# Sepsis/fungemia; [**Female First Name (un) **] (TORULOPSIS) glabrata
# Presacral fluid collection secondary to fistulous connection
with bowel - drain placed
# Atrial flutter with [**Female First Name (un) 5509**]
# Ulcerated aortic ulcer/plaque
# Abnormal appearing gallbladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low blood pressure and large amounts of
drainage from your rectum. You were found to have sepsis, which
appears to be due fungus in your blood. You were also found to
have a signficant collection of stool in your pelvis, next to
your recturm, for which Interventional Radiology placed a drain.
You were treated with antibiotics for your infections.
Your gallbladder appears very abnormal on ultrasounds that we
have obtained. At this moment, it does not appear to be
infected, but time will tell what the underlying process in your
gallbladder is.
Your heart rate was very high at times, so you were started on
two medicines to control your heart rate - metoprolol and
diltiazem. Please continue to take these medications.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2194-12-30**] at 10:40 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"576.1",
"584.9",
"V15.3",
"V10.52",
"280.9",
"110.3",
"311",
"276.2",
"569.81",
"995.92",
"041.4",
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"362.50",
"567.22",
"403.90",
"493.20",
"V44.3",
"305.1",
"V87.41",
"287.49",
"V49.86",
"112.5",
"V10.05",
"575.11",
"V45.73",
"427.32",
"585.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18176, 18251
|
9012, 15939
|
458, 520
|
18576, 18576
|
3853, 8989
|
19503, 19807
|
3137, 3258
|
17519, 18153
|
18272, 18555
|
15965, 17496
|
18727, 19480
|
3273, 3834
|
276, 420
|
576, 2467
|
18591, 18703
|
2489, 2915
|
2931, 3121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,434
| 172,501
|
54917
|
Discharge summary
|
report
|
Admission Date: [**2194-9-26**] Discharge Date: [**2194-10-16**]
Date of Birth: [**2138-11-1**] Sex: M
Service: SURGERY
Allergies:
iodine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
S/p motor vehicle collision
Major Surgical or Invasive Procedure:
[**2194-10-14**] Left ring finger DIP joint primary arthrodesis
History of Present Illness:
Mr. [**Known lastname 112165**] is a 55yo male, unrestrained backseat passenger in
rollover MVC on [**2194-9-26**]. Hypoxic with EMS en route to hospital.
[**Location (un) 2611**] Coma Scale on ED arrival was 15, but required intubation
for respiratory distress. He was transported to [**Hospital1 18**] for
further management.
Past Medical History:
COPD, HTN
Social History:
"social" alcohol
Family History:
Non-contributory
Physical Exam:
Physical Exam upon presentation:
O(2)Sat: 88 on nonrebreather Low
Constitutional: Boarded, c-collar in place
HEENT: Bilateral periorbital ecchymosis, extraocular
movements intact, midface stable C. collar
Chest: Left chest wall tenderness
Cardiovascular: Regular Rate and Rhythm
Abdominal: Distended, diffusely tender
Pelvic: Stable
Extr/Back: No obvious deformity
Skin: Abrasions on right knee
Neuro: No focal deficits
On discharge:
VS: 98.8, 81, 122/78, 20, 93%/RA
GEN: Comfortable, NAD.
HEENT: C-collar in place
CARDIAC: Normal S1, S2. RRR. No M/R/G
PULM: Lungs diminished at bases. No W/R/R.
ABD: Soft/nontender/nondistended. + bowel sounds.
EXT: + pedal pulses. No edema, cyanosis, clubbing.
NEURO: AAOx4, normal mentation.
Pertinent Results:
[**2194-9-26**] Echocardiogram
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis by 2D (doppler interrogation of the aortic
valve was not obtained due to poor image quality). The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
[**2194-9-26**] CT Head
1. Bifrontal hematomas overlying both orbits. No retrobulbar
hematoma or
evidence of traumatic globe injury.
2. No acute intracranial process.
3. Mucosal thickening of the ethmoid air cells, likely related
to intubation, though no air-fluid levels within the sinuses to
suggest occult fracture.
[**2194-9-26**] CT C-spine
-Non-displaced fracture of the left pedicle of C7
-Possible non-displaced fracture of the anterior tubercle of the
left
transverse process of C7.
-Vertebral artery on the left at the C7 level (seen on CTA
chest) appears
normal without signs of traumatic injury - though more cephalad
vertebral
artery not imaged.
[**2194-9-26**] CT Torso
1. Endotracheal tube tip at carina, proximal repositioning is
recommended.
2. Extensive bilateral atelectasis, but no contusion or
hemothorax.
3. Severe mediastinal lipomatosis, though no mediastinal
hematoma. No
evidence of traumatic injury to the thoracic aorta.
4. Fracture of the pedicle of C7 on the left with possible
fracture of the anterior tubercle of the transverse process on
the left, better characterized on cervical spine CT.
Contrast-enhanced vertebral artery at the C7 level appears
normal without evidence of traumatic injury.
5. Numerous bilateral rib fractures as detailed above. No
pneumothorax.
6. Nondisplaced fractures of the left transverse process of the
L1 through L3 vertebral bodies.
7. Fatty liver
[**2194-9-27**] 6:18 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2194-9-27**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2194-9-29**]):
Commensal Respiratory Flora Absent.
BACILLUS SPECIES; NOT ANTHRACIS. MODERATE GROWTH.
CLINICAL SIGNIFICANCE UNCERTAIN.
BACILLUS SPECIES IS A RARE CAUSE OF LIFE-THREATENING
PNEUMONIA IN
THE IMMUNOCOMPROMISED HOST AND THE PREMATURE NEONATE.
LEGIONELLA CULTURE (Final [**2194-10-4**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2194-9-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
Reported to and read back by DR.[**Last Name (STitle) 2194**],[**First Name3 (LF) 900**] AND
[**Last Name (LF) **],[**First Name3 (LF) **] @ 05:39,
[**2194-9-30**].
ACIDFAST BACILLI. FEW seen on concentrated smear.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Final [**2194-10-2**]):
NEGATIVE FOR M. TUBERCULOSIS BY NAAT. AWAIT CULTURE
RESULTS. TEST
PERFORMED BY [**State **] STATE LABORATORY [**2194-10-2**].
[**2194-9-30**] Left hand film
Three views of the left hand have no comparisons. There is a
transverse
intra-articular fracture at the base of the distal phalanx of
the ring finger. The fracture line extends to both the volar and
distal aspects of the phalanx with fracture fragments present
along the volar aspect of the joint. No other fractures,
however, the hand and wrist are subopitmally viewed. Mild soft
tissue swelling.
[**2194-9-30**] CT Torso
1. Moderate-sized left pneumothorax without evidence of
tension. Two left pleural tubes terminate in the posterior left
pleural space.
2. Subtotal atelectasis of bilateral lower lobes is slightly
increased since prior. Ground-glass opacities in the upper
lobes, left greater than right, are nonspecific, but compatible
with aspiration or infection in the correct clinical setting.
3. Small bilateral pleural effusions, right greater than left.
4. New small perihepatic ascites and pelvic fluid.
5. Numerous osseous injuries, similar to prior, including
slightly displaced fracture of the inferior angle of the left
scapula, bilateral rib fractures with segmental fractures of the
left third through fifth ribs, L1-L3 left transverse process
fractures.
[**2194-9-30**] CT LUE
1. Comminuted, intra-articular fracture of the base of the
distal phalanx of the left ring finger. 0.4 cm ossific fragment
is present dorsal to the distal head of the intact middle
phalanx of this digit.
2. Subcentimeter ossific fragments are also present along the
volar aspect of the distal head of the middle phalanx of left
ring finger. Joint is mild hyperextended.
3. Ovoid 0.6 cm corticated ossific body adjacent to the ulnar /
distal aspect of the capitate of indeterminant chronicity. No
evidence for acute fracture of the capitate.
4. Widening of the scapholunate interval suggestive for
scapholunate ligament injury / disruption. MR examination of
the left wrist would provide further imaging evaluation if
clinically warranted.
[**2194-10-2**] Echocardiogram
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
normal (LVEF 70%). The right ventricular cavity is dilated with
depressed free wall contractility (the apical half of the RV
free wall appears severely hypokinetic. There is no pericardial
effusion.
Impression: RV dysfunction (? RV contusion)
Compared to prior of [**2194-9-26**], the RV is still hypokinetic
(infundibular/RVOT free wall was severely hypokinetic in prior
study).
[**2194-10-6**] MR [**Name13 (STitle) 2853**]
1. C5-6 interspinous ligamentous edema, consistent with acute
injury;
however, no evidence of ALL or PLL complex or spinal cord
injury.
2. Left C7 pedicle and articular pillar fracture, extending into
superior
articulating facet, without evidence of joint capsular
disruption or alignment abnormality.
3. Moderate C3-4 right neural foraminal narrowing.
[**2194-10-10**] CTA CHEST W&W/O C&RECONS, NON-CORONARY
Though there has been interval resolution of a left pneumothorax
from
[**9-30**], there is little change in segmental atelectasis at
the bilateral lower lobes. There is no pulmonary embolus.
[**2194-10-11**] HAND (AP, LAT & OBLIQUE)
FINDINGS: Again seen is an oblique intra-articular fracture at
the base of the fourth distal phalanx with multiple small
fracture fragments. There continues to be angulation of the
distal fourth digit at the fracture site with associated soft
tissue swelling. No callus formation is visualized.
Brief Hospital Course:
The patient is a 55 M who was an unrestrained back seat
passenger in MVC rollover(serum EtOH 204). He was initially
awake and following commands, but was intubated in the trauma
bay for increasing respiratory distress with possible
aspiration. The patient was subsequently pan-scanned revealing
bifrontal hematomas and rib fractures. He was brought to the
TSICU for further resuscitation and management.
His ICU course as follows by systems:
Neuro: GCS 15 and moving all extremities in the trauma bay, the
patient was intubated for progressive respiratory distress and
was kept intubated and sedated on fentanyl and versed until HD
9. Propofol was also used to facilitate daily wake ups. He
required paralysis with cisatracurium for ventilation until HD
7. A hard collar was in place at all times per spine
recommendations for C7 fracture. NG pain medication was added
HD8. Propofol was discontinued on [**10-4**] in order to facilitate
ongoing vent wean. He continued to have his ventilator weaned
and successfully extubated the am of HD 12. On [**10-9**] he sustained
a fall and began to complain of thoracic spine tenderness. He
underwent CT imaging showing fracture of the right lateral
aspect of the T12 vertebral body. Spine surgery were
re-consulted and recommended a TLSO brace to be worn while out
of bed.
CV: After being initially hemodynamically stable on admission,
the patient required a Neo-Synephrine drip after intubation.
Echo and CXR were unremarkable, but he required ongoing pressor
support with Levophed until [**10-2**]. As his respiratory status
improved, his blood pressure stabilized.
Resp: On arrival to the ED, the patient was having difficulty
maintaining his O2 saturation and became tachypneic, likely
secondary to extensive rib fractures. He was intubated in the
trauma bay for respiratory distress. On his initial CT, there
were large dependant fluid collections which were read as likely
atelectasis, but were somewhat concerning for aspiration
pneumonia. He was bronched on arrival to the TSICU for
persistent hypoxia which improved with suctioning. On HD 3, he
began to exhibit symptoms of ARDS, and his CXR was in keeping
with this finding. He was placed in ARDS ventilatory settings
but had an increasing PEEP requirement for adequate oxygenation
complicated by a large left pneumothorax on [**9-27**] requiring urgent
chest tube decompression with immediate improvement. He was
aggressively diuresed but required a prolonged wean from the
ventilator. Bronchoscopy with BAL was performed for persistent
RLL collapse on [**9-27**] and culture was positive for acid-fast
bacilli. He was placed in respiratory isolation and further
data from the state laboratory was negative for TB. Infectious
disease consultation was obtained for presumed aspiration
pneumonia with acid-fast bacilli, and initial empiric vancomycin
and Zosyn were de escalated to Zosyn on [**9-30**]. On [**9-30**], a repeat
CXR revealed increase in a left subpulmonic pneumothorax and a
second, posterior chest tube was placed with satisfactory
resolution. Repeat bronchoscopy was performed on [**10-1**] for RLL
collapse on chest CT, with purulent sputum aspirated and sent
for culture. Diuresis continued. On [**10-3**], the ventilator was
switched to APRV mode to facilitate weaning and continued
through the morning of [**10-5**]. PEEP and FIO2 were able to be
weaned, and on [**10-6**], he was tolerating pressure support. The
apical chest tube was removed on [**10-6**]. He extubated on [**10-7**] and
tolerated this well and has remained on nasal canula oxygen. He
continued to be weaned off his oxygen requirement, until he was
on room air and oxygen saturations were above > 90%.
GI: While intubated, he was kept NPO. Tube feeds were started
on HD2 and advanced to goal, which he tolerated without
difficulty. Once extubated, he was started on a regular diet
and tolerated this until discharge.
GU: He had a Foley placed in the ED and produced adequate urine
during his ICU stay, responding appropriately to diuresis.
Endo: Sliding scale insulin coverage was provided in the ICU.
Heme/ID: His WBC began to climb though he did not spike any
fevers and none of his cultures came back positive as of HD 5.
He did have a bronch on [**9-27**] which showed non-anthracis bacillus.
As noted above, he was treated initially with vancomycin and
Zosyn, then de escalated to Zosyn alone. AFB+ culture data did
not reveal TB. Infectious disease consultation was obtained,
and a 10 day course of Zosyn was completed [**10-6**]. His
temperature curve was monitored after this.
MSK: Found to have 4th metacarpal and distal phalanx fractures,
splinted by Hand surgery and referred for outpatient follow up.
His floor course as follows:
On HD 14 ([**2194-10-10**]), the patient was transferred to the inpatient
medical/surgical unit for further management. He was continued
on bedrest until he was fitted for a TLSO brace.
On HD 15 he received his TLSO brace and was evaluated by
physical therapy. His oxygen requirement was weaned to room air
and his oxygen saturations were kept above > 90%. His pain was
well controlled with oral medications.
On HD 16 his Foley catheter was discontinued and he was voiding
large amounts of urine without difficulty.
On HD 17 (On [**2194-10-14**]) he was taken to the OR by Plastics Hand
Surgery for a primary left ring finger distal interphalangeal
joint arthrodesis. He will need to stay in the splint for 2
weeks and then he will need it to be changed to ulnar gutter
type cast to be worn for 4 weeks. He will require a 7 day course
of Keflex antibiotics post-operatively. He will remain non
weight bearing precautions to his left hand but may weight bear
through his forearm. His vitals remained stable and he remained
afebrile up to the day of discharge.
He will require follow up with his PCP upon return to his home
state of [**State 108**] - this was explained to patient prior to
discharge. He also understands that he will need to follow up
with an Orthopedic Spine and Plastic Surgeon within the next [**1-27**]
weeks.
Medications on Admission:
Xanax 1mg Daily
Albuterol prn
Afrin prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol-Ipratropium [**1-27**] PUFF IH Q6H:PRN wheezing
3. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times
a day Disp #*24 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR [**Hospital1 **]
7. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg [**1-27**] tablet(s) by mouth every 4 hours Disp
#*90 Tablet Refills:*0
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO QID
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*120
Tablet Refills:*1
11. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Transdermal
Patch Refills:*1
12. ALPRAZolam 1 mg PO BID:PRN anxiety
RX *alprazolam [Xanax] 1 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
- Bifrontal hematomas
- C7 left pedicle fracture
- L1-L3 transverse process fractures
- Left [**3-4**] rib fractures
- Right [**9-4**] rib fractures
- T12 vertebral body fracture
- Left ring finger distal phalanx base fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 **] after you
were involved in a motor vehicle collision. Upon evaluation,
you were found to have the following injuries: fractures of
your cervical (neck) spine bone; rib fractures, mid and lower
spine bones, left ring finger and the bones in your lower back.
Your spine injuries in your neck and mid back did not require
any operations- instead you were fitted for a hard cervical
collar and a corset type brace for your mid back fracture.
Your neck brace needs to be worn at all times for at least
another 2 weeks. You will need to follow up with a Spine surgeon
upon your return to your home in [**State 108**] for xrays to determine
if the collar can be removed.
Your corset brace needs to be worn when you are out of bed -
while in bed with your head of bed up on at least 2 full pillows
you do not need to wear the brace. You may apply the brace in a
sitting position on the side of the bed.
You may remove both braces for showering while seated in a
shower chair. It is importnat that someone be with you when
showering to make sure that you have minimal movements.
DO NOT take any tubs baths until all braces no longer need to be
worn.
You will need to keep the splint on your right hand for the next
2 weeks. After that time a short arm cast will need to be
applied that will be worn for 4 weeks.
DO NOT bear any weight on your left hand - you may bear weight
through your left forearm.
* You have rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
You are prescribed antibitoics for your left finger injury -
please be sure to complete the entire course as directed.
Followup Instructions:
Follow up with your PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 112166**] [**Telephone/Fax (1) 112167**]) as you
have indicated you wanted to do within the first week that you
arrive home.
Should you want follow up here at [**Hospital1 1170**] in [**Location (un) 86**] the following surgeons can be contact[**Name (NI) **] for
appointments and/or questions regarding your recent hospital
stay:
*Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], Orthopedics Spine Surgery [**Telephone/Fax (1) 3573**]
*Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], Plastic Surgery (Hand) [**Telephone/Fax (1) 31444**]
*Trauma & Acute Care Surgery Clinic [**Telephone/Fax (1) 600**]
Completed by:[**2194-10-29**]
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44,265
| 168,014
|
34493
|
Discharge summary
|
report
|
Admission Date: [**2121-3-28**] Discharge Date: [**2121-3-31**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Fish Product
Derivatives
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Angioedema and recent fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 79252**] is an 87F with PMH of atrial fibrillation on
coumadin, HTN, HL, eczema, and angiodema who presented with
right facial and upper lip angioedema, as well as a recent fall.
On [**2121-3-25**], she awoke in the middle of the night to go to the
bathroom. She denies any loss of conscioussness or head trauma
during the fall. She also denies feeling dizzy, chest pain,
palpitations, or other symptoms before or during the fall. She
was unable to get off the floor immediately after falling and
waited several hours before calling Lifeline. Her daughter
arrived early in the morning and helped her back into bed. The
daughter reported that on [**2121-3-27**], Ms. [**Name14 (STitle) 79253**] seemed confused
and altered from her baseline mental status. Then, on [**2121-3-28**],
the patient experienced facial swelling, and she was brought to
the [**Hospital1 18**] out of concern for her recent fall and facial
swelling.
Ms. [**Known lastname 79252**] has experienced facial swelling once before. In
[**2120-10-8**], she experienced intermittent facial and tongue
swelling controlled with Benadryl, and in [**2120-12-8**], she was
hospitalized and intubated for increased facial and tongue
swelling. This was thought to be due to her lisinopril, which
was discontinued. Since then, her allergy regimen has been
Zyrtec 10 mg daily, famotidine 20 mg [**Hospital1 **], fexofenadine 60 mg
[**Hospital1 **], prednisone 5 mg every third day.
On review of systems, the patient denied any recent chest pain,
dyspnea, feelings of throat constriction, fevers, chills,
nausea, vomiting, diarrhea, constipation, urinary or fecal
incontinence, changes in vision, or numbeness/tingling in her
her hands or feet.
In the ED, vital signs were T 98.9 HR 79 BP 136/64 RR 16 O2 sat
100. Labs were notable for WBC 11.1, INR 1.2, glucose 173. The
patient was given 40 mg IV solumedrol, 50mg IV benadryl, and
40mg IV pepcid. Given her recent fall while on coumadin a NCHCT
was obtained showing a new left caudate lesion that was not
present on a previous head CT in [**2121-2-13**].
In the ICU, vital signs were T98-98.8 HR 52-87 BP 112-151/40-80
RR 14-21 SPO2 91%. For her angioedema, the patient was given
solumedrol and H1 and H2 blockers, and it improved
significantly. For her CVA, she was placed on heparin for her
subtherapeutic INR, and MR of her neck was taken. For her atrial
fibrillation, she was placed on heparin.
Past Medical History:
Angioedema: pruritis and periorbital and lip/tongue edema,
intubated in MICU - workup C4, C1 inhib neg, IgE neg for
pineapple, scallops, ESR 28, TSH low at 0.096, free t4 and t3
normal. AntiTPO abs neg. Treated with steroid taper, currently
on prednisone 2.5-5mg QOD.
Atrial fibrillation
Hypertension
Hyperlipidemia
Osteoporosis
Osteoarthritis
s/p right hip replacement
eczema
Hayfever as a child
Social History:
Smoking: Denies
EtOH: 1 glass wine/week
Drugs: Denies
Lives in ind living facility in [**Location (un) **].
Walks with walker
Family History:
-1st cousin with peanut allergy developed in his 80s.
-No FH of asthma or eczema
Physical Exam:
BP 144/49 HR 67 SpO2 961L
General: Alert, oriented, no acute distress
HEENT: Upper lip slightly swollen, areas of erythematous skin
over lip/cheek, Sclera anicteric, MMM, oropharynx clear, no
tongue swelling.
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: no edema, 2+ pulses,
Neuro: A+Ox3
CN II-XII intact
Motor [**6-11**] in UE and LE BL
Sensation to LT intact in UE and LE
FTN intact
Pertinent Results:
Labs on admission:
[**2121-3-28**] 09:20AM BLOOD WBC-11.1* RBC-4.22 Hgb-12.4 Hct-37.6
MCV-89 MCH-29.3 MCHC-32.8 RDW-13.2 Plt Ct-203
[**2121-3-29**] 03:02AM BLOOD WBC-7.1 RBC-3.80* Hgb-11.5* Hct-33.9*
MCV-89 MCH-30.1 MCHC-33.8 RDW-12.9 Plt Ct-184
[**2121-3-29**] 11:08AM BLOOD Hct-35.5*
[**2121-3-28**] 09:20AM BLOOD Neuts-85.1* Bands-0 Lymphs-10.6*
Monos-3.7 Eos-0.5 Baso-0.1
[**2121-3-28**] 09:20AM BLOOD PT-13.7* PTT-22.3 INR(PT)-1.2*
[**2121-3-29**] 03:02AM BLOOD PT-15.2* PTT-150* INR(PT)-1.3*
[**2121-3-28**] 09:20AM BLOOD Glucose-173* UreaN-23* Creat-1.0 Na-137
K-4.0 Cl-101 HCO3-25 AnGap-15
[**2121-3-29**] 03:02AM BLOOD Glucose-259* UreaN-24* Creat-0.9 Na-136
K-3.5 Cl-105 HCO3-20* AnGap-15
[**2121-3-29**] 03:02AM BLOOD CK-MB-3 cTropnT-<0.01
[**2121-3-29**] 11:08AM BLOOD CK-MB-3 cTropnT-<0.01
[**2121-3-29**] 03:02AM BLOOD Triglyc-83 HDL-62 CHOL/HD-2.7 LDLcalc-89
[**2121-3-28**] 09:20AM BLOOD TSH-0.69
[**2121-3-29**] 03:02AM BLOOD TSH-0.22*
[**2121-3-28**] 09:20AM BLOOD T4-6.8 T3-87
.
CT HEAD
FINDINGS: There is a new 2 x 1.5 cm hypoattenuating focus
centered in the head of the left caudate lobe, compatible with
an acute - subacute infarct. Again noticed is right
parieto-occipital encephalomalacia and chronic lacunar infarcts
in the bilateral basal ganglia. There is hypoattenuation of the
periventricular and subcortical white matter consistent with
sequelae of small vessel ischemic disease. There is no mass
effect or shift of midline structures. The ventricles and sulci
are mildly prominent consistent with age-related involutional
changes as well as showing ex vacuo dilatation of the occipital
[**Doctor Last Name 534**] on the right. The visualized paranasal sinuses and mastoid
air cells are well aerated. No fractures are present.
IMPRESSION: New left caudate head infarct. MRI may be performed
for further evaluation.
.
CXR:
IMPRESSION: No fracture noted, no acute intrathoracic process.
.
MRI ([**2121-3-29**]): Prelim read -- Acute left caudate head infarct.
MRA neck demonstrates 50% stenosis of the left proximal internal
carotid artery and 50% stenosis in both vertebral arteries in
the V2 segment. No enhancing brain lesion.
.
CT torso ([**2121-3-30**]): Prelim read -- No definite malignancy. No
PE. Heterogeneous thyroid w numerous nodules should be
correlated to non-urgent thyroid ultrasound. Subcutaneous nodule
in the left breast should be correlated to mammogram.
Brief Hospital Course:
87 year old woman with h/o angioedema, atrial fibrillation on
Coumadin, HTN, and HL who was transferred from the ICU for
further workup of her stroke and angioedema. She stopped
Lisinopril in [**12-16**] and currently is not on any medications that
are known to cause angioedema. She has been followed by allergy
since fall [**2120**] and work-up has been negative thus far (except
for TSH that is low, and a normal FT4). She was treated with
increased prednisone and antihistamines and responded well. She
had CT torso which was negative for internal malignancy. Old
SPEP was negative and new UPEP was negative. C1q inhibitor was
pending at the time of discharge. She will F/U with her primary
allergist Dr.[**Name (NI) 65857**] regarding further work up and the need
for Endocrinology follow up as she had multiple thyroid nodule
on CT of the torso and abnormal TSH (toxic mulinodular goiter?).
Her thyroid ultrasound was pending at the time of discharge. In
regards to her stroke, there was a new left caudate hypodensity
seen on NCHCT on [**3-28**] that was not previously seen on [**2121-2-13**].
MRI showed acute left caudate head infarct. MRA neck
demonstrates 50% stenosis of the left proximal internal carotid
artery and 50% stenosis in both vertebral arteries in the V2
segment. The TTE on [**2121-3-31**] was negative for mural thrombus or
cardiac source. However, cardioembolic stroke was suspected to
be the cause. She received Lovenox bridge until her INR was >2.
She was discharged to rehab for instability. She and her
relatives were informed regarding the thyroid follow up and the
pulmonary nodule found on CT. total discharge time 45 minutes.
She was asked to call [**Telephone/Fax (1) 2574**] to schedule appoint with
stroke neurology for a follow up.
Medications on Admission:
Home meds
Coumadin 2.5 mg 1 tab MWF;1/2tab all other days
metoprolol 50 mg [**2-8**] tab am; 1 tab pm
Claritin 10 mg 1 tab(s) once a day
Triamcinolone topical 0.1% 1 app QID
Norvasc 10 mg 1 tab(s) once a day
calcium and vitamin D combination 600 mg-200 units 1 tab(s) TID
Fosamax 70 mg 1 tab(s) 1X/W
Zocor 20 mg 1 tab(s) once a day (at bedtime)
Meds on Transfer
Heparin IVSS
Warfarin 2.5 po daily
Fexofenadine 60 mg [**Hospital1 **]
Famotidine 20 mg daily
Simvastatin 20 mg po daily
Amlodipine 20 mg daily
Metoprolol 25 mg daily
Prednisone 50 mg (part of taper)
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: then 5 mg every other day.
Disp:*30 Tablet(s)* Refills:*0*
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching rash.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Primary Diagnoses:
Angioedema
Stroke without residual defecits
Atrial fibrillation
.
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Discharge Condition:
Excellent
Discharge Instructions:
Dear Mrs. [**Known lastname 79252**],
You had a small stroke. Your INR was too low. You also had some
angioedema (swelling) that improved with steroids.
MEDICATION CHANGES:
. Prednisone 5 mg every other day.
4. discontinue the Zyrtec 10 mg at night and stay on the [**Doctor First Name **]
60 mg po BID (I am concerned maybe it contributes to her
possible mental status issues).
Followup Instructions:
On your CT exam, you were found to have a heterogeneous thyroid
with numerous nodules. A thyroid ultrasound was done but the
results are pending at the time you left the hospital. Please
follow up with your PCP regarding the results. You may need to
see an Endocrinologist for these thyroid nodules. You were also
found to have a subcutaneous nodule in the left breast that
should be correlated to mammogram (please ask your PCP to check
with his/her mamogram records).
|
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|
3360, 3443
|
8932, 9647
|
9758, 9843
|
8344, 8909
|
9949, 10104
|
3458, 4093
|
9864, 9893
|
10124, 10335
|
244, 272
|
344, 2780
|
4131, 6521
|
2802, 3201
|
3217, 3344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,070
| 109,439
|
3763
|
Discharge summary
|
report
|
Admission Date: [**2141-6-4**] Discharge Date: [**2141-7-6**]
Service:
CHIEF COMPLAINT: Recurrent empyema
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 16926**] is an 80 year old
man who presents with shortness of breath and tachycardia.
Mr. [**Known lastname 16926**] had a left thoracoplasty in [**2088**] for
tuberculosis which was performed in the Soviet [**Hospital1 1281**]. He did
well until [**2141-5-3**] when he developed an empyema. An
empyema tube was placed to drain the subsequent empyema.
Over the next several days Mr. [**Known lastname 16926**] developed a
pericardial effusion with evidence of tamponade.
Pericardiocentesis was performed but the right ventricle was
punctured. Subsequently a balloon drain was placed. By [**2141-6-16**], Mr. [**Known lastname 16927**] empyema had not improved. He was
subsequently evaluated by Dr. [**Last Name (STitle) 952**] for surgical
intervention regarding this empyema.
PAST MEDICAL HISTORY: 1. Tuberculosis in [**2084**], status post
left thoracoplasty; 2. Pericardial effusion; 3. Mitral
valve prolapse; 4. Gastric cancer, status post Roux-en-Y
gastrectomy; 5. Multiple pneumonias; 6. Left thoracentesis;
7. Gastroesophageal reflux disease; 8. Nephrolithiasis; 9.
Coronary artery disease, cardiac catheterization performed in
[**2141-3-3**] which revealed mitral valve prolapse, diastolic
dysfunction and coronary artery disease. He may be a
candidate for coronary artery bypass graft in the future.
10. Empyema; 11. Bronchopleural fistula.
SOCIAL HISTORY: No use of tobacco or ethanol.
ALLERGIES: Quinine which causes rash.
OUTPATIENT MEDICATIONS: Metoprolol 12.5 mg b.i.d., Percocet,
Tylenol #3, Vioxx, Triazolam, Colace.
REVIEW OF SYSTEMS: Negative unless otherwise stated above.
PHYSICAL EXAMINATION: Vital signs, temperature 97.2, pulse
68, blood pressure 120/60, respirations 28, oxygen
saturations 96% on 2 liters. Mr. [**Known lastname 16926**] is an elderly
gentleman who appeared his stated age. His heart is regular
in rate and rhythm. He has diffuse crackles which are
greater on the left side. Abdomen is nontender,
nondistended, normoactive bowel sounds. Extremities were
significant for 2+ edema, greater on the right side. He has
a left-sided chest tube.
HOSPITAL COURSE: Mr. [**Known lastname 16926**] was taken to the Operating
Room on [**2141-6-16**] where a left-sided decortication of
empyema was performed, serratus anterior and latissimus dorsi
flaps were placed to close the empyema cavity. The
pericardial window was also constructed. Samples of Mr.
[**Known lastname 16927**] empyema revealed infection by Escherichia coli and
Stenotrophomonas. He was placed on Ceftriaxone which he will
take until [**7-19**] and Bactrim which he will take until [**7-23**] for this infection. Mr. [**Known lastname 16926**] had a prolonged air leak
during his hospital stay and chest tube was left to suction
until [**6-29**]. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were also placed
following his surgery. One [**Location (un) 1661**]-[**Location (un) 1662**] was discontinued on
[**7-2**] and the second [**Location (un) 1661**]-[**Location (un) 1662**] drain was cut and left
to drain to open air. It will be removed at a later visit.
Mr. [**Known lastname 16926**] [**Last Name (Titles) 8337**] his chest tube to water-seal and
subsequently the chest tube was discontinued on [**7-5**], after
being gradually removed. Mr. [**Known lastname 16927**] hospital stay was
also complicated by impaired renal function. His renal
function was gradually improving and will be followed by Dr.
[**First Name (STitle) **] on an outpatient basis. He will also have a visiting
nurse [**First Name (Titles) **] [**Last Name (Titles) **] him on monitoring his renal function. On
[**7-6**], Mr. [**Known lastname 16926**] was doing well and was thought stable to
be discharged from the hospital.
Examination at the time of discharge revealed vital signs of
98.6, pulse 86, blood pressure 128/60, respirations 18,
oxygen saturation 96% on room air. His head is
normocephalic, atraumatic. His neck is supple. His heart is
regular rate and rhythm. His lungs are clear to auscultation
bilaterally with slightly decreased breathsounds over the
area of his incision. Incision and drain sites are clean,
dry and intact. There remains on [**Location (un) 1661**]-[**Location (un) 1662**] drain which
is open to air. His abdomen is soft, nontender, nondistended
with normal bowel sounds. His end-to-side anastomosis are
without cyanosis, clubbing or edema. Mr. [**Known lastname 16926**] had a
PICC line placed on [**6-26**].
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Docusate 100 mg p.o. b.i.d.
4. Ceftriaxone 2 gm intravenously q. 24 hours until [**7-10**]
5. Bactrim double strength one tablet p.o. b.i.d. until [**7-14**]
6. Lansoprazole 30 mg p.o. q.d.
7. Percocet 1 to 2 tablets q. 4 to 6 hours as needed for
pain
8. Lasix 20 mg p.o. q.d. (this medication is only to be
started after specific instructions by a physician)
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is to be discharged home with
visiting nurse care. The visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] in
general care of Mr. [**Known lastname 16926**] as well as administering
intravenous antibiotics. The visiting nurse will also draw
blood in assistance of monitoring Mr. [**Known lastname 16927**] renal
function.
DISCHARGE DIAGNOSIS:
1. Status post left decortication with serratus and
latissimus flaps
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 16928**]
MEDQUIST36
D: [**2141-7-5**] 19:20
T: [**2141-7-5**] 19:42
JOB#: [**Job Number 16929**]
|
[
"403.91",
"041.4",
"424.0",
"V10.05",
"458.2",
"V12.01",
"423.9",
"584.5",
"510.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.51",
"37.12",
"34.91",
"37.23",
"86.74",
"37.24",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
4696, 5140
|
5557, 5906
|
2303, 4673
|
1652, 1728
|
1812, 2285
|
5155, 5536
|
1748, 1789
|
100, 119
|
148, 953
|
976, 1539
|
1556, 1627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,493
| 152,154
|
13965
|
Discharge summary
|
report
|
Admission Date: [**2101-10-17**] Discharge Date: [**2101-10-21**]
Date of Birth: [**2037-8-22**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient presented on [**10-17**] to the emergency room as a transfer from [**Location (un) 620**] [**Hospital1 18**]
where the patient had complained of bilateral flank pain,
increased severity, with diarrhea and vomiting, and pain
radiating to the back. The patient had had a CT scan that was
done that demonstrated liver masses. He was transferred to
[**Hospital1 18**].
PAST MEDICAL HISTORY: Significant for CAD, status post non-Q-
wave MI in [**2090**], status post PTCA stent, paroxysmal AFib,
hypertension, hyperlipidemia, non-insulin dependent diabetes
type 2, colonic polyps, chronic diarrhea, history of lower GI
bleed attributed to hemorrhoids, hypertension x 20 years.
PAST SURGICAL HISTORY: As above.
MEDICATIONS AT HOME: Atenolol 100 mg once a day, aspirin 81
mg daily, glipizide 5 mg in the morning and 2.5 mg in the
p.m., folate and multivitamin.
SOCIAL HISTORY: A 50-pack-year history of smoking; 2 to 3
glasses of wine per night; no IV drug use.
FAMILY HISTORY: No family history of cancer.
On admission to the ED, the patient's hematocrit was 23.3. He
was transfused with 2 units of packed cells. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] was consulted as well as hepatology for abdominal
pain that initially presented on the left side, then
localized to the right upper quadrant.
PHYSICAL EXAMINATION ON ADMISSION: The patient's temperature
was 97.6, heart rate 97, BP 149/61, with a respiratory rate
11, 97% on room air. He was in no acute distress. EOMs were
intact. He did have scleral icterus. No lymphadenopathy. His
lungs were clear. HEART: Regular rate and rhythm. A positive
3/6 systolic murmur at the left lower sternal border
radiating to the neck. ABDOMEN: Soft, protuberant,
nondistended, nontender, nontympanitic. Negative rebound. No
guarding. No [**Doctor Last Name **] sign. No masses. No groin hernias.
RECTAL: Exam was positive for blood with mucous. EXTREMITIES:
No clubbing, cyanosis. Palpable femoral pulses bilaterally
and dopplerable PT/DP, left greater than the right.
LABORATORY DATA: White count on admission 13.2, hematocrit
23.3. Sodium 140, potassium 5.8, chloride 104, CO2 of 27, BUN
48, creatinine 1.1, glucose 153. AST was 65, ALT 112,
alkaline phosphatase 113, total bilirubin 6.2. CK was 440.
Troponin was 0.02. Tox screen was negative for alcohol,
salicylate and Tylenol. Lactate was 6.1 at the outside
hospital. The UA was negative.
RADIOLOGIC STUDIES: An abdominal CT was done that
demonstrated enumerable hepatic masses, with the largest
loculated in segment 8. Nodular contour of the liver as well
as extensive gastric, splenic, and umbilical varices
suggestive of underlying cirrhosis. The patient was noted to
have extensive lymphadenopathy; including celiac, portal,
gastric, and retroperitoneal. Thrombus was noted within the
right portal vein. There was apparent patent left portal
vein. No obvious segmental perfusion differences. He had a
replaced hepatic artery from the superior mesenteric artery.
HOSPITAL COURSE: He was made n.p.o. and started on IV
hydration after the transfusion. A Foley catheter was placed
in his bladder. UA was negative. He was scheduled for an EGD
given the low hematocrit. He was also started on IV heparin
for portal vein thrombus and started on serial hematocrit's
q.6h.. He was also started on empiric Cipro and Flagyl. It
was also noted by hepatology that there was no history of
chronic liver disease or hepatitis; although, he did have
synthetic dysfunction with an INR of 1.6, an albumin of 2.2
and total bilirubin of 6.2. The concern was that the portal
vein thrombus was possibly associated with tumor. Concern was
for hepatocellular carcinoma versus pancreaticobiliary CA,
although less likely. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] saw the patient, who
had been transferred to the surgical intensive care unit,
where an EGD was performed to rule out varices and rule out
gastric neoplasm.
An EGD demonstrated no varices seen in the esophagus, clotted
blood seen in the whole stomach, varices were seen in the
fundus with a blood clot, the duodenum appeared normal.
Impression was of varices seen at the fundus with blood in
the whole stomach. No varices noted in the esophagus. The
patient was bolused with octreotide followed by an IV drip of
octreotide at 50 mcg per hour. He was started on proton pump
inhibitor IV b.i.d. and kept n.p.o. with serial q.6h.
hematocrit's. It was noted on the CT scan that had been done
at the [**Location (un) 620**] [**Hospital1 18**] that findings were most consistent with
diffuse metastatic disease. There was involvement of the
liver, portal, mesenteric, and retroperitoneal lymph nodes.
He had extensive portal vein thrombosis, and the liver lesion
was amendable to CT-guided biopsy if desired. There was also
cholelithiasis noted.
A cardiology consult was obtained for evaluation of cardiac
enzymes given severe anemia and concern for MI with a CK of
440, which increased to 896, a CK/MB of 4.20 that increased
to 12, and a CK/MB index that was 1.0 that increased to 1.3,
and troponin 0.019 that increased to 0.07. The first set was
from the outside hospital, and the second set was upon
admission to [**Hospital1 18**]. Recommendations included holding aspirin,
keep hematocrit greater than 30, hold on antiplatelet agents
given thrombocytopenia and active bleeding, no further need
for cycling enzymes. It was felt that the patient had demand
ischemia. Given severity of GI bleed, it was unlikely for the
him to be anticoagulated for an MI; and he was to be
medically managed. He was maintained on telemetry. He was
continued on the beta blocker for heart rate and BP control.
He was further transfused in the ICU with 2 units of packed
cells for a hematocrit of 27.5. AST was 117, ALT 49, alkaline
phosphatase 90, total bilirubin decreased to 4.8, LDH was
242, amylase was 61 and lipase 81. He was started on nadolol
20 mg daily. His hematocrit continued to trend down to 25.4.
He received another 2 units of packed red blood cells. His
INR was 1.8, PTT 39.3, PT 19.4. His hematocrit increased to
28. He also received FFP for the elevated INR as well as
vitamin K subcutaneously x3 days. His blood pressure remained
stable between 125/58 and 129/46. Heart rate ranged between
76 to 70. O2 saturations were 99% on 2 liters nasal cannula.
His AFP was noted to be 3386. His abdomen was mildly
distended, but soft/nontender with positive bowel sounds. CEA
was 11. CA19-9 was 140.
It was felt the patient had cirrhosis and hepatocellular
carcinoma with multiple lesions with portal vein thrombosis
with lymph nodes as well as gastric varices and that the
lesions were unresectable. An oncology consult was obtained.
It was felt that he likely had hepatocellular carcinoma. A
family meeting occurred to discuss the therapeutic options.
Outpatient followup was scheduled. It was felt that he was
not a candidate for transplantation or resection, and TIPS
was not an option in this patient.
He was transferred from the surgical intensive care unit to
the medical surgical unit on [**2101-10-19**]. Abdomen was
soft/nontender, positive distention with positive __________
. His vital signs remained stable. He was started on
spironolactone, and he was scheduled to complete a 7-day
course of ciprofloxacin. His white blood cell count was 10.3,
hematocrit 30.3, creatinine was normal at 0.__________ . His
INR was 1.8, PTT 39.9, AST 100, ALT 46, alkaline phosphatase
90, total bilirubin 4.3, amylase was 48, lipase 76. His
octreotide was stopped. He was tolerating a regular diet. His
stools were guaiac negative. Of note, he had some penile
edema; and a Foley was in place. He did have difficulty once
the Foley was removed. On [**10-19**], Foley required
replacement for bladder distention. His Foley was removed,
and he was able to urinate on the second try.
DISCHARGE STATUS: He was discharged home in stable condition
on [**2101-10-21**]. Vital signs were stable. Blood pressure
ranged between 99 to 117/51 and 60, with a heart rate of 60,
O2 saturation was 91% on room, blood sugars were between
__________ while in the hospital. He was to resume his
glipizide at home. His weight was 84 kg. He was ambulatory.
He was scheduled to follow up in the outpatient clinic with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**11-7**] at 1:20 in the afternoon. He
was also scheduled to follow up with oncology in the
outpatient clinic.
FINAL DIAGNOSES: Unresectable cholangiocarcinoma complicated
by portal vein thrombosis, gastric varices; upper
gastrointestinal bleeding, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2101-10-21**] 15:36:59
T: [**2101-10-22**] 10:05:41
Job#: [**Job Number 41737**]
|
[
"401.9",
"578.9",
"155.0",
"414.01",
"272.4",
"196.2",
"456.8",
"V45.82",
"452",
"571.2",
"250.00",
"412",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
1178, 1549
|
3218, 8680
|
929, 1058
|
896, 907
|
8698, 9085
|
185, 563
|
1564, 3200
|
586, 872
|
1075, 1161
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,028
| 106,691
|
36894
|
Discharge summary
|
report
|
Admission Date: [**2183-6-26**] Discharge Date: [**2183-7-14**]
Date of Birth: [**2135-3-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2183-7-2**]
PROCEDURES:
1. Open reduction internal fixation of bilateral maxillary
Lefort
I fracture with multiple approaches
2. Open reduction internal fixation of right orbital floor blow
out fracture with titanium plate.
3. Open reduction internal fixation of nasoorbitoethmoid
fracture
4. Open reduction internal fixation of nasal fracture
5. Open reduction internal fixation of nasomaxillary complex
fracture, Lefort II, right with multiple approaches.
6. Complex layerered closure laceration, nasal dorsum
[**2183-7-2**]
Tracheostomy
[**2183-7-8**]
1. Posterior cervicothoracic arthrodesis, C5 to T1.
2. Instrumentation, posterior, C5 to T1.
3. C7 and C6 laminectomy.
4. T1 laminotomy.
5. Open reduction of fracture-dislocation.
6. Application of local autograft.
7. Application of allograft for fusion augmentation.
History of Present Illness:
48 F s/p fall down 13 stairs at home sustaining significant
facial trauma; +EtOH. Intubated for airway protection because
due to combativeness. Transported to [**Hospital1 18**] for further care.
Past Medical History:
HTN, psoriasis
Social History:
Alcoholism
Family History:
Noncontributory
Physical Exam:
PE: (in ICU)
On exam, the patient is intubated and sedated. She reveals a 4
x
3 cm stellate laceration over her nasal bridge with exposed bone
and muscle. She has a 4 cm transverse subciliary laceration
down
to muscle. The patient has a full thickness partial avulsion of
[**12-28**] to [**12-27**] of her right upper lip. The patient demonstrates
bilateral peri-orbital ecchymosis. No facial step offs. Bony
instability at nasal bridge. No nasal septal hematoma.
Significant intra-oral lesions associated with partial avulsion
of upper lip. Edentulous. Midface instability noted.
Pertinent Results:
[**2183-6-26**] 11:37PM TYPE-ART PO2-149* PCO2-47* PH-7.40 TOTAL
CO2-30 BASE XS-3
[**2183-6-26**] 11:37PM LACTATE-0.7 K+-3.4*
[**2183-6-26**] 07:34AM GLUCOSE-113* UREA N-8 CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14
[**2183-6-26**] 07:34AM ALT(SGPT)-35 AST(SGOT)-58* ALK PHOS-61 TOT
BILI-0.3
[**2183-6-26**] 07:34AM LIPASE-107*
[**2183-6-26**] 07:34AM PT-11.4 PTT-26.2 INR(PT)-0.9
[**2183-6-26**] 04:56AM WBC-18.2* RBC-3.50* HGB-12.3 HCT-35.7*
MCV-102* MCH-35.2* MCHC-34.5 RDW-12.2
[**2183-6-26**] 04:56AM PLT COUNT-276
CT Head [**2183-6-26**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Extensive midface trauma detailed in the separately reported
CT of the
facial bones and paranasal sinuses.
CT c-spine [**2183-6-26**]
IMPRESSION: Fracture of the posterior elements of C6. No acute
cervical
spine malalignment.
CT Sinus/Mandible [**2183-7-3**]
IMPRESSION: Status post repair of bilateral Le Fort I fractures
and right Le [**Location 56204**] fracture. High-density fluid within all the
paranasal sinuses
consistent with blood. Proptosis of the right eye when compared
to the left with no evidence of retrobulbar hemorrhage, and
intact globe and lens.
Repeat CT Sinus/Mandible [**2183-7-9**]
IMPRESSION: Essentially stable appearance status post repair of
bilateral Le Fort I and right Le [**Location 56204**] fractures, with
high-density fluid within
paranasal sinuses representing blood. Proptosis of the right eye
when
compared to the left continues, although there is slight
diminution of the
low-density fluid anterior to the right eye. No signs of an
infection are
demonstrated, though this (non-enhanced) study is certainly not
the most
sensitive method.
T-spine [**2183-7-12**]
FINDINGS: On the current study, there is some anterior
displacement of C4
with respect to C5 with slight angulation at this intervertebral
disc space. Minimal residual prominence of the anterior soft
tissues are seen. Posterior fusion device is again noted at C5
and T1.
Brief Hospital Course:
She was admitted to the Trauma service. Orthopedic Spine and
Plastic surgery were initially consulted. she was taken to the
operating room on [**7-2**] for repair of her multiple facial
fractures; a tracheostomy was also performed at that time by
Trauma Surgery. Postoperatively she was taken to the Trauma ICU
where she remained sedated and vented. On [**7-8**] she was taken to
the operating room by orthopedic spine surgery for stabilization
of her spine fractures. There were no intraoperative
complications. Postoperatively she remained in the Trauma ICU
and was eventually weaned from sedation and extubated. A
Dobbhoff was placed early on and tube feedings were initiated.
During her ICU stay she intermittently had high fever spikes and
was pan cultured. Infectious disease was consulted given the
leukocytosis and elevated lipase and amylase levels. It was felt
the fever spikes were secondary to acute pancreatitis which did
resolve and also because of sputum came back positive for
Klebsiella and she was started on a 10 day course of
Levofloxacin.
She was eventually transferred to the regular nursing unit where
her mental status slowly showed improvement. A Swallow
evaluation was done for which she initially failed. The Dobbhoff
remained and tube feeding continued until patient self removed
the Dobbhoff. A trial with oral diet was done for which she was
able to eat without any overt signs of aspirating. Her diet was
then upgraded t regular with supervision for all meals.
Her tracheostomy was downsized to a 6 french, fenestrated,
cuffless. She tolerated this without difficult.
She was evaluated by Physical and Occupational is being
recommended or acute rehab after her hospital stay.
Medications on Admission:
atenolol 50', lisinopril 10', HCTZ 12.5', hydroxizinge [**10-14**]
QHS
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-27**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units
Injection TID (3 times a day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-31**]
hours as needed for fever or pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours) as needed for constipation.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
13. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal DAILY
(Daily) as needed for constipation.
14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
s/p Fall
Multiple facial fractures - LeForte fracture
Right orbital fracture
Avulsion laceration right lip
T7 compression fracture
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Call your doctor or go to the ER if you experience any high
fevers, increased pain, or purulent drainage from your wounds.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma surgery for
evaluation of tracheostomy removal. Call [**Telephone/Fax (1) 6429**] for an
appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1007**], Orthoepdic Spine; call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks in Plastics surgery, call [**Telephone/Fax (1) 5343**] for
an appointment.
|
[
"873.20",
"870.8",
"873.43",
"401.9",
"802.6",
"577.0",
"291.81",
"E880.9",
"802.0",
"801.01",
"802.8",
"303.01",
"802.4",
"805.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.74",
"02.02",
"31.1",
"21.72",
"08.81",
"21.81",
"76.79",
"03.53",
"27.51",
"81.03",
"81.63",
"76.92"
] |
icd9pcs
|
[
[
[]
]
] |
7371, 7429
|
4144, 5856
|
323, 1153
|
7603, 7683
|
2103, 4121
|
7854, 8253
|
1460, 1477
|
5978, 7348
|
7450, 7582
|
5883, 5955
|
7707, 7831
|
1492, 2084
|
275, 285
|
1181, 1378
|
1400, 1416
|
1432, 1444
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,912
| 142,859
|
3514
|
Discharge summary
|
report
|
Admission Date: [**2189-3-14**] Discharge Date: [**2189-3-30**]
Date of Birth: [**2108-2-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Light-headedness
Major Surgical or Invasive Procedure:
[**3-23**] CABG x 4
History of Present Illness:
81yo F with a h/o HTN and hyperlipidemia, no significant h/o CAD
p/w pre-syncope. Pt was in her USOH until she awoke at 5am
feeling that she urgently needed to go to the bathroom to move
her bowels. Immediately when she touched the floor, she felt
light-headed and went to the ground. She does not remember what
she fell on, but denies LOC. No chest pain, mild shortness of
breath. No palpitations. She immediately got up and then went to
the bathroom and had a large volume loose stool. The stool was
coated with bright red blood from her known hemorrhoids. She
then went to her son's room (they live together) and he gave her
an aspirin and a klonopin (pt takes regularly for anxiety). No
prior syncopal episodes.
.
Of note, she hardly ever has chest pain. She occasionally has
substernal "soreness" when she lies down, that lasts for a brief
amount of time and then goes away on its own. She has a h/o
"heartburn" for which she takes Prevacid 10mg daily. She gets
"palpitations" occasionally, but also lasts for a short while
and goes away on its own, last time over a month ago. Nor
orthopnea/PND. Last Thursday, she cycled for 20 minutes without
getting winded. She says that she would get somewhat short of
breath after climbing up one flight of stairs, but not winded.
.
She does admit to poor PO intake over the last few weeks. For
Lent, she gave up lunch (3 days) and overall has been drinking
less fluids. She lost 30 lbs 2 years ago for hyperglycemia, but
then has gained it back over the last 2 years. She also has a
history of anxiety well controlled with klonopin 0.5mg daily
.
In the ED, a CT head was negative. CXR with no PNA. UA negative.
1st set negative. Not orthostatic in the ED. 2nd set of enzymes
positive with TropT 0.43, CK 230, MB 20. She was started on a
heparin drip and sent to the floor.
.
Currently she feels well. No chest pain, no dyspnea, no
palpitations. Feels a little anxious from the news.
.
Past Medical History:
Hypertension
Hyperlipidemia
Elevated Blood sugars, diet controlled in the past
Cervical Cancer s/p TAH
Hemorrhoids
Arthritis
Sciatica
Social History:
Significant for the absence of tobacco use. There is no history
of alcohol abuse or illicit drug use.
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
Blood pressure was 106/66 mm Hg while seated. Pulse was 92
beats/min and regular, respiratory rate was 20 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
no appreciable JVP. The carotid waveform was normal. There was
no thyromegaly. There were no chest wall deformities, scoliosis
or kyphosis. Of note there was reproducible chest pain at the
base of the sternum. The respirations were not labored and there
were no use of accessory muscles. The lungs were clear to
ascultation bilaterally with normal breath sounds and no
adventitial sounds or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There was a 2/6 systolic ejection
murmur heard only at the RUSB.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
[**2189-3-29**] 06:05AM BLOOD Hct-32.5*
[**2189-3-28**] 04:55AM BLOOD WBC-10.5 RBC-3.53*# Hgb-10.4*# Hct-29.5*#
MCV-84 MCH-29.4 MCHC-35.1* RDW-15.6* Plt Ct-403
[**2189-3-28**] 04:55AM BLOOD Plt Ct-403
[**2189-3-30**] 07:35AM BLOOD Glucose-139* UreaN-28* Creat-1.0 Na-139
K-4.4 Cl-104 HCO3-26 AnGap-13
CHEST, THREE VIEWS [**2189-3-27**]: Compared with [**2189-3-24**], there
are stable small bilateral pleural effusions. There is
persistent linear atelectasis in the right mid and lower lung
zones. There is persistent cardiomegaly and evidence of CABG.
There is no pneumothorax or new consolidation.
Echo [**2189-3-23**]:
Prebypass: No atrial septal defect is seen by 2D or color
Doppler. Left
ventricular wall thicknesses are normal. Overall left
ventricular systolic
function is normal (LVEF>55%). Right ventricular systolic
function is normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in
the descending thoracic aorta. Trace aortic regurgitation is
seen. The mitral
valve leaflets are structurally normal. Trivial mitral
regurgitation is seen.
Post Bypass: Preserved biventricular function. No new aortic or
valvular
abnormalities are observed.
Brief Hospital Course:
Cardiac catheterization on [**3-16**] showed LM and 3 vessel disease
and cardiac surgeyr was consulted. Carotid u/s showed < 40 %
stenosis bilaterally. Femoral u/s on [**3-20**] showed a stable
pseudoaneurysm.
She was taken to the operating room on [**2189-3-23**] where she
underwent a CABG x 4. She was transferred to the ICU in critical
but stable condition. She was extubated by POD #1. She was
weaned from her vasoactive drips and transferred to the floor on
POD #2. She was transfused 2 units PRBCs for a hematacrit of 21
with appropriate increase to 29. She other wise did well
postoperatively, and She was ready for discharge to rehab on POD
7.
Medications on Admission:
Klonipin 0.5mg qday
Prevacid 10mg daily
Norvasc 10mg qday
Lipitor 5mg qday
Vit D and calcium
ASA 81mg qday
Ibuprofen prn up to tid
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
8. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
[**Hospital1 **] (2 times a day) as needed for hemorrhoids.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
CAD, NSTEMI
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Elevated Blood sugars, diet controlled in the past
Cervical Cancer s/p TAH
Hemorrhoids
Arthritis
Sciatica
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
Remove sternal staples [**2189-4-13**].
Followup Instructions:
You should follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within the next
1-2 weeks. You can make an appointment at your convenience by
calling [**Telephone/Fax (1) 608**].
Dr. [**Last Name (STitle) 911**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2189-3-30**]
|
[
"414.01",
"455.8",
"285.9",
"401.9",
"410.71",
"272.0",
"997.2",
"112.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7524, 7594
|
5547, 6201
|
338, 360
|
7824, 7832
|
4337, 5524
|
8157, 8476
|
2614, 2696
|
6383, 7501
|
7615, 7615
|
6227, 6360
|
7856, 8134
|
2711, 4318
|
7667, 7803
|
282, 300
|
388, 2321
|
7634, 7646
|
2343, 2479
|
2495, 2598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
998
| 149,668
|
12864
|
Discharge summary
|
report
|
Admission Date: [**2153-10-7**] Discharge Date: [**2153-10-23**]
Date of Birth: [**2099-6-21**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Volume overload.
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old man
status post living-unrelated transplant [**2153-9-5**].
Transplant was difficult due to severe atherosclerotic
disease of aorta to iliac vessels. Postoperatively,
ultrasound demonstrated reasonable arterial flow, but the
renal vein was unable to be visualized. The patient was
brought back to the OR on [**2153-9-6**] for exploration of
kidney, which demonstrated no evidence of renal vein
thrombosis.
On [**2153-10-7**], the patient presented with increased
weight gain, lower extremity edema, nausea, vomiting. Patient
after postop course was remarkable for DGF (ATN) and the
patient reports making approximately 1100 cc of urine per
day. Creatinine and BUN have been relatively elevated, BUN in
the 90s, creatinine 4.0 postoperatively. Patient also reports
dysuria. Patient complains of shortness of breath, dizziness,
lightheadedness. The patient has approximately 3 loose bowel
movements per day. Decreased appetite but stable. Three pound
weight gain over the last few days. Lasix was increased
recently to 80 once daily without improvement. No
hemodialysis postoperatively.
PAST MEDICAL HISTORY: End-stage renal disease status post
living-unrelated transplant [**2153-9-5**] complicated by
poor arterial flow, status post exploration of kidney [**2153-9-6**], history of type 1 diabetes with complications,
complicated by retinopathy requiring bilateral laser surgery,
as well as right vitrectomy, history of neuropathy in both
hands and legs, history of CVA with some left-sided weakness,
history of CAD, history of MI on several occasions in the
past and 6 stents placed since [**2152-7-4**], history of PVD with
bilateral lower extremity bypass and toe amputation
bilaterally, status post myocardial infarctions, also has a
history of ejection fraction of 20%, GERD.
PAST SURGICAL HISTORY: Cholecystectomy, status post living-
unrelated renal transplant [**2153-9-5**], with exploration
of kidney on [**2153-9-6**], status post bilateral lower
extremity bypass, status post toe amputation bilaterally,
status post placement of 6 cardiac stents in [**2152**].
MEDICATION ON ADMISSION: Tacrolimus 2 and 2, MMF 500 q.i.d.,
Valcyte 450 every other day, Bactrim SS 1 tab once daily,
nystatin S and S 5 cc p.o. q.i.d., Protonix 40 mg once daily,
Colace 100 mg b.i.d., Toprol XL 25 mg once daily, Lasix 40 mg
once daily, PhosLo tabs, Plavix 75 once daily, rapamycin 2 mg
once daily.
ALLERGIES: Ativan and nonsteroidal anti-inflammatory drugs.
PHYSICAL EXAM: Temperature 96.8, heart rate 80, 114/68, 96
room air. No acute distress, awake, alert, oriented x3.
Cranial nerves grossly intact. CV regular rate and rhythm.
Lungs: Decreased breath sounds at bilateral base, right
greater than left. Abdomen: Well-healed incision, soft,
nontender, nondistended. Extremities: [**4-6**]+ pitting edema.
LABS ON ADMISSION: The patient had a WBC of 1.9, hematocrit
of 33.2, PT of 13.9, PTT 27.8, platelets 240, sodium 129, K
4.2, chloride 91, bicarbonate 24, BUN and creatinine 81 and
4.1, glucose 230.
HOSPITAL COURSE: So, the patient was admitted. Renal was
consulted. Patient was given IV Lasix. Plan was discussed
with Dr. [**Last Name (STitle) **]. Chest x-ray obtained on [**2153-10-7**]
demonstrating failure with bilateral effusions consistent
with fluid overload. On [**2153-10-8**], an ultrasound was
obtained of the kidney, duplex ultrasound, demonstrating
normal appearance of the renal transplant with normal
resistive indices ranging from 0.60 to 0.69, and also comment
about bilateral pleural effusions.
Patient went to ultrafiltration on [**2153-10-7**]. Patient
does have a left AV fistula which ultrafiltration was
performed through that. A 2-D echo was performed on [**2153-10-9**] demonstrating ejection fraction less than 20%,
compared with prior study that was reviewed on [**2152-6-27**].
Right ventricle is now dilated with freewall hypokinesis, and
the estimated pulmonary artery systolic pressure has
increased. Severity of mitral regurg and pulmonary artery
hypotension are also increased.
The patient continued with tacrolimus, rapamycin, MMF,
Valcyte. Cardiology was consulted. Cardiology met with
patient and felt that patient should be on aspirin, Plavix.
Suggested adjustment changes to medications. Agreed with 80
mg of IV Lasix for goal weight to be -1 to 2 liters. Wound
care nurse met with patient on [**2153-10-9**] because of
sacral pressure ulcers, in which the patient had a right
gluteal, left gluteal pressure ulcer, and made
recommendations in regards to dressing changes. A right foot
x-ray was obtained because of a right heel ulcer,
demonstrating that there was no radiologic evidence of
osteomyelitis.
On [**2153-10-11**], a right-sided ultrasound-guided
thoracentesis performed by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **], in which
they removed 1300 cc of clear serosanguineous fluid. There
were no complications. During hospitalization, patient had
CMV viral load sent off which demonstrated that CMV-DNA was
not detected. On [**2153-10-11**], the patient had a cardiac
cath performed demonstrating baseline moderate-severe
elevation in right heart pressures with low cardiac index.
With dopamine infusion, no change in PCX and PA pressures, or
systolic blood pressure, with progressive increase in cardiac
index. A right HT left in place for continued hemodynamic
monitoring in the CCU with drug therapy.
So, the patient was on the cardiac service for monitoring,
and transplant saw the patient daily and also managed his
immune suppressant medications. Wound care frequently saw
patient for his decubitus pressure ulcers on his gluteus and
right heel. Infectious disease was consulted because of
fevers, and blood cultures were sent on [**2153-10-14**],
in which a blood culture, sputum culture and urine culture
were sent off, as well as a catheter-tip from PA line. All
were unremarkable except for blood culture on [**2153-10-14**] demonstrating Pseudomonas aeruginosa. The patient was
placed on Flagyl, Zosyn, vancomycin on [**2153-10-15**],
after he had a temperature and ID made recommendations. The
patient started having diarrhea, so C. diff was sent off
demonstrating no C. diff, no ova and parasites on [**2153-10-16**]. Repeat CMV viral load was obtained demonstrating
not detected.
Podiatry came to see patient on [**2153-10-16**] for his
right heel ulcer. Physical therapy/ occupational therapy saw
patient and were consulted. On [**2153-10-16**], patient
had ultrafiltration through his left upper extremity fistula.
He tolerated the procedure well. The patient was changed from
multiple antibiotics to meropenem, continued on Lasix.
Patient had repeat blood cultures on [**2153-10-17**] which
demonstrated no growth. On [**2153-10-19**], urine culture
obtained demonstrated no growth as well. Patient continued on
ultrafiltration on [**2153-10-17**]. Also, patient had
ultrafiltration on [**2153-10-19**], in which 1.5 L of
fluid removed. Patient's Lasix drip was discontinued on
[**2153-10-19**]. Patient was started on Epogen for anemia.
Patient was transferred from cardiac service to transplant
service on [**2153-10-21**], since patient was stable from
a cardiac standpoint, but cardiology was still continuing to
see patient. On [**2153-10-23**], the patient had a PICC
line placed for IV antibiotics, and also had his
ultrafiltration as well. Serial chest x-rays demonstrated
improved CHF. On [**2153-10-23**], placement of PICC line
demonstrates that there was more slightly prominent right
pleural effusion, satisfactory position to right-sided PICC
line, and this film was compared to a previous film. Question
whether or not it was due to position, but because patient
had very good saturations of 96-97% on room air, that
clinically patient had no new findings of shortness of
breath, chest pain which he did not require any oxygen, Dr.
[**Last Name (STitle) **] felt safely with confidence that the patient could go
home. Patient was transitioned from FK to rapamycin while
patient was an inpatient, and since the patient has been
here, he has been on a single dose of rapamycin 6 mg once
daily. Levels range from 7.3 to [**10-23**] which was 10.9.
So, even though patient was deconditioned and physical
therapy thought he should go to rehab, his wife who is an ICU
nurse felt strongly that she could take care of him with
services at home. So, the patient was discharged to home with
services on the following medications: tamsulosin 0.4 mg at
bedtime, calcium acetate 667--2 tabs t.i.d. with meals,
Bactrim SS 1 tab once daily, Protonix 40 mg q. 24, aspirin
325 mg once daily, Tylenol 325--1-2 tablets q. [**5-9**] h. p.r.n.,
Plavix 75 mg once daily, MMF 250 b.i.d., Ambien 1 mg at
bedtime, Valcyte 450 every other day, Epogen 4000 units q.
Monday, Wednesday and Friday, B-Complex, Vitamin C, folic
acid, isosorbide 1 tablet t.i.d., nystatin 10 mL p.o. q.i.d.,
tacrolimus 6 mg once daily, metolazone 10 mg once daily,
bumetanide 3 mg b.i.d., Aldactone 25 mg once daily, also
meropenem 500 mg q. 12 for 2 days, and ciprofloxacin 500 mg
once daily x4 days. Patient will also be on an insulin fixed
dose of 5 units of NPH for breakfast and 4 units for dinner,
and also sliding scale.
Patient has a [**Hospital 39569**] hospital bed at home. Patient has
PICC line care, IV pole pump, saline flushes, heparin
flushes. Physical activity can be weightbearing. The patient
is follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] next week.
Call [**Telephone/Fax (1) 673**] for an appointment. Patient should follow-
up with Dr. [**First Name (STitle) 1075**] which is his cardiologist in [**Location (un) 47**].
Patient should have wound care to his gluteal area and to his
right heel with DuoDerm gel and Aloe [**Doctor First Name **] ointment to his
heel with protective gauze. The patient should follow-up with
his podiatrist in [**Location (un) 47**] as soon as possible for an
appointment. Also, patient's wife should call Dr. [**Last Name (STitle) **]
this Friday for record of his weight since being home and
report that Dr. [**Last Name (STitle) **] by calling [**Telephone/Fax (1) 673**].
FINAL DIAGNOSES: A 54-year-old status post living-unrelated
transplant with congestive heart failure/fluid overload.
MAJOR SURGICAL PROCEDURES:
1. Cardiac catheterization to evaluate pulmonary pressures.
2. Peripherally inserted central catheter line placement for
bacteremia, specific organism Pseudomonas aeruginosa.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2153-10-24**] 11:36:49
T: [**2153-10-24**] 12:58:48
Job#: [**Job Number 39570**]
|
[
"250.61",
"V45.82",
"428.21",
"V49.72",
"790.7",
"V58.67",
"424.0",
"707.07",
"996.81",
"041.7",
"588.81",
"414.01",
"357.2",
"707.05",
"787.91",
"403.91",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.91",
"39.95",
"38.93",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
3279, 10389
|
2058, 2339
|
2725, 3066
|
10407, 10954
|
173, 191
|
220, 1336
|
3081, 3261
|
1359, 2034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,460
| 197,513
|
32340
|
Discharge summary
|
report
|
Admission Date: [**2165-1-14**] Discharge Date: [**2165-1-18**]
Date of Birth: [**2143-1-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
n/v/d
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 21 year-old female with a history of IDDM who presents
with 5 day hx of nausea, vomiting, diarrhea, frequent. The
patient reports that she has had poor control of her glucose
levels for the last 8 months and for this reason has started
seeing an endocrinologist last week (per patient saw someone in
[**Last Name (un) **]). She reports having worsening glucose control (FS
200-500) at home until this AM when her glucose levels were
unreadable (HIGH). Her nausea, vomiting and diarrhea started on
wednesday and improved somewhat on Friday. She worsened again on
Sat/Sunday with increasing nausea and vomiting.
.
In the ED, inital vitals were 116/98 rr 18 98% RA. Exam
unremarkable, mildly somnolent. IVF- 2L. 5U humalog was given
and was started on an insulin gtt. UCG was negative.
.
ROS: The patient denies any fevers, chills, weight change
constipation, melena, hematochezia, chest pain, shortness of
breath, orthopnea, PND, lower extremity edema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
Type I diabetes diagnosed at age 4, never had DKA per patient,
on insulin pump for the last 7 years
Social History:
College student at BU, studying business and will graduate this
year. Working now as an intern at the prudential. Does not smoke
and drinks 2-3 glasses wine/week.
Family History:
Mother with thyroid cancer, diabetes
Physical Exam:
Physical Examination
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, no thyromegaly or
nodular thyroid
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: rrr, (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Tender: throughout, but RUQ most tender
Extremities: Right: Absent, Left: Absent
Skin: Not assessed, No Rash:
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
==========
Labs
==========
[**2165-1-16**] 05:25AM BLOOD WBC-9.2 RBC-4.15* Hgb-12.9 Hct-36.7
MCV-88 MCH-31.0 MCHC-35.0 RDW-13.7 Plt Ct-331
[**2165-1-15**] 09:44AM BLOOD WBC-10.1 RBC-3.70* Hgb-11.6* Hct-33.2*
MCV-90 MCH-31.4 MCHC-35.0 RDW-13.5 Plt Ct-319
[**2165-1-15**] 12:57AM BLOOD WBC-11.0 RBC-3.92* Hgb-12.4 Hct-35.6*
MCV-91 MCH-31.7 MCHC-35.0 RDW-13.4 Plt Ct-334
[**2165-1-14**] 11:35AM BLOOD WBC-15.1* RBC-4.56 Hgb-14.3 Hct-42.6
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.1 Plt Ct-387
[**2165-1-14**] 11:35AM BLOOD Neuts-84.6* Lymphs-11.5* Monos-3.3
Eos-0.3 Baso-0.3
[**2165-1-16**] 05:25AM BLOOD Glucose-82 UreaN-3* Creat-0.7 Na-138
K-3.2* Cl-108 HCO3-21* AnGap-12
[**2165-1-15**] 09:51PM BLOOD Glucose-98 UreaN-3* Creat-0.7 Na-140
K-3.2* Cl-111* HCO3-22 AnGap-10
[**2165-1-15**] 02:03PM BLOOD Glucose-200* UreaN-4* Creat-0.7 Na-140
K-4.4 Cl-111* HCO3-18* AnGap-15
[**2165-1-15**] 09:44AM BLOOD Glucose-130* UreaN-5* Creat-0.7 Na-138
K-3.7 Cl-110* HCO3-16* AnGap-16
[**2165-1-15**] 05:23AM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-139
K-3.6 Cl-111* HCO3-18* AnGap-14
[**2165-1-15**] 12:57AM BLOOD Glucose-188* UreaN-8 Creat-0.8 Na-134
K-3.5 Cl-107 HCO3-17* AnGap-14
[**2165-1-14**] 04:50PM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-142
K-4.5 Cl-109* HCO3-13* AnGap-25*
[**2165-1-14**] 11:35AM BLOOD Glucose-277* UreaN-17 Creat-1.1 Na-140
K-4.7 Cl-100 HCO3-11* AnGap-34*
[**2165-1-14**] 09:17PM BLOOD Amylase-390*
[**2165-1-14**] 04:50PM BLOOD ALT-37 AST-32 AlkPhos-126*
[**2165-1-14**] 11:35AM BLOOD ALT-45* AST-39 AlkPhos-152* TotBili-0.2
[**2165-1-14**] 09:17PM BLOOD Lipase-1416*
[**2165-1-14**] 04:50PM BLOOD Lipase-1209*
[**2165-1-14**] 11:35AM BLOOD Lipase-139*
[**2165-1-14**] 04:50PM BLOOD TSH-0.26*
===========
Radiology
===========
CT A/p [**1-14**] - Uncomplicated pancreatitis with mild fat
stranding around the tail of the pancreas.
CXR [**1-14**] - The heart is normal in size and there is no vascular
congestion or pleural effusion. No convincing evidence of acute
focal pneumonia.
Brief Hospital Course:
This a 21 year old man with diabetes who presented with 5 days
of nausea, vomiting and DKA.
#Diabetic ketoacidosis: Likely [**3-3**] to insulin pump malfuction.
Pt volume resuscitated in the ICU and started on Insulin gtt.
Remained on insulin gtt until Bicarbonate was 20. At that time,
with the help of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult, patient was started on Lantus
40 Units and restarted on her insulin pump. Due to a problem
with the site of the patient's insulin pump, BS trended up to
400 after pump was restarted and was placed back on an IV gtt of
Insulin on hd #2. She did not re-develop an anion gap, and was
placed back on her insulin pump on hd #3. Urine ketones trended
down and AG trended down to 10. However, there was a problem a
problem with the pump on HD #3 and the decision was made to
obtain a new pump. The patient was discharged on Lantus and
Humalog SS based on carbohydrate intake with the plan to
reinitiate the pump when a new one is obtained. She will follow
up with the [**Hospital **] clinic as an outpatient.
# Hematemesis: No vomiting after admission; nausea improved and
Hct was stable. Likely small esophageal tear from several days
of vomiting.
# Lipase elevation: CT scan a/p consistent with mild
pancreatitis. Elevated enzymes may be related to DKA process,
and trended down.
# Pneumonia: There was a question of a RLL opacity on CXR on
admission, but given low index of suspicion for pna , antibx
were stopped on hd #3. Patient had no fevers, sputum or
leukocytosis. Received 3 days of azithromycin.
Medications on Admission:
Humalog pump
Discharge Medications:
1. Lantus 100 unit/mL Cartridge Sig: Forty (40) Units
Subcutaneous once a day: Please continue until your obtain your
new insulin pump .
Disp:*1 bottle* Refills:*2*
2. Humalog 100 unit/mL Cartridge Sig: One (1) Unit Subcutaneous
with meals: Please use 1 unit for 5 g of carbs. Correction goal
to 125 .
Disp:*1 cartridge* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Diabetes
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] with diabetic ketoacidosis. You were
started on an insulin drip and your acidosis improve. You were
transitioned to your insulin pump, but your sugars remained
elevated. This was thought to be secondary to a problem with
your pump. You were started on subcutaneous insulin and your
sugars improved. Until you obtain a new pump, please take Lantus
40 units in the morning and Humalog with meals as directed by
your Endocrinologist.
.
You also had a CT scan of your abdomen that showed mild
pancreatitis.
.
You were given 3 days of antibiotics for a Chest x ray that was
suspicious for pneumonia. You had no other signs of symptoms of
pneumonia so these antibiotics were stoppped.
.
Please follow up with your Endocrinologist at your earliest
convenience.
.
Please seek immediate medical care if you experience chest pain,
dizziness, persistent elevated blood sugars, light headedness or
any other change from your baseline health status.
Followup Instructions:
Please follow up with you endocrinologist at the [**Hospital **] clinic.
Completed by:[**2165-1-18**]
|
[
"577.0",
"250.13",
"530.7",
"996.57",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6587, 6593
|
4580, 6165
|
321, 327
|
6649, 6668
|
2559, 4557
|
7693, 7797
|
1782, 1820
|
6228, 6564
|
6614, 6628
|
6191, 6205
|
6692, 7670
|
1835, 2540
|
276, 283
|
355, 1463
|
1485, 1586
|
1602, 1766
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,216
| 125,531
|
23775
|
Discharge summary
|
report
|
Admission Date: [**2198-5-26**] Discharge Date: [**2198-6-1**]
Date of Birth: [**2170-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
N/V
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
28 yo M with h/o DM, severe gastroparesis s/p gastric pacer and
Botox therapy, who presented to ED with nausea & vomiting x 4
days, acutely worse x 1 day. Emesis was clear. No hematemesis.
No F/C/S. No abdominal pain, diarrhea, or constipation. He feels
that this is similar to his prior episodes. Of note, pt has been
admitted multiple times for N/V related to gastroparesis, most
recently in [**2198-3-7**]. During that admission, pt also reported
coffee ground emesis and underwent EGD, which revealed
esophagitis but no other obvious pathology.
In ED, he received IVF and promethazine x2 for nausea.
Reportedly guaiac negative in ED. Had onset of coffee-ground
emesis x 1, Hct stable.
Past Medical History:
-Type 1 Diabetes Mellitus: diagnosed at age 2, c/b retinopathy.
blind in left eye, very poor visual acuity in right eye.
-Chronic renal insufficency: baseline Cr ~ 1.6-2; + proteinuria
-Gastroparesis: since [**2194**]. Received Botox injection to the
pylorus in 3/[**2197**]. s/p Gastric stimulator placed on [**2197-11-10**].
Flare regimen includes reglan, Zelnorm, phenergan, compazine,
anzemet, and IV erythromycin
-h/o hypoglycemic seizure
-Hypertension
-Migraines
-Depression
-Anemia
Social History:
Patient lives with his wife who is very dedicated to his care.
Denies tobacco, alcohol, and illicit drug use. He is currently
unemployed and on disability.
Family History:
Paternal grandfather with [**Name (NI) 59282**]
Mother and sister with thyroid disease
Physical Exam:
-VS: T 99.2 P 88 BP 170/100 RR 22 O2 98% RA
-Gen: very uncomfortable-appearing M, vomiting coffee-ground
emesis intermittently
-HEENT: EOMI. OP clear with dry MM
-Neck: no lymphadenopathy
-Heart: nl S1?S2, no murmurs
-Lungs: CTAB
-Abdom: soft, non-tender, non-distended, positive BS
-Extrem: no edema, warm
-Neuro/Psych: alert, oriented
Pertinent Results:
[**2198-5-26**] 03:10PM WBC-7.0 RBC-4.17* HGB-11.2*# HCT-32.3*#
MCV-78* MCH-26.8* MCHC-34.6 RDW-12.9
[**2198-5-26**] 03:10PM NEUTS-66.5 LYMPHS-22.8 MONOS-6.3 EOS-3.4
BASOS-0.9
[**2198-5-26**] 03:10PM PLT COUNT-354
[**2198-5-26**] 03:10PM CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-2.2
[**2198-5-26**] 09:20PM HCT-29.7*
[**2198-5-26**] 09:20PM HCT-29.7*
[**2198-5-26**] 09:20PM MAGNESIUM-2.1
[**2198-5-26**] 09:20PM GLUCOSE-379* UREA N-20 CREAT-2.0* SODIUM-138
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19
.
EKG: [**2198-5-29**] ST @ 130 bpm, nl axis, nl intervalsno acute STTW
changes
.
Micro:
ucx [**5-29**] (-), [**5-28**] (-)
bcx [**5-28**] pending
bcx [**6-1**]: [**1-8**] bottle of CNSA
.
Radiology
[**5-31**] RUE U/S (-) DVT
[**5-29**] bilateral LENI (-) DVT
[**5-28**] CXR AP: no acute cardiopulmonary process
[**5-28**] KUB: No obstruction
Brief Hospital Course:
This is a 28 yo M with history of DM I, gastroparesis, HTN, and
CRI who presented with gastoparesis flare, hyperglycemia, and
coffee-ground emesis. For his gastroparesis he was maintained
on erythromycin IV Q8 hours, Anzemet, Reglan, Compazine,
Phenergan, and Tegaserod. He received aggressive IV fluid
hydration, with improvement of his creatinine. He was initially
kept NPO but his diet was advanced as tolerated. On discharge
he was tolerating a regular diabetic diet.
.
For his coffee-ground emesis, GI evaluated the patient and did
not recommend scope. He had no further episodes of coffee
ground emesis and his HCT remained stable. Of note, the patient
is a Jehovah's witness & refused blood transfusion.
.
On the floor his course was notable for uncontrollable blood
sugars (300-500, although minimal anion gap), necessitating
transfer to the ICU for insulin drip on [**2198-5-28**]. On [**5-30**] he was
transitioned of the insulin gtt and given [**1-8**] his home dose of
glargine. Given poor PO, he required a D5 1/2 NS gtt, which was
d/c'd [**5-31**]. [**Last Name (un) **] consulted and recommended continuing his home
lantus dose.
.
His ICU course was also notable for low grade fevers and
leukocytosis; CXR and bilateral LENIs were negative. Blood
cultures were drawn off a PICC line and grew [**1-8**] coag-negative
Staph Aureus on the day after discharge. The PICC line had been
discontinued on discharge. The patient was called by the
Hospitalist Attending on call and instructed to return to
hospital if he became symptomatic. He will need surveillance
cultures drawn through his PCP's office.
.
Finally, despite significant volume resuscitation the patient
continued to have sinus tachycardia. He reported that this was
his baseline. He was advised to discuss this with his PCP.
Medications on Admission:
omeprazole 20 QD
nortriptyline 10 QHS
Tegaserod 6 mg [**Hospital1 **]
Promethazine 25 mg PO Q6H
Metoclopramide 10 mg PO Q6H:prn
Lantus 25 units SC qhs
Insulin Lispro SC q6h as needed
Valsartan 80 mg [**Hospital1 **]
Discharge Medications:
1. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED).
7. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime: Please take at 4:30 pm tomorrow
(Sat), 6 pm on Sun, 7:30 on Mon, and 9:00 on Tuesday.
8. Promethazine 25 mg Tablet Sig: One (1) Tablet PO four times a
day as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
10. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
gastroparesis
insulin dependent diabetes mellitus
gastritis
hypertension
anemia
tachycardia
Discharge Condition:
good, blood sugars under reasonable control, tolerating po
Discharge Instructions:
Please contact your physician or present to the ER if you
experience recurrent vomiting, diarrhea, blood in your stools,
elevation of your blood sugars or other concerns.
.
Please take all your medications as directed. Your lantus dose
should be taken at 4:30 pm on Saturday, 6:00 pm Sunday, 7:30 pm
Monday, and 9:00 pm Tuesday.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3617**] on [**6-7**] at 8 am.
.
Please follow-up with Dr [**Last Name (STitle) **] within 2 weeks at
[**Telephone/Fax (1) 60706**]. You should discuss your elevated heart rate with
him.
.
Please follow-up with Dr [**First Name (STitle) 679**] within 2 weeks at [**Telephone/Fax (1) **].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"536.3",
"285.9",
"585.9",
"V58.67",
"401.9",
"535.50",
"427.89",
"311",
"250.53",
"578.0",
"362.01",
"250.63",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6157, 6163
|
3122, 4935
|
317, 338
|
6298, 6358
|
2231, 3099
|
6736, 7188
|
1761, 1850
|
5201, 6134
|
6184, 6277
|
4961, 5178
|
6382, 6713
|
1865, 2212
|
274, 279
|
366, 1057
|
1079, 1571
|
1587, 1745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,678
| 190,433
|
46202
|
Discharge summary
|
report
|
Admission Date: [**2132-1-24**] Discharge Date: [**2132-1-25**]
Date of Birth: [**2055-7-21**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / PhosLo
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Nausea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 76-year-old woman with a history signficant for
insulin dependent DM, Stage IV CKD not on dialysis, s/p
splenectomy presented to the emergency department with nausea
and vomiting that began acutely this AM. States the vomiting was
non-bloody/non-bilious was followed by abdominal pain, which is
diffuse and cramping. She states that her last bowel movement
was 2 days ago, but that this is typical for her. She continues
to pass gas and reports no sensation of abdominal distension.
She denies fevers/chills, denies dysuria, and reports no sick
contacts or recent travel.
.
In the ED, initial VS were: T 97.0, p 131, bp 221/86, r 20,
100%RA.
On examination, she was found to have diffuse tenderness to
palpation without guarding or rebound, and was found to be guiac
negative per rectum. Her EKG demonstrated sinus tachycardia at
126, LAD, NI, TWF in AVF, TWI 1 and AVL (new compared to prior).
She received 10mg IV metoprolol as well as 100mg labetalol
without significant change in her blood pressure or tachycardia.
Her labs were notable for a lactate level of 2.2. She was given
vancomycin and zosyn empirically, and her lactate decreased to
1.6 after 3L of IV fluids. She had one episode of nb/nb emesis,
but responded well to zofran. A CT abdomen and pelvis suggested
of early or mild pancreatitis; however, her lipase was not
elevated. There was no evidence of bowel obstruction, with
moderate fecal loading. She was subsequently evaluated by the
surgical service, who judged her abdominal exam to be benign,
and ruled that she did not have any acute surgical issues.
Shortly after ingesting PO contrast, the patient developed an
area of urticaria on her upper back. This area diminished in
size and became less pruritic throughout the course of her ED
stay.
.
On arrival to the MICU, her vital signs were T 99.0, P 137, BP
224/88, R 20 SO2 100%RA. She states that she is resting
comfortably, with mild nausea but no abdominal pain.
Past Medical History:
PMH:
HTN
DM II, recently started on insulin, w h/o DKA
Stage IV CKD secondary to diabetic nephropathy
Gout
Dyslipidemia
Secondary hyperparathyroidism
Anemia
L Papillary renal cell carcinoma
Social History:
Denies EtOH, tobacco, illicits.
Family History:
Non-contributory.
Physical Exam:
Vitals: T: 99.0 BP: 211/82 P: 117 R: 14 O2: 100%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD; 5x3cm area of faint
erythema over left posterior neck/upper chest, not raised.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2132-1-24**] 08:03AM PLT COUNT-385
[**2132-1-24**] 08:03AM NEUTS-85.4* LYMPHS-10.9* MONOS-2.9 EOS-0.4
BASOS-0.4
[**2132-1-24**] 08:03AM WBC-20.2*# RBC-4.10* HGB-11.9* HCT-34.5*
MCV-84 MCH-28.9 MCHC-34.3 RDW-13.2
[**2132-1-24**] 08:03AM LIPASE-28
[**2132-1-24**] 08:03AM ALT(SGPT)-15 AST(SGOT)-23 ALK PHOS-159* TOT
BILI-0.3
[**2132-1-24**] 08:16AM LACTATE-2.2*
[**2132-1-24**] 12:03PM LACTATE-1.6
[**2132-1-24**] 07:12PM GLUCOSE-264* UREA N-66* CREAT-2.2* SODIUM-143
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-18
.
[**2132-1-24**]:
CT OF THE ABDOMEN: Limited evaluation of the lung bases displays
coronary
artery calcifications. The lungs are otherwise clear. No
concerning
pulmonary nodules or pleural or pericardial effusions are
present. The distal esophagus is mildly distended with oral
contrast material, suggesting reflux. A small hiatal hernia is
once again seen.
Evaluation of the solid intra-abdominal organs is limited
without IV contrast. The margins of the pancreas appear
somewhat blurry, with mild increase in peripancreatic stranding,
suggestive of early or mild pancreatitis. The liver,
gallbladder, adrenal glands, and bowel appear unremarkable as
compared to prior examinations. Patient is status post
splenectomy. Calcification in the posterior interpolar portion
of the left kidney is unchanged. Perinephric fat stranding
bilaterally is nonspecific. No free air, free fluid, or
pathologically enlarged lymph nodes are present. Atherosclerotic
calcifications are noted in the aorta and its branches.
CT OF THE PELVIS: Calcifications within the uterus is suggestive
of fibroids. The bladder is unremarkable. Multiple phleboliths
are seen. There is moderate amount of fecal loading in the colon
with a large fecal ball within the rectum. No free fluid, and no
pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No concerning sclerotic or lytic lesions are
seen.
IMPRESSION:
1. Findings suggestive of early or mild pancreatitis.
Correlation with serum amylase/lipase levels recommended.
2. No evidence of bowel obstruction. Moderate amount of fecal
loading within the colon and rectum.
.
[**2132-1-24**] KUB:
FINDINGS: There is no evidence of free air. The lung bases are
clear. The
osseous structures appear intact. Bowel gas pattern is
non-obstructive with stool in the colon, including within the
rectum. Phleboliths are seen along with vascular calcifications.
IMPRESSION: No evidence of free air or small bowel obstruction.
Moderate
amount of fecal loading.
Brief Hospital Course:
This is a 76-year-old woman with a history of IDDM, Stage IV CKD
not on dialysis, s/p splenectomy presents with nausea and
nonbloody-nonbilious vomiting for one day, with sinus
tachycardia and hypertension without evidence of end-organ
ischemia.
.
# NAUSEA/VOMITING: The patient's history and benign abdominal
exam was not suggestive of an acute abdominal process, and
instead was more consistent with a viral gastroenteritis. She
was responsive to zofran and fluid resuscitation. Her abdominal
discomfort improved without direct intervention.
.
# HYPERTENSION: The patient had similar hospital admissions in
the past with significantly elevated blood pressures without
evidence of end-organ ischemia. This does not appear to be a
hypertensive emergency, and [**Known lastname **] have been due to her inability
to take her home antihypertensives in the setting of her nausea
and vomiting. Notably, she is on clonidine 0.3 mg [**Hospital1 **], which [**Known lastname **]
cause reflex hypertension when withdrawn. Her blood pressure
was slowly reduced with IV labetalol, and her home
anti-hypertensives were restarted.
.
# SINUS TACHYCARDIA: Likely a sequelae of her inability to take
her home antihypertensives and possibly a stress response to
viral illness; her tachycardia improved steadily with labetalol
and with her home anti-hypertensives.
.
# DM: On glargine 15mg at home, blood sugars elevated to 260s
at the time of admission, likely in the setting of an acute
stress response with illness. Patient was continued on her home
dose of insulin. This can be uptrated by her PCP as needed.
.
# LEUKOCYTOSIS: Likely due to viral illness or stress response.
No bandemia and patient remained afebrile. CBC trended down
during admission.
.
# CKD: BUN and creatinine were elevated during admission
possibly in the setting of dehydration, though patient has an
unclear baseline. Her creatinine will be rechecked by her
primary care physician next week.
Medications on Admission:
ACARBOSE [PRECOSE] - 25 mg Tablet - 2 Tablet(s) PO TID
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) PO Qday
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) PO QD
CALCITRIOL - 0.25 mcg Capsule - 1 One Cap PO five days /week
CLONIDINE - 0.3 mg Tablet - 1 Tablet(s) PO BID
FEBUXOSTAT [ULORIC] - 40 mg Tablet - 1 tab PO QD
FUROSEMIDE - 80 mg Tablet - 1 (One) Tab PO QD
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 15 units
daily
LABETALOL - 100 mg Tablet - 1 tab po bid
LISINOPRIL - 40 mg Tablet - 1 tab po bid
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 2 tab po tid
with meals
ASCORBIC ACID - (OTC) - 500 mg Tablet - 1 Tab po qd with Iron
ASPIRIN [ASPIRIN [**Hospital1 **]] - 81 mg Tablet, Chewable - 1 tab PO
QD
CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 (One) Tablet(s)
by mouth three times a day with meals to bind phosphorus
Discharge Medications:
1. acarbose 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 5 days
weekly.
5. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
6. Uloric 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lantus 100 unit/mL Solution Sig: Fifteen (15) Subcutaneous
once a day.
9. labetalol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
10. lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO
three times a day.
12. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
14. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
15. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
16. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
17. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for indigestion.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroenteritis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 116**],
It was a pleasure taking care of you on this admission. You
came to the hospital because you were having nausea and
vomiting. You were found to have a high blood pressure because
you were unable to keep your medications down. With IV fluids
and anti-emetics, your symptoms improved. No changes were made
to your blood pressure medications. You will need to see your
PCP next week for a repeat of your blood work.
.
Return to the hospital if you develop chest pain, shortness of
breath, increased nausea, vomiting, diarrhea, fevers, chills, or
any other concerning signs or symptoms.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2132-1-29**] at 10:20 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2132-2-13**] at 10:20 AM
With: [**Doctor First Name **] FERN, RNC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2132-11-12**] at 10:00 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"403.90",
"272.4",
"583.81",
"250.40",
"585.4",
"276.51",
"274.9",
"427.89",
"V10.52",
"V58.67",
"588.81",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10031, 10037
|
5902, 7867
|
319, 325
|
10109, 10109
|
3359, 5879
|
10906, 11832
|
2583, 2602
|
8760, 10008
|
10058, 10088
|
7893, 8737
|
10259, 10883
|
2617, 3340
|
257, 281
|
353, 2305
|
10124, 10235
|
2327, 2518
|
2534, 2567
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
540
| 160,169
|
49139
|
Discharge summary
|
report
|
Admission Date: [**2151-2-1**] Discharge Date: [**2151-2-25**]
Date of Birth: [**2099-6-23**] Sex: M
Service: PLASTIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient was admitted [**2151-2-1**]
for elective hernia repair to be done via component
separation. The patient has a history of hypertension, sleep
apnea, and atrial fibrillation. He was admitted to the SSU
house staff on [**2151-2-1**] status post surgery, and received 4500
cc of lactated Ringer's and three units of packed red blood
cells. The patient was extubated postoperative and found to
be in rapid atrial fibrillation as high as 170. He had
episodic rapid afibribillation after surgery with his
colectomy done on [**2150-3-26**], which was treated with oral and
intravenous beta blockers. The patient also had asymptomatic
bradycardia at that time. He was recommended for pacemaker
placement by Cardiology, but this never occurred. He was
transferred to the Surgical Intensive Care Unit today for
postoperative management of right ventral hernia repair.
PAST MEDICAL HISTORY: Significant for hypertension, sleep
apnea, atrial fibrillation.
PAST SURGICAL HISTORY: Ileal bypass, colectomy, knee
arthroscopy, right hemicolectomy.
MEDICATIONS: Allopurinol, Lexapro, Lopressor, Accupril,
doxazosin, Protonix, [**Doctor First Name **], Coumadin.
ALLERGIES: Percocet, ..................
PHYSICAL EXAMINATION: The patient was lethargic, obese male,
complaining of painless cough. Vital signs: Temperature
97.3, heart rate 126 to 156, respiratory rate 14, blood
pressure 150/89, oxygen saturation 100% on 2 liters. Head,
eyes, ears, nose and throat: Extraocular movements intact,
pupils equal, round and reactive to light and accommodation,
nasogastric tube in place. Neck: Supple. Lungs: Clear to
auscultation bilaterally. Heart: Irregularly irregular,
tachycardia, S1 and S2. Abdominal binder in place.
[**Location (un) 1661**]-[**Location (un) 1662**] drain with serosanguinous output. Extremities:
No cyanosis, clubbing or edema. Neurologic: The patient is
alert and oriented x 3, moving all extremities.
LABORATORY DATA: White blood count 12, platelets 255.
Sodium 141, potassium 3.8, chloride 113, bicarbonate 19, BUN
10, creatinine 1.2, glucose 134. Magnesium 1.2.
HOSPITAL COURSE: The [**Hospital 228**] hospital course was
complicated. The delirium and agitation associated with
possible alcohol withdrawal were treated with Ativan and
Haldol, as well as prolonged intubation. On [**2-4**], Ativan
dose was revised. On [**2-4**], it was noted that the patient
was disoriented, also likely due to narcotics. Therefore,
narcotics were held until mental status was clear.
An electroencephalogram was checked to rule out hypercarbia
as a possibility. The patient's signs of alcohol withdrawal
were treated with oral librium, continued as needed Ativan as
per CIWA scale. On [**2-5**], arterial blood gas was normal.
The patient was noted to have increased output per his
[**Location (un) 1661**]-[**Location (un) 1662**] drains for the first few days post-surgery.
Large fluid output was noted on [**2-5**] at approximately
greater than 2 liters per day. Total parenteral nutrition
was started on [**2-5**], with continued fluid management as well.
The patient was continued on prolonged intubation on BiPAP.
Noted was a high [**Location (un) 1661**]-[**Location (un) 1662**] drain output, likely secondary
to significant abdominal wall lymphedema seen in the
operating room previously.
Meanwhile, for total parenteral nutrition use, the patient
was started on a regular insulin sliding scale. On [**2-8**],
hematocrit was noted to be stable, with electrolytes stable,
and INR was normalizing. It was still noted that source of
high [**Location (un) 1661**]-[**Location (un) 1662**] drain output was probably due to abdominal
wall lymphedema. Discontinue intravenous Ancef.
On [**2-10**], the patient was noted to be in improved mental
status. On [**2-10**], the patient was also noted to have
increased stable scrotal edema, for which elevation and
scrotal support were continued.
On [**2-11**], it was noted that small amounts of drainage from
the center left area of the transverse abdominal incision,
and persistent large amounts of scrotal edema. Also on [**2-11**], it was recommended that the patient would be discontinued
from total parenteral nutrition and continue tube feeds and a
pureed diet. Encourage ambulation and out of bed.
On [**2-12**], the abdominal wound had a central area of skin
necrosis, as well as turbid fluid drainage. This was
consistent with an abdominal midline incision dehiscence.
The patient was scheduled to go back to the operating room on
[**2-13**] for wound incision and drainage.
On [**2-13**], to address the infected abdominal wound, a
debridement, irrigation and washout, removal of mesh was
done, with subsequent VAC placement, as well as placement of
four new [**Location (un) 1661**]-[**Location (un) 1662**] drains, with old [**Location (un) 1661**]-[**Location (un) 1662**] drains
removed. Estimated blood loss was minimal, with a soft
tissue specimen sent for culture and pathology. There were
no complications during surgery.
Postoperatively, the patient was sent to the Post-Anesthesia
Care Unit intubated. The patient restarted total parenteral
nutrition as well as tube feeds. Zosyn was continued, with
serial cultures. Results of wound cultures showed
Enterococci as well as staphylococcus aureus. Cultures
showed +2 polys, +2 gram-positive cocci, +1 gram-positive
rods.
On [**2-15**], the patient was returned again for repeat
incision and drainage of the abdominal wound, as well as for
a VAC change. The patient was stable. The patient was
transferred back to the Intensive Care Unit. Repeat incision
and drainage was done for increase of necrotic tissue noted
in the wound. The patient had four VAC changes in total by
the time of discharge.
On [**2-16**], the patient had vacuum-assisted closure. He was
awake, alert, and oriented, interactive. On [**2-16**], it was
noted a Stage II sacral decubitus ulcer. Duoderm was
applied. The patient was kept off his back, with frequent
turning, optimal nutrition, and continued Duoderm dressings.
On [**2151-2-16**], the patient was also extubated without
complications, and the patient was transferred to the floor
on the same day, without complications, tolerating an oral
diet, as well as sufficient pain management.
On [**2-18**], Electrophysiology service was consulted
regarding the patient's episodes of atrial fibrillation and
bradycardia. They recommended pharmacologic therapy
including beta blocker (metoprolol). This was initiated.
The patient was sent back to the operating room for
vacuum-assisted closure change again, with no complications.
The patient continued to be followed by the Electrophysiology
fellow and staff. His digoxin was continued to be held
concerning frequent episodes of alternating tachyarrhythmias
and a bradycardia including a seven beat episode of
ventricular tachycardia at 11 p.m. on [**2-13**]. In the
meantime, the patient was able to ambulate out of bed,
followed closely by Physical Therapy. Pain was controlled
with oral dilaudid.
On [**2-20**], continued to taper total parenteral nutrition.
Caloric counts were obtained for adequate nutrition.
Recommended ambulation four times a day. Intravenous Zosyn
was continued. On [**2151-2-22**], the patient had another
vacuum-assisted closure apparatus change at the bedside.
[**Location (un) 1661**]-[**Location (un) 1662**] drains were still in place and draining.
On [**2-22**], discussed with EPS the possibility of
instituting a pacemaker for definitive management of
tachy/brady arrhythmia. On [**2-26**], one of the [**Location (un) 1661**]-[**Location (un) 1662**]
drains was pulled out mistakenly. It was decided that the
[**Location (un) 1661**]-[**Location (un) 1662**] drains did not need to be reinserted.
Electrocardiogram done on [**2-23**] showed mild left
ventricular systolic dysfunction, +3 mitral regurgitation,
and decreased left ejection fraction of 30 to 40%, down from
previously 55% in [**2150-3-25**].
On [**2-24**], it was noted that the patient was cleared for
procedure of VVI pacer implantation, which was successfully
performed without complications. The patient was continued
on intravenous antibiotics, a sling was placed on the left
arm, and head of the bed elevated 45 degrees. Metoprolol was
changed to 50 mg by mouth three times a day, Zestril 2.5 mg
by mouth once daily was added, as well as Digoxin 0.25 mg
once daily was added for noting of left ventricular systolic
dysfunction. Metoprolol was adjusted for prophylactic rate
control. Recommendation was that Coumadin could be restarted
on [**2151-2-24**], with heparin subcutaneously to be continued until
therapeutic INR could be reached.
The patient was screened for rehabilitation for [**Hospital3 6373**] Network.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: The patient will be discharged to
acute rehabilitation with telemetry services at [**Hospital6 19682**] Network on [**Hospital3 **].
DISCHARGE DIAGNOSIS:
1. Ventral hernia.
2. Status post hemicolectomy.
3. Incision and drainage, VAC changes.
4. Atrial fibrillation, tachy/brady syndrome
DISCHARGE MEDICATIONS:
1. Miconazole nitrate powder.
2. Albuterol sulfate 0.83 mg/ml inhalation every six hours
as needed for shortness of breath.
3. Heparin subcutaneously 5000 units every eight hours until
therapeutic INR of 2.3 is reached.
4. Acetaminophen 325 mg one to two tablets every four to six
hours as needed for pain.
5. Zosyn 4.5 mg vial one vial every six hours.
6. Dilaudid 2 to 4 mg one tablets by mouth every four to six
hours as needed for pain.
7. Lisinopril 2.5 mg by mouth once daily.
8. Metoprolol 50 mg by mouth three times a day.
9. Coumadin 7.5 mg by mouth daily at bedtime.
10. Protonix 40 mg by mouth once daily.
11. Digoxin 0.25 mg by mouth once daily.
Note: If the patient is not able to be given Zosyn, possible
to give Augmentin 500 mg by mouth three times a day.
DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], telephone number [**Telephone/Fax (1) 20278**], within one week,
and to call for an appointment.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], M.D. [**MD Number(1) 2648**]
Dictated By:[**Last Name (NamePattern1) 17322**]
MEDQUIST36
D: [**2151-2-25**] 09:39
T: [**2151-2-25**] 09:40
JOB#: [**Job Number 103099**]
cc:[**Numeric Identifier 103100**]
|
[
"707.0",
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"291.0",
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"780.57",
"427.1",
"427.31",
"998.59",
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] |
icd9cm
|
[
[
[]
]
] |
[
"53.61",
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"37.82",
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] |
icd9pcs
|
[
[
[]
]
] |
9042, 9176
|
9358, 10141
|
9197, 9335
|
2307, 8994
|
10166, 10714
|
1165, 1387
|
1410, 2289
|
9009, 9018
|
176, 1053
|
1076, 1141
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,846
| 180,471
|
35246
|
Discharge summary
|
report
|
Admission Date: [**2168-12-10**] Discharge Date: [**2168-12-12**]
Date of Birth: [**2104-6-24**] Sex: M
Service: MEDICINE
Allergies:
Optiray 300
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 64 year old male with metastatic melanoma on sutent,
Hx chemotherapy induced hypotension who presents with
hematemasis. The patient states that last night he felt
nauseasted, vomited food x3, then had vomting x2 with a small
amount of bright red blood followed by one emisis with darker
black material. He has not had any further vomiting since
approximately 11pm last night. He has not been lightheaded or
dizzy other than when blowing his nose. He denies any diarrhea
or melena in colostomy bag.
.
In ED, the patient had no further vomiting. On arrival to the
ED, his HCT was 30 which decreased to 27, from baseline 36-40.
He underwent NG lavage with 1.5 L NS, which showed mostly clear
liquid with a small amount of blood, no bile. GI was consulted
who recommended ICU admission and EGD. The patient received PPI,
2 PIV and T/S. In addition, there was an right infiltrate on
CXR, prescribed CTX and Azithromycin.
Vitals on arrival to ED: 98.2 95 132/88 18 100
Vitals on transfer: HR 90, BP 134/78, 20 98%RA
.
ROS:
(+)+ weight loss, + cough
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
PMH:
1. Metastatic Melanoma (lung, pleural, and liver)now on sutent
2. Hemorrhoid surgery that was complicated by sphincter damage
requiring diversion with a colostomy 30 years ago.
3. axillary LN dissection
4. Seasonal allergies.
5. Chemotherapy-induced HTN
6. thumb amputation
7. toe amputation because cyst infection
8. right side pleural effusion s/p Thoracentesis
.
PSurgH: Melanoma excision of his thumb, and hemorrhoid surgery
complicated by sphincter damage requiring colostomy 30 years
ago.
Social History:
Married, lives in [**Location **]. He worked as an electronics
technician. He never smoked cigarettes, drank alcohol, or used
illicit drugs.
Family History:
His mother died fo pancreatic cancer while his father had kidney
failure. He has 2 sisters, one of them has stage I breast
cancer, and a brother who contracted HCV from IVDA. He has one
daughter, who has thyroid cancer, and 3 sons who are all
healthy.
Physical Exam:
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: firm over liver, NT/ND, normoactive bowel sounds,
colostomy intact w/o bloody stool or melena
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l. absent left thumb
Skin: no rashes or lesions noted, no petechia
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
Pertinent Results:
[**2168-12-10**] 01:00PM PT-12.5 PTT-150* INR(PT)-1.1
[**2168-12-10**] 01:00PM PLT COUNT-189#
[**2168-12-10**] 01:00PM NEUTS-75.2* LYMPHS-21.8 MONOS-2.4 EOS-0.4
BASOS-0.2
[**2168-12-10**] 01:00PM WBC-2.7*# RBC-3.25* HGB-10.4* HCT-30.3*
MCV-93 MCH-32.1* MCHC-34.4 RDW-18.8*
[**2168-12-10**] 01:00PM CK-MB-NotDone cTropnT-<0.01
[**2168-12-10**] 01:00PM ALT(SGPT)-44* AST(SGOT)-86* CK(CPK)-62 ALK
PHOS-302* TOT BILI-1.5
[**2168-12-10**] 01:00PM estGFR-Using this
[**2168-12-10**] 01:00PM GLUCOSE-93 UREA N-17 CREAT-0.8 SODIUM-136
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-13
[**2168-12-10**] 01:04PM HGB-11.3* calcHCT-34
[**2168-12-10**] 03:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2168-12-10**] 03:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2168-12-10**] 03:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2168-12-10**] 04:45PM PLT COUNT-160
[**2168-12-10**] 04:45PM NEUTS-77.7* LYMPHS-18.1 MONOS-3.2 EOS-0.7
BASOS-0.2
[**2168-12-10**] 04:45PM WBC-2.2* RBC-2.96* HGB-9.5* HCT-27.8* MCV-94
MCH-32.2* MCHC-34.3 RDW-18.7*
[**2168-12-10**] 05:30PM PT-11.8 PTT-28.0 INR(PT)-1.0
Brief Hospital Course:
64 yo male w/ malignant melanoma on sutent therapy who presents
with UGIB s/p EGD that was significant for esophagitis who is
now being transferred from ICU to OMED.
.
The patient underwent EGD on [**2168-12-10**], which showed (1) erythema
and ulceration in the gastroesophageal junction compatible with
esophagitis, (2)small hiatal hernia, (3) Schatzki's ring, with
otherwise normal EGD to third part of the duodenum. He was
treated with PPI and carafate. His antihypertensive medications
were held. The patient remained hemodynamically stable.
Initially, the patient expressed a strong desire to avoid blood
transfusion. Patient was transferred to the floors, where he
remained otherwise hemodynamically stable. Prior to discharge
he was transfused two units of blood for a hct of 25. Patient
was discharge with instructions to follow up with his oncologist
regarding permanently discontinuing vs restarting his sutent
therapy.
Medications on Admission:
Sutent last dose [**12-6**], currently off for two weeks
AMLODIPINE 10 mg Tablet One Tablet(s) by mouth daily
CIMETIDINE 300 mg Tablet 1 (One) Tablet(s) by mouth every six
(6) hours as needed for heartburn And take one hour before Ct
Scans
CODEINE-GUAIFENESIN 100 mg-10 mg/5 mL Liquid - 10 ml by mouth
every six (6) hours as needed for cough
HYDROCHLOROTHIAZIDE 25 mg Tablet - one Tablet(s) by mouth daily
OXYCODONE 5 mg Capsule 1 Capsule(s) by mouth every 3 hours as
needed for as required for breakthrough pain
OXYCODONE 10 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by
mouth twice a day
OXYGEN 2 liters via nasal canula while a sleep and with exertion
Diagnosis: hypoxia secondary to lung metastasis and pleural
effusion
MAGNESIUM OXIDE 250 mg Tablet - 1 (One) Tablet(s) by mouth once
a day
MULTIVITAMIN
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO 3 hours as
needed for pain.
7. Magnesium Oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
8. OXYGEN 2 liters via nasal canula while a sleep and with
exertion
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Esophagitis
Anemia
Malignant Melanoma
Discharge Condition:
Stable
Discharge Instructions:
You were seen in the hospital because you vomited blood. You
underwent endoscopy that showed esophagitis. You remained
stable, but we found your hematocrit to be low. We transfused
you with 2 units of packed red blood cells.
We have made the following changes to your medications:
(1) We have switched your tagamet (cimetidine) to another
medication called pantoprazole which will protect the lining of
your esophagus and stomach.
(2) We have started you on a medication called sucralfate.
(3) We have stopped your amlodipine and hydrochlorothiazide.
Please follow up with your oncologist regarding whether you
should continue taking sutent.
If you should experience lightheaded, fevers, chills, vomiting
blood, falls, or any concerning symptoms please call your PCP or
return to the emergency room.
Followup Instructions:
Please follow up with your oncologist Dr. [**Last Name (STitle) 4151**] on [**2168-12-14**]
4:00pm at [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]. She will decide
whether you should continue to take sutent. She can also check
your blood pressure and see if you should restart your blood
pressure medications.
*** Please make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**] in
Gastroenterology. The number is ([**Telephone/Fax (1) 10499**].
Completed by:[**2168-12-14**]
|
[
"E933.1",
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icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7002, 7008
|
4403, 5339
|
284, 290
|
7099, 7108
|
3155, 4380
|
7962, 8501
|
2290, 2543
|
6202, 6979
|
7029, 7078
|
5365, 6179
|
7132, 7388
|
2558, 3056
|
7417, 7939
|
236, 246
|
318, 1593
|
3071, 3136
|
1615, 2116
|
2132, 2274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,337
| 174,597
|
40209
|
Discharge summary
|
report
|
Admission Date: [**2184-9-22**] Discharge Date: [**2184-10-1**]
Date of Birth: [**2130-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Ampicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram
Coronary Artery Bipass Graft x1(LIMA-LAD)
History of Present Illness:
Ms. [**Known lastname **] is a 53 female s/p stenting of the proximal LAD and
s/p V.fib arrest in 11/[**2182**]. She who presented today with
substernal chest pain. The patient reports that the pain began
at 8:30PM when she stood up in her kitchen. the pain was [**6-20**]
with radiation to the left arm, mild nausea and diaphoresis. She
took a SL NTG with minimal relief. She called EMS and received
another Nitro SL in transit.
In [**Hospital1 18**] ED, initial vital signs were 98.6, 80, 110/63, 16
and100%on RA. She was given an additional two NTG and Morphine
IV which resolved the pain. EKG shows new TWI in lead V2, no
other changes. Troponins (-). Placed in observation and
underwent nuclear scan that showed a reversible distal anterior
wall and apical perfusion defect.
Given the findings on the nuclear study, the patient underwent
catheterization that revealed an osteal lesion not amenable to
intervention. CT surgery was contact[**Name (NI) **] regarding surgical
intervention.
Past Medical History:
noninsulin dependent diabetes mellitus
Dyslipidemia
hypertension
S/p Cardiac Arrest [**10/2183**]
Social History:
4th grade teacher, remote smoking history. Quit 25 years ago,
smoking [**12-14**] ppd for 5-10 years. Drinks [**12-14**] glasses of wine per
week. Denies drug use.
Family History:
Mother: Died of heart failure at age of 52 secondary to a
"virus". No history of arrythmias, syncope, or sudden death in
the family.
Physical Exam:
On Admission:
VS: 97.3 127/85 80 18 9%RA
General: Appears well and in NAD. Lying in bed.
HEENT: PERRLA, EOMI, anicteric, MMM, OP clear
CV: RRR, S1 and S2, no m/r/g
Lung: CTAB, no w/r/r
Abdomen: Soft, NT/ND, BSx4
Ext: No gross deformity or edema
Neuro: Awake, alert and oriented. CN II-XII intact. Moving all
extremeties.
Pertinent Results:
[**2184-9-23**] Nuclear Perfusion Study - IMPRESSION: 1. Reversible
distal anterior wall and apical perfusion defect. 2. Normal wall
motion with an ejection fraction of 67%.
[**2184-9-23**] Cardiac Cath - COMMENTS: 1. Single vessel coronary
artery disease 2. Ostial 80% stenosis involving the left
anterior descending coronary artery proximal to the previously
deployed stent 3. Withhold clopidogrel. 4. Cardiac surgery
consultation FINAL DIAGNOSIS:
1. One vessel coronary artery disease. 2. Ostial 80% stenosis of
the LAD proximal to the previously deployed stent.
[**2184-9-30**] 03:11AM BLOOD WBC-9.5 RBC-3.24* Hgb-10.2* Hct-29.2*
MCV-90 MCH-31.5 MCHC-34.9 RDW-11.8 Plt Ct-159
[**2184-9-22**] 09:50PM BLOOD WBC-7.3 RBC-4.36 Hgb-13.8 Hct-37.5 MCV-86
MCH-31.8 MCHC-36.9* RDW-11.9 Plt Ct-220
[**2184-9-30**] 03:11AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-29 AnGap-12
[**2184-9-22**] 09:50PM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-143
K-3.7 Cl-109* HCO3-24 AnGap-14
Intra-op TEE [**9-27**]
Conclusions
PREBYPASS: NORMAL LV SYSTOLIC FUNCTION, LVEF . 55%, NO SWMA. The
left atrium is normal in size. Left ventricular wall thicknesses
and cavity size are normal. Right ventricular chamber size and
free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
POST BYPASS: unchanged. Normal EF, no dissection seen after
cannula removed.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2184-9-27**] 18:16
Brief Hospital Course:
She was admitted to the floor. On [**2184-9-23**], the patient
underwent cardiac catheterization that showed an 80% stenosed
LAD ostial lesion. Plavix was held and the patient underwent
Plavix washout.
On [**9-27**] she was taken to the operating Room where single vessel
grafting was performed. She was stable, weaned from Neo
Synephrine, awoke intact and was extubated. Beta blocker was
resumed and she was diuresed towrds her preoperative weight.
Blood pressure would not tolerate resuming Diovan. This should
be addressed as an outpatient. Physical Therapy worked with her
for strength and mobility.
CTs and wires were removed without incident. Arranagements were
made for out patient follow up. Wounds were clean and healing
well at discharge on POD 4 to home.
Medications on Admission:
aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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 TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*qs 1 month ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x1 [**2184-9-27**]
s/p coronary stenting
anxiety/depression
s/p appendectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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**]) on [**2184-11-3**] 1:00
Cardiologist: Dr.[**Name (NI) 13892**] office will call you with an appt.
Please call to schedule appointments with:
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47598**] ([**Telephone/Fax (1) 9386**]in [**3-16**] 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**
Completed by:[**2184-10-1**]
|
[
"V45.82",
"272.4",
"V58.63",
"V12.53",
"311",
"V58.66",
"414.01",
"300.00",
"250.00",
"V15.82",
"401.9",
"285.1",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6273, 6330
|
4151, 4924
|
302, 392
|
6509, 6688
|
2228, 2665
|
7612, 8200
|
1738, 1872
|
5387, 6250
|
6351, 6488
|
4950, 5364
|
2682, 4128
|
6712, 7589
|
1887, 1887
|
252, 264
|
420, 1418
|
1901, 2209
|
1440, 1540
|
1556, 1722
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,746
| 186,241
|
36900
|
Discharge summary
|
report
|
Admission Date: [**2163-1-20**] Discharge Date: [**2163-1-24**]
Date of Birth: [**2113-11-18**] Sex: F
Service: SURGERY
Allergies:
Penicillins / acetaminophen-codeine
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Palpitations, weakness, pre-syncopal
Major Surgical or Invasive Procedure:
Endoscopy [**2163-1-20**]
Endoscopy [**2163-1-24**]
History of Present Illness:
Ms. [**Known lastname 9241**] is a pleasant 49-year-old female who has a history
of a laparoscopic Roux-en-Y gastric bypass done in [**2161-11-12**].
She was recently admitted to the hospital with episodes of
melanoma as well as a decrease in her hematocrit. She was kept
as an inpatient and endoscopy was done which found a small
marginal ulcer which was attributed to because of bleeding. Her
hematocrit eventually stabilized and she was discharged home.
She states that she was doing well yesterday; however, today,
she started feeling more episodes of "blacking out" and
dizziness on exertion.
Past Medical History:
1. Depression and anxiety On medications Resolved
2. Hypertension No medications required currently
3. Type 2 diabetes mellitus- Resolved
4. Hyperlipidemia with delineated triglycerides- resolved
5. Obstructive sleep apnea requiring BiPAP- No symptoms
6. Severe gastroesophageal reflux-Resolved
7. Fatty liver.
8. Iron deficiency anemia.
9. Stress urinary incontinence- No recent episodes
10. Low back pain.
PAST SURGICAL HISTORY:
1. Wisdom tooth extraction ([**2132**]).
2. Tubal ligation ([**2149**]).
3. Laparoscopic Roux-en-Y Gastric Bypass in [**2161-11-12**].
Social History:
Former smoker, quit many years ago. Does not
drink excessively or use drugs. Homemaker, marries, lives with
husband. [**Name (NI) **] two sons.
Family History:
Stroke, obesity, hyperlipidemia.
Physical Exam:
Vital signs: Temperature 98.1 Blood Pressure 120/80 Heart Rate
65 Respiratory Rate 18 Oxygen 995 room air
Constitutional: No acute distress, normal affect, feels well
Neuro: Alert and oriented to person, place and time
Cardiac: Regular rate and rhythm, normal S1,S2, no murmurs, rubs
or gallops
Lungs: Clear to auscultation, bilaterally, no rales, rhonchi or
wheezing
Abdomen: Normoactive bowel sounds, soft, non-tender,
non-distended, no rebound tenderness or guarding
Extremities: No clubbing, cyanosis or edema
Pertinent Results:
[**2163-1-20**] 10:27AM BLOOD UreaN-20 Creat-0.7 Na-139 K-3.9 Cl-105
HCO3-27 AnGap-11
[**2163-1-20**] 10:27AM BLOOD Hct-20.9*
[**2163-1-21**] 07:25AM BLOOD Glucose-83 UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-105 HCO3-27 AnGap-12
[**2163-1-21**] 07:25AM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.8 Mg-1.8
[**2163-1-21**] 07:25AM BLOOD ALT-20 AST-22 LD(LDH)-166 AlkPhos-45
Amylase-44 TotBili-1.6*
[**2163-1-21**] 02:15AM BLOOD Hct-21.5*
[**2163-1-21**] 12:35PM BLOOD Hct-25.4*
[**2163-1-21**] 09:00PM BLOOD Hct-23.5*
[**2163-1-22**] 07:55AM BLOOD Hct-26.7*
[**2163-1-22**] 05:20PM BLOOD Hct-25.3*
[**2163-1-23**] 08:15AM BLOOD Hct-26.8*
[**2163-1-24**] 09:40AM BLOOD Hct-24.7*
[**2163-1-24**] 03:45PM BLOOD Hct-27.3*
[**2163-1-20**] Endoscopy:
Previous Roux-en-Y gastric pypass; Ulcer at the gastro-jejunal
anastamosis, with previously-placed clips and no bleeding
No blood in the examined GI tract; Otherwise normal EGD to third
part of the duodenum
[**2163-1-24**] Endoscopy:
Previous Roux-en-Y gastric pypass
Ulcer at the gastro-jejunal anastamosis, with previously-placed
clips and no bleeding
No blood in the examined GI tract
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Mrs. [**Known lastname 9241**] was directly admitted from clinic on [**2163-1-20**] due to persistent symptoms of weakness, palpitations and
pre-syncope as well as a hematocrit level of 20.9. Upon arrival
to the general surgical [**Hospital1 **], she received 3 units of packed
red blood cells and was placed on a pantoprazole drip. She was
subsequently transferred to the intensive care unit for a repeat
endoscopy, which confirmed the presence of a known 7 mm ulcer at
the gastrojejunal anastamosis. Additionally, at this time, a
visible vessel was also noted with subsequent placement of two
endoclips resulting in hemostasis. Serial hematocrits initially
increased and then stabilized. The pantoprazole drip was
discontinued and intravenous pantoprazole twice daily was
initiated.
On hospital day #5, a repeat endoscopy was performed with
findings of the known ulcer at the gastro-jejunal anastamosis,
with previously-placed clips and no bleeding. No blood was
visualized in the examined GI tract and the study was otherwise
normal EGD to third part of the duodenum. The intravenous
pantoprazole was transitioned to oral pantoprazole and the
patient's diet was advanced, which was well tolerated. She
denied any further symptoms of acute bleeding and both her
hematocrit levels and vital signs remained stable. She was
discharged to home with instruction to return to the Emergency
Department with any further signs or symptoms of bleeding. She
was instructed to continue taking Pantoprazole 40mg [**Hospital1 **] as well
as Colace and Iron. She was also instructed to have a repeat
Hct lab test next week ([**2163-1-31**]) and have results phoned or
faxed to Dr.[**Name (NI) **] office. She is following up at the [**Hospital **]
clinic as well in 1 week for further evaluation.
Medications on Admission:
1. fludrocortisone 0.1 mg 1 Tablet daily
2. citalopram 20 mg 1 Tablet Daily
3. pantoprazole 40 mg 1 Tablet, Delayed Release (E.C.) twice
daily
4. ferrous gluconate 240 mg (27 mg Iron) 2 Tablets daily
5. multivitamin Tablet, Chewable Sig: 2 Tablets daily
6. docusate sodium 50 mg/5 mL Liquid Sig 10 mL twice daily prn
7. cholecalciferol (vitamin D3) 1,000 unit [**Unit Number **] Tablet daily
8. Calcium Citrate + D 315-200 mg-unit [**Unit Number **] Tablets tid
Discharge Medications:
1. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. ferrous gluconate 240 mg (27 mg Iron) Tablet Sig: Two (2)
Tablet PO once a day.
5. multivitamin Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day.
6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation.
Disp:*500 mL* Refills:*0*
7. cholecalciferol (vitamin D3) 1,000 unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
8. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO three times a day.
9. Outpatient Lab Work
Please recheck Hct in 1 week (Monday, [**2163-1-31**]) and fax or
phone results to Dr.[**Name (NI) **] office.
Phone: [**Telephone/Fax (1) 3201**]
Fax: [**Telephone/Fax (1) 2833**]
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were readmitted from Dr.[**Name (NI) **] office on [**2163-1-20**] with
dizziness and a decreased hematocrit level. You received a
blood transfusion and underwent a repeat endoscopy. The
endoscopy confirmed the presence of a 7 mm ulcer at the
gastrojejunal anastamosis, which was identified on your previous
admission. However, a visible blood vessel was also identified
at this site, which was not seen previously and provides an
explanation for your gastrointestinal bleeding. Two endoclips
were successfully applied to this visible blood vessel with
resultant cessation of bleeding. Subsequently, your hematocrit
level was monitored serially with an appropriate upward trend.
A repeat endoscopy was performed on [**2163-1-24**] which did not
reveal any active bleeding. Additionally, your hematocrit
remained stable. Therefore, we were able to advance your diet
and discharge you from the hospital.
At the time of discharge, your hematocrit levels were stablized.
You were not experiencing any symptoms of bleeding. You were
tolerating a Stage 5 diet, voiding adequate amounts of urine and
had normal bowel function.
Please refrain from undergoing any MRI procedures for 1 month.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*You are getting dehydrated. Signs of dehydration include dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You have blood in your urine.
*You develop a fever greater than 101.5 and/ or chills
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
You should be taking Iron, Colace/Miralax, and Protonix 40 mg
twice a day by mouth. These prescriptions were previously given
to you.
You must avoid taking any NSAIDS such as Ibuprofen or Advil.
Take Tylenol for pain management if needed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
If you develop any of the symptoms listed below or anything else
concerning to you, please see your PCP or go to your nearest ER.
Please keep all follow up appointments.
Followup Instructions:
Please call Dr.[**Name (NI) **] office at [**Telephone/Fax (1) 3201**] to make a
follow-up appointment within 3 weeks
Provider: [**Name10 (NameIs) 11170**] [**Last Name (NamePattern4) 11171**], MD ([**Hospital **] clinic) Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2163-2-2**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2163-5-2**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2163-10-27**] 8:30
Completed by:[**2163-1-24**]
|
[
"V45.86",
"724.2",
"571.8",
"285.1",
"534.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6851, 6857
|
3580, 5378
|
333, 387
|
6924, 6924
|
2384, 3557
|
9517, 10200
|
1798, 1832
|
5890, 6828
|
6878, 6903
|
5404, 5867
|
7075, 9494
|
1481, 1620
|
1847, 2365
|
257, 295
|
415, 1017
|
6939, 7051
|
1039, 1458
|
1636, 1782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,255
| 103,255
|
10044
|
Discharge summary
|
report
|
Admission Date: [**2169-10-30**] Discharge Date: [**2169-11-4**]
Date of Birth: [**2100-2-18**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Morphine Sulfate / Tegretol
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Lower Lip melanoma
Major Surgical or Invasive Procedure:
1) Re-excision of lower lip melanoma
2) Rt mental nerve biopsy
3) Lt Estlander flap to lower lip
History of Present Illness:
69 y/o man with lower lip melanoma. Patient underwent excision
and repair of
right lower lip mass during previous admission of [**2169-10-9**]. He
was readmitted due to positive margins for re-excision and
reconstruction.
Past Medical History:
Essential Tremor
AAA, repaired
CRI s/p nephrectomy on hemodialysis
CAD s/p 4 vessel stenting
Lower lip melanoma
Social History:
The patient has a significant smoking history of two packs per
day times 55 years, with occasional alcohol use. He has an
occupational history as a retired
brick layer. Currently lives alone w/ daughter, who helps w/
his care.
Family History:
Father died at age 62 with coronary artery
disease. Mother died at 50 years old with breast cancer. He
has one brother with a heart attack history. Two brothers
with coronary artery bypass grafting history. Sister died at
67 from cancer.
Physical Exam:
T 98.0, BP 98/33, P 79, RR 16, SpO2 97% on RA.
A+O x3
PERRLA, no focal sensorimotor deficit.
JVP could not be appreciated.
Regular S1, S2. II/VI SEM @ RUSB.
LCA anteriorly.
+BS. soft abdomen, multiple abdominal scars, large R sided
hernia w/ extrusion bowel contents into R side of abdomen.
+L femoral bruit.
+R cephalic fistula bruit and thrill.
1+ dp pulses b/l.
Pertinent Results:
[**2169-10-30**] 08:47PM GLUCOSE-81 UREA N-47* CREAT-5.8* SODIUM-138
POTASSIUM-6.0* CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2169-10-30**] 08:47PM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-2.1
[**2169-10-30**] 08:47PM WBC-9.5# RBC-3.25* HGB-11.2* HCT-32.8*
MCV-101* MCH-34.4* MCHC-34.0 RDW-13.4
[**2169-10-30**] 08:47PM PLT COUNT-208
[**2169-10-30**] 08:47PM PT-13.2 PTT-28.0 INR(PT)-1.1
Brief Hospital Course:
After the operation he was admitted to the ICU for observation.
During the night following admission, the patient continued to
bleed out of the unclosed openings of his mouth. Eventually
required surgicell packing of oral cavity to stave off continued
bleeding. Unclear [**Name2 (NI) **] loss quantity but hematocrit remained
stable. Secondary to the ongoing bleeding and significant
drainage of dark red contents from NGT it was felt that the
patient should remain intubated until HD 2. Given inability to
intubate through the oropharynx, pt was extubated over
bronchoscope by ENT, w/o complication. Secondary to the ongoing
bleeding, Plavix and ASA were held Pt has been continued on
cefazolin 1g renally dosed w/ plan to continue for 7 day course
for propylaxis.
On HD2, pt developed low grade temperature to 100.4, and sputum
and urine were sent. Sputum grew out 4+ GNR and 4+ GPC in
clusters, chains, pairs. There was no indication for treatment
as pt was w/o s/sx of PNA and developed no further temperature.
He was maintained on IV Lopressor and transitioned to orals on
HD 3.
His fluid status was largely determined by HD. Only 1.3L taken
off on HD1 and pt remains w/ some residual UE edema. Daily CXRs
were followed and O2 requirements were closely monitored.
He underwent another session of HD and 3L were taken off. His
breathing improved (95-97% on RA) and he voided after his Foley
catheter was discontinued.
On day af his dicharge he was able to ambulate, void and breathe
w/o difficulty. His surgical sites were d/c/i.
Medications on Admission:
toprol xl 25 po qd
atorvastatin 40mg po qd
furosemide 40mg po qd
nephrocaps
sevalamar 400mg po tid
aspirin
plavix
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Acetaminophen 160 mg/5 mL Elixir Sig: Four (4) PO Q6H (every
6 hours) as needed for pain.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed: Avoid Tylenol when taking
Percocet/Roxicet.
Disp:*500 ML(s)* Refills:*0*
4. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
7. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*10 Capsule, Sust. Release 24HR(s)* Refills:*0*
8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*28 Capsule(s)* Refills:*0*
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*50 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower lip melanoma
Discharge Condition:
Stable
Discharge Instructions:
Keep wounds clean and dry. Contact ENT if you experience fever
>101, shaking chills, difficulty in breathing or swallowing, lip
swelling or discharge (possible infection), wound dehiscence.
Mobilize at least three to four times daily.
Followup Instructions:
with Dr [**Last Name (STitle) 1837**] in one week. Please call [**Telephone/Fax (1) 7732**] to
schedule an appointment.
Completed by:[**2169-11-4**]
|
[
"998.11",
"518.81",
"585",
"172.0",
"428.0",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"04.12",
"27.42",
"39.95",
"96.71",
"27.57",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
4982, 4988
|
2124, 3670
|
314, 413
|
5057, 5065
|
1706, 2101
|
5348, 5499
|
1062, 1306
|
3834, 4959
|
5009, 5036
|
3696, 3811
|
5089, 5325
|
1321, 1687
|
256, 276
|
441, 664
|
686, 800
|
816, 1046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,521
| 151,764
|
8926
|
Discharge summary
|
report
|
Admission Date: [**2189-10-19**] Discharge Date: [**2189-10-23**]
Date of Birth: [**2147-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
[**2189-10-19**] - coronary artery bypass grafting (left internal mammary
artery-Left anterior descending artery, Saphenous vein
graft(SVG)-Diagonal artery, SVG-Posterior descending artery)
History of Present Illness:
This 42 year old white male was recently diagnosed with
hypertension and hyperlipidemia and had an abnormal EKG at a
routine visit. He then had an abnormal exercise stress test and
underwent cardiac catheterization on [**8-31**] which revealed 2
vessel coronary artery disease. He is scheduled for surgery on
[**10-19**].
Past Medical History:
Hypertension
hyperlipidemia
Social History:
Race: Caucasian
Last Dental Exam: 1.5 years ago
Lives with: Wife and 3 children
Occupation: Organizes trade shows
Tobacco: none
ETOH: none
Family History:
Father had type 1 DM and CABG in his 50s
Physical Exam:
Admission:
HR 83 100%RA
LBP 145/88 RBP 131/95
Height: 5'[**89**]" Weight: 103.4 kg
General: well-developed, well-nourished male in no acute
distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
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:
[**2189-10-19**] 10:06AM HGB-15.3 calcHCT-46
[**2189-10-19**] 10:06AM GLUCOSE-104 LACTATE-2.1* NA+-140 K+-4.0
CL--103
[**2189-10-19**] 02:03PM PT-16.3* PTT-32.7 INR(PT)-1.4*
[**2189-10-19**] 03:21PM WBC-7.7 RBC-4.34* HGB-13.1*# HCT-36.5*#
MCV-84 MCH-30.2 MCHC-36.0* RDW-13.3
[**2189-10-19**] 03:21PM UREA N-12 CREAT-0.7 CHLORIDE-112* TOTAL
CO2-24
[**2189-10-19**] 03:30PM GLUCOSE-103 NA+-137 K+-3.6
[**2189-10-21**] 06:55AM BLOOD WBC-8.0 RBC-4.52* Hgb-12.9* Hct-39.4*
MCV-87 MCH-28.6 MCHC-32.9 RDW-14.0 Plt Ct-92*
[**2189-10-21**] 06:55AM BLOOD Plt Smr-LOW Plt Ct-92*
[**2189-10-21**] 06:55AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-139
K-4.9 Cl-106 HCO3-23 AnGap-15
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 31009**]
Final Report
HISTORY: CABG.
FINDINGS: In comparison with the study of [**10-21**], the patient has
taken a
somewhat better inspiration. Persistent opacification at the
left base is
consistent with atelectatic changes. Less prominent atelectatic
changes are seen at the right base.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Indication: Intraoperative TEE for CABG.
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.2 cm <= 3.4 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions: Prebypass
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2189-10-19**] at
1000 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Trivial mitral
regurgitation. Aorta is intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2189-10-19**] for elective
surgical management of his coronary artery disease. He was taken
directly to the Operating Room where he underwent coronary
artery bypass grafting to three vessels. Please see operative
note for details. In summary he had Coronary artery bypass
grafting x3; left internal mammary artery grafted to the left
anterior descending, reverse saphenous vein graft to the first
diagonal and right coronary artery. His bypass time was 70
minutes with a crossclamp of 50 minutes. Postoperatively he was
taken to the intensive care unit for monitoring. Over the next
several hours, he awoke neurologically intact and was extubated.
Beta blockade, aspirin and a statin were resumed.
On postoperative day one, he was transferred to the step down
unit for further recovery. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. He was gently diuresed towards his preoperative
weight. CTs were removed on POD 2 and temporary pacing wires on
day 3. The remainder of his hospital stay was uneventful. On
POD4 he was discharged home with visiting nurses.
Medications on Admission:
ASA 81 mg PO daily
Lisinopril 2.5 mg PO daily
Simvistatin 80 mg PO daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/ fever.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
5. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO twice a day: 25mgm
twice a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for pain for 1 months.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
coronary artery disease-s/p coronary artery bypass grafting
Hypertension
hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
Please shower daily. Wash incision with soap and water. No
lotions, creams or powders to incision for 6 weeks.
No driving for 1 month and takign narcotics.
No lifting greater then 10 pounds for 10 weeks.
Please call with any questions or concerns.
Take all medications as directed
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] in [**1-13**] weeks.([**Telephone/Fax (1) 31010**])
Dr. [**Last Name (STitle) 120**] in [**1-13**] weeks. ([**Telephone/Fax (1) 31010**])
Completed by:[**2189-10-23**]
|
[
"458.29",
"401.9",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7224, 7332
|
5223, 6410
|
347, 539
|
7464, 7471
|
1870, 5200
|
7997, 8306
|
1117, 1160
|
6534, 7201
|
7353, 7443
|
6436, 6511
|
7495, 7974
|
1175, 1851
|
284, 309
|
567, 892
|
914, 944
|
960, 1101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,759
| 153,363
|
26406+57498
|
Discharge summary
|
report+addendum
|
Admission Date: [**2114-1-19**] Discharge Date: [**2114-1-25**]
Date of Birth: [**2040-12-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD, Colonoscopy
History of Present Illness:
73yoM with pmh sig for bleeding duodenal ulcer in setting of
anti-coagulation, discharged on the day prior to presentation
after a month long hospitalization, who presents to [**Hospital1 18**] ED
from rehab with BRBPR. Denies abdominal pain, vomitting,
dizziness, chest pain.
.
Recent hospitalization after being found on the floor 4 days
after a fall. Hospital course included ARF in the setting of
rhabdo, DVT treated initially with anti-coagulation but
anti-coagulation discontinued and IVC filter placed when pt
found to have guaiac positive stool. EGD revealed large duodenal
ulcer with adherent clot (treated with Bicap three times and
injection). [**Hospital 65303**] hospital course also complicated by
NSTEMI/demand ischemia, facial wound, UTI.
.
On [**1-19**] in the [**Name (NI) **] pt was briefly hypotensive to sbp 80s, hct 22
(last Hct was 31 24hours prior), NG neg, blood started, 4L NS
given, taken to GI suite where EGD w/o active bleed. After
negative EGD went for tagged rbc scan which was negative.
Admitted to MICU after having received 2 units of prbc
Past Medical History:
Parkinson's disease
Hypertension
Errectile dysfunction
Dyslipidemia
Social History:
Lives alone on [**Location (un) 470**] of 3 story multi-family home. No
tobacco/EtOH.
Family History:
NC
Physical Exam:
Tc=99 P=116 BP=137/P RR=16 96 % on 2L
Gen - NAD
HEENT - PERRLA EOMI
Heart - RRR, no M/R/G
Lungs - CTAB anteriorly
Abdomen - Soft, NT, ND, hyperactive BS
Ext - circular lesions across both legs
Skin - wound with eschar; left side of face, chest, LLE
Neuro - CN II-XII grossly intact, 4/5 strength x 4, pill-rolling
tremor at baseline
Pertinent Results:
Admission Labs:
[**2114-1-18**] 05:10AM PLT COUNT-269
[**2114-1-18**] 05:10AM WBC-15.3* RBC-3.70* HGB-10.8* HCT-31.2*
MCV-84 MCH-29.3 MCHC-34.8 RDW-14.4
[**2114-1-18**] 05:10AM CALCIUM-8.0* PHOSPHATE-2.6* MAGNESIUM-1.8
[**2114-1-18**] 05:10AM GLUCOSE-79 UREA N-41* CREAT-2.4* SODIUM-136
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13
[**2114-1-19**] 07:30AM PT-13.2 PTT-27.1 INR(PT)-1.2
[**2114-1-19**] 07:30AM NEUTS-84.5* LYMPHS-11.1* MONOS-3.0 EOS-1.1
BASOS-0.3
[**2114-1-19**] 07:30AM WBC-11.8* RBC-2.61*# HGB-8.3* HCT-22.5*#
MCV-86 MCH-31.9 MCHC-37.1* RDW-14.5
[**2114-1-19**] 07:30AM GLUCOSE-111* UREA N-49* CREAT-2.5* SODIUM-137
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-23 ANION GAP-12
[**2114-1-19**] 05:59PM HCT-24.1*
[**2114-1-19**] 05:59PM CK-MB-NotDone
[**2114-1-19**] 05:59PM CK(CPK)-78
[**2114-1-19**] 09:27PM HCT-35.2*#
Brief Hospital Course:
LGIB
In the MICU pt. received 3 more U PRBCs. His Hct was stable
after transfusion. He was prepped with Golytely and taked for
Colonoscopy, which showed localized ulceration, erythema and
congestion with no bleeding noted at 30 cm. These findings are
compatible with ischemic colitis vs. infection less likely IBD.
No blood was seen in the colon or to terminal ileum. Given his
clinical scenario ischemic colitis was felt to be the most
likely explanation. As his hct had been stable he was
transferred to the floor and monitored. His PPI was initially
continued IV BID -> PO BID -> PO QD. His SBP was maintained >
120. His diet was advanced as tolerated, which pt. tolerated
well with no further bleeding.
.
UTI: he finished a 7 day course of Cipro for UTI on the floor.
Repeat UA/UCx performed [**1-24**], showed persistent LE, WBCs,
bacteria -> foley changed, repeat UA and U Cx sent after foley
removal, pending at time of discharge. Urine culture from [**1-24**]
grew Pseudomas, sensis pending at time of discharge, discharged
on a course of Zosyn to treat this, with a plan to follow up
sensis and alert Rehab with any necessary changes in antibiotics
(phone # [**Telephone/Fax (1) 34988**]- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8651**], 4W).
.
PD: His Neurologist Dr. [**Last Name (STitle) 65301**] was contact[**Name (NI) **] and his Sinemet
dose was changed to his outpatient dose: 50/200 TID. He worked
with PT and OT, who recommended Acute Rehab on discharge.
.
BPH: His Flomax was held in an attempt to maintain higher BPs.
He was discharged with a foley and follow-up with Urology, and
decision to restart Flomax was deferred to this appointment.
.
CAD: ASA held given recent bleed, Statin restarted on discharge
as CKs had normalized.
.
CRF: Pt. was hydrated, and Cr monitored QD, with Cr stable at
2.0-2.2 over admission (this may be his new baseline) He was
set up with Renal f/u following discharge.
Medications on Admission:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
5. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
8. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 9 days.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q8H (every 8 hours).
10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID
(4 times a day).
11. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One
(1) Appl Topical DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Medications:
1. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO TID (3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol Sig: One
(1) Appl Topical DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Piperacillin-Tazobactam in D5W 2.25 g/50 mL Piggyback Sig:
One (1) Intravenous Q6H (every 6 hours) for 14 days.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Ischemic Colitis
Secondary:
UTI
Parkinson's Disease
BPH
R Common femoral DVT
Hyperlipidemia
Acute Renal Failure
Facial Necrosis
Discharge Condition:
Stable- hct had been stable for 4 days, not requiring further
transfusion, and pt. had no more blood per rectum
Discharge Instructions:
Please call your doctor or come to the ER if you have any
bleeding with bowel movements, diarrhea, nausea, vomiting, chest
pain, shortness of breath, or any other symptoms that concern
you.
Followup Instructions:
Renal: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Date/Time:[**2114-1-30**] 4:30
Urology: Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2114-2-12**] 10:30
Neurology: Dr. [**Last Name (STitle) 65301**], [**Telephone/Fax (1) 65302**], [**2-15**] at 10:15
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7677**] [**Telephone/Fax (1) 65304**], [**Last Name (LF) 766**], [**1-29**] at 11:00 AM.
Plastic Surgery: [**Telephone/Fax (1) 4652**], Feruary 10th at 1:30 PM. Please
call your PCP and have her fax a referral to the Plastic Surgery
office prior to this appointment.
GI: EGD and Flexible Sigmoidoscopy on [**2114-3-21**] with Dr. [**First Name (STitle) 2643**] on
[**Initials (NamePattern4) 1388**] [**Last Name (NamePattern4) 517**], [**Hospital Ward Name 121**] 8, at 9:30. An instruction packet
about the preparation for the test will be mailed to your house
prior to the test.
Completed by:[**2114-1-25**] Name: [**Known lastname 11491**],[**Known firstname **] [**Doctor Last Name 4572**] Unit No: [**Numeric Identifier 11492**]
Admission Date: [**2114-1-19**] Discharge Date: [**2114-1-25**]
Date of Birth: [**2040-12-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4143**]
Addendum:
PPI changed to [**Hospital1 **] per GI recs
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**Name6 (MD) **] [**Name8 (MD) 4144**] MD [**MD Number(2) 4145**]
Completed by:[**2114-1-25**]
|
[
"272.4",
"796.3",
"280.9",
"557.9",
"556.8",
"532.70",
"332.0",
"578.9",
"530.20",
"599.0",
"584.9",
"414.01",
"458.9",
"041.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9075, 9281
|
2916, 4873
|
322, 340
|
7179, 7293
|
2031, 2031
|
7531, 9052
|
1657, 1661
|
6045, 6896
|
7019, 7158
|
4899, 6022
|
7317, 7508
|
1676, 2012
|
277, 284
|
368, 1445
|
2048, 2893
|
1467, 1537
|
1553, 1641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,363
| 146,509
|
34598
|
Discharge summary
|
report
|
Admission Date: [**2138-8-10**] Discharge Date: [**2138-8-15**]
Service: MEDICINE
Allergies:
Penicillins / Cipro / citalopram / Sulfa(Sulfonamide
Antibiotics)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
femoral neck fixation surgery
History of Present Illness:
[**Age over 90 **] yo F with hx of OSA, HTN, GERD, OA who presents s/p fall.
Patient reports that she was sitting in her chair and fell
asleep. The phone rang and she got up to answer the phone. She
usually puts on her slippers when walking around the house, but
she did not. She slipped on a floor rug and fell. She denies any
LOC, head strike. She denied any prior chest pain, palpitations
or lightheadedness. She denies any prior seizure history. She
fell on her left side and hurt her hip. She subsequently was
taken to the ED for evaluation.
The patient at baseline is not very active. She is able to
ambulate only 1 block or 1 flight of stairs without getting SOB.
She denies history of chest pain, palpitations, orthopnea,
syncope or presyncope. She has chronic LE edema since her knee
replacement surgeries several years ago.
In the ED, initial vs were 98 175/99 88% ra.
Labs were unremarkable
Past Medical History:
- OSA - uses 3L O2 at night
- HTN
- GERD
- skin CA
- breast mass s/p resection
- hysterectomy
- b/l knee replacements
Social History:
lives alone, occasional ETOH, no tobacco
Family History:
cousin with cancer of unknown type
Physical Exam:
Vitals: T 97.9, BP 175/85, HR 90, RR 20, O2 92%5L
GENERAL: obese woman laying in bed, alert and oriented, in no
acute distress
HEENT: moist mucous membranes, extraoccular movements intact,
sclera anicteric, OP clear
NECK: supple, no LAD, neck obesity
PULM: decreased breath sound anteriorly on the right and left,
with some wheeazing.
CV: Very distant heart sounds. normal S1/S2, no mrg
ABD: soft NT ND normoactive bowel sounds, no r/g
EXT: LLE shorter than right and externally rotated. Pain with
palpation at left hip. Distal pulses palpable. Bilateral ankle
edema with signs of venous stasis on left foot.
NEURO: Alert and orientedx3. CNs2-12 intact, motor function
limited due to left hip pain. Sensory function grossly intact
Pertinent Results:
ADMISSION:
[**2138-8-10**] 10:14PM BLOOD WBC-9.2 RBC-4.92 Hgb-14.2 Hct-43.0 MCV-88
MCH-28.9 MCHC-33.1 RDW-14.0 Plt Ct-232
[**2138-8-10**] 10:14PM BLOOD Neuts-82.4* Lymphs-12.1* Monos-3.8
Eos-1.5 Baso-0.2
[**2138-8-10**] 10:14PM BLOOD Plt Ct-232
[**2138-8-10**] 10:14PM BLOOD PT-10.2 PTT-20.3* INR(PT)-0.9
[**2138-8-10**] 10:14PM BLOOD Glucose-120* UreaN-18 Creat-0.7 Na-145
K-4.4 Cl-105 HCO3-34* AnGap-10
DISCHARGE:
[**2138-8-15**] 03:34AM BLOOD WBC-8.2 RBC-3.80* Hgb-10.9* Hct-33.6*
MCV-89 MCH-28.6 MCHC-32.3 RDW-14.0 Plt Ct-222
[**2138-8-14**] 05:20AM BLOOD Neuts-80.7* Lymphs-11.2* Monos-4.9
Eos-3.1 Baso-0.1
[**2138-8-14**] 05:20AM BLOOD PT-12.7* PTT-28.5 INR(PT)-1.2*
[**2138-8-15**] 03:34AM BLOOD Glucose-114* UreaN-20 Creat-0.6 Na-139
K-4.1 Cl-100 HCO3-33* AnGap-10
[**2138-8-15**] 03:34AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
[**2138-8-12**] 08:34AM BLOOD Type-ART pO2-123* pCO2-51* pH-7.39
calTCO2-32* Base XS-5
IMAGING:
CTA chest [**2138-8-12**]
1. Limited evaluation for PE. No large main or segmental
pulmonary embolism.
2. Small pleural effusions and perifissural fluid.
3. Enlarged pulmonary artery can be seen in pulmonary
hypertension.
4. Extensive irregular calcified and noncalcified
atherosclerotic plaque of the descending aorta.
TTE [**2138-8-12**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Doppler parameters are most consistent with Grade II
(moderate) left ventricular diastolic dysfunction. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with normal free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. 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. No
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
NOTE: Report edited at 6:21 pm on [**2138-8-12**] to remove mention of
lack of spontaneous echo contrast in the left atrium (this could
not be adequately assessed).
Brief Hospital Course:
Ms. [**Known lastname 79401**] is a [**Age over 90 **] yo F with hx of OSA, HTN, GERD, OA who
presented after a mechanical fall resulting in a left hip
fracture. Hip Surgery was performed on [**8-11**], and patient
required ICU admission post-operatively because of poor
respiratory status.
.
## LEFT FEMORAL NECK FRACTURE (s/p Hemiarthroplasty on [**2138-8-11**]):
The surgery proceeded without any major complications.
Post-operatively the patient was not extubated due to poor
respiratory status and she was transferred to the medical ICU.
In the ICU, her respiratory status rapidly improved and she self
extubated on the morning of [**8-12**]. She started working with
physical therapy shortly therefater. She will need 2 weeks of
lovenox post operatively for DVT prophylaxis. She will follow-up
in orthopedics clinic in ~2 weeks as scheduled.
.
## HYPOXEMIA - The patient has hypoxemia at baseline. She
reports that her oxygen saturation on room air is normally "Very
Low" at home. She wears 3 liters of nasal cannula at night
normally. Her chronic hypoxemia is likely from obstructive sleep
apnea and obesity hypoventilation syndrome. CTA and TTE during
this admission showed pulmonary hypertension which is likely
from chronic hypoxemia. She likely also had some acute insults
superimposed including post-op atelectasis due to pain and
shallow breathing. Workup for other contributing factors
included a CTA which was negative for PE. A chest x-ray
indicated a possible aspiration pneumonia and therefore the
patient was started on clindamycin. She has two days remaining
of a 7 day course. She was able to be weaned to 4L NC by
discharge.
.
CHRONIC MED CONDITIONS
## GERD - continue home dose of omeprazole
.
## LE edema - trace edema on exam. will continue home lasix
TRANSITIONAL ISSUES:
# Anticoagulation with lovenox x 2 weeks.
Medications on Admission:
1. Omeprazole Dose is Unknown PO DAILY
2. Furosemide 40 mg PO 2X/WEEK (TU,SA)
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 40 mg PO 2X/WEEK (TU,SA)
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen 1000 mg PO TID
5. Vitamin D 800 UNIT PO DAILY
6. Calcium Carbonate 500 mg PO TID
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Clindamycin 450 mg PO Q6H Duration: 2 Days
last dose [**2138-8-17**]
10. Lidocaine 5% Patch 2 PTCH TD DAILY
apply along left hip, long incision
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation or RR < 12; use only for severe breakthrough
pain if tramadol doesn't work
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 1 TAB PO BID:PRN constipation
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
15. Enoxaparin Sodium 30 mg SC Q12H Duration: 2 Weeks
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left femoral neck fracture s/p mechanical fall
Primary
- Hip Fracture
- Hypoxemia
- Aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair
Discharge Instructions:
Ms. [**Last Name (Titles) 79402**], it was a pleasure taking care of you here at
[**Hospital1 18**]. You were admitted to the hospital after you fractured
your hip. Afterwards, you came to the medical instensive care
unit because you required a higher than normal breathing support
to maintain normal oxygen levels. We are also treating you with
2 more days of antibiotics for a pneumonia.
******WOUND CARE******
- You can get the wound wet/take a shower immediately. No baths
or swimming for at least 4 weeks. Any stitches or staples that
need to be removed will be taken out at your 2-week follow up
appointment. No dressing is needed if wound continued to be
non-draining.
******WEIGHT-BEARING******
- Weight-bearing as tolerated left lower extremity
******MEDICATIONS******
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink eight 8-oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on Fridays.
******ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2138-9-2**] at 8:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2138-9-2**] at 8:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"E938.3",
"820.09",
"530.81",
"401.9",
"V10.83",
"782.3",
"518.89",
"496",
"518.81",
"327.23",
"V46.2",
"715.90",
"518.0",
"E885.9",
"799.02",
"458.29",
"278.03",
"416.8",
"V43.65",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
7424, 7494
|
4653, 6434
|
293, 324
|
7643, 7643
|
2273, 4630
|
9176, 9740
|
1470, 1506
|
6655, 7401
|
7515, 7622
|
6525, 6632
|
7804, 9153
|
1521, 2254
|
6455, 6499
|
234, 255
|
352, 1255
|
7658, 7780
|
1277, 1396
|
1412, 1454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,280
| 171,280
|
54726
|
Discharge summary
|
report
|
Admission Date: [**2180-6-22**] Discharge Date: [**2180-6-24**]
Date of Birth: [**2159-6-20**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Intoxication/ ? suicide attempt
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
21F visiting from [**State 4565**] who presents with a likley suicide
attempt. History is obtained from the medical record and the
patient's father. [**Name (NI) **] was last seen normal at 2am [**2180-6-22**],
drinking with friends. [**Name (NI) **] report, had expressed reported
passive SI. Per the father, she called her mother in the early
morning, was crying and apologizing, talking about taking pills.
Her father, who is visiting from [**Country 2559**], then went over to the
apartment she was staying in, where he met the ambulance. He
reports that the patient's roomate found her lathargic and
surrounded by bottles of sertraline and lorazepam.
Patient was brought to the ED, was somnolent on arrival, per ED
team with rapid deterioration of mental status. Initial vitals
05:20 0 98 102 116/83 15 100% 15L. Pt noted on exam to have
mild + inducible clonus, pupils mildly dilated, equal, reactive.
With discussion with the patient's father, she was electively
intubated for airway protection. She was given 10mg etomodate
and 100mg of succinylcholine. She was placed on a fentanyl drip
and given 2L IVF.
Interestingly, initial and repeat tox screen negative for benzos
and tricyclics, but Etoh of 206.
On arrival to the MICU, patient is intubated and sedated but
able to follow simple commands.
Past Medical History:
Depression/Anxiety - followed by therapist in LA, where she has
been living recently. No hx prior SA's. Was started on
anti-depressant about 1 month ago.
?ADHD
Social History:
Patient grew up in [**Country 2559**] and [**Country 2784**]. Studied at BU for 2
years but has most recently been living in LA. Moved back to
[**Location (un) 86**] this past week with plan to go back to school. Per
father, no tobacco or illicits, + EtOH.
Family History:
Noncontributory.
Physical Exam:
Admission exam:
Vitals: T: BP: P: R: O2:
General: intubated and sedated, following commands and moving
all extremities.
HEENT: Sclera anicteric, MMM, oropharynx with OG tube in place.
Pupils dilated but reactive, with evidence of ocular clonus
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: prominent adventitial ventilator shounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: hyperactive reflexes, moving all extremities. No
myoclonus
Discharge exam:
General: alert, awake, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear. PERRL
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: hyperactive reflexes, moving all extremities. No
myoclonus
Pertinent Results:
[**2180-6-22**] 03:58PM GLUCOSE-89 UREA N-5* CREAT-0.6 SODIUM-141
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-25 ANION GAP-11
[**2180-6-22**] 03:58PM CK(CPK)-116
[**2180-6-22**] 03:58PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.7
[**2180-6-22**] 03:58PM PT-10.9 PTT-27.4 INR(PT)-1.0
[**2180-6-22**] 06:40AM URINE UCG-NEGATIVE
[**2180-6-22**] 06:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2180-6-22**] 06:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2180-6-22**] 05:30AM WBC-5.8 RBC-4.33 HGB-13.0 HCT-38.4 MCV-89
MCH-30.1 MCHC-34.0 RDW-12.4
[**2180-6-22**] 05:30AM PLT SMR-NORMAL PLT COUNT-292
CHEST (PORTABLE AP) Study Date of [**2180-6-22**] 6:13 AM
PORTABLE SUPINE CHEST RADIOGRAPH: An endotracheal tube tip is
at the level of
the clavicles. A nasoenteric catheter courses below the
diaphragm with the
tip in the stomach. The lungs appear clear. No opacity or
edema is
identified. There is no pleural effusion. No pneumothorax is
evident.
Cardiomediastinal and hilar contours appear within normal
limits.
IMPRESSION: Endotracheal tube at the level of the clavicles.
No acute
cardiopulmonary process.
ECG Study Date of [**2180-6-22**] 6:00:16 AM \
Sinus rhythm. The tracing is within normal limits. No previous
tracing
available for comparison.
[**2180-6-22**] 06:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
Patient is a 21F with history of depression recently started on
meds, who presents with lethargy and likely suicide attempt,
intubated for airway protection. She was treated for:
Possible suicide attempt she was montiored and psychiatry was
called to evaluate her in the ICU. She was transferred to the
general medical floor for observation overnight. At the time of
discharge to inpatient psych hospitalization she was medically
cleared. Social work was also called.
Toxic ingestion: Unclear if patient actually ingested
medications, or just EtOH based on negative tox screen, but
ativan does not show up on a tox screen. Also, Zoloft would
likely not be apparent from standard tox screen. She was given a
banana bag. She was given IVF and her qt was montiored. Her
lytes were normal.
She initially had signs of serotonin syndrome including
hyperactive reflexes, and ocular clonus. VS and EKG was
montiored for QT prolongation.
Intubation for airway protection was made in the ER and she was
extubated during her first 24 hours in the icu without event.
Etoh intoxication, level of 206 on admission was treated with
supportive care and was placed on CIWA. At discharge she was not
[**Doctor Last Name **] on her CIWA scale.
Transitional issue
Dispo to inpatient Psych hospitalization.
Medications on Admission:
Zoloft
Ativan
Discharge Medications:
1. Thiamine 100 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Cyanocobalamin 50 mcg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1) Ethanol intoxication questionable overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 111895**] it was our pleasure to take care of you at the
[**Hospital1 18**]. You were admitted for ingestation and a possible suicide
attempt. A tube was placed to breath for you and that tube was
removed when you were safe. You were treated with several
vitamins in order help you. You were monitored for any
abnormalities in your vital signs. We called psychiatry to come
speak with you.
We made the following changes to your medications:
Thiamine PO 1mg daily for 3 days
FoLIC Acid 1 mg PO/NG DAILY
Cyanocobalamin 50 mcg PO/NG DAILY
Followup Instructions:
Per psychiatry team
We recommend that you see your PCP in the next month
Completed by:[**2180-7-5**]
|
[
"305.02",
"969.4",
"E950.9",
"980.0",
"E950.3",
"300.4",
"969.09",
"314.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6206, 6221
|
4732, 6026
|
304, 317
|
6311, 6311
|
3226, 4709
|
7053, 7156
|
2148, 2167
|
6091, 6183
|
6242, 6290
|
6052, 6068
|
6462, 6903
|
2182, 2794
|
2810, 3207
|
6932, 7030
|
233, 266
|
345, 1667
|
6326, 6438
|
1689, 1852
|
1869, 2132
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,361
| 108,781
|
22803
|
Discharge summary
|
report
|
Admission Date: [**2146-10-4**] Discharge Date: [**2146-10-10**]
Date of Birth: [**2125-4-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
Placement of a hemodialysis tunneled catheter
History of Present Illness:
Ms. [**Known lastname 58968**] is a 21 y/o female with a h/o renal failure [**12-30**]
FSGS Dx [**12/2144**] (not on HD, being evaluated for transplant) who
presented to outpatient clinic for routine follow-up and was
noted to have an elevated creatinine to 16. Pt admitted to
feeling fatigued x 2-3 months, though this improved somewhat
with Procrit injections. She noted N/V and cold symptoms for the
prior 3 weeks. She described a non-productive cough, fatigue,
malaise, and N/V. She denied any hemetemesis or melena. She
denied any abdominal pain. Over the past few days prior to
presentation she also c/o fatigue and dizziness with exertion
(walking from one room to another), but denied
CP/SOB/palpitations. She denied confusion or difficulty with
speech. She noted 2 pillow orthopnea but denies PND. She
admitted to poor PO intake over past few weeks, but denied
diarrhea.
.
Pt presented to the ED with T 98.0, HR 80, BP 170/103, RR 18,
99%RA. Bedside TTE obtained showed moderate pericardial effusion
without RV collapse. A right femoral dialysis catheter was
placed by the renal service for urgent HD, and pt was
transferred to [**Hospital Unit Name 153**] for HD. She was without CP/SOB/N/V upon
arrival to the [**Hospital Unit Name 153**].
.
In the [**Hospital Unit Name 153**] the pt underwent HD and 0.5L of fluid was removed.
In the AM of [**2146-10-6**] in the CCU, she was slightly tachycardic
(HR 100's) but otherwise hemodynamically stable. Pulsus
paradoxus noted to be 10. Tunneled HD line (right IJ) was placed
by IR. Echo was repeated and showed a pericardial effusion with
worsening pericardial pressures, thought to be consistent with
early cardiac tamponade physiology. Patient was then transferred
to the CCU for closer monitoring given the acute change in the
echo.
.
She was monitored ON in the CCU and was then transferred to
medicine hemodynamically stable with no clinical evidence of
pericardial tamponade.
Past Medical History:
CRF - dx early [**2144**], biopsy proven FSGS, not on HD, being
evaluated for transplant. diagnosis made incidentally with
elevated SBP at routine sports physical.
HTN - [**12-30**] ARF.
Social History:
She denied tobbacco, alcohol, or IVDU. She admitted to
occasional marijuana use. Mother present in room at time of
interview.
Family History:
She has no family history of kidney disease or nephrolithiasis.
She also has no family history of diabetes or early coronary
disease. Her father died of [**Name (NI) 4278**] lymphoma and
neurofibrosarcoma.
Physical Exam:
VS: 99.5 178/108 73 18 100% RA; pulsus was <5
GEN: NAD
HEENT: PERRLA, sclera anicteric, OP clear, MMM, no LAD, no
carotid bruits. No JVD.
CV: regular, nl s1, s2, +S4. no murmurs, rubs.
PULM: CTA B, no r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL
NEURO: alert & oriented x 3, no asterixis.
Pertinent Results:
[**2146-10-4**] WBC-9.2# RBC-2.66* Hgb-7.7* Hct-21.3*# Plt Ct-185
[**2146-10-5**] WBC-8.5 RBC-2.53* Hgb-7.2* Hct-20.2* Plt Ct-222
[**2146-10-5**] WBC-8.3 RBC-2.71* Hgb-7.6* Hct-22.0* Plt Ct-231
[**2146-10-6**] WBC-8.6 RBC-2.59* Hgb-7.5* Hct-21.7* Plt Ct-234
[**2146-10-7**] WBC-6.3 RBC-2.42* Hgb-7.1* Hct-20.5* Plt Ct-209
[**2146-10-8**] WBC-7.6 RBC-2.60* Hgb-7.6* Hct-22.1* Plt Ct-223
[**2146-10-10**] WBC-8.6 RBC-2.59* Hgb-7.6* Hct-22.6* Plt Ct-217
[**2146-10-4**] Neuts-76.7* Lymphs-17.8* Monos-2.9 Eos-2.3 Baso-0.2
.
[**2146-10-7**] Lupus-NEG
[**2146-10-7**] ACA IgG-6.2 ACA IgM-8.0
.
[**2146-10-4**] Glucose-100 UreaN-114* Creat-16.3*# Na-140 K-3.3 Cl-100
HCO3-22
[**2146-10-5**] Glucose-95 UreaN-72* Creat-11.8*# Na-142 K-3.1* Cl-104
HCO3-24
[**2146-10-5**] Glucose-83 UreaN-30* Creat-6.5*# Na-141 K-3.6 Cl-105
HCO3-25
[**2146-10-6**] Glucose-91 UreaN-35* Creat-8.2*# Na-141 K-4.0 Cl-104
HCO3-25
[**2146-10-7**] Glucose-89 UreaN-16 Creat-5.6*# Na-141 K-3.7 Cl-102
HCO3-30
[**2146-10-8**] Glucose-85 UreaN-14 Creat-4.9* Na-142 K-3.6 Cl-103
HCO3-31
[**2146-10-10**] Glucose-90 UreaN-38* Creat-7.6*# Na-138 K-3.7 Cl-96
HCO3-31
.
[**2146-10-5**] calTIBC-211* Ferritn-94 TRF-162*
[**2146-10-7**] Cryoglb-NO CRYOGLO
[**2146-10-5**] TSH-4.6*
[**2146-10-6**] TSH-3.9
[**2146-10-5**] PTH-176*
[**2146-10-6**] Free T4-1.3
[**2146-10-7**] HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE
[**2146-10-5**] ANCA-NEGATIVE B
[**2146-10-5**] C3-86* C4-26
[**2146-10-7**] HCV Ab-NEGATIVE
.
[**2146-10-4**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2146-10-4**] URINE Blood-SM Nitrite-NEG Protein-500 Glucose-TR
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2146-10-4**] URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
.
[**2146-10-4**] CXR PA/Lateral
Cardiac silhouette is moderately-to-severely enlarged, due to
cardiomegaly and/or pericardial effusion. There is no evidence
of elevated central venous or pulmonary arterial or left atrial
pressures. No pulmonary edema or pleural effusion is present.
Dr. [**Last Name (STitle) **] was paged to report these findings.
.
[**2146-10-5**]
Successful placement of a right IJ HD catheter.
.
[**2146-10-5**] Echo
Moderate circumferential pericardial effusion with
echocardiographic evidence for increased pericardial pressures
c/w early
tamponade physiology.
.
[**2146-10-10**] Echo
The left atrium is elongated. The right atrium is moderately
dilated. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic
regurgitation. The mitral valve appears structurally normal with
trivial
mitral regurgitation. There is borderline pulmonary artery
systolic
hypertension. There is a small pericardial effusion. There are
no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2146-10-5**],
the pericardial effusion appears smaller. There is no evidence
of tamponade.
Brief Hospital Course:
21 y/o female with h/o ESRD [**12-30**] to FSGS awaiting transplant who
presented with nausea and worsening fatigue and was found to
have ARF (cr 16) c/b a pericardial effusion. She was initially
admitted to the [**Hospital Unit Name 153**] for urgent HD. She was then transferred to
the CCU given her pericardial effusion that was found to have
early signs of tamponade. She was monitored overnight in the CCU
and was transferred to the medicine floor hemodynamically stable
with no clinical signs of tamponade and a normal pulsus. The
following issues were addressed during this hospitalization.
.
1. Pericardial Effusion
The [**Hospital **] hospital course was significant for a pericardial
effusion. The etiology was most likely [**12-30**] to ARF on CRI [**12-30**]
FSGS. The effusion most likely accumulated over the past few
months prior to admission. Her vitals remained stable throughout
admission. There was no evidence of tamponade physiology on
admission. She had a brief echo in the ED which r/o signs of
tamponade. A repeat echo on [**2146-10-5**] was concerning for early
tamponade physiology. She was transferred to the CCU and
monitored ON. She was hemodynamically stable with no clinical
signs/symptoms of tamponade. She was then trasferred to the
medicine floor. Her pulsus was monitored daily along with her BP
and HR. After session of HD, her clinical evidence of volume
overload improved which likely resolved her pericardial
effusion. A repeat echo on [**2146-10-10**] revealed a smaller
pericardial effusion with no signs of tamponade. She will most
likely need a repeat echo after discharge in [**11-29**] weeks.
.
2. ESRD [**12-30**] to FSGS on HD
She has a h/o FSGS proven on biopsy in 2/[**2144**]. She is currently
on the transplant list. Renal followed the pt during the entire
admission and the pt had HD sessions after placement of a right
IJ HD tunneled catheter on [**2146-10-5**]. Upon discharge, HD was
orchestrated with the help of social work in [**Hospital1 3597**] where pt goes
to college on a MWF schedule. Pt's admission symptoms improved
after HD sessions along with her clinical picture of volume
overload.
Medications on Admission:
Lasix 20 mg PO daily
Iron 65 mg PO BID
Lisinopril 40 mg PO daily
Cozaar 100 mg PO daily
Renagel 800 mg PO TID with meals
Procrit 5000 units MWF
Zemplar
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ESRD
Pericardial effusion
Discharge Condition:
The patient was discharged hemodynamically stable afebrile with
appropriate follow up.
Discharge Instructions:
Please call your new PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or seek medical
attention in the emergency department if you experience any
chest pain, shortness of breath, fever, chills, nausea,
vomiting, diarrhea, abdominal pain, or any other concerning
symptom.
.
Please take all medications as prescribed.
.
Please keep all follow up appointments.
.
You will start dialysis at [**Hospital1 3597**] Dialysis on a Monday,
Wednesday, and Friday schedule. Your first session will be on
Wednesday, [**10-12**] at 3PM. Your new PCP will be Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Followup Instructions:
Please follow up with your new PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-29**] weeks
by calling [**Telephone/Fax (1) 41132**] for an appointment.
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-1-3**] 9:10
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-10-10**] 10:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2146-10-12**]
|
[
"420.0",
"285.21",
"584.9",
"403.91",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9005, 9011
|
6328, 8482
|
322, 370
|
9090, 9179
|
3274, 6305
|
9896, 10522
|
2708, 2916
|
8684, 8982
|
9032, 9069
|
8508, 8661
|
9203, 9873
|
2931, 3255
|
276, 284
|
398, 2337
|
2359, 2548
|
2564, 2692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,445
| 142,204
|
16751
|
Discharge summary
|
report
|
Admission Date: [**2132-12-10**] Discharge Date: [**2132-12-14**]
Date of Birth: [**2057-1-10**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Respiratory distress
HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with
a large tobacco history, history of laryngeal cancer status
post XRT in [**2124**], who was recently admitted to [**Location 1268**]
VA for workup for six weeks of progressive dyspnea. Workup
at that time included treatment of pneumonia and anemia.
Exercise stress test at that time was positive for inferior
defect, but thought by Cardiology to be insignificant. His
chest CT was notable for slightly increased pulmonary
opacities in the right middle lobe and right upper lobe. The
patient was then bronchoscoped at [**Location (un) 538**] VA with 180
cc of saline infused for bronchoalveolar lavage, with only 60
cc received by suctioning back. His airways were otherwise
normal. The patient developed hypoxemia during the
bronchoscopy. His post-bronchoscopy course was complicated
by tachypnea and poor oxygen saturation of 80% on room air.
He was transferred to [**Hospital1 69**]
and, after one to two hours of continued respiratory distress
and an episode of emesis, the patient was intubated
electively for fear of impending respiratory failure and
aspiration.
REVIEW OF SYSTEMS: Negative for chest pain, positive for
shortness of breath, negative fever and chills, negative
changes in vision or hearing, positive cough, no
palpitations, no changes in bowel movements, no changes in
urine, no back pain, rash or headache.
PAST MEDICAL HISTORY: Hypertension, narrow-angle glaucoma,
dysthymia, laryngeal cancer status post XRT in [**2115**],
bilateral cataracts, history of testicular cancer status post
orchiectomy bilaterally, gastroesophageal reflux disease,
peripheral vascular disease with femoral bypass of the right
to the left, status post carotid endarterectomy in [**2128**],
anemia with a negative esophagogastroduodenoscopy and
colonoscopy workup, slight vocal cord paralysis, status post
prostatectomy after prostate cancer, 3 cm abdominal aortic
aneurysm. During the patient's recent VA admission, he had a
stress MIBI ([**11-20**]) for ten minutes. Left ventricular
function was 71%, with partially reversible inferior defect.
The patient has also been noted to have a newly evolved
positive PPD.
SOCIAL HISTORY: 75 pack year history of tobacco, negative
alcohol, negative intravenous drug use. He lives with his
wife, and he is currently retired.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: Trisalicylate 70 mg three times a
day, cilostazol 100 mg twice a day, Colace 100 mg twice a
day, iron sulfate 325 mg three times a day, Fosinopril 20 mg
by mouth once daily, metoprolol XL 150 mg by mouth once
daily, nitroglycerin as needed, oxybutynin 5 mg by mouth once
daily, Rabeprazole 20 mg twice a day, Senna as needed,
simvastatin 20 mg by mouth once daily, artificial tears two
drops four times a day, aspirin 325 mg by mouth once daily.
PHYSICAL EXAMINATION: His heart rate was 100, blood pressure
originally 255/98, which decreased to 184/59, respiratory
rate 12, oxygen saturation 100% on 100% non-rebreather.
General: This is a moderately obese Caucasian male, lying in
bed, in no acute distress. His pupils are small, equal. He
has no lymphadenopathy, no jugular venous distention. His
neck with post-radiation changes. Cardiovascular: Regular
rate and rhythm, no murmurs. His lungs are clear to
auscultation bilaterally. His abdomen was soft, nontender,
with normal active bowel sounds, positive for a pulsatile
mass. Extremities: No cyanosis, clubbing or edema, with
good distal pulses. He is alert and oriented prior to his
intubation.
LABORATORY DATA: On presentation, sodium 139, potassium 5.5,
chloride 103, bicarbonate 24, BUN 26, creatinine 1.5, glucose
139. White blood cells 15.1, hematocrit 43.4, platelets 212.
ALT 26, AST 49, alkaline phosphatase 91, total bilirubin 0.5,
amylase 38, lipase 24. Calcium 9.7, phosphorus 4.7. CK was
drawn, which was 66, troponin less than 0.3. Arterial blood
gas was 7.36/42/52 on room air, and then increased to
7.35/47/185 on 100% non-rebreather. His chest CT done on
[**12-10**] shows increased right middle lobe and right upper
lobe opacities with tree-and-[**Male First Name (un) 239**] appearance with small
nodules consistent with inflammatory process. His chest
x-ray at the outside hospital showed no pneumonia or
infiltrates. His chest x-ray at [**Hospital1 190**] showed vascular engorgement on the right. A
repeat after intubation shows proper tube placement with
slight increase in vascular engorgement on the right vs
atelectasis. His electrocardiogram on admission was normal
sinus rhythm at 100, normal axis, left atrial enlargement,
intraventricular conduction delay more pronounced, ST
depression, minimal on V4, V5, V6.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit, given his respiratory distress. The patient was
placed on Levaquin and Flagyl. There was concern for
pulmonary embolism, and the patient had a CT angiogram which
was negative for thrombus. However, it showed bilateral
lower lobe opacities, consistent with either multifocal
pneumonia or aspiration. The patient was changed to
clindamycin intravenously. His bronchoalveolar lavage
results came back from the VA, which showed 0-5 PMNs, [**5-9**]
epis, few gram-positive cocci in pairs and chains, and rare
gram-positive rods. Acid fast bacilli was negative.
Mycology is pending. It was felt that the organisms were
likely contaminate that is sometimes seen during
bronchoscopy. Sputum culture grew out oropharyngeal flora.
The patient was ruled out via cardiac enzymes. His blood
pressure was more stabilized. He was extubated after one day
without complication. He was placed on a face mask, and
transitioned over to nasal cannula. He was placed on a
thickened liquid diet, which he was able to tolerate without
any evidence of aspiration. He had a right subclavian line
which was subsequently discontinued. His Foley was
discontinued.
The patient was transferred to the floor. He was weaned to
room air, during which he had oxygen saturation of 95%. He
desaturated slightly to 92% while ambulating. However, the
patient was asymptomatic. He was transitioned from
intravenous to oral clindamycin 300 mg by mouth every six
hours. Thus far his urine culture and blood cultures are no
growth to date. It was felt that the patient was stable for
discharge to home rather than transfer back to the VA. He
should follow up with the pulmonologists at [**Location 1268**] for
further evaluation. In addition, it is recommended that his
positive PPD conversion that was noted two years ago be
further evaluated. At present, he has no cough or symptoms
consistent with tuberculosis, and had a negative acid fast
bacilli during lavage.
DISCHARGE DIAGNOSIS:
1. Respiratory distress
2. Aspiration pneumonia
DISCHARGE MEDICATIONS: The patient is to continue all of his
outpatient medications, and take clindamycin 300 mg by mouth
every six hours for seven additional days, for a total of a
ten day course.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 13803**]
MEDQUIST36
D: [**2132-12-13**] 21:00
T: [**2132-12-14**] 00:00
JOB#: [**Job Number 47347**]
|
[
"401.9",
"997.3",
"518.81",
"507.0",
"V10.46",
"V10.21",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7039, 7460
|
6964, 7015
|
2600, 3047
|
4940, 6943
|
3070, 4922
|
1339, 1582
|
161, 183
|
212, 1319
|
1605, 2374
|
2391, 2573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,948
| 120,693
|
22969
|
Discharge summary
|
report
|
Admission Date: [**2200-1-19**] Discharge Date: [**2200-1-23**]
Date of Birth: [**2118-1-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 3223**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
selective angiography [**1-19**], [**1-20**] (the latter with
embolization)
History of Present Illness:
81 yr male had colonoscopy in Nedeham on [**1-17**], 8mm polyp in
cecum with ooze after polypectomy s/p local cauterization comes
back with profuse post polypectomy bleeding, Hct of 19 ,
hypotension.
Past Medical History:
1. Atrial fibrillation, status post pacer [**2191**]
2. hypertension
3. s/p hernia repair.
4. coronary artery disease status post coronary artery bypass
graft in [**2193-3-28**], three vessels, unknown anatomy
h/o inferior myocardial infarction, history of
echoin [**2194-7-28**] with ejection fraction 50 percent with
moderate tricuspid regurgitation, biatrial enlargement,
mild
left ventricular hypertrophy, moderate mitral
regurgitation,
moderate pulmonary artery systolic hypertension, and
aortic
sclerosis.
Nuclear stress test in [**2196-3-28**] with a moderate to large
fixed
inferior defect without reversibility.
5. Hyperlipidemia.
6. History of first degree AV delay and right bundle branch
block.
7. symptomatic bradycardia and complete heart block
necessitating
8. Guidant pacemaker, history of cardioversion in [**Month (only) **]
[**2194**], atrial fibrillation to normal sinus rhythm.
9. CRI
10. History of anemia with hematocrit 35 and MCV 73 also in
[**2193**].
Social History:
The patient is married. Retired and worked for the town of
[**Location (un) 620**] Sewer Department. He drinks alcohol occasionally but
does not smoke
Family History:
No known history of coronary artery disease or blood disease.
Physical Exam:
99.4/98.5 70 120/60 18 98%RA
gen: NAD, AAOx3
CV: + s1s2
Pulm: CTA b/l
Abd: mildly distended, nontender
Ext: no c/c/e
Pertinent Results:
[**2200-1-19**] 09:50AM BLOOD WBC-6.0 RBC-2.33*# Hgb-6.2*# Hct-19.1*#
MCV-82# MCH-26.7* MCHC-32.4 RDW-17.9* Plt Ct-97*#
[**2200-1-19**] 01:45PM BLOOD WBC-5.4 RBC-2.94*# Hgb-8.5*# Hct-25.0*#
MCV-85 MCH-28.8 MCHC-33.8 RDW-16.9* Plt Ct-81*
[**2200-1-19**] 05:28PM BLOOD WBC-5.6 RBC-2.84* Hgb-8.2* Hct-22.7*
MCV-80* MCH-28.9 MCHC-36.2* RDW-16.1* Plt Ct-47*
[**2200-1-19**] 11:45PM BLOOD Hct-24.8* Plt Ct-83*#
[**2200-1-20**] 12:45AM BLOOD WBC-5.1 RBC-3.17* Hgb-9.3* Hct-25.7*
MCV-81* MCH-29.5 MCHC-36.4* RDW-15.9* Plt Ct-83*
[**2200-1-20**] 04:41AM BLOOD Hct-28.8*
[**2200-1-20**] 07:27AM BLOOD Hct-27.9*
[**2200-1-19**] 09:50AM BLOOD PT-15.6* PTT-24.9 INR(PT)-1.4*
[**2200-1-19**] 05:28PM BLOOD PT-14.2* PTT-25.8 INR(PT)-1.2*
[**2200-1-20**] 07:27AM BLOOD PT-14.7* PTT-25.4 INR(PT)-1.3*
[**2200-1-19**] 09:50AM BLOOD Glucose-106* UreaN-53* Creat-2.7*# Na-139
K-7.0* Cl-108 HCO3-20* AnGap-18
[**2200-1-20**] 12:45AM BLOOD ALT-11 AST-15 AlkPhos-47 Amylase-48
TotBili-2.6*
[**2200-1-20**] 12:45AM BLOOD Lipase-25
[**2200-1-20**] 12:45AM BLOOD Albumin-2.8* Calcium-7.5* Phos-2.9 Mg-1.6
[**1-19**] angiography: No evidence of active contrast extravasation
in the superior or inferior mesenteric artery territories. No
evidence of other vascular malformations.
[**1-20**] angiography:
Active arterial bleeding in the proximal right colon at the
level consistent with the patient's recent polypectomy site,
site embolized
.
[**2200-1-23**] 06:45AM BLOOD Hct-27.5*
Brief Hospital Course:
The patient was admitted and was transfused throughout the night
to maintain hemodynamic stability; he also received concomitant
fresh frozen plasma when appropriate.
Neuro: no issues, acetaminophen for pain control
CV: The patient came to [**Hospital1 18**] with massive lower GI bleeding,
for which he received over 6 units initially in the ED. The
patient was admitted to the ICU for serial hematocrit checks,
and constant vital sign monitoring. The patient was taken to
angiography to localize the bleeding site, which was not
initially localized; for details, please see report. On [**1-20**],
the patient was taken back to angiography, where the site of
bleeding near the prior polypectomy site, and was embolized; for
more details, please see report. The patient's hematocrit
stabilized after a total of 18 units; it was felt that the
patient would not tolerate an operation given his extensive
cardiac history. His hematocrit was monitored every 4-6 hours,
and remained stable until [**2200-1-22**], when his hematocrit dropped
from 27.4 to 24.8; the patient was transfused 2 units, and his
hematocrit rose to 29.2. The patient was having no more bloody
or melenic stools.
Pulm: Stable, the patient had one episode of wheezing, during
which his vital signs were stable. The patient had not received
any respiratory treatments, and could not remember his
medication at home.
GI/GU: The patient was initially made NPO, and received
famotidine. Once the patient's hematocrit had stabilized, he
was given clear liquids; his diet was advanced as his hematocrit
continued to remain stable, which he tolerated well. His urine
output was routinely monitored with a Foley catheter in place.
Heme: As previously mentioned, serial hematocrits were
performed, and the patient was transfused when necessary; he
also received concomitant FFP when appropriate. The patient was
constantly monitored.
Endo: The patient was initially put on an insulin drip for close
blood sugar monitoring. He was changed to a sliding scale once
they were controlled.
Proph: The patient received famotidine for GI prophylaxis, and
had pneumoboots as anticoagulation was not an immediate option.
On discharge, the patient's hematocrit was stable, and the
patient was no longer having any bloody bowel movements or
bright red blood per rectum. The patient was afebrile, vital
signs stable, ambulating, tolerating regular diet, urinating,
and doing well.
Medications on Admission:
ASA, Coumadin, Gemfibrozil 600', Atorvastatin 40'', Famotidine
20'', Metoprolol 75'', lisinopril 20', albuteral, atrovent,
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Niacin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
profuse post polypectomy bleeding/ lower GI bleed
Discharge Condition:
stable
Discharge Instructions:
You may have several dark or marroon bowel movements following
your discharge, which is normal.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You may see dark/black material when you have a bowel
movement; please seek medical attention if you have a large
bright red bowel movement (not dark marroon however)
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications except coumadin.
You may restart your Coumadin and Aspirin on Saturday [**2200-1-25**].
* Continue to ambulate several times per day.
Followup Instructions:
You should follow up with your primary care doctor 1-2 weeks
after discharge. Follow-up with your PCP regarding your Coumadin
and monitoring your INR. Have your INR cheched on Wednesday
[**2200-1-29**]
Please follow up with Dr. [**Last Name (STitle) 519**] as needed; call ([**Telephone/Fax (1) 5323**] to
schedule an appointment if necessary.
[**Known firstname **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2200-2-3**]
|
[
"V45.81",
"585.9",
"414.00",
"403.90",
"V45.01",
"998.11",
"427.31",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.91",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
6983, 6989
|
3584, 6028
|
329, 406
|
7082, 7090
|
2103, 3561
|
8421, 8910
|
1878, 1941
|
6202, 6960
|
7010, 7061
|
6054, 6179
|
7114, 8398
|
1956, 2084
|
274, 291
|
434, 635
|
657, 1691
|
1707, 1862
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,011
| 167,770
|
13326
|
Discharge summary
|
report
|
Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-2**]
Date of Birth: [**2068-7-10**] Sex: M
CHIEF COMPLAINT:
1. Shortness of breath.
2. Hypotension.
with no known history of coronary artery disease, status post
cholecystectomy, history of hypertension, history of
hyperlipidemia, questionable history of CHF, peptic ulcer
disease who presents to an outside hospital one day prior to
admission with one week of epigastric / chest pain. The
patient states that pain was worse after eating and was
persistent. Denies history of chest pain. Denies radiation to
epigastric. No vomiting, positive nausea, positive anorexia,
no subjective fevers at home.
At the outside hospital the patient was noted to have an
increased white blood cell count to 12.3, ALT of 258, AST
256, amylase 448, lipase of 1212, T bilirubin of 2.0.
Abdominal ultrasound was done at the outside hospital but
report was not available. The patient was then sent to [**Hospital1 1444**] for emergent ERCP to treat
gallstone pancreatitis / cholangitis.
Pre-procedure the patient's blood pressure was 88/58, status
post 900 cc of D5 half normal saline given en route from
outside hospital. The patient's IVFs were increased and BP
rose to 96. After given Versed and Fentanyl the patient's
blood pressure dropped to 84. During the procedure, the blood
pressure was 75/53 and fluids were continued. By the end of
procedure, 1300 cc of normal saline were given and blood
pressure was 91/49. The patient then began to complain of
shortness of breath and was hypoxic requiring 100%
non-rebreather to maintain a saturation of 92%. The MICU team
was then called to further evaluate the patient for ICU
admission.
ERCP showed a common bile duct of 10 mm. After [**Last Name (LF) 40561**],
[**First Name3 (LF) **] pus was drained and stone was extracted. Medications
given during ERCP included Fentanyl 125 micrograms, Glucagon
0.2 mg, Midazolam 0.5 mg IV. The patient was also given
Ampicillin, Levofloxacin and Flagyl.
On review of systems the patient denied orthopnea, denied
dyspnea on exertion, denied chest pain, denied lower
extremity edema, denied melena, denied bright red blood per
rectum, denied shortness of breath, denied wheezing, denied
dysuria, pyuria in the past.
PAST MEDICAL HISTORY:
1. Peptic ulcer disease H pylori positive in [**2124**].
2. Status post cholecystectomy approximately six years prior
to admission.
3. Hypertension blood pressure approximately 140 at home.
4. Hyperlipidemia.
5. Questionable history of chronic renal insufficiency.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Procardia.
2. Avapro.
3. Lipitor.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No alcohol or tobacco use. The patient lives
at home with wife and children. He is retired.
PHYSICAL EXAMINATION: Blood pressure approximately 80 to
90/50, 02 saturation 92% on 100% non-rebreather, heart rate
120s, respiratory rate 25 to 30. HEENT - extraocular muscles
are intact. Pupils are equal, round and reactive to light.
JVP about 10 cm. Neck is supple. Heart - tachycardic,
questionable S3, normal S1, S2. Lungs - positive bibasilar
crackles half way up, no egophony, no dullness to percussion.
Abdomen - status post cholecystectomy, open scar, slight
distention, positive bowel sounds, no tenderness, no rebound,
no guarding. Extremities - trace 1+ pitting edema, warm and
well perfused.
LABORATORY DATA: Not available upon initial evaluation of
patient.
EKG - Sinus tachycardic at 147 beats per minute, axis
indeterminate, J point elevation in V1, V2, V3, V4, no acute
ST-T segment changes, 1 mm Q in II and F.
ASSESSMENT AND PLAN: This is a 62 year-old male with history
of peptic ulcer disease, status post cholecystectomy,
hypertension, questionable history of chronic renal
insufficiency who presents with ascending cholangitis and
gallstone pancreatitis, now status post ERCP with hypotension
and hypoxia.
1. In terms of the patient's ascending cholangitis and
sepsis hypotension pre-procedure suggests that the patient
already had septic physiology prior to ERCP most likely from
a biliary source secondary to obstruction by gallstone.
Drainage already achieved by ERCP. The plan was to continue
Ampicillin, Levofloxacin and Flagyl to cover for biliary
flora.
2. Pulmonary edema - no previous history of CAD. Ejection
fraction is unknown, history of hypertension. Chest x-ray
consistent with pulmonary edema. It was felt that the patient
might have diastolic dysfunction exacerbated by tachycardia
or may have had a low ejection fraction prior to admission.
However the patient denied any symptoms of heart failure.
Plan was for echocardiogram in the A.M. and for possible Swan
placement to guide pressor / IV fluid treatment. The
patient's cardiac enzymes were also planned to be sent.
Aspirin was held because of recent procedure.
3. Fluid status - it was felt that the patient would most
likely need fluid resuscitation for sepsis. However the
patient's hypoxia was concerning. It was unclear at this time
whether this patient was in CHF or pulmonary edema secondary
to ARDS. It was thought at this time the Fenard ICU team
would attempt to give Lasix to improve hypoxia but suspected
that the patient would need to be intubated shortly and a PA
catheter placed for guidance of fluid resuscitation.
4. Acute renal failure - the patient was anuric upon
admission to the Fenard ICU with a creatinine from outside
hospital of 2.8. Although it had been written on the outside
hospital records that the patient had a history of chronic
renal insufficiency, the patient and the patient's family
denied any such history. There was no baseline creatinine in
our computers to determine what his renal function was prior
to admission. A creatinine and urine electrolytes were
planned to be checked.
5. Pancreatitis - the patient's amylase, lipase were planned
to be followed and along with hematocrit, calcium and
glucose.
6. Pulmonary - the patient had pulmonary edema on chest
x-ray and by exam and hypoxia. It was felt that the patient
most likely would have to be intubated for his hypoxia and
pulmonary edema. An ABG was sent.
HOSPITAL COURSE: The patient was quickly transferred to the
ICU from the ERCP suite. On arrival to the [**Hospital Ward Name 332**] ICU the
patient was pleasant, oriented times three although
respiratory rate had increased to 40 breaths per minute. O2
saturations continued to be in the 90s on 100%
non-rebreather. The patient's heart rate was also increased
to 130s to 140s with occasional PVCs. Although the patient
was anuric it was decided we would try a course of Lasix
first 20, 80 and then 160 mg IV given without any response.
Foley was placed however only 70 cc of concentrated urine was
obtained. It was then decided this was probably not due to
congestive heart failure but most likely secondary to
overwhelming sepsis and the decision was made to intubate the
patient. Anesthesia was called and IV fluids were started in
the patient's peripheral IVs.
The patient was intubated and became more profoundly
hypotensive post intubation. The patient received Etomidate
pre intubation. He became agitated and required Ativan and
Fentanyl and eventually needed four points restraints. A
femoral line was quickly placed and IV fluids were run wide
open. The patient's blood pressure continued to drop into the
70s and Dopamine was started. Levo was quickly added as the
patient's blood pressure did not respond to Dopamine then
Neo-Synephrine. The patient received maximal doses of three
vasopressors and wide open fluids were also continued. One liter
of normal saline and one liter of D5 with three amps of bicarb
were running wide open at all times. Vasopressin was then added
at 0.04 units per minute and Epinephrine drip was also added as
the patient's blood pressure continued to drop.
The patient then had asystolic arrest, frequent doses of
epinephrine / Atropine bicarb were administered and CPR was
started and continued throughout administration of these
medications. The patient was very difficult to oxygenate and
large amounts of yellow, brownish frothy watery substance
came out of the patient's ET tube. The patient repeatedly had
PEA arrests and continued to ooze copious yellow secretions
from the ET tube.
Five pressors were running at maximum doses. Since the
patient did not seem to respond to pressors, it was felt that
the patient's hemodynamic deterioration was most likely
secondary to severe hypoxia. The patient was prone however
did not improve his hypoxia. The patient was then tried on
several recruitment breaths and inspiratory pauses without
much improvement in oxygenation. Serial ABGs showed severe,
worsening acidosis.
After over one hour of CPR and multiple doses of Epinephrine,
Atropine were given, there was no improvement in the
patient's hemodynamic and respiratory status. Resuscitation
efforts ceased after two hours of attempts approximately 1:30
A.M. The family was notified all of the events during the
resuscitation efforts. At approximately 1:30 A.M. the patient
had asystolic arrest. Pupils were fixed and dilated. There
was no response to pain, no spontaneous breaths or heart
sounds were heard.
The patient's family was notified and wife declined autopsy.
ME was notified and declined case.
DISCHARGE DIAGNOSIS:
1. Sepsis / ARDS / pulmonary edema.
2. Cholangitis / pancreatitis.
DISCHARGE CONDITION: Expired.
Dr.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] [**MD Number(4) 2438**]
Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36
D: [**2131-7-10**] 17:00
T: [**2131-7-11**] 12:47
JOB#: [**Job Number 40562**]
|
[
"997.1",
"401.9",
"038.9",
"428.0",
"576.1",
"577.0",
"574.50",
"427.5",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"96.04",
"96.71",
"38.91",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
9487, 9752
|
2723, 2741
|
9395, 9465
|
6237, 9374
|
2582, 2707
|
2872, 6220
|
133, 2266
|
2288, 2559
|
2757, 2850
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,333
| 158,323
|
27820
|
Discharge summary
|
report
|
Admission Date: [**2165-6-5**] Discharge Date: [**2165-6-11**]
Date of Birth: [**2094-1-21**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Aspirin / Cephalosporins
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Transferred from OSH for pneunonia/respiratory failure
Major Surgical or Invasive Procedure:
s/p intubation
central line
History of Present Illness:
This is a 71 y/o F with a PMHx of protein c/s deficiency and
recurrent DVTs/PEs on anticoagulation s/p IVC filter,
parkinson's disease, and chronic renal insufficency who
originally presented to an OSH on [**5-14**] with abd pain. She was
treated for pancreatitis, which she has had before, with
resolution. However, her course was complicated by a cough and
shortness of breath. A bronchoscopy revealved diffuse [**Female First Name (un) **]
pneumonia and enterobacter pneumonia. Fluconazole was started.
She developed respiratory distress and hypotension and was
intubated on [**6-2**]. She was also put on a dopamine drip. On [**6-4**],
she was extubated and weaned off dopamine, but on [**6-5**] she
developed worsening metabolic acidosis and was re-intubated
electively for fatigue. She was transferred to [**Hospital1 18**] ICU for
further care.
.
At [**Hospital1 1388**] MICU, her pneumonia was treated with levofloxacin and
fluconazle with improvement. She successfully extubate on [**6-6**]
and was transferred to the medical floors for further care.
Past Medical History:
#Protein C/S deficiency c/b recurrant DVTs/PEs
#Hx of IVC filter placement
#Hyperchol
#Parkinson's
#s/p appy
#Bowel perforation d/t SBO s/p colostomy
#Macular degeneration/cataracts
#hx of pancreatitis [**12/2164**]
Social History:
Lives at home with significant other. Quit etoh >25 yrs ago,
quit tob >10 yrs ago. Unclear smoking hx.
Family History:
Non-contributory
Physical Exam:
VS: T97.7 HR 58 BP 158/65 RR 20
GEN: Alert and oriented x 3, NAD
HEENT: Anicteric, MMM, thrush in oropharynx
NECK: R IJ in place
CV: Regular, normal s1,s2; no m/g/r
RESP: bibasiliar crackles, left > right
ABD: Soft, nondistended. +BS, colostomy intact
EXT: 1+ pedal edema. Pulses 2+
NEURO: Non-focal
Pertinent Results:
OUTSIDE HOSPITAL RECORDS:
ABG [**6-5**] 9am 7.25!37!83!16 on 6L NC
ABG [**6-5**] 11am 7.22!44!68 on 9L NC
Lactate [**6-3**] 0.6
.
MICRO:
Sputum Cx [**6-3**] Enterobacter ([**Last Name (un) **] to gent, cefeime, ceftaz,
aztreonam, levaquin, cipro, imipenem, ceftriaxone); (resis to
amp, keflex, unasyn)
Urine Cx [**6-3**] Yeast
Blood Cx 6/24,6/29,[**6-2**] NGTD
BAL [**5-24**] Many yeast
.
TTE [**6-3**] EF 60-65%. Nml LV fxn. Mild LAE. RA/RV nml. Tr MR. [**First Name (Titles) **] [**Last Name (Titles) **]R.
.
LENI [**6-3**] Neg for DVT bilat.
.
Bronchoscopy [**5-24**]: Oropharynx [**Female First Name (un) 564**], fairly extensive. Mild
moderate bronchitis present throughout. Frothey secretions in
main airways. Considerable patches of what appeared to be
[**Female First Name (un) 564**] were present.
.
CT chest [**5-22**]: Bibasilar atelectasis or infiltrate, small
effusions and RUL infiltrate. No mass, nodule, or LAD.
.
V/Q scan [**5-21**]: Low probability of PE.
.
WBC-8.8 Hct-29.0* MCV-87 Plt Ct-266
Neuts-72* Bands-2 Lymphs-5* Monos-1* Eos-12* Baso-0 Atyps-0
Metas-6* Myelos-2*
Hapto-323*
.
PT-29.5* PTT-31.7 INR(PT)-3.1*
.
Na-144 K-3.8 Cl-116* HCO3-19* Glucose-81 UreaN-17 Creat-1.8*
Calcium-8.2* Phos-3.1 Mg-1.8
.
BLOOD Lactate-0.8
.
ABG (Intubated): pH-7.40 pO2-306* pCO2-27*
.
ALT-3 AST-9 LD(LDH)-269* AlkPhos-107 Amylase-50 TotBili-0.2
Albumin-2.8* Lipase-46
.
HIV Ab-NEGATIVE
SPEP-PND
UPEP-PND
IMAGING
CXR: [**2165-6-5**]
IMPRESSION:
1. Abnormal position of the ET tube terminating in right main
bronchus.
2. Mild pulmonary edema.
3. Left lower lobe consolidation could be due to infectious
process or
atelectasis. Small left pleural effusion.
Brief Hospital Course:
This is a 79 year old female with PMHx of protein c/s defiency
and recurrent DVTs/PEs on anticoagulation s/p IVC filter, and
parkinson's disease, who presented to an OSH on [**5-14**] with a
partial small bowel obstruction and pancreatitis. Her hospital
course was complicated by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and enterobacter pneumonia
and was intubated twice before transferring to [**Hospital1 18**] for further
care.
.
# RESPIRATORY FAILURE:
Intubated and transferred to [**Hospital1 18**] for fatigue and increasing
acidosis. Her acidosis improved and she was extubated without
complications.
.
# PNEUMONIA:
She had a CXR upon admission to [**Hospital1 18**] which showed a LLL
consolidation and left pleural effusion with some pulmonary
edema. We continued to treat her enterobacter and [**Female First Name (un) **]
pneumonia with fluconazole and levofloxacin and she improved
over the hospital course, and did not require oxygen on
discharge. She will complete a 14 day course of fluconazole and
levofloxacin after discharge. She was diuresed adequately with
furosemide. Albuterol nebs were given to her but she became
tremulous and it was stopped. There is a question of why she
would be infected with [**Female First Name (un) **] pneumonia and an
immunocomprimised state is a possibility. Her HIV test is
negative. Her SPEP and UPEP are pending at time of discharge.
Please follow up for results.
.
# CHRONIC RENAL FAILURE:
Per her outpatient clinic (PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32496**],
1-[**Telephone/Fax (1) 58523**]):
Creatinine 2.0 in [**1-7**], and 2.5 in [**8-6**]. She is
currently at her baseline. (Cr=1.8 today.) She had a renal u/s
that was neg for hydronephrosis.
.
# NON-ANION GAP METABOLIC ACIDOSIS:
Per outpatient clinic, she has chronic metabolic acidosis. Her
bicard in [**2165-1-2**] was 20. She is currently at 21. Liekly due
to chronic renal insufficiency.
.
# NORMOCYTIC ANEMIA
Non-hemolytic, guaiac negative. Likely anemia of chronic
disease. Consider outpatient workup including colonoscopy.
.
# H/O DVT/PE:
She has protein C/S deficiency and is s/p IVC filter. She takes
coumadin and Fragmin at home with an INR goal of [**1-4**]. She had a
negative LENIs at OSH. She will continue coumadin 2.5 mg qDay
and prophylactic enoxaparin (30mg QD)on discharge.
.
# ORAL THRUSH:
Resolved at discharge with fluconazole.
.
# PANCREATITIS: resolved upon tranfer from OSH. Unclear
etiology. Will need further workup as an outpatient. [**Month (only) 116**]
consider MRCP.
.
# PARKINSONS DISEASE:
Continued outpatient Ropinirole HCl and Carbidopa-Levodopa.
.
# CHRONIC PAIN:
She has seen pain management in the past. She is currently on a
fentanyl patch, a lidocaine patch on her wrist. Percocet was
given for breakthrough pain.
Medications on Admission:
Meds at Home:
Coumadin - unclear dose (2.5mg qD at OSH)
Fragmin 2500U SC qd
Lipitor 20 qD
Lasix 80mg tid
Requip 4mg tid
Sinemet 1 tab tid
Duragesic patch 100mcg
Vicodin prn
Zoloft 200 qD
Xanax 0.5mg [**Hospital1 **] prn
Relpax(eletriptan) 40mg prn
Neurontin 300 tid
Klonipin 0.5mg tid prn
MVI/Vit B6
*
Meds on transfer:
Imipenem 250 IV q8
Pulmicort [**Hospital1 **]
Fluconazole 100 IV qD
Combivent q4
PPI
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Ropinirole 1 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
Disp:*360 Tablet(s)* Refills:*2*
6. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD TO WRIST ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Gabapentin 300 mg Tablet Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*2*
12. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
once a day.
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain: breakthrough
pain.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 12366**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
[**Female First Name (un) 564**] and Enterobacter pneumonia
Sepsis in the context of pneumonia (resolved upon transfer from
OSH)
Hypotension likely due to sepsis (resolved upon transfer from
OSH)
Respiratory failure, s/p intubation 2x
Metabolic acidosis
Anemia of chronic disease
Pancreatitis of unclear etiology (resolved upon transfer from
OSH)
Anasarca, due to fluid resuscitation
.
SECONDARY DIAGNOSIS:
Chronic renal failure
Parkinson's disease
Hypercoagulable state (h/o recurrent DVTS/PEs)due to Protein C/S
deficiency
Discharge Condition:
hemodynamically stable, afebrile, ambulating
Discharge Instructions:
Please take all medication as prescribed. Please follow up with
all appointments. If you feel chest pain or shortness of
breath, contact your physician [**Name Initial (PRE) 67808**]. Please also see
your physician if you continue to have cough, or if you have
fever or chills.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-3**] weeks
after discharge from rehab.
|
[
"482.83",
"276.2",
"577.0",
"584.9",
"585.4",
"285.29",
"289.81",
"V58.61",
"112.0",
"518.81",
"272.0",
"332.0",
"112.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9070, 9122
|
3897, 6772
|
349, 378
|
9710, 9757
|
2206, 3874
|
10086, 10216
|
1852, 1870
|
7227, 9047
|
9143, 9143
|
6798, 7100
|
9781, 10063
|
1885, 2187
|
255, 311
|
406, 1475
|
9569, 9689
|
9162, 9548
|
1497, 1714
|
1730, 1836
|
7118, 7204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,868
| 167,496
|
52918
|
Discharge summary
|
report
|
Admission Date: [**2163-5-30**] Discharge Date: [**2163-6-2**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 year old woman with hx of ESRD on HD, diastolic CHF, PVD s/p
bilateral lower leg amputations, and atrial fibrillation
presenting with shortness of breath. She was recently
discharged from [**Hospital1 18**] on [**2163-5-14**] following an admission for
hypertensive urgency complicated by hypoxia due to pulmonary
edema. During that admission, she was placed on CPAP, had blood
pressure control with a nitroglycerin gtt initally and had extra
HD/UF sessions. There was no clear etiology to the
decompensation as she had no clear cardiac ischemic event nor
missed HD session. She was discharged to resume her usual MWF
dialysis sessions.
.
On Saturday night she first noted shortness of breath when she
was trying to sleep. She stated that everytime that she would
try to lay flat she would get more short of breath. She denied
chest pain, cough, or diaphoresis. She had no
fevers/chills/sweats prior to coming to the hosptial. She stated
that before coming into the hospital that she noted her heart
was racing.
.
In the ED, her initial vital signs were T not recorded HR 113 BP
230/112 38 100%NRB. She was started on a nitroglycerin gtt. She
was started on CPAP. She received lasix 100 mg x1 to which she
urinated ~80cc. She received 1 dose of ceftriaxone and was
prescribed 1 dose of levofloxacin.
Past Medical History:
- Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure
Social History:
Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.
Family History:
Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.
Physical Exam:
VS: 96 78 163/80 23 100% 5L
GEN: NAD
HEENT: AT, NC, PERRLA, arcus senilus, EOMI, no conjunctival
injection, anicteric, OP clear, MMM, Neck supple, no LAD, no
carotid bruits
CV: RRR, nl s1, s2, 3/6 systolic murmur at apex
PULM: crackles [**12-23**] way up from base, dullness at bases
ABD: soft, NT, ND, + BS, no HSM
EXT: bilateral BKA w/o evidence of skin breakdown. no femoral
bruits. biphasic thrill in AV graft to left arm
NEURO: alert & orientedx3, CN II-XII grossly intact, [**4-25**]
strength throughout upper extremities. No sensory deficits to
light touch appreciated. No asterixis
PSYCH: appropriate affect
Pertinent Results:
EKG [**2163-5-30**]:Sinus rhythm. Left ventricular hypertrophy with ST-T
wave changes. Left atrial abnormality. Compared to the previous
tracing of [**2163-5-13**] the ST-T wave changes are more prominent and
may represent superimposed inferolateral ischemic process.
Followup and clinical correlation are suggested.
.
Renal U/S [**5-31**]: IMPRESSION: No solid renal masses identified.
Echogenic kidneys consistent with chronic renal disease and
multiple bilateral small simple renal cysts.
.
CXR: Cardiac silhouette is difficult to assess as there are
dense fluffy bilateral perihilar consolidations, obscuring the
heart borders. Pulmonary vascularity is increased, with
cephalization. There are small bilateral pleural effusions,
right greater than left. There is no pneumothorax.
.
[**2163-3-24**] TTE - The left atrium is moderately dilated. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is severe mitral annular
calcification. There is moderate functional mitral stenosis
(mean gradient 9 mmHg) due to mitral annular calcification.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion.
IMPRESSION: Severe symmetric LVH with a small cavity and
hyperdynamic systolic function. Minimal resting LVOT
obstruction. Moderate functional mitral stenosis. Moderate
pulmonary hypertension.
.
Microbiology:Sputum
[**2163-5-31**] 8:46 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2163-5-31**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
Brief Hospital Course:
73 year old woman with hx of diastolic CHF, DM2, ESRD on HD
presenting with acute hypoxia and hypertensive urgency
.
# Hypoxia: Given her hx of severe dCHF, difficulty removing
fluid at HD due to LVOT obstruction, pulmonary edema on
presentation CXR, hypoxia appeared most consistent with
diastolic CHF exacerbation. As she was hypertensive to the 200s
systolic and reported palpitations prior to admission, both htn
and perhaps a.fib with RVR caused worsening of her pulmonary
edema on presentation. Although she had leukocytosis, she was
without fever, cough, sputum production to suggest underlying
pulmonary infection. She does have hyperinflated lungs on CXR
and was mildly bronchospastic on admission, so she was started
on azithromycin, spireva, and albuterol nebs. Cardiac enzymes
x3 showed flat troponin at 0.04-0.05 and negative MBI so as not
to suggest ischemic event. As she has no PFTs in our system,
she should follow up for outpatient PFTs. Additionally, as she
is on 2L O2 via nasal cannula at night (prescribed by outside
MD), she should have outpatient sleep study.
.
# Leukocytosis: All cell lines were up on presentation however
this was pre HD/UF so unlikely due entirely to
hemoconcentration. She was, however, without fever and no clear
source of infection. CXR showed pulmonary edema and small
effusions without clear evidence of infiltrate and she was
without cough and fever. UA was negative for infection. She
had no GI symptoms to suggest as possible infective source. As
she was initially mildly bronchospastic on exam, she was started
on azithromycin x 5 day course.
.
# ? COPD: No formal diagnosis, however lungs markedly
hyperinflated on CXR and with significant pack year history of
tobacco use with continued use (although less so). There was
initially some concern for COPD contributing to her hypoxia
given mild bronchospasm on presentation. She was started on
spireva and albuterol nebs as well as azithromycin and her exam
improved markedly. She should follow up for outpatient PFTs.
.
# Erythrocytosis: Previous baseline hct high 20s-low 30s. She
presented with hct 51-->43. Last HD/UF session was 3 days PTA
so seemed unlikely all hemoconcentration; she did report poor PO
however. She has not been receiving epogen at HD session per
renal as her hgb has been > goal. Renal U/S was negative for
mass suggestive of erythropoietin producing mass. An epo level
was sent.
.
# End-stage renal disease: She was continued on her home phos
binder and nephrocaps and was continued on HD qMWF as per her
normal schedule.
.
# Atrial fibrillation: She remained in NSR while in house and
INR was therapeutic on presentation. She was supratherapeutic on
day of discharge. Thus, she was advised not to take her dose of
coumadin on [**6-1**]. She was continued on metoprolol and coumadin.
.
# HTN: She was briefly on nitro gtt upon arrival to the ICU
given SBPs in the 200s. She was, however, quickly titrated off
and post HD, SBPs were stable in the 120-140s range on
metoprolol alone. Upon transfer to the medical floor pt's home
regimen of BB, CCB, [**Last Name (un) **], ACEI were restarted with good effect
(BP's 120's-140's). She will go home on this regimen.
.
# Diabetes mellitus type 2 with complication of nephropathy:
She was continued on her home dose NPH with sliding scale
coverage.
.
# Hypercholesterolemia: She was continued on her outpatient
dose simvastatin.
.
# GERD: She was continued on outpatient ranitidine.
Medications on Admission:
Aspirin 325 mg Tablet DAILY
Simvastatin 80 mg DAILY
Sevelamer HCl 800 mg TID W/MEALS
Ranitidine HCl 150 mg [**Hospital1 **]
Metoprolol Tartrate 100 mg [**Hospital1 **]
Lisinopril 30 mg DAILY
Irbesartan 150 mg daily
Diltiazem HCl SR 120 mg DAILY
Nephro-caps daily
Warfarin 2 mg PO 2X/WEEK (MO,FR)
Warfarin 3 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA).
NPH 4 units [**Hospital1 **].
BRIMONIDINE 0.15 % Drops - 1 Drops(s) in the right eye DAILY
LATANOPROST 0.005 % Drops - 1 Drops(s) in the right eye HS
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: dose on [**6-1**] held.
Disp:*30 Tablet(s)* Refills:*2*
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*qs Cap(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4)
units Subcutaneous twice a day: to be taken QAM and Qdinner.
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*2*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
15. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Major:
COPD flare
HTN urgency
ESRD on HD
.
Minor:
DM
afib
HTN
hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with shortness of breath and high blood
pressure. For this you were admitted to the ICU and placed on
non-invasive ventilation and a nitro drip. You were given a
session of dialysis for which your breathing and blood pressure
improved. You were restarted on your home regimen of blood
pressure meds with good effect.
.
If you develop fevers, chills, increasing shortness of breath,
chest pain, weight gain >3lbs, or any other concerning symptom,
please contact your doctor or go to the emergency room.
.
Please take your medications as prescribed and follow up with
the appointments below.
.
You should also continue your already arranged hemodialysis
session on M/W/F. You should also resume having your INR checked
for proper coumadin dosing as you were at dialysis sessions.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-7-14**] 12:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2163-8-29**]
11:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2163-12-7**]
1:40
|
[
"272.0",
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"588.81",
"V18.0",
"428.0",
"530.81",
"305.1",
"424.0",
"585.6",
"V17.3",
"V49.75",
"443.9",
"V58.61",
"425.1",
"428.33",
"V58.67",
"250.40",
"403.91",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11248, 11325
|
5677, 9159
|
334, 340
|
11446, 11455
|
3484, 5617
|
12300, 12742
|
2571, 2830
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9722, 11225
|
11346, 11425
|
9185, 9699
|
11479, 12277
|
2845, 3465
|
5654, 5654
|
275, 296
|
368, 1681
|
1703, 2301
|
2317, 2555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,058
| 158,838
|
52824
|
Discharge summary
|
report
|
Admission Date: [**2174-11-14**] Discharge Date: [**2174-11-23**]
Date of Birth: [**2092-10-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
ICD firing x2.
Major Surgical or Invasive Procedure:
Ventricular Tachycardia ablation
History of Present Illness:
Mr [**Known lastname 108925**] is an 82 year old man with ischemic cardiomyopathy
(EF 30-35% in [**2172**]), coronary artery disease, status post CABG
in 93 and multiple coronary interventions, status post ICD
implantation and upgrade to biventricular ICD, presenting with 2
episodes of ICD firing this morning. It felt like a punch in
his chest. The first episode woke him from sleep and the second
one occurred about a 1/2 hour later. The patient denied feeling
unwell, lightheaded, dizzy or fainting. He denied any chest
pain or pressure, SOB or dyspnea on exertion. He had been
feeling well overall. He has never felt a shock before.
However, he says he was told by his physician that his ICD had
fired in the past, but he did not feel it at that time. He
reports stable DOE at baseline and a 3lb weight gain.
In the ED, his initial VS were: 97.2 72 125/70 14 100% ra. EP
was consulted and interrogated his pacer. They found that he
has underlying AF and has had ~10 episodes of VT. He
successfully paced out of all but 2, which required ICD firing.
In the ED, he was having more runs of VT 120-130, but has been
hemodynamically stable. He received a bolus of amiodarone 150mg
x1. His most recent vitals are: HR 85, BP 130/88, RR 16 Sats
99% RA.
In the CCU, the patient felt well and was asymptomatic; however,
he developed continuous slow VT and the decision was made to
take him to the lab for an ablation. In the lab he underwent a
successful ablation of a single focus of VT in inferior left
ventricle close to his septum. After the procedure the VT was
non-inducible. Patient is having a few PVCs.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: [**2157**] (LIMA-LAD,SVG-RCA,SVG-OM1/OM2)
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**10/2168**]:
1. Native severe three vessel coronary artery disease.
2. Patent LIMA->LAD, patent SVG->OM2->OM2 with widely patent
stent,
ulcerated stenosis in the SVG->RCA, with distal 30% in-stent
restenosis.
3. Successful stenting of the SVG-RCA.
4. Mild ventricular diastolic dysfunction.
.
[**3-/2166**]
1. Successful stenting of the saphenous vein graft to RCA.
2. Patent vein graft to obtuse marginal (stented [**4-17**]).
.
[**3-/2166**]: Three vessel coronary artery disease. Patent LIMA-LAD,
moderately diseased SVG-RCA and totally occluded SVG-OM1/OM2.
Successful stenting of the SVG-OM1-OM2.
.
[**3-/2158**]: Left Main and two vessel CAD. Normal ventricular
function
.
-PACING/ICD: [**Hospital1 **]-ventricular ICD ([**Company 1543**] Concerto, generator
changed [**2174-1-7**])
_____ PR Amplitude | Threshold | Impedance
Atrial Lead 1.8 mV | 0.5 V | 432 ohms
RV Lead 14.7 mV | 1.8 V | 390 ohms
LV Lead 13.1 mV | 0.9 V | 603 ohms
.
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation
- CHF (systolic and diastolic) s/p ICD/pacer
- prior IMI '[**41**] s/p CABG '[**57**], s/p PCI
- CHB/VF
- Hypothyroidism
- Mitral regurgitation
- CKD - stage IV.
Social History:
Married. Lives with his wife. [**Name (NI) **] several grown children. Use
to have a furniture business. Now retired.
-Tobacco history: Denies.
-ETOH: 1 beer rarely.
-Illicit drugs: Denies.
Family History:
Father died of an MI at age 62. Mother with diabetes. No family
history of arrhythmia, cardiomyopathies, or sudden cardiac
death.
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 8. no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. soft systolic murmur at apex. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. femoral sheath in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT dop +
Left: Carotid 2+ DP 1+ PT dop +
Pertinent Results:
ADMISSION LABS [**2174-11-14**]:
[**2174-11-14**] 08:05AM WBC-5.0 Hgb-10.9* Hct-32.3* Plt Ct-135*
[**2174-11-14**] 08:05AM Neuts-66.2 Lymphs-25.1 Monos-6.1 Eos-2.4
Baso-0.2
[**2174-11-14**] 08:05AM PT-19.7* PTT-30.1 INR(PT)-1.8*
[**2174-11-14**] 08:05AM Glucose-121* UreaN-60* Creat-2.5* Na-143 K-4.5
Cl-105 HCO3-27 AnGap-16
[**2174-11-14**] 08:05AM CK(CPK)-63
[**2174-11-14**] 08:05AM cTropnT-0.06*
[**2174-11-14**] 08:05AM Calcium-9.5 Phos-3.5 Mg-2.1
STUDIES:
[**11-14**] CXR:
As compared to the previous radiograph, there is no relevant
change. The position and course of the ICD is constant.
Unchanged minimal
cardiomegaly without evidence of overhydration. Calcifications
and mild
tortuosity of the thoracic aorta. No focal parenchymal opacities
suggesting pneumonia, no pleural effusions. No pneumothorax.
Brief Hospital Course:
Mr [**Known lastname 108925**] is a 82 yo male with a ischemic cardiomyopathy (EF
30-35% in [**2172**]), coronary artery disease, status post CABG in 93
and multiple coronary interventions, status post ICD
implantation and upgrade to biventricular ICD, presenting with 2
episodes of ICD firing this morning s/p EP ablation.
1. Ventricular Tachycardia: The patient presents with 2 episodes
of ICD firing while at home 30 minutes apart. There were no
preceding events or symptoms. He came to the ED and his pacer
was interrogated. They found that he has underlying AF and has
had ~10 episodes of VT. He successfully paced out of all but 2,
which required ICD firing. He continued to have runs of VT
120-130 in the ED, but remained hemodynamically stable. He
received a bolus of amiodarone 150mg x1, but continued to have
slow VT in the CCU. The decision was made to take him to the EP
lab for ablation. In the lab he underwent a successful ablation
of a single focus of VT in inferior left ventricle close to his
septum. After the procedure the VT was non-inducible. The
patient was continued on 200mg amiodarone and carvedilol
increased to 25 mg [**Hospital1 **]. The patient's groin site was
complicated by bleeding and hematoma after an episode of nauesa
and vomiting. Pressure was applied for 30 minutes and bleeding
stopped. Patient developped aneurysm in the cath insertion.
[**Hospital1 **] surgery was consulted and recommended thrombin
injection, which went succesfully on [**Hospital1 766**] [**2174-11-21**]. The
patient remained hemodynamically stable and had an episode of
slow VT that he was ATP paced out of. The patient will continue
amiodarone 200mg daily and carvedilol 25mg [**Hospital1 **].
2.. Pseudoaneurysm: Patient underwent U/S on [**11-18**] that showed
2.8cm pseudoaneurysm. He was evaluated by [**Month/Year (2) 1106**] surgery and
coumadin was held. The patient's Hct was monitored and remained
stable. He underwent on [**2174-11-21**] thrombin injection to repair
the pseudoaneurysm.
3. Acute on chronic anemia - The patient had a groin bleed on
[**11-15**] after nausea/vomiting following his ablation. Pressure
was held for 30mins he remained hemodynamically stable. The
patient Hct remained stable between 26-28. The patient had no
further evidence of bleeding. On [**11-17**] his Hct trended down to
24 and was transfused 1U pRBC. He was continued on his
outpatient epoetin, folic acid and B12.
4. Acute on Chronic kidney disease - The patient's baseline
creatinine is 2.3-2.8. His creatinine trended up to 3.1 likely
from hypovolemia in the setting of nausea/vomiting and poor po
intake. Lasix and spironolactone were held transiently but
restarted prior to discharge.
5. Chronic Systolic Heart failure: Secondary to ischemic
cardiomyopathy. Patient remained euvolemic. Initially lasix
and spironolactone were held in the setting of acute kidney
injury but these were restarted prior to discharge. Continued
on other home medications
6. Atrial fibrillation: Coumadin was held in the setting of
bleeding from the groin. The patient was restarted on coumadin
with a goal INR of [**12-28**] and was continued on carvedilol.
7. Hypothyroidism: The patient was continued on levothyroxine.
8. BPH: The patient was continued on finasteride.
Medications on Admission:
# Allopurinol 100 mg Tablet PO daily
# Amiodarone 200 mg Tablet 0.5 (One half) Tablet(s) PO once a
day
# Calcitriol 0.25 mcg Capsule PO once a day
# Carvedilol 12.5 mg Tablet PO BID
# Epoetin Alfa [Procrit] 10,000 unit/mL Solution 0.5ml weekly as
directed
# Finasteride [Proscar] 5 mg Tablet PO daily
# Folic Acid 1 mg Tablet PO TID
# Furosemide 40mg PO daily
# Levothyroxine [Synthroid] 100 mcg Tablet PO daily
# Simvastatin 20 mg Tablet PO QHS
# Spironolactone 25 mg Tablet 0.5 (One half) Tablet(s) by mouth
once a day
# Warfarin [Coumadin] 2mg tabs 1.25mg PO daily at 16:00
# Aspirin 81mg PO daily
# Cyanocobalamin [Vitamin B-12] 1,000 mcg Tablet PO daily
# Omega-3 Fatty Acids [Fish Oil] 1,200 mg-144 mg Capsule PO BID
# Psyllium [Metamucil] 0.52 gram Capsule by mouth twice a day
# Pyridoxine [Vitamin B-6] 100 mg Tablet PO daily
# Vitamin E 100 unit Capsule PO once a day
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Fish Oil 1,200-144-216 mg Capsule Sig: One (1) Capsule PO
twice a day.
13. Procrit 10,000 unit/mL Solution Sig: 0.5 ml Injection once a
week.
14. Metamucil 0.52 g Capsule Sig: One (1) Capsule PO twice a
day.
15. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
18. Outpatient Lab Work
Please check INR at Dr.[**Name (NI) 2935**] office on [**11-28**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Ventricular Tachycardia
Ischemic Cardiomyopathy
Atrial fibrillation
Chronic Kidney disease Stage 4.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Your internal defibrillator fired because of Ventricular
tachycardia, a dangerous heart rhythm. You had an ablation which
eliminated the heart tissue where the rhythm came from. You
developed a pseudoaneuysm in your right groin after the
procedure which was fixed with a thrombin injection. We have
made the following changes to your medications:
1. Increase the amiodarone to 200 mg daily from 100 mg
2. Increase the Carvedilol to 25 mg twice daily
3. Continue Warfarin (coumadin) at 2.0 mg instead of 2.5 mg.
Please check your INR on [**2173-11-28**] at Dr.[**Name (NI) 2935**] office.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1911**] if weight
goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Please keep all follow up [**Last Name (STitle) 4314**]. We have scheduled the
following [**Last Name (STitle) 4314**] for you:
Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1911**], EP Cardiology
Appt: [**12-15**] at 1:40pm
Telephone: [**Telephone/Fax (1) 62**]
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] Phone: [**Telephone/Fax (1) 2205**] Date/time: [**12-12**] at
3:20pm.
.
Pulmonology:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2175-1-11**] 10:45
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2175-1-18**] 2:00
.
[**Month/Day/Year **]:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2174-12-1**] 3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2174-12-1**] 4:15
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
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"285.1",
"244.9",
"V45.81",
"998.12",
"427.31",
"414.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"99.29",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
11398, 11404
|
5847, 9144
|
290, 325
|
11558, 11558
|
5009, 5824
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4046, 4178
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10074, 11375
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|
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2566, 3603
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12050, 12429
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236, 252
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353, 2472
|
11572, 11679
|
3634, 3819
|
2494, 2546
|
3835, 4030
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,118
| 181,796
|
54327
|
Discharge summary
|
report
|
Admission Date: [**2174-12-13**] Discharge Date: [**2174-12-17**]
Date of Birth: [**2108-3-25**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
66F with a long history of recurrent pericarditis and a chronic
pericardial effusion who presents with a month of palpitations,
2 weeks of cough, and a 1 of escalating DOE as well as a
prolonged recurrence of her typical pericaritis symptoms. She
reports that her first attack of pericarditis was in [**2151**] and
characterized by positional and pleuritic chest pain. This has
recurred several times over the past 23 years. She has treated
this with Motrin 800 mg PO TID with good effect in the past.
Approximately 1 year ago she was incidentally noted to have a
pericardial effusion. This was monitored on ECHO for 9 months,
and was noted to be stable to slightly enlarging so she
underwent pericardioscentesis on [**2174-10-26**]. Evaluation of that
fluid showed a benign transudate without evidence of infection
or malignancy. Since that time her pericarditis has been
smoldering with persistent pleuritic chest pain that radiates to
her neck and is worse lying on her left side, and relieved with
NSAIDs and sitting forward. For the past month she has noted
occassional palpitations and increased fatigue. Her appetite has
been low and she has been eating less, but her weight is
increased. For the past 2 weeks she has had a new cough without
symptoms of a URI. Approximately a week ago she began to have
worsening DOE to the point that she gets winded with walking
just 4 steps. Given her ongoing symptoms, she called her
cardiologist. He referred her to the ED for further management.
In the ED, initial vitals were 98.3 88 123/75 24 98% on 4L. She
was noted to be in Afib with a rate around 130 shortly
thereafter. A AP CXR showed possible new pleural effusion on the
L. A bedside ECHO showed no evidence of RA or RV collapse. She
was bolused NS 1000 mL and received morphine 4 mg IV x1 for
pain. She was admitted to the CCU for further management.
Before coming up to the CCU she was ordered for a PA and LAT CXR
which confirmed a new left pleural effusion 1/3 up the lung
field as well as a mild right pleural effusion.
On arrival in the CCU she was in sinus at around 80/min. She
reported ongoing chest pain which is pleuritis and positional,
as well as DOE.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
- Chronic pericardial effusion, first diagnosed [**12-22**] during an
admission at OSH for acute cholecystitis. Extensive infectious
and inflammatory work-up (including thyroid and autoimmune) as
outpt has been negative. Echo has shown moderate sized effusion,
alongside the right ventricle, suggestive of some elevation in
the intrapericaridal presure. Echos have shown some stranding
suggesting partial organization. Last ESR was 16.
- Recurrent pericarditis. Initial event was in [**2151**]. Pt reports
weeklong period of intense sharp, diffuse chest pain, worse with
breathing and moving, better leaning forward, radiating to the
trapesius muscles. Did not see a doctor at the time, but her
then has had 6-7 episodes of fatigue and CP following URIs that
are similar in nature (CP is pleuritic, painful wearing a bra,
diffuse, non-radiating, better sitting forward, last for days).
In [**10/2174**] a cultute of the effusion grew coag negative Staph,
but this was felt to be a contaminant. Otherwise, evaluation at
that time was negative for infection or malignancy, and the
fluid was consistent with a transudate.
- Recent abdominal US has shown multiple partial septated cysts
up to 4.3cm in the left liver lobe.
- anxiety
- s/p cholecystectomy [**12-22**]
- s/p tonsillectomy as a child
- s/p hysterectomy 20 years ago for endometriosis
- New Afib [**11/2174**]
Social History:
- She lives alone and works as an attorney
- Tobacco history: Denies - smoked x 3 yrs in her 30s; quit in
[**2149**]
- ETOH: 1 glass of wine every 2 weeks
- Illicit drugs: Denies
- Travelled to [**Country 14363**] and the Filipines and suffered febrile
and diarrheal illnesses in both places
Family History:
- Father: CAD/PVD
- Brother: Hyperlipidemia
- Maternal grandfather: hypertension and stroke
- Paternal grandfather: hypertension and stroke
- No family history of early CAD or sudden death
Physical Exam:
On admission:
VS: 98.3 90 112/74 22 97% on 4L
GENERAL: NAD but dyspneic with conversation. 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 11 cm.
CARDIAC: PMI difficult to localize. 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. Absent breathsounds at
the left base with dullness to percussion 1/3 up the lung field,
no other wheezes, rales, or rhonchi
ABDOMEN: BS+, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ LE edema bilaterally
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+
.
On discharge: same as above except:
GENERAL: Not dyspneic with conversation.
Lungs: Absent BS at L base with dullness only at base.
Pertinent Results:
On admission:
[**2174-12-13**] 07:05PM BLOOD WBC-12.1* RBC-3.87* Hgb-11.5* Hct-33.2*
MCV-86 MCH-29.8 MCHC-34.7 RDW-13.8 Plt Ct-611*#
[**2174-12-13**] 07:05PM BLOOD PT-13.9* PTT-21.3* INR(PT)-1.2*
[**2174-12-13**] 07:05PM BLOOD Glucose-110* UreaN-16 Creat-0.8 Na-136
K-4.6 Cl-101 HCO3-21* AnGap-19
[**2174-12-13**] 07:05PM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
[**2174-12-14**] 06:04AM BLOOD LD(LDH)-114
[**2174-12-14**] 02:15PM PLEURAL WBC-1570* Hct,Fl-2.0* Polys-43*
Lymphs-29* Monos-13* Meso-15*
[**2174-12-14**] 02:15PM PLEURAL TotProt-4.3 LD(LDH)-152
[**2174-12-13**] 07:05PM BLOOD cTropnT-<0.01
[**2174-12-13**] 07:05PM BLOOD proBNP-887*
[**2174-12-14**] 06:04AM BLOOD TSH-5.2*
[**2174-12-14**] 06:04AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2174-12-14**] 10:56AM BLOOD ANCA-NEGATIVE B
[**2174-12-16**] 06:45AM BLOOD [**Doctor First Name **]-PND
[**2174-12-16**] 06:45AM BLOOD HIV Ab-NEGATIVE
[**2174-12-14**] 06:04AM BLOOD HCV Ab-NEGATIVE
On discharge:
[**2174-12-17**] 08:15AM BLOOD WBC-8.0 RBC-3.70* Hgb-11.2* Hct-32.1*
MCV-87 MCH-30.3 MCHC-35.0 RDW-13.8 Plt Ct-622*
[**2174-12-17**] 08:15AM BLOOD PT-13.6* PTT-21.6* INR(PT)-1.2*
[**2174-12-17**] 08:15AM BLOOD Glucose-112* UreaN-20 Creat-0.8 Na-140
K-4.6 Cl-102 HCO3-26 AnGap-17
[**2174-12-17**] 08:15AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
[**12-13**] EKG: Atrial fibrillation with rapid ventricular response.
Modest diffuse ST-T wave changes are non-specific. Since the
previous tracing of [**2174-10-31**] atrial fibrillation has replaced
sinus rhythm and ST-T wave changes are present.
[**12-13**] CXR: 1. Interval development of moderate left base opacity
may represent combination of pleural effusion and atlectasis;
underlying consolidation cannot be excluded. 2. Small right
pleural effusion with overlying atelectasis.
[**12-14**] Echo: Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion suggestive of
pericardial constriction. The mitral valve leaflets are mildly
thickened. There is a trivial/physiologic pericardial effusion.
The effusion appears circumferential. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There is an anterior space which most likely
represents a prominent fat pad. The echo findings are suggestive
but not diagnostic of pericardial constriction. Compared with
the prior study (images reviewed) of [**2174-10-31**], there is
probably a slight increase in the size of the pericardial
effusion. It appears echo dense and not free flowing. There may
be some adherence to the underlying myocardium. There is a new
septal "bounce" seen on the current study. Taken together, these
suggest pericardial constriction/effusive constrictive
physiology.
[**12-15**] Cardiac MR:
1. Moderate, circumferential, complex appearing pericardial
effusion with tethering of the myocardium to the pericardial
effusion and the pericardium. Pericardial late gadolinium
enhancement, suggestive of pericardial inflammation. Flattening
of the interventricular septum during inspiration, consistent
with constrictive physiology. No CMR evidence of myocarditis.
2. Normal left ventricular cavity size with normal regional left
ventricular systolic function. The LVEF was normal at 64%. The
effective forward LVEF was low-normal at 56%.
3. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 64%.
4. Mild mitral and tricuspid regurgitation.
5. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
6. Left atrial enlargement.
[**12-16**] CXR PA/lat:
1. No evidence of post-procedure pneumothorax, satisfactory
post-procedure
reduction of right pleural effusion.
2. Worsening left pleural effusion, left lower lobe atelectasis
and new mild pulmonary venous hypertension
[**10-31**] CT chest:
1. Mediastinal edema and possible phlegmon, with reactive lymph
nodes, may represent inflammation, mediastinitis cannot be
excluded. No evidence of mediastinal gas or abscess.
2. Trace pericardial effusion.
3. Hypodense and hypoattenuating liver lesions, likely cysts.
4. 9mm inferior left lobe thyroid nodule can be further
evaluated by ultrasound.
***PENDING RESULTS***
[**12-14**] pleural fluid cytology
[**12-16**] serum [**Doctor First Name **]
Brief Hospital Course:
66F with a history of chronic pericardial effusion and recurrent
pericarditis of unclear etiology who presented with escalating
DOE and was found to have new Afib. She spontaneously converted
into sinus and her symptoms improved somewhat. Admission CXR was
notable for left sided effusion, now s/p thoracentesis of bloody
exudate. Cardiac MRI showing constrictive pattern, started on
steroids with improvement of symptoms.
.
# Dyspnea on exertion: DOE was felt to be related to a
combination of pleural effusion and flash edema from Afib. Her
Afib was successfully treated (see below). Thoracentesis was
done and 1200mL of pleural fluid removed is consistent with
exudate by lytes criteria (Pleural/serum protein 0.8, LDH 1.3).
This was felt to be likely an inflammatory exudate, though
malignancy cannot be excluded. Culture did not grow anything.
CXR after [**Female First Name (un) 576**] did not show evidance of pneumothorax. She
initially had a 2L O2 requirement which was attributed to
splinting and had no requirement with ambulation at discharge.
Rheumatology was consulted and pt. had negative [**Doctor First Name **], HIV, and
HCV Ab.
.
# Pericardial effusion and pericarditis: This has been chronic.
She was hemodynamically stable without pulsus. TTE showed
complex fluid, likely bloody and exudatative, without enough
fluid to tap. TTE was inconclusive for constrictive pericardial
effusion. Cardiac MRI was c/w constrictive picture. She was
initially started on colchicine and high dose aspirin.
Prednisone 40mg was added and continued at discharge. Ibuprofen
was stopped. Patient's symptoms improved significantly after
steroids were started.
.
# RHYTHM: Pt. was found to be in new Afib, then converted to
sinus spontaneously. Paroxysmal Afib was suspected which could
be due to her chronic pericardial effusion and recurrent
pericarditis. Low dose metoprolol was started. TSH was mildly
elevated, patient asymptomatic, no indication for levothyroxine.
CHADS2 score 0-1, so no anticoagulation started.
.
# Anxiety: Continued home lorazepam and escitalopram.
.
# Transitional Issues:
-steroid taper for pericarditis: cardiologist, rheumatologist
-possible CT [**Doctor First Name **] consult for constrictive pericarditis as
outpt?: cardiologist
-f/u cytology of pleural fluid, ensure outpt. cancer screening
up to date: PCP
[**Name Initial (PRE) **]/u thyroid nodule on CT with ultrasound and TSH in 6 weeks:
PCP
Medications on Admission:
- Ibuprofen 800 mg PO Q8H
- Escitalopram 10 mg PO DAILY
- Lorazepam 0.5 mg PRN anxiety
- Multivitamin PO DAILY
- Omega-3 fatty acids PO BID
- Colchicine 0.6 mg PO BID
Discharge Medications:
1. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO prn as needed
for anxiety.
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. omega-3 fatty acids Oral
5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. aspirin 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for Pain.
8. metoprolol succinate 25 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:*0*
9. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Atrial fibrillation
2. Recurrent pericarditis
3. Pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for management of shortness of
breath related to both an irregular heart rhythm called atrial
fibrillation and for fluid collections around your heart and
lungs. You were started on a new medication called metoprolol
(beta blocker) for atrial fibrillation. Fluid was drained from
your lung. You were treated for pericarditis with steroids,
colchicine, and aspirin with improvement. We believe that this
is inflammatory in nature; you should see a rheumatologist for
follow-up. The fluid around your heart (pericardial effusion)
and your lungs (pleural effusions) will need continued
monitoring.
.
Some of your medications were changed during this admission:
START prednisone until your doctor tells you to stop it
START aspirin as needed for pain
START pantoprazole to prevent stomach bleeding
START metoprolol succinate
START Calcium + Vitamin D for bone health while taking steroids
.
Of note, a small thyroid nodule was noted on your imaging which
should be further evaluated by ultrasound as an outpatient. Your
thyroid function was also abnormal. This should be followed up
by your primary care physician.
Followup Instructions:
Dr.[**Name (NI) 111276**] office should call you on Monday with an
appointment to be seen by him within the next week and with a
referral to a rheumatologist.
.
You should call Dr.[**Name (NI) 103853**] office at [**Telephone/Fax (1) 31019**] on Monday to
schedule an appointment to be seen within the next 1-2 weeks.
|
[
"300.00",
"423.2",
"511.9",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
13947, 13953
|
10296, 12372
|
315, 330
|
14066, 14066
|
5897, 5897
|
15401, 15722
|
4606, 4796
|
12944, 13924
|
13974, 14045
|
12752, 12921
|
14217, 15378
|
4811, 4811
|
6855, 10273
|
256, 277
|
358, 2889
|
5911, 6841
|
14081, 14193
|
12395, 12726
|
2911, 4281
|
4297, 4590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,168
| 125,272
|
19413
|
Discharge summary
|
report
|
Admission Date: [**2100-7-5**] Discharge Date: [**2100-7-27**]
Date of Birth: [**2039-11-15**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Macrobid /
Lodine
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Weakness, fatigue, anorexia, anxiety
Major Surgical or Invasive Procedure:
[**2100-7-6**]: Drain Placement by Interventional Radiology of
abdominal collection
[**2100-7-9**]: Drain Placement by Interventional Radiology of pelvic
collection
History of Present Illness:
60-year-old female s/p Lap Sleeve Gastrectomy [**2100-6-28**], discharged
3 days ago, present to ER feeling tired, weak, + anorexia, and
anxious. She denies nausea/vomiting. no fever/chills. having
daily BM/flatus. She has been taking in water PO but not the
shakes. Per pt she does not like the taste of the shakes and has
no appetite.
Past Medical History:
PMH:
- CAD
- HTN
- Arthritis
- Basal cell CA on scalp s/p excision
- T2DM (resolved after wt loss)
- distant h/o nephrolithiasis
PSH:
- Laparoscopic sleeve gastrectomy on [**2100-6-28**]
- Laparoscopic gastric band placement in [**4-/2093**]
- Laparoscopic gastric band removal on [**2099-7-21**]
- Cardiac catheterization in [**12/2095**]
- Scalp basal cell cancer s/p excision five years ago
- Dx LSC x ~4 for pelvic pain
- D+C x 2
- Cystoscopy
Social History:
Non-smoker, non-drinker. Current child care provider out of her
home.
Family History:
Mother died of heart attack at age 72. Father died of lung
cancer at 71
Physical Exam:
VS: T= 97.3, HR= 81, BP= 157/91, RR= 18, SaO2= 99% on room air
PE:
Gen: Awake, alert, oriented x 3
HEENT: Anicteric. Tacky mucosal membranes. EOMI, PERRLA
Neck: No JVD, no LAD
CV: RRR
Pulm: CTAB
Abd: Soft, mildly tender to palpation, obese, ventral drain in
place, second drain from rear/flank in place
Ext: Warm and well perfused. Some non-pitting LE edema
Neuro: No focal deficits
Pertinent Results:
[**2100-7-5**] Upper GI Study
IMPRESSION: Prominent-appearing gastric fundus with leak along
the inferior
edge. The gastric sleeve portion is patent. A followup CT
examination can be
performed to assess for leakage of administered contrast.
[**2100-7-6**] CT Abd/Pelv c Contrast
IMPRESSION:
1. Complex fluid and gas collections in the surgical bed and
splenic hilum,
most compatible with abscess. There is also dependent complex
fluid in the
pelvis likely related to the post surgical state although
infection cannot be
excluded.
2. A filling defect is seen within a left lower lobe pulmonary
artery
centrally, highly concerning for a PE. As this study is not
adequate for
assessment of pulmonary embolism, a dedicated pulmonary embolism
study can be
obtained if required.
[**2100-7-6**] CT Guided Needle Placement
IMPRESSION: 1. Uneventful percutaneous abscess drainage of a
perigastric fluid
collection. 8 French [**Last Name (un) 2823**] catheter in place. Complete
resolution of fluid
collection anterior to the stomach, small residual fluid
collection in the
splenic hilum, it was recommended that the patient lie on her
right side to
facilitate drainage of the residual fluid through the catheter.
[**2100-7-9**] CT Guided Procedure
IMPRESSION:
Successful placement of percutaneous drainage catheter placement
into the
right lower quadrant abscess. 10 cc of fluid was sent for
microbiology.
[**2100-7-13**] 4:30 pm ABSCESS NEW ANTERIOR MIDLINE ABSCESS.
GRAM STAIN (Final [**2100-7-13**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): BEADED GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
IN CHAINS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
FLUID CULTURE (Final [**2100-7-17**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
YEAST. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
VIRIDANS STREPTOCOCCI. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2100-7-17**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2100-7-14**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2100-7-26**]: CT cath change: IMPRESSION:
1. Epigastric drain in appropriate position with demonstration
of gastric
anastomotic leak. The drain was repaired and was functioning
well after the procedure.
2. Right lower quadrant drain sits at the periphery of a 3.5 x
5.0 cm fluid collection. Small subhepatic fluid collection is
likely too small to drain.
3. Small left pleural effusion.
[**2100-7-27**] 05:37AM BLOOD WBC-12.5* RBC-2.89* Hgb-8.4* Hct-27.7*
MCV-96 MCH-29.1 MCHC-30.5* RDW-17.0* Plt Ct-654*
[**2100-7-27**] 05:37AM BLOOD WBC-12.5* RBC-2.89* Hgb-8.4* Hct-27.7*
MCV-96 MCH-29.1 MCHC-30.5* RDW-17.0* Plt Ct-654*
[**2100-7-27**] 05:37AM BLOOD PTT-84.7*
Brief Hospital Course:
The patient presented to [**Hospital1 69**] on
[**2100-7-5**] complaining of fatigue, anxiety, and anorexia. In the
ED, the patient was made NPO and sent for an upper GI study,
which showed a leak in her recent sleeve gastrectomy ([**2100-6-28**]).
She was admitted to the SICU for closer monitoring. On HD10, she
was transferred to a regular hospital floor (West 2b) due to her
improving status.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. A left lower
lobe pulmonary artery embolism was noted incidentally on CT scan
and therapeutic anticoagulation was started. The patient was
maintained on therapeutic heparin with goal PTT of 60-80
throughout her hospital stay. She was transitioned to Lovenox
120mg Q12h at discharge.
GI/GU/FEN: The patient was initially kept NPO until a final read
of her upper GI study was performed on HD1. On HD1 a leak was
discovered on the patient's UGI and an NGT was placed. CT
revealed complex fluid and gas collections compatible with an
abscess as well as dependent complex fluid in the pelvis. An IR
drain was then placed to drain the abdominal abscess on HD1 with
improvement in symptoms of abdominal pain and distention per the
patient. The patient reported increasing lower abdominal/pelvic
pain over the ensuing days and on HD4 another IR drain was
placed in the pelvis with improvement of symptoms and drainage
of fluid. On HD8, IR replaced the dislodged RLQ percutaneous
drain of the RLQ abscess with improvement in drainage and
abscess size. Also on HD8, IR aspirated the anterior midline
antraabdominal fluid collection with complete resolution on
post-procedure images. On the day prior to discharge, IR
replaced the epigastric drain with improvement in fluid
collection size. The patient was admitted with an elevated
creatinine of 1.3. Her creatinine continued to rise and returned
to 1.1 by HD9, 0.9 by HD11, and back to baseline of 0.6 on
discharge.
ID: The patient arrived with an elevated white count of 12.1,
which peaked at 28.5 on HD7, after which it trended down to 12.8
on discharge. The patient was started on
cipro/flagyl/fluconazole on HD1. Micro was unable to obtain
sensitivities due to high mixed bacteria burden of her initial
cultures. On HD 6 the patient was switched to
cefepime/vancomycin/flagyl/fluconazole. Fluconazole was replaced
by Micafungin on HD9. On HD18, she was placed back on
fluconazole from micagfungin. On discharge, her antibiotics were
flagyl/fluconazole/ertapenam with instruction to continue these
medications for 2 weeks post-discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. (See PULM above for
anticoagulation details)
Prophylaxis: The patient received subcutaneous heparin early in
her hospital stay and was started on therapeutic anticoagulation
after a LLL PE was discovered on CT (see PULM above for
anticoagulation details). She was encouraged to ambulate and get
OOB to chair as tolerated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3-4
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Atenolol 50 mg PO DAILY
Please crush before administration!
2. OxycoDONE-Acetaminophen Elixir [**4-29**] mL PO Q4H:PRN pain
RX *Roxicet 5 mg-325 mg/5 mL [**4-29**] mL by mouth every four (4)
hours Disp #*350 Milliliter Refills:*0
3. Ranitidine (Liquid) 150 mg PO BID
RX *ranitidine HCl 15 mg/mL 10 mL by mouth twice a day Disp
#*500 Milliliter Refills:*1
4. Pravastatin 20 mg PO DAILY
CRUSH medication before taking
5. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
6. Paroxetine 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
3. Enoxaparin Sodium 120 mg SC Q12H
4. ertapenem *NF* 1 gram Injection Q24H abdominal abscesses
Duration: 2 Weeks Reason for Ordering: Wish to maintain
preadmission medication while hospitalized, as there is no
acceptable substitute drug product available on formulary.
2 weeks after discharge from hospital
5. Fluconazole 400 mg IV Q24H Duration: 2 Weeks
2 weeks after discharge from hospital
6. Lorazepam 0.25-0.5 mg IV Q4H:PRN anxiety
7. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash
8. Paroxetine 20 mg PO DAILY
9. Ranitidine (Liquid) 150 mg PO BID
10. Sodium Chloride Nasal [**12-21**] SPRY NU TID:PRN dry nose
11. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 2 Weeks
2 weeks after discharge from hospital
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12564**] Hospital Network
Discharge Diagnosis:
Staple Leak s/p Laparoscopic Sleeve Gastrectomy
Left Lower Lobe Pulmonary Embolism
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Bariatric Surgery Service at [**Hospital1 1535**] after experiencing a staple leak
after your laparoscopic sleeve gastrectomy.
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
1. You may continue medications to treat the pain from your
operation. These medications will make you drowsy and impair
your ability to drive a motor vehicle or operate machinery
safely. You MUST refrain from such activities while taking these
medications.
2. You should continue taking a chewable complete multivitamin
with minerals. No gummy vitamins.
3. You should continue taking Zantac liquid 150 mg twice daily
for one month. This medicine prevents gastric reflux.
4. You should continue taking Actigall 300 mg twice daily for 6
months. This medicine prevents you from having problems with
your gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-4**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Department: BARIATRIC SURGERY
When: [**2100-8-18**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Best Parking: [**Hospital Ward Name 23**] Garage
Weight Loss Surgery Center
[**Hospital1 69**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
[**Location (un) 830**]
[**Location (un) 86**] , [**Telephone/Fax (1) 47701**]
|
[
"415.19",
"V10.83",
"276.52",
"539.89",
"V85.42",
"401.9",
"278.01",
"716.90",
"300.00",
"E878.6",
"300.22",
"041.09",
"414.01",
"112.89",
"584.9",
"276.51",
"567.22",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.29",
"88.76",
"54.91",
"38.97",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10542, 10607
|
5521, 9083
|
361, 530
|
10754, 10754
|
1965, 4761
|
13150, 13562
|
1474, 1547
|
9690, 10519
|
10628, 10733
|
9109, 9667
|
10905, 11623
|
1562, 1946
|
4797, 5498
|
285, 323
|
12794, 13127
|
558, 898
|
11648, 12782
|
10769, 10881
|
920, 1370
|
1386, 1458
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,771
| 158,329
|
47937
|
Discharge summary
|
report
|
Admission Date: [**2160-11-30**] Discharge Date: [**2160-12-17**]
Date of Birth: [**2095-8-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Ischemic necrosis of right lung with abscess formation.
Major Surgical or Invasive Procedure:
01/-[**1-12**]: Right thoracotomy with extrapleural approach to
completion right pneumonectomy.
[**2160-12-1**]: Flexible bronchoscopy. Bronchoalveolar lavage, right
lower lobe. Protected specimen brush aborted, right middle lobe.
History of Present Illness:
Ms. [**Known lastname 101073**] is a 65-year-old woman, now about 7 weeks after
video-assisted right upper lobectomy for a T1N0 non-small cell
carcinoma. Postoperatively, this was
complicated by a severe pneumonia treated with antibiotics with
very slow resolution. She returned in followup with worsening
cough and persistent infiltrate in the lung. Bronchoscopy showed
inability to cannulate the right middle lobe, making it
worrisome for middle lobe torsion syndrome. This had previously
been ruled out by a CT scan at her original hospitalization in
[**Month (only) **]. We did obtain an airway CT with IV contrast, which
showed poor perfusion to the right lung. A perfusion scan was
obtained that showed essentially no perfusion to the right lung,
confirming ischemic necrosis
of unclear etiology. She has agreed to a completion
pneumonectomy.
Past Medical History:
Right upper lobectomy for T1N0 non-small cell carcinoma [**10-11**]
Autoimmune hepatitis
Osteoporosis
Social History:
works as a CPA. Drinks 5 glasses wine per week, quit smoking 25
years ago after smoking one pack per day for 20 years.
Family History:
Father died from colon CA
Physical Exam:
VS: T: 98.4 HR: 60-70 SR BP: 110/70 Sats: 94% RA
General: 65 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: faint scattered rhonchi left lower lobe otherwise clear
GI: benign
Extr: warm no edema
Incision: right thoracotomy site well healed
Skin: coccyx region dry, flakey with sloughing of skin
Neuro: non-focal
Pertinent Results:
[**2160-12-12**] WBC-13.2* RBC-3.11* Hgb-9.4* Hct-27.5* Plt Ct-409
[**2160-12-10**] WBC-16.7* RBC-3.32* Hgb-10.1* Hct-29.2* Plt Ct-416
[**2160-12-9**] WBC-12.0* RBC-3.18* Hgb-9.5* Hct-27.7* Plt Ct-322#
[**2160-12-8**] WBC-10.8 RBC-2.95* Hgb-8.9* Hct-25.2* Plt Ct-205
[**2160-12-6**] WBC-11.8* RBC-3.01* Hgb-9.2* Hct-25.1* Plt Ct-266
[**2160-12-5**] WBC-21.1*# RBC-3.03* Hgb-8.8* Hct-25.8* Plt Ct-442*
[**2160-11-30**] WBC-15.5* RBC-4.09* Hgb-12.0 Hct-34.0* Plt Ct-405
[**2160-12-15**] Glucose-90 UreaN-11 Creat-0.7 Na-138 K-3.7 Cl-101
HCO3-27
[**2160-12-12**] Glucose-92 UreaN-10 Creat-0.6 Na-138 K-4.2 Cl-101
HCO3-29
[**2160-12-8**] Glucose-100 UreaN-7 Creat-0.6 Na-138 K-4.0 Cl-100
HCO3-31
[**2160-12-11**] cTropnT-0.01 [**2160-12-11**] cTropnT-0.02* [**2160-12-10**] CK-MB-2
cTropnT-0.03*
[**2160-12-5**] CK-MB-19* MB Indx-2.9 cTropnT-0.07*
[**2160-12-15**] Albumin-3.0* Calcium-8.3* Phos-3.4 Mg-2.1
[**2160-12-1**] Albumin-3.2* Calcium-8.3* Phos-4.1 Mg-2.1
[**2160-12-15**] TSH-2.5
Cultures:
[**2160-12-5**] 12:45 pm TISSUE Site: LUNG RIGHT LUNG.
GRAM STAIN (Final [**2160-12-5**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2160-12-8**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2160-12-11**]): NO GROWTH.
ACID FAST SMEAR (Final [**2160-12-6**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2160-12-8**]):
NO FUNGAL ELEMENTS SEEN.
[**2160-12-1**] 9:36 am BRONCHOALVEOLAR LAVAGE RLL BAL.
GRAM STAIN (Final [**2160-12-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. in
Pairs
RESPIRATORY CULTURE (Final [**2160-12-3**]): ~3000/ML
OROPHARYNGEAL FLORA.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2160-12-1**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2160-12-16**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2160-12-2**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2160-11-30**] 11:00 am BLOOD CULTURE LINE-PERIPHERAL #2.
Blood Culture, Routine (Final [**2160-12-6**]): NO GROWTH.
CXR:
[**2160-12-14**] Again seen is the hydropneumothorax of the right lung,
comprised of approximately [**2-4**] fluid and including a small
amount of air at the lung base. The mediastinum is midline. The
left lung is grossly clear.
[**2160-12-11**] The right- sided hydrothorax persists and the air-fluid
level is at the height corresponding to 3 cm above the carina.
As before there exist a few small air-fluid cavities within the
gross fluid collection which is bordered below by the diaphragm
[**2159-12-9**] There are several lucent regions overlying the fluid in
the left hemithorax. It is unclear whether this could represent
loculated gas or possibly merely the superimposed subcutaneous
emphysema. Opacification at the left base is consistent with
atelectasis, though supervening pneumonia cannot be definitely
excluded.
[**2160-11-30**] Stable appearance of right lower lobe parenchymal
opacification and loculations of air in the right upper lobe
space.
Chest CT:
1. Marked attenuation of the right lower lobe blood supply,
demonstrated by this first contrast-enhanced postoperative CT
scan may be responsible for progression of right lower lobe
consolidation to necrosis since [**2160-10-24**].
2. Persistent right middle lobe collapse since [**0-**] be
due to now
completely occluding stricture or impaction of inflamed or
otherwise narrowed bronchus, less likely torsion.
3. No decrease in size of large, persistent, airfilled right
pleural space; possible right lower lobe bronchopleural fistula.
Decrease in fluid volume could be due to two-way transit through
the fistula.
4. Left lower lobe ground-glass opacities, possibly aspiration
of secretions from right bronchopleural fistula.
Brief Hospital Course:
Mrs. [**Known lastname 101073**] presented to the ED on [**2161-11-30**] with a persistent
cough and low grade temps. While in the ED she was pan
cultured, CXR showed right lower lobe parenchymal opacification
and loculation of air in the right upper lobe
space. She was started on IV Vancomycin and Zosyn for pulmonary
infiltrate and elevated white count. Thoracic surgery was
consulted and recommended a bronchoscopy which was done on
[**2160-12-1**] and showed anatomic distortion of the right middle lobe
causing narrowing and compression. Subsequently a Chest CT
showed no perfusion of the remaining right lung. A V/Q scan
confirmed no ventilation or perfusion. Pulmonary Medicine was
consulted and given the functional pneumonectomy that completion
of pneumonectomy is necessary. A preoperative work-up was done
for Ischemic necrosis of right lung with abscess formation. On
[**2160-12-5**] she was taken to the operating room for successful
Right thoracotomy with extrapleural approach to completion right
pneumonectomy. She was extubated in the operating room and
transferred to the SICU for further management. Her pain was
managed by the acute pain service with an Bupivacaine Epidural.
The chest-tube was to water-seal. A foley was in place. Low
dose beta-blocker was started when BP tolerated. On POD1-4 she
remained in the SICU. The chest tube was removed POD 1. She was
transfused 2 units of packed red blood cells for a HCT 25 to 29.
Pressors were wean to off. The antibiotics were discontinued
once her cultures were negative and she remained afebrile. She
was gently diuresed to her preop weight. Transferred to the
floor. The epidural was removed and PO pain medications were
titrated for comfort. The foley was removed and she voided. On
POD6 she had an episode of Atrial fibrillation a rate in the
180's with spontaneous conversion to sinus rhythm. The
beta-blocker was increased and electrolytes were replete. She
continued to have intermittent atrial fibrillation. Cardiology
was consulted they recommended Toprol 100 daily, an
echocardiogram which was normal with an EF >55%. The TSH was
2.5. Pulmonology saw the patient for the persistent cough. They
recommended increasing H2 blockers to [**Hospital1 **], humidification and
bronchodilators. Over the course of her hospitalization with
aggressive pulmonary toileting, nebulizers and humidification
the cough improved. Her appetite was slow to return and
required supplements and encouragement. On POD12 she remained in
sinus rhythm for > 24 hours. Oxygen saturations was 96% RA.
She was followed by physical therapy throughout her hospital
course. They recommended outpatient pulmonary rehab. She was
discharged to home with VNA and will follow-up with Dr. [**Last Name (STitle) **]
as an outpatient.
Medications on Admission:
Fosamax 70mg wkly, calcium 500+D daily, cough medicine
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Five (5) ML PO every twelve (12) hours
as needed.
Disp:*30 ML(s)* Refills:*0*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
8. Nebulizer Machine
Saline Nebs 3xday prn
9. Saline Solution Sig: Three (3) ML Miscellaneous three
times a day as needed for cough.
Disp:*100 ML* Refills:*0*
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
12. Calcium 500 + D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right upper lobe mass s/p RULobectomy [**10-11**]
H/o elevated liver enzymes, initially thought to be due to
autoimmune hepatitis but liver biopsy at [**Hospital1 2025**] ruled this out.
Osteoporosis.
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, or sputum production
-Chest pain
-You may shower.
-No driving while taking narcotics
Continue incentive spirometer, walk frequently
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] Date/Time:[**2160-12-25**] 3:30
pm on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] [**Telephone/Fax (1) 62**] [**1-22**] at 3:00pm
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center.
Completed by:[**2160-12-18**]
|
[
"V15.82",
"338.18",
"998.59",
"427.31",
"E878.8",
"733.00",
"162.3",
"513.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04",
"34.79",
"32.59"
] |
icd9pcs
|
[
[
[]
]
] |
10523, 10581
|
6343, 9138
|
380, 613
|
10826, 10835
|
2237, 3641
|
11157, 11732
|
1771, 1799
|
9243, 10500
|
10602, 10805
|
9164, 9220
|
10859, 11134
|
1814, 2218
|
4481, 6320
|
3710, 4448
|
284, 342
|
641, 1491
|
1513, 1617
|
1633, 1755
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,808
| 140,385
|
48686
|
Discharge summary
|
report
|
Admission Date: [**2173-4-24**] Discharge Date: [**2173-4-30**]
Date of Birth: [**2113-7-29**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 59 yo female with a history of Addison disease, COPD, on
0.5 dexamethasone daily, presented to NWH with a couple days
fever, cough, n/v/d, lethargy. Per pt and family, she was
feeling on unwell on Friday and called daughter. [**Name (NI) **] vomited 2
times, no blood, food contents. Daughter [**Name (NI) 28167**] mother in bed
w/temp of 103.7, mildly confused, weak and took to hospital
([**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 3714**]). Found to be hypotensive and given 100mg
hydrocortisone and 3L IVF at OSH. SBP remained 65-80 and pt was
transferred to [**Hospital1 18**] for further management of hypotension;
concern for possible sepsis or adrenal crisis. Pt reports some
epigastric pain prior to vomitting, also some lingering cough
from a pneumonia she was recovering from during prior
hospitalizaition several weeks ago. Also noted some mild leg
swelling and ?SOB. B/c of N/V pt did not take any of her meds on
Friday.
.
At [**Hospital1 18**], initial VS were: 96.7 76 83/47 19 93% 4L NC, although
SBP dropped to 65 when sitting up. She has received 1L IVF here
(probably 5L total incl EMS and OSH). Exam with L basilar
crackles, patient mentating well, good UOP. Bedside U/S showed
30% IVC collapse with respiration, no pericardial effusion, no
abdominal fluid. Has RIJ and got vanc, pip-tazo. VS at time of
singout were: 80s 85/50 18-22 96,3L; was concern she'd need
pressors but BP improved. CXR per prelim showed atelectasis.
Access also includes 18g PIV.
.
Of note, per records, pt reported fatigue and occasional dizzy
spells at office visit on [**2173-4-9**] (told pt to reduce pain meds).
Pt called [**Hospital 3782**] clinic on [**2173-4-14**] and [**2173-4-16**] stating she
continued to feel lightheaded ans was concerned b/c her bp had
been low while in the hospital (80/50) although at that time she
reported feeling fine. However, on [**2173-4-16**] she was dizzy. Pt
pt reported taking 2 percocets Q 6-7 hrs, was eating and
drinking, "but not a lot". She was advised [**Doctor First Name **] increae POs and
decreasing percocet use w/further eval recommended. However at
that time she was unable to drive, plan was to visit UC
tomorrow. On [**4-17**] at [**University/College **] urgent care pt was seen for
dizziness in addition to episodes of discomfort in her chest,
with some shortness of breath, lasting a few minutes, mild,
increasing in frequency. Had one episode of pressure in the
chest which radiated to her left arm. Per records faithfully
compliant with dexamethasone 0.25 mg daily for Addisons.
.
ROS was otherwise negative. The pt denied recent unintended
weight loss, hematemesis, coffee-ground emesis, dysphagia,
odynophagia, chest pain, palpitations.
Past Medical History:
- Addison's disease (dx 8-9 years ago [**2-24**] fatigue) - on low dose
dexamethasone followed by [**Doctor Last Name **].
- Baseline hyponatremia [**2-24**] adrenal insufficiency
- chronic low back pain
- paraesophageal hernia and gastric volvulus requiring surgical
repair in [**2169-7-23**]
- post-thoracotomy syndrome - followed by pain clinic, on
chronic percocet
- Diverticulitis/Diverticulosis
- Internal hemorrhoids
- IBS
- GERD
- Hiatal hernia
- s/p cholesystectomy ([**2142**])
- Migraines
- EtOH abuse
- COPD
- depression/anxiety
- h/o Tb - treated x 18months
- gastric stricture s/p dilatation
Social History:
Recently divorced and lives alone. 30 years x 1.5 ppd tobbacco,
last Etoh [**4-29**], previously drinking [**3-26**] liter liquor daily x [**2-25**]
years "quit regular etoh few years ago". Denies IVDU. One
daughter is her social support.
Family History:
Non-contributory. Son with alcohol abuse, daughter with
psychiatric issues.
Physical Exam:
Admission Physical Exam
Vitals: T: 97.2 BP: 104/53 P: 70 R: 15 SaO2: 96% 3L
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, mild dry MM, no
lesions noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated;
RIJ in place
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales;
has mild chronic cough
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history but does
not remember some of events when had very high fever. Cranial
nerves II-XII intact. Normal bulk, strength and tone throughout.
No abnormal movements noted. No deficits to light touch
throughout.
Discharge exam:
Afebrile, VSS (SBP 140s)
General: AO x 3, NAD
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, slightly distended, NABS, no HSM, no fluid wave
Ext: no c/c/e, wwp
Neuro: AO x 3, CN II-XII, non-focal exam
Pertinent Results:
Admission labs ([**2173-4-24**]):
-WBC-7.7 RBC-3.73* Hgb-12.2 Hct-34.7* MCV-93 MCH-32.6* MCHC-35.0
RDW-13.2 Plt Ct-203 Neuts-88.4* Lymphs-9.4* Monos-1.7* Eos-0.2
Baso-0.4
-Glucose-130* UreaN-15 Creat-0.8 Na-131* K-4.1 Cl-102 HCO3-24
AnGap-9
-ALT-25 AST-32 LD(LDH)-179 AlkPhos-59 Amylase-44 TotBili-0.2
-Lipase-15
-ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
-Glucose-122* Lactate-0.9 K-4.0
.
Discharge labs ([**2173-4-30**]):
[**2173-4-30**] 05:15AM BLOOD WBC-9.2 RBC-3.10* Hgb-9.8* Hct-28.7*
MCV-93 MCH-31.6 MCHC-34.1 RDW-13.4 Plt Ct-254
[**2173-4-30**] 05:15AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2173-4-25**] 05:00AM BLOOD ALT-25 AST-32 LD(LDH)-179 AlkPhos-59
Amylase-44 TotBili-0.2
.
[**2173-4-24**] CXR:
Right IJ line ends at the cavoatrial junction. Thre is no
pneumothorax.
There are mild reticular bibasilar opacities and mild vascular
congestion.
Right basilar opacity has mildly improved. Mild hyperinflation
of the lungs.
Calcified granulomas at the right lung apex are stable.
IMPRESSION: Mild vascular congestion. Improving right bascilar
opacity.
.
[**2173-4-26**] CXR:
FINDINGS: A right pleural effusion is best seen on the lateral
projection and
is mild to moderate in size. A poorly defined opacity in the
right lower lobe
has progressed since [**2173-4-24**] and most likely represents an
evolving pneumonia,
linear densities in the medial right lower lobe likely represent
atelectasis.
Fluid seen in both major fissures is new since [**2173-3-23**].
IMPRESSION:
1. Bilateral pleural effusions, larger on the right, but small
in volume.
2. Evolving hazy opacity in the right lower lobe likely reflects
pneumonia.
.
[**2173-4-26**] RUQ u/s:
FINDINGS: Liver appears normal in echotexture without focal
abnormality or
intrahepatic biliary ductal dilatation. Moderate-sized layering
right pleural
effusion. Trace perihepatic ascites. No fluid is seen in both
lower
quadrants or within the pelvis. The gallbladder is surgically
absent. The
proximal common duct is mildly dilated measuring 7 mm and is
nonspecific in
the setting of cholecystectomy. The visualized pancreatic neck
and proximal
body are unremarkable. The remainder of the pancreas is obscured
by overlying
bowel gas. Main portal vein is patent with antegrade flow.
Intrahepatic
portion of the IVC has normal ultrasound appearance. The
proximal aorta is
normal in caliber and the distal aorta is obscured.
The right kidney measures 9.6 cm and the left kidney measures
10.9 cm.
Preserved corticomedullary differentiation and cortical
thickening
bilaterally. Adrenal glands are not well visualized on
ultrasound.
IMPRESSION:
1. Moderate layering right pleural effusion.
2. Trace perihepatic ascites without significant fluid in the
four quadrants
or pelvis.
3. Status post cholecystectomy. Proximal common duct measures 7
mm,
minimally dilated and nonspecific.
4. Adrenal glands not well visualized on ultrasound.
.
[**2173-4-28**] KUB:
FINDINGS:
Supine and upright views of the abdomen demonstrate multiple
dilated loops of
small bowel. There is no pneumatosis or free air. There is air
in the
rectosigmoid colon. Surgical clips project over pelvis. Small
bilateral
pleural effusions are noted. Right lower lobe hazy opacity
appears improved
from [**2173-4-26**] exam.
IMPRESSION:
Multiple dilated loops of bowel, compatible with obstruction .
No free air.
.
[**2173-4-29**] CT abd:
IMPRESSION:
1. No small bowel obstruction.
2. Mild intrahepatic biliary ductal dilatation with the common
duct maximally
measuring 1.5 cm, unchanged since [**2169-7-23**].
3. Small-moderate bilateral pleural effusions, right greater
than left.
4. Effusions in combination with mild periportal edema, small
amount of
simple ascites and subcutaneous edema suggest increased volume
status.
Brief Hospital Course:
This is a 59 yo woman with PMHx significant for Addison's
disease on chronic steroids, COPD, chronic pain who presented to
OSH with fever, cough, n/v/d, and lethargy. Found to be
hypotensive and transferred to [**Hospital1 18**] for further management of
hypotension; concern for possible sepsis or adrenal crisis.
.
# Hypotension: Likely secondary to adrenal insufficiency and
mild hypovolemia in the setting of not taking steroids and
inadequate PO intake from nausea and vomiting. Patient was
started on stress dose steroids (100 mg of Hydrocortisone) and
received IV fluid boluses with subsequent improvement in her
blood pressures. On admission she received broad antibiotics out
of concern for sepsis; however, these were discontinued
secondary to low clinical suspicion for bacterial illness and
rapid improvement with hydration. Blood and urine cultures were
negative. Endocrine was contact[**Name (NI) **] regarding steroid tapering and
recommended Hydrocortisone 50 mg [**Hospital1 **] through [**4-26**], then
decreasing to double her home dose for 3 days, then continuing
her on home dose. Her blood pressures remained stable prior to
transfer to the floor. On the medical floor, her steroids were
tapered accordingly to Endocrine recommendations. However, as
she developed a pneumonia (see below), she was discharged on 1
mg twice daily of Dexamethasone to be taken until her
antibiotics are completed (higher dose kept in setting of
current infection). At that time, she is to decrease her dose
to 0.5 mg twice daily until follow-up with her primary
endocrinologist.
.
# Adrenal insufficiency: This episode of hypotension was likely
secondary to nausea/vomiting (secondary to viral illness) and
relative adrenal insufficiency due to inability to take po
steroids and concurrent stress. She responded quickly to IV
fluids and stress-dose steroids. Her steroids were slowly
weaned, however she was continued on a higher-dose (1 mg twice
daily of dexamethasone) due to her concurrent pneumonia. She
was instructed to taper to 0.5 mg twice daily afte completion of
her antibiotics and to stay on this dose until follow-up with
her endocrinologist. She recently had been hospitalized for
another episode of hypotension at [**Hospital3 **] prior to this
hospitalization; the etiology of this is not clear. Her BPs
were stable during this hospitalization.
.
# Pneumonia, bacterial: Patient reported development of a cough
and slight shortness of breath during her hospitalization.
Initial CXR was negative for a PNA, however repeat CXR
demonstrated progression of a RLL infiltrate. She was afebrile
and concern for resistant organisms was very low, so she was
started on Ciprofloxacin for a 7-day course. She had small
bilateral pleural effusions on CXR; in discussion with
pulmonary, these were too small to be tapped. She remained
afebrile, with improvement in her respiratory symptoms. Her O2
sats were stable at 94-96%/RA. She would benefit from a repeat
CXR next week to ensure no enlargement of the effusions. These
effusions are likely secondary to her aggressive fluid
resuscitation on arrival.
.
# Abdominal distension without obstruction - The patient
complained of acute on chronic abd distension (for months, with
worsening over the past few days), without n/v. She noted
excess flatus chronically and irregular bowel bovements. Abd
u/s was negative for ascites (slight perihepatic fluid only,
likely secondary to her aggressive fluid resuscitation). KUB
was read as obstruction, however upon review with the
radiologist, the KUB was only significant for dilated bowel. A
subsequent CT abd revealed NO evidence of obstruction. She was
started on simethicone and miralax with improvement in her
symptoms. She was tolerating a regular diet for several days
without any difficulty.
.
# Hyponatremia - stable during her hospitalization
.
# COPD: continued on outpatient regimen of combivent and advair.
.
# Depression/Anxiety: continued on outpatient regimen. She was
seen by SW during hospitalization as she does have many
stressors in her family life. She would likely benefit from a
neuropsych evaluation, as there is concern that this may be
impacting her abilityto manage her medications and health on her
own.
.
# Chronic Pain: continued on outpatient regimen. Initially,
frequency of narcotics were reduced in setting of hypotension,
but were restarted at her home dose during her hospitalization.
She was recommended to taper these medications, as they can be
contributing to her constipation and hypotension, however she
notes that her pain is still at a constant and chronic level,
requiring her current dose of medications.
.
# GERD - continued on PPI
Medications on Admission:
Per Atrius records:
Gabapentin 600 mg tid
Abilify 2 mg daily
Klonopin 0.5 mg [**Hospital1 **], 1 mg qhs
Duloxetine 60 mg daily
Nexium 40 mg daily
Lamictal 200 mg qhs
Lidocaine patch
Advair - dose unknown
Dexamethasone 0.5 mg daily (recently decreased from 0.5 mg twice
daily)
Trazadone 200 mg qhs prn
Calcium citrate-vit D3 2 tabs twice daily
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
2. aripiprazole 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety: one tablet in the morning, one tablet
at dinner, 2 tablets at night.
4. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day.
6. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 days: Please take this dose through
[**2173-5-3**]. Then start 0.5 mg twice daily on Tuesday, [**2173-5-4**]. .
Disp:*12 Tablet(s)* Refills:*0*
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: Last dose on [**2173-5-3**]. .
Disp:*6 Tablet(s)* Refills:*0*
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO BID (2 times a day) as needed for constipation.
Disp:*qs grams* Refills:*0*
12. trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for insomnia.
13. simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas, bloating.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
14. calcium citrate-vitamin D3 315-200 mg-unit Tablet Sig: Two
(2) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Hypotension
Adrenal insuffieciency
Pneumonia, bacterial
Abdominal distension without obstruction
Hyponatremia
COPD
Chronic back pain, chronic post-thoracotomy pain
GERD
Depression, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
O2 sats 95-96%/RA at rest, >92% while ambulating
Discharge Instructions:
You were admitted for low blood pressure, nausea, vomiting, and
fever. You required several liters of fluid and high-dose
steroids to bring your blood pressure back to normal. Your
steroid dose was slowly tapered to 1 mg twice of dexamethasone,
which you will continue through [**2173-5-3**]. On [**2173-5-4**], you should
decrease your dose to 0.5 mg twice daily and continue this dose
until your follow-up with Dr. [**Last Name (STitle) **].
Your initial work-up did not show evidence of an infection, but
a repeat chest x-ray on [**4-26**] showed concern for a developing
pneumonia, so you were started on Ciprofloxacin for a 7-day
course. This antibiotic is generally well-tolerated, but can
rarely cause rupture of the Achilles' tendon in the ankle. If
you develop pain in the ankle, please STOP this antibiotic
immediately. The last dose will be on Monday, [**2173-5-3**]. Your
xray also showed some fluid in the lung spaces, but this was too
small to be drained. You should have a follow-up xray next week
to ensure this is not getting bigger.
You also had abdominal distension, so an ultrasound was done,
which ruled out signficant fluid in the belly. An xray showed a
lot of air in the bowel, so a CT scan was done to evaluate for
obstruction. This was negative for obstruction and only
confirmed gas in the colon.
.
MEDICATION CHANGES:
1. START Dexamethasone 1 mg twice daily through Monday, [**2173-5-3**].
Change back to 0.5 mg dexamethasone twice daily on Tuesday,
[**2173-5-4**]. Continue this dose until you see Dr. [**Last Name (STitle) **] on
[**5-12**].
2. START Ciprofloxacin 500 mg twice daily and continue through
Monday, [**2173-5-3**].
3. CONTINUE Miralax and simethicone as needed for constipation
and gas.
No other medication changes were made.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 85132**]
Phone: [**Telephone/Fax (1) 17476**]
Appointment: Tuesday [**2173-5-4**] 10:40am
Department: SPINE CENTER
When: FRIDAY [**2173-5-7**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2173-5-12**] at 4:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2173-5-3**]
|
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icd9cm
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,563
| 174,954
|
16261
|
Discharge summary
|
report
|
Admission Date: [**2154-8-6**] Discharge Date: [**2154-8-10**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intra-aortic balloon pump
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 46371**] is a [**Age over 90 **] M with a
history of coronary artery disease s/p CABG in [**2124**], CHF with EF
of %, paroxysmal atrial fibrillation not on anticoagulation who
presents with 4 hours of substernal chest pain. He awoke in the
morning feeling well, and worked on his car (changed a bulb,
which involved laying under the car). Afterward he was returning
to his house and he climbed up 10 steps when he had sudden onset
of substernal chest pain. It was [**11-11**] severity, constant. He
took SL nitroglycerin x 4 or 5 doses with no significant relief.
He also took Tylenol and Maalox without improvement. He began to
feel diaphoretic and uncomfortable, so called his family, who
called EMS to bring him to ED.
.
Of note, he has generally been feeling well for the past few
months. He feels his CHF has been under good control, with
minimal edema, orthopnea or PND. However, he does report
increasingly frequent exertional angina (typically with carrying
groceries or walking longer distances) over the past few weeks
for which he has taken SLNG a few times per week.
.
In the ED, his initial vitals were T 97, HR 104, BP 84/50, RR
16, O2 100% 2L NC. An EKG was performed and showed LBBB which
met Sgarbossa criteria for evolving myocardial infarction. He
was given full-dose aspirin and plavix-loaded and taken to the
cardiac cath lab. There, cath revealed complete stenosis of his
RCA graft (felt likely to be old, as wire could not be passed)
and 99% proximal stenosis of his LAD graft. A drug-eluting stent
was placed in this location with subsequent good flow noted.
Given hypotension to SBP in 80s during the procedure, a balloon
pump was placed.
.
On arrival to the floor, he reports feeling significantly better
than earlier in the day and is chest-pain free. He is on 2L O2
by NC but denies SOB at rest. Cannot urinate from the supine
position, but otherwise no complaints at this time.
.
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. No dysuria. No
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. All of the other review of
systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2124**] and 2 vessel SVG stenting in [**2148**] followed by
failed attempt to open an occluded OM branch on [**3-/2149**] due to
persistent angina.
-PERCUTANEOUS CORONARY INTERVENTIONS:
s/p DES to SVG-RCA and SVG-LAD ([**2148**]). SVG to OM known occluded.
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p MI, CABG, PCI as above.
- AAA s/p repair
- Chronic systolic CHF (EF 25-30%)
- Hyperlipidemia
- Chronic kidney disease (baseline creatinine 1.6-2.2)
- s/p L carotid endarterectomy [**2143**]
- s/p cholecystectomy
- GERD
- hearing loss
- Nephrolithiasis
- Mesenteric ischemia (celiac artery stenosis, occluded [**Female First Name (un) 899**])
- Dizziness
- Chronic pleural effusion s/p talc pleuridesis
Social History:
Lives alone, but sons lives within [**Street Address(2) 46372**] and involved
in care. No HHA or other help at home. Quit smoking >40y ago;
used to smoke 3ppd x 20 years. No alcohol. No recreational
drugs.
Family History:
Father died of MI in 70s
Physical Exam:
On Admission:
PHYSICAL EXAMINATION:
HR: 63 BP: 112/50 O2: 100% 3L NC RR:18
Gen: AxO x3
HEENT: no JVP, no carotid bruits, CEA scar on left
CV:distant heart sounds, balloon pump
Resp: CTAB anteriorly
Abd: soft, NT/ND
Ext: cool feet, 1+ DP pulses, no edema bilaterally
Groin: L+R with no signs of ecchymosis or hematoma, slight
oozing
.
On Discharge:
afebrile HR:56-65 BP:102-117/51-59 RR:15-18 O2sat:96-100%RA
Gen: pleasant elderly man, AOx3
HEENT: no JVP
CV: distant heart sounds but nl S1, S2, no murmurs
Lungs: CTAB, no wheezes or rales
Abd: soft, NT/ND
Ext: cool feet, 1+ DP pulses b/l, no edema
Groin: R-sided bruising and ecchymoses with small hematoma,
L-side no hematoma or bruising
Pertinent Results:
Admission Labs:
[**2154-8-6**] 01:30PM BLOOD WBC-8.3# RBC-3.84* Hgb-12.5* Hct-37.1*
MCV-97 MCH-32.5* MCHC-33.6 RDW-15.0 Plt Ct-116*
[**2154-8-6**] 01:30PM BLOOD PT-13.9* PTT-22.2 INR(PT)-1.2*
[**2154-8-6**] 01:30PM BLOOD Glucose-141* UreaN-63* Creat-2.9* Na-139
K-4.3 Cl-103 HCO3-22 AnGap-18
[**2154-8-6**] 05:35PM BLOOD Calcium-8.8 Phos-4.1 Mg-2.4
.
Cardiac Enzymes:
[**2154-8-6**] 05:35PM BLOOD CK-MB-22* MB Indx-10.4* cTropnT-0.52*
proBNP-3678*
[**2154-8-7**] 02:52AM BLOOD CK-MB-41* MB Indx-10.5* cTropnT-1.03*
(PEAK)
.
Discharge Labs:
[**2154-8-10**] 07:00AM BLOOD WBC-4.7 RBC-3.45* Hgb-11.0* Hct-32.6*
MCV-95 MCH-31.8 MCHC-33.6 RDW-15.2 Plt Ct-95*
[**2154-8-9**] 05:04AM BLOOD PT-14.2* PTT-25.6 INR(PT)-1.2*
[**2154-8-10**] 07:00AM BLOOD Glucose-94 UreaN-44* Creat-1.9* Na-141
K-4.3 Cl-105 HCO3-27 AnGap-13
.
Other Results:
EKG ([**8-6**])Regular wide complex tachycardia - possibly
idioventricular rhythm. Compared to the previous tracing of
[**2154-5-31**] wide complex tachycardia is now present.
.
Cardiac Cath ([**8-6**])
1. Native three-vessel coronary artery disease.
2. Occluded SVG-RCA with possible stent fracture.
3. 95% ostial stenosis of SVG-LAD with 40% mid-stent ISR.
4. Successful IABP placement.
5. Successful PCI of the SVG-LAD with a 3.5 x 15 mm Promus DES.
.
TTE ([**8-7**])
EF 30%. Left ventricular cavity dilatation with moderate
regional and global systolic dysfunction c/w multivessel CAD.
Mild-moderate mitral regurgitation. Compared to the prior study
dated [**2153-8-29**], the left ventricular systolic function is
similar. The right ventricle was not well visualized on this
study.
.
ECG ([**8-9**])
Wandering atrial pacemaker. Intraventricular conduction delay.
Brief Hospital Course:
Pt is a [**Age over 90 **]yoM with CAD s/p CABG and prior PCI who presented with
chest pain and EKG changes consistent with inferior wall [**Age over 90 **].
.
# Inferior Wall [**Name (NI) **] - Pt presented with chest pain and EKG
changes consistent with inferior wall MI with peak CKMB of 41
and troponin of 1.03. Pt underwent urgent cardiac
catheterization for revascularization. In the cath lab, initial
angiography revealed an occluded SVG-RCA. Attempts were made to
cross the occlusion with multiple wires. At this point, the
patient's blood pressures dropped, so an IABP was inserted via
the right femoral artery. They then accessed the left femoral
artery, and repeat angiography of the SVG-LAD revealed a 95%
stenosis at its ostium. They treated this lesion with PTCA and
one drug-eluting stent. Final angiography revealed no residual
stenosis, no evidence of dissection and TIMI 3 flow. Patient was
transferred to the CCU for close monitoring. He was stable
enough to be transferred to the floor. Post-procedure Echo
showed EF of 30%, which was similar to his previous baseline. He
was discharged home on an appropriate post-MI regimen including
plavix, aspirin, atorvastatin, and lisinopril. Patient was
trialed on a low-dose beta-blocker but he became quite
bradycardic so it had to be discontinued.
.
# Hypotension - Patient became hypotensive during the procedure
requiring placement of IABP. On arrival to the CCU, pt's
pressures were quite stable, so pt was successfully weaned off
the IABP on [**8-7**]. Pt's blood pressures remained in the low 100s
until the time of discharge, which is likely his baseline as he
was mentating appropriately and clinically quite stable.
.
CHRONIC ISSUES
.
# Congestive Heart Failure: Repeat Echo on this admission showed
essentially no change in pt's EF post-[**Month/Day (4) **] - it remained
depressed at 25-30%. Pt remained euvolemic throughout his stay,
complaining only of some minor shortness of breath when lying
flat. His blood pressures remained in the low 100s, so he could
not be fully re-started on all of his home medications prior to
discharge. His spironolactone was held and his lasix dose was
decreased to 80mg daily at the time of discharge. He was advised
to follow-up with his primary doctor to re-add/titrate these
medications appropriately.
.
# Chronic Renal Failure: Pt's creatinine was initially elevated
post-procedure likely from the contrast load he received, but it
gradually returned to baseline without any further intervention.
.
# Atrial Fibrillation: Pt was consistently bradycardic and in
sinus rhythm post-procedure. His bradycardia prevented us from
successfully starting a beta-blocker on him. He was continued on
amiodarone.
.
TRANSITIONAL ISSUES
.
Pt needs to follow-up with his outpatient cardiologist regarding
the appropriate doses of lasix and spironolactone he needs to be
on given his low blood pressures. A beta-blocker should be
started in him as well if his heart rate can tolerate it.
Medications on Admission:
- Amiodarone 200 mg PO M/W/F
- Isosorbide mononitrate 120 mg PO daily
- Furosemide 80 mg PO QAM, 40 mg PO QPM
- Lisinopril 2.5 mg PO daily
- Nitroglycerin 0.4 mg SL PRN
- Omeprazole 40 mg PO daily
- Pravastatin 40 mg PO daily
- Spironolactone 25 mg PO daily
- Trazodone 50 mg PO QHS
- Aspirin 325 mg PO daily
- Multivitamin 1 tab PO daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
2. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes as needed for chest pain: [**Month (only) 116**] eepeat
x 2 tabs. If pain continues, take third tab and call 911.
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ST-elevation myocardial infarction corrected by a drug-eluting
stent to the left anterior descending artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for a heart attack and underwent a procedure in which they
re-opened a blocked vessel in your heart. Your blood pressures
were a bit low during the procedure so you were initially
monitored in the cardiac intensive care unit while a balloon
pump temporarily supported your pressures but that was
successfully removed. You recovered from your procedure well
enough to be sent to the regular hospital floor.
.
The following medications were changed during your
hospitalization:
1. Stop taking your Pravastatin 40mg daily and instead start
taking Atorvastatin 80mg daily to lower your cholesterol.
2. Please start taking Plavix 75mg daily.
3. While you were in the hospital, you were on Furosemide 80mg
daily which is lower than your typical home dose. We would like
for you to weigh yourself tomorrow morning after you urinate and
write down the weight, this will be your baseline weight.
Continue to weigh yourself on the same scale everyday. If you
gain 3lbs in one day a) call Dr. [**Last Name (STitle) **] and b) please take an
additional 40mg of Furosemide (Lasix) that evening.
4. While you were in the hospital, we did not give you your
daily Spironolactone 25mg because your blood pressures were low.
Please do not resume taking your spironolactone until you have
discussed this with Dr. [**Last Name (STitle) **].
5. Please stop taking your omeprazole and start taking
ranitidine 150mg daily for your heartburn.
.
Please continue taking all of your other home medications.
Followup Instructions:
In addition to the following appointments, please call
[**Telephone/Fax (1) 1144**]
to make an appointment with Dr. [**Last Name (STitle) **] in one to two weeks.
.
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2154-9-4**] at 8:30 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT MEDICINE
When: THURSDAY [**2154-10-17**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: MONDAY [**2154-11-4**] at 10:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 9045**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"403.90",
"414.01",
"272.4",
"428.22",
"428.0",
"412",
"585.9",
"414.04",
"V45.82",
"458.29",
"584.9",
"427.31",
"780.52",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"37.61",
"00.40",
"88.56",
"37.22",
"00.45",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
10743, 10801
|
6265, 9252
|
228, 280
|
10952, 10952
|
4542, 4542
|
12685, 13780
|
3792, 3818
|
9641, 10720
|
10822, 10931
|
9278, 9618
|
11102, 12662
|
5082, 6242
|
3833, 3833
|
2837, 3108
|
3869, 4167
|
4181, 4523
|
4910, 5066
|
178, 190
|
308, 2728
|
4558, 4893
|
3847, 3847
|
10967, 11078
|
3139, 3552
|
2750, 2817
|
3568, 3776
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,894
| 135,249
|
37757
|
Discharge summary
|
report
|
Admission Date: [**2176-10-1**] Discharge Date: [**2176-10-6**]
Date of Birth: [**2121-3-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2176-10-1**] - Minimally invasive mitral valve repair through a right
axillary thoracotomy with resection of posterior leaflet P2 and
mitral valve annuloplasty with a 32mm Future CG annuloplasty
ring.
History of Present Illness:
55 year old gentleman with a history of mitral valve
regurgitation followed by serial echocardiogram. His most recent
transesophageal echocardiogram showed a partially flail
posterior
leaflet (P3 and P2) with a highly eccentric, severe jet of MR.
There was evidence of a torn chordae of the posterior leaflet.
The ejection fraction was normal, there was no LV dilatation and
left atrial enlargement with normal PA pressures. Mr. [**Name13 (STitle) 6955**]
is
asymptomatic of his mitral valve disease. He has been referred
by
his cardiologist for minimally invasive mitral valve repair.
Cath
showed nl.cors and 4+ MR.
Past Medical History:
Mitral regurgitation
HTN
back pain
ETOH abuse
right facial fractures with MVA (teenager)
Social History:
Occupation: Radiation instructor in ship yard;
apt. maintenance
Last Dental Exam:6 months ago
Lives with wife and daughter in [**Name (NI) 3012**] [**State 1727**]
Race: Caucasian
Tobacco: Smoked for 5 years in his 20's.
ETOH: 6-8 beers daily
Family History:
Noncontributory
Physical Exam:
VS: T: 98.0 HR: 60-70 SR BP: 120-140/90 Sats: 97% RA
General: 55 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes
Neck: supple no lymphadenopathy
Card: RRR normal S1, S2
Resp: decreased breath sounds bilateral otherwise clear
GI: benign
Extr: warm no edema
Incision: Right MIE site clean with steri-strips. no erythema
Neuro: non-focal
Pertinent Results:
[**2176-10-1**] ECHO
Prebypass
No atrial septal defect is seen by 2D or color Doppler. 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 aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are myxomatous. There is moderate/severe
mitral valve prolapse.( anterior leaflet - A2 portion ) There is
partial posterior mitral leaflet flail. (P2 and P3 portions)
Torn mitral chordae are present. Moderate to severe (3+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2176-10-1**] at
900am.
Post bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine. Biventricular systolic function is normal.
Annuloplasty ring seen in the mitral position. It appears well
seated and there is mild mitral regurgitation seen in the
posteromedial commissure. The mean gradient across the mitral
valve is 5 mm Hg. Dr [**Last Name (STitle) **] aware of post bypass findings
Brief Hospital Course:
Mr. [**Name13 (STitle) 6955**] was admitted to the [**Hospital1 18**] on [**2176-10-1**] for surgical
management of his mitral valve regurgitation. He was taken to
the operating room where he underwent a minimally invasive
mitral valve repair. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next few hours, he awoke neurologically
intact and was extubated. On postoperative day one, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. On POD3 he had
a brief episode of NSVT in the setting of a large amount of
diuresis. His electrolytes were repleted. He continued to be
monitored with no further ectopy. He continued on beta-blockers.
His pain was controlled with motrin and hydromorphone. He
continued to make steady progress and was discharged to home
with his wife and [**Name (NI) 269**].
Medications on Admission:
Lisinopril 10'
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] [**Location (un) 269**]
Discharge Diagnosis:
Mitral regurgitation
HTN
back pain
ETOH abuse
right facial fractures with MVA (teenager)
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound isssues.
2) Monitor daily weights. Report any weight gain of 2 pounds in
24 hours or 5 pounds in 1 week.
3) Report any fever of greater then 100.5.
4) Wash incision daily with soap and water. Please shower daily.
No lotions creams or powders to incisions for 6 weeks.
5) No driving while using narcotics.
6) Take motrin 800mg every 8 hours for 2 weeks then stop.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 83788**] in [**1-2**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 1683**] in [**1-2**] weeks. [**Telephone/Fax (1) 35326**]
Call all providers for appointments.
Completed by:[**2176-10-6**]
|
[
"424.0",
"401.9",
"285.9",
"428.0",
"V15.82",
"305.01",
"427.89",
"724.2",
"E944.4",
"429.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
4296, 4371
|
3293, 4231
|
341, 547
|
4504, 4511
|
2006, 3270
|
5106, 5451
|
1587, 1604
|
4392, 4483
|
4257, 4273
|
4535, 5083
|
1619, 1987
|
282, 303
|
575, 1194
|
1216, 1307
|
1323, 1571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,922
| 163,825
|
7226
|
Discharge summary
|
report
|
Admission Date: [**2114-6-22**] Discharge Date: [**2114-6-29**]
Date of Birth: [**2033-10-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
shortness of breath, tx for left main disease and intraaortic
balloon pump
Major Surgical or Invasive Procedure:
s/p cardiac catheterization with left main, and LAD stents
s/p intraaortic balloon pump and swan ganz catheter placement
History of Present Illness:
80 year old female with CAD s/p CABG '[**09**] (SVG ->LAD), DM, CHF EF
30% presented to OSH with 1 day of shortness of breath,
orthopnea, found to be in CHF, ruled in for NSTEMI, taken to
cath lab found to have significant (?90%) left main disease and
?occlusion of vein graft, elevated PCWP 40, CVP 27, swan and
intraaortic balloon pump were placed and she was diuresed. Her
peak CK was 706 and peak CK-MB 70. She is now being transferred
to [**Hospital1 18**] for consideration of further intervention. When she
underwent CABG in [**2109**], only a graft to the LAD could be
performed, due to diffuse disease in the other vessels and the
aorta was severely calcified and unable to be crossclamped.
.
At OSH, she was started on dobutamine, nipride and heparin gtt.
The dobutamine and nipride were weaned off and per OSH report
prior to transfer, CVP 12, PCWP 20, CO 3.1 CI 1.6 (CI increased
to 2.5 once nipride was restarted). Patient currently feeling
better, much less short of breath, no chest pain. No abd pain.
.
On review of symptoms, 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. Denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
*** Cardiac review of systems is notable for current absence of
chest pain, currently no dyspnea, PND, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Coronary artery disease s/p 1 vessel CABG (SVG->LAD); known 3VD
congestive heart failure, EF 30%
HTN
hypercholesterolemia
Insulin dependent diabetes mellitus
Hypothyroidism
Status post appendectomy
Status post tonsillectomy
Status post right eye laser surgery
CDiff
Social History:
Lives alone, has 4 children (3 out of state, one in [**Location 26769**]). Lives in [**Hospital3 400**]. Quit tobacco [**2095**]. No EtOH
or other drug use.
Family History:
non-contributory
Physical Exam:
VS: T 98.9F HR 79 BP 116/55 17 95/5Ln.c.
CVP 11 PA 53/34 mean 42 Cardiac index 2.3
Balloon pump:
Assisted systole 99
augmented diastole 137
IABP mean 90
systolic unloading 17
.
Gen: elderly female, lying flat, NAD. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, ND, No HSM. Mild TTP epigastrium. No
abdominial bruits.
Ext: No c/c/e. Right groin with swan ganz in place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: 2+ DP
Left: 2+ [**Hospital **]
MEDICAL DECISION MAKING
Pertinent Results:
LABORATORY DATA:
OSH
Na 135 K 3.6 (repleted) Cl 98 Bicarb 31 BUN 28 Cr 1.5
WBC 12.5 Hct 30.8 Plt 238
INR 1.5 PTT ?
peak CK 706, peak CK-MB 70.
.
STUDIES:
.
CARDIAC CATH at OSH performed on [**2114-6-19**] demonstrated:
severe left main and ?occlusion of SVG->LAD graft (unable to
find official report)
HEMODYNAMICS:
CVP 27/27 RV 71/12 (26) PA 67/26 (44) LV 114/17 (35) AO 88/44
.
[**2114-6-21**] CT Abd/Pelvis at OSH: no retroperitoneal hemorrhage.
Patchy airspace opacities in the lung bases ?pneumonia.
Indeterminate 2.8 x 2.3 cm left adrenal mass. Dense renal
cortices in a patient status post a recent cardiac cath,
suggestive of ATN. Pancolonic diverticulosis.
[**Hospital1 18**] Admission labs:
[**2114-6-22**] 4:00p.m. CK: 113 MB: 5
.
[**2114-6-25**] 04:50AM BLOOD CK-MB-4 cTropnT-2.2*
[**2114-6-25**] 10:34PM BLOOD CK-MB-3 cTropnT-1.94*
[**2114-6-26**] 05:50AM cTropnT-1.93*
[**2114-6-26**] 03:01PM cTropnT-1.68*
[**2114-6-26**] 11:06AM BLOOD %HbA1c-6.6*
.
EKG [**2114-6-23**]:
Normal sinus rhythm. Borderline short P-R interval. Delayed R
wave
transition. Occasional premature ventricular contractions. Q
waves in
leads III and aVF suggest possible prior inferior myocardial
infarction.
Downsloping ST segment depressions noted in leads I, aVL and
V5-V6 suggest
possible anterolateral ischemia. Compared to the prior tracing
of [**2110-11-20**] the anterolateral ST segment abnormalities are new.
Clinical correlation is suggested.
.
ECHO [**2114-6-23**]:
Conclusions:
LA is moderately dilated. LV wall thicknesses and cavity size
are normal. Moderate regional LV systolic dysfunction with
thinning and akinesis of the inferior and inferolateral walls,
and hypokinesis of the anterior wall (lateral wall contracts
best). Overall LV systolic function is moderately depressed (EF
30%). RV chamber size and free wall motion are normal. The AV
leaflets (3) are mildly thickened but AS is not present. No AR.
The MV leaflets are mildly thickened. Mild (1+) MR is seen.
Mild PA systolic hypertension.
.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w
multivessel CAD. Mild pulmonary hypertension. Compared with the
report of the prior study (images unavailable for review) of
[**2110-11-19**], left ventricular function may have slightly declined.
Mild pulmonary hypertension is now identified. The other
findings are similar.
.
Cardiac Catheterization at [**Hospital1 18**]:[**2114-6-25**]
1. Selective angiography of the LMCA showed a heavily calcified
4-4.5 mm
calibre LMCA. mid LMCA there was a tapering 90% leison. The LAD
was
calcified proxially with a 80% lesion. The mid LAD, just prior
to the
SVG TD had a 70% lesion. The LCX had no critical lesions.
2. Limited hemodynamics revealed moderated central aortic
hypertension.
3. The proximal LAD lesion was directly stented with a 3.5 mm
taxus
stent. The final angiogram showed TIMI III flow with no residual
stenosis, no dissection, no perforation and no embolisation.(see
PTCA
comments)
4. The LMCA lesion was directly stented with two overlapping 4.0
mm
vision stents and post dilated with the stent balloon and a 4.5
mm
balloon. The final angiogram showed TIMI III flow with no
residual
stenosis, no dissection, no perforation and no embolisation.
(see PTCA
comments)
FINAL DIAGNOSIS:
1. Critical LMCA lesion with diffuse LAD lesions.
2. Central aortic hyertension
3. Successful stenting of the LAD (Drug eluting)
4. Successful stenting of the LMCA (Bare metal)
.
URINE CULTURE (Final [**2114-6-25**]):
YEAST. >100,000 ORGANISMS/ML
Brief Hospital Course:
80 year old female with CAD s/p CABG (SVG->LAD), DM, CHF EF 30%
presented to OSH with CHF, NSTEMI s/p intraaortic balloon pump
during diagnostic cardiac cath with significant left main
disease. She was transferred to [**Hospital1 18**] with intra-aortic balloon
pump in place and underwent repeat cardiac catheterization with
placement of two stents in the LMCA and LAD.
.
# CAD - History of 3VD and CABG with SVG to LAD (unable to
bypass other vessels given diffuse disease). Had NSTEMI at OSH
with peak CK 706, MB 70. During cath at OSH was found to have
significant left main disease and SVG graft occlusion and IABP
was placed. Patient was transfered to [**Hospital1 18**] CCU and continued on
ASA, HD statin, plavix, BBlocker, Heparin gtt. She was taken for
catheterization at [**Hospital1 18**] with stents placed in LAD and LCMA.
IABP was pulled without complications after catheterization. The
patient has been instructed to continue on all her cardiac
medications on discharge and to follow-up with her cardiologist,
Dr. [**Last Name (STitle) 26770**], at [**Hospital3 **] on [**7-26**]. It is recommended that
she have follow-up imagining to monitor the patency of her LMA
stent in 3 months. She was instructed to continue her ASA and
Plavix.
.
# Pump - Patient had known h/o EF of 30% on previous ECHO.
Patient was transferred from OSH with IABP in place. Initally a
swan ganz catheter was placed demonstrating elevated filling
pressures. She was maintained on nipride and nitro gtt for
afterload reduction. IABP was pulled just after cathaterization.
Aggressive diuresis was continued throughout hospital course.
ACEI increased once blood pressure tolerated it for afterload
reduction (increased from 20mg to 30mg on [**6-22**], then to 40mg on
[**6-27**]). Due to hypertension (SBP in 140s) off of nitro drip,
increased b-blocker to Toprol XL 150mg po daily. Even I/Os were
maintained with Lasix 80mg po twice daily.
.
# Rhythm - NSR with PVCs.
.
# Anemia - Acute blood loss associated with cardiac cath and
removal of balloon pump. Patient transfused one unit of PRBCs on
[**6-26**] with good hematocrit response. Hematocrit remained stable
throughout remainder of hospitalization.
.
# Chronic renal failure - Pt managed with aggressive diuresis,
with improvement in creatinine to baseline of 1.6.
.
# Urinary tract infection - U/A with many RBCs, few WBCs, and
few bacteria. Urine culture demonstrated many yeast. Patient
finished a 10 day course of Ciprofloxacin while admitted.
.
# DM - NPH was held because of hypoglycemia at OSH. Patient was
treated with glargine 12 units QHS and ISS. Hemoglobin A1c of
6.6 demonstrated good glycemic control prior to hospitalization.
Pt resumed home NPH/regular regimen on discharge.
.
# Depression - Outpatient fluoxetine dosage was continued.
.
# Dermatitis - Pt developed contact dermatitis to bleached
sheets, which was treated with benadryl, clobetasol, and
avoidance of bleached sheets with good response.
.
# Hypothyroidism - Home levoxyl dosage was continued.
.
# FEN - The patient has been instructed to continue a cardiac,
low sodium diet.
.
# Code: FULL for this admission
.
Patient was ambulated around the floor on day of discharge and
maintained good oxygen saturations >94% on RA. She was
discharge to home with physical therapy services to increase her
exercise tolerance. The patient has been instructed on
continuing a low sodium diet and weighing herself daily. All
medications were discussed and the importance of continuing to
take her lasix doses when she wakes up in the morning and right
after lunch was emphasized. She will be following up with her
primary care physican and her cardiologist at [**Hospital3 **].
Medications on Admission:
ASA 325 daily
fluoxetine 10 mg daily
NPH 22units qam and 10 units qhs
regular insulin 10units qhs
lasix 80mg po daily
levoxyl88mcg daily
lisinopril 20mg daily
lopressor 50mg po bid
vytorin 10/40 daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*3*
5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous qam.
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous at bedtime.
7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Ten (10)
units Subcutaneous at bedtime.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*3*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*3*
11. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
Disp:*qs 2 weeks * Refills:*0*
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Vytorin [**9-/2087**] 10-80 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1.) Coronary artery disease
2.) Non ST elevation myocardial infarction
3.) Congestive heart failure
diabetes mellitus
Discharge Condition:
stable, ambulating with oxygen saturation maintained >92% on RA
Discharge Instructions:
You were in the hospital because of a blockage in your coronary
arteries and had a catherization with two stents placed. During
this time you had a balloon pump placed in your aorta to help
with your heart function, and this was removed after your
catherization.
Please take all medications as instructed and continue to keep
all health care appointments.
Please adhere to a low salt diet and weight yourself every day
and if your weight increases by > 3 lbs, call your physician.
If you experience chest pain, worsening shortness of breath,
lightheadedness, or your condition worsens in any way, seek
immediate medical attention.
Followup Instructions:
Recommended imaging to evaluate patency of Left Main Coronary
artery stent in approximately 3 months. You have been scheduled
to follow-up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26770**] at his
[**Location (un) 10961**], [**Hospital1 8**] location on [**7-26**] at 2:30PM.
Dr. [**Last Name (STitle) 26770**] will at this time arrange for follow-up imaging of
your stent. If you are unable to keep this appointment, please
call Dr.[**Name (NI) 26771**] office at [**Telephone/Fax (1) 5985**] to reschedule.
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 26772**]
[**Last Name (NamePattern1) 26773**] ([**Telephone/Fax (1) 26774**]) on [**7-4**] at 9:15am.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,559
| 151,770
|
21541
|
Discharge summary
|
report
|
Admission Date: [**2196-6-6**] Discharge Date: [**2196-7-26**]
Date of Birth: [**2132-7-16**] Sex: M
Service: MEDICINE
Allergies:
cefepime / vancomycin / Allopurinol
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Acute leukemia
Major Surgical or Invasive Procedure:
Right subclavian CVL
Bone marrow biopsy x2
History of Present Illness:
63 yo m with hx polycythemia [**Doctor First Name **] with myeloid metaplasia s/p
splenectomy on hydroxyurea therapy, now with fevers and 49%
other cells concerning for leukemic transformation. Pt was in
usoh until 7 days ago when he began to experience fevers on/off.
Fevers as high as 102. Sx a/w muscle and joint aches located
in knees and shoulders. He reports that his knees have been
particularly bothering him R > L. Pt denies CP, SOB, cough, URI
sx, diarrhea, abd pain, or any other complaints. He did go into
OSH ED in NH and CXR neg, U/A neg; he was sent home. Of note,
pt with labs drawn on [**5-27**] with WBC 21 (stable) with relatively
normal diff, plts 260, and dropping hct of 33. Thus, Dr. [**Last Name (STitle) 2539**]
decreased hydroxyurea from 1500 qd to 1000 qd. Today, pt
returned to Dr. [**Last Name (STitle) 2539**] office at [**Hospital1 **] where labs were
drawn. He was thus sent here to ED.
In ED, vitals were T 99.8, HR 72, BP 119/72, RR 16, O2 97% RA.
CXR did not reveal any frank abnormalities; u/a was negative.
WBC 24 with 49% other on diff. LDH 4000. Pt given cefepime 2 g
x 1.
Past Medical History:
Polycythemia [**Doctor First Name **] with myeloid metaplasia on hydroxyurea
therapy. S/p splenectomy [**2188**] complicated by hemorrhage and
portal vein thrombosis.
Anklyosing spondylitis
Hypothyroidism
Social History:
Patient lives in [**Location (un) 3844**], denies alcohol or tobacco use.
He is a retired schoolteacher.
Family History:
mother with lung cancer, father with DM, no history of
hematologic disorders
Physical Exam:
Vitals: 99.5, 100/64, 84, 20, 96% RA
Gen: Pleasant, NAD
HEENT: No OP erythema or exudate.
Pulm: CTA Bilaterally.
CV: RRR. No m/r/g.
Abd: +BS. NTND. No HSM.
Ext: No edema. Resolving left forearm papular rash. Knees w/o
warmth, erythema, or swelling. No pain
Pertinent Results:
[**2196-6-6**] 06:05PM WBC-24.8* RBC-2.35* HGB-9.2* HCT-27.4*
MCV-117* MCH-39.2* MCHC-33.7 RDW-20.3*
[**2196-6-6**] 06:05PM NEUTS-28* BANDS-0 LYMPHS-17* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-7* OTHER-49*
[**2196-6-6**] 06:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL
HOW-JOL-OCCASIONAL FRAGMENT-OCCASIONAL
[**2196-6-6**] 06:05PM PT-33.9* PTT-32.0 INR(PT)-3.4*
[**2196-6-6**] 06:05PM WBC-24.8* RBC-2.35* HGB-9.2* HCT-27.4*
MCV-117* MCH-39.2* MCHC-33.7 RDW-20.3*
[**2196-6-6**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-TR
====================
Microbiology:
[**2196-7-11**] 2:50 pm BLOOD CULTURE Source: Line-central.
**FINAL REPORT [**2196-7-25**]**
Blood Culture, Routine (Final [**2196-7-20**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. COLISTIN AND Tigecycline REQUESTED BY DR. [**Last Name (STitle) 4091**]
[**2196-7-17**].
COLISTIN <=2 MCG/ML, Sensitivities performed by [**Hospital1 **]
laboratories.
SENSITIVE TO Tigecycline @ 0.125 MCG/ML, MIC
interpretations are
based on manufacturer's guidelines that are FDA
approved
Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2196-7-12**]):
Reported to and read back by DR. [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **] PAGER#
[**Serial Number **] @
0418 ON [**2196-7-12**].
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2196-7-12**]): GRAM
NEGATIVE ROD(S).
[**2196-7-12**] 7:32 am BLOOD CULTURE Source: Line-central line.
**FINAL REPORT [**2196-7-18**]**
Blood Culture, Routine (Final [**2196-7-15**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin = 4 MCG/ML, Sensitivity testing performed
by Etest.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2196-7-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by DR. [**Last Name (STitle) **] [**2196-7-13**] 10:25AM.
Aerobic Bottle Gram Stain (Final [**2196-7-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2196-7-21**] 11:47 am BRONCHOALVEOLAR LAVAGE LLL.
GRAM STAIN (Final [**2196-7-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2196-7-23**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2196-7-21**]):
TEST CANCELLED, PATIENT CREDITED.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2196-7-22**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2196-7-22**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
====================
Imaging:
Knee x-ray [**2196-6-8**]:
Three views of the right knee show no fracture or dislocation.
Joint spaces
are normal. Note is made of mild tricompartmental osteophytosis.
There is a
small enthesophyte at the insertion of the quadriceps tendon.
Chest CT [**2196-6-13**]: 1. Peribronchial infiltration and ground-glass
opacity with bilateral lower lobe predominance may be infectious
or inflammatory. Leukemic infiltrate is considered less likely
given the rapid development. Appearance is not consistent with
pulmonary edema.
2. Several new nodules measuring up to 1 cm may be related to
above process. Recommend CT followup after resolution of acute
symptoms.
3. Diffuse abnormal bone mineralization related to patient's
known AML.
4. Probable hepatomegaly.
5. Diverticuosis.
Bilateral LE duplex [**2196-6-13**]:
Grayscale and color Doppler son[**Name (NI) 493**] imaging was performed of
the bilateral common femoral, superficial femoral, popliteal,
peroneal, and
posterior tibial veins. Normal compressibility, flow, and
augmentation was
demonstrated.
TTE [**2196-6-13**]:
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Mild pulmonary
artery systolic hypertension. Dilated aortic sinus.
Compared with the prior study (images reviewed) of [**2196-6-7**],
the findings are similar.
DISCHARGE LABS:
[**2196-7-26**] 12:00AM BLOOD WBC-3.1* RBC-2.66* Hgb-8.7* Hct-25.6*
MCV-96 MCH-32.5* MCHC-33.8 RDW-16.3* Plt Ct-388
[**2196-7-26**] 12:00AM BLOOD Neuts-57 Bands-2 Lymphs-17* Monos-14*
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-4* Blasts-2* NRBC-2*
[**2196-7-26**] 12:00AM BLOOD Plt Smr-NORMAL Plt Ct-388
[**2196-6-13**] 01:56AM BLOOD Fibrino-716*
[**2196-7-26**] 12:00AM BLOOD Gran Ct-1829*
[**2196-7-25**] 06:10AM BLOOD Gran Ct-1856*
[**2196-7-26**] 12:00AM BLOOD Glucose-93 UreaN-18 Creat-0.6 Na-139
K-4.8 Cl-102 HCO3-29 AnGap-13
[**2196-7-26**] 12:00AM BLOOD ALT-12 AST-16 LD(LDH)-198 AlkPhos-141*
TotBili-0.3
[**2196-7-26**] 12:00AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9
Brief Hospital Course:
63 yoM with PMH polycythemia [**Doctor First Name **] with myeloid metaplasia s/p
splenectomy on hydroxyurea therapy who is admitted with fever
leukocytosis with 49% blasts, newly diagnosed AML, treated with
7+3 followed by MEC, course complicated by VRE, E. coli ESBL, C.
diff, drug rash..
# Leukocytosis: persistently elevated WBC at 21K, last check on
[**5-27**] showed no blasts, now admitted with 49% blasts, concerning
for leukemic conversion to AML, bone marrow biopsy was
consistent with AML . Echocardiogram prior to chemotherapy
showed LVEF 65% and was otherwise unremarkable. He was treated
with 7+3 and reached his nadir [**6-15**] (day 7). He then developed
18% peripheral blasts into recovery of his counts, so he was
again induced with MEC. On [**7-15**], repeat BM showed ablation of
bone marrow with fibrosis. Counts slowly recovered and ANC
>1800 prior to discharge. Repeat bone marrow biopsy on [**2196-7-26**]
pending.
# Fever: 3 episodes of febrile neutropenia. 1) Admitted with
spiking fevers to 102, chest x-ray showed left lobe infiltrate
concerning for developing pneumonia. He was started on
vancomycin, cefepime. Levofloxacin was added in ICU and later
discontinued. Micafungin was added for fungal coverage when
patient continued to spike fevers on antibiotics. No culture
growth, and fevers resolved with treatment of leukemia. 2) [**7-11**]
d10 of MEC, spiked to 102 with tachycardia, tachypnea, SBP ~90s,
started on vanc/[**Last Name (un) 2830**] and aggressive IVF. Sepsis resolved. Cx
[**7-11**] with Ecoli sensitive to meropenem. Cx [**7-12**] and [**7-13**] with
VRE, on dapto. Patient continued to spike daily fevers. Ddx
included drug fever, fungal PNA (CT showing "tree-in-[**Male First Name (un) 239**]"
lesions). Bronchoscopy was performed and patient empirically
started on Voriconazole pending BAL galactomanin results.
Patient also developed diarrhea, C. diff toxins were negative,
but PCR positive, so patient started on PO Vancomycin.
# Drug rash: rash to cefepime, IV vancomycin, allopurinol per
skin biopsy. Diffuse erythematous rash spreading from central
to distal, involving the face, mildly pruritic but otherwise
asymptomatic. Resolved over time with cessation of cefepime.
Cef was changed to aztreonam and [**Last Name (un) 2830**] during the course of his
rash, which progressed on both antibiotics. Eventually he was
placed on cipro/tobra for GNR coverage; his E.Coli cx from [**7-11**]
was resistant to cipro and intermediate to tobra. In
consultation with derm and ID, meropenem was felt okay to
rechallenge.
# Afib: with RVR. Asymptomatic, other than some "stomach
queasiness". Found in afib w RVR on routine physical exam one
morning. Given lopressor 5mg IV x2 with little response.
Started PO lopressor and digoxin, which overnight caused [**1-21**]
second pauses. This was then d/c'd and changed to dilt PO,
which was increased to 90 QID. He spontaneously converted to
sinus on [**7-10**] after ~4-5 days in fib. In sinus rhythm on
discharge but continuing dilt 90QID. Would consider coumadin if
afib recurs.
# Diffuse edema and PMR like joint pain: occurred suddenly after
starting MEC. Diffuse edema in joints, severe pain bilaterally
in TMJs, shoulder girdle, wrists/fingers, knees/ankles. Placed
on steroids for 2 days only, after which symptoms resolved.
Unclear cause.
# Hypoxia: Was noted to be hypoxic to 80s while sleeping early
into hospital course, placed on nonrebreather and transferred to
ICU for monitoring and management. Repeat chest x-ray was
suspicious for pneumonia vs. leukemic infiltrate vs. pulmonary
edema, so his abx coverage was broadened to vancomycin, cefepime
and levofloxacin and he was also given lasix. Pt improved and
was transferred back to BMT service. CT chest was done and
showed ground glass opacity suspicious for infection vs.
inflammation.
# Knee pain: He complained of right knee pain on admission, exam
showed small effusion and did not show signs of infection. Pain
and swelling was believed to be related to possible leukemic
infiltrate. Pain controlled with lidocaine patch. Resolved with
treatment of leukemia.
# History of portal vein thrombosis: Occurred in the setting of
spleenectomy which was complicated by portal vein thrombosis and
hemorrheage. Given expected thrombocytopenia with chemotherapy,
and the need for urgent central line placement, warfarin was
held and INR reversed with FFP and Vitamin k. Repeat CT abdomen
showed resolution of portal vein thrombosis, so coumadin was not
restarted on discharge.
# Hypothyroidism: Continue levothyroxine.
# Transitional issues: Follow up galactomanin from BAL, if
negative, plan to DC voriconazole and restart Fluconazole.
Ertapenem/Daptomycin last day [**8-4**]. PO vancomycin last day
[**8-18**]. Follow up bone marrow biopsy result. Reassess
need to continue PO diltiazem as patient remained in sinus
rhythm since [**7-10**].
Medications on Admission:
allopurinol 150 qd
furosemide 20 qd
hydroxyurea 1000 mg qd
omeprazole 20 qd
levothyroxine 75 qd
Warfarin as directed
Discharge Medications:
1. omeprazole 20 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*
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ertapenem 1 gram Recon Soln Sig: One (1) g Intravenous once a
day for 9 doses: last day [**8-4**].
Disp:*9 g* Refills:*0*
4. daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 11578**]y (480)
mg Intravenous Q24H (every 24 hours) for 9 days: Last day
[**2196-8-4**].
Disp:*QS QS* Refills:*0*
5. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for nausa; anxiety.
Disp:*20 Tablet(s)* Refills:*0*
6. voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*10 Tablet(s)* Refills:*0*
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
8. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
9. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 23 days: Last day [**8-18**].
Disp:*184 Capsule(s)* Refills:*0*
10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a
day for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AML
Drug Allergy
C. dificile infection
Vancomycin-resistant Enterococcal bacteremia
E. coli (ESBL) bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3082**],
It was a pleasure to take care of you at [**Hospital1 18**] during your
hospital stay. You came to the hospital with fevers and was
found to have leukemia. You were started on chemotherapy called
"7+3" which you tolerated well. When you were just starting
your chemotherapy, you were found to have low oxygen level in
your blood. You were transferred to ICU for a short time for
monitoring of your oxygen levels while you were on supplemental
oxygen.
Your bone marrow biopsy in the middle of chemotherapy showed no
signs of malignant cells. You will need a repeat bone marrow
biopsy soon as your cell counts are recovering. This will be
done at follow up in the clinic. You can stop your hydroxyurea
for polycythemia because these cells should be treated from the
chemotherapy. Please start Acyclovir (antiviral) for
prophylaxis.
You had an irregular heart beat (atrial fibrillation) while you
were sick. We started you on a heart rate control medication
called Diltiazem. Your heart rhythm converted back to normal.
If this irregular heart beat starts again, you may need
anticoagulation with coumadin. Please continue diltiazem and
follow up with your doctors.
You had intermittent fevers during this hospital stay. Your
blood grew E. coli and Enterococcus (two types of bacteria) and
you were treated with antibiotics through the vein. You
developed rashes on your back and on your chest while you were
on the antibiotics. Dermatologists saw you and biopsied your
rash, which showed allergic reaction to medications. You were
taken off switched over to other antibiotics. You will continue
on Meropenem and Daptomycin (antibiotics) until [**8-4**].
Your CT scan of your lung was concerning for fungal infection.
We started you on Voriconazole (antifungal). This may change
depending on the final result of your bronchoscopy. Please
follow up with your doctor.
You also had some loose stools while you were here, and we found
a bacterial infection in your intestines. We treated you with
oral antibiotic, and you will continue Vancomycin till [**8-18**].
We also stopped your lasix because your blood pressures were on
the lower side and you do not have significant edema.
We stopped your Coumadin because your portal vein thrombosis is
no longer present.
MEDICATION CHANGE:
START Daptomycin (last day [**8-4**])
START Ertapenem (last day [**8-4**])
START Vancomycin (last day [**8-18**])
START Acyclovir
START Voriconazole (may change depending on the final result
from your bronchoscopy)
START Diltiazem 90mg three times a day
STOP Coumadin
STOP Hydroxyurea
STOP Lasix
STOP Allopurinol
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2196-7-29**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], 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
**Please follow up Galactomanin result from BAL, if negative,
plan to switch Voriconazole to Fluconazole for prophylaxis
If A-fib recurs, may need anticoagulation.
Department: DERMATOLOGY AND LASER
When: FRIDAY [**2196-10-7**] at 9:30 AM
With: [**Name6 (MD) 2975**] [**Name8 (MD) 2976**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2196-7-27**]
|
[
"427.31",
"112.0",
"041.4",
"524.62",
"238.4",
"599.0",
"527.2",
"720.0",
"790.7",
"E930.5",
"287.49",
"008.45",
"799.02",
"288.03",
"E933.1",
"780.61",
"693.0",
"285.22",
"244.9",
"E849.7",
"719.06",
"276.3",
"205.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"86.11",
"41.31",
"38.93",
"38.97",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
15837, 15889
|
9472, 14076
|
310, 355
|
16043, 16043
|
2254, 6965
|
18867, 19688
|
1878, 1956
|
14572, 15814
|
15910, 16022
|
14430, 14549
|
16194, 18844
|
8783, 9449
|
1971, 2235
|
7219, 8766
|
6998, 7183
|
256, 272
|
383, 1509
|
16058, 16170
|
14099, 14404
|
1531, 1739
|
1755, 1862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,365
| 184,294
|
49258
|
Discharge summary
|
report
|
Admission Date: [**2181-11-19**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2130-11-15**] Sex: F
Service: MEDICINE
Allergies:
Abacavir / Vancomycin / Haldol / Heparin Agents / Bactrim Ds /
Actonel
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
HPI: 51 female with PMH significant for HIV, HCV cirrhosis s/p
orthotopic transplant in [**2179**] c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear and
varices, pancytopenia, transferred from MICU after presenting
with one day of BRBPR and hematemesis on [**2181-11-19**]. She stated
that she had several large bowel movements one day prior to
admission with BRBPR and large clots. Later that evening she had
4 episodes of vomiting blood. The following day she was very
weak, felt palpitations and was admitted to the hospital.
ED course: HCT was 13 with prior HCT recorded as 24.7. Urgent
endoscopy revealed no source of bleeding. She was given 80mg IV
protonix and 80mg oxycontin. She had a femoral cortis placed.
Her blood was sent for type and crossmatch. She was admitted to
MICU.
Past Medical History:
# HIV, last CD 4 count 51 and VL <50 in [**8-14**]
# HCV s/p liver xplant 2/[**2179**]. Transplant complicated by a
anhepatic period x 24 hours due to edematous primary transplant
necessitating second liver, Also complicated by PE with
placement of IVC filter. Recent liver biopsy [**5-/2181**] showed
rurrent HCV and stage 2 fibrosis - currently being monitored.
Last VL [**2181-8-8**] 1.46 mill -followed by Dr. [**Last Name (STitle) 497**] and Dr.
[**Last Name (STitle) 724**]
# Pancytopenia: w/u Wih Dr. [**Last Name (STitle) 103261**] [**8-/2181**] (see note), BM biopsy
consistnet with HIV related anemia.
# Chronic methadone use: recently stopped, now on oxycontin
# Depression - on celexa
# Fibromyalgia/Chronic Pain
# CRI (baseline creat 1.3-1.9)
# Anemia: baseline 28-30, BM bx thought c/w HIV related anemia
Social History:
Lives alone in [**Location (un) 1411**]. has boyfriend involved in care. Works in
family restaurant. Substance abuse counsellor. Divorced.
Former IV heroine, cocaine user.
Tobb: 1ppd
Etoh none
lives alone in [**Location (un) 1411**]. [**Name (NI) **] boyfriend stays over. Works in
family restaurant. Substance abuse counsellor. Divorced.
Former IV heroine, cocaine user.
Tobb: 1ppd
Etoh none
Family History:
Mom: RA, breast ca, AMI
Dad: MI
[**Name (NI) **]: IVDU
Sister: Asthma
[**Name (NI) **] ca: uncle
Physical Exam:
Tmax 98.9 Tc98.5 BP 108-123/57-67 HR 74 (70-80) RR 20 O2 95%RA
I/O 120/620 (today) +2145 (net LOS)
Gen- Awake, alert, appropriate female in NAD
Heent- PERRL, EOMI, anicteric
Neck- supple, no LAD, JVP flat
Cor- RRR, no M/R/G
Chest- CTABL
Abd- soft, NT, ND no G/R. Positive bowel sounds. Y-shaped scar-
well healed
Ext- no c/c/e
Neuro- AAO x 3; CN II-XII intact. No focal findings.
Skin- Multiple spider angioma on skin.
Pertinent Results:
[**2181-11-19**] 04:30PM PLT COUNT-81*
[**2181-11-19**] 04:30PM NEUTS-59.1 LYMPHS-30.7 MONOS-7.9 EOS-2.1
BASOS-0.2
[**2181-11-19**] 04:30PM WBC-2.5* RBC-1.27*# HGB-4.3*# HCT-13.2*#
MCV-104* MCH-33.9* MCHC-32.7 RDW-18.4*
[**2181-11-19**] 04:30PM ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-3.0
MAGNESIUM-2.2
[**2181-11-19**] 04:30PM LIPASE-61*
[**2181-11-19**] 04:30PM ALT(SGPT)-14 AST(SGOT)-25 ALK PHOS-63
AMYLASE-41 TOT BILI-1.1
[**2181-11-19**] 04:30PM estGFR-Using this
[**2181-11-19**] 04:30PM GLUCOSE-107* UREA N-42* CREAT-1.7* SODIUM-139
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
[**2181-11-19**] 04:39PM HGB-4.4* calcHCT-13
[**2181-11-19**] 06:05PM PT-13.8* PTT-37.1* INR(PT)-1.2*
[**2181-11-19**] 07:41PM FK506-4.8*
[**2181-11-19**] 11:19PM HCT-22.5*#
CT CHEST [**2181-11-23**]: 1. New small amount of intra-abdominal
ascites. 2. 6 mm peripheral right upper lobe nodule, which may
have mildly increased in size. Diagnostic considerations again
include infectious or neoplastic entities. Short interval
follow-up is recommended.
3. Scattered centrilobular ground-glass opacities with upper
lobe predominance, which in a [**Last Name (LF) 1818**], [**First Name3 (LF) **] represent respiratory
bronchiolitis.
.
ECHO [**2181-11-22**]: Conclusion- The left atrium is normal in size.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. Mild pulmonary hypetension.
.
LIVER U/S [**2181-11-21**]: 1. Increased moderate amount of ascites. 2.
Elevated resistive index in the right hepatic artery of
uncertain significance. Clinical correlation and short-term
followup is recommended. 3. Splenomegaly.
Brief Hospital Course:
Assessment and Plan:
51 yo W with h/o HIV, HCV cirrhosis s/p orthotopic transplant
[**2179**], presented with acute GI bleed.
.
# GI Bleed: Patient was admitted to the MICU for acute drop in
HCT associated with hematemesis. EGD on night of admission
showed Grade I varices with no active bleed, normal stomach and
duodenum. It is felt that her bleeding was variceal in nature
given hematemesis, and patient had recent colonoscopy that did
not demonstrate any potential sources of bleeding. Repeat EGD
demonstrated esophageal varices as well as gastropathy. Banding
was not done as that would likely make gastric varices worse. If
patient were to re-bleed, there is no further endoscopic
intervention and she would require urgent TIPS. HCT trend from
27.8, 28.4, to 26.1. Patient's HCT trended down slowly and was
noted to have guaiac positive stool, but no acute drop occurred
and patient had no further episodes of bright red blood, melena
or dark stools. Patient was therefore maintained on PPI [**Hospital1 **] and
nadolol. Patient was treated with ceftriaxone x 5 days for
prophylaxis in setting of GI bleed.
.
# HIV: She has chronically low CD4 counts and has had difficulty
with different regimens due to anti-rejection meds. Patient was
continue on home regimen of antiretrovirals and dapsone and
azithromcyin for MAC/PCP [**Name Initial (PRE) 1102**].
.
# Cirrhosis / transplant: Her last biopsy did show a progression
to stage 3 fibrosis in her transplanted liver. Patient also with
portal hypertension, ascites and variceal bleed demonstrating
worsening of her liver disease. Patient's tacrolimus level was
monitored with a goal fo [**4-13**] and was dosed weekly.
.
# Prior pulmonary nodules seen on imaging: CT CHEST revealed 6mm
peripheral RUL nodule with mild increase in size, ? infectious
vs neoplastic. Recommend short interval follow up CT. Also some
ground glass opacities centrilobular, likely bronchiolitis in
[**Month/Day (3) 1818**]. Patient was directed to follow up findings on CT in a
few months.
.
# Pancytopenia: Patient is pancytopenic at her baseline. Prior
workup was unrevealing but pointed toward effect of HIV or
antiretrovirals.
.
# Depression: Mood seems appropriate. Patient states she was
thinking of becoming nursing assistant and will now likely need
to change her plans due to progression of fibrosis of her liver
transplant. She was continued on home dose celexa.
.
# Fibromyalgia: She takes oxycontin 40mg [**Hospital1 **] at home for pain.
This was continued in house.
.
# ARF: Patient was noted to have impaired creatinine clearance
with serum creatinine elevated to 1.7. Her baseline creatinine
is 1.1-1.4, and her creatinine and BUN returned to baseline
during her course. Her ARF was felt to be secondary to to
dehydration and hypovolemia due to bleeding and poor PO intake.
She had good urine output and creatinine clearance improved with
fluids. At time of discharge, patient was again started on lasix
and aldactone without difficulty.
.
# HIT Positive in past: All heparin products were held.
Medications on Admission:
- Azithromycin 600 q Thursday
- Citalopram 60 qd
- Dapsone 100 qd
- Marinol 10 [**Hospital1 **]
- Truvada 200-300 qd
- Epo 40,000 units qweek
- Lasix 20 qd
- Ativan 1mg [**Hospital1 **] prn
- Nelfinavir 1250 [**Hospital1 **]
- Oxycontin 40 [**Hospital1 **]
- oxycodone 5 prn
- Phenergan 25 prn
- Prograf 0.5 twice weekly
Discharge Medications:
1. Azithromycin 600 mg Tablet Sig: One (1) Tablet PO 1X/WEEK
(TH).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*20 * Refills:*2*
6. Nelfinavir 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*6*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: [**1-9**]
Tablet Sustained Release 12 hrs PO Q12H (every 12 hours).
11. Prograf 0.5 mg Capsule Sig: One (1) Capsule PO twice a week.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Take medication 12 hours apart from Truvada.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Variceal bleed, Hepatitis C, cirrhosis s/p transplant,
acute renal failure
Secondary: HIV, Pulmonary nodule
Discharge Condition:
Good with stable hematocrit
Discharge Instructions:
You were admitted to the hospital because of a variceal bleed.
You were given 4 units of blood. Your hematocrit ( marker of
blood level) has been stable.
.
You are due for a dose of Boniva on [**12-28**]. Please
contact your primary care physician to obtain this dose.
.
You have been started on a new medication called Ciprofloxacin.
This is to prevent an infection in your abdomen (belly). you
were also started on pantoprazole to decrease acid in your
stomach. Please take this dose 12 hours apart from the Truvada.
.
Please take all your medications as prescribed. Do not make any
changes to your medication without consulting your physician.
.
If you develop any worrisome symptoms such as vomiting blood or
blood in your stool, chest pain, shortness of breath, please
return to the emergency room.
.
Please call Dr. [**Last Name (STitle) 497**] to make a follow up appointment in [**1-9**]
weeks.
.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 497**] by calling ([**Telephone/Fax (1) 1582**] in [**1-9**]
weeks.
|
[
"584.9",
"585.9",
"V58.69",
"276.52",
"E878.0",
"311",
"042",
"996.82",
"V12.51",
"276.51",
"518.89",
"456.20",
"305.1",
"729.1",
"572.3",
"789.59",
"284.1",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9870, 9876
|
5296, 8346
|
344, 356
|
10037, 10067
|
3051, 5273
|
11020, 11139
|
2498, 2596
|
8718, 9847
|
9897, 10016
|
8372, 8695
|
10091, 10997
|
2611, 3032
|
296, 306
|
384, 1220
|
1242, 2064
|
2080, 2482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,847
| 150,701
|
16316
|
Discharge summary
|
report
|
Admission Date: [**2142-5-22**] Discharge Date: [**2142-5-27**]
Date of Birth: [**2092-4-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
Living related renal transplant [**2142-5-22**]
History of Present Illness:
Mr. [**Known lastname 46505**] is a 50-year-old gentleman with end-stage renal
disease and significant cardiac history. After an extensive
workup and extensive
discussion of the risks and benefits of the transplant, he
strongly desired to proceed with a living-related renal
transplant.
Past Medical History:
* CAD, s/p acute anterior MI with CABG at [**Hospital1 2177**] [**2134**]
* ischemic cardiomyopathy: [**5-20**] TTE: EF 15-20% with global HK;
2+MR, [**12-19**]+TR, pulm HTN
* HTN
* DMII. Last A1c 6.8 [**10-23**]
* CRF, creatinine slowly rising over past few years
* anemia
* thrombocytopenia
Social History:
former tobacco use, quit [**2129**]. Runs two restaurants. Has 5
children. social etoh twice a month
Family History:
His mother has diabetes. His father died of
stomach cancer. maternal GF died at age 48 of likely MI
Physical Exam:
(on discharge)
97.9 69 174/76 20 100%RA
RRR
CTAB
soft, appropriate tenderness
incision C/D/I with staples in place
no edema
Brief Hospital Course:
This patient was admitted for his surgery and prepared/consented
as per standard. There were no intra-op complications. Please
see operative report for details. The patient was taken to the
ICU post-operatively and started on a nitro gtt to maintain SBP
and PA pressures<50. He was transfered to the floor on POD2
after swan removal once he was stable from a cardiac point of
view. His home medications were resumed, and he was ambulating.
His pain was moderately controlled. On POD3, PCA was stopped and
he was started on ASA. The pt received 75mg of ATG. He
experienced some indigestion during the day, with an EKG that
was unremarkable. He received MMF and FK in the post-operative
period as per standard. On POD3, he received 1 unit pRBC for
postoperative anemia (Hct 21.5). He was otherwise well. POD4 he
did well and was able to be discharged to home in the AM of
POD5. He will follow-up in the [**Hospital 1326**] Clinic tomorrow for
lab draw and levels.
Medications on Admission:
coreg 6.25", ASA 325', lipitor 40', avandia, erytropoeitin,
phoslo, lasix80', lisinopril 5
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*500 ml* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. 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*
10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
Disp:*240 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD
ESRD
Discharge Condition:
good
good
Discharge Instructions:
Call Dr. [**Last Name (STitle) 816**] if fevers, chills, nausea, vomiting, inability to
take medications, decreased urine output, weight gain > 3 lbs in
a day, edema, incision redness/bleeding/drainage.
Adhere to 2 gm sodium diet
.
PROGRAF dose may be adjusted based on laboratory levels. [**First Name4 (NamePattern1) 5036**]
[**Last Name (NamePattern1) **]-Chrazn will contact you if there are changes.
Followup Instructions:
**PLEASE FOLLOW-UP IN [**Hospital **] CLINIC TOMORROW MON [**5-28**] for
LABS.
.
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-5-31**]
9:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2142-5-31**] 10:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-6-5**] 8:30
.
**Follow-up with your cardiologist at [**Hospital1 2025**] as soon as possible.
|
[
"414.00",
"285.21",
"416.8",
"403.91",
"414.8",
"V45.81",
"585.6",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"99.04",
"88.72",
"89.64",
"00.91"
] |
icd9pcs
|
[
[
[]
]
] |
3988, 3994
|
1404, 2370
|
319, 369
|
4049, 4062
|
4516, 5084
|
1137, 1238
|
2511, 3965
|
4015, 4028
|
2396, 2488
|
4086, 4493
|
1253, 1381
|
275, 281
|
397, 686
|
708, 1002
|
1018, 1121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,946
| 133,808
|
6288
|
Discharge summary
|
report
|
Admission Date: [**2127-10-1**] Discharge Date: [**2127-10-3**]
Date of Birth: [**2055-1-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
Endoscopy
Suturing of forehead laceration
History of Present Illness:
Mr. [**Known lastname **] is a 71 y/o male with hx of diabetes, HTN and no prior
hx of GI bleed, who presents with sudden onset of massive BRBPR
around 9:30 PM. He was in his USOH today and went to a meeting
from 6:30 - 8:30 where he ate nothing unusual and had no ETOH.
He felt sudden urgency to move bowels and passed large amount of
bright red blood x 3. He was lightheaded/dizzy and then
syncopized, hitting his head on a dining room chair. EMS was
called and found him alert and oriented, but with an SBP 80-90
and thready pulse. He received 2 L IVF by EMS.
.
In the ED, VS were T 96.8, HR 60-70's (on home atenolol), SBP
110-130's/60-80's, 100% on RA. He received 10 stitches in his
frontal lac, and his c-spine was cleared clinically. NG lavage
was negative (300 cc placed; 100 cc returned of clear/non-bloody
stomach contents). Hct was 33.1 without known baseline, and he
was given 2 units RBC and 2L NS.
.
Patient says last colonoscopy was 2-3 years ago at OSH and was
reportedly normal. Denies known hemorrhoids, polyps, or
diverticulosis.
Past Medical History:
- HTN
- Hypercholesterolemia
- Diabetes
Social History:
-- prior smoker in 30's; denies ETOH/IVDU
-- married, two children
-- works at [**Company **] School of Public Health.
Family History:
-- No hx of colon cancer or any chronic GI illnesses
Physical Exam:
VS in the ED: T 96.8, HR 60-70's, SBP 110-130's/60-80's, 100% on
RA
VS on arrival to the MICU: afebrile, HR 84, BP 148/99, RA
General: comfortable, elderly man
HEENT: + Conjunctival pallor, OP clear
LUNGS: CTA b/l
CARDIO: rate regular, no murmurs appreciated
ABD: + BS, soft, NTND, no HSM
EXT: No edema, pulse 2+
SKIN: stiches over lac on right forehead; small abrasion on
bridge of nose; several spots of erythema on face where he fell
[**Last Name (LF) **], [**First Name3 (LF) **] GI fellow note/exam: Bright blood on glove. No masses,
no prostate enlargement
Exam unchanged upon discharge
- he had a bowel movement with no blood noted
Pertinent Results:
ADMISSION LABS:
[**2127-10-1**] 01:28AM BLOOD WBC-11.7* RBC-4.66 Hgb-10.3* Hct-33.1*
MCV-71* MCH-22.1* MCHC-31.2 RDW-15.2 Plt Ct-211
[**2127-10-1**] 04:52AM BLOOD WBC-12.6* RBC-4.50* Hgb-10.8* Hct-32.7*
MCV-73* MCH-24.0* MCHC-33.1 RDW-17.8* Plt Ct-148*
[**2127-10-1**] 01:28AM BLOOD Glucose-236* UreaN-27* Creat-1.1 Na-140
K-3.9 Cl-105 HCO3-24 AnGap-15
[**2127-10-1**] 01:25AM BLOOD Glucose-227* Lactate-2.7* Na-139 K-3.9
Cl-102 calHCO3-27
CXR [**10-1**]:
1. No acute cardiopulmonary process.
2. Apparent ectasia of the thoracic aorta, which correlation
to prior
cross-sectional imaging if available would be ideal for further
evaluation.
Head CT [**10-1**]:
1. No acute intracranial injury.
2. Prominent bifrontal extra-axial CSF spaces, likely reflecting
cortical
atrophy.
EGD [**10-2**]:
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Colonoscopy [**10-2**]:
Impression: Diverticulosis of the throughout the colon
No active or stigmata of bleeding noted.
Otherwise normal colonoscopy to cecum and terminal ileum
Brief Hospital Course:
Mr. [**Known lastname **] is a 71 yo M with DM and HTN, admitted with acute lower
GIB.
#. GIB: Patient had no further episodes of BRBPR while in the
MICU. Initial lactate 2.7 which decreased to 0.9 after 4 liters
IVFs and 2 units prbcs. Hct remained above 30 in the MICU and
required no further transfusions. Started on IV protonix [**Hospital1 **].
EGD and colonoscopy performed on HD2 showed multiple diverticuli
which was felt to be the source of bleeding. MCV 71 initially
concerning for malignancy, however patient has h/o thalassemia
and reportedly has had a low MCV in the past. Further work up
should be performed in the outpatient if not already done. On
the floor his Hct remained stable and he had no bleeding.
#. s/p SYNCOPAL EVENT: Clear precipitant of hypovolemia/GI
bleed, however ruled out for MI and no evidence of arrythmia
during hospital stay. Hit head requiring stichtes on right
forehead [**2127-10-1**]. Head CT negative. Stiches will need to be
removed in [**5-23**] days ([**Date range (1) 24403**])
#. HTN: Initially held home lisinopril and atenolol in setting
of GI bleed. He was started on his home medications upon
discharge.
#. DIABETES: Held metformin in house. SSI during stay.
#.HYPERLIPIDEMIA: Contiued lipitor 10 mg and Niacin.
Medications on Admission:
Metformin 850 [**Hospital1 **]
Niaspan 1000 daily
Lipitor 10
Atenolol 25 daily
Lisinopril 40 daily
Centrum
ASA 81
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Niacin 1,000 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower Gastrointestinal Bleed
Diverticulosis
Head laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had a lower gastrointestinal
bleed. You lost a significant amount of blood that resulted in
you dropping your blood pressure. This drop in blood pressure
resulted in you losing consciousness. You had a colonoscopy and
and upper endoscopy which did not reveal an active source of
bleeding. The most likely source of your bleeding was from
diverculosis which are outpouchings in the wall of your
intestines. You are at high risk for a repeat bleed. If this
occurs, you should go to the emergency room right away.
You also received emergency care of a forehead laceration with
sutures. It is very important to follow these directions
carefully to make sure you are healing well, and to be sure you
do not develop an infection.
* Gently wash the wound with mild soap and warm water 2-3 times
per day, pat dry, and apply a clean bandage as needed.
* If there is crusting between the sutures, you can gently
remove this by mixing equal parts of hydrogen peroxide and
water. Apply this with a Q-tip to dissolve the crusting. See
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] removal in 5 days.
* For the first 6 months the scar tissue may react differently
to the sun -- use at least SPF 15 sunscreen if you will be in
the sun.
No changes were made to your medications. Take all medications
as prescribed, and always review your medication list with your
physician.
Followup Instructions:
Name: [**Last Name (LF) 24404**],[**First Name3 (LF) **] J.
Address: [**Apartment Address(1) 24405**], [**Hospital1 **],[**Numeric Identifier 24406**]
Phone: [**Telephone/Fax (1) 24407**]
Appt: [**10-8**] at 2pm
Your PCP should evaluate your sutures for consideration of
removal at this visit. Facial sutures are usually removed after
5-7 days.
Department: GASTROENTEROLOGY
When: FRIDAY [**2127-10-31**] at 10:00 AM
With: [**Name6 (MD) 81**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"280.0",
"276.52",
"272.4",
"401.1",
"780.2",
"250.00",
"562.12",
"873.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
5412, 5418
|
3517, 4789
|
342, 398
|
5522, 5522
|
2426, 2426
|
7126, 7790
|
1695, 1749
|
4953, 5389
|
5439, 5501
|
4815, 4930
|
5673, 7103
|
1764, 2407
|
275, 304
|
426, 1478
|
2443, 3494
|
5537, 5649
|
1500, 1542
|
1558, 1679
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,708
| 130,938
|
813+55237
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-9-20**] Discharge Date: [**2162-9-27**]
Date of Birth: [**2089-12-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neomycin
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
fever, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72yo F quadriplegic with chronic indwelling foley, presented
from [**Hospital1 1501**] to [**Hospital1 18**] ED via EMS on [**2162-9-20**] w/ decreased mental
status, cloudy urine, fever, and hypotension.
.
In the ER, her SBP dropped quickly from 100 to 60s and code
sepsis called. She was noted to have milky white urine coming
from her indwelling foley catheter. Her foley catheter was then
changed and she was started on IV abx - zosyn (despite report of
vague allergy) and linezolid. She initially required pressors
for blood pressure control.
.
Early in the [**Hospital Unit Name 153**] course pt was weaned off pressors. Blood cx's
returned with pan sensitive e. coli. Urine culture at present is
grown two separate GNR's, and decision was made to continue with
double GNR coverage (Zosyn and levofloxacin) out of concern for
possible reistant pseudomonas. Other complication early in
course of [**Hospital Unit Name 153**] stay included reanl failure which is responding
well to re-hydration. Pt also complained of a headache in the
[**Hospital Unit Name 153**]. CT of head was without acute findings, and headache
responded fully to tylenol, therefore no further work up was
pursued by the [**Hospital Unit Name 153**] team.
.
On arrival to floor pt denies any complaints.
Past Medical History:
# C4 quadriplegic s/p fall [**5-21**]
# hiatal hernia
# HTN
# h/o decubitus ulcers
# diverticulitis
# recurrent UTI from indwelling foley catheter -> + VRE in past
# neurogenic bladder
# muscle spasms - often precede development of UTI
# ?DM - "diet controlled"
# h/o seizures
# h/o herpes zoster
Social History:
Lives in [**Location **] ([**Location (un) **] Manor). No tob, no EtOH. Married, husband
is very involved in her care.
Family History:
NC
Physical Exam:
VS - T 98, BP 132/45, HR 72, RR 16, sats 95% on RA
Gen: Thin, elderly female, in contorted positioning, NAD.
HEENT: Neck supple. R IJ in place. Nontender, dsg c/d/i. PERRLA,
OP clear, no exudates or erythema. MM moist
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly and laterally, along her sides.
Abd: Soft, NTND. Hypoactive BS. No HSM noted on exam. No
suprapubic tenderness or CVAT.
Ext: 2+ PT/DP pulses bilaterally. No c/c/e. Skin dry.
Neuro: Oriented x 3.
Pertinent Results:
HCT 25-26
folate 10.6, ferritin 258, B12 156, Fe 5, TIBC 159
WBC 33 -> 7.8
.
Creatinine 2.3 -> 1.0
FENa 0.46%
.
Sodium 147 -> 130's -> 146
Lactate 3.9 -> 2.3
.
alb 2.8
.
INR 1.3 -> 1.1
.
Cortisol 33, TSH 2.2
.
MICRO:
[**2162-9-20**] - contaminated
[**2162-9-20**] - [**2-20**] blood cx with pan sensitive e coli (see below)
[**2162-9-22**] - blood cultures no growth to date
C diff negative x 4
[**2162-9-23**] - bullous aspirate: gram stain negative, culture with no
growth
[**2162-9-24**] - urine culture with no growth
.
AEROBIC BOTTLE (Final [**2162-9-23**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2162-9-23**]):
REPORTED BY PHONE TO [**Location (un) **] [**Doctor Last Name 5756**] AT 1:58A [**2162-9-21**].
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
PATHOLOGY:
Skin, left forearm, superficial epidermis ('jelly roll')
specimen (A):
Thin strips of epidermis with minimal necrosis, see note.
Note: The vast majority of the epidermis present in this
specimen is viable, arguing against a diagnosis of
TENS/[**Doctor Last Name **]-[**Location (un) **]. While a few eosinophils are noted adjacent
to the epidermis, in the context of such a superficial specimen,
the finding is not specific. The separation of the epidermis
appears to be at the dermal-epidermal junction. Dr. [**Last Name (STitle) 5757**]
notified of diagnosis on [**2162-9-24**].
.
IMAGING:
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The evaluation
of the upper abdomen is severely limited due to beam hardening
effect from patient's arms.
There are small bilateral pleural effusions, right greater than
left, with bilateral dependent atelectasis.
In this limited evaluation of the upper abdomen, the liver,
gallbladder, spleen, pancreas, and adrenals are unremarkable.
There is no large stone in the kidneys, and both kidneys are
excreting contrast symmetrically. The aorta and its major
abdominal branches are patent. There is no evidence of bowel
obstruction.
CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: The previously
seen ([**2162-9-20**] CT) right retroperitoneal/paracolic
gutter fluid collection is no longer visualized. Large bowel
diverticulosis is present without evidence of diverticulitis. A
small amount of free fluid is present in the presacral area.
Additionally, there is extensive subcutaneous edema consistent
with anasarca.
There are no suspicious lytic or blastic lesions in the osseous
structures. Degenerative changes are noted.
CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the
above findings.
IMPRESSION: Limited study. Anasarca with bilateral small pleural
effusions and small amount of fluid in the presacral area. Large
bowel diverticulosis without evidence of diverticulitis. No
evidence of renal stones but since the evaluation is limited an
ultrasound can be helpful if there is a persistent concern for
renal stones.
.
HEAD CT WITHOUT CONTRAST.
CLINICAL INDICATION: Mental status changes. Assess for
intracranial hemorrhage.
Multiple axial images are obtained from base to vertex without
intravenous contrast administration. Comparison is made to the
prior head CT from [**2162-2-2**].
There are no focal lesions seen within the brain parenchyma. The
sensitivity of the examination is lower due to the lack of
intravenous contrast administration. No midline shift, mass,
mass effect, or hemorrhage is noted. A small low density is seen
within the right frontal lobe on image 23, suggestive of an old
infarct. This was present on the previous exam. The calvarium is
intact. There is no subdural hemorrhage. Slightly decreased
attenuation is noted involving the left frontal white matter,
which probably represents volume averaging. The calvarium is
intact.
IMPRESSION: No acute intraparenchymal hemorrhage seen.
.
[**2162-9-20**] CXR - The tip of a right internal jugular vein overlies
the mid SVC. The radiograph is otherwise insignificantly
changed. Numerous calcified granulomas scattered throughout both
lungs with upper lobe predominance. No airspace consolidations
are identified. The heart and mediastinal contours with a
calcified aorta are unchanged. No pneumothorax is identified.
IMPRESSION: Right IJ catheter overlying mid SVC without
pneumothorax.
Brief Hospital Course:
# E coli Urosepsis:
Patient was initially admitted to the ICU per the sepsis
protocol. She was managed with levophed and IVF to sustain her
blood pressure and was covered broadly with linezolid (given h/o
VRE) + zosyn. Once GNR identified in blood, linezolid was d/c
and patient was double covered with levofloxacin/zosyn pending
sensitivities. Blood cultures grew pan sensitive E coli and
thus antibiotics were tailored to levofloxacin only with a plan
for a total of 14 days to treat. Her foley was replaced and
repeat urinalysis and urine culture [**2162-9-24**] negative for evidence
of persistent infection and surveillance blood cultures are
negative. Initial urine culture was contaminated. No other
source of infection identified: CT abdomen for continued stomach
spasms was negative for inflammatory pathology and CXR was
without evidence of an infiltrate. Of note, numerous calcified
granulomas throughout both upper lung zones (seen on previous
CXRs here at [**Hospital1 18**]) suggest history of remote tb or histo
exposure. No current cough to suggest active infection.
.
# Bullous rash:
Patient developed superficial bullae on her left forearm at the
site of an IV infiltration. Dermatology was consulted for
concern for SJS or TEN. Patient refused punch biopsy but shave
biopsy showed no evidence of epidermal necrosis to suggest TEN
or SJS. Possibility of bullous pemphigoid was considered, but
punch bx would be needed to diagnose this. Aspirate gram stain
and culture were negative for underlying infection. Treatment
would likely be topical steroid given age and comorbidities.
However, no further lesions have developed. Plan to continue
current wound care for now with PCP [**Last Name (NamePattern4) 702**].
.
# Acute renal failure:
Admission creatinine 2.3. FENa 0.46%, suggesting prerenal.
Creatinine returned to baseline with IVF.
.
# Headache:
Patient complained of pain behind her eyes while in the ICU.
Ophthamology was consulted and found no evidence of acute
issues. Head CT showed no evidence of bleed. Patient refused
LP and headache responded to tylenol. Patient continues to have
occasional tension in the right temporal region, which improves
with massage to the area.
.
# Anemia:
Patient's hematocrit remained stable between 25-26. B12 was low
and is being repleted IM. Folate and iron studies were normal.
Elevated ferritin suggestive of possible AOCD.
.
# Muscle spasms:
Patient has been having increased muscle spasms since her
admission. On the day of discharge, these have improved some.
In addition, whe will be given an additional noontime dose of
her tizanidine in hopes of improved symptom relief.
.
# Hypertension: Patient's atenolol and nifedipine have been
held. These can be slowly reintroduced if her blood pressure
remains elevated.
.
# Psych: Continued on mirtazapine
.
# FEN: Nutrition was consulted given albumin 2.8. Patient
refused boost supplements. Would recommend increase protein in
diet. Patient admitted with hypernatremia (148). This improved
in the ICU with D5W. She again required D5W for correction on
the day of discharge and will need her sodium rechecked in 2
days.
.
# PPX: Heparin SC, PPI as per home
.
# COMM: with patient, her husband, and her son
husband - [**Name (NI) 5758**] (husband) [**Telephone/Fax (1) 5759**]
son - [**Name (NI) **] [**Name (NI) 5760**] [**Telephone/Fax (1) 5761**]
niece - [**Name (NI) **] [**Name (NI) 1169**] 617-785-35xx
.
# CODE: FULL (per her [**Hospital1 1501**] sheet)
.
# DISPO: Patient discharged back to [**Hospital **] nursing home
Medications on Admission:
Juven 1 pkg [**Hospital1 **]
Atenolol 50mg QD
azo-cranberry 300mg QD
Fluticasone 50mcg 2 sprays in each nostril QD
MVI QD
Omeprazole 20mg QD
Zinc sulfate 220mg caps 1 tab PO QD
Nifedipine ER 60mg QD
Docusate 100mg [**Hospital1 **]
Gabapentin 200mg [**Hospital1 **]
Vitamin c 500mg tab [**Hospital1 **]
Lyrica 25mg TID
Pilocarpine 5mg TID
Mirtazipine 7.5mg QHS
Bisacodyl 10mg PR QAM prn
Senna 2tabs PO QD prn
Enulose 10gm/15mL -> give 30mL PO QD prn
Clonazepam 0.5mg PO BID prn anxiety
Tylenol prn
MOM 30mL PO QHS prn
Zanaflex 6mg PO BID
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. azo-cranberry
300 mg po qd
3. Juven
1 pkg [**Hospital1 **]
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
10. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO tid.
11. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QAM (once a day (in the morning)) as needed for constipation.
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
14. Enulose 10 g/15 mL Solution Sig: Thirty (30) mL PO once a
day as needed for constipation.
15. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
16. Tizanidine 2 mg Tablet Sig: 2-3 Tablets PO tid: Please take
3 tablets qam, 2 tablets qnoon, 3 tablets qpm.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q8H (every 8 hours).
18. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days: through [**2162-10-4**].
19. Cyanocobalamin 1,000 mcg/mL Solution Sig: One Hundred (100)
mcg Injection DAILY (Daily) for 3 days: through [**2162-9-29**].
20. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
E coli septicemia secondary to urinary tract infection
acute renal failure
anemia
B12 deficiency
diarrhea
headache
muscle spasms
bullous rash
history of hypertension
Discharge Condition:
good: afebrile, taking good po, repeat urinalysis negative
Discharge Instructions:
Please monitor for temperature > 101, low blood pressure,
worsening mental status, or other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 5762**] within 1-2 weeks.
Please follow-up with your neurologist within 1-2 weeks.
Name: [**Known lastname 664**]-[**Known lastname 76**],[**Known firstname 665**] Unit No: [**Numeric Identifier 666**]
Admission Date: [**2162-9-20**] Discharge Date: [**2162-9-27**]
Date of Birth: [**2089-12-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neomycin
Attending:[**First Name3 (LF) 667**]
Addendum:
The patient remained stable while in the hospital overnight from
[**2162-9-26**] to [**2162-9-27**]. Day of discharge is [**2162-9-27**]. She was seen
by Dermatology on this day who recommened outpatient follow up
if her L arm bullous lesion (thought to be pressure induced)
does not heal within 1-2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 668**] Manor
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 669**] MD [**MD Number(2) 670**]
Completed by:[**2162-9-27**]
|
[
"266.2",
"596.54",
"787.91",
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"709.8",
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"286.9",
"285.9",
"038.42",
"599.0",
"553.3",
"584.9",
"344.00",
"784.0",
"995.92",
"401.9"
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icd9cm
|
[
[
[]
]
] |
[
"86.11",
"00.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14770, 14966
|
7622, 11191
|
313, 320
|
13708, 13769
|
2610, 7599
|
13930, 14747
|
2103, 2107
|
11778, 13422
|
13519, 13687
|
11217, 11755
|
13793, 13907
|
2122, 2591
|
245, 275
|
348, 1630
|
1652, 1951
|
1967, 2087
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,807
| 104,717
|
53068
|
Discharge summary
|
report
|
Admission Date: [**2127-8-6**] Discharge Date: [**2127-8-14**]
Date of Birth: [**2074-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath, fever
Major Surgical or Invasive Procedure:
Large volume paracentesis [**8-9**] and 28.
History of Present Illness:
HPI: 53 year old male with HIV, ESLD (sober for a week), chronic
illness, no medical care, presented with malaise and mild SOB.
Found to have HCT 19, melena ?????? believe to be subacute, low grade
temps (100.3), ascites. Para results pending, already on zosyn.
Transfused 3 units and hemodynamically stable, making urine,
sitting on a medical floor. Requesting transfer to further care.
On [**8-6**] (HD#2) went for EGD to eval melena/suspicion for
varices; unable to tolerate [**1-18**] hypoxia while lying flat and
resting tachycardia to 100-110. Returned to the medical floor
stable, but then hematemesis of 100-150cc bright red blood with
increased tachycardia to 120s and hypoxia requring NRB to keep
sats >=90%.
Bolused 1L [**Hospital **] transferred to ICU, intubated for airway. At
intubation, copious bloody secretions suctioned from ETT.
Octreotide started. On PPI. 2 PIV (bilat antecubs). Transferred
to MICU, intubated in prep for EGD.
ROS: Negative for fevers, chills, nightsweats, chest pain,
shortness of breath, cough, abdominal pain, nausea, vomiting,
diarrhea, melena, hematochezia, hematemesis, dysuria. No
paresthesias or weakness. Otherwise pertinent positives as
above.
Past Medical History:
PMH: HIV+, unclear stage (dx in pts 40s)
Social History:
SH: Drinks 2 large coffee cups of vodka per day. Reports last
drink approx 1 week ago. HIV+ from partner. Off meds for years.
Reports being diagnosed with AIDS. Smokes 1/2-1 PPD. Denies
IVDU.
Family History:
FH: Father with dementia. Mother healthy. [**Name2 (NI) **] alcohol abuse.
Physical Exam:
PHYSICAL EXAM:
VS: T 96.9 BP 157/105 P 122 VENT: AC 450 x12, FiO2 100%;
Sat 99%
GEN: cachectic man
HEENT: prominent temporal wasting, purple-black exudates on
tongue NECK: Supple, no LAD, no appreciable JVD
CV: normal S1S2, no murmurs, rubs or gallops
PULM: CTAB, no w/r/r, fair air movement bilaterally
ABD: + caput medusae, massively distended, normoactive bowel
sounds, no organomegaly, no abdominal bruit appreciated
SKIN: dry, scaling skin on upper trunk, waxy skin on ankles with
bilateral venous stasis changes
EXT: Warm and well perfused, symmetric distal pulses, 2+
bilateral leg edema to the abdomen
NEURO: sedated for intubation; + asterixis prior to intubation
Pertinent Results:
[**2127-8-6**] 11:02PM URINE HOURS-RANDOM CREAT-141 SODIUM-LESS THAN
[**2127-8-6**] 09:19PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.022
[**2127-8-6**] 09:19PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-TR
[**2127-8-6**] 09:19PM URINE RBC-[**11-6**]* WBC-[**2-19**] BACTERIA-NONE
YEAST-NONE EPI-0
[**2127-8-6**] 09:19PM URINE AMORPH-MOD
[**2127-8-6**] 09:15PM GLUCOSE-106* UREA N-38* CREAT-1.5* SODIUM-136
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-25 ANION GAP-9
[**2127-8-6**] 09:15PM estGFR-Using this
[**2127-8-6**] 09:15PM ALT(SGPT)-22 AST(SGOT)-38 LD(LDH)-260* ALK
PHOS-42 TOT BILI-3.2*
[**2127-8-6**] 09:15PM ALBUMIN-1.8* CALCIUM-7.4* PHOSPHATE-3.8
MAGNESIUM-1.7
[**2127-8-6**] 09:15PM WBC-6.3 RBC-3.16* HGB-10.2* HCT-31.7*
MCV-100* MCH-32.2* MCHC-32.1 RDW-22.0*
[**2127-8-6**] 09:15PM NEUTS-65.1 LYMPHS-28.6 MONOS-4.2 EOS-1.5
BASOS-0.5
[**2127-8-6**] 09:15PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2127-8-6**] 09:15PM PLT SMR-VERY LOW PLT COUNT-53*
[**2127-8-6**] 09:15PM PT-18.4* PTT-39.4* INR(PT)-1.7*
[**2127-8-6**] 09:15PM WBC-6.3 LYMPH-29 ABS LYMPH-1827 CD3-93 ABS
CD3-1700 CD4-9 ABS CD4-170* CD8-77 ABS CD8-1413* CD4/CD8-0.1*
Labs from OSH:
WBC 7.8, H/H 8.9/19--->25.6, plts 65
136, 4.6, 108, 23, 32, 1.3, 98
Ca 7.7, Mg 1.7
AST 46, ALT 24, ALK Phos 47, Tbili 3.4, serum albumin 1.2, total
protein 7.0, amylase 97, lipase 28
Ammonia 38
Ferritin 368
Fe 80
TIBC 100
Folate 14
Vit B12 919
TSH 6.6
INR 1.5
UA - dark yellow, cloudy, ph 6, 1+ bili, 2+ blood, 2+ leuk est,
10-20 WBCs, + ammonium urate crystals
Imaging:
[**8-6**]: Abd U/S - large ascites, shrunken liver, patent portal
vein, GB wall thickening, multiple gallstones; splenic
calcifications
Brief Hospital Course:
53 year old male with ESLD, HIV presenting with multiple
complaints transferred to [**Hospital1 18**] with fevers, fount to have UTI
at OSH, now with hematemesis from a gastric ulcer now s/p EGD
with clipping of vessel and [**State **] tube removal.
Pt's condition continued to decline during his hospital
admission. The hematemesis resolved, but all other issues
continued to be problem[**Name (NI) 115**]. [**Name2 (NI) **] developed hypernatremia, had
poor oxygen saturation, and became hypotensive despite repeated
albumin boluses. Pt was made DNR/DNI on [**8-13**] and then was made
CMO the morning of [**8-14**]. He was pronounced dead at 10:45 am on
[**2127-8-14**]. Mother was informed and she declined autopsy.
#. Renal failure: Elevated Creatinine and decreased UOP -
Patient with Cr of 1.6 BL now 2.0 more or less this entire
admission, unknown baseline. Given low muscle mass, this is
quite elevated.
- Previously, urine lytes showed ATN, now, lytes consistent with
pre-renal state
- Will give 500ml of 5% albumin for fluid and albumin resus
- Parancetesis on [**8-13**] with goal to relieve pressure on renal
vasculature which may be contributing to ARF
#. Altered Mental Status - Patient with AMS on arrival, had
improved but now worsening. Unclear if this is AIDS dementia,
uremic, or hepatic encephalopathy
- Now awake, alert, and agitated.
- Will try again with NG lactulose plus lactulose enema as
before
#. ESLD: patient with tense ascites, thrombocytopenia,
coagulopathy. Given history of EtOH abuse, this is the most
likely cause. Chronic Hepatitis also a concern.
-Propranolol 10mg TID PO for varices
-MELD score 18, unlikely candidate for transplant given alcohol
use and likely uncontrolled HIV disease
-US of portal venous system showed blood flow with possible
ileus
-Large vol parancentesis x 2 during admission. Labs of
peritoneal fluid consistent with cirrhosis
# Gaseous distension of colon: Ongoing problem for this Pt.
Etiology unclear.
- Passing gas. Stool more solid now.
- Add back lactulose as tolerated and lactulose enema x 1 today
- [**Month (only) 116**] be contributing to high intraabdominal pressure which may
be complicating ARF
#. Leukocytosis and fever - Patient transferred from OSH with
fevers and +UA, which makes UTI most likely diagnosis. patient
also HIV+ with CD4 count of 170, making opportunistic infection
a concern. Urine cultures X2 negative here.
- BCx results pending
- Paracentesis fluid not c/w SBT. On ceftriaxone for ?UTI from
osh ?????? CTX until [**2127-8-13**]
- As of [**2127-8-13**] WBC rising with mild neutrophilia. Source of
infection unclear. CXR concerning for aspiration. UCx pending.
- Repeating paracentesis on [**2127-8-13**]
#. Hematemesis - From bleeding gastric ulcer. Patient noted to
have 1.5L of frank hematemesis at time of EGD, which prompted
[**State **] tube placement. FDP and D-dimer elevated, along with
decreased haptoglobin and thrombocytopenia. HCT now stabilized.
-discontinued Octreotide
-cont protonix 40mg IV BID
-f/u Hepatology recs
-transfuse for HCT < 25
# Thrombocytopenia ?????? multifactorial. Related to liver disease
and AIDS most likely
- Infused 1 U [**8-12**] with good effect
-transfuse platelets if <50 given recent UGIB
#. HIV - CD count 170 here. will hold on treatment at this time.
[**Month (only) 116**] need PCP prophylaxis now as CD4 count <200.
- started atovaquone
- ID holding HAART for now given poor PO absorption
#. Alcoholism
- Holding CIWA scale for now to be able to eval encaphalpathy
Medications on Admission:
Meds on Admission: from OSH - pt on no meds at home
zosyn 3.375g q6
protonix 40mg IV BID
folic acid 1mg PO daily
MVI 1 po daily
thiamine 100 mg po daily
nicotine patch
metoclopromide 5-10mg IV q6 prn
morphine 2-4 mg IV q3 prn
D5N at 80 per hour
Discharge Disposition:
Home with Service
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2127-8-14**]
|
[
"780.99",
"V08",
"458.9",
"599.0",
"560.1",
"572.2",
"287.5",
"531.00",
"789.59",
"276.0",
"571.2",
"584.9",
"285.1",
"303.90",
"286.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"97.01",
"38.93",
"44.93",
"96.6",
"96.71",
"45.13",
"44.43",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8390, 8409
|
4555, 8095
|
339, 384
|
8460, 8469
|
2692, 4532
|
8525, 8563
|
1903, 1979
|
8430, 8439
|
8121, 8126
|
8493, 8502
|
2009, 2673
|
273, 301
|
412, 1612
|
8140, 8367
|
1634, 1677
|
1693, 1887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,899
| 167,383
|
30692+57714
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-4-1**] Discharge Date: [**2184-4-12**]
Date of Birth: [**2123-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
61 year-old man admitted from [**Hospital3 8063**] for mental
status changes and agitation. Patient was admitted to
[**Hospital1 **] on [**3-29**] through Section 35 for court-ordered alcohol
detox. On admission to [**Hospital1 **], patient was noted to be
oriented without confusion. On [**3-30**], he received 1 mg PO ativan
Q4H. Overnight on [**3-30**], patient became confused and
disoriented. At the time, BP=130/80, P=83, RR=18, O2 sat = 93%
RA. He was incontinent of stool and was noted to be trying to
"pick things off the floor that were not there". He was given
trazodone without effect and then a total of 3 mg ativan. He
was transferred to [**Hospital1 18**] on the morning of [**3-31**] for further
management.
Past Medical History:
1. alcohol abuse; per report, heavy drinking in last year with
constant alcohol use in last 2 weeks before admission to detox
2. hep C
3. emphysema
4. ? cirrhosis
Social History:
alcohol abuse; current smoker; no illicits
Family History:
non-contributory
Physical Exam:
T 96.0 HR 62 BP 156/86 RR 13 100% O2 sat on RA
Gen: leather 4-point restraints; somnolent; arousable to voice
but quickly falls back asleep; mumbles responses to questions;
intermittently incoherent
HEENT: atraumatic; pupils 3->2 bilaterally
Neck: supple
CV: RRR; nl S1, S2; no m/r/g
Lungs: clear to auscultation bilaterally (anterior)
Abd: limited exam due to tense abdominal muscles; non-tender to
palpation; decreased bowel sounds
Extrem: no c/c/e
Neuro: sedated; arousable to voice; oriented x2; moving all
extremities; pt unable to cooperate with remainder of exam.
Pertinent Results:
[**2184-4-2**] 06:08AM BLOOD WBC-5.3 RBC-3.59* Hgb-13.0* Hct-38.1*
MCV-106* MCH-36.3* MCHC-34.2 RDW-13.0 Plt Ct-197
[**2184-3-31**] 10:30AM BLOOD WBC-5.3 RBC-3.67* Hgb-13.4* Hct-38.9*
MCV-106* MCH-36.5* MCHC-34.5 RDW-13.1 Plt Ct-153
[**2184-3-31**] 10:30AM BLOOD Neuts-55.8 Lymphs-32.4 Monos-6.6 Eos-3.4
Baso-1.7
[**2184-3-31**] 10:30AM BLOOD Plt Ct-153
[**2184-4-2**] 06:08AM BLOOD Glucose-113* UreaN-5* Creat-0.8 Na-141
K-3.2* Cl-106 HCO3-26 AnGap-12
[**2184-3-31**] 10:30AM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
[**2184-4-1**] 05:40AM BLOOD ALT-70* AST-137* LD(LDH)-324* AlkPhos-82
TotBili-0.9
[**2184-3-31**] 10:30AM BLOOD ALT-71* AST-120* AlkPhos-95 Amylase-39
TotBili-0.8
[**2184-3-31**] 10:30AM BLOOD Lipase-30
[**2184-4-1**] 05:40AM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.1 Mg-2.4
[**2184-3-31**] 10:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2184-3-31**] 07:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2080*
POLYS-59 LYMPHS-32 MONOS-4 EOS-5
[**2184-3-31**] 07:10PM CEREBROSPINAL FLUID (CSF) PROTEIN-54*
GLUCOSE-69
[**2184-3-31**] 07:10PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-550*
POLYS-69 LYMPHS-25 MONOS-1 EOS-5
[**2184-3-31**] 10:49AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2184-3-31**] 10:49AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2184-3-31**] 10:49AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-9.0*
LEUK-NEG
[**2184-3-31**] 10:49AM URINE RBC-[**2-9**]* WBC-O-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
.
[**3-31**] CXR (PA and lateral):
1. No acute cardiopulmonary process.
.
2. Mild anterior wedge compression fractures of multiple
vertebral bodies of uncertain chronicity.
[**3-31**] Head CT without Contrast:
Normal head CT
.
[**4-1**] Head CTA:
Normal CT angiogram from the level of the carotids at
approximately C2-3 to the cranial vertex.
.
[**3-31**] CSF
GRAM STAIN (Final [**2184-3-31**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
On arrival to the ED, T=97, HR=80, BP=128/85, RR=16, 98% O2 sat
on RA. He was awake and conversant and grossly oriented x3 but
with occasional rambling speech. He denied any somatic
complaints. He became increasingly confused and agitated, and
was given a total of 105 mg valium IV, 2 mg subcutaneous ativan,
and 10 mg IM haldol. Urine and serum tox screens were negative.
Noncontrast head CT showed no intracranial hemorrhage. An LP
was performed which was significant for xanthochromia. Gram
stain of CSF was negative; culture of CSF was negative
(preliminary). A head CTA was ordered which showed no evidence
of aneurysm. He was transferred to the MICU for further care.
.
The patient was given valium as per CIWA scale. After transfer
to the MICU, he required an additional 10 mg valium, as per
CIWA. He was given folic acid, thiamine, and multivitamins.
His mental status gradually improved over the course of the next
24 hours. He was awake, alert, and oriented x3 at the time of
discharge.
Medications on Admission:
ativan
trazodone
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for CIWA>10 for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 1559**]
Discharge Diagnosis:
Acute Alcohol Withdrawal and Delirium Tremens
Alcohol Abuse
Discharge Condition:
Good - no further episodes of hallucinations or agitation.
Discharge Instructions:
You were diagnosed with alcohol withdrawal syndrome. You should
continue your care at a detoxification facility. You should
avoid alcohol use in the future.
Followup Instructions:
Recommend followup with Alcoholics Anonymous and other
counseling services as needed.
Please see your primary care doctor within one month of
discharge.
Name: [**Known lastname 12113**],[**Known firstname **] Unit No: [**Numeric Identifier 12114**]
Admission Date: [**2184-4-1**] Discharge Date: [**2184-4-12**]
Date of Birth: [**2123-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1455**]
Addendum:
Addendum to discharge summary.
The patient was initially prepared for discharge on Monday [**4-5**].
Other the course of that prior weekend he was tapered down on
standing ativan to just 1mg QID and required very little prn
dosages. Then on the evening of [**4-5**] he became acutely agitated
requiring restraints, haldol 15 mg, and ativan 12 mg. He was
confused and no longer alert and oriented x3. That evening, we
increased his ativan then transitioned him to a diazepam taper.
He received standing diazepam from [**Date range (1) 12115**] but then required no
more benzos. His mental status significantly improved and the
restraints were removed. He was alert and oriented x3 and
interactive appropriately. He was aggreeable to placement for
long term etoh recovery. This plan was discussed with his
family.
.
Other issues: his urinalysis had some RBCs and WBCs. On [**4-9**], it
grew out enterococcus so we started ampicillin for a 7 day
course. Please complete this course. We recommend repeat U/A
and cx in [**2-8**] weeks.
.
In terms of his hepatitis C, the viral load was nondetected.
.
In terms of his anemia: it was macrocytic and thought [**1-9**] BM
suppression. Folate and B12 were normal. Ferritin was slightly
elevated.
.
Daughter is [**Name2 (NI) **] at [**Telephone/Fax (1) 12116**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 12117**] [**Hospital1 6688**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**]
Completed by:[**2184-4-12**]
|
[
"492.8",
"041.04",
"787.6",
"599.7",
"599.0",
"303.01",
"291.0",
"070.70",
"571.5",
"281.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7651, 7859
|
4134, 5144
|
335, 352
|
5498, 5559
|
2002, 4070
|
5766, 7628
|
1376, 1394
|
5211, 5307
|
5415, 5477
|
5170, 5188
|
5583, 5743
|
1409, 1983
|
274, 297
|
380, 1114
|
1136, 1300
|
1316, 1360
|
4099, 4111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,675
| 105,244
|
11896
|
Discharge summary
|
report
|
Admission Date: [**2145-10-3**] Discharge Date: [**2145-10-19**]
Date of Birth: [**2109-4-22**] Sex: F
Service: [**Location (un) **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 36 year old female
with history of renal cell carcinoma with metastatic disease to
the spine, status post nephrectomy with medical therapy
complicated by drug-induced pneumonitis. She presented with
progressive dyspnea, acute onset on the morning of admission. The
patient was on 3 liters of oxygen at home for the past seven
days. She noted her breathing to be increasingly labored with
tachypnea. The patient denied any chest pain, palpitations,
diaphoresis, nausea, or vomiting. She does have a history of
chronic cough with clear sputum. Of note, the patient felt more
comfortable sitting up and leaning forward. In the Emergency
Department, ultrasound of her lower extremities were performed to
evaluate for thrombus. A chest computerized tomography scan
showed moderate-sized pericardial effusion and the patient was
admitted to the Coronary Care Unit.
PAST MEDICAL HISTORY: 1. Renal cell carcinoma diagnosed in
[**2142-12-12**] during workup for miscarriage. The patient
had a nephrectomy at that time. In [**2143-4-11**] the patient
was started on interleukin 2 therapy. From [**2144-9-10**] to
[**2144-12-11**] the patient was started on PTK/787
chemotherapy, from [**2145-2-10**] to [**2145-8-10**] the patient
was enrolled in a clinical trial and was treated with
CTI-779/Interferon, however, this was stopped in [**2145-8-10**]
secondary to question of pneumonitis. Since then the patient
has been on 3 liters of oxygen at home. Then in [**2145-8-10**]
the patient was found to have spinal metastases. She was
status post radiation therapy to L2 to C3. Of note, in
[**2145-9-10**] the patient had a bronchoscopy with biopsy with
no evidence of carcinoma to her lungs. 2. Anemia of chronic
disease.
ADMISSION MEDICATIONS:
1. Famotidine 20 mcg t.i.d.
2. Tizanidine 6 mg t.i.d.
3. Tessalon pearls 100 mg q. 4 hours prn cough
4. Oxycodone 5 mg q. day
5. Fentanyl patch 25 mcg per hour q. 3 days
6. Zoloft 100 mg q. day
7. Zomira 4 mg intravenously q. 3 to 4 hours
8. Celebrex 100 mg t.i.d.
9. Clonazepam 0.25 to 0.5 q.h.s.
10. Decadron 40 mg taper
ALLERGIES: Keflex, Zithromax, Penicillin, Iodine,
Prednisone-all cause hives.
SOCIAL HISTORY: The patient lives at home with her husband and
five year old son. [**Name (NI) **] son will be starting first grade this
week, this is a very important milestone for her. Of note, her
parents are here from [**Location 8398**]in [**Location (un) 86**] to provide
supportive care. The patient denies any alcohol or tobacco use.
FAMILY HISTORY: No history of cancer.
PHYSICAL EXAMINATION: Temperature 99.4, blood pressure
107/55, heartrate 93, respiratory rate 28, oxygen saturation
99% on 4 liters nasal cannula. In general the patient
appears frail and tachypneic with mild respiratory distress,
leaning forward. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, panting, dry mucous membranes.
Neck: Supple, cachectic with persistent slow eye movements,
unable to assess for jugulovenous pressure. Cardiovascular:
Muffled heartsounds, faint S1 and S2, no rub appreciated.
Lungs, poor air movement, faint crackles bilaterally at bases
left greater than right. Abdomen, soft, nontender,
nondistended. Extremities, wasted 2+ dorsalis pedis pulses,
warm and well perfused, no edema.
LABORATORY DATA: White blood count 14.6, hematocrit 40.0,
platelets 420, PT 13.4, INR 1.2. Chem-7 with sodium 138,
potassium 4.2, chloride 101, bicarbonate 28, BUN 10,
creatinine 0.5, glucose 121. Studies: 1. Chest x-ray,
diffuse interstitial thickening involving all portions of the
lung without favoring any distribution. Interval development
of pleural effusion from [**2143-7-12**], new right T6 fracture.
Examination features of congestive heart failure/pulmonary
edema, superimposed on persistent interstitial changes of
pneumonitis. 2. Lower extremity doppler, no evidence of
deep vein thrombosis. 3. Chest computerized tomography
scan, new moderate pericardial effusion with associated
interstitial and alveolar opacities. Question of underlying
interstitial metastatic process in the lungs which can not be
distinguished from other inflammatory process such as drug
reaction. 4. Electrocardiogram, normal sinus rhythm at 86
beats/minute, normal axis, normal intervals, TWI/flattening
in 1, AVL, AVR, V1 to V2, no ST elevations.
ASSESSMENT/PLAN: This is an unfortunate 36 year old female with
metastatic renal cell carcinoma to the spine, now with
progressive dyspnea times one day. Computerized tomography scan
with evidence of pericardial effusion. The patient is admitted
to Coronary Care Unit for pericardial drain placement.
HOSPITAL COURSE: 1. Coronary Care Unit course - The patient was
in the Coronary Care Unit from [**2145-10-3**] to [**2145-10-11**]. The patient was admitted to Coronary Care Unit and noted
to have a moderate pericardial effusion and was tapped for 470 cc
of straw-colored fluid with the drain left in place. Over the
next few days the drain continued put out 150 to 200 cc of fluid.
In the meantime, the cytology came back positive for malignant
cells. On [**10-7**], the patient had a pericardial window
performed with removal of drainage tube. In the Coronary Care
Unit the patient's heartrates had been in the 90s to 115 with
blood pressure of 85 to 100/40s to 50s. She required numerous
small fluid boluses secondary to low blood pressure and low urine
output. She had increasing oxygen requirement, hence the
pericardectomy SaO2 96 to 97% on 6 liters with 70% nebulizer
scoop mask. The patient desatted to the low 80s when she had
occasional coughing spells which caused diaphoresis and
increasing pain. The patient was on Celebrex, Zanaflex, Fentanyl
patch 50 mcg/hr and Oxycodone for pain control.
2. Pulmonary - After pericardiectomy the patient was transferred
to the medical floor. Her shortness of breath was not improving
and she required and had increasing oxygen requirement now to 6
liters of oxygen plus 100% scoop mask. After discussion with
Oncology, Dr. [**Last Name (STitle) **] and the pulmonology attending it was decided
that the patient would have a repeat bronchoscopy and repeat
biopsy to diagnose her pulmonary interstitial disease. On
[**10-13**], the patient had bronchoscopy with biopsy. Pathology
returned positive for carcinoma in the lymphatic system. The
patient continued to have periods of coughing and shortness of
breath where she would desat down to the low 80s. A repeat chest
x-ray following bronchoscopy revealed no evidence of
pneumothorax. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**], Palliative RN was consulted. Per her
recommendations, Ativan and inhaled 1% Lidocaine was used to
try to depress the cough.
Following many lengthy discussions with the patient and family it
was decided that code status be changed from full code to Do-Not-
Resuscitate/ Do-Not-Intubate, on [**2145-10-18**]. At this time
the patient's pulmonary status was progressively deteriorating.
She was tachypneic to the 40s and very agitated. We attempted to
diurese the patient with Lasix, however, there was little
improvement in her respiratory status. On [**2145-10-18**] a
Morphine and Ativan drip were started. The patient was no longer
responsive, however, her respiratory rates were now in the
mid 20s with decreased work of breathing.
3. Cardiovascular - Echocardiogram following the pericardiectomy
showed resolution of the pericardial effusion. She continued to
be hypotensive down into the mid 70s to 80s. The patient was
given some normal saline boluses as well as gentle rehydration
with intravenous fluids. However, this was eventually stopped
secondary to increased pulmonary and lower extremity edema
although there is no evidence of congestive heart failure.
4. Pain - Initially the patient's pain was well controlled on a
Fentanyl patch 50 mcg/hr with Oxycodone for breakthrough pain.
However, the patient's pain requirement increased throughout her
stay. Given the patient's pain and increased agitation, Morphine
drip was started on [**10-18**] with better control of her pain.
5. Heme - The patient's hematocrit continued to decrease during
this stay. On [**10-17**], the patient was transfused with 1
unit of packed red blood cells with a hematocrit of 30.2.
6. Oncology - On [**2145-10-14**], the results of the
transbronchial biopsy was discussed with the patient and her
family. Present were her oncologist (Dr. [**Last Name (STitle) **], the attending
physician (Dr. [**Last Name (STitle) **] as well as medicine resident (Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]),
the patient's husband and her mother. The patient understood
that her condition was terminal with poor prognosis, and that
she would not be considered for a mini-allo BMT, due to the
severity of her disease. She understood that her life expectancy
was likely measured in days to weeks and that there was no role
for further chemotherapy, only palliative. At that time the
family was looking into hospice care for the patient, but the
patient's condition progressively worsened over the next several
days. The patient had a long discussion with her husband on
[**10-18**] and it was decided that her code status would be
changed from full code to Do-Not-Resuscitate/Do-Not-Intubate. One
of the family's concern was about the well-being of the patient's
five year old son.
[**Name (NI) 15110**] to progressive discomfort with tachypnea and cough, the
patient required increasing doses of opiates, ativan, and
oxygen therapy. She was switched to morphine and ativan drip
for comfort after further discussion with the family. Her family
was present on [**10-19**] at 3 PM when the patient died.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 37489**]
MEDQUIST36
D: [**2145-10-20**] 15:06
T: [**2145-10-20**] 17:54
JOB#: [**Job Number 37490**]
cc:[**Last Name (STitle) 37491**]
|
[
"V10.52",
"733.13",
"285.9",
"515",
"196.1",
"197.0",
"198.89",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31",
"37.0",
"33.27"
] |
icd9pcs
|
[
[
[]
]
] |
2734, 2757
|
4865, 10216
|
1958, 2370
|
2780, 4847
|
188, 1072
|
1095, 1935
|
2387, 2717
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,093
| 158,597
|
9727
|
Discharge summary
|
report
|
Admission Date: [**2129-1-10**] Discharge Date: [**2129-1-14**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 12997**] is a [**Age over 90 **]F with a history of CAD, chronic sCHF,
Alzheimer's vs. vascular dementia and a recent admission for
BRBPR who presented to the ED today with rib pain after a fall.
She isn't sure exactly what happened, but says she was carrying
a bowl of oatmeal and a cup of coffee and thinks she burned her
finger, dropped the bowl and fell. No LOC. Did hit her chin,
which is bruised. She denies any further BRBPR since her last
admission. She claims to have been having regular BMs since
discharge w/o increase in frequency.
.
In the ED her HCT was notably 19. She was mentating at her
baseline at that time. CT Chest revealed new pneumomediasteinum
thoracics was consulted felt that this finding could most likely
be explained by popped pulmonary bleb after the fall that then
tracted to the mediastinum. They did not feel a surgical
intervention was warranted. She was admitted to the MICU for
monitoring. She was transfused 2 units PRBC HCT 19->28 and has
remained stable now X 3 blood draws. Her stool has been GUIAC
Negative in the MICU.
.
Of note, she has had two recent admissions to [**Hospital1 18**] for GIB, one
at the end of [**Month (only) 1096**] and one earlier this month from
[**Date range (1) 32840**]. At the [**Month (only) 1096**] admission, she declined colonoscopy
but underwent CT abd/pelvis which showed mild focal thickening
of the sigmoid colon suggestive of a inflammatory or infectious
colitis. She then underwent flex sig examination which showed
grade 1 internal hemmrhoids but was otherwise normal (no
evidence of bleeding). Bleeding was attributed to known
diverticulosis or possibly to hemorrhoids. During her second
admission, 2 transfusions were attempted (the first was stopped
halfway due to a blown IV, the second was stopped after 1 hour
due to an asymptomatic low-grade fever of 100.6). Hct ultimately
rebounded to 30 and she was discharged home.
.
Prior to transfer, pt sitting in chair comfortable not in pain.
The pt has not noted any bleeding in stool. Denies CP, SOB,
LH/Dizziness.
Past Medical History:
-Coronary Artery Disease
-Chronic systolic CHF with EF 30% in [**2127-1-20**]
-Benign Hypertension
-Hyperlipidemia
-History of presyncope and falls
-Syphillis in the [**2086**], treated with "shots" (RPR titer 1:2 in
[**9-26**]:1 in [**1-/2127**])
-Early dementia due to cerebrovascular disease vs. Alzheimers,
seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27532**] in Behavioral Neurology
-s/p hysterectomy [**2074**]
-History of of breast lump, s/p excision - benign, per patient
-History of fluid drainage from her left knee
Social History:
Home: lives alone, but lives nearby to a friend in a connected
apartment. She cooks for herself, pays her own bills, and bathes
herself independently. She is ambulatory with a cane. Close
friend [**Name (NI) **] [**Name (NI) 32838**] is her health care proxy. She
previously worked for [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 32839**] making boots. Denies
etoh/illicits; remote tobacco hx. She never had any children and
reports not having any family. She does mention two people as
supports - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32838**] and [**First Name8 (NamePattern2) 9097**] [**Last Name (NamePattern1) 732**].
Family History:
Denies fam hx of GI bleeding or malignancy.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.8 BP:112/59 P:70s R:18 O2:98%RA
General: Alert, oriented X 1, no acute distress, sitting
comfortable in chair
HEENT: Sclera anicteric, MMM, oropharynx clear, ecchymosis on
chin healing
Neck: supple, no LAD, trachea midline
Lungs: diminished BS, no wheezes, rales, ronchi,crackles present
CV: irregular rate and rhythm, no murmurs, rubs, gallops
Abdomen: softly distended, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis, 2+ edema to mid
calf
.
Discharge Physical Exam:
Vitals: T:98.3 BP:90s-110s/70s-90s P:80s-90s R:18 O2:97%RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, ecchymosis on
chin healing
Neck: supple, no LAD, trachea midline
Lungs: diminished BS, no wheezes, rales, ronchi,crackles present
in L lung dependent side
CV: irregular rate and rhythm, no murmurs, rubs, gallops
Abdomen: softly, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis, 2+ edema to mid
calf
Pertinent Results:
PERTINENT LABS:
[**2129-1-10**] 10:37PM BLOOD WBC-9.9 RBC-2.48*# Hgb-6.1*# Hct-19.8*#
MCV-80* MCH-24.7* MCHC-31.1 RDW-18.1* Plt Ct-364
[**2129-1-11**] 05:23AM BLOOD PT-11.7 PTT-25.9 INR(PT)-1.1
[**2129-1-10**] 11:40PM BLOOD Ret Aut-3.8*
[**2129-1-10**] 11:40PM BLOOD LD(LDH)-299* CK(CPK)-81 TotBili-0.2
[**2129-1-10**] 10:37PM BLOOD cTropnT-<0.01
[**2129-1-10**] 11:40PM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-1-11**] 05:23AM BLOOD cTropnT-<0.01
.
IMAGING:
CXR:
IMPRESSION:
1. No displaced fracture, however, if clinical concern for
fracture persists of the ribs, suggest dedicated rib series,
which is more sensitive.
2. Persistent severe enlargement of the cardiac silhouette and
small
bilateral pleural effusions.
.
ECHO:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thickness and cavity
size are normal with low normal global systolic function (LVEF
50-55%). [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Severe (4+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate to severe pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is a
small to moderate sized pericardial effusion. No evidence of
pneumopericardium is identified.
IMPRESSION: Normal leftventricular cavity sizes with preserved
regional and low normal global systolic function. Severe mitral
regurgitation. Moderate to severe pulmonary artery
hypertensionl. Right ventricular cavity enlargement with free
wall hypokinesis. Small to moderate circumferential pericardial
effusion without evidence of hemodynamic compromised (may be
absent in the setting of pulmonary artery hypertension).
Moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of [**2127-1-29**], the
pericardial effusion is slightly larger. The other findings are
similar.
.
CT ABD & PELVIS W/O CONTRAST
IMPRESSION:
1. Trace air tracking through the anterior chest wall into
retrosternal space without sternal fracture extending into
apparently the anterior pericardium consistent with
pneumopericardium, question traumatic source, but etiology
unclear. Recommend close follow-up clinically and imaging to
resolution.
2. Massive cardiomegaly worsened as compared to [**2126**], but stable
since
[**2128-11-18**]. Unchanged moderate-to-large simple
pericardial effusion.
3. No intraperitoneal or retroperitoneal hematoma.
4. Left renal cyst.
5. Anasarca.
.
CT CHEST W/O CONTRAST
1. Trace air tracking through the anterior chest wall into
retrosternal space without sternal fracture extending into
apparently the anterior pericardium consistent with
pneumopericardium, question traumatic source, but etiology
unclear. Recommend close follow-up clinically and imaging to
resolution.
2. Massive cardiomegaly worsened as compared to [**2126**], but stable
since
[**2128-11-18**]. Unchanged moderate-to-large simple
pericardial effusion.
3. No intraperitoneal or retroperitoneal hematoma.
4. Left renal cyst.
5. Anasarca.
Brief Hospital Course:
[**Age over 90 **]F with two recent admissions for LGIB of unclear etiology
(thought to be diverticulosis vs. hemorrhoids) who presents with
rib pain after a fall and was found to have low Hct to 19.8
(recent baseline upper 26-30).
.
# Anemia of Acute blood loss: She did not have evidence of acute
bleed (guaiac negative, no collection/hematoma on imaging). This
acute drop in hct is most likely related to rectal bleeding
which prompted her two prior admissions, though she does not
recall any BRBPR since the last time she was admitted. Baseline
Hct seems to be in the upper 20s (in the low 30s going back
earlier in [**2127**]). MCV is low at 80; she previously had normal
MCVs years ago which argues against chronic thalassemia as the
cause. Last admission, iron studies showed iron 18, TIBC 233,
ferritin 45, transferrin 179. B12, folate levels were normal in
[**2126**]. No evidence of hemolysis was noted on lab work during this
admission. She was transfused 2 [**Location **] for which her Hct
increased to 29 and has remained stable for 4 days of
monitoring. Her stools have remained guaiac negative. Most
likely this acute episode bleeding occurred several days prior
to admission and may have contributed to her recent fall. We
have discontinued Aspirin. We continued ferrous sulfate. The pt
is refusing any further GI evaluation currently. She understands
the risk of continual bleeding which includes death.
.
# Mechanical Fall: patient admitted with right chest pain, and
echymosis on her chin related to mechanical fall. Physical exam
did not suggest fracture in the mandible, long bones of the arms
or lower extremities. Etiology is likely deconditioning and
syncope from acute anemia. Myocardial infarction was ruled out
with cardiac biomarkers, EKG did not show any changes from
prior, and ECHO was unchanged, showing a small pericardial
effusion without evidence of tamponade.
.
# RIB PAIN: Most likely secondary to falls. She did not have any
new acute fractures on imaging. Her pain was controlled with
Lidocaine patches and tylenol prn.
.
# Pneumomediastinum: CT of chest showed air in mediastinum w/o
evidence of rib/sternal fracture and without evidence of
puncture wound on chest wall. Thoracic surgery evaluated the pt
and feel that she most likely burst a pulmonary bleb during her
fall and the resulting leak of air tracked up into her
mediastinum. The pt did not have crepitus on palpation of chest
wall or pain in anterior chest. She showed no laboratory or
clinical signs of infection either. No further intervention was
taken.
.
# Dementia: according to the [**Hospital 228**] health care proxy [**Name (NI) 775**],
patient is unable to attend to her personal finances or
organizing medicaitons at home. She has had many falls and did
not appear to be thriving at home. In evaluation of the
patient's mental status, she was oriented to person and place,
occasionally to date. She was conversant but confabulated often.
.
# Atrial Fibrillation: The pt has long standing A-fib on rate
control with metoprolol. We discontinued her ASA dose and
recommend that this medication not be restarted considering her
high risk of bleeding. She was monitored on telemetry and no
events were noted.
.
# Systolic Congestive Heart Failure: Last echo [**1-/2127**] showed:
Severe left ventricular systolic dysfunction. Moderately dilated
right ventricle with moderately depressed function. Moderate to
severe mitral regurgitation. Moderate to severe tricuspid
regurgitation. Severe pulmonary artery systolic pressure. She
was euvolemic on exam. We continued Furosemide, Lisinopril and
metoprolol.
.
# Hypertension- We continued Lisinopril, Metoprolol.
.
# Living situation- Currently the pt lives alone in an
apartment. She does not have family members locally who are
involved in her life. She currently depends on her neighbors for
completion of activities of daily living. After discussion with
her neighbors it was discovered that she no longer can pay her
own bills or do her laundry. She makes some meals for herself
but relies on her neighbors for most of her cooking. She also
has become less mobile lately and more prone to falls at home.
The decision was made with the pt that she be placed in a long
term living facility following this hospitalization.
.
# Transitional- We recommend that the pt follow up with her PCP
[**Name Initial (PRE) 176**] [**11-22**] wks following this hospitalization. We are holding
aspirin considering her multiple prior GI bleeds. Currently the
pt is refusing further workup for her recurrent GI bleeds.
.
# CONTACT:[**Name (NI) 775**] HCP [**Telephone/Fax (1) 32841**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (god daughter)
[**Telephone/Fax (1) 32842**]
Medications on Admission:
1. ferrous sulfate 325 mg PO once a day
2. docusate sodium 100 mg PO BID
3. senna 8.6 mg [**11-22**] Capsules PO twice a day as needed for
constipation.
4. furosemide 20 mg PO daily
5. lisinopril 10 mg PO DAILY
6. metoprolol succinate 100 mg PO once a day
7. aspirin 81 mg PO DAILY
8. Miralax 17 gram Powder PO once a day as needed for
constipation.
Discharge Medications:
1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
7. Miralax 17 gram/dose Powder Sig: Seventeen (17) gram PO once
a day.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to affected area on chest.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 32843**] & [**Hospital **] Care Center - [**Street Address(1) **]
Discharge Diagnosis:
Primary
Mechanical Fall
Secondary
Pneumomediastinum
Anemia of acute blood loss
Diverticulosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms [**Known lastname 12997**],
It was a pleasure taking care of you in your while at [**Hospital1 1535**]. As you know, you were admitted
after you fell in your house. Your red blood cell count was low
and we transfused you with blood and your blood level
normalized. We noted that there was a small amount of air in
your chest from the fall. You were seen by surgery and monitored
in the hospital for three days. You remained comfortable and we
think that the air in your chest is not dangerous or going to
cause you any discomfort.
We are prescribing a lidocaine patch for your pain.
START
Lidocaine patch for pain
STOP
Aspirin, this can cause bleeding
weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with your primary care provider when you are
discharged from rehabilitation
|
[
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"294.20",
"285.1",
"401.1",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14383, 14488
|
8490, 13232
|
254, 260
|
14627, 14627
|
4864, 4864
|
15580, 15676
|
3635, 3680
|
13633, 14360
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14509, 14606
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13258, 13610
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14809, 15557
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3720, 4278
|
210, 216
|
288, 2359
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14642, 14785
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4880, 8467
|
2381, 2939
|
2955, 3619
|
4303, 4845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,667
| 132,775
|
19711+57082+57083
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2198-1-1**] Discharge Date: [**2198-1-4**]
Date of Birth: [**2123-5-17**] Sex: M
Service: Neurosurgery
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 53311**] is a
74-year-old gentleman who was transferred to [**Hospital1 346**] from an outside hospital.
He had presented to the Emergency Room with complaints of the
sudden onset of weakness in the bilateral legs and arms. The
arm weakness worse than the leg weakness. He reports that it
sudden in onset and that he had fallen two to three times
over the past two days. He denies any loss of consciousness.
He also denies any headaches, visual changes, numbness,
tingling, chest pain, shortness of breath, or palpitations.
He also states that he has had no recent illnesses.
He was seen at [**Hospital6 2561**] where he was noted to
have bilateral subdural hematomas and was transferred to [**Hospital1 1444**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Chronic obstructive pulmonary disease.
4. Bladder cancer; status post urethral diversion.
5. Gastritis.
6. Ethanol.
7. Chronic renal insufficiency (with a creatinine of 2 to
3).
8. TAF.
9. Colon cancer; status post resection.
MEDICATIONS ON ADMISSION:
1. Verapamil 80 mg by mouth three times per day.
2. Lisinopril 40 mg by mouth once per day.
3. Lipitor 10 mg by mouth once per day.
4. Lasix 60 mg by mouth once per day.
5. Zinc 50 mg by mouth once per day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives with his wife and daughter. [**Name (NI) **] has
two to three glasses of wine per day. He denies any
intravenous drug use.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was
transferred to [**Hospital1 69**] and
admitted to the Intensive Care Unit where he was started on
Dilantin 1 mg intravenously as a loading dose and then 100 mg
by mouth three times per day.
He was initially ruled out for a myocardial infarction. He
remained stable and was taken to the operating room on
[**2198-1-2**]. He underwent parietal and subdural bur
hole openings with evacuation of bilateral hematomas.
He did well intraoperatively and was transferred to the
Postanesthesia Care Unit. Upon arrival, he was extubated and
arousable. He was coughing on his own. He was alert and
oriented. He was answering all questions appropriately. He
was following commands. He left arm movement actually
improved after his surgery. He continued to do well in the
Postanesthesia Care Unit overnight and was transferred to the
floor the next day.
He continued to do well on the floor. He was moving all
extremities well. He was out of bed ambulating. He was seen
by Physical Therapy today who noted that he would benefit
from a short-term stay in rehabilitation.
ASSESSMENT/CONDITION AT DISCHARGE: The patient is a
74-year-old male who had a complicated past medical history
and was status post bilateral subdural hematoma with drainage
on [**1-2**]. He was neurologically stable.
DISCHARGE DISPOSITION: To be discharged to [**Hospital 3058**]
rehabilitation.
MEDICATIONS ON DISCHARGE:
1. Furosemide 40 mg by mouth once per day.
2. Acetaminophen 325-mg tablets one to two tablets by mouth
q.4-6h. as needed.
3. Famotidine 20 mg by mouth twice per day.
4. Thiamine HCl 100 mg by mouth once per day.
5. Folic acid 1 mg by mouth once per day.
6. Multivitamin.
7. Verapamil 120 mg by mouth q.8h.
8. Phenytoin (Dilantin) 100-mg extended release tablets one
tablet three times per day.
9. Oxycodone 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed (for pain).
10. Docusate sodium 100 mg by mouth twice per day.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Doctor First Name 53312**]
MEDQUIST36
D: [**2198-1-4**] 15:18
T: [**2198-1-4**] 19:42
JOB#: [**Job Number 53313**]
Name: [**Known lastname 9938**], [**Known firstname **] Unit No: [**Numeric Identifier 9939**]
Admission Date: Discharge Date: [**2198-1-8**]
Date of Birth: Sex: M
Service: Neurosurgery
This addendum covers the dates of [**2198-1-4**] to
[**2198-1-8**], the time of his discharge.
Patient continued to be afebrile with vital signs stable. He
did easily awaken to stimulation and did follow commands.
His dressing was clean, dry, and intact. He did undergo
repeat CAT scan of the head, which showed no interval change
in the bilateral frontal small residual subdural collections
and no new areas of hemorrhage.
He continued to be neurologically stable, and was discharged
to [**Hospital 4227**] Rehab in [**Location 2708**]. He will follow up in one
month's time with Dr. [**Last Name (STitle) 365**] and was to have staples removed
on [**2198-1-9**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 1042**]
MEDQUIST36
D: [**2198-4-16**] 12:43
T: [**2198-4-17**] 08:11
JOB#: [**Job Number 9940**]
Name: [**Known lastname 9938**], [**Known firstname **] Unit No: [**Numeric Identifier 9939**]
Admission Date: Discharge Date: [**2198-1-8**]
Date of Birth: Sex: M
Service: Neurosurgery
This addendum covers the dates of [**2198-1-4**] to
[**2198-1-8**], the time of his discharge.
Patient continued to be afebrile with vital signs stable. He
did easily awaken to stimulation and did follow commands.
His dressing was clean, dry, and intact. He did undergo
repeat CAT scan of the head, which showed no interval change
in the bilateral frontal small residual subdural collections
and no new areas of hemorrhage.
He continued to be neurologically stable, and was discharged
to [**Hospital 4227**] Rehab in [**Location 2708**]. He will follow up in one
month's time with Dr. [**Last Name (STitle) 365**] and was to have staples removed
on [**2198-1-9**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 1042**]
MEDQUIST36
D: [**2198-4-16**] 12:43
T: [**2198-4-17**] 08:11
JOB#: [**Job Number 9940**]
|
[
"593.9",
"V10.05",
"272.0",
"E888.9",
"401.9",
"852.21",
"535.50",
"496",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
3118, 3175
|
3202, 6361
|
1347, 1598
|
1785, 2894
|
2909, 3094
|
254, 1018
|
1040, 1321
|
1615, 1756
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,850
| 165,677
|
29282
|
Discharge summary
|
report
|
Admission Date: [**2156-1-20**] Discharge Date: [**2156-2-6**]
Date of Birth: [**2083-6-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Found collapsed, unresponsive, with right sided weakness.
Major Surgical or Invasive Procedure:
NIL
History of Present Illness:
Ms. [**Known lastname 70385**] is a 72 yo female w/AF on coumadin, diastolic CHF,
prior CVA, who was found down, unresponsive, by her husband the
morning of [**1-19**]. She had last been seen the night prior, in her
USOH. She was brought to [**Hospital3 10310**] Hospital and a head CT
showed a large left MCA stroke. She was intubated and
transferred here.
Brief MICU course:
On arrival here, she was admitted to the SICU with neurology
following. Her initial head CT demonstrated the aforementioned
CVA as well as 2 mm of subfalcine herniation. She intermittently
required neo to keep her perfusion pressure high while she was
sedated on propofol. She was febrile to 101 while in the SICU
but all of her cultures remained negative. She was extubated on
[**1-21**] and called out to Neuro Step-Down on [**1-22**].
She has been making progress while on the floor. She has been
awake and alert, and was initially aphasic but then began
speaking single words. She would intermittently follow commands.
Her bp was stable in the low 90s-100s (reportedly her baseline).
She remained afebrile throughout her floor course. CXR's
demonstrated CHF and diuresis was attempted with lasix 10 IV
q6h.
On [**1-27**]. Stat head CT showed no change in the stroke or
herniation. Her vitals remained unchanged. A cardiology consult
was called to assess her CHF, and they recommended continued
diuresis. ABG was 7.49/45/65 on either 2 or 4 L O2. She became
more tachypneic, to the low 30s, and was transferred to the
MICU. Since in the MICU, she has become progressively worse and
developed CHF and pna. Her mental status has progressively
worsened. After medical treatment for several day, family
decided to change goal of care to comfort measure only due to
decline in quality of life. She is now called out to the floor
as she no longer require ICU level of respiratory care.
Past Medical History:
1. AF on coumadin
2. CHF
3. prior CVA with unknown location
4. ? cardiac amyloid
5. back surgery
Social History:
Lives at home caring for husband who is ill with heart problems
and kidney failure. Has been under a lot of "stress" lately per
daughter. Former heavy smoker, quit 10 years ago. No EtOH or
illicit drug use.
Physical Exam:
Physical Exam:
vitals T 100 HR 75 (afib) BP 140/76 RR 16 Pox 95%
Intubated. OG tube in place.
General appearance: critically ill. There is
Heart: irregularly irregular
Lungs: clear to auscultation bilaterally.
Abdomen: soft, nontender
Extremities: no clubbing, cyanosis or edema
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues.
NEUROLOGICAL: Intubated. Obtunded. Minimal eye opening and head
movement to voice. Does not follow commands. Pupils are 1.5 and
consensually reactive bilaterall. Disks sharp. Corneals and
nasal tickle intact. ? right face weakness. OCRs intact.
Decerebrate posturing of right arm and leg to noxious stimuli.
Left arm and leg withdraw to noxious but without clear
purposeful
movements. Plantar responses extensor bilaterally.
Pertinent Results:
Laboratory results:
[**2156-1-20**] 12:40PM PT-16.0* PTT-26.7 INR(PT)-1.5*
[**2156-1-20**] 12:40PM PLT COUNT-185
[**2156-1-20**] 12:40PM NEUTS-91.1* LYMPHS-5.1* MONOS-3.7 EOS-0
BASOS-0.1
[**2156-1-20**] 12:40PM WBC-11.3* RBC-3.92* HGB-12.8 HCT-36.1 MCV-92
MCH-32.7* MCHC-35.6* RDW-15.3
[**2156-1-20**] 12:40PM CK-MB-10 MB INDX-4.6
[**2156-1-20**] 12:40PM cTropnT-0.05*
[**2156-1-20**] 12:40PM CK(CPK)-218*
[**2156-1-20**] 12:40PM GLUCOSE-149* UREA N-32* CREAT-1.3* SODIUM-139
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-28 ANION GAP-18
[**2156-1-20**] 07:40PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-2.1
[**2156-1-20**] 07:40PM WBC-8.8 RBC-3.59* HGB-11.8* HCT-33.5* MCV-93
MCH-32.8* MCHC-35.2* RDW-15.2
[**2156-1-20**] 07:40PM PLT COUNT-153
[**2156-1-20**] 01:13PM TYPE-[**Last Name (un) **] PH-7.53* COMMENTS-GREEN
[**2156-1-20**] 07:40PM PT-16.5* PTT-27.4 INR(PT)-1.5*
EKG: AF with ventricular rate in 60s, PVC, NSIVCD, TWI in 1/aVL,
V5-6
Relevant Imaging:
1)OSH NCHCT: large left MCA territory hypodensity with
edema involving terriorty supplied by inferior division of LMCA
with territory supplied by superior divisions less affected.
There is small amount of rightward deviation of the caudate head
toward the anterior [**Doctor Last Name 534**] of the left lateral ventricle.
2)Cxray ([**1-27**]): Moderately severe pulmonary edema has recurred
accompanied by slight increase in moderate-to-severe
cardiomegaly and small bilateral pleural effusions.
Opacification in the left lower lobe is probably a combination
of atelectasis and dependent edema. Feeding tube ends in the
stomach. No pneumothorax.
3)TTE ([**1-21**]): The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] 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. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
4)Head CT [**1-27**]: 1. Stable CT appearance of a large MCA
territory infarct. 2. Stable 2 mm degree of subfalcine
herniation.
5)Carotid u/s [**1-21**]: There is no stenosis in the bilateral
internal carotid arteries, in their cervical portion.
6)EEG ([**1-27**]): diffuse encephalopathy
Brief Hospital Course:
Brief MICU course:
On arrival here, she was admitted to the SICU with neurology
following. Her initial head CT demonstrated the aforementioned
CVA as well as 2 mm of subfalcine herniation. She intermittently
required neo to keep her perfusion pressure high while she was
sedated on propofol. She was febrile to 101 while in the SICU
but all of her cultures remained negative. She was extubated on
[**1-21**] and called out to Neuro Step-Down on [**1-22**].
She had been making progress while on the floor. She had been
awake and alert, and was initially aphasic but then began
speaking single words. She would intermittently follow commands.
Her bp was stable in the low 90s-100s (reportedly her baseline).
She remained afebrile throughout her floor course. CXR's
demonstrated CHF and diuresis was attempted with lasix 10 IV
q6h.
On [**1-27**]. Stat head CT showed no change in the stroke or
herniation. Her vitals remained unchanged. A cardiology consult
was called to assess her CHF, and they recommended continued
diuresis. ABG was 7.49/45/65 on either 2 or 4 L O2. She became
more tachypneic, to the low 30s, and was transferred to the
MICU. Since in the MICU, she became progressively worse and
developed CHF and pna. CHF was treated with diuresis and
antibiotics for pneumonia. Despite medical care, her mental
status progressively worsened. After medical treatment for
several days, family decided to change goal of care to comfort
measures only due to decline in quality of life. She was called
out to the floor as she no longer required ICU level of
respiratory care. Ms [**Known lastname 70385**] passed away on [**2156-2-6**].
Medications on Admission:
Digoxin 0.125 mcg daily
Furosemide 40 mg daily
Spironolactone 25 mg daily
Coumadin 5 mg daily
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
|
[
"428.0",
"507.0",
"434.11",
"041.4",
"277.39",
"V15.82",
"518.0",
"427.31",
"427.1",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.08",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8126, 8135
|
6303, 7946
|
372, 377
|
8187, 8197
|
3457, 4416
|
8254, 8265
|
8093, 8103
|
8156, 8166
|
7972, 8070
|
8221, 8231
|
2646, 3438
|
275, 334
|
4434, 6280
|
405, 2270
|
2292, 2391
|
2407, 2616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,771
| 199,886
|
10254
|
Discharge summary
|
report
|
Admission Date: [**2174-12-10**] Discharge Date: [**2174-12-28**]
Date of Birth: [**2100-9-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
R great toe abscess
Major Surgical or Invasive Procedure:
Kidney biopsy
Hemodialysis temporary femoral line (discontinued)
Hemodialysis tunnelled line (internal jugular vein) placed
[**2174-12-27**]
History of Present Illness:
Mr. [**Known lastname 1637**] is a 74 yo M with CAD, HTN, PVD, DM type II with
neuropathy s/p amputation of right first, second, third toes
several years ago and underwent recent revision of right hallux
amputation due to chronic ulcer/skinbreakdown from bony spur.
He had been healing well with no complications from the
procedure. However, on the day prior to admission the VNA noted
a white scab on the surface of the incision. At that time there
was no erythema at the site. He was also noted to be weak,
lethargic and less interactive over the past three days. He
additionally had poor PO intake. He did not have any fevers
over the three days - despite being checked frequently. He
presented to podiatry clinic as he had been having foot
discomfort the day of admission. During this appointment he was
noted to have pus over his incision site. While at the
outpatient clinic, pus and [**Known lastname **] were able to be expressed from
the area. He was sent to the ED for further work up.
.
Of note, his daughter has also recently been concerned for a
change in his mental status over the past two days, specifically
that he was more lethargic and weak than usual. At baseline he
ambulates with a walker, however recently he has refused to walk
due to weakness and foot discomfort. She noted that he was
leaned to the left in his chair which was not typical. She was
concerned that he had some right sided weakness, however he was
never examined for this. He did not have slurred speech or
facial droop.
.
This year he was admitted in [**Month (only) **] for bilateral pulmonary
embolism and in [**Month (only) **] for acute renal failure.
.
In the ED VS were T 98.7, BP 159-170/60-63, HR 64-71, RR 14, O2
sat 97% on RA, BG 419. Exam was notable for right foot with
open ulcer with no pus or crepitus, erythema and warmth on
dorsum of right foot, normal neurologic exam, cranial nerves
intact. Labs were notable for lactate of 4.0, Cr 1.3, glucose
419. [**Month (only) **] cultures sent in ED. CT head was unremarkable.
Foot xray suggestive of osteomyelitis. He was treated with 1gm
Vancomycin and Zosyn to cover infection. He received 10U
insulin for hyperglycemia and 3L IVF for dehydration.
.
On arrival to the floor, the patient denies any pain. He is
alert and oriented x2 (person, place).
.
ROS as above. He otherwise denies any falls, dizziness,
lightheadedness, palpitations, chest pain or shortness of
breath. He denies any fevers, chills or night sweats. No
change in his bowel and bladder habits.
Past Medical History:
Type 2 diabetes, managed by [**Last Name (un) **] (HgbA1c 6.8 [**6-19**])
Alzheimer's Dementia
Hypertension
Alcoholic cirrhosis
Esophageal varices, middle third
Portal gastropathy
CAD, s/p MI [**9-/2172**]
Peripheral vascular disease
s/p 3 toe amputations
s/p stroke [**2170**], no residual deficits
s/p right CEA
Left cataract surgery [**6-/2173**]
Right cataract surgery [**8-/2173**]
GERD
Gait abnormality
Urinary/bowel incontinence
Social History:
He was living up until five months ago with his daughter
[**Name (NI) 803**] in [**State 5887**]. He has been living at a rehab most
recently - Sunrise. He is now close to some of his family
members who live up in this area. Positive tobacco use (6
cigars/day), 1-2 beers/week, no drug use.
Family History:
Significant for diabetes and heart disease in his immediate
family members.
Physical Exam:
VS: T 97.8, HR 68, BP 159/58, RR 17, O2sat 100% on RA
GEN: Pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g. Distant heart sounds.
ABD: ND, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, weakly palpable DP pulses. s/p amputation of the
first, second and third toes with small ulcer noted at incision
site. No pus, crepitus. Minimal serosanguinous drainage.
Erythema, warmth along dorsal aspect of right foot.
SKIN: no rashes/no jaundice
NEURO: AAOx2 (person, place). Cn II-XII intact. 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
pass-pointing on finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
LABORATORIES ON ADMISSION:
[**2174-12-10**] 01:50PM PT-17.1 PTT-31.5 INR(PT)-1.5
[**2174-12-10**] 01:50PM WBC-8.8 (NEUTS-82.3 LYMPHS-11.8 MONOS-5.1
EOS-0.6 BASOS-0.2) HGB-13.3 HCT-39.7 PLT COUNT-130
[**2174-12-10**] 01:50PM SODIUM-134 POTASSIUM-4.7 CHLORIDE-97 TOTAL
CO2-25 UREA N-24 CREAT-1.3 GLUCOSE-419
[**2174-12-10**] 02:03PM LACTATE-4.0
[**2174-12-10**] 04:22PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1 TRANS EPI-0-2, [**Month/Day/Year 3143**]-SM NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG, COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2174-12-10**] 05:13PM LACTATE-2.9
.
LABORATORIES ON DISCHARGE:
[**2174-12-28**] 03:30AM [**Month/Day/Year 3143**] WBC-7.3 Hgb-9.7 Hct-28.7 Plt Ct-192.
[**2174-12-28**] 11:30AM [**Month/Day/Year 3143**] PTT-75.9
[**2174-12-28**] 03:30AM [**Month/Day/Year 3143**] Na-135 K-4.2 Cl-100 HCO3-30 UreaN-48
Creat-4.5 Glucose-200 Calcium-7.8 Phos-4.6 Mg-2.0
.
OTHER LABORATORIES:
[**2174-12-28**] 03:30AM [**Month/Day/Year 3143**] LD(LDH)-239
[**2174-12-28**] 03:30AM [**Month/Day/Year 3143**] Triglyc-175 HDL-19 CHOL/HD-5.3 LDLcalc-46
Cholest-100
[**2174-12-27**] 06:45AM [**Month/Day/Year 3143**] VitB12-1265
[**2174-12-26**] 11:14AM [**Month/Day/Year 3143**] calTIBC-208 Folate-10.9 Ferritn-262
TRF-160
[**2174-12-26**] 11:14AM [**Month/Day/Year 3143**] Ret Aut-3.3
[**2174-12-26**] 05:29AM [**Month/Day/Year 3143**] ALT-19 AST-32 LD(LDH)-249 AlkPhos-351
TotBili-0.5 Lipase-61
[**2174-12-22**] 07:07PM [**Year/Month/Day 3143**] GGT-306
[**2174-12-27**] 03:25PM [**Month/Day/Year 3143**] PTH-112
[**2174-12-26**] 01:30PM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2174-12-23**] 03:48PM [**Year/Month/Day 3143**] ANCA-NEGATIVE [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-NEGATIVE [**Doctor First Name **]-NEGATIVE
[**2174-12-11**] 12:54AM [**Month/Day/Year 3143**] CRP-173.0
[**2174-12-11**] 12:54AM [**Month/Day/Year 3143**] ESR-38
[**2174-12-24**] 04:00AM [**Year/Month/Day 3143**] C3-52 C4-25
[**2174-12-19**] 04:50AM [**Year/Month/Day 3143**] C3-38 C4-25
[**2174-12-27**] 06:45AM [**Month/Day/Year 3143**] Vanco-16.0
[**2174-12-26**] 01:30PM [**Month/Day/Year 3143**] HCV Ab-NEGATIVE
[**2174-12-11**] 01:18AM [**Month/Day/Year 3143**] Lactate-2.0
[**2174-12-10**] 05:13PM [**Month/Day/Year 3143**] Lactate-2.9
[**2174-12-10**] 02:03PM [**Month/Day/Year 3143**] Lactate-4.0
.
CHEM-7 TREND
[**2174-12-27**] Glucose-98 UreaN-7 Creat-5.3 Na-135 K-4.0 Cl-101
HCO3-29
[**2174-12-26**] Glucose-94 UreaN-97 Creat-6.6 Na-138 K-4.1 Cl-102
HCO3-26
[**2174-12-24**] Glucose-130 UreaN-108 Creat-6.9 Na-140 K-4.7 Cl-105
HCO3-22
[**2174-12-24**] Glucose-153 UreaN-109 Creat-7.1 Na-136 K-5.7 Cl-104
HCO3-23
[**2174-12-23**] Glucose-98 UreaN-103 Creat-6.6 Na-137 K-5.4 Cl-103
HCO3-22
[**2174-12-24**] Glucose-130 UreaN-108 Creat-6.9 Na-140 K-4.7 Cl-105
HCO3-22
[**2174-12-24**] Glucose-153 UreaN-109 Creat-7.1 Na-136 K-5.7 Cl-104
HCO3-23
[**2174-12-23**] Glucose-98 UreaN-103 Creat-6.6 Na-137 K-5.4 Cl-103
HCO3-22
[**2174-12-23**] Glucose-64 UreaN-99 Creat-6.7 Na-138 K-5.2 Cl-103
HCO3-23
[**2174-12-22**] Glucose-94 UreaN-95 Creat-6.3 Na-136 K-4.8 Cl-102
HCO3-22 [**2174-12-22**] Glucose-53 UreaN-90 Creat-6.2 Na-136 K-5.0
Cl-104 HCO3-22
[**2174-12-21**] Glucose-57 UreaN-76 Creat-5.5 Na-135 K-4.7 Cl-103
HCO3-22
[**2174-12-20**] Glucose-57 UreaN-66 Creat-4.6 Na-136 K-4.7 Cl-104
HCO3-22
[**2174-12-19**] Glucose-92 UreaN-53 Creat-3.6 Na-137 K-4.6 Cl-105
HCO3-24
[**2174-12-18**] Glucose-54 UreaN-42 Creat-3.3 Na-137 K-3.9 Cl-104
HCO3-25
[**2174-12-17**] Glucose-241 UreaN-32 Creat-1.9 Na-135 K-4.8 Cl-101
HCO3-24
[**2174-12-16**] Glucose-144 UreaN-21 Creat-1.2 Na-139 K-3.8 Cl-104
HCO3-26
[**2174-12-15**] Glucose-186 UreaN-14 Creat-1.1 Na-138 K-4.0 Cl-102
HCO3-28 [**2174-12-13**] Glucose-237 UreaN-14 Creat-1.0 Na-135 K-3.4
Cl-100 HCO3-26 [**2174-12-11**] Glucose-225 UreaN-19 Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-28 [**2174-12-10**] Glucose-419 UreaN-24 Creat-1.3
Na-134 K-4.7 Cl-97 HCO3-25
.
STUDIES:
FOOT (AP & LAT) SOFT TISSUE RIGHT [**2174-12-10**] IMPRESSION: Findings
are concerning for osteomyelitis involving the distal aspect of
the first metatarsal head. If necessary, MRI with contrast can
further characterize this process. There is no subcutaneous air
or acute fracture.
.
CT HEAD W/O CONTRAST [**2174-12-10**]
IMPRESSION: No evidence of hemorrhage or significant change
compared to prior study. MRI with diffusion-weighted images is
more sensitive in evaluation for acute ischemia/infarct and for
vascular detail.
.
FOOT AP,LAT & OBL RIGHT [**2174-12-12**]
Compared with [**2174-12-10**], there has been additional debridement of
the distal first metatarsal. There is some residual bony
fragmentation at the resection site, and overlying skin changes.
Remainder of the right foot is stable.
.
PATHOLOGY [**2174-12-12**]
Right toe ulcer:
Granulation tissue with focal necrosis, acute and chronic
inflammation and fragments of bone
.
CHEST PORT. LINE PLACEMENT [**2174-12-14**]
1. A left PICC line catheter has been placed with tip projecting
over the atriocaval junction.
2. Diminished left lung volume due to the presence of basilar
atelectasis with mild elevation of the left hemidiaphragm.
3. The right upper lobe pulmonary opacity has decreased in size
on today's examination.
.
TTE (Complete) Done [**2174-12-14**]
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Transmitral Doppler and tissue
velocity imaging are consistent with Grade I (mild) LV diastolic
dysfunction. 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 masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Physiologic mitral
regurgitation is seen (within normal limits). The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2174-5-23**], no change.
.
RENAL U.S. [**2174-12-18**]
COMPARISON: [**2174-10-14**].
FINDINGS: The right kidney measures 12.6 cm. The left kidney
measures 12.7 cm. There is no evidence of hydronephrosis or
stones. Bladder appears grossly unremarkable.
IMPRESSION: No evidence of hydronephrosis.
.
ECG Study Date of [**2174-12-21**]
Sinus rhythm. P-R interval prolongation. Early R wave
progression.
Compared to the previous tracing of [**2174-10-14**] atrial premature
beats are no
longer seen. Rate 63, PR 234, QRS 72, QT/QTc 430/435, P 36, QRS
37, T 38
.
PORTABLE ABDOMEN [**2174-12-22**]
SUPINE PORTABLE ABDOMINAL RADIOGRAPH: Nonspecific gas pattern.
Stool in the colon limits sensitivity of study. Vascular
calcifications.
IMPRESSION: Somewhat limited study but no gross acute
radiographic abdominal abnormality demonstrated.
.
RENAL BIOSPY [**2174-12-22**]
Exudative endocapillary proliferative glomerulonephritis with
IgA dominance, consistent with the post-infectious-type
glomerulonephritis that is associated with Staphylococcal
infection..
Diabetic nephropathy.
Light Microscopy: The specimen consists of renal cortex and
medulla, containing approximately 20 glomeruli, of which 5 are
globally sclerotic. The remainder all show varying degrees of
exudative endocapillary proliferation. Mesangial matrix is
increased; nodule formation is present. Basement membranes are
overtly thickened, only occasional double contours are seen. No
crescents are noted. There is moderate interstitial fibrosis
and tubular atrophy. Patchy chronic inflammation accompanies
the scarring. Intact tubulointerstitum shows minimal
inflammation. Arteries show moderate intimal fibroplasia.
Arterioles show moderate mural thickening, with prominent
hyaline change. Immunofluorescence: The specimen consists of
renal cortex only, containing approximately 7 glomeruli, of
which 1 is globally sclerotic. There is granular peripheral
capillary loop and mesangial staining for IgG (0-trace), IgA
(2+), IgM (trace), C3 (3+), kappa ([**12-14**]+), lambda (1+) and C1q
(trace - 1+). Albumin and fibrin are non-contributory.
Electron microscopy: Findings will be issued in an addendum.
.
UNILAT UP EXT VEINS US LEFT [**2174-12-23**]
Normal pulsed Doppler waveforms were seen in the left subclavian
vein and normal waveforms and normal compressibility was noted
in the internal jugular, axillary, brachial, and basilic veins
in the left arm. The cephalic vein contains the PICC line which
extends essentially from wall to wall and no flow could be
detected around the PICC line which fills the lumen of the
cephalic vein. CONCLUSION: Left cephalic PICC line. No evidence
of deep venous thrombosis.
.
RIGHT UPPER QUADRANT ULTRASOUND [**2174-12-25**]: The study is compared
to an ultrasound of the same area from [**2174-12-8**]. The
penetration is suboptimal. There is no focal hepatic lesion
detected though evaluation is limited. The gallbladder is normal
without wall thickening or pericholecystic fluid. Several small
stones are noted layering within its lumen. The patient was not
able to move very well, so it was difficult to evaluate whether
these are mobile or not. There is no intra- or extra-hepatic
biliary ductal dilation. The portal vein was patient with flow
in an appropriate direction. There was no evidence of a
right-sided hydronephrosis or right upper quadrant ascites.
There is a right- sided pleural effusion.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Right pleural effusion.
.
TUNNELLED CATH PLACEMENT [**2174-12-27**]
IMPRESSION: Successful placement of a double lumen 19 cm
tip-to-cuff tunneled hemodialysis catheter through the right
internal jugular vein with tip located in the cavoatrial
junction. The catheter is ready to use.
Brief Hospital Course:
#. ACUTE RENAL FAILURE
The patient was diagnosed with post-infectious
glomerulonephritis (C3 deposition in mesangium and somewhat
linear IgA), s/p renal biopsy [**12-22**] (see above report). There
continues to be no recovery of renal function thus far with low
urinary output. Strict ins and outs were monitored with a coude
catheter, which was discontinued upon discharge. Prior to
diagnosis of post-infectious GN, the patient failed a fluid
challenge although evaluation of urine lytes were consistent
with a prerenal etiology. On admission, the patient had [**3-17**]
bottles of [**Month/Day (4) **] cultures +MRSA related to his OM. Although he
cleared this infection in 24 hours on IV antibiotics
(vancomycin/zosyn), he developed the related acute GN,
post-staphylococcus bacteremia. Although one would expect full
renal recovery with post-infectious GN, Mr. [**Known lastname 1637**] is an
elderly gentleman with poor renal reserve, with likely
subclinical diabetic/hypertensive nephropathy prior to the
insult of the post-infectious GN.
.
HD was initiated ([**2173-12-24**]) via a temporary femoral catheter, and
he received 3 HD sessions while in house; we expect him to
recover renal function some time in the coming weeks. As
followup, ANCA, [**Doctor First Name **] are negative. A hemodialysis IJ tunneled
catheter was placed [**2174-12-27**] and the patient tolerated
hemodialysis #3 well on the HD line that same day. Vancomycin
is planned for a 6 week course (D1= [**2175-12-11**]) and was given with
hemodialysis after HD was initiated. Vancomycin should continue
to be dosed at HD. Of note, metformin, lisinopril, glyburide
(home regimen) were held when the patient developed ARF and
hypotension was avoided with SBP goal of 140 to prevent further
renal damage. At rehabilitation, his ins and outs should be
monitored closely as improving urinary output is a sign of
improved renal function. Epogen should also be given at HD until
Mr. [**Known lastname 1637**] recovers renal function. Transfusion of [**Known lastname **] was
deferred at HD per renal recommendations. At rehabilitation,
please continue to monitor his HCT for an expected rise with
epogen.
.
# RIGHT 1ST METATARSAL OSTEOMYELITIS
Mr. [**Known lastname 1637**] was s/p right great toe metatarsal debridement in OR
and closed by podiatry [**2173-12-17**], at the bedside. IV vancomycin and
zosyn were begun upon admission. After the culture and
sensitivies returned showing MRSA ID consultants recommended
monotherapy with vancomycin for 6 weeks. A PICC line was placed
and vancomycin levels were checked daily. As the patient
developed ARF, the vancomycin became supratherapeutic and was
held for ~ 1 week. His levels were checked daily and his
vancomycin remained therapeutic during this period of ARF. When
HD was initiated, vancomycin was dosed at hemodialysis. Of
note, the patient has a PICC line in his left upper extremity.
This line may be utilized for IV vancomycin dosing if renal
function recovers and hemodialysis (and thus vancomycin dosing
at HD) is discontinued. He will complete his 6 week course of
intravenous vancomycin [**2175-1-21**] (Day 1 was [**2175-12-11**]). Please
consider removing the PICC line at rehabilitation depending on
the patient's disposition. He is scheduled for outpatient
followup with ID, Dr. [**Last Name (STitle) **]. In rehabiliation, please monitor is
vancomycin trough prior to each HD adjust dosage as necessary.
Also, check a CBC and electrolytes weekly. Upon discharge,
please fax these results weekly to Dr. [**Last Name (STitle) **] (see post-discharge
prescription order).
.
Upon discharge the foot wound appears to be healing well. He is
scheduled for outpatient podiatry followup. Please continue to
elevate right leg, per podiatry. Continue OOB to chair and RLE
NWB forefoot. Mr. [**Known lastname 1637**] will need aggressive PT due to his
extended hospital stay.
.
# MRSA BACTEREMIA:
He had associated +MRSA [**Known lastname **] culture on admission (4/4 bottles
of [**Known lastname **] cultures) but survellience [**Known lastname **] cultures are all
negative thus far. An echocardiogram was performed to look for
any evidence of endocarditis with high grade bacteremia. The
patient had no stigmata of endocarditis including no new murmur
on physical exam. The ECHO was technically a poor study but no
vegetations were seen on ECHO; regardless, the patient will be
on a 6 week course of IV vancomycin for OM which would treat any
underlying endocarditis. Vancomycin trough on [**2174-12-27**] prior to
HD #3 was therapuetic (16) for OM.
.
# HYPERTENSION
Lasix and lisinopril were discontinued (2 out of 3 medications
of home regimen). Lasix was discontinued due to the patient's
dehydration on presentation and also will not be effective now
secondary to his low UOP. Lisinopril is also being held in ARF.
His goal SBP was 140s to prevent renal hypoperfusion. His
betablocker was continued at his home dosage. Amlodipine 10 mg
was begun for renal recommendations. His [**Date Range **] pressure will
also be controlled by volume removal at HD.
.
# CHRONIC DIASTOLIC HEART FAILURE:
EF 70% on echo from 06/[**2173**]. Volume control was provided with
HD. Lisinopril was held in setting of ARF.
.
# TYPE 2 DIABETES MELLITUS-
Home regimen of oral hypoglycemics, actos, glyburide, and
metformin, were held in the setting of ARF. His BS was
controlled on Lantus to 8 units qHS; humalog insulin sliding
scale was also provided. Of note the heparin drip can be mixed
in D5W or NS. At rehabilitation, please consider a heparin drip
with NS to ensure better glucose control.
.
# ANTICOAGULATION/ History of pulmonary emboli ([**6-19**]). Mr.
[**Known lastname 34143**] INR was subtherapeutic upon discharge. He was started
on a heparin drip and was administered 7.5 mg coumadin daily, to
which he became therapeutic. Although, [**First Name8 (NamePattern2) **] [**Doctor Last Name 9231**] pharmacy in
[**Location (un) 1110**] where he fills his coumadin prescription, he has been on
coumadin 10 mg daily since [**11-19**]. However, coumadin was held in
preparation for the renal biopsy and also then hemodialysis
temporary and tunnelled line placements. He was also given FFP
prior to and subsequently to the renal biopsy. Heparin drip was
restarted after the renal biospy and held prior to the HD line
placement procedures. He is on heparin drip upon tranfer to [**Hospital **]
[**Hospital **] rehab. The plan is to restart his coumadin upon the
evening of discharge ([**2174-12-28**]) and bridge with heparin drip
until the patient is therapeutic on coumadin. Per PCP, [**Name10 (NameIs) **] plan
is to continue anticoagulation for a 12 months course of
anticoagulation due to extent of multiple pulmonary emboli.
.
# CORONARY ARTERY DISEASE
Mr. [**Known lastname 1637**] is s/p MI in [**2171**], and he was continued on his home
Toprol regimen.
.
# HYPERLIPIDEMIA
Consider discontinuing Zetia and possibly substituting statin as
Zetia may have adverse CV effects (preliminary data); see above
lipid panel. Will defer this to PCP.
.
# DEMENTIA (STABLE): Continued aricept and namenda
.
# F/E/N: Repleted lytes PRN. Continue diabetic diet. Began
sevelamer, Phoslo for hyperphoshatemia which phosphorus trending
down upon discharge.
.
# PPx: Provided bowel regimen (senna), PPI (home regimen),
pneumoboots/ heparin drip for DVT prophylaxis
.
# Access: PIV x 2
.
# Code Status: Full
.
# Communication: Daughter, [**Name (NI) 803**], cell [**Telephone/Fax (1) 34144**]
.
# Dispo: Acute rehabilitation for heparin drip, hemodialysis,
and physical therapy. IV antibiotics will be dosed at HD; Also
will need intense PT at rehab with the goal of returning patient
to [**Hospital3 **].
.
Medications on Admission:
Actos 15mg daily
Toprol 25 mg daily
Prinivil 40 mg daily
Zetia 10 mg daily
Lasix 40 mg daily
Coumadin 7.5 mg daily q M,W,F,Sat,Sun
Coumadin 5 mg daily q Tues, Thurs **Although, [**First Name8 (NamePattern2) **] [**Doctor Last Name 9231**]
pharmacy in [**Location (un) 1110**] where he fills his coumadin prescription, he
has been on coumadin 10 mg daily since [**11-19**].**
Glyburide 10 mg [**Hospital1 **]
Aricept 5 mg daily
Namenda 10 mg daily
Fiber Laxative 1 tbsp powder daily
Imodium 2 mg prn
SL NTG prn
Calcium and vit D
Protonix 40 mg daily
Metformin unknown dose
Discharge Medications:
1. Outpatient Lab Work
Please fax the following weekly laboratories to your infectious
disease specialist, Dr. [**Last Name (STitle) **]. Her fax number is: ([**Telephone/Fax (1) 1353**]
for patients. Office number for patients is ([**Telephone/Fax (1) 4170**].
1. CBC
2. BUN/Creatinine
3. Vancomycin trough
2. Outpatient Lab Work
Please check vancomycin level on [**2174-12-29**] prior to hemodialysis.
Adjust dosage of vancomycin as per nephrologist at [**Hospital1 9494**].
3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Coumadin 7.5 mg Tablet Sig: 7.5 Tablets PO once a day.
6. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
7. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Vancomycin 500 mg IV HD PROTOCOL
15. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) per Weight-Based Dosing Guidelines
Intravenous drip.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary
Acute renal failure secondary to post-infectious
glomerulonephritis
Right toe osteomyelitis, MRSA (methicillin resistant
Staphylococcus aureus)
.
Secondary
Type 2 diabetes mellitus
Dementia
Hypertension
Peripheral vascular disease
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted with right toe osteomyelitis, an infection of
the bone with MRSA (methicillin resistant Staphylococcus aureus)
bacteria. You were treated with intravenous antibiotics, and
the plan is to continue those antibiotics for 6 weeks
(completion of antibiotic course=[**1-21**]). The antibiotics
will be given with hemodialysis at rehabilitation.
.
You also developed renal failure during this admission and were
initiated on hemodialysis. The renal failure was due to
post-infectious glomerulonephritis (diagnosed by kidney biospy)
and was related to the bone infection which was also present in
your [**Month (only) **] stream. You quickly cleared the bacteremia ([**Month (only) **]
infection) on intravenous antibiotics. A tunnelled hemodialysis
line was placed so that you may continue dialysis as an
outpatient. The time course of dialysis is dependent on if you
recover kidney function. You may recover some renal function in
several weeks.
.
Please keep all followup appointments.
.
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 [**Month (only) **] 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.
Followup Instructions:
1. An outpatient appointment has been scheduled on [**2175-1-4**] at
10:30 AM for you with an infectious disease specialist, Dr.
[**Last Name (STitle) **]. Her office is located in the basement of the [**Hospital Unit Name 3269**] at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].
.
2. Please followup with your liver doctor at the following
scheduled appointment: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2175-1-10**] 10:45 AM.
.
3. Please followup with your primary care doctor at the
following scheduled appointment: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O.
Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2175-1-23**] 11:30 AM; Her office is
located at [**Apartment Address(1) 34145**] B.
.
4. Please followup with your podiatrist at the following
scheduled appointment: Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM
Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2175-1-16**] 4:40 PM. His office is
located at [**Hospital3 **] [**Hospital 1225**] Hospital on the [**Location (un) 470**] of
the [**Hospital Ward Name 121**] building, [**Hospital Ward Name 517**].
.
5. Please followup with a renal (kidney) specialist at the
following scheduled appointment: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], MD
on
[**2175-2-8**] 10:00 AM. You were seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 61**] [**Hospital 1225**] Hospital while an inpatient. Depending the
recovery of your renal function at rehabilitation on
hemodialysis, you may need outpatient followup with a renal
specialist. His office is located in the [**Hospital Ward Name 23**] Buidling, [**Hospital 34146**] Medical Specialities at [**Hospital1 18**] [**Hospital Ward Name 516**].
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57,985
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Discharge summary
|
report
|
Admission Date: [**2146-11-7**] Discharge Date: [**2146-11-16**]
Date of Birth: [**2070-3-24**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Ceftriaxone / Vancomycin / Aztreonam
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 yo male with a history of asthma, gout, BPH, CRF (baseline
Cr: 1.5-2.0) with two recent hospitalizations for pan-sensitive
enterococcus complicated by AV endocarditis with resultant
cerebral septic infarcts and a epidural abscess. On the day of
admission, the patient had a fever of 101.1 at rehab. Since the
patient has a history of infection (currently on daptomycin),
the patient was sent to the hospital. On presentation to the
emergency room, the patient had vitals signs of T: 99.9, BP:
149/79, HR: 86, RR: 16, O2 saturation: 100% room air. In the ED,
his NG tube was noted to be coiled in his mouth. Per the nursing
care at [**Hospital1 **], the patient was receiving tubefeeds. The
patient can answer questions "yes or no," which seems to be his
new baseline. Per his daughter, he has some better days.
.
The patient is unable to give a clear history due to altered
mental status.
.
The patient was originally admitted [**Date range (1) 71686**] with 6 weeks of
fevers and back pain. The patient was found to have bacteremia
from pan-sensitive enterococcus with complications including
aortic valve endocarditis and resultant septic emboli to the
brain and spinal epidural abscess. The route of enterococcal
infection remains unclear, though there was mention of a
transurethral resection of the prostate (TURP) vs. prostate
biopsy being the possible source of infection. The patient
underwent a L5 laminectomy and S1 laminectomy and epidural
abscess evacuation on [**9-30**]. The patient had altered mental
status and tremors. Neurology evaluated the patient and thought
his tremors were likely a result of his bacteremia and possible
CNS infection (LP not recommended).
.
The patient was readmitted from rehab and stayed in the hospital
from [**Date range (1) 71687**] with continued fevers and lethargy. During this
hospitalization, the patient had an aspiration event with a
brief period of hypotension and respiratory distress that
required intubation. Over the course of his hospitalizations,
the patient's treatment has been complicated by allergies to
antibiotics including ampicillin, ceftriaxone, vancomycin and
aztreonam. The severity of these reactions remains unclear. Upon
discharge from his last hospitalization, the patient was started
on daptomycin with a course to last until [**11-14**].
Past Medical History:
1. Asthma
2. Cataracts
3. Gout
4. Benign prostate hypertrophy (Prostate biopsy [**2143**], TURP [**2144**],
cystoscopy/transrectal US [**6-/2146**])
5. Chronic kidney disease (baseline 1.5-2.0)
6. Epidural Abscess s/p L5-S1 Laminectomy on [**9-30**]
7. Aortic Endocarditis
8. Bactermia [**1-17**] Enterococcus
9. Normocytic anemia
10. Cerebral infarcts (likely from endocarditis)
11. Myoclonic jerking in upper extremities
12. h/o Atrial fibrillation with rapid ventricular rate
Social History:
Per OMR: Born in [**Location (un) 6847**]. Lives with his wife and two of his
kids. Has 3 children and many grandchildren. Denies any IVDU or
alcohol use. Quit smoking 25 years ago.
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals (on floor): T: 98.0 BP: 154/68 HR: 91 RR: 14 97%2L
Gen: Patient in NAD. Answers questions with yes/no
inconsistently.
HEENT: AT/NC, [**Last Name (un) **], EOMI, anicteric, no conjuctival pallor, dry
mucous membranes, no erythema, no rhinorrhea/ discharge,
NECK: supple, trachea midline, no LAD, no thyromegaly. No nuchal
rigidity
LUNG: On anterior auscultation, has scattered wheezing. No
rhonchi or crackles, though limited.
CV: S1&S2, tachycardic. II/VI systolic murmur heard best at
RUSB.
JVD: No elevated JVP.
ABD: Soft/+BS/ NT/ ND/no rebound/ no guarding/ no hepatomegaly/
no splenomegaly
EXT: 3+ pitting edema in right arm to forearm. Left arm normal.
Pitting edema in left arch of foot-3+. 2+ pitting edema
throughout tibia bilaterally. Exquisite tenderness to lower
extremities with light touches.
NEURO: Neuro exam limited due to patient compliance. Able to
wiggle arms and legs though not able to lift against gravity.
Decreased plantarflexion on left. 3+ patellar/Achilles reflexes
bilaterally. Decreased rectal tone. 3/5 strength upper
extremities bilaterally (flexion, extension at shoulder and
elbow)
Pertinent Results:
[**2146-11-7**] 03:49AM BLOOD WBC-17.8* RBC-3.13* Hgb-8.2* Hct-27.8*
MCV-89 MCH-26.3* MCHC-29.5* RDW-16.6* Plt Ct-646*
[**2146-11-8**] 04:23AM BLOOD WBC-18.8* RBC-2.85* Hgb-7.8* Hct-24.8*
MCV-87 MCH-27.2 MCHC-31.4 RDW-17.0* Plt Ct-714*
[**2146-11-9**] 05:45AM BLOOD WBC-16.1* RBC-2.55* Hgb-7.0* Hct-22.7*
MCV-89 MCH-27.5 MCHC-30.8* RDW-16.2* Plt Ct-589*
[**2146-11-10**] 04:06AM BLOOD WBC-22.1* RBC-2.65* Hgb-7.2* Hct-22.9*
MCV-86 MCH-27.2 MCHC-31.5 RDW-17.0* Plt Ct-816*
[**2146-11-13**] 05:47PM BLOOD WBC-16.7* RBC-3.05* Hgb-8.5* Hct-26.6*
MCV-87 MCH-27.8 MCHC-31.9 RDW-16.2* Plt Ct-746*
[**2146-11-14**] 06:50AM BLOOD WBC-15.4* RBC-2.94* Hgb-8.0* Hct-25.5*
MCV-87 MCH-27.1 MCHC-31.2 RDW-16.0* Plt Ct-697*
[**2146-11-7**] 03:49AM BLOOD Neuts-72* Bands-1 Lymphs-12* Monos-5
Eos-5* Baso-1 Atyps-1* Metas-2* Myelos-1*
[**2146-11-12**] 04:45AM BLOOD Neuts-87.9* Lymphs-7.4* Monos-3.7 Eos-0.7
Baso-0.3
[**2146-11-7**] 03:49AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2146-11-7**] 03:49AM BLOOD PT-14.8* PTT-63.7* INR(PT)-1.3*
[**2146-11-10**] 08:45PM BLOOD PT-14.1* PTT-32.4 INR(PT)-1.2*
[**2146-11-11**] 04:09AM BLOOD PT-14.6* PTT-35.0 INR(PT)-1.3*
[**2146-11-8**] 04:23AM BLOOD Fibrino-425*
[**2146-11-8**] 04:23AM BLOOD FDP-10-40*
[**2146-11-13**] 03:39AM BLOOD ESR-145*
[**2146-11-9**] 05:45AM BLOOD Ret Aut-3.5*
[**2146-11-7**] 03:49AM BLOOD Glucose-138* UreaN-33* Creat-1.5* Na-149*
K-4.2 Cl-114* HCO3-26 AnGap-13
[**2146-11-10**] 04:06AM BLOOD Glucose-146* UreaN-32* Creat-2.0* Na-146*
K-4.7 Cl-109* HCO3-27 AnGap-15
[**2146-11-14**] 06:50AM BLOOD Glucose-86 UreaN-23* Creat-1.7* Na-146*
K-4.2 Cl-109* HCO3-26 AnGap-15
[**2146-11-7**] 03:49AM BLOOD ALT-122* AST-104* LD(LDH)-305* CK(CPK)-50
AlkPhos-190* TotBili-0.3
[**2146-11-8**] 04:23AM BLOOD ALT-79* AST-40 LD(LDH)-257* AlkPhos-170*
TotBili-0.3
[**2146-11-11**] 04:09AM BLOOD ALT-31 AST-21 AlkPhos-139* TotBili-0.4
[**2146-11-8**] 04:23AM BLOOD Calcium-8.2* Mg-2.2
[**2146-11-14**] 06:50AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1
[**2146-11-8**] 04:23AM BLOOD Hapto-342*
[**2146-11-12**] 04:45AM BLOOD Cortsol-28.5*
[**2146-11-12**] 04:45AM BLOOD Cortsol-37.1*
[**2146-11-12**] 04:46AM BLOOD Cortsol-42.2*
[**2146-11-13**] 03:45AM BLOOD ANCA-NEGATIVE B
[**2146-11-13**] 03:45AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2146-11-13**] 03:39AM BLOOD CRP-151.6*
[**2146-11-11**] 04:09AM BLOOD C3-152 C4-49*
[**2146-11-11**] 05:38PM BLOOD C3-148 C4-49*
[**2146-11-10**] 04:35AM BLOOD Type-ART pO2-57* pCO2-39 pH-7.46*
calTCO2-29 Base XS-3 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2146-11-10**] 04:34PM BLOOD Type-ART Temp-37.8 pO2-72* pCO2-37
pH-7.49* calTCO2-29 Base XS-4 Intubat-NOT INTUBA
[**2146-11-11**] 05:06AM BLOOD Type-ART pH-7.47*
[**2146-11-7**] 03:38AM BLOOD Lactate-1.4
[**2146-11-10**] 04:35AM BLOOD Lactate-2.5*
[**2146-11-10**] 09:02PM BLOOD Lactate-1.1
[**2146-11-11**] 05:06AM BLOOD freeCa-1.09*
[**2146-11-12**] 05:27AM BLOOD freeCa-1.05*
Cardiology Report ECG Study Date of [**2146-11-7**] 3:20:52 AM
Rhythm is probably sinus but baseline artifact makes assessment
difficult.
Consider left ventricular hypertrophy by voltage. Delayed R wave
progression
with late precordial QRS transition is non-specific. Modest ST-T
wave changes
are suggested but baseline artifact makes assessment difficult.
Since the
previous tracing of [**2146-10-28**] there is probably no significant
change but
baseline artifact in the limb leads makes comparison difficult.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 162 102 374/423 46 31 36
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-11-7**] 3:22
AM
1. Persistent multifocal opacities, most severe in retrocardiac
region
concerning for infection.
2. Pulmonary edema and small bilateral pleural effusions.
Portable TTE (Complete) Done [**2146-11-8**] at 4:10:32 PM
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Mild to
moderate ([**12-17**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: No vegetations seen. Mild aortic regurgitation. Mild
to moderate mitral regurgitation. Normal global and regional
biventricular systolic function.
MRI OF THE CERVICAL, THORACIC AND LUMBAR SPINE DATED [**2146-11-8**]
COMPARISONS: MRI of the lumbar spine dated [**2146-10-29**] and
[**2146-10-19**]
FINDINGS:
MR CERVICAL SPINE: The vertebral body height and alignment is
preserved..
There is loss of intervertebral disc height and signal
throughout the cervical
spine. However, there is no evidence of abnormal increased T2
signal within
the disc spaces to suggest discitis. There is no abnormal STIR
signal within
the vertebral bodies to suggest an infectious process. However,
the lack of
intravenous contrast does prevent complete evaluation.
Multilevel degenerative changes are again noted throughout the
cervical spine,
as detailed on the prior report from [**2146-9-28**]. Since that
time, there is a
stable appearance of the large disc bulges at C4-5, C5-6 and
C6-7, with a
stable appearance of the spinal canal and neural foraminal
narrowing. This
again is noted to indent the ventral aspect of the cord which is
remodeled.
There is no definite abnormal increased T2 signal within the
cord. The
visualized posterior fossa is unremarkable.
MR THORACIC SPINE: The vertebral body height and alignment is
maintained.
There is a stable scoliosis. The bone marrow signal is mildly
heterogeneous,
without increased T2 STIR signal to suggest edema. The
intervertebral discs
preserve their height and signal, without evidence of discitis.
Again, the
lack of intravenous contrast precludes complete evaluation, but
there are no
findings to indicate an underlying infection. The thoracic cord
demonstrates
a normal morphology. There is linear T2 hyperintensity within
the thoracic
cord that likely is artifactual in nature or may represent the
central canal.
The thoracic cord otherwise demonstrates normal signal
intensity. Mild disc
bulges are again noted at a few levels, not significantly
changed since the
prior study from [**2146-9-15**].
MR LUMBAR SPINE: Post-surgical changes are again noted status
post L5
laminectomy, there is a stable appearance of the post-surgical
collection at
the L5 level posteriorly. There is also persistent edema in the
posterior
soft tissues, not significantly changed since the prior study.
At the L5-S1
disc space, there is persistent T2 hyperintensity at the
endplates as well as
within the disc, not significantly changed since prior
examination. The soft
tissue phlegmon that extends immediately posterior to the L5-S1
disc extends
along the nerve roots and is stable in appearance since the
prior study when
accounting for differences in technique. There is no definite
evidence of an
epidural abscess, although the lack of intravenous contrast does
decrease
sensitivity.
The vertebral body height and alignment is otherwise preserved,
with mild
retrolisthesis of L2 on L3. Endplate degenerative changes are
again noted at
other levels, most prominent at the L1-L2 disc space. There are
disc bulges
at several levels as detailed previously, without interval
change.
Bilateral pleural effusions are noted. There is a hyperintense
focus in the
left kidney, stable since the prior study.
1. Stable appearance of the abnormal T2 and STIR signal at the
L5-S1 disc,
with extension into the epidural soft tissues, consistent with
discitis and
osteomyelitis with epidural phlegmon. These findings are stable
since the
prior study. There are no findings to indicate progression, nor
are there
findings specific for an epidural abscess, although the lack of
intravenous
contrast does decrease sensitivity. Post-surgical changes are
also noted
status post laminectomy, without interval change.
2. Degenerative changes of the cervical and throacic spine as
detailed above,
without findings to indicate an infectious process. However, the
lack of
intrtravenous contrast does decrease sensitivity.
Neurophysiology Report EEG Study Date of [**2146-11-9**]
IMPRESSION: This is an abnormal routine EEG due to slowing and
disorganization of the background rhythm. No EEG correlate was
noted
associated with small jerking movements of his left arm. There
were no
epileptiform discharges or electrographic seizures noted.
Slowing and
disorganization of the background suggests a mild to moderate
encephalopathy. Medications, toxic/metabolic disturbances, and
infection are common causes. Clinical correlation is
recommended.
Radiology Report TC WHITE BLOOD CELL STUDY Study Date of
[**2146-11-9**]
INTERPRETATION: Following injection of autologous white blood
cells labeled with
Tc-[**Age over 90 **]m images of the whole body and chest were obtained at 2
hours. These
images show small focus of increased tracer uptake in the right
anterior fourth
rib. There is early physiologic margination of the white cells
in the lungs,
but no focal uptake. No other regions of abnormal uptake.
IMPRESSION: Small focus of increased tracer uptake in the right
anterior fourth
rib which could represent focal marrow uptake although infection
would be
difficult to exclude. This area could be further evaluated with
physical exam.
No other abnormal focus identified.
Radiology Report UNILAT UP EXT VEINS US RIGHT Study Date of
[**2146-11-8**] 1:10 PM
IMPRESSION:
1. Occlusive thrombus in the right cephalic vein as before.
2. A 3mm focal area of nonocclusive thrombus is seen within the
lumen of the
right internal jugular vein. This vessel otherwise remains
patent.
3. No DVT is seen in the right subclavian vein, right axillary
vein or right
brachial vein.
Portable TTE (Complete) Done [**2146-11-11**] at 3:25:01 PM FINAL
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with mild distal anterior, septal and inferior
hypokinesis. 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 masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. Mild (1+) aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2146-11-8**],
the findings are similar. The wall motion abnormalities seen on
the current study were probably present on the prior study.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2146-11-12**] 9:47 PM
1. No pulmonary embolism, aortic dissection or aneurysm.
2. Large bilateral pleural effusions, increased since [**10-30**] as well as
progressive consolidation involving the aerated portion of both
lungs,
strikingly progressed in the left lung, all progressed and new
from [**10-30**]. Concern is for pneumonia.
3. Extensive atherosclerotic disease.
4. Biliary sludge.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-11-13**] 3:54
AM
HISTORY: Cough and fever.
One portable view. Comparison with [**2146-11-12**]. Patchy bilateral
parenchymal
opacities are again demonstrated. The costophrenic sulci are
blunted
consistent with pleural fluid as before. The heart and
mediastinal structures
are unchanged.
IMPRESSION: No significant change.
Radiology Report ANKLE (AP, MORTISE & LAT) LEFT Study Date of
[**2146-11-14**] 7:47 PM
Preliminary Report !! WET READ !!
1.Osseous fragment adjacent to the lateral malleolus with
demineralization of
the donor site in the lateral malleolus, could represent old
fracture with
bone loss, however if the patient has acute symptoms relating to
this area, a
bone scan or MRI scan is recommended to rule out an
osteomyelitis.
2. Possible old avulsion fracture of the medial malleolus.
3. Degenerative changes and minimal left ankle joint effusion
URINE CULTURE (Final [**2146-11-14**]):
YEAST. >100,000 ORGANISMS/ML..
URINE CULTURE (Final [**2146-11-11**]):
YEAST. >100,000 ORGANISMS/ML..
URINE CULTURE (Final [**2146-11-8**]):
YEAST. >100,000 ORGANISMS/ML..
[**2146-11-10**] 8:51 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
[**2146-11-8**] 4:23 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Final [**2146-11-14**]): NO GROWTH.
[**2146-11-7**] 9:52 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2146-11-7**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2146-11-7**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2146-11-11**] 4:57 am SPUTUM Site: EXPECTORATED
**FINAL REPORT [**2146-11-13**]**
GRAM STAIN (Final [**2146-11-11**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2146-11-13**]):
RARE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
76 yo M with recent VRE endocarditis, spinal abcesses s/p
laminectomy, recent prolonged intubation for aspiration PNA,
readmitted to [**Hospital1 18**] from rehab with recurrent aspiration, was
stable on the floor; being treated with meropenem, when had an
acute epsiode of tachypnea and respiratory distress, then
transferred to the MICU with hypoxic respiratory failure.
.
# Aspiration Pneumonia:
Patient has a history of recurrent aspiration pneuonia. He was
on a prolonged course of Daptomycin (last day was supposed to be
[**11-14**]) for the spinal epidural abscesses and was started on
Meropenem for pneumonia on [**11-8**]. The patient was switched from
Daptomycin/Meropenem to Linezolid/Meropenem on [**11-10**] for better
lung penetration to treat the pneumonia as well as to complete
the epidural abscess treatment. He was empirically started on
oseltamivir on presentation for the flu, but the oseltamivir was
discontinued when the state lab results returned negative. On
[**11-10**], he acutely desaturated on the floor with O2 requirement
rising from 2L to 5L nasal cannula with increased work of
breathing. CT-A showed multifocal pneumonia, bilateral pleural
effusions and was negative for pulmonary embolism. Patient has
had elevated BNP and may have had component of diastolic CHF
decompensation. The patient was stabilized and transferred back
to the general medical floor on [**2146-11-13**] on 3L of oxygen by
nasal canula. On discharge, patient saturating 95% on 2L. He
has had O2 saturations in the low 90s when tested on room air,
though it drops when he does not breathe deeply enough.
The patient will need one more day of treatment with Meropenem
and Linezolid to complete an 8 day course of Linezolid and a 10
day course of Meropenem.
# Leukocytosis:
Leukocytosis was likely unrelated to prior VRE as antibiotic
course completed or spinal process as no interval change. Blood
cultures negative to date, and urine cultures positive for
yeast. After fluconazole treatment began for persistent
funguria, patient's WBC began to trend down. ESR and CRP
elevated during hospitalization, which may be related to gout
flare or another inflammatory process.
.
# Funguria:
Patient's UA on [**11-10**] showed eosinophils. Urine cultures x 3
showed growth of yeast >100,000 colonies. Per ID
recommendations, the patient was started on fluconazole
treatment 400mg daily for 14 days, starting [**11-14**] in the PM.
Renal ultrasound was done to rule out fungal ball and showed
none.
The patient will need 11 more days of fluconazole treatment. He
will need a repeat urine culture after finishing the full course
of treatment.
.
# Epidural abscess s/p L5-S1 laminectomy:
MRI was unchanged from previous. The patient had been on a
prolonged course of Daptomycin to end [**11-14**], but was switched
from Daptomycin to Linezolid on [**11-10**] to also cover for the MRSA
pneumonia. No further antibiotic treatment will be necessary
for the epidural abscess after this course of linezolid. He
does sometimes complain of bilateral leg pain associated with
his lower back pain. The patient was evaluated by the
Neurosurgery team on presentation, and it was felt that his
neuro exam was stable.
.
# Lower Extremity Pain:
Lower extremity pain bilaterally appears to be neuropathic,
likely secondary to nerve damage from epidural abscess. Tagged
WBC scan did not show any uptake in the lower extremities,
though there may have been increased uptake in the right
anterior fourth rib. Per Pain team consult on presentation,
patient was continued on his fentanyl patch and gabapentin and
was given PRN IV dilaudid in small doses of 0.25mg, which he
only received on occasion. Of note, the patient appears to
minimize pain frequently and was more likely to admit to pain
when in the presence of his family. His gabapentin was
uptitrated to 400mg twice daily. Per pain consult team, low
dose amitryptiline may be added as well as long as mental status
remains stable. In the setting of large dose narcotics, patient
will need to be on a strong bowel regimen.
.
# Altered mental status:
Patient had presented with altered mental status, only
responding "yes" and "no" to questions. Neurology was
consulted, and the patient had received an EEG which did not
show any active epileptiform activity, though it did show
slowing and
disorganization of the background signals, which suggested a
possible mild
encephalopathy. Encephalopathy may have been secondary to
infection, or he may have just been recovering slowly from
intubation a couple weeks prior. He was noted by the ICU team,
who was familiar with him from previous hospitalization, to be
much more lucid and conversant than when he was at time of
previous discharge to rehab. On discharge, the patient is lucid
and verbally responsive, oriented to person, place, and year.
.
# Myoclonic jerks:
Patient has occasional myoclonic movements of upper and lower
extremities. There was no EEG correlation noted of these
myoclonic jerks to any epileptiform activity. These may have
been more pronounced in the setting of infection.
.
# Lower extremity weakness:
The patient presents with lower extremity weakness that was
similar to his last admission, per Neurosurgery. It likely
relates to neurological damage and generalized deconditioning.
The patient was evaluated by physical therapy and requires
maximum assist to stand. He will need regular physical therapy
for strengthening.
.
# Left Ankle pain:
His left ankle appeared to have increased tenderness to
palpation, both on the medial and lateral side. The patient
likely had a gout flare, so he was started on a brief prednisone
taper, starting with two days of 30mg prednisone.
Because of his increased pain in the left ankle, Xrays of his
left ankle were done to rule out osteomyelitis. Xray showed
osseous fragment adjacent to the lateral malleolus with
demineralization of the donor site in the lateral malleolus,
which likely represents old fracture with bone loss though it
does not rule out osteomyelitis. Because the tagged WBC scan
had been negative for uptake in the lower extremities,
osteomyelitis is unlikely in this site. The left ankle is not
significantly warm or erythematous, but gout is the most likely
etiology of his pain.
.
# Anemia:
Patient has stable anemia during this admission with Hct around
24 (range 20-27), likely a combination of anemia of chronic
disease and iron deficiency anemia, per iron studies in [**Month (only) 359**].
Patient may benefit from being started on iron supplementation
upon discharge. He will need a good bowel regimen in the
setting of iron and pain medications.
.
# Hypertension:
Patient's hypertension has been stable during this
hospitalization with just metoprolol tartrate 37.5mg [**Hospital1 **] and
amlodipine 10mg daily. The patient was on oral hydralazine as
well for blood pressure control prior to this hospitalization,
but this was discontinued because his blood pressure has been so
well controlled with systolic in 110s-120s without it.
.
# Right arm swelling:
The patient was noted to have a superficial cephalic vein clot
on his right arm without the presence of DVT during an
ultrasound on his last admission. He was not anticoagulated
during this hospitalization because the affected vein was
superficial and would not put patient at risk for pulmonary
embolism.
.
# Transaminitis:
The patient presented with mild transaminitis, which had been
trending down from previous hospitalization, including elevated
LDH but normal total bilirubin levels. His LFTs trended down
back to normal prior to discharge. Patient's INR was elevated
mildly to 1.2-1.3 during this hospitalization. The atorvastatin
was stopped in the setting of transaminitis and was not
restarted upon discharge.
# Thrombocytosis:
Platelets in the 600Ks during this hospitalization, likely
reactive thrombocytosis.
# Diarrhea:
The patient has persistent diarrhea on presentation and was
noted to be Negative for C. difficile in the setting of
long-term antibiotics.
.
# Nutrition:
Meds were crushed in applesauce. Patient failed multiple speech
and swallow evaluations. Video Swallow study on [**11-15**] cleared
patient for ground solids and nectar-thick liquids with Ensure
pudding supplementation. Of note, patient does cough while
eating, but coughing does not correlate to aspiration, so he
needs close followup to evaluate for aspiration. He will likely
need repeat Video Swallow on [**10-30**]. Please monitor intake
carefully, as he is known to not eat sufficiently; patient may
need to start tube feeds to supplement nutrition.
# CODE: FULL -- Patient had expressed some interest in changing
code status to DNR/DNI, but needed to have a family discussion.
Patient's code status should be re-addressed when possible with
himself and his family.
# CONTACT: DAUGHTER, WIFE
Medications on Admission:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipatin.
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
8. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
11. Hydralazine 10 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 10 days: Last day [**11-14**].
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
6. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 12 days.
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) solution
Inhalation Q6H (every 6 hours).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) solution Inhalation Q6H (every 6
hours).
14. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1)
Intravenous Q12H (every 12 hours) for 1 days.
15. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 1 days.
16. Prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO DAILY
(Daily) for 4 days: [**2146-11-16**] - 30mg
[**2146-11-17**] - 20mg
[**2146-11-18**] - 10mg
[**2146-11-19**] - 5mg .
17. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnosis:
Aspiration Pneumonia
Secondary Diagnoses:
Hx of Spinal Epidural Abscess
Bilateral Lower Extremity Weakness and Pain
Hypertension
Funguria
Gout
Anemia
Discharge Condition:
- Alert when awakened and verbally responsive
- Oriented to self/year/place
- Requires Maximum Assist to Stand. Limited by leg weakness and
bilateral lower extremity pain.
Discharge Instructions:
Dear Mr. [**Known lastname 724**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital because you had pneumonia after aspirating food
into your lungs. You were treated for pneumonia with strong
antibiotics. Your course of antibiotics for the epidural
abscesses in your lower back has also finished. You were
started on an antifungal medicine for a yeast infection in your
urine. You were also started on treatment for a gout flare in
your left ankle.
The following changes were made to your medications:
- We INCREASED your Gabapentin to 400mg twice daily
- We ADDED Fluconazole 400mg daily x 12 more days
- We ADDED Prednisone which you will take with a quick taper:
[**2146-11-16**] - 30mg prednisone
[**2146-11-17**] - 20mg prednisone
[**2146-11-18**] - 10mg prednisone
[**2146-11-19**] - 5mg prednisone
- We STOPPED your Hydralazine for your blood pressure because
your other blood pressure medications have been working very
well during this hospitalization
- We ADDED Meropenem and Linezolid antibiotics as listed below
which need to be continue for one more day intravenously to
treat your pneumonia
Followup Instructions:
Cardiologist:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2146-12-1**] 8:40
Primary Care Physician:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**Last Name (STitle) **]
[**Last Name (LF) 766**], [**12-19**] 1:15pm
([**Telephone/Fax (1) 71688**]
[**Location (un) 47**] Office
|
[
"238.71",
"507.0",
"403.90",
"333.2",
"112.2",
"790.4",
"600.00",
"428.33",
"493.90",
"428.0",
"585.9",
"324.1",
"787.91",
"274.01",
"482.42",
"511.9",
"453.81",
"280.9",
"518.81",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
30392, 30475
|
18559, 22650
|
317, 323
|
30689, 30864
|
4592, 17685
|
32065, 32446
|
3390, 3409
|
28748, 30369
|
30496, 30496
|
27460, 28725
|
30888, 32042
|
3449, 4573
|
30558, 30668
|
17720, 18536
|
272, 279
|
351, 2671
|
30515, 30537
|
22665, 27434
|
2693, 3174
|
3190, 3374
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,645
| 116,647
|
19606
|
Discharge summary
|
report
|
Admission Date: [**2122-5-25**] Discharge Date: [**2122-5-31**]
Date of Birth: [**2061-3-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2122-5-26**] Off pump coronary artery bypass grafting times four (Left
internal mammary artery to left anterior descending artery,
Saphenous vein graft to Ramus, Saphenous vein graft to Obtuse
Marginal, Saphenous vein graft to Right coronary artery)
History of Present Illness:
Mr. [**Known lastname 20825**] is a 61 year old male experiencing left sided chest
discomfort which radiates toward left shoulder for about two
months, occuring with activity and rest, lasting about 2
minutes. He was referred to cardiac surgery after a cardiac
catheterization revealed severe coronary artery disease.
Past Medical History:
Coronary artery disease, multiple PCI
Unstable angina
Aortic Aneurysm
Carotid stenosis (left occlusion, 99% right stenosis)
Hypertension
Pericarditis
Dyslipidemia (intolerant to lipitor)
Pancreatitis
Colon polyps
Diverticulosis
Peripheral artery disease
Permanent pacemaker (syncopal episode) - guidant pacr
s/p Pancreatectomy
s/p Splenectomy
Surgical repair of Abdominal Aortic aneurysm
Social History:
Mr. [**Known lastname 20825**] works in production at ice cream factory.
He lives with his spouse.
[**Name (NI) **] has a 50 pack year history, and his last cigarette was on
[**5-22**].
He imbibes 5 drinks each day on saturday and sunday.
Family History:
His mother had carotid disease and died at age 66.
Physical Exam:
Pulse: 50 AV paced Resp: 14 O2 sat: 96 %
B/P Right: 145/83 Left: 122/70
Height: 5'8" Weight: 172 #
General:
Skin: Dry [x] intact [x] multiple areas of red discoloration
circular non raised have been occuring for last year
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 100% AV paced
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal alert and oriented x3
Pulses:
Femoral Right: +2 Left: cath site
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Pertinent Results:
[**2122-5-25**] Carotid U/S: 1. Occluded left ICA. 2. 70 to 79% right ICA
stenosis.
[**2122-5-26**] Echo: PRE-BYPASS: 1.The left atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
3. Right ventricular chamber size and free wall motion are
normal. 4. There are complex (mobile) atheroma in the aortic
arch. There are complex (mobile) atheroma in the descending
aorta. 5. There are three aortic valve leaflets. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. 6.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. 7. There is no pericardial effusion. POST
Off Pump CABG: Pt is on Phenylephrine and intermittently paced.
1. Biventricular function is unchanged. 2. Aorta is intact.
Visualized Mobile atheromas appear to be still present. 3. Other
fingings are unchanged Dr. [**First Name (STitle) **] notified in person of the
results.
[**2122-5-31**] CXR: There is new pleural effusion seen on the lateral
view, most likely right, corresponding to the clinical findings.
The cardiomediastinal silhouette is stable. The pacemaker leads
are in the right atrium and right ventricle. The patient is
after median sternotomy and CABG. There is no pneumothorax.
[**2122-5-25**] 03:59PM BLOOD WBC-10.4 RBC-4.66 Hgb-15.1# Hct-44.2
MCV-95 MCH-32.5* MCHC-34.3 RDW-13.6 Plt Ct-305
[**2122-5-31**] 10:25AM BLOOD WBC-13.3* RBC-2.94* Hgb-9.4* Hct-28.6*
MCV-98 MCH-32.1* MCHC-32.9 RDW-14.0 Plt Ct-330
[**2122-5-25**] 03:59PM BLOOD PT-14.2* PTT-31.9 INR(PT)-1.2*
[**2122-5-29**] 06:45AM BLOOD PT-12.6 INR(PT)-1.1
[**2122-5-25**] 03:59PM BLOOD Glucose-100 UreaN-20 Creat-0.9 Na-140
K-4.6 Cl-102 HCO3-28 AnGap-15
[**2122-5-31**] 10:25AM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-135
K-4.4 Cl-102 HCO3-24 AnGap-13
[**2122-5-28**] 07:25PM BLOOD ALT-18 AST-50* LD(LDH)-439* AlkPhos-71
Amylase-23 TotBili-0.4
Brief Hospital Course:
Mr. [**Known lastname 20825**] was admitted on [**2122-5-25**] from [**Hospital6 1109**]
to cardiac surgery for a pre-operative work-up. On [**2122-5-26**] he
underwent an off pump coronary artery bypass grafting times
four. Please see the operative note for details. He was
transferred in critical but stable condition to the cardiac
surgery intensive care unit. By post-op day one the patient was
extubated, alert and oriented, neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
He was found suitable for transfer to telemetry at this time. He
continued to make good progress. Chest tubes and pacing wires
were discontinued without complication. The patient's permanent
pacemaker was interrogated by the electrophysiology service.
Beta blocker was started and the patient was gently diuresed
toward his preoperative weight. He did have a brief burst of
post-operative atrial fibrillation and was started on
amiodarone. The remainder of his post-op course remained
uneventful and he was discharged to home in good condition with
VNA services on post-op day five.
Medications on Admission:
lopressor 100 mg daily
Norvasc 10 mg daily
ASA 325 mg daily
Mmultivitamin
Omeprazole 20 mg daily
simvastatin 20 mg daily started [**5-22**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: then 400mg daily for 7 days then 200mg daily
ongoing.
Disp:*75 Tablet(s)* Refills:*1*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*1*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): check leiver function test in one month.
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
14. 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:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass x 4
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] for Dr. [**Last Name (STitle) **](cardiac surgery) at [**Hospital1 **] in 3 weeks ([**Telephone/Fax (1) 6256**]), please call for
appointment.
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**] (PCP) in [**12-26**] weeks ([**Telephone/Fax (1) 37064**]), please call for
appointment.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32255**] (cardiologist) in 4 weeks ([**Telephone/Fax (1) 6256**]),
please call for appointment.
See Dr. [**First Name (STitle) 1557**] (MW Vascular) in 1 month.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2122-6-2**]
|
[
"411.1",
"440.0",
"441.4",
"V45.01",
"305.1",
"433.30",
"423.1",
"440.21",
"427.31",
"414.01",
"562.10",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
7480, 7529
|
4515, 5618
|
330, 584
|
7627, 7633
|
2439, 4492
|
8144, 8934
|
1615, 1667
|
5808, 7457
|
7550, 7606
|
5644, 5785
|
7657, 8121
|
1682, 2420
|
280, 292
|
612, 932
|
954, 1343
|
1359, 1599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,208
| 139,033
|
68
|
Discharge summary
|
report
|
Admission Date: [**2200-4-25**] Discharge Date: [**2200-4-28**]
Date of Birth: [**2139-8-15**] Sex: F
Service: [**Year (4 digits) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
R renal mass
Major Surgical or Invasive Procedure:
Right Laparoscopic Radical Nephrectomy
History of Present Illness:
60yF with CAD and ESRD on HD with a nearly 4cm left renal mass
concerning for malignancy.
Past Medical History:
1. Diabetes type 2 c/b retinopathy, neuropathy - pt not
currently taking meds due to insurance issue
2. Reactive airway disease; ?Asthma; 50+PY smoking and likely
COPD.
3. Depression
4. History of pulmonary nodules consistent with calcified
granuloma
5. Menorrhagia
6. Hypertension, poorly controlled. H/o hypertensive urgency.
7. Hypercholesterolemia.
8. Chronic lower back pain.
9. CRI, most recent Cr values in the 4's.
10. Thyroid mass never followed up with biopsy
11. Osteoporosis
12. Left renal mass concerning for RCC but never followed up for
biopsy
13. Chronic anemia thought [**12-24**] CKD, not on Epo
14. MGUS
15. CHF: [**2200-1-2**], TTE demonstrated moderate to severe global
left
ventricular hypokinesis (LVEF = 30 %), moderate MR, and moderate
pulmonary artery hypertension
Social History:
Lives with roomate in [**Last Name (un) 813**] in apt. She grew up with her family
as a carnival worker and traveled with them. Illiterate. smokes
1ppd, has 50 pack yr history. no etoh/illicits. on SSI
currently. only family support seems to be her [**Last Name (un) 802**] in NY.
Family History:
Multiple family members with DM, MI, CVA. Uncle and two cousins
had kidney disease requiring dialysis. Mother with breast
cancer.
Physical Exam:
AVSS
Gen: NAD
Abd: soft, NT, ND
Incisions: clean/dry/intact
Brief Hospital Course:
Patient was admitted to [**Last Name (un) 159**] after undergoing laparoscopic
Right radical nephrectomy. No concerning intraoperative events
occurred; please see dictated operative note for details. The
patient received perioperative antibiotic prophylaxis. The
patient was transferred to the ICU in stable condition for
monitoring due to extensive comorbidities and not for any
intraoperative complication. On POD0, pain was well controlled
on PCA, hydrated for urine output >30cc/hour, provided with
pneumoboots and incentive spirometry for prophylaxis, and
ambulated once. She was seen by the cardiology service and the
nephrology service and underwent HD while int he ICU. On POD1,
the patient was restarted on home medications, basic metabolic
panel and complete blood count were checked, pain control was
transitioned from PCA to oral analgesics, diet was advanced to a
clears/toast and crackers diet. On POD2, Foley was removed
without difficulty and diet was advanced as tolerated. Prior to
discharge the patient underwent a CT scan with contrast of the
chest to evaluate pulmonary nodules seen on CXR. She underwent
HD after this. The remainder of the hospital course was
relatively unremarkable. The patient was discharged in stable
condition, eating well, ambulating independently, voiding
without difficulty, and with pain control on oral analgesics. On
exam, incision was clean, dry, and intact, with no evidence of
hematoma collection or infection. The patient was given explicit
instructions to follow-up in clinic with Dr. [**Last Name (STitle) 770**] in 3 weeks
and to also call for follow-up with nephrology and cardiology.
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Omeprazole 20 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*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each
hemodialysis).
Disp:*60 Capsule(s)* Refills:*2*
11. 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*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
R Renal mass
Discharge Condition:
Stable
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, except hold NSAID
(aspirin, and ibuprofen containing products such as advil &
motrin,) until you see your urologist in follow-up
-Call your Urologist's office today to schedule/confirm your
follow-up appointment in 3 weeks AND if you have any questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids
Followup Instructions:
Please call Dr.[**Name (NI) 825**] office for follow-up. Please call
your cardiologist for follow-up.
Completed by:[**2200-4-29**]
|
[
"V58.67",
"428.22",
"424.0",
"403.91",
"189.0",
"362.01",
"733.00",
"428.0",
"246.9",
"272.0",
"416.8",
"357.2",
"V17.49",
"496",
"V18.0",
"305.1",
"724.2",
"V16.3",
"250.50",
"273.1",
"414.01",
"285.21",
"250.40",
"585.6",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.21",
"39.95",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
4871, 4877
|
1861, 3509
|
341, 382
|
4934, 4943
|
6190, 6324
|
1631, 1762
|
3532, 4848
|
4898, 4913
|
4967, 6167
|
1777, 1838
|
289, 303
|
410, 501
|
523, 1316
|
1332, 1615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,094
| 133,570
|
35763
|
Discharge summary
|
report
|
Admission Date: [**2180-2-22**] Discharge Date: [**2180-7-4**]
Date of Birth: [**2126-10-22**] Sex: M
Service: SURGERY
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Transfer from Outside Hospital with acute pancreatitis and acute
renal failure.
Major Surgical or Invasive Procedure:
1. Tracheostomy [**2180-3-8**]
2. Drain placement in IR [**2180-4-28**]
3. Drain upsizing in IR [**2180-5-3**]
4. Drain change in IR [**2180-5-9**]
5. Takedown of end of the enterocutaneous fistula with
small-bowel resection and primary anastomosis, extended
adhesiolysis, repair of enterotomy, G-tube placement, and
J-tube
placement [**2180-5-25**].
History of Present Illness:
Mr. [**Known lastname **] is a 54 year old male, with a history of HTN,
ulcerative colitis, resection of a non-malignant brain tumor,
alcohol abuse, chronic methadone maintenance, and ulcerative
colitis s/p colectomy who was transferred [**2180-2-22**] from
an Outside Hospital with acute alcoholic pancreatitis evolving
into necrotizing pancreatitis complicated by respiratory failure
s/p tracheostomy.
Past Medical History:
Hypertension, Ulcerative colitis s/p colectomy, J pouch, Removal
of nonmalignant brain tumor, Alcohol abuse, Chronic Methadone
Maintenance
Social History:
Lives w/sister. History long-term smoking. Chronic alcohol use.
Denies IVDU.
Family History:
Not-contributory
Physical Exam:
At Discharge:
.
VS: 99.4 PO, 120/80, 107, 20, 96% RA
GENERAL: Thin, well appearing male appearing older than stated
age in NAD.
HEENT: Sclerae anicteric. O-P clear, intact.
NECK: Supple. Thyroid NT/non-palp. No lymphadenopathy.
LUNGS: CTA(B).
HEART: RRR; nl S1/S2 w/o m/c/r. No S3/S4.
ABDOMEN: (L)Abdominal G-Tube and J-Tube insertion sites patent &
c/d/i with drain sponge/DSD. G-Tube clamped. J-Tube receiving
tubefeeds. (L) flank JP tip cut, draining into ostomy bag, which
is intact. Abdomen soft/NT/ND.
EXTREM: No c/c/e.
MUSCULOSKELATAL: Overall cachetic with significant muscle mass
wasting during hospitalization. Improving conditioning.
Ambulates with assist.
NEURO: A+Ox3. Affect somewhat flat, but pleasant. Interacts
appropriately. Exam non-focal/grossly intact.
SKIN: Intact w/o lesion or rash.
Pertinent Results:
THIS IS A VIDEO OROPHARYNGEAL SWALLOW STUDY: [**2180-6-28**].
.
FINDINGS: Oropharyngeal swallow video fluoroscopy was performed
in conjunction with the speech and swallow division. Multiple
consistencies of barium were administered. Barium passes freely
through the oropharynx and esophagus without evidence of
obstruction. There was no gross aspiration or penetration.
.
IMPRESSION: No gross aspiration or penetration.
.
[**2180-6-22**] CHEST PORT. LINE PLACEMENT:
Tip of the left subclavian line projects over the upper SVC.
Tracheostomy
tube in standard placement, nasogastric tube ends in the
stomach. Lung
volumes remain quite low, but improved since earlier in the day,
small linear areas of atelectasis are seen in both lower lungs
and a tiny fissural component of pleural fluid on the right is
unchanged. Upper lungs clear. Normal cardiomediastinal and
hilar silhouettes.
.
[**2180-6-22**] ABD/PELVIC CT W/CONTRAST:
1. Peripancreatic inflammatory changes and retroperitoneal
collections are little changed since [**2180-6-2**] except to note
increasing peripancreatic air.
This is concerning for persistent sinus tract, fistula or
contained perforation.
2. Collection of fluid in the anterior abdomen has improved and
is no longer evident.
3. Asymmetric dilation of small bowel loops raises the
possibility of partial small bowel obstruction, however dilated
loops and fluid extend to the rectum without transition point.
4. Moderate intra- and extra- hepatic biliary dilatation as well
as
gallbladder sludge is unchanged since [**2180-6-2**].
.
[**2180-6-22**] EKG:
Sinus tachycardia. ST-T wave abnormalities. Since the previous
tracing
of [**2180-5-18**] the rate has increased. ST-T wave abnormalities are
more marked.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
144 0 80 288/435 0 56 26
.
[**2180-6-13**] G/GJ/GI TUBE CHECK:
Under fluoroscopic guidance, a small amount of water-soluble
Conray
contrast was injected via the patient's G-tube. Contrast passed
freely
without obstruction into the stomach without evidence of
extraluminal leak. Thereafter, similar injection of
water-soluble contrast was done via the patient's J-tube which
also passed without obstruction into the small bowel. Prior to
the study, a scout radiograph of the abdomen was taken which
excluded the upper and left abdomen from the field of view,
though demonstrated the aforementioned feeding tubes as well as
multiple air-filled loops of bowel. Degenerative change is also
noted in the lumbar spine.
.
IMPRESSION: Patent G and J tubes without evidence of
obstruction.
.
[**2180-6-2**] ABD/PELVIC CT W/CONTRAST:
1. Marked peripancreatic inflammatory changes, with multiple
retroperitoneal collections. One collection adjacent to the
second/third portion of the duodenum contains air, fluid, and
suggestion of enteric contrast, and appears to track to the
floor of the stomach, at which point the fascial plane is poorly
defined. This raises the concern of a sinus tract, fistula, or
contained perforation. No frank extravasation of oral contrast
is identified.
2. Large pocket of fluid within the anterior abdomen, with
surrounding
enhancement of the adjacent peritoneum, raises the suspicion for
infected
fluid and associated peritonitis.
3. Intrahepatic biliary ductal dilatation, with dilatation of
the CBD.
4. Gallbladder stone/sludge.
5. Bibasilar atelectasis, with small left pleural effusion.
.
MICROBIOLOGY:
[**2-22**] UCx + enterococcus
[**2-23**] BCx + coag neg staph [**1-21**]
[**2-28**] Sputum Cx + yeast
[**3-1**] C-diff Neg
[**3-3**] BCx P
[**3-18**]: BCx: GPC clusters
[**3-20**]: Sputum ENTEROBACTER CLOACAE, YEAST
[**3-26**]: GRAM NEGATIVE ROD, BUDDING YEAST
[**4-2**]: BCx: GPC
[**4-15**] drain cx: 1+ GNR
[**4-18**] drain: GPR, GNR
[**4-20**]: drain: (x2) Enterobacter [**Last Name (un) 2830**]-[**Last Name (un) 36**], Lactobacillus
[**4-21**]: BCx x2 NGTD
[**4-25**]: abscess pseudomonas
[**4-29**]: drains pseudomonas
[**5-26**]: sputum with >25PMNs and 3+ GNR
Brief Hospital Course:
The patient with history of ulcerative colitis s/p colectomy was
transferred from an Outside Hospital on [**2180-2-22**] intubated for
management of acute pancreatitis and ARDS. He remained
intubated, aggressive IVF resucitation started, foley catheter
in place, flagyl and ceftriaxone for presumed aspiration
pneumonia, sedation prn, methadone continued.
[**2-23**]: Spiked temp 101.2. Pan cultured. Bladder pressure up to 21.
Continued difficulty with sedation. Tense abdomen. Continued
ventilatory support, nasojejunal tube placed for tube feeding,
continued antibiotics, IVF, vancomycin started.
[**2-24**]: Discontinued flagyl, ceftriaxone and started zosyn,
continued vancomycin, IVF, ventilatory support, started
propofol, weaned FiO2 and PEEP.
[**2-25**]: Started tube feeds, continued ventilatory support,
antbiotics, IVF.
[**2-29**]: Flexiseal placed with >1L output, in/out afib but
responsive to betab blockade and predominantly in sinus rhythm,
NGT replaced, NGT in early am pulled back and pt potentially
aspirated gastric contents (moderate amount contents suctioned
from ETT), no sign change on CXR, Tubefeeds held, maintenance
IVF, central line changed and tip sent for cx.
[**3-1**]: Temp spike 101.5.
[**3-4**]: Temp 101.2, opening eyes to voice in am [**3-5**], retaining
CO2 so placed on vent overnight.
[**3-5**]: Increased insulin in TPN.
[**3-6**]: Weaned vent, started clonidine, increased beta blockers.
[**3-7**]: Started trophic feeds, then held in am.
[**3-8**]: s/p trach, increased insulin in TPN, increased O2
requirements s/p trach improved throughout day, lasix held as
renal functions borderline, propofol infusion increased during
evening given mild agitation and tachypnea on vent.
[**3-9**]: Acute decompensation, CT demonstrated hemorrhagic
pancreatitis, 5 units PRBC.
[**3-10**]: 2 units PRBC, RUQ U/S, TPN
[**3-12**]: Insulin reduced in TPN due to low blood sugars, no acute
issues.
[**3-13**]: s/p 1 unit PRBC
[**3-14**]: HCT stable, clonidine increased to 0.2mg patch, lasix 20mg
IV x2 doses with good response.
[**3-15**]: Cont Lasix, TPN, vent wean. Urine lytes sent in setting of
diuresis.
[**3-16**]: Increase clonidine patch, 1-2L neg, diurese prn, in
evening question if patient vasovagal with SBP to 80s (started
on neo, 500cc bolus, stable HCT), panculture for fever.
[**3-19**]: Increase lopressor; standing Ativan.
[**3-20**]: Increase ativan to 1mg q6hrs atc. Febrile 100.5. Free water
1L given for hypernatremia.
[**3-21**] Briefly on trach mask -> resp acidosis.
[**3-22**]: Acidosis while on trach mask; lasix 20mg IV x 2 given,
received 1 L free H20 for hypernatremia, methadone increased to
Q8, ativan interval increased.
[**3-23**]: Precedex started for better sedation/agitation control,
fentanyl infusion weaned off. Goal to be on methadone/dex only
with prn ativan and slowly wean dex. Autodiuresis; net -1L.
[**3-24**]: Trophic Tubefeeds, question aspiration event, Tubefeeds
held.
[**3-25**]: Haldol started, precedex stopped, aggitation slightly
improved, Tubefeeds retried.
[**3-28**]: moved to different room with improved neuro status, med
list pared down due to polypharmacy; encephalopathy metabolic
workup negative, LFTs slightly elevated. Tolerated TCM overnight
with reasonable ABGs.
[**3-29**]: Neuro stable. Advanced tube feeds. D/C central line.
[**3-30**]: CT head normal, Tubefeeds switched to renal formulation,
replaced on vent for increased work of breathing.
[**3-31**]: (L) pleural tap with 500cc straw appearance fluid, mixed
metabolic and respiratory alkalosis, Methadone increased back to
20mg [**Hospital1 **] for suspected withdrawal, spiked Temperature and
pancultured, NGT output looks like tubefeed;thus tubefeeds held,
Hypernatremic 152 water deficit 3liter started on D5W 100 cc/hr
[**4-1**]: unable to tolerate TCM >2 hrs in AM, back on PS. TCM trial
again in evening, tolerated overnight. Hypernatremic, free water
deficit 4L, continue to replete with D5W. Also prerenal ARF on
top of the chronic renal insufficiency, with 2 episodes of SBP
80s, 2 liters LR total given, low rate LR infusion started, to
reassess in AM.
[**4-2**]: Continue tolerating TCM.
[**4-3**]: Retroperitoneal perforation with collection (air +
contrast) found, Tubefeeds held, meropenem started, PMV placed,
transfused 2 U PRBCs. NGT placed to suction, kept strict NPO.
[**4-4**]: New onset atrial flutter. Rate in 150s with hypotension on
phenylephrine drip, cardioconversion attempted converted to
sinus rythm, cardiac enzymes sent. Spiked fever 101.6 F; blood
cultures sent. Left sub clavian placed, TPN started. Required
fluid bolus overnight.
[**4-5**]: OR plan cancelled due to concern of Retroperitoneal
collection/cyst in direct connection with small bowel, would
hold off unless patient looks septic per Dr. [**Last Name (STitle) **]. Stable
overnight with intermittent agitation issues, improved with
fentanyl but later impoved with versed.
[**4-6**]: Placement of PMV continuously, subsequently PCO2 goes up,
he experienced increased work of breathing. US: Tumefactive
sludge in the gallbaldder,Dilated CBD.
[**4-7**]: c/o abdominal pain in PM relieved with burp/NGT placement
but pain on percussion & palpation on exam.
[**4-8**]: NGT clamp trial for 6hours, residual 0. Tolerate the
trach, restless overnight. Bolus of Lasix given with good
response for positive fluid balance.
[**4-22**]: Agitated, no acute events. Unable to wean vent. A-line out.
[**4-23**] Continued diuresis, pressure support weaned to 8, calcium
removed from TPN secondary to hypercalcemia.
[**4-25**]: IR procedure, 2 drains, tolerated trach mask for 24 hrs, up
in chair per PT, clearing own secretions.
[**4-26**]: Vancomycin held. No acute events.
[**4-27**] Vancomycin held, Pseudomonas resistant to Gentamycin, so
Amikacin started, PTH level <6.
[**4-28**] To OR for retroperitoneal tube exchange x 2, post-operative
hypotension improved with 1L NS and 2 units PRBCs, no pressors
required. Hourly drain irrigation and drainage system.
[**4-30**] No acute events.
[**5-1**] No acute events.
[**5-2**]: No acute events.
[**5-3**]: s/p OR with up-size of retroperitoneal drains,
retroperitoneal debridement.
[**5-4**]: no acute events.
[**5-5**] Normal saline and calcitonin for hypercalcemia, more
lethargic, not hypercarbic, decreased methadone to 2.5mg Q12.
[**5-6**]: Stopped flagyl. No acute events.
[**5-7**]: No acute events. Hypercalcemia being treated with
fluids/lasix.
[**5-8**]: Cdif sent, flexiseal placed.
[**5-9**]: s/p OR - changed superior chest tube, discontinued
inferior chest tube and placed penrose.
[**5-11**]: Brief self-limited episode of sanguineous NGT output, TPN
30kcal/2.0protein. No acute events.
[**5-12**] Sinogram - no isolated leak.
[**5-13**] Stopped dialysate infusions; transferred to the floor.
[**5-14**] NGT discontinued on transfer x2, replaced x2.
[**5-17**] CT done. Speech/swallow consult ordered. Discontinued
Amikacin per ID, given no contrast in RP.
[**Date range (1) 66375**] No events - cont TPN, NPO, NGT.
[**5-25**] OR for ex lap/LOA/fistula takedown/small bowel
resection/G-tube/J-tube.
[**5-26**] In SICU, transiently on pressors.
[**5-29**] Hypernatremia; more purulent output from [**Doctor Last Name **].
[**5-30**] [**Doctor Last Name 406**] with mild purulent outpt. D5W for hypernatremia.
Transferred back to floor. Dilaudid PCA for pain.
[**5-31**] HCT 25.0; transfused 1 unit PRBC with HCT increased to
28.9. PT/OT consulted.
[**6-1**] Still on TPN. OOB with PT. Overnight started trophic
tubefeeds at 10mL/hr.
[**6-2**] Started vancomycin. CT abd/pelvis done: peri-pancreatic
stranding, with collection adjacent to 2nd/3rd portion of the
duodenum; + 12x7x5cm fluid collection anterior in the abdomen.
[**6-3**] Started zosyn/flagyl. Tubefeeds held. IR drainage of
abdominal collection.
[**6-4**] Cont TPN with fat. On antibiotics. MOM down J-tube.
[**6-5**] IV to PO methadone, IV to PO Lopressor. Started trophic
tubefeeds via J-tube.
[**6-6**] Discontinued Vancomycin/Flagyl, cont Zosyn. On Tubefeeds at
10mL/hr. Was out of bed, standing with PT.
[**6-7**] On TPN. Foley removed, condom catheter placed.
[**6-8**] Tubefeeds increased to 20mL/Hr with good tolerability.
Methadone increased to 15mg TID via J-tube with improved pain
control.
[**6-9**] Experienced two epidodes nausea and vomitting 300-400mL
emesis; Tubefeeds held. KUB performed, which revealed multiple
air-filled loops of small and large bowel are
noted. There is no evidence of obstruction, free air, or
pneumatosis. G-Tube/J-tube study with contrast was performed;
revealed both were patent and placement was appropriate. Both
G-tube and J-tube placed to gravity drainage. NG tube placed.
[**6-10**] G-tube with minimal output, decreased from baseline.
Difficult to flush.
[**6-11**] G-tube repositioned in radiology with return of output.
[**6-12**] JP amylase sent.
[**6-13**] G-tube study with contrast performed; G-tube patent with
appropriate placement. Opened to gravity drainage. NG tube
discontined.
[**6-15**] Trophic tubefeeds restarted at 10mL/hr with good
tolerability. Allowed 1 cup jello daily.
[**6-16**] Tubefeeds increased to 20mL/Hr with good tolerability,
continued TPN
[**6-18**] Tube feeds stopped due to abdominal distention
[**6-19**] [**6-21**] continued TPN, J tube to gravity
[**6-22**] started linezolid/zosyn empirically for hypotension,
desaturations, NG tube placed, transferred to the ICU for
continued monitoring, PICC removed and cultured, central line
placed
[**6-23**] zosyn discontinued, meropenem started
[**6-24**] transfused 2 units RBC for low hematocrit, transferred to
the floor for monitoring. Continued linezolid and meropenem
until 6/18 per ID recommendations, continued TPN
[**6-26**] started tube feeds at 10cc/hr
[**6-27**] tube feeds advanced to 20 cc/hr
[**6-28**] Video swallow study performed; no aspiration
[**6-29**] Trach downsized to # 6 cuffless with cap trial. Diet sips
with single jello serving. G-Tube clamped. Tubefeeds advanced.
Continued on TPN.
[**6-30**] Continued on tubefeeds, TPN. Diet advanced to clears.
[**7-1**] Diet advanced to diabtetic dysphagia regular (thin liquids,
pureed solids). Continued on TPN. Tubefeeds advanced.
[**7-2**] Continued on TPN, tubefeeds advanced toward goal.
[**7-3**] Tubefeeds at goal of 80mL/Hr; well tolerated. Received
one-half bag TPN. New PICC placed; CVL discontinued. Re-screened
for rehabilitation. Restarted on Mirtazepine QHS. JP drain
advanced; new ostomy bag placed.
[**7-4**] Tubefeeds 3/4 Strength with 60g beneprotein additive at
goal of 80mL/Hr via J-Tube well tolerated. Receiving IV
antibiotics and medications via PICC. G-Tube clamped. Tolerating
diet with small PO intake. Weaned off TPN.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a diabetic,
soft dysphagia diet with fair PO intake and tubefeeds at goal
via the J-Tube with G-Tube clamped. JP drain cut with ostomy bag
applied around site; drain being slowly advanced. Ambulating
with assistance, voiding without assistance, and pain was well
controlled. The patient was discharged to a rehabilitation
facility. He will complete his current course of IV antibiotics.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Lisinopril 20mg PO daily, ASA 325mg PO daily, Atenolol 75mg PO
BID, Methadone 70mg PO daily.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb treatment Inhalation Q6H (every 6
hours) as needed for wheezing, SOB.
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-21**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
3. Methadone 10 mg/5 mL Solution Sig: 7.5 mL (15mg dose) PO TID
(3 times a day): Per J-Tube.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed for
SOB/wheezing.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-24**]
hours as needed for fever or pain.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation: Per J-Tube.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for fungus.
8. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Haloperidol 1-2 mg IV Q4H:PRN agitation
10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
12. Metoclopramide 10 mg IV Q6H
13. Ondansetron 4 mg IV Q8H:PRN nausea
14. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN pain
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime): [**Month (only) 116**] give via J-Tube if unable to tolerate PO.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily): [**Month (only) 116**] give via J-tube if unable to take
PO.
17. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 4 days: Last dose 6/19.
Disp:*16 Recon Soln(s)* Refills:*0*
18. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1)
Intravenous Q12H (every 12 hours) for 4 days: Last dose 6/19.
Disp:*8 doses* Refills:*0*
19. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
20. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units
Injection ASDIR (AS DIRECTED): As directed per Regular Insulin
Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
Radius speciality Hospital of [**Hospital1 392**]
Discharge Diagnosis:
Primary:
1. Retroperitoneal sepsis with enterocutaneous fistula.
2. Necrotizing pancreatitis.
3. Malnutrition and failure to thrive.
4. ARDS
5. Dysphagia
Secondary:
1. Chronic Pain
2. Ulcerative Colitis s/p colectomy at Outside Hospital 2/[**2180**].
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-28**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If JP drain in place, please keep to bulb suction.
*If tube to a drainage collection system, note color,
consistency, and amount of fluid in the drain. Call the doctor,
nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount increases
significantly or changes in character. Be sure to empty the
drain frequently. Record the output, if instructed to do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*JP draining into ostomy bag.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount
increases significantly or changes in character.
*Be sure to empty the ostomy bag frequently. Record the output,
if instructed to do so.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
*If the drain should become dislodged, or fall out, leave ostomy
bag over drain site to collect additional fluid, and call
clinic. The drain coming out dose not necessitate the patient to
return to the hospital, call the clinic for instructions first,
if it is after hours call the hospital number and ask for the
surgical resident on-call.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please call ([**Telephone/Fax (1) 81323**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 81324**] (PCP) in 2-3weeks.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2180-7-10**]
11:00 am ( Dr. [**Last Name (STitle) 468**] is covering for Dr. [**Last Name (STitle) **] )
Completed by:[**2180-7-4**]
|
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icd9cm
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[
[
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[
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icd9pcs
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[
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19971, 20047
|
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|
351, 716
|
20343, 20352
|
2281, 6257
|
24872, 25267
|
1421, 1439
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17775, 19948
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20068, 20322
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17657, 17752
|
20376, 21831
|
21847, 24849
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1454, 1454
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1468, 2262
|
232, 313
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744, 1149
|
1171, 1311
|
1327, 1405
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,270
| 150,850
|
34250+57910
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-8-7**] Discharge Date: [**2118-8-24**]
Date of Birth: [**2067-1-31**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
febrile neutropenia
Major Surgical or Invasive Procedure:
exploratory laparotomy
History of Present Illness:
Mr. [**Known lastname 40860**] is a 51 yoM with AML s/p 7+3 and HiDAC who never
achieved remission. He has been peristently pancytopenic, but
was sent home following admission [**Date range (3) 78859**] for fever and
neutropenia on levofloxacin, voriconazole and acyclovir. He
presented to the 7F outpatient clinic today ([**2118-8-7**]) for
clofarabine and ara-c and was found to have a temperature of
100.9. He was initiated on aztreonam and vancomycin after a CXR,
blood and urine cultures were obtained prior to antibiotics. He
also received his clofarabine in the outpatient clinic as
planned.
Mr. [**Known lastname 40860**] states he was feeling fine at home this morning and
had a temp of 98. Once he arrived at the hospital, he felt cold
and had chills. At that time his temperature was up. He reports
he's otherwise been feeling well, denies feeling sick. His
review of systems is positve for rhinitis, some pressure behind
the eyes. No headaches, cough, sore throat, nausea, vomiting or
diarrhea. He does report constipation x 4 days. He has not been
taking his stool softners. Denies rashes, skin lesions. ROS
reviewed in detail and is otherwise negative.
Past oncologic history:
Pt was admitted on [**2118-5-6**] for work-up of pancytopenia found
by his PCP. [**Name10 (NameIs) **] consult was obtained and he underwent a
bone marrow
biopsy on [**2118-5-8**] which showed AML. He was started on
induction 7+3 chemotherapy on [**2118-5-13**]. The pt's counts were
slow to return, and he eventually was started on GCSF. He had a
BM bx on [**6-20**] with persistent immature cells. Thus he underwent 5
cycles of HIDAC, which he tolerated well. On [**7-6**] he had a
repeat BM aspirate which revealed an empty marrow. His counts
remained low for an additional 4 weeks. He was finally
discharged home with close follow up on [**2118-7-23**] after undergoing
a bone marrow biopsy on [**2118-7-21**] which showed 20% immature cells
consistent with persistent AML. He initiated clofarabine/ara-c
on [**2118-8-5**].
.
Past Medical History:
Past oncologic history:
Pt was admitted on [**2118-5-6**] for work-up of pancytopenia found
by his PCP. [**Name10 (NameIs) **] consult was obtained and he underwent a
bone marrow
biopsy on [**2118-5-8**] which showed AML. He was started on
induction 7+3 chemotherapy on [**2118-5-13**] after a transthoracic
echo demonstrated a normal ejection fraction, and a tunnelled
line placed was placed on
[**2118-5-13**]. He initially tolerated this therapy very well,
however his course was ultimately complicated by the development
of severe mucositis, fevers and abd pain. All of his cultures
were negative in spite of an extensive work up. The pt's counts
were slow to return, and he eventually was started on GCSF. He
had a BM bx on [**6-20**] with persistent immature cells. Thus he
underwent 5 cycles of HIDAC, which he tolerated well. On [**7-6**] he
had a repeat BM aspirate which revealed an empty marrow. His
counts remained low for an additional 4 weeks. He was finally
discharged home with close follow up on [**2118-7-23**] after undergoing
a bone marrow biopsy - results pending.
.
Past Medical History:
- Morbid obesity
- Hypertension
- GERD
- Osteoarthritis
- Gout
- Iron deficiency anemia--underwent EGD and colonoscopy [**2-/2117**]
wihtout any clear abnormalities.
Social History:
Patient lives alone, was formerly married and is now divorced.
He has one son, aged 16, who lives with him. He works in heating
and air-conditioning repair with his cousin. [**Name (NI) **] denies any
tobacco or alcohol use; he formerly smoekd 1 PPD for about 17
years, quitting at age 29. He formerly drank heavily, but has
not drank for about three years. He has had prior asbestos
exposure.
Family History:
[**Name (NI) **] father died at age 64 in a motor vechicle accident.
His mother is in good health in [**Name (NI) 26692**]. He has 5
siblings (4 sisters and 1 brother), all of whom are in good
health. He does report a family history of diabetes. He denies
any family history of blood disorders or cancer.
Physical Exam:
VS: 115/70 HR 90 RR 20 T 98.2 (101.4 T max) 96-98% RA
GEN: NAD, A&Ox3, non-diaphoretic
HEENT: op without lesions, no erythema or exudates
CV: sinus, no mrg
PULM: CTAB, no dullness to percussion
ABD: soft, NTND, no organomegaly, no guarding or rebound
EXT: no edema, rashes
LN: no cervical, supraclavicular, axillary or inguinal
adenopathy
Line: mild oozing around insertion, no erythema
Pertinent Results:
[**2118-8-7**] 10:00AM BLOOD WBC-0.6* RBC-2.70* Hgb-8.2* Hct-21.4*
MCV-79* MCH-30.5 MCHC-38.6* RDW-13.2 Plt Ct-12*
[**2118-8-7**] 10:00AM BLOOD Neuts-82* Bands-0 Lymphs-14* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-2*
[**2118-8-7**] 10:00AM BLOOD Glucose-137* UreaN-18 Creat-1.0 Na-133
K-3.5 Cl-99 HCO3-25 AnGap-13
[**2118-8-7**] 10:00AM BLOOD ALT-16 AST-18 LD(LDH)-138 AlkPhos-146*
TotBili-0.8
[**2118-8-7**] 10:00AM BLOOD Albumin-3.4 Calcium-8.9 Phos-3.7 Mg-1.4*
.
CXR [**2118-8-7**]: In comparison with study of [**8-2**], there is little
change. The cardiac silhouette remains at the upper limits of
normal and there is some tortuosity of the aorta. Specifically,
no evidence of acute pneumonia.
Brief Hospital Course:
51 yoM with AML s/p 7+3 and HiDAC without remission and
persistent pancytopenia who presented with a fever to 100.9 (Tm
101.4) following clofarabine and AraC (given [**2118-8-5**]). Briefly,
he was admitted with neutropenic fevers and soon developed
significant abdominal pain and peritoneal signs. Abdominal CT
scan without significant abnormality. Typhlitis was considered
given neutropenia. He was taken to the OR on [**2118-8-13**] for
exploratory laparotomy; this showed viable intestine. He
continued on broad spectrum antibiotics and required ICU level
care and continued ventilator support. His course was further
complicated by hypotension requiring pressor therapy, acute
renal failure requiring initiation of continuous renal
replacement therapy, VRE bacteremia, and diffuse anasarca. He
was covered with meropenem, daptomycin, acyclovir, and
caspofungin. Transfusion support was continued.
On [**2118-8-22**] he was transfered from the SICU to the MICU team for
further management of his multiple medical issues. On [**8-23**], he
continued to decompensate requiring multiple pressors and
stopping of CVVH. Mean blood pressures remained at 60 despite
full pressor support. His oxygenation status also
intermittently worsened. His family was called to see him given
his declining condition. After discussion with his family, it
was decided for him to become DNR and ultimately comfort
measures. He died on [**2118-8-24**] at 8:41 am in the presence of
multiple close family members. Autopsy was declined.
Medications on Admission:
1. Lidocaine 5 %Adhesive Patch, 1 Topical QD
2. Morphine SR 15 mg One Tablet PO Q12H
3. Lorazepam 0.5 mg One Tablet PO Q6H as needed for nausea.
4. Lisinopril 30 mg PO DAILY
5. Omeprazole 20 mg Capsule PO once a day.
6. Metoprolol Tartrate 100 mg PO three times a day.
7. Zolpidem 5 mg Tablet One Tablet PO HS as needed for insomnia.
8. Acyclovir 400 mg PO three times a day.
9. Docusate Sodium 100 mg PO BID (not taking)
10. Senna 8.6 mg PO BID prn (not taking)
11. Bisacodyl 10 mg PO DAILY (Daily) as needed (not taking)
12. Ondansetron 8 mg Tablet PO Q8H as needed for nausea.
13. Voriconazole 200 mg PO Q12H
14. Morphine 15-30 mg PO Q4H as needed for pain.
15. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Appl Rectal TID
16. Glyburide 5 mg Tablet PO BID
17. Metformin 500 mg PO BID
18. Allopurinol 300 mg Tablet PO DAILY
19. Levofloxacin 750 mg PO daily
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
.
Neutropenia
Acute renal failure
Acute myelogenous leukemia
Respiratory failure
VRE bacteremia
Anasarca
Abdominal pain
Atrial fibrillation
Hypothermia
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Name: [**Known lastname 12707**],[**Known firstname **] J Unit No: [**Numeric Identifier 12708**]
Admission Date: [**2118-8-7**] Discharge Date: [**2118-8-24**]
Date of Birth: [**2067-1-31**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Addendum: Correct time of death was 8:51 am on [**2118-8-24**].
Discharge Disposition:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2118-8-24**]
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55,973
| 196,614
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4033
|
Discharge summary
|
report
|
Admission Date: [**2182-5-28**] Discharge Date: [**2182-6-5**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin /
metoclopramide / Doxepin
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
Chief Complaint: weakness, fatigue
Reason for MICU transfer: persistent hypotension, symptomatic
anemia
Major Surgical or Invasive Procedure:
Right IJ placed [**5-28**]
Right midline removed [**5-30**]
History of Present Illness:
Ms [**Known lastname 17759**] is a 61F with complex past medical history including
diabetes, status post renal transplant x3, status post pancreas
transplant, currently on peritoneal dialysis who presents with 2
days of severe weakness and fatigue. She was recently admitted
with hypotension, bacteremia,E coli sepsis and discharged on 14
day course of meropenem, of which she has five days left. She
reports cough x 1 day without sputum production. She reports one
episode of chest discomfort yesterday at rest with associated
lightheadedness and nausea but no vomiting. She is also
concerned about progressive increase in incoordination of hands
bilaterally over the past ~month such that she is unable to hold
a spoon to feed herself. She does admit to decreased oral intake
over the past few days as a result of this. She denies fevers,
chills, abdominal pain, shortness of breath (prior to
admission).
Upon admission to the ED, initial VS were 98 80 80/39 18 100%
4l. Blood pressure did drop temporarily to 70/30. She was given
1 L IV fluid with inadequate response. Given that patient is
ESRD on dialysis, discussed with nephrology who advised against
excessive fluid resuscitation as this has led to rapid
decompensated CHF in the past. A central line was placed, and
the patient was then started on Norepinephrine with adequate
response. Her CK MB and troponins were elevated at 48 and 2.56
respectively. Her EKG was not significantly changed from her
baseline. She was evaluated by cardiology who did not feel this
was reflective of ACS. Work up in ED also revealed anemia with
HCT of 22, down from 30 on recent discharge. In ED exam was also
notable for non-tender abdomen and brown stool guaiac negative.
She was typed and crossed for two units of blood and was started
on her first unit in the ED. During the infusion she experienced
some transient chest discomfort with no other symptoms, not felt
to represent transfusion reaction. Given recent admission for
sepsis, cultures were sent, CXR done, and patient broadened with
Vancomycin, already given meropenem at rehabilitation. Given
chronic low-dose steroids, she was given stress dose steroids
with MethylPREDNISolone Sodium Succ 125 mg IV x 1.
On arrival to the MICU, patient complained of some chest
discomfort and dyspnea during blood transfusion, w/o
palpitations, diaphoresis. She still c/o feeling extremely
fatigued and weak.
Review of systems:
(+) Per HPI
+ dryness and pain of finger tips, discoloration of nails
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies palpitations vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
arthralgias or myalgias. (anuric w/ about 100cc/day, no urinary
symptoms).
- Denies h/o PUD.
Past Medical History:
# Ischemic cariomyopathy/CHF; EF 35% in [**4-/2182**]-> 30% [**5-/2182**]
# h/o severe MR s/p repair in [**1-/2182**]
# NSTEMI [**7-/2181**], s/p [**Year (4 digits) **] to LAD [**9-/2181**]
# CABGX5 vessel [**1-/2182**]
# s/p renal transplant ([**2157**])
-- c/b chronic rejection
-- second renal transplant ([**2160**])
# s/p pancreas transplant
-- with allograft pancreatectomy ([**5-/2174**])
-- redo pancreas transplant ([**6-/2175**])
-- admission for acute rejection ([**7-/2180**]), resolved with
increased immunosupression
# Diabetes mellitus type I
-- c/b neuropathy, retinopathy, dysautonomia
-- no longer requires regular insulin after the pancreas
transplant, but has been given SS while on high-dose prednisone
in house
# Autonomic neuropathy
# Sleep disordered breathing
-- Unable to tolerate CPAP; uses oxygen 2L NC at night
# Osteoporosis
# Hypothyroidism
# Pernicious anemia
# Cataracts
# Glaucoma
# Anemia of CKD, on Aranesp in the past
# R foot fracture c/b RLE DVT
# Chronic LLE edema
# Recurrent E. coli pyelonephritis
# s/p anal polypectomy ([**5-/2176**])
# s/p bilateral trigger finger surgery ([**8-/2178**])
# s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
Social History:
Child psychiatrist, on disability. Has been in and out of
hospitals in the last 8 months. Was longest at [**Hospital3 **],
most recently at [**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **].
Mobile with wheelchair but unable to do transfers.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Father with MI at 57.
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: 106/58 88 93% on 2L NC 99.1F
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, left
pupilary abnormality (per patient chronic/known)
Neck: supple, difficult to assess JVP
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
LSB
Lungs: + crackles to mid-lung fields bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
[**Location (un) **]: cool, normal capillary refill, no cyanosis, [**12-24**]+ edema BL
LE
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
gait deferred, finger-to-nose impaired, ?asterixis vs tremor
Pertinent Results:
ADMISSION
[**2182-5-28**] 12:30PM BLOOD WBC-5.3 RBC-2.03*# Hgb-7.0*# Hct-22.0*#
MCV-109* MCH-34.6* MCHC-31.8 RDW-22.3* Plt Ct-205
[**2182-5-28**] 12:30PM BLOOD Neuts-81.1* Lymphs-9.4* Monos-6.2 Eos-3.0
Baso-0.3
[**2182-5-28**] 12:30PM BLOOD PT-13.2* PTT-29.3 INR(PT)-1.2*
[**2182-5-28**] 12:30PM BLOOD Glucose-86 UreaN-46* Creat-5.9* Na-134
K-3.5 Cl-96 HCO3-27 AnGap-15
[**2182-5-28**] 07:00PM BLOOD Calcium-7.9* Phos-5.4* Mg-1.6
.
PERTINENT
[**2182-5-28**] 07:00PM BLOOD Ret Man-3.5*
[**2182-5-28**] 07:00PM BLOOD ALT-8 AST-83* LD(LDH)-473* CK(CPK)-317*
AlkPhos-73 TotBili-0.4
[**2182-5-28**] 12:30PM BLOOD CK-MB-48* MB Indx-15.0*
[**2182-5-28**] 12:30PM BLOOD cTropnT-2.56*
[**2182-5-28**] 07:00PM BLOOD CK-MB-48* MB Indx-15.1* cTropnT-2.54*
[**2182-5-29**] 02:10AM BLOOD CK-MB-60* MB Indx-16.4* cTropnT-2.74*
[**2182-5-29**] 11:25AM BLOOD CK-MB-57* MB Indx-17.5* cTropnT-2.68*
[**2182-5-31**] 02:27AM BLOOD Albumin-2.4*
[**2182-5-30**] 02:30AM BLOOD Hapto-115
[**2182-5-28**] 11:09PM BLOOD Ammonia-15
[**2182-5-30**] 02:30AM BLOOD TSH-16*
[**2182-5-29**] 02:10AM BLOOD tacroFK-5.2
[**2182-5-31**] 05:31AM BLOOD tacroFK-4.2*
[**2182-5-28**] 08:45PM BLOOD O2 Sat-94
[**2182-5-28**] 01:59PM BLOOD Lactate-1.1
[**2182-5-29**] 06:14AM BLOOD Lactate-2.5*
.
DISCHARGE
[**2182-6-5**] 05:42AM BLOOD WBC-3.2* RBC-2.89* Hgb-9.4* Hct-29.7*
MCV-103* MCH-32.7* MCHC-31.8 RDW-23.8* Plt Ct-273
[**2182-6-5**] 05:42AM BLOOD PT-26.2* PTT-35.7 INR(PT)-2.5*
[**2182-6-5**] 05:42AM BLOOD Glucose-80 UreaN-52* Creat-5.9* Na-136
K-3.5 Cl-97 HCO3-31 AnGap-12
[**2182-6-3**] 06:15AM BLOOD ALT-4 AST-23 LD(LDH)-316* AlkPhos-69
TotBili-0.2
[**2182-6-3**] 06:15AM BLOOD Albumin-2.1* Calcium-7.6* Phos-4.8*
Mg-1.8
[**2182-6-5**] 05:42AM BLOOD tacroFK-4.1*
.
CXR [**2182-5-28**]
No significant interval change since [**5-19**] noting left basilar
opacity due to combination of pleural effusion with underlying
atelectasis and
possible consolidation.
.
CXR [**5-31**]
Increasing left greater than right pleural effusions, represent
residua of improved congestive heart failure.
.
ECHO [**5-30**]
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. LV
systolic function appears moderately-to-severely depressed
(ejection fraction 30 percent) secondary to extensive severe
inferior, posterior, and lateral wall hypokinesis/akinesis; the
apex is also hypokinetic. Mechanical dyssynchrony is present.
The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. A mitral valve annuloplasty ring is present. Severe
(4+) mitral regurgitation is present (after accounting for
acoustic shadowing from the mitral annuloplasty ring). The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2182-5-20**], the mitral regurgitation is significantly
increased, as is the pulmonary artery pressure.
.
CT Abd/Pelvis [**6-4**]
IMPRESSION:
1. No findings to explain patient's source of bacteremia.
2. Unchanged small left pleural effusion with compressive
atelectasis.
3. Unremarkable pancreatic transplant.
4. Appropriately positioned peritoneal dialysis catheter with
peritoneal
dialysate present.
Brief Hospital Course:
60 year old female with a complicated past medical history
including DMI, on peritoneal HD, s/p pancreas transplant, CHF,
and recent admission for GNR sepsis who presents with malaise,
weakness and refractory hypotension felt related to cardiogenic
shock in the setting of demand ischemia and volume overload.
# Hypotension: Patient presented to ED with generalized weakness
without focal complaints or findings. SBP in 80s, reaching as
low as 70 in ED. She was given 1L of fluid without much
improvement. She was started on Norepinephrine in ED with
improvement to near baseline SBP of 90s. Does report recent
decreased po intake due to generalized fatigue so possible that
she was volume depleted at onset. Recent admission with Ecoli
sepsis treated with meropenem, which patient was still taking on
admission and completed during this stay. CXR, blood culture,
midline tip, and peritoneal dialysis fluid samples were all
negative for infection. She was continued on levophed until [**5-30**]
when she was successfully weaned off. As no infectious source
was identified, cause of hypotension was felt to be cardiogenic
shock in setting of fluid overload (see below). Her blood
pressures remained near her baseline in the 90s-100s systolic,
occasionally dipping to the 80s after peritoneal dialysis
sessions. She was continued on her home doses of midodrine and
fludocortisone.
# Acute on Chronic Systolic and Diastolic CHF: It was felt that
the fluid patient received in the ED might have triggered an
acute exacerbation of heart failure. Echocardiogram showed
posterior/lateral/inferior/apical hypokinesis similar to prior
but w/ worsening MR and pulmonary hypertension. Elevated cardiac
enzymes on admission thought to be due to demand ischemia in
setting of hypotension and anemia rather than acute thrombus.
She noted symptoms of shortness of breath and orthopnea that
improved with fluid removal via peritoneal dialysis. She weighed
at 64.6kg at discharge.
.
# Coronary artery disease: Patient is s/p MI and CABGx5 [**2-3**]
(LIMA-LAD, SVG-D / OM1 / OM2 / PDA). She also has severe mitral
regurgitation s/p repair in [**2-3**]. Patient presented with
atypical chest pain and elevated cardiac enzymes peaking at 2.74
and 60. EKG was unchanged. Patient was evaluated by cardiology
in the ED who felt that her elevated cardiac enzymes were likely
secondary to some myocardial ischemia in the setting of
hypotension. Her plavix was discontinued as she had been
revascularized earlier this year. Her statin and home dose
aspirin were continued. She had no further episodes of chest
pain and her cardiac enzymes trended down.
# Anemia: Presnted with Hct lower than her baseline at 22.
Received 2.5 units over the course of her stay. Anemia not
consistent with hemolysis, B12 or folate deficiency. Iron
studies showed anemia of chronic disease. Colonscopy in [**2180**]
revealed normal colon to terminal ileum with small hemorrhoids.
Her epo dose was increased. Renal service recommended
transfusion for hematocrit <25. We discussed options for blood
transfusions as an outpatient - including follow up with
pharesis center at [**Location (un) 745**] Wellesly, which is close to her,
versus [**Hospital1 18**]. I spoke w/ the pharesis center ([**Telephone/Fax (1) **]) who
will need an outpatient provider (PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], nephrologist
Mark Willilam, etc) to fill out an order form for blood
transfusions. I emailed her PCP with this information at
discharge.
# Tremors: Patient with complaints of bilateral hand tremors
that have been intermittent over the past few months. Tremors
resolved after a few days. Patient had full use of her hands at
discharge.
# ESRD s/p failed renal transplants: Remained on peritoneal
dialysis with goal net negative over the course of her stay due
to her volume overload. Her discharge weight was 64.6kg. She was
continued her home medications.
#DM1 s/p pancreas transplant: She was given stress dose steroids
in the ED as she remains on low dose steroids chronically for
her graft. Her tacrolimus level was checked daily and her dose
was adjusted accordingly. She was continued on cellcept and
prednisone. She was discharged on 1.5mg tacrolimus twice a day.
# GNR Bacteremia: Noted on previous admission and was of unclear
source. Patient has had repeated episodes of bacteremia, usually
from different organisms but the possibility of suppressive
therapy has been brought up in the past. Infectious disease was
consulted who did not feel there was a particular organism that
could be targeted with suppressive therapy especially as patient
is largely anuric. She completed her fourteen day course of
meropenem during this stay. Surveillance blood cultures were
drawn after the completion of her course and were pending at
discharge. CT abdomen did not reveal any GI/GU occult source of
infection. She will follow-up with transplant infectious disease
as an outpatient.
# Diarrhea: Chronic. Improved with immodium. C diff negative
during this hospitalization.
# Afib: History of paroxysmal afib. Remained in sinus rhythm on
amiodarone. Warfarin was subtherapeutic initially but became
therapeutic at discharge on an increased dose of coumadin.
# Hypothyroidism: Noted to have elevated TSH to 41 and low T4
during last admission, so levothyroxine dose was increased to
125mcg with plan to repeat TSH in 6 weeks. Repeat TSH on [**2182-5-30**]
was improved to 16 so she was continued on this increased dose.
This could be contributing to her depressed mood. TSH should be
rechecked in 4 weeks as an outpatient.
# Glaucoma: Continued home eye drops and methazolamide
# Skin and Nails: Patient noted to have dry and scaling skin,
hyperkeratotic nails and hyperpigmented areas on fingertips that
are painful. Recent fungal cultures were negative. Dermatology
felt this was most likely fungal but also note she is on chronic
fluconazole therapy. They recommended vaseline for skin peeling.
# Depression: Previously was a high functioning psychiatrist but
feels she's had trouble with executive function and cognitive
slowing recently. She was seen by psychiatry who did not feel
she met criteria for depression. They felt she could benefit
from low-dose ritalin once her thyroid function is replaced
adequately and if it is felt to be safe relative to her cardiac
history.
.
TRANSITIONAL ISSUES
1. Would recommend weekly hematocrit and coordination with a
pharesis center for scheduled transfusions (coordinate with
patient's PCP or nephrologist)
2. She will continue to need weekly check of her tacrolimus
TROUGH and fax results to [**Hospital1 18**] to ensure it remains within the
4-7 range
3. Consider starting low-dose ritalin as an outpatient once her
thyroid function is repleted and if potential cardiac effects
are considered to be outweighted by potential benefits
4. She has outpatient follow-up with dermatology for nail
discoloration and discomfort
5. She has Outpatient follow-up with infectious disease
regarding suppressive therapy
Medications on Admission:
1. Acyclovir 400 mg PO Q12H
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Clopidogrel 75 mg PO DAILY
7. Creon 12 2 CAP PO TID W/MEALS
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
9. Fluconazole 100 mg PO MWF
10. Fludrocortisone Acetate 0.1 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 100 mg PO Q48H
13. Lanthanum 500 mg PO TID W/MEALS
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Methazolamide 50 mg PO TID
hold for sbp < 100
17. Midodrine 15 mg PO TID
18. Mycophenolate Mofetil 500 mg PO BID
19. Nephrocaps 1 CAP PO DAILY
20. Omeprazole 20 mg PO BID
21. PredniSONE 5 mg PO DAILY
22. Tacrolimus 1 mg PO Q12H
23. Warfarin 1 mg PO DAILY16
24. Lactaid *NF* (lactase) 3,000 unit Oral TID
25. Epoetin Alfa 20,000 UNIT IV ONCE Duration: 1 Doses
Please give [**5-24**]
26. Acetaminophen 325-650 mg PO Q6H:PRN pain
27. Simethicone 40-80 mg PO QID:PRN gas/bloating
28. Meropenem 500 mg IV Q24H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q12H
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Creon 12 2 CAP PO TID W/MEALS
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Epoetin Alfa 10,000 UNIT SC QMOWEFR Start: HS
9. Fluconazole 100 mg PO 3X/WEEK (MO,WE,FR)
10. Fludrocortisone Acetate 0.1 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 100 mg PO EVERY OTHER DAY
13. Lanthanum 500 mg PO TID W/MEALS
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
15. Levothyroxine Sodium 125 mcg PO DAILY
16. Methazolamide 50 mg PO TID
17. Midodrine 15 mg PO TID
18. Mycophenolate Mofetil 500 mg PO BID
19. PredniSONE 5 mg PO DAILY
20. Simethicone 40-80 mg PO QID:PRN gas
21. Cyanocobalamin 1000 mcg PO DAILY Start: In am
22. Loperamide 2 mg PO QID:PRN loose stools
23. Restasis *NF* (cycloSPORINE) 1 DROP OU [**Hospital1 **]
* Patient Taking Own Meds *
24. Lactaid *NF* (lactase) 3,000 unit Oral TID
25. Nephrocaps 1 CAP PO DAILY
26. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
27. Warfarin 1 mg PO DAYS ([**Doctor First Name **],MO,WE,FR,SA)
28. Warfarin 2 mg PO DAYS (TU,TH)
29. Tacrolimus 1.5 mg PO Q12H
30. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
Acute exacerbation of systolic heart failure
Hypotension
End-stage renal disease on peritoneal dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 17759**],
You were admitted to [**Hospital1 18**] because of low blood pressures and
low blood counts. You were given blood and your blood pressures
initially support from medications requiring monitoring in the
intensive care unit. You had some heart strain and your heart
was not pumping as well as usual. You improved after some fluid
was removed with dialysis. Please Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
The following medications were changed:
1. Increase your tacrolimus
2. Your warfarin dose was changed
3. Start taking Vitamin B12
Followup Instructions:
Department: TRANSPLANT
When: MONDAY [**2182-6-10**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2182-6-12**] at 9:30 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DERMATOLOGY AND LASER
When: THURSDAY [**2182-6-20**] at 11:00 AM
With: [**Doctor Last Name **],KATHEEN [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,200
| 105,357
|
8785
|
Discharge summary
|
report
|
Admission Date: [**2150-7-10**] Discharge Date: [**2150-7-22**]
Date of Birth: [**2067-2-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol / Warfarin
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
lower leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo f w/ a hx/of htn, OA and myelodysplastic syndrome who
presents with c/o severe right leg and knee pain since tuesday.
Pt was seen by rheumatlogy and was started on prednisode taper
and increased oxycodone frequency with no effect pt unable to
ambulate 2nd pain. Initially right foot pain sevearl weeks ago
with great two swelling; evaluated for gout and had uric acid on
[**6-11**] was 3.2. Seen by pcp who [**Name9 (PRE) 30692**] tramadol then pt
improved but pain returned. Pt seen by rheumologist who started
on prednisone, which has been tapering prednisone and now down
to 10mg/daily (although pt did not take for last few days b/c of
pain and associated nausea). Although foot pain improveed, pain
continued to increase in the R knee and lower leg over the last
3 days ago. Pt unable to weight bear (at baseline pt is abulator
w/out a walker since hip replacement). Pt says pain is like an
ache. Finally pain was intolerable despite oxycodone and
tramadol and pt was brought by family to ED.
.
In the ED, initial vitals were 98.2 103 140/59 18 97%. Patient
given 2 of morphine, 2 zofran and 650 tylenol. US showed right
DVT. She was started on lovenox; she has a warfarin allergy.
Patient discussed with BMT attending and she had refused
treatment for MDS. He recommended admission to medicine.
.
On arrival to the floor pt VS were stable 98.8 128/62 108 18
96%. Pt was having pain in the leg and appeared very
uncomfortable but otherwise had no other complaints.
.
Review of sytems:
(+) Per HPI feels hot but denies fever, chills, night sweets.
Does acknowledge nausea no vomitting which is associated with
pain. Has some constipation w/pain meds she's been taking for
leg.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea, or
abdominal pain. No recent change in bowel or bladder habits, no
blood or melena. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Right colon adenoCA in [**Month (only) 205**]/[**2146**] s/p right colectomy in
[**Month (only) **]/[**2146**]
- Myelodysplastic syndrome
- Hypertension
- Osteopenia
- Multiple thyroid nodules followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2177**]
- s/p TAH-BSO in [**2124**] d/t left ovarian cyst - a benign
cystadenoma
- s/p appendectomy
- s/p THR at [**Hospital3 **] Hosp [**Month (only) **]/[**2148**]
Social History:
She lives alone and is almost completely independent until
worsening of her pain two days ago. She has two daughters. She
endorses occasional ETOH, denies smoking.
ADLS: independent
IADLS: independent
Services at home: daughter helps with shopping
Assistive Device: none
Family History:
Brother who had leukemia and died at the age of 69. Two sisters
with breast cancer, diagnosed in their 80s. Brother with a
stroke, CAD, not premature. Mother with ?stomach cancer.
Physical Exam:
Physical Exam on Admission:
VS: 98.2 103 140/59 18 97%
GENERAL: Pt appears uncomfortable in bed. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No LAD. mucus membranes mildly dry
NECK: Supple, JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND, moderately obese abdomen. No HSM or
tenderness appreciated on exam. No abdominial bruits
appreciated.
EXTREMITIES: WWP, +2 pulses pedal and radial bilateral. R knee
appears moderately swollen. no erythema appreciated on R leg,
cord not palpated. R leg did not feel warmer than left. R Leg
held carefully by pt, painful to move.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Physical Exam on Discharge:
Pertinent Results:
LABS on day of Discharge:XXXX
.
.
[**2150-7-10**] 08:38AM BLOOD WBC-10.9 RBC-3.30* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.1 MCHC-34.3 RDW-16.5* Plt Ct-71*
[**2150-7-10**] 08:38AM BLOOD Neuts-56 Bands-6* Lymphs-18 Monos-7 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0 Blasts-10*
[**2150-7-10**] 08:38AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2150-7-10**] 08:38AM BLOOD Plt Smr-VERY LOW Plt Ct-71*
[**2150-7-11**] 06:04AM BLOOD PT-14.4* PTT-38.5* INR(PT)-1.2*
[**2150-7-13**] 10:24AM BLOOD Fibrino-1030*
[**2150-7-10**] 08:38AM BLOOD ESR-26*
[**2150-7-10**] 08:38AM BLOOD Glucose-148* UreaN-13 Creat-0.7 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
[**2150-7-13**] 03:18AM BLOOD ALT-16 AST-33 LD(LDH)-693* AlkPhos-241*
TotBili-0.7
[**2150-7-12**] 06:10AM BLOOD proBNP-1604*
[**2150-7-11**] 06:04AM BLOOD Calcium-8.4 Phos-1.9* Mg-2.1
[**2150-7-14**] 04:11AM BLOOD Albumin-2.6* Calcium-8.0* Phos-1.7*
Mg-2.4
[**2150-7-13**] 03:18AM BLOOD Hapto-470*
[**2150-7-10**] 08:38AM BLOOD CRP-225.3*
[**2150-7-12**] 09:20AM BLOOD Type-ART pO2-62* pCO2-32* pH-7.50*
calTCO2-26 Base XS-1
[**2150-7-12**] 09:20AM BLOOD Lactate-1.7
[**2150-7-12**] 09:20AM BLOOD O2 Sat-93
[**2150-7-12**] 09:20AM BLOOD freeCa-1.10*
[**2150-7-11**] 06:04AM BLOOD WBC-11.1* RBC-3.26* Hgb-9.5* Hct-28.6*
MCV-88 MCH-29.3 MCHC-33.3 RDW-16.4* Plt Ct-63*
[**2150-7-12**] 06:10AM BLOOD Neuts-37* Bands-22* Lymphs-24 Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* Blasts-11*
[**2150-7-11**] 04:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2150-7-11**] 04:08AM URINE Blood-TR Nitrite-NEG Protein-75
Glucose-NEG Ketone-50 Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG
[**2150-7-11**] 04:08AM URINE RBC-1 WBC-1 Bacteri-MOD Yeast-NONE
Epi-[**1-23**]
[**2150-7-11**] 04:08AM URINE CastGr-0-2
.
C diff negative x3
Blood cultures no growth to date
.
---------------
[**2150-7-10**] KNEE (AP, LAT & OBLIQUE) RIGHT X-Ray: There are no
signs of acute fractures or dislocations. There is no joint
effusion. No focal lytic or blastic lesions are present. No
significant degenerative changes are identified. Vascular
calcifications are seen within the medial soft tissues.
.
[**2150-7-10**] Bilateral lower extremity venous ultrasound:
Duplicated mid right superficial femoral vein, with DVT within
only one of these vessels. Otherwise unremarkable.
.
[**2150-7-10**] CXR (PA and Lat): Cardiomegaly is stable. Right lower
lobe atelectasis has almost resolved. Small left pleural
effusion with adjacent atelectasis has markedly improved. There
is no evident pneumothorax. There is S-shaped scoliosis. The
aorta is tortuous.
.
[**2150-7-12**] KUB: There is mild distention of multiple small bowel
loops that are air filled. There is some gas in the colon. There
are few air-fluid levels. Moderate-to-severe degenerative
changes are in the lumbar spine. There is a right hip
prosthesis.
.
[**2150-7-13**] CT Torso W/Contrast: 1. New multifocal airspace
opacities in the lungs, most severe in the right lower and
middle lobes, which may be infectious. However, a short interval
followup is suggested to assess for resolution.
2. Focal filling defect within a segmental branch of right upper
lobe,
suspicious for pulmonary embolism.
3. Left breast calcified nodule, which is unchanged from prior
study, and
mammographic correlation is again suggested.
4. Mild dilation of both small and large bowel loops, with
evidence of a
prior bowel resection. These findings could reflect an ileus.
5. Cholelithiasis, within a distended gallbladder. No
gallbladder wall
thickening or pericholecystic fluid.
.
[**2150-7-13**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>65%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension.
.
[**2150-7-13**] CXR: Low lung volumes with bibasilar consolidations,
right more than left, could represent atelectasis, however,
superimposed infection/aspiration is not excluded.
.
[**2150-7-13**] CT Head W/Out Contrast: IMPRESSION: Normal
non-contrast CT of the head.
.
[**2150-7-14**] LUE U/S: Large hematoma which extends from the
antecubital space distally through most of the forearm. No
discrete fluid collection identified.
.
[**2150-7-14**] RUQ U/S: Cholelithiasis with no sign of cholecystitis.
.
[**2150-7-21**] TTE: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad. IMPRESSION: Normal
biventricular systolic function. No vegetations seen.
.
[**2150-7-21**] CXR (PA and Lat): Consolidation largely in the right
middle lobe has improved since [**7-15**] though not entirely
cleared. Small bilateral pleural effusions are unchanged. Mild
cardiomegaly is longstanding. Left PIC catheter tip ends just
before the junction with the right brachiocephalic vein.
Brief Hospital Course:
Pt is a 83 yo f w/ a hx/of htn, OA and myelodysplastic syndrome
who presents with c/o severe right leg and knee pain since
tuesday. Pain became intolerable despite oxycodone and tramadol
and pt was brought by family to ED.
.
In the ED, initial vitals were 98.2 103 140/59 18 97%. Patient
given 2 of morphine, 2 zofran and 650 tylenol. US showed right
LE DVT. She was found to have a RLE DVT and started on lovenox.
On [**7-12**], she was transferred to the MICU after nausea, vomiting,
respiratory distress and multifocal pneumonia. Had CTA of torso
that showed a chronic PE and multifocal pneumonia and CT abdomen
showed ileus. Febrile on admission to MICU, was tachycardic to
the 130's.
.
MICU [**Location (un) **] COURSE
# Hypoxia: The original thought by the floor team prior to
transfer was PE given that the patient was admitted for DVT.
She was sent for a CTA which showed what was read as chronic PE
and a multifocal PNA. She was started empirically by the floor
team on vancomycin, cefepime, and flagyl for the PNA. This on
top of her chronic pleural effusion are the likely reasons for
her hypoxia. The patient had an ECHO done on the 23rd that
showed EF of >65% and trace MR. We continued the abx for her
PNA, and for double coverage of pseudomonas, we started
tobramycin. None of her Cxs grew anything. The patient did not
require intubation while in the ICU. For the PE and h/o DVT,
the patient had originally started lovenox, however given her
MDS and the dropping platelet count, we had to stop the
anticoagulation. She is now currently speaking with palliative
care as she has had some difficulty deciding on whether she
would like an IVC filter (as she currently cannot be
anticoagulated).
.
# Sepsis: Patient with fever, tachycardia, tachypnea, hypoxia
consistent with SIRS and likely source her MF PNA. Currently
hemodynamically stable, however, so no shock. We continued his
antibiotics as above. As his C-diff was negative, we d'ced the
flagyl on the day of transfer. She remains on tobramycin, vanc,
and CFP. Tobramycin peak and trough were ordered for her next
dose on the floor as this was requested by pharmacy. We
monitored the patient's lactate which remained normal. We did
not have to put in a CVL as she did not require pressors.
.
# Abdominal Distension: ABd ct read shows ileus vs partial
obstruction. Patient may also be impacted given stool in rectum.
Out of concern of abdominal infx, we checked lfts and lipase
which were wnl. Only an alk phos was elevated. We dropped an
NGT which was putting out up to 1L over 12 hours at first. The
output drastically reduced over 3 days, and we also prescribed a
very aggressive bowel regimen with colace, senna, lactulose PR.
We did not have to manually disimpact her. On the day of
transfer, her NGT output slowed, and we were able to clamp it.
She started on sips and tolerated that well. We started
lactulose via NGT. -We also checked a C-diff and started flagyl
empirically, but d/c'ed it after the c-diff was negative
.
# Tachycardia: Sinus tachycardia in setting of fever, right knee
pain, and PE.
We have been treating fever with Tylenol PO/PR. We did a TTE
which showed no RV strain. Finally, she is still deciding on an
IVC filter as above for possible future PE.
.
# MDS: Has 11 blasts (highest to date) and 22 bands concerning
for progression of disease. Dr. [**Last Name (STitle) 410**] has been following, and
as per his recommendations, we have restarted her on procrit.
There is ongoing discussion currently regarding possible
treatment of her MDS. Dr. [**Last Name (STitle) 410**] is following, and has been
speaking with her regarding her IVC filter as well. ideally,
her counts will recover and there will be a possibility of
restarting anticoagulation for her clots. We have had to
transfuse her on the unit (transfusion threshold of Hct of 21)
and received platelets x 1 for a PICC line placement, but our
threshold is 20.
.
ON RETURN TO THE FLOOR:
Once fever came down, tachycardia improved. Pt had BM in the
MICU with help of enemas. NG tube was removed and diet advanced.
Stopped methylnatrexone. For multifocal pneumonia, pt was on
vancomycin, cefepime, and tobramycin (planning for 10 day
course); tobramycin d/c'ed on [**7-17**]. MICU team spoke with Dr.
[**Last Name (STitle) 410**] who wanted a permanent IVC filter placed instead of
anticoagulation due to her thrombocytopenia and risk of
bleeding. Pt declined. Lovenox was stopped, and Procrit was
started. Palliative care was consulted regarding her refusal of
IVC filter. After further discussion w/patient, pt decided that
she wanted to be made DNR/DNI. She is not receiving any
anticoagulation given low platelets. She was given platelets for
PICC line placement and has been receiving them regularly along
with pRBC as needed. Leg pain was significantly improved and pt
was advancing diet as tolerated. Pt continued to spike low grade
fevers in the evenings which were controlled with tylenol but no
infectious source could be identified; may be related to MDS. Pt
also had diarrhea after agressive treatment of her ileus but
this improved with time and pt was C diff negative x3. Echo
showed no vegetations and nl EF. Repeat CXR showed improving
consolidation. Repeat blood cultures were negative. and final
repeat C diff was negative. A follow-up CT of the abdomen and
pelvis was declined by the patient.
.
After several family meetings with the pt, family members, Dr
[**Name (NI) 410**] (pt's hematologist), the geriatric fellow, social work
and primary medicine team the patient and her family decided to
return home with hospice services.
.
Pt initially was full code however, after speaking with
palliative care and other healthcare providers, she stated that
she wanted to be made DNR/DNI. This change was made in her code
status during this admission.
.
Medications on Admission:
Prednisone 10mg
Amlodpine 5mg
Oxycodone 2.5mg Q4 prn (for leg pain)
Procrit weekly
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. Zofran 8 mg Tablet Sig: 0.5 - 1 Tablet PO every eight (8)
hours as needed for nausea.
Disp:*8 Tablet(s)* Refills:*2*
3. Procrit Weekly
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary:
DVT
Fever
Chronic PE
.
Secondary:
Ileus
Multifocal pneumonia
Transfusion dependent Myelodysplastic Syndrome
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 severe left leg pain in
the knee area. You were found to have and blood clot in the vein
in your leg. Because you had an allergy to coumadin, you were
treated with lovenox. You also experienced recurring fevers
while you where in the hospital. Unfortunately you developed
severe constipation, nausea and vomiting in addition to
pneumonia. You were transferred for a few days to the intensive
care unit. You received antibiotics and blood and platelet
transfusions. Your symptoms improved and you were transferred
back to the regular medicine floor. You had a bout of
significant diarrhea concerning for infection but infection
workup was negative. You symptoms improved, you completed your
antibiotics and you were able to be discharged from the hospital
to home with hospice services.
.
The following changes were made to your medications...
- Please START taking Tylenol and Zofran as needed for nausea.
- Please STOP taking prednisone and amlodipine
- Please CONTINUE taking Procrit.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **] hematologist (Dr. [**Last Name (STitle) 410**] and other health care providers.
.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **] hematologist (Dr. [**Last Name (STitle) 410**] and other health care providers.
.
Department: GERONTOLOGY
When: TUESDAY [**2150-7-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"V45.79",
"511.9",
"416.2",
"285.9",
"V58.61",
"V45.72",
"733.90",
"574.20",
"998.12",
"V88.01",
"V10.05",
"287.5",
"372.30",
"564.09",
"715.90",
"238.75",
"V85.4",
"560.1",
"518.82",
"038.9",
"482.1",
"995.91",
"507.0",
"V43.64",
"E879.8",
"401.9",
"453.41"
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16825, 16883
|
10601, 16453
|
311, 317
|
17044, 17044
|
4448, 10578
|
18501, 18969
|
3188, 3373
|
16587, 16802
|
16904, 17023
|
16479, 16564
|
17227, 18478
|
3388, 3402
|
4429, 4429
|
253, 273
|
1842, 2400
|
346, 1824
|
3416, 4399
|
17059, 17203
|
2422, 2883
|
2899, 3172
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,169
| 140,364
|
17641
|
Discharge summary
|
report
|
Admission Date: [**2136-4-6**] Discharge Date: [**2136-4-12**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is an
81-year-old gentleman with complaints of low back pain and
leg pain from spinal stenosis. He also has grade I anterior
listhesis at L4 and L5.
PAST MEDICAL HISTORY:
1. Right carotid bruit which was asymptomatic.
2. IMI in [**2114**].
3. Coronary artery bypass graft in [**2127**] times four, stress
test since CABG with no ischemia.
4. Insulin-dependent diabetes.
5. Acid reflux disease.
6. Hepatitis C diagnosed in [**2115**].
PHYSICAL EXAMINATION: General: The patient was in no acute
distress. He was alert and oriented times three. Cardiac:
Regular rate and rhythm, II/VI systolic murmur. Lungs:
Clear. Abdomen: Soft, positive bowel sounds. Extremities:
No cyanosis, clubbing or edema. He has positive pedal
pulses. He has some mild scoliosis. He does have 2+ carotid
bruit on the right side. His gait is symmetric. He does
have decreased sensation to the bilateral feet.
HOSPITAL COURSE: The patient was admitted status post a
lumbar fusion at the L4-5 level without intraoperative
complication. Postoperatively, his vital signs were stable.
He was afebrile. His motor strength was [**4-18**] in his IPs,
quads, AT, and [**Last Name (un) 938**] on the left side. His hamstrings were 4+.
On the right side, he was 5- in the IP, 5 in the quad, 4 in
the hamstrings, 4 in the AT, and 4+ in the [**Last Name (un) 938**]. His reflexes
were absent. His toes were downgoing. His incision was
clean, dry, and intact.
He had a postoperative chest x-ray which was clear. His
laboratories remained stable. His cardiac status remained
stable. He did have actually a CSF leak at the time of
surgery and was on flat bed rest until [**2136-4-8**].
On [**2136-4-7**], he had an episode of hematemesis. GI was
consulted. The patient was placed back in the ICU. He had
an endoscopic examination of his abdomen which showed no
evidence of GI bleeding. It was thought that perhaps the
patient was having a small ileus. He was kept n.p.o., had a
NG tube to low wall suction that was removed on [**2136-4-9**]. He
began having clear liquids with no further episodes of
hematemesis or lower GI bleeding. His vital signs have
remained stable. His crit has been stable. His crit on
[**2136-4-10**] was 31.8 which was stable.
The patient was seen by Physical Therapy and Occupational
Therapy and found to require acute rehabilitation. His vital
signs have remained stable. His incision is clean, dry, and
intact. His drains were removed on postoperative day number
two and three. He had some slurred speech and some
somnolence on postoperative day number four. A head CT was
obtained which was negative for any stroke or hemorrhage.
His neurologic status has improved. He has been out of bed,
ambulating in his TLSO brace with Physical Therapy and his
vital signs have remained stable.
DISCHARGE MEDICATIONS:
1. Insulin sliding scale.
2. Nystatin swish and swallow for oral thrush.
3. Percocet one to two tablets p.o. q. four hours p.r.n.
4. Dulcolax sup q.d. p.r.n.
5. Heparin 5,000 units subcutaneously q. 12 hours.
6. Multivitamin one capsule p.o. q.d.
7. Pantoprazole p.o. q. 24 hours.
8. Ramipril 10 mg p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Chlorpromazine 25 mg p.o. t.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP: The patient will follow-up in ten days for staple
removal with Dr. [**Last Name (STitle) 1327**].
DISPOSITION: The patient was discharged to rehabilitation on
[**2136-4-12**].
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2136-4-12**] 10:34
T: [**2136-4-12**] 10:39
JOB#: [**Job Number 49122**]
|
[
"560.1",
"578.0",
"997.4",
"250.61",
"070.51",
"E878.8",
"998.89",
"724.02",
"997.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.07",
"45.13",
"99.04",
"77.79",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
2973, 3358
|
1051, 2950
|
594, 1033
|
301, 571
|
3383, 3847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,994
| 173,769
|
36577
|
Discharge summary
|
report
|
Admission Date: [**2159-12-4**] Discharge Date: [**2159-12-7**]
Date of Birth: [**2077-3-7**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Hemodialysis
History of Present Illness:
82 y/o male ESRD on HD, DM, HTN admitted after presenting with
shortness of breath to dialysis. He was unable to be dialyzed
and was sent to the ED.
While in the ED, he was noted to have elevated JVP, pulmonary
edema. In addition, he was noted to be 6.8kg above his dry
weight. Initial vital signs were T-97.1, HR-58, BP-110/58, SaO2-
100% on RA. He received 3 dosees of SL NTG, lasix 40mg IV x 1
and placed on a non-invasive breathing mask. His tidal volumes
were into the 150s and patient seemed to be in respiratory
distress. He was intubated and admitted to the MICU. Renal was
consulted for urgent dialysis. He underwent HD yesterday and
4.5L of fluid was removed. Patient was stablized and extubated.
He remained hemodynamically stable. Given his current condition,
he was transferred to the floor for further care.
Past Medical History:
ESRD
Diabetes
Hypertension
Hypercholesterolemia
Asthma/COPD?
Social History:
Lives with friend who takes care of him. has son who is also
involved in care. Denies ETOH or tobacco. Otherwise unable to
obtain
Family History:
NC
Physical Exam:
VITAL SIGNS:
T=98.9 BP=174/64 HR=80 RR=22 O2=100% on 2L
.
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing male in NAD
HEENT: JVD- 10cm. No LAD. Moist mucous membranes. Normocephalic,
atraumatic. No conjunctival pallor. No scleral icterus. OP
clear. Neck Supple, No LAD.
CARDIAC: Regular rate and rhythm. No m/r/g. Normal S1, S2. JVP=
10cm
LUNGS: Decreased breath sounds at bases with right-sided
crackles. Good air movement bilaterally- no signs of respiratory
distress at this time.
ABDOMEN: Obese. +bs, soft, NT/ND.
EXTREMITIES: 2+ edema in b/l LE. No calf pain. 2+ dorsalis
pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-29**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission labs
[**2159-12-4**] 12:30PM BLOOD WBC-8.8 RBC-4.18* Hgb-12.2* Hct-37.1*
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.9* Plt Ct-224
[**2159-12-4**] 12:30PM BLOOD PT-12.7 PTT-76.7* INR(PT)-1.1
[**2159-12-4**] 12:30PM BLOOD Glucose-172* UreaN-28* Creat-4.7* Na-137
K-3.8 Cl-97 HCO3-32 AnGap-12
[**2159-12-4**] 12:30PM BLOOD cTropnT-0.04*
[**2159-12-6**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2159-12-4**] 12:30PM BLOOD Albumin-3.4 Calcium-7.5* Phos-5.1* Mg-1.9
[**2159-12-4**] 12:36PM BLOOD Type-[**Last Name (un) **] pO2-113* pCO2-67* pH-7.29*
calTCO2-34* Base XS-2 Comment-GREEN TOP
[**2159-12-4**] 12:36PM BLOOD Glucose-166* Lactate-1.2 Na-134* K-3.8
Cl-93*
[**2159-12-4**] 09:27PM BLOOD Type-ART FiO2-40 pO2-79* pCO2-58* pH-7.42
calTCO2-39* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU
Discharge Labs
[**2159-12-7**] 06:00AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.0
[**2159-12-7**] 06:00AM BLOOD Glucose-38* UreaN-21* Creat-3.7*# Na-142
K-3.4 Cl-100 HCO3-32 AnGap-13
[**2159-12-7**] 06:00AM BLOOD WBC-6.9 RBC-4.21* Hgb-12.1* Hct-37.0*
MCV-88 MCH-28.8 MCHC-32.7 RDW-16.1* Plt Ct-207
TTE:The left atrium is normal in size. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. Dilated aortic sinus.
CXR [**2159-12-6**]:
Comparison is made with prior study performed a day earlier.
Improve left retrocardiac opacity consistent with improving
atelectasis, there are new plate-like atelectasis in the right
mid lung; right lower lobe aeration has also improved.
Cardiomediastinal contours are unchanged, small bilateral
pleural effusions are stable, there is no pneumothorax. Mild
pulmonary edema is stable.
Brief Hospital Course:
82yo male with ESRD on HD, HTN, DM2 admitted for shortness of
breath
1. Pulmonary Edema with acute on chronic diastolic heart
failure:
Patient admitted with SOB [**1-29**] pulmonary edema and volume
overload which improved with hemodialysis on his usual schedule.
Per discussion with renal, it is possible they were
underdialyzing him and he needs more agressive dialysis. He was
continued on his usual HD schedule here (T/Th/Sat) and was
extubated without difficulty and satting mid to high 90s on room
air at time of discharge. He had an ECHO which revealed "Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function and diastolic
dysfunction. Since he was mildly hypertensive, his [**Last Name (un) **] was
uptitrated. He was ruled out for MI. He should continue on low
salt cardiac diabetic renal diet to avoid issues with volume
overload in the future.
2. Respiratory Failure:
Improved as above with dialysis. He did not have any focal
infiltrates or fever to suggest leukocytosis. He was also given
albuterol and ipratropium nebs as needed for wheezing as he is
on Advair but he is unsure why he is on this medication.
3. COPD/Asthma:
Patient continued to wheeze during his admission. Unclear
pulmonary history and PCP was on vacation so we were unable to
obtain further information regarding his pulmonary status. He
was continued on advair and albuterol/ipratropium nebs.
4. Hypercholesterolemia: Continued Simvastatin at home dose
5. Hypertension: Continued amlodipine, labetalol, valsartan.
Patient on olmesartan at home but substituted for valsartan in
house. Valsartan increased to 160mg daily.
6. ESRD on HD: He was continued on his hemodialysis on
Tu/Thurs/Sat schedule.
7. Type 2 Diabetes Mellitus, uncontrolled and with
complications: Continue insulin + SS. Lantus dose decreased at
night for low blood sugar in am [**2159-12-7**]
8. Diarrhea: Pt was having loose stools on [**2159-12-7**]. C. diff
toxin was ordered but not sent. He should have C diff checked if
diarrhea recurs although he has not been on antibiotics here and
did not have a leukocytosis.
Medications on Admission:
NephroVites 1
Simvastatin 20 QHS
Trazadone 20 QHS
IC Amlodipine 10 Daily
Labetolol 600 [**Hospital1 **]
Olmesartan 20mg Daily
Renagel 400mg TID prior to meals
Lantus 8U daily
Advair
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q 24H (Every
24 Hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q4H (every 4 hours) as
needed for SOB, wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Olanzapine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. Insulin sliding scale
Please follow attached sliding scale. Fixed dose of lantus- 4U
every night
16. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Diastolic heart failure, End-stage kidney disease (on
hemodialysis)
Secondary: Diabetes Mellitus
Discharge Condition:
Good. Vital signs stable.
Discharge Instructions:
You were admitted to the hospital with shortness of breath.
While here, it was found that you were fluid overloaded for
unclear reasons. You underwent dialysis with an improvement in
your symptoms. An ultrasound of your heart showed mild
dysfunction. Because of this, it is important that you limit
your fluid and salt intake. Your symptoms improved and you did
well while here. You worked with physical therapy who
recommended that you should go to rehab when you got discharge
to build up strength. Upon discharge, you no longer complained
of respiratory problems.
The following changes were made to your medications:
1. Stop taking your trazadone
2. Decrease your lantus to 4U everynight
3. Please start taking famotidine 20mg by mouth every day
4. Please start taking ipratropium nebs every 6 hours as needed
for shortness of breath/wheezing
5. Please start taking albuterol nebs every 4 hours as needed
for shortness of breath/wheezing
6. Increase your dose of olmesartan to 40mg by mouth daily
7. Please take olanzapine 2.5mg by mouth twice a day as needed
for agitation
Followup Instructions:
Resume regular dialysis schedule on discharge
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 803**]
[**Last Name (NamePattern1) **], in [**12-29**] weeks. You can contact her at [**Telephone/Fax (1) 82786**]
Completed by:[**2159-12-8**]
|
[
"428.0",
"285.21",
"518.81",
"272.0",
"403.91",
"428.33",
"585.6",
"V45.11",
"250.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8871, 8941
|
4924, 7061
|
323, 349
|
9092, 9121
|
2391, 4901
|
10260, 10568
|
1450, 1454
|
7294, 8848
|
8962, 9071
|
7087, 7271
|
9145, 10237
|
1469, 2372
|
264, 285
|
377, 1202
|
1224, 1287
|
1303, 1434
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,763
| 165,811
|
51884
|
Discharge summary
|
report
|
Admission Date: [**2143-6-7**] Discharge Date: [**2143-6-11**]
Service: MICU
CHIEF COMPLAINT: Dyspnea.
HISTORY OF PRESENT ILLNESS: This is the fifth hospital
admission this year for this 79-year-old African American man
with end-stage chronic obstructive pulmonary disease.
Patient noted worsened dyspnea for the week prior to
admission; nursing home M.D. noted that it was acutely worse
two days prior to admission, and at that time increased his
prednisone dose from 50-80 mg q day, and increased his
albuterol and ipratropium nebulizer treatments to 4x a day.
Patient also reported increased cough productive of yellow
sputum.
At baseline, he is not dyspneic at rest when wearing oxygen,
although he is dyspneic with even minimal ambulation. He and
his family have noted a significant progressive decline in
his exercise tolerance during the past year.
On arrival, he appeared in respiratory distress. Blood
pressure 113/83, pulse 102, respirations 22, O2 saturation
98% on 100% nonrebreather.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease, oxygen dependent.
Recent FEV1 of 0.62 which is 22% of predicted, FVC of 1.99,
total lung capacity 106% of predicted.
2. Prostate cancer with bone metastases.
3. Chronic atonic bladder and is chronically catheterized.
4. Multifocal atrial tachycardia.
5. Renal mass. CT scan of the abdomen in [**2143-2-16**]
showed a large cystic mass with multiple septations and small
area of enhancement.
MEDICATIONS:
1. Prednisone 80 mg q day, day #3.
2. Albuterol and ipratropium nebulizers qid.
3. Atrovent two puffs q6h.
4. Ventolin 4 mg po qid.
5. Flovent two puffs [**Hospital1 **].
6. Protonix.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Divorced. He has several children who live
in the area. He quit smoking two years ago. Does not drink
alcohol. He has been living in the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing
Home Rehabilitation since discharge from [**Date range (1) 107423**] [**Hospital1 1444**] admission for chronic
obstructive pulmonary disease flare. Before then, he had
been living alone at home. He is a retired air conditioning
and heating plant operator.
PHYSICAL EXAM ON PRESENTING TO THE EMERGENCY DEPARTMENT:
Pulse 80, blood pressure 138/72, respirations 22, O2
saturation 98% on nonrebreather. General: Thin elderly man
appearing younger than his stated age, appearing in distress,
breathing with accessory muscles. Chest: Inspiratory and
expiratory wheezes bilaterally. Cardiovascular: Regular,
rate, and rhythm, no murmur. Abdomen: Soft, nontender,
nondistended with positive bowel sounds. Extremities: No
edema.
On admission, white blood cell count 14.6. Differential:
Neutrophils 87%, lymphocytes 9.8%, bands 0. Hematocrit 39.3,
platelets 203. Urinalysis: Yellow, hazy, specimen with
specific gravity of 1.021, large blood, positive nitrates,
moderate leukocyte esterase, 21-50 red blood cells, 21-50
white blood cells, and many bacteria.
Sodium 138, potassium 4.2, chloride 99, CO2 31, BUN 23,
creatinine 0.8, glucose 124, CPK 58, troponin less than 0.3.
Calcium 9.4, phosphorus 2.6, magnesium 1.9. Arterial blood
gas on [**2143-6-7**]: PH 7.38, pCO2 59, pO2 171. Blood cultures
taken on [**2143-6-7**] had no growth as of [**2143-6-11**]. Urine
culture [**2143-6-7**] showed mixed flora.
Electrocardiogram: Sinus tachycardia at 100 beats per minute
with a normal axis, slight ST depressions in V5 and V6.
Chest x-ray showed large lung volumes, no infiltrate or
effusion.
IMPRESSION, PLAN, AND HOSPITAL COURSE: A 79-year-old male
with end-stage chronic obstructive pulmonary disease
presenting with respiratory distress. Impression was chronic
obstructive pulmonary disease flare with possible upper
respiratory infection as precipitant given his reports of
increased sputum.
ISSUES:
1. Chronic obstructive pulmonary disease exacerbation: On
admission, he was started on high dosed intravenous steroids,
Solu-Medrol at 80 mg IV tid, and was given albuterol and
Atrovent nebulizer treatments every three hours. He
experienced subjective improvement in his symptoms daily,
although he continued to have wheezing and dyspnea on minimal
exertion, which was his baseline even on discharge.
On [**2143-6-10**], he was switched from IV steroids to oral
steroids, which was prednisone 60 mg [**Hospital1 **], and switched from
beta agonist and Atrovent nebulizers to inhaler treatments,
additionally a steroid inhaler was started. Subjectively
felt better over the next 24 hours, only requiring an
albuterol nebulizer treatment once.
Given his end-stage chronic obstructive pulmonary disease and
his dyspnea with almost any activity, the Intensive Care
Unit's attending pulmonologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**]
suggested that the patient may benefit from opioid treatment
to blunt his sensation of dyspnea and to improve his quality
of life. On discharge, the patient is to start MS Contin 15
mg [**Hospital1 **] and this can be titrated as needed. Of note, he will
need to start on a laxative regimen after starting the opioid
treatment.
His prednisone dose was decreased from 60 mg [**Hospital1 **] to 60 mg q
day on [**2143-6-11**]. Given that patient has some wheezing even
with high-dosed steroids, we suspect that he may not be very
steroid responsive. We will write for prolonged taper from
high-dosed steroids. He will continue on the beta agonist,
Atrovent, and steroid MDIs as an outpatient, and will
continue nebulizer treatments as needed.
He developed mild tachycardia and anxiety, and were given
frequent albuterol nebulizer treatments. As such, we did not
continue giving him oral albuterol as he had been receiving
prior to admission.
Patient is do not resuscitate/do not intubate. As of now, he
is willing to try noninvasive ventilation. Unfortunately,
given his end-stage lung disease, he is likely to have
recurrent hospitalizations in the future.
2. Urinary tract infection: Started on levofloxacin 500 mg q
day on [**2143-6-8**]; will complete last dose on [**2143-6-14**].
3. Atonic bladder: He remained on Foley catheter while
in-house.
4. Likely renal mass on CT scan in [**2143-2-16**]. The
patient would not be an operative candidate even if he had
renal cell carcinoma; no further workup is indicated at this
time.
5. Prostate cancer: He sees an oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Hospital1 69**] for Lupron injections
q3 months; last given in [**5-21**].
6. Disposition: To rehabilitation facility; will likely need
[**Hospital 4820**] nursing home placement thereafter as he is probably
too chronically ill to care for himself at home.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation.
2. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg q day, last dose [**2143-6-14**].
2. Protonix 40 mg q day.
3. Prednisone 60 mg po q day x1 week, then 40 mg po q day x1
week, then 20 mg po q day x1 week, then 10 mg po q day
chronically. The M.D. at the rehabilitation center will
likely need to titrate these doses based on the patient's
symptomatology.
4. Salmeterol discus one puff [**Hospital1 **].
5. Ipratropium MDI two puffs qid.
6. Flovent 110 mcg per puff two puffs [**Hospital1 **].
7. Albuterol nebulizer treatment q2-4h prn for worsening
dyspnea.
8. Ipratropium nebulizer treatments q4h prn for worsened
dyspnea.
9. MS Contin 15 mg [**Hospital1 **], hold for oversedation.
10. Colace 100 mg [**Hospital1 **], hold for loose stools.
11. Senokot two tablets q hs, hold for loose stools.
12. Please continue on [**12-20**] liters nasal cannula oxygen for
goal O2 saturation of over 90%.
DISCHARGE CONDITION: Stable.
FOLLOWUP: Please [**Name6 (MD) 138**] primary M.D., [**Doctor Last Name 5717**] at [**Telephone/Fax (1) 250**] to
schedule an appointment in [**10-7**] days. The patient already
has an appointment with his oncologist, Dr. [**Last Name (STitle) **] in
[**2143-8-19**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2143-6-11**] 14:23
T: [**2143-6-18**] 13:22
JOB#: [**Job Number 107424**]
|
[
"276.3",
"198.5",
"185",
"593.9",
"599.0",
"518.81",
"491.21",
"518.89",
"596.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7790, 8347
|
6790, 6874
|
6897, 7768
|
3594, 6769
|
105, 115
|
144, 1015
|
1037, 1708
|
1725, 3576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
188
| 150,463
|
20257
|
Discharge summary
|
report
|
Admission Date: [**2157-11-17**] Discharge Date: [**2157-11-20**]
Date of Birth: [**2105-5-18**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman
with hepatitis C cirrhosis, hepatocellular carcinoma who had
an orthotopic liver transplant in [**2157-1-6**]. The
patient has recurrent cirrhosis. Had a liver biopsy done on
the 12th. He developed abdominal pain and hypotension. He
received Demerol and Xanax as premedication. His blood
pressure prior to the procedure was 126/65. His heart rate
was 60. The biopsy was done, and the patient was taken to the
daycare area. He stated that he was sleeping in the recovery
area; and he woke up about an hour and a half after the
procedure with abdominal pain, stabbing in quality, primarily
in the right upper quadrant and right mid abdomen. He
developed some lightheadedness, some nausea and some
diaphoresis. His blood pressure was rechecked and found to be
90/60 with a heart rate of 75. His oxygen saturation was 98%
on room air. He had no vomiting, no chest pain, no shortness
of breath. His labs demonstrated a hematocrit of 29.3, which
was down from 35.5 on the day prior. Two large-bore IV's were
placed, and he was taken to the CT scanner and transferred to
the medical ICU for close monitoring.
PAST MEDICAL HISTORY: Consistent with cirrhosis, hepatitis
C, hepatocellular carcinoma. He had RFA x 3. He had a liver
transplant in [**2157-1-6**]. He has recurrent hepatitis C
after transplant. He has steroid-induced diabetes which is
now improving. He is status post appendectomy, status post
tonsillectomy. He carries a diagnosis of hypertension. Status
post cervical laminectomy, a right forearm ORIF, a bone graft
was taken from hip to the elbow for that surgery. Status post
knee surgery and chronic lower back pain.
ALLERGIES: He has an allergy to CODEINE, for which he gets a
rash.
OUTPATIENT MEDICATIONS: He takes Bactrim 1 pill daily,
Protonix 40 mg p.o. b.i.d., Percocet p.r.n. for pain, Prograf
0.5 mg p.o. b.i.d., ribavirin 200 mg p.o. b.i.d., interferon
135 mcg subcutaneously weekly (his last dose was on [**2156-11-13**]), atenolol 50 mg daily, Lasix 20 mg b.i.d., Neupogen
300 mg subcutaneously each week (his last dose was [**11-10**]), Procrit 40,000 units subcutaneously (his last dose was
[**2157-11-11**]). He also takes Paxil 10 mg daily.
SOCIAL HISTORY: He is a __________ . He is currently not
working. He is married. The patient's wife is very active in
his care. He denies any alcohol. He has a positive tobacco
history; 2 packs per day x 30 years, but he quit before his
liver transplant. He is not using IV drugs.
FAMILY HISTORY: His father has renal failure. His mother has
hypothyroidism.
PHYSICAL EXAMINATION: His vitals is 96.1 for a temperature,
his heart rate is 65, his blood pressure is 115/67, his
respiratory rate is 16, he is [**Age over 90 **]% on room air. He is lying
in bed in no acute distress. His skin has multiple tattoos.
There is no jaundice. His head, eyes, ears, nose, and throat
are PERRLA. His sclerae are anicteric. His oropharynx is
clear. His membranes are moist. He has no jugular venous
distention. His chest is clear to auscultation but has poor
respiratory effort. Cardiovascular; he is regular rate and
rhythm. His abdomen; he has a Chevron scar. His bowel sounds
are positive. He is nondistended. He has mild tenderness with
percussion. He has diffuse tenderness with moderate palpation
that is worse in the right upper quadrant with rebound and
guarding. The patient neurologically is somnolent but easily
arousable. He is awake, alert, and oriented x3. He has slight
asterixis. His upper and lower extremities strength is
grossly intact.
IMAGING STUDIES: His CT abdomen and pelvis showed new
hemoperitoneum, new increased ascites, a stable fluid
collection and hepatic fissure and porta hepatis.
BRIEF REVIEW OF HOSPITAL COURSE: The patient - as is
mentioned before in the HPI - was transferred to the medical
ICU. He was transfused 2 packed red blood cells, platelets
and fresh frozen plasma. He was to have his hematocrit
checked q.6h., and he was also given dDAVP. At approximately
6:15 on the night of [**11-17**], the transplant surgery
service was consulted. The patient had some right upper
quadrant tenderness without distention and without
peritonitis. He was transferred to the transplant surgery
service for serial hematocrit's, serial exams with platelets.
At the time of transfer, the patient's hematocrit had gone
from 27 to 29. He had already received 2 units of packed
cells and 2 units of FFP. His hematocrit seemed to be stable.
On hospital day #2, the patient reported he was doing better.
He was generally without complaints. His hematocrit was
stable; it was 30.2 that day. His INR was also stable at 3.1.
The abdomen remained somewhat tender, especially in the right
upper quadrant. The plan was to restart the patient's home
doses of medications, to monitor his hematocrit and transfuse
him liberally in the event that he needed transfusion. The
hepatology service was also following the patient along with
the medical team. On hospital day #3, the patient was
transferred to the floor. His Foley was discontinued. His
oxygen was discontinued. All his home medications were
restarted. His hemoglobin and hematocrit continued to be
followed very closely. The transplant surgery team was
managing the patient's immunosuppression medications.
DISCHARGE DISPOSITION: On hospital day #4, the patient was
discharged to home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS: Bleed after liver biopsy.
DISCHARGE MEDICATIONS: The patient was to restart his prior
home medications. The patient was given Percocet 5/325; he
was dispensed 60 tablets. He was to take that medication q.4-
6h. for p.r.n. pain. He was also given atenolol 50 mg p.o.
daily; he was dispensed 30 tablets and given 2 refills. He
was also given tacrolimus 0.5 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS: He was to follow up in the
transplant surgery clinic for routine laboratory information.
The patient was also to follow up with Dr. [**First Name (STitle) **] in 1 to 2
weeks in order to have a follow-up appointment to evaluate
him and make sure he was doing okay.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 18027**]
MEDQUIST36
D: [**2157-12-16**] 10:48:37
T: [**2157-12-16**] 11:37:24
Job#: [**Job Number 54383**]
|
[
"401.9",
"E878.0",
"E878.8",
"996.82",
"070.54",
"571.5",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"99.04",
"99.07",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
5489, 5546
|
2689, 2751
|
5651, 5979
|
5600, 5627
|
3930, 5465
|
6004, 6540
|
1940, 2389
|
2774, 3736
|
185, 1320
|
1343, 1915
|
2406, 2672
|
5571, 5578
|
3754, 3912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,537
| 131,447
|
89
|
Discharge summary
|
report
|
Admission Date: [**2186-2-4**] Discharge Date: [**2186-2-21**]
Date of Birth: [**2126-9-17**] Sex: F
Service: NEUROLOGY
Allergies:
Haldol / Prozac / Paxil / Sinemet Cr
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
FTT
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
The pt is a 59 year-old right-handed with progressively
worsening stiffness, weakness, and dysarthria since [**2183**] who is
sent in from her rehab for generalized weakness , decline and
difficulty eating. The patient is followed by Dr. [**First Name (STitle) 951**] in the
movement disorders division who notes an extensive negative
workup in his most recent assessment of [**2186-1-10**] (see below).
Per
the record the stiffness started after a fall on ICE in [**2183**].
She
was admitted 7/21-26/07 for left leg dystonia. Possible
etiologies considered at that time included hereditary spastic
paraparesis, Parkinsons, and multiple systems atrophy. Little
evidence could be found for any of these disorders.
An new EMG today demonstrated a generalized, moderately severe,
chronic and ongoing disorder of motor neurons or their axons.
The patient has been on tizanidine, flexeril, baclofen, sinemet,
and artane - none with particularly significant effect.
Past Medical History:
depression,
rotator cuff injury,
osteopenia,
colectomy,
appendectomy
Per Dr.[**Name (NI) 1033**] [**2186-1-10**] note:
"Extensive prior evaluations were summarized in my note from [**6-11**], [**2185**], including multiple brain and spine imaging studies
that
have failed to yield an explanation for her symptoms. She also
was admitted. She has had negative HTLV 1 and 2 testing,
negatively glutamic acid decarboxylase antibodies, negative
spinal fluid analyses including absence of oligoclonal bands,
normal ceruloplasmin, negative RPR, negative Lyme serology,
negative [**Doctor First Name **], rheumatoid factor, and HIV test. EMG also was
reported to be normal in 08/[**2185**]. She was admitted in [**2185-7-24**]
with increased mobility difficulties. The additional evaluation
did not reveal a clear etiology. They initiated a trial of
tizanidine, and this may have helped somewhat. They also reduced
her Flexeril dose."
Social History:
Ms. [**Known lastname 1034**] currently is living at the [**Hospital 745**] Healthcare
Center nursing home.
Family History:
Notable for arthritis of the spine in her father
who also had limited use of one arm when he was older, but the
specifics again are difficult to clarify. She also has a son
with "arthrogryposis" who is in a wheelchair.
Physical Exam:
Vitals: T:98 P:96 R:18 BP:118/70 SaO2:95%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: edema in the lower extremities bilaterally, 2+
radial, pulses.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: The patient regards the examiner and carries
papers with sheets of words that she points to in order to
communicate. She has another sheet with the alphabet on it that
she uses to spell out her words. She is able to communicate this
way however slowly. She indicated that she had heartburn. She
follows commands. Her responses to yes/no questions were correct
with vibration (versus not) of the tuning fork.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk.
VFF to confrontation. There is no ptosis bilaterally.
Funduscopic
exam was limited as the patient kept blinking and turning away.
EOMI without nystagmus. Normal saccades. Facial sensation intact
to pinprick. No facial droop, facial musculature symmetric.
Hearing intact to finger-rub bilaterally. Palate elevates
symmetrically. 5/5 strength in trapezii and SCM bilaterally.
Tongue protrudes only minimally and is very slow from side to
side.
-Motor: Right upper extremity more mobile than left. Right upper
extremity is spastic. Left upper extremity is hypertonic and
flexed. Bilaterally lower extremities are extended even at the
ankle. They are extremely hypertonic. She can move both lower
extremites, but only at the hips and then only minimally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout.
-Coordination: FNF was slow but smooth and accurate with the
RUE.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
Plantar response was extensor bilaterally.
-Gait: unable to walk.
Pertinent Results:
Laboratory Data:
141 104 12 AGap=12
----I----I----<120
4.1 29 0.5
Ca: 9.7 Mg: 2.4 P: 3.2
14.9
3.5>---<207
42.4
UA Negative for infection.
Radiologic Data:
EMG:IMPRESSION:
Abnormal study. The electrophysiologic findings are most
consistent with a generalized, moderately severe, chronic and
ongoing disorder of motor neurons or their axons. The findings
do
not support stiff-person syndrome or dystonia.
CXR:IMPRESSION: No acute cardiopulmonary process detected.
LENI: NO DVT in LLE.
VIDEO SWALLOW: IMPRESSION: Intermittent aspiration with thin
barium.
G-tube placement:
IMPRESSION: Successful percutaneous gastrojejunostomy tube
placement. The tube is now ready for use.
PLAN: The T-fastener skin sutures (green-colored sutures) can be
cut and released in [**8-3**] days (ON [**2-25**]).
Brief Hospital Course:
Ms. [**Known lastname 1034**] is a 59-year-old woman who was admitted for
further evaluation of her chronic progressive movement disorder.
Based on her exam, which with her progression by the time of
this admission showed mixed upper and lower motor neuron signs,
and based on her EMG on the day of admission showing motor
neuron disease, she was diagnosed with amyotrophic lateral
sclerosis (ALS).
1. ALS. She was set up to follow up in the [**Hospital **] clinic. After a
pulmonology consult, it was seen that she did well with her
respiratory status when sitting upright during the day, but has
paradoxical breathing at night. She was transferred for one
night to the ICU for BiPAP titration, and she should now use
this at night.
2. Dysphagia. She passed a swallow eval, but was given a PEG for
supplemental nutrition and with the expectation that her
dysphagia will progress. She can take some nutrition by mouth
and is getting tube feeds as in the discharge instructions.
*** The T-fastener skin sutures (green-colored sutures) can be
cut and released in [**8-3**] days (between [**2-25**] and [**2-28**]). ***
3. Spasticity. She was started on tizanidine (Zanaflex) and
Flexeril for painful spasticity, and was given a Lidoderm patch
for the pain. This did improve her, though she remains highly
spastic.
4. Anxiety. Psychiatry was consulted for her anxiety and
recommended Ativan as ordered (with caution for her respiratory
status) and Buspar, in addition to continuing her Lexapro.
5. CODE STATUS: After length discussions with her, she decided
to be a DNR/DNI.
Medications on Admission:
MVI
B12 100mcg daily
Zanaflex 2-mg qam 4-mg qhs
Celebrex 100 mg twice each day
Metamucil [**Hospital1 **]
Detrol LA 2-mg [**Hospital1 **]
COlace 100 [**Hospital1 **]
Maalox 30ml daily
Baclofen 20mg TID
Senna 2 tabs qhs
Ambien 1 qhs
Fosamax qmonday
Lidoderm patch 12hours on 12hours off
Lexapro 30 daily
Tyelnol 325-650 PRN
Ativan 0.5mg PRN anxiety
Flexeril PRN spasms
meclizine PRN dizzyness
Lacutlose PRN
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Psyllium Packet Sig: One (1) Packet PO BID (2 times a
day).
4. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Thirty (30) ML PO DAILY (Daily).
6. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY. (): On left
hip: on 12 hours, then off 12 hours.
11. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO SEE BELOW ():
Give at 4 am, 6 am, 10 am, 2 pm, 6:30 pm, 10:30 pm.
13. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-25**] Sprays Nasal
QID (4 times a day) as needed.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
16. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
17. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
18. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
19. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) INH Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
21. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety: Hold for RR < 12.
22. Tizanidine 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
23. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection DAILY (Daily).
24. Buspirone 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
25. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary:
Amyotrophic Lateral Sclerosis
Secondary Diagnosis:
Dysphagia
Urinary Tract infection
Depression
Anxiety
Spasticity
Discharge Condition:
Stable, non-ambulatory, able to tolerate thickened POs but has
PEG for supplemental nutrition. On Bipap. Neuro exam notable for
severe pseudobulbar palsy leading to anarthria and dysphagia,
tongue fasciculations, atrophy of hands, diffuse weakness,
severe spasticity of LEs.
Discharge Instructions:
Ms. [**Known lastname 1034**], you were admitted to the hospital for progressive
weakness. You have been diagnosed with Amyotrophic Lateral
Sclerosis based on your clinical history and your most recent
EMG.
It has been recommended by the pulmonary doctors that [**Name5 (PTitle) **]
continue using BiPAP at night to help preserve your respiratory
function. Please continue to use BiPAP.
If any of your symptoms worsen in any way please contact your
physician or come to the emergency room.
Followup Instructions:
Please follow up with the following appointments:
1. [**Hospital **] CLINIC Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 1038**], M.D.
Phone:[**Telephone/Fax (1) 558**]
Date/Time:[**2186-3-8**] 11:00
2. Provider: [**Name (NI) 1039**] HARRIER, PT Date/Time:[**2186-3-8**] 1:00
3. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1040**]
Date/Time:[**2186-5-19**] 1:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
Completed by:[**2186-2-21**]
|
[
"786.09",
"787.20",
"783.7",
"599.0",
"335.20",
"300.00",
"311",
"309.81",
"344.00",
"733.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"93.90",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
9876, 9953
|
5595, 7173
|
302, 317
|
10122, 10398
|
4766, 5572
|
10939, 11577
|
2408, 2629
|
7630, 9853
|
9974, 10014
|
7199, 7607
|
10422, 10916
|
3599, 4747
|
2644, 3156
|
258, 264
|
345, 1312
|
10035, 10101
|
3171, 3582
|
1334, 2266
|
2282, 2392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,078
| 128,044
|
28893
|
Discharge summary
|
report
|
Admission Date: [**2159-10-22**] Discharge Date: [**2159-11-16**]
Date of Birth: [**2116-10-21**] Sex: M
Service: PLASTIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 26411**]
Chief Complaint:
Left knee question osteomyelitis, left knee osteoarthritis.
Major Surgical or Invasive Procedure:
1. Left knee proximal tibia open biopsy.
2. Left knee antibiotic spacer.
3. Transfer of free anterolateral thigh flap from the right
thigh to the left knee with microvascular anastomosis.
4. Split-thickness skin grafting of right thigh donor site.
5. Partial closure of left knee arthrotomy.
History of Present Illness:
43 year old male with a complex orthopedic history. In [**8-/2156**] he
suffered a complex proximal tibia fracture requiring multiple
surgical procedures. On [**2156-9-13**] he had an ORIF with external
fixator and then a split thickness skin graft. The external
fixator was removed in [**10-2**]. The pt continued to have pain and
a CT scan noted a nonunion along the medial side of the tibial
plateau fracture and pt underwent repair in [**2157-6-26**] with ORIF
with iliac crest bone graft, removal of deep hardware and
placement of a medial proximal tibial locking plate applied to
the medial tibia over the nonunion site with a total of 8
locking screws. Due to continued complaints of pain, in [**Month (only) 958**] of
[**2157**], he underwent surgical lysis of adhesions with a medial and
lateral meniscectomy. This surgical intervention did not help
and patient continued to have pain localized to the left leg,
both medially and laterally in the region of the plate so he
underwent hardware removal on [**2158-6-23**]. An intraop tissue sample
was sent from the L. tibia which grew rare coag negative staph.
At this time, ID got involved and recommended no antibiotics and
watchful waiting.
Patient continued to be followed in both ID and [**Date Range **] clinics
regularly. On [**2159-1-1**], pt underwent a bone scan that showed mild
uptake in the L. knee. He then had a follow up tagged WBC scan
that showed focal uptake of tracer in the lateral aspect of the
proximal left tibia in region of previous MDP uptake -
consistent with osteomyelitis. He was seen back in [**Hospital **] clinic on
[**2159-3-14**] at which time they discussed case with Dr. [**Last Name (STitle) 5322**],
orthopedics, and agreed for repeat tagged WBC scan in upcoming
months and to monitor his inflammatory markers. The pt followed
up with Dr. [**Last Name (STitle) 5322**] on [**2159-8-29**] for his ongoing chronic knee pain
at which time operative options were discussed. Patient decided
on total knee replacement due to his unbearable knee pain. ID
recommended that tissue be sent from the OR and if there was
growth of CoNS, he would be treated aggressively with 6-8 weeks
of IV abx and likely oral regimen following.
The patient came in [**2159-10-22**] and was admitted to the plastics
surgery service for aLeft knee proximal tibia open biopsy, Left
knee antibiotic spacer,Transfer of free anterolateral thigh flap
from the right thigh to the left knee with microvascular
anastomosis, Split-thickness skin grafting of right thigh donor
site, and partial closure of left knee arthrotomy.
Past Medical History:
Hypertension
Gout
GERD
Mild asthma
s/p motorcycle accident with multiple left leg fractures ([**9-2**])
Previous Surgeries:
Umbilical Hernia Repair
Pt reports a history of approx 15 operations on L leg including:
LLE External Fixation, release compartment syndrome
Open reduction, internal fixation left proximal tibial nonunion
with iliac crest bone graft [**2157-7-6**]
STSG Left Lower Extremity
Left knee arthroscopic partial medial and lateral
meniscectomy [**3-4**]
Removal of hardware [**2158-6-23**]
Social History:
+ETOH
denies Tobacco/Street drugs
***Has had ongoing issues with narcotics and pain management
since the accident in [**2155**]. [**Hospital1 18**] made many attempts to wean
him off of pain meds but patient unable to do so. He was
referred to Pain Clinic [**2158-3-14**]. He was eventually referred
to pain clinic closer to where he lives. Of note, the patient
has had a history of narcotic contract violations in the past at
Integrated Pain Clinic in [**Location (un) 5450**], [**Location (un) 3844**]. He was
terminated from their clinic on [**2159-2-23**]. He did
receive opioid medications on [**2159-9-17**], from Dr. [**First Name (STitle) 1075**].
Family History:
n/a
Physical Exam:
From Preop PE:
General: Well groomed, limping into exam room
Psych: alert and oriented x 3, speech clear, no tremors, PERL
3mm bil
Dental: cracked tooth left lower back
Head and neck ROM: Limited
Heart: ns-1, s2, s-3 s-4 no murmurs, no carotid bruits bil
Lungs: CTAB
Abdomen: rounded, soft, non-tender, no masses
Extremities: +dp bil, full knee flex./ext right, limited left
knee flex., limited ROM left hip, full dorsi/plantar flexion
bil., well healed incisions/flaps left., decreased sensation
left lower ext., localized left knee pain.
Other: No cervical lymphadenopathy bil, no thyroid masses,
trachea midline
Discharge PE:
General: NAD
CV: ns-1, s2, s-3 s-4 no murmurs, no carotid bruits bil
Lungs: CTAB
Abdomen: rounded, soft, non-tender, no masses
Extremities: +dp bil, incisions C/D/I over left knee, donor site
healing well
Pt. able eo ambulate with crutches and touch down weaight
bearing only.
Pertinent Results:
CBCs:
[**2159-10-23**] 04:53AM BLOOD WBC-13.6* RBC-3.62*# Hgb-10.5*#
Hct-30.7*# MCV-85 MCH-29.0 MCHC-34.3 RDW-14.6 Plt Ct-223
[**2159-10-23**] 10:58PM BLOOD Hct-25.6*
[**2159-10-24**] 02:07AM BLOOD WBC-16.4* RBC-3.07* Hgb-8.7* Hct-26.6*
MCV-87 MCH-28.4 MCHC-32.9 RDW-14.7 Plt Ct-188
[**2159-10-25**] 12:40PM BLOOD WBC-11.9* RBC-3.00* Hgb-8.4* Hct-25.7*
MCV-86 MCH-27.9 MCHC-32.5 RDW-14.5 Plt Ct-192
[**2159-10-25**] 12:40PM BLOOD Neuts-80.2* Lymphs-13.5* Monos-5.1
Eos-1.0 Baso-0.3
.
CHEMISTRIES:
[**2159-10-24**] 02:07AM BLOOD Glucose-113* UreaN-23* Creat-2.8*# Na-138
K-4.4 Cl-109* HCO3-21* AnGap-12
[**2159-10-24**] 08:04PM BLOOD Glucose-115* UreaN-19 Creat-2.0* Na-137
K-5.0 Cl-107 HCO3-22 AnGap-13
[**2159-10-25**] 12:40PM BLOOD Glucose-154* UreaN-17 Creat-1.6* Na-136
K-4.7 Cl-107 HCO3-24 AnGap-10
.
CHEMISTRIES:
[**2159-10-24**] 02:07AM BLOOD Calcium-6.8* Phos-4.7* Mg-1.6
[**2159-10-24**] 08:04PM BLOOD Calcium-8.1* Phos-2.6*# Mg-2.0
[**2159-10-25**] 12:40PM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0
UricAcd-7.1*
.
VANCO LEVELS:
[**2159-10-24**] 01:38PM BLOOD Vanco-25.2*
[**2159-10-25**] 06:00AM BLOOD Vanco-7.8*
.
URINE CHEMISTRIES:
[**2159-10-24**] 11:25AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2159-10-24**] 11:25AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2159-10-24**] 11:25AM URINE RBC-54* WBC-17* Bacteri-FEW Yeast-NONE
Epi-<1
[**2159-10-24**] 11:25AM URINE CastGr-7* CastHy-3*
[**2159-10-24**] 11:25AM URINE AmorphX-RARE
[**2159-10-24**] 11:25AM URINE Mucous-RARE
[**2159-10-24**] 11:25AM URINE Hours-RANDOM Creat-62 Na-70
[**2159-10-24**] 11:25AM URINE Osmolal-292
[**2159-10-24**] 08:04PM URINE Hours-RANDOM Creat-61 Na-55
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
[**2159-10-22**] and had a 1. Left knee proximal tibia open biopsy, 2.
Left knee antibiotic spacer, 3. Transfer of free anterolateral
thigh flap from the right thigh to the left knee with
microvascular anastomosis, 4. Split-thickness skin grafting of
right thigh donor site, 5. Partial closure of left knee
arthrotomy. The patient tolerated the procedures well. He was
extubated successfully and taken to the recovery room. He was
subsequently taken to the floor in stable condition.
Neuro: Immediately post-operatively, the patient was maintained
on Dilaudid PCA. As soon as he could tolerate POs the following
meds were added along with the dilaudid PCA: Tylenol 1000mg
every 6 hours ATC, oxycontin 50 mg po Q8h, neurontin 1200 mg
TID. On [**2159-10-24**] the patient was still complaining of pain so a
Pain consult was called and they increased his Oxycontin from
50mg to 60mg Q8h and they also added a Ketamine IV infusion. On
[**2159-10-25**], the patient's pain was well controlled but he was
noted to be sleepy and to be having trouble speaking clearly.
He actually requested that the ketamine IV infusion be stopped
and the team was in agreement so the Ketamine was discontinued
the morning of [**2159-10-25**]. The Pain Service agreed with this and
requested that we re-consult them when attempting to wean
patient off of the dilaudid PCA and when trying to taper off the
oxycontin. The dilaudid PCA was discontinued in the afternoon
on [**2159-10-25**] and patient was transitioned to dilaudid PO for
breakthrough pain. He continued to require very high doses of
dilaudid and was transitioned to oxycontin with oxycodone for
breakthrough pain. At the time of discharge, his pain was well
controlled with 120mg oxycontin TID and oxycodone 20mg q 4
hours prn. He will follow up with the pain clinic.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient had room air oxygen saturations of 87%
for several days postoperatively so was maintained on O2 2L n/c
to keep sats > 95%; vital signs were routinely monitored. At
the time of discharge, his oxygen saturations were in the high
90's on room air.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. On POD#2, patient's creatinine rose
to 2.8 and a Renal Consult was requested. Per Renal
recommendations for Acute Tubular Nephrosis (ATN), Toradol IV
was discontinued, all anti-hypertensive medications were
discontinued, Vancomycin was renally dosed, and patient was kept
well hydrated. On POD#3, creatinine corrected to 1.6 following
said interventions and continued to trend down and normalize to
1.2-1.3. Foley was removed on [**2159-10-27**]. Vancomycin was
discontinued to protect his kidneys. Several medications (HCTZ,
valsartan, PPI, allopurinol and amlodipine) were d/c'd due to
possible renal effects. Intake and output were closely
monitored and the patient maintained excellent urine output. At
the time of discharge, his Cr had come down to 1.4. He had a
renal ultrasound which showed no hydronephrosis. He was told to
follow up in the renal clinic.
ID: Post-operatively, the patient was given IV cefazolin x 24
hours and Vancomycin/Daptomycin IV afterwards. The patient
spiked a temperature to 101.9 on POD#2 and had blood cultures,
UA and chest xray sent. Chest xray was clear and UA showed a
small amount of bacteria. Patient was given four doses of
ciprofloxacin for question of UTI. Vancomycin was eventually
discontinued due to body rash. Dermatology was consulted and
skin biopsy showed pathology consistent with vancomycin drug
rash. Patient was given steroidal cream and medications to
control pruritus all with good effect. Patient was continued on
Daptomycin IV alone and will go home with IV daptomycin until
[**2159-12-3**] with VNA. Additionally, ID added rifampin to be started
on [**2159-11-19**]. Patient continues to be followed by the [**Date Range **]
Disease service and will follow up with Dr. [**First Name (STitle) 1075**].
Prophylaxis: The patient was maintained on a Heparin drip
post-operatively for flap protection through [**2159-10-29**].
His PTT was mainatained between 50-70 during this time. On
[**10-29**], patient was started on Lovenox SQ. He was also
started on Aspirin 121.5 mg PO QD postoperatively. He will go
home with lovenox for 4 weeks.
At the time of discharge on POD#25, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating on crutches, cleared by PT, voiding without
assistance, and pain was well controlled.
Medications on Admission:
Albuterol
allopurinol
amlodipine
fluticasone/salmeterol
gabapentin
indomethacin
Percocet
Diovan
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily) for 30 days: Please take daily but discontinue 5
days prior to knee replacement surgery.
Disp:*45 Tablet, Chewable(s)* Refills:*2*
2. Daptomycin 500 mg Recon Soln Sig: Two (2) Recon Soln
Intravenous Q24H (every 24 hours) for 17 days: end date [**2159-12-3**].
Disp:*38 Recon Soln(s)* Refills:*0*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 bottle* Refills:*2*
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain/Fever for 30 days.
Disp:*240 Tablet(s)* Refills:*0*
6. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) for 30 days.
Disp:*180 Capsule(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
9. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for dry skin.
Disp:*1 tube/tub* Refills:*1*
10. wheelchair
with elevated and removable leg rests
dx: L proximal tibia excision with musculocutaneous flap from L
thigh to left knee
11. Saline Flush 0.9 % Syringe Sig: One (1) syringe Injection
prn as needed for flushes.
Disp:*20 synringes* Refills:*1*
12. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous prn
as needed for flushes.
Disp:*qs syringes* Refills:*0*
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
14. Outpatient Lab Work
weekly CBC, BMP, CK
All laboratory results should be faxed to [**Month/Day/Year **] disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
constipation.
16. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*168 Tablet Sustained Release 12 hr(s)* Refills:*0*
17. Oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*168 Tablet(s)* Refills:*0*
18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation DAILY (Daily).
21. Nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
22. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
23. Rifampin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours for 14 days: Please start on MONDAY [**2159-11-19**] .
Disp:*42 Capsule(s)* Refills:*2*
24. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day
for 9 days: Take 4 tablets (at once) daily for 3 days. Then
take 2 tablets daily (at same time) for 3 days. Then take 1
tablet daily for 3 days.
Disp:*21 Tablet(s)* Refills:*0*
25. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 4 weeks.
Disp:*60 syringes* Refills:*0*
26. Hospital Bed
Patient requires a hospiotal bed due to his orthopedic issues.
He will likely need this through [**2159-12-28**] or longer
depending on his next surgical outcome.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. Left knee chronic osteomyelitis.
2. Left knee post-traumatic arthritis.
3. Left knee status post Schatzker 6 tibial plateau
fracture nonunion.
Discharge Condition:
Stable
Discharge Instructions:
You were admitted on [**2159-10-22**] for a surgical procedure. Please
follow these discharge instructions.
MEDICATION CHANGES
DISCONTINUE Hydrochlorothiazide, DISCONTINUE Valsartan (diovan),
DISCONTINUE Allopurinol, DISCONTINUE Pantoprazole, DISCONTINUE
amlodipine (norvasc)
START RIFAMPIN on MONDAY
-Left knee immobilizer at all times until [**Date Range **] knee replacement
-You may be "touch-down weight bearing" on the left leg but you
may not put any weight on it
-mobilize using crutches as learned with Physical Therapist
-you have an allergy to Vancomycin which has been documented on
your records at [**Hospital1 18**] but you will need to remember the name of
this medication for future reference at other institutions.
-continue applying your steroid cream to body rash until full
resolved
-you may apply Aquaphor lotion to the right thigh flap donor
site/skin graft site when it appears dry.
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.
* No strenuous activity
* Okay to shower while seated, but no baths until after directed
by your surgeon
Followup Instructions:
Please follow up with the following providers:
Provider: [**Name10 (NameIs) **] Disease [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/time: [**2159-11-26**] 9:30am
Provider: [**Name10 (NameIs) 10701**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone [**Telephone/Fax (1) 721**] Date/time:
[**2159-11-29**] at 12:30pm
Provider: [**Name10 (NameIs) 2225**] [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time: [**2159-12-4**] 10:00
Provider: [**Name10 (NameIs) 1957**] [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-12-5**] 12:45 ([**Month/Day/Year **])
Provider: [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:
[**Telephone/Fax (1) 1652**] Date/Time: [**2159-12-7**] 10:10AM
Please call Dr.[**Name (NI) 29526**] office for an appointment: ([**Telephone/Fax (1) 69715**] [**Hospital Ward Name 23**] 2 Plastic Surgery
|
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3,417
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24211
|
Discharge summary
|
report
|
Admission Date: [**2154-3-19**] Discharge Date: [**2154-4-9**]
Date of Birth: [**2114-4-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Descending Aortic Dissection
Major Surgical or Invasive Procedure:
[**2154-3-20**] Redo sternotomy, Endovascular Stent Placement to
Ascending, Arch and Descending Aorta, Right Axillo-femoral
Bypass Grafting, with Reconstruction of Innominate and Left
common carotid artery.
[**2154-3-20**], [**2154-3-21**] Re-exploration for bleeding
[**2154-4-1**] Sternal Rewiring
History of Present Illness:
Mr. [**Known lastname **] with a 39 year old male with Marfans syndrome. He
underwent an aortic valve replacement and replacement of his
ascending aorta in [**2153-5-20**] at the [**Hospital1 18**] for an acute aortic
dissection. His postoperative course at that time was
complicated by respiratory failure, atrial fibrillation and deep
vein thrombosis. He required tracheostomy and placement of PEG
tube. Since that time, he made full recovery and has been
followed by serial CT scans. A CT scan in [**2153-12-20**] was
notable for an extensive aortic dissection extending into the
great vessels of the chest. These findings were not changed
since prior exam in [**2153-6-20**]. Unfortunately, the diameter of
the descending thoracic aorta increased substantially, which was
suggestive of continued leak from the true lumen into the false
lumen. Additionally, the early enhancement of the false lumen
relative to the true lumen was also consistent with continued
leak into the false lumen. Based on the above results, he
underwent re-evaluation and was admitted for further evaluation
and surgical intervention.
Past Medical History:
Marfans Syndrome, History of Aortic Dissection s/p Aortic Valve
Replacement and Ascending Aorta Replacement in [**2153-5-20**], History
of Postop Deep Vein Thrombosis, History of Post-op Atrial
Fibrillation, Asthma, Gastroesophageal Reflux Disease, Hiatal
Hernia, s/p Hernia repair, s/p Foot surgery
Social History:
Denies tobacco. Admits to occasional ETOH. He is married and
lives with his wife. [**Name (NI) **] is an electrical engineer.
Family History:
Denies connective tissue disorders. No history of premature CAD.
Physical Exam:
Vitals: T 96.9, BP 138/78, HR 72, RR 18, SAT 96% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, PERRL, EOMI
Neck: supple, no JVD, soft transmitted murmur noted
Heart: regular rate, normal s1s2, no rub, 3/6 SEM noted
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, CN 2-12 grossly intact, MAE, nonfocal
with 5/5 strength in all extremities
Pertinent Results:
[**2154-4-9**] 01:11AM BLOOD Hct-28.9*
[**2154-4-7**] 04:20AM BLOOD WBC-9.6 RBC-3.33* Hgb-9.2* Hct-27.4*
MCV-82 MCH-27.7 MCHC-33.7 RDW-16.5* Plt Ct-913*
[**2154-4-7**] 04:20AM BLOOD Plt Ct-913*
[**2154-4-9**] 01:11AM BLOOD UreaN-13 Creat-0.8 Na-138 K-4.1
[**2154-4-7**] 04:20AM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-135
K-4.0 Cl-101 HCO3-23 AnGap-15
[**2154-4-4**] 01:05AM BLOOD ALT-13 AST-20 AlkPhos-152* Amylase-94
TotBili-2.1*
[**2154-4-4**] 01:05AM BLOOD Lipase-72*
[**2154-4-6**] 03:03AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.8
[**2154-4-8**] 09:05PM BLOOD Vanco-33.6
Brief Hospital Course:
Mr. [**Known lastname **] is a 39year old male status post AVR and Aortic
dissection repair in [**5-/2153**] whose post operative course was
complicated by ARDS, DVT, and post op AF. He had evidence of
increased dissection of his descending thoracic aorta by CTA of
the chest in 12/[**2153**]. Given the severity of his disease the
cardiac surgery service was consulted regarding surgical repair
of his aorta. Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2154-3-19**] and
was worked up in the usual preoperative manner. He was taken to
the OR on [**2154-3-20**] and underwent a redo sternotomy with endostent
placement of his Asc aorta/arch/desc aorta, innominate to Left
carotid artery bypass, right axillary to right femoral artery
bypass performed by Dr[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1290**], [**Doctor Last Name **], and
[**Doctor Last Name **]. Postoperatively he continued to have significant
bleeding for which he was taken back to the OR. The innominate
artery stump was found to be bleeding and was sutured. He was
then taken back to the cardiac surgery recovery unit (CSRU).
Overnight he had a low SVO2 and hemodynamic instability for
which a bedside TEE was obtained and showed a possible
pericardial tamponade. A bedside sternotomy was performed and
clots were evacuated from the pericardial cavity. On
postoperative day(POD) 1 he remained on pressor support and
Interventional pulmonology was consulted regarding hypoxic
respiratory failure. On POD2 A CT chest and lower extremity U/S
did not show evidence of thromboembolism. His pressors were
weaned. On POD3 he remained on ventilator support and his
oxygentation was improving. His lumbar drain was removed. On
POD4 He became hypertensive requiring nitroglycerine for BP
control. On POD 5 He was awakened neurologically intact and
extubated. He became febrile to 101F for which blood and urine
cultures were sent and antibiotics started. On POD7 Mr.
[**Known lastname **] developed copious brown sternal drainage. On POD8 he
was transferred to the cardiac stepdown unit for further
recovery. The physical therapy service was consulted for
strenghtening and mobility. On POD 9 He developed new onset
aphasia and mild right sided weakness. He became agitated and
combative requiring sedation for diagnostic CTA. CTA did not
reveal any acute hemorrhage. He was transferred back to the
CSRU and placed back on pressor support. The stroke team was
consulted for evaluation. He was reintubated and placed on
ventilator support. A postoperative embolus was suspected for
which cerebral angiogram, lower ext doppler, and carotid U/S
were performed which did not show any evidence of embolus or
occlusion. On POD 11 the infectious disease service was
consulted for fever and leukocytosis. On POD 12 a chest CT
revealed sternal dehiscience for which he was taken back to the
OR for sternal rewiring and mediastinal exploration. No signs
of mediastinitis were seen. He empirically remained on broad
spectrum antibiotics. Pan cultures remained essentially negative
except for a mediastinal culture which grew out coagulase
negative staphylococcus. As his clinical status improved, he was
weaned from sedation and re-extubated without further incident.
His neurologic deficits resolved. He eventually transferred to
the SDU for telemetry and continued medical management. He
worked daily with physical therapy to improve strength and
mobility. Antibiotics were continued but titrated according to
ID recommendations. His fevers and leukocytosis gradually
resolved. A PICC line was eventually placed for a six week
course of Vancomycin. A repeat head CT scan prior to discharge
was unremarkable. The rest of his hospital course was uneventful
and he was medically cleared for discharge on [**2154-4-9**]. He will
follow up with Dr. [**Last Name (STitle) 1290**] in [**4-24**] weeks. He will also be
monitored weekly by the ID service.
Medications on Admission:
Labetolol 400 [**Hospital1 **], Protonix 40 qd, Norvasc 10 qd, Aspirin 81 qd,
Advair. Previously on Wafarin which was stopped in [**2153-12-20**]
by cardiologist.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) for 14 days.
Disp:*42 qs* Refills:*0*
11. Vancomycin
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Thoracic Aortic Aneurysm - s/p repair, Postoperative Bleeding,
Possible Postoperative Stroke, Sternal Drainage with ?Wound
Infection, Marfans Syndrome, History of Aortic Dissection - s/p
Aortic Valve Replacment and Replacement of Ascending Aorta in
[**2153-5-20**], History of Postop Atrial Fibrillation, History of Deep
Vein Thrombosis, Asthma, GERD, Hiatal Hernia, s/p Hernia Repair,
s/p Foot Surgery
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-24**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-22**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) 20683**] in [**2-22**] weeks - call for appt.
Infectious Disease, Dr. [**Last Name (STitle) 2716**] - call for appt([**Telephone/Fax (1) 11486**])
Completed by:[**2154-5-22**]
|
[
"998.11",
"998.31",
"759.82",
"518.5",
"276.4",
"V12.51",
"286.9",
"434.11",
"997.02",
"441.03",
"423.0",
"041.11",
"453.8",
"V42.2",
"996.1",
"784.3",
"427.31",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.73",
"39.71",
"37.12",
"34.03",
"96.6",
"39.31",
"88.41",
"34.79",
"96.72",
"39.29",
"39.23",
"96.04",
"88.63",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9028, 9086
|
3466, 7432
|
349, 651
|
9533, 9540
|
2871, 3443
|
9858, 10277
|
2277, 2343
|
7645, 9005
|
9107, 9512
|
7458, 7622
|
9564, 9835
|
2358, 2852
|
281, 311
|
679, 1794
|
1816, 2117
|
2133, 2261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,984
| 170,503
|
31311
|
Discharge summary
|
report
|
Admission Date: [**2173-11-7**] Discharge Date: [**2173-11-13**]
Date of Birth: [**2092-10-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Januvia
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transfer from [**Hospital3 **] for pulmonary edema
Major Surgical or Invasive Procedure:
PICC Line placement
Transesophageal ECHO
Gastric Endoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 81 y/o M with an extensive history of severe AS,
CAD s/p stent placement in [**10-13**] and [**9-12**], DM, and CHF, and PAD
s/p stent placemnt who presented to [**Hospital6 3105**] on
[**2173-11-5**] with flash pulmonary edema. Mr. [**Known lastname **] had been discharged
from [**Hospital1 18**] on [**2173-10-30**] after a cardiac catheterization and BMS
placement to the LCx and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 3 to the LAD arteries. Since
discharge, Mr. [**Known lastname **] followed up with Dr. [**Last Name (STitle) **] in his clinic and
was noted to have an elevated systolic blood pressure and was
subsequently started on Lisinopril (dose unknown).
On Friday [**11-5**], Mr. [**Known lastname **] was lying supine in bed and suddenly
became dyspneic. Soon after, Mr. [**Known lastname **] had worsening dyspnea while
standing and had "gurgily" breath sounds. EMS was called by pt's
son and patient's respiratory status declined. He was intubated
in the field and taken by ambulance to [**Hospital3 19345**]. His field O2 sats are unclear.
On arrival to the ER, patient's SBP was > 230 and was intubated.
He was transferred to the floor for further medical management.
Pt was diuresed and started on a nitro gtt for BP control. Pt
had a temp > 101 at OSH and was started on IV Ceftriaxone.
Pt was transferred to [**Hospital1 18**] for further management. Upon
arriving to floor, patient's VS were 101.8, 113, 141/65, 84, 22,
97% 4L NC.
Past Medical History:
CLL - f/b Dr. [**First Name (STitle) 1557**] at [**Hospital 3278**] Medical Center, previously on
rituximab 1 year ago.
CAD s/p BMS to LCx in [**9-12**]
Chronic diastolic CHF
AS
NIDDM II
PAD s/p stents
PUD
HTN
hyperlipidemia
Social History:
Moved to U.S. from [**Country 651**]. Lives with his son. Retired. Smokes
[**1-6**] cigs/day. Rare ETOH use.
Family History:
No history of cancer, CAD, or HTN. Father had diabetes.
Physical Exam:
VS - 101.8, 100.8, 95, 142/56, 77, 19, 99% 2L NC
Gen: Elderly gentleman resting comfortably lying flat. Oriented
x3, mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. III/VI systolic murmur loudest in LUSB. No S3
or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Rhonci L and R bases
Abd: Soft, NTND. No HSM or tenderness.
Ext: No edema, 1+ DP.
Skin: Excoriations in different stages of healing on most
surfaces. Fading erythematous rash on hands and feet.
Pertinent Results:
[**2173-11-7**] 08:26PM GLUCOSE-74 UREA N-26* CREAT-1.5* SODIUM-145
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-31 ANION GAP-15
[**2173-11-7**] 08:26PM CK(CPK)-107
[**2173-11-7**] 08:26PM CK-MB-5 cTropnT-0.93*
[**2173-11-7**] 08:26PM WBC-22.9*# RBC-3.85*# HGB-10.6*# HCT-32.1*
MCV-84 MCH-27.6 MCHC-33.0 RDW-14.6
TEE [**11-11**]: No vegetations found. Depressed left ventricular
function. Severe aortic stenosis. Complex atheroma in the
ascending aorta and descending thoracic aorta.
Renal US [**11-9**]:
1. Bilateral simple renal cysts. No hydronephrosis. 1-cm
angiomyolipoma in the left kidney.
2. Mildly elevated RIs bilaterally suggest of renal parenchymal
disease.
3. Bilateral tardus parvus waveforms of the main renal arteries.
Ultrasound cannot exclude bilateral renal artery stenosis.
CXR [**11-7**]: The current study demonstrates mild-to-moderate
cardiomegaly, unchanged compared to the prior study. The
previously demonstrated interstitial edema currently has been
progressed involving both interstitium and alveolar space. There
is also increase in left retrocardiac atelectasis and bilateral
pleural effusions. The left subclavian line tip is at the
junction of brachiocephalic vein and SVC.
Brief Hospital Course:
Mr. [**Known lastname **] is an 81 year old chinese speaking gentleman with CAD
w/BMS and DES, AS, presenting as OSH transfer in diastolic CHF
in context of severe AS.
Acute on Chronic diastolic heart failure: Patient presented to
OSH with SBPs > 230 and flash pulmonary edema and was intubated.
Patient was diursed and maintained on nitrolycerin drip. Pt was
extubated prior to transfer and on arrival SBP on was 142. Pt
was continued on nitro gtt and transitioned to PO
antihypertensives with metoprolol and hydralazine. Pt was also
restarted on his home lasix and remained euvolemic for the
remainder of the hospital course.
Coronary Artery Disease: Patient with 2v disease, s/p BMS in LCx
and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 3 in LAD one week ago. Patient with EKG changes (ST
depressions in precordial lateral leads) suggestive of demand
ischemia, with old RBBB. Patient was throught at OSH to be
having NSTEMI, and was started on heparin gtt. Patient's enzymes
were flat at OSH, however Trop at [**Hospital1 18**] was 0.93. This elevation
in troponin is likely related to subendocardial ischemia in the
setting of increased demand. Pt had GI bleeding in setting of
elevated PTT, and so heparin stopped and pt was transfused 1u
pRBCs. Here pt was medically managed with aspirin, plavis,
atorvastatin and beta-blocker. ACE inhibitor was held due to
renal failure.
Severe Aortic stenosis: Last echo [**10-13**] showed severe AS of 0.8.
Hypertensive urgency in setting of Severe AS likely precipitated
CHF, with dietary indescretions.
MSSA Bacteremia: Pt found to be febrile, pancultured and found
to have MSSA bacteremia. He was started on Nafcillin and PICC
line was placed for outpt antibiotics. Pt had a TEE negative for
vegetations and will thus require at 2-4 weeks of antibiotics
course. He will be seen by ID in 2 weeks at which point
remainder of course will be determiend.
HTN: Blood pressures were poorly controlled and pt initially
required nitroglycerin drip. Goal SBP given AS is 130-150.
Changed home regimen to beta-blocker and hydralazine with good
control. Pt was extensively counseled on need for low sodium
diet.
DM II: Oral medications were held and pt controlled with lantus
and insulin sliding scale.
Chronic Lymphoblastic Leukemia: The patient remained stable with
a mild anemia and thrombocytosis.
Dyslipidemia: Continued on atorvastatin
Peptic Ulcer Disaese: Continued on home pantoprazole.
Medications on Admission:
Atorvastatin 80 mg PO DAILY
Clonidine 0.1 mg PO TID
Glipizide 10 mg [**Hospital1 **]
Clopidogrel 75 mg daily
Levemir 13u + SSI
Pantoprazole 40 mg PO Q24H
Metoprolol Succinate 100 mg qday.
Hydroxyzine HCl 10 mg [**Hospital1 **]
Aspirin 81 mg
Furosemide 40 mg PO bid
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day for 4 weeks.
Disp:*56 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) bag
Intravenous Q4H (every 4 hours) for 2 weeks.
Disp:*84 bag* Refills:*1*
8. Levemir 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
four times a day: resume sliding scale at home.
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush for 2
weeks.
Disp:*20 ML(s)* Refills:*1*
11. Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection every
four (4) hours for 2 weeks: flush after each antibiotic dose.
Disp:*60 syringes* Refills:*1*
12. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis
CHF
Staph Bacteremia
Gastritis
Hypertension
Renal Artery Stenosis
Discharge Condition:
stable
hct 32.2
bun 33
creat 1.4
wbc 5.0
Discharge Instructions:
You have an infection in your blood that is caused by the staph
bacteria. You will need antibiotics for 2-4 weeks. the
echocardiogram did not show any evidence of bacteria on your
valves. You do have aortic stenosis which is not new and may
need to be surgically repaired. You will see Dr. [**Last Name (STitle) **] in a few
weeks to discuss this. Close attention should be paid to your
blood pressure and blood sugar to keep them well controlled. You
had an endoscopy to look at your stomach which showed gastritis,
an irritation of the stomach lining. Protonix needs to be taken
twice daily for 4 weeks to heal this irritation. You will need
another endoscopy in 6 weeks to show that this has been healed.
This has been scheduled at the [**Hospital **] clinic here at [**Hospital1 18**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet: Information was given to you and
your sons about low sodium diet and congestive heart failure
management.
Fluid Restriction:
.
Congratulations on quitting smoking. Information was given to
you on admission regarding smoking cessation and preventing
relapses.
.
New medicines for you are the antibiotic. The other medicines
remain the same except the chantix and fexofenadine which you
have not been taking at home. The clonidine has been replaced by
Hydralazine. You will take the antibiotics for 2 weeks, then you
have an appointment in the infectious disease clinic here. The
doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] if you should continue the antibiotics for
another 2 weeks.
.
Please call Dr. [**Last Name (STitle) **] if you have any fevers, chills, weakness or
trouble breathing or for any other concerning symptoms.
Followup Instructions:
Podiatry:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2173-11-30**] 1:40
.
Primary Care:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 91**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-12-6**]
3:00
.
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 7960**] Date/Time:
Wednesday [**12-1**] at 11:30am.
.
Gastroenterology:
Repeat endoscopy
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **],EAST PROCEDURES ENDOSCOPY SUITES
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2173-12-27**] 1:00. Office will send out
instructions and contact you prior to the procedure. A
translator has been scheduled.
.
Infectious Disease:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **], MD Phone: [**Telephone/Fax (1) 457**] Date/time: Office
will call you with an appt.
Completed by:[**2173-11-15**]
|
[
"998.2",
"428.33",
"790.7",
"E849.7",
"424.1",
"535.41",
"041.11",
"V45.82",
"599.0",
"440.1",
"204.10",
"533.90",
"E870.8",
"428.0",
"414.01",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8525, 8600
|
4355, 6812
|
330, 391
|
8726, 8769
|
3121, 4332
|
10595, 11587
|
2316, 2374
|
7128, 8502
|
8621, 8705
|
6838, 7105
|
8793, 10572
|
2389, 3102
|
240, 292
|
419, 1924
|
1946, 2173
|
2189, 2300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,348
| 112,047
|
8952
|
Discharge summary
|
report
|
Admission Date: [**2180-7-30**] Discharge Date: [**2180-8-2**]
Date of Birth: [**2123-9-22**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Erythromycin Base
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
dyspnea, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56yoW with metastatic BAC lung ca on weekly Taxol-carboplatinum
who presented to the ED on [**7-30**] with fever and dyspnea. She had
a recent hospitalization on the thoracic surgery service
[**Date range (1) 31081**] with large left spontaneous pneumothorax that was
treated with a chest tube and removed prior to discharge with a
residual small left apical pneumothorax. She had been in her
normal state of health on intermittent home oxygen (2L n/c)until
[**7-29**] when she developed a cough productive of clear sputum with
blood streaking and a fever to 100.8. On initial presentation to
the ED T 102.3 HR 131 BP 136/65 RR 16 84%RA, 95% 2Lnc. CXR
showed persistant but not enlarged left apical PTX and a new RUL
consolidation. CTAngiogram of chest was negative for PE. She was
treated with cefepime, vancomycin, and metronidazole for concern
of pneumonia. Thoracic surgery was consulted. She desaturated on
2Lnc to 80% and was placed on a 100%non-rebreather with O2
saturation improving to 99%. She denied having chest pain,
tightness, or pleuritic pain. She was admitted to the MICU for
antibiotic treatment and was weaned to 2L O2 by n/c. Prior to
transfer out of the ICU she felt much better and was anxious to
go home.
Past Medical History:
Lung cancer - diagnosed 6yrs ago, BAC, with mets to pleura and
ribs, currently on Taxol-carboplatinum
Pulmonary embolism - [**2178**], on warfarin
Depression/Anxiety
s/p LLL lobectomy [**2174**]
s/p hysterectomy [**2163**]
s/p appendectomy [**2153**]
s/p tonsillectomy
Social History:
works as storekeeper in boutique, lives w/ husband, daughter and
2 grandchildren
Family History:
non contributory
Physical Exam:
On admission;
T 100.3 HR 102 BP 116/81 RR 20 95% 2L n/c
Gen: NAD, speaking in half to full sentences, anxious
HEENT: PERRL, anicteric, conjunctiva pink, OP clear, MMM
Neck: supple, no LAD, JVP nondistended
CV: tachy, regular, no mrg
Resp: bronchial breath sounds, decreased left base, no
crackles/rhonchi/wheeze
Abd: +BS, soft, NT, ND, no masses
Ext: no edema, 1+ DPs bilaterally, healing abrasion LLE
Neuro: A&Ox3, CN II-XII intact, MAEW
.
On discharge
AF, VSS
Gen: NAD speaking in full sentences. Less anxious
Otherwise exam unchanged
Pertinent Results:
Labs on admission:
Na 140, K 3.7, Cl 100, Bicarb 30, BUN 30, Cr 0.5
WBC 5.5, Hgb 9.8, Hct 27.7
.
Labs on discharge:
hgb 8.6, plt 305, wbc 4.2
INR 1.5
.
Urine and blood cultures negative
.
sputum culture not accepted
.
CXR
1) Stable small left apical pneumothorax, unchanged from
[**2180-7-25**].
2) Interval worsening right upper lobe opacity, likely
infectious or
aspiration related given its rapid development.
3) Mild interval worsening in left mid and lower lung zone
opacities, which
may be related to the patient's underlying tumor and/or
infection/aspiration.
Correlate with the subsequent CT.
4) Persisting small left pleural effusion.
5) At least one destructive left-sided rib lesion, likely a
metastasis.
.
CTA chest: no pulmonary embolus. Numerous ill-defined lung
nodules bilaterally with more confluent opacity in the left
upper lobe, bronchial narrowing, and irregular interlobular
septal thickening and ground- glass opacities representing
metastatic BAC. Increase in size of soft tissue mass destroying
a portion of the T7 vertebral body and medial left 7th rib.
Deformity of the left 6th rib at the site of previously seen
destructive lesion. Chronic fracture deformity of theleft
lateral 8th rib. Pneumothorax on the left, approximately 15% of
the left hemithorax.
Brief Hospital Course:
A/P: 56yoW with metastatic bronchoalveolar lung cancer with a
recent admission for spontaneous pneumothorax presenting with
fever, dyspnea, persistant small-moderate pneumothorax.
.
# Dyspnea/Fever: Ms. [**Known lastname 31082**] presentation of fever, dyspnea,
productive cough and known sick contacts were considered most
concerning for pneumonia. PE was considered however the patient
was therapeutic on coumadin and CT angiogram of the chest,
although poor study, was negative. Ms. [**Known lastname 16462**] was therefore
treated broadly to cover for community and hospital aquired
pneumonia with ceftriaxone, vancomycin, and azithromycin. She
was hypoxic on presentation above her baseline need for 2L n/c
oxygen. She was placed on a 100% non-rebreather mask with good
oxygenation in the emergency room and spent one night in the
intensive care unit where she was treated supportively and was
rapidly weaned back to nasal cannula oxygen and was transferred
to the floor the next day. Her dyspnea improved along with her
hypoxia. Ms. [**Known lastname 16462**] remained afebrile the rest of her admission
and the aggressiveness of her antibiotic regimen was weaned,
first with the discontinuation of vancomycin. She was
transitioned to cefdinir and azithromycin oral therapy prior to
discharge without decompensation. She received her usual home
regimen of inhalers as well. She was encouraged to walk and was
able to walk with 2 L N/C maintaining oxygen saturations>92%
prior to discharge.
.
# Lung ca: patient getting weekly Taxol. Dr. [**Last Name (STitle) 3274**] following
and will decide on therapy. She was continued on dexamethasone
.
# Depression-Ms. [**Known lastname 16462**] has struggled with longstanding
depression. It was decided to increase her zoloft to 100 qday.
.
# Anemia: Ms. [**Known lastname 16462**] has a normocytic normochromic anemia.
Studies are suggestive of anemia of chronic disease/likely
hypoproliferation secondary to chemotherapy. Will transfuse for
hct<25.
.
# Anticoagulation: Ms. [**Known lastname 16462**] was continued on her home regimen
of comadin at 5mg qday. She became supratherapeutic with the
institution of antibiotics and her dose was decreased and she
became subtherapeutic. She is sent out with her home regimen
and instructions to follow up with her PCP this week for INR
check
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Cefdinir 300 mg Capsule Sig: One (1) Capsule PO bid () as
needed for pneumonia for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs inhaler* Refills:*0*
9. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Capsule(s)* Refills:*0*
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
11. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Continue home oxygen as needed
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please continue antibiotics as directed, your coumadin dose may
change over the course of the weekend as directed by Dr.
[**Last Name (STitle) **], take Coumadin 7.5 mg each day until then. If you do
not hear from Dr. [**Last Name (STitle) **] or one of his partners by [**Name (NI) 2974**]
evening, call his office and do not take your coumadin that
night until you hear from them.
Followup Instructions:
Please follow up at Dr.[**Name (NI) 31083**] office to have your INR
checked [**Name (NI) 2974**] [**8-3**] at 9am at [**Street Address(2) **]. in [**Location (un) 620**]. He
will call you to let you know what dose of coumadin to take on
Thursday night and there after. Follow up with Dr. [**Last Name (STitle) 3274**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"482.9",
"799.02",
"197.2",
"285.22",
"162.8",
"198.5",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7296, 7302
|
3886, 6235
|
307, 314
|
7356, 7365
|
2571, 2576
|
7797, 8233
|
1980, 1998
|
6258, 7273
|
7323, 7335
|
7389, 7774
|
2013, 2552
|
253, 269
|
2687, 3863
|
342, 1572
|
2590, 2668
|
1594, 1865
|
1881, 1964
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,760
| 125,040
|
49599
|
Discharge summary
|
report
|
Admission Date: [**2101-9-22**] Discharge Date: [**2101-10-3**]
Date of Birth: [**2046-12-1**] Sex: M
Service: [**Doctor Last Name 1181**]
HISTORY OF THE PRESENT ILLNESS: This is a 54-year-old male
with the past medical history of chronic right lower
extremity DVT, acute left lower extremity DVT, brain abscess
secondary to a dental procedure on [**2101-8-2**]. He had a
craniotomy and thrombocytopenia secondary to cephalosporins.
History of DVT in right leg for four years. He has saddle
embolus, pulmonary embolisms, which is why he is in the
hospital. The patient had a dental procedure; root canal and
crown placement that lead to a brain abscess, and on
[**2101-8-2**] he had a craniotomy. Two weeks ago he had a fall
after the craniotomy. So, for the following two weeks, he
was less mobile than usual. Shortness of breath began three
to four days prior to admission with worsening dyspnea on
exertion, worse with walking, eating, going to the bathroom,
all activities of daily living. He started with palpitations
while standing, but he was without chest pain. He had a
positive cough with some phlegm, but no [**Year (4 digits) **]. He has an
extensive family history of cancer. It was unknown what
workup was done four years ago for the DVT.
PAST MEDICAL HISTORY: History revealed chronic right lower
extremity DVT, acute left lower extremity DVT, brain abscess,
thrombocytopenia secondary to cephalosporins.
ALLERGIES: The patient is allergic to CEPHALOSPORINS.
MEDICATIONS ON ADMISSION:
1. Vancomycin 1.5 grams b.i.d.
2. Flagyl 500 mg t.i.d.
3. Decadron ?????? mg q.d.
4. Tylenol p.r.n.
FAMILY HISTORY: Mother: Breast cancer. Aunt: [**Name (NI) **] clot.
Father: Pancreatic cancer. Sister: [**Name (NI) **] cell lymphoma.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: The patient was afebrile, 99.1; [**Name (NI) **] pressure
138/96; heart rate 107; respiratory rate 18; oxygen
saturation 95% on room air. GENERAL: The patient was a well
appearing male in mild distress. CARDIAC: Tachycardiac and
regular; no murmurs, rubs, or gallops. PULMONARY: Clear to
auscultation bilaterally. ABDOMEN: Positive bowel sounds,
soft, nontender, nondistended. EXTREMITIES; left lower
extremity revealed a dark purple ecchymosis and tenderness on
the anterior thigh. Right lower extremity revealed a
palpable clot in the popliteal fossa.
LABORATORY DATA: Labs on admission revealed the following:
the patient had a white count of 7.6, hematocrit 34.9,
platelet count 227,000, sodium 141, potassium 3.9, chloride
105, bicarbonate 25, BUN 12, creatinine 0.7, and platelet
count of 163, PT of 12.7, INR 1.1, PTT 22.0. Urinalysis
positive nitrites, negative protein, negative glucose, trace
ketone, small bilirubin, negative leukocyte esterase, few
bacteria and 0 to 2 whites.
EKG: Sinus tachycardia at 117 with T-wave inversions in 3,
AVL and AVF. Ultrasound from [**9-22**] revealed right DVT
popliteal vein, left popliteal vein DVT. CT angiogram
revealed large central PEs. Chest x-ray revealed no acute
cardiopulmonary process.
HOSPITAL COURSE:
PULMONARY: The patient was admitted to the MICU because of
bilateral PEs. The patient underwent thrombectomy. The
patient was started on heparin after thrombectomies and the
patient's pulmonary status improved. The patient had
[**Location (un) 260**] filter placement following thrombectomy due to
large clot burden.
GI: The patient's hematocrit began to fall. After being on
Heparin, the patient had an upper EGD on [**2101-9-26**], which
showed grade IV esophagitis in the middle third and the lower
third of his esophagus. The patient was started on Protonix
b.i.d. with resolution of the bleed. The patient also had
decreasing hematocrit due to [**Year (4 digits) **] loss into legs following
[**Location (un) 260**] filter placement. The bleed also resolved on its
own.
INFECTIOUS DISEASE: The patient has a brain abscess. The
patient continued treatment with Vancomycin. The patient
will complete treatment on the [**6-10**].
HEMATOLOGY: The patient was on heparin following
thrombectomy. The patient was transitioned to Coumadin. The
patient had no problems with the transition.
DISPOSITION: The patient has hopeful discharged to a
rehabilitation facility as the patient needs physical therapy
with large right leg swelling pain on walking and difficulty
with activities of daily living. The patient will need
outpatient colonoscopy to rule out occult malignancy. The
patient has had multiple CTs that showed no occult malignancy
or no metastatic disease.
CONDITION ON DISCHARGE: The patient is stable.
FINAL DIAGNOSIS:
1. Bilateral pulmonary embolus.
2. Bilateral DVT right greater than left.
MEDICATIONS ON DISCHARGE:
1. Vancomycin 1500 IV q.d.
2. Flagyl 500 PO t.i.d.
3. Ambien 5 for sleep.
4. Iron 325 PO q.i.d.
5. Trandolapril 4 mg PO q.d.
6. Coumadin 5 mg PO h.s.
7. Pantoprazole 40 mg PO q.12h.
8. Hydrochlorothiazide 25 mg PO q.d.
9. Colace 100 mg PO b.i.d.
10. Amlodipine 5 mg PO q.d.
11. OxyContin 20 mg PO q.12h.
12. Oxycodone 10 mg PO q.4h. to 6h.p.r.n.
13. Colchicine 0.6 mg PO b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Doctor Last Name 103743**]
MEDQUIST36
D: [**2101-10-3**] 11:38
T: [**2101-10-3**] 11:42
JOB#: [**Job Number 38126**]
|
[
"453.8",
"578.1",
"E878.8",
"324.0",
"401.9",
"998.12",
"530.10",
"444.0",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.7",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
1659, 1785
|
4795, 5456
|
1537, 1642
|
3140, 4626
|
4692, 4769
|
1808, 3122
|
1309, 1511
|
4651, 4675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,443
| 147,575
|
27678
|
Discharge summary
|
report
|
Admission Date: [**2183-1-13**] Discharge Date: [**2183-1-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
Fine Needle Aspiration of Lung Mass
History of Present Illness:
86 year old male with CAD s/p CABG, recent pacer placement for
cardiac arrest while on vacation in [**State 108**], DM, A-fib on
coumadin last INR checked 2 weeks ago, HTN, COPD on 2L home O2
at night who presented to geriatric clinic with 4 days of
progressive fatigue and decreased PO intake. He also reports
chills and urinary incontinence. Of note, his son noted bright
red blood in the patient's stool 4 days ago. In the office, his
BP was 90/40 sitting and 80/40 standing. His HR was 70, but he
is on Coreg. The patient reports that he has been taking all of
his medications as prescribed.
.
In the ED, his Hct was 25 (down from 40 in [**6-1**]), Cr was 3.3, K
was 6.8. He was given kayexalate, insulin, d50, ca gluconate.
The patient had grossly bloody stool. NGL was performed and
demonstrated brownish hemoccult positive fluid that cleared with
50 cc.
.
ROS: denies diarrhea, fever, chills, nausea/vomiting, CP,
orthopnea, pedal edema; endorses chronic SOB that is stable,
depression, 45lb weight loss over the last 4 months - 30 of
which was related to change in dietary habits, recently lost an
additional 15lbs after CABG, stable L leg weakness
Past Medical History:
- DM
- A. fib on coumadin
- CAD s/p V-pacer/AICD [**11/2182**]
- s/p CABG (unknown date, but likely few years ago)
- CRI: baseline 2.0 in [**6-1**]
- HTN
- COPD on 2L NC at night
- L femur fracture [**2182**]
- L hip replacement [**2175**]
- Stroke [**2166**]
- Macular degeneration
- Hypercholesterolemia
- Depression
Social History:
lives with son, daughter-in-law and grandson; prior to CABG in
[**12-2**], the patient was able to make meals for himself, enjoyed
gardening, moves around in a scooter; been feeling depressed
after the death of his wife in [**5-2**]; recently moved from
[**State 108**] --> [**State 531**] --> [**Location (un) 86**]; is 1 of 11 children, only 6 are
still living -- recently went to [**State 108**] to spend time with two
sisters and a brother
Family History:
CVA - brothers (2)
Physical Exam:
VS: Wt 74.9kg 96.5 70 103/46 18 90% on RA
GEN: alert, tearful when discussing wife
[**Name (NI) 4459**]: dry MM, PERRLA, EOMI,
Cor: medial sternotomy scar intact, RRR, no m/r/g, nontender
pacer pocket
Lungs: CTA anteriorly
ABD: NABS/S/NT/ND, no HSM
EXT: WWP (warmed with bear-hugger), 2+ DP/PT pulses, no edema
NEURO: A+O x3, strength 5/5 upper and lower extremity flexors
and extensors, CN II-XII individually tested and intact
Skin: thin with multiple ecchymosis
Pertinent Results:
[**2183-1-13**] PORTABLE CXR: 0.89 cm opacity overlying the lower
medial right lung zone. This finding could be external to the
patient and could be reevaluated on followup chest radiograph.
Left lower lobe linear atelectasis.
.
[**2183-1-13**] EKG: v-paced at 69 beats per minute, left axis, ST
depressions in I and avL, (no comparisons)
.
CT chest:
IMPRESSION: 1) 8.0cm right lower lobe mass or abscess. Although
the associated small to moderate pleural effusion is mobile, the
presence of pleural thickening both close to and remote from the
mass as well as extensive mediastinal adenopathy and a 1 cm left
adrenal nodule are suggestive of malignant spread. 2) Moderate
to severe emphysema. 3) Severe atherosclerosis, coronary, aortic
and abdominal. 4) Chronic cholelithiasis.
5) Small, hypervascular left renal lesion. 6) Interatrial
lipoma.
.
CT Chest FNA:
IMPRESSION: Successful CT guided FNA of right lower lobe mass.
Core needle biopsy was not performed at this time due to the
patient's recent aspirin use and elevated INR. If clinically
indicated, this can be performed once the patient's coagulopathy
has resolved.
The attending Dr. [**First Name (STitle) **] [**Name (STitle) **] was present and assisted
throughout the procedure.
.
FNA lung mass:
POSITIVE FOR MALIGNANT CELLS
Consistent with poorly differentiated, non-small cell
carcinoma with sarcomatoid features.
Note: Immunohistochemical studies performed on cytospin
preparations reveal immunoreactivity for keratin MNF-116.
No immunoreactivity is seen for S-100 or HMB-45.
.
CXR PA and Lat:
Right lower lobe lung mass status post biopsy. No pneumothorax.
.
Brief Hospital Course:
# GIB: appears lower and secondary to supratherapeutic INR. Per
family, had colonoscopy in [**2181**]. Given vitamin K and FFP. Plan
for no scope at this time. No further coumadin given difficult
to control INR and GIB. Hct remained stable.
.
# Supratherapeutic INR: likely due to poor po intake in setting
of being on coumadin. No further coumadin.
.
# Lung Mass: Found to have RLL mass on CXR which was confirmed
on CT with malignant appearance. CT guided FNA revealed poorly
diff NSCLC. Oncology was consulted and recommended outpatient
staging PET/CT (which was scheduled on [**2183-2-3**]) and follow up
with Dr. [**Last Name (STitle) **] on the 11th in oncology clinic for possible
palliative chemotherapy if he is interested in this.
.
# Urinary tract infection: Patient with leukocytosis, dirty UA,
hypothermia, hypotension, and lactate of 3.0. finished 7 day
course of zosyn for E. coli UTI [**Last Name (un) 36**] to zosyn. Initially treated
with a few days of vanco when concern for epsis with unclear
source, this was discontinued.
.
# CAD: s/p CABG several years ago and pacer placement in
[**Month (only) **].
TTE showed preserved EF with severe pulm htn. Continued on
ASA/BB/ACEI. Family to review meds with PCP in light of recent
malignancy diagnosis and utility of multiple meds.
.
# ARF: Improved with volume resucitation and treatment of
infection. Restarted ACEI after hydration.
.
# DM: Patient with hyperglycemia. Continued on glargine with
sliding scale insulin.
.
# Depression: Social work consulted, started on mirtazepine.
.
# HTN: Held norvasc given hypotension. Restarted coreg.
.
# Communication: [**Known firstname 9241**] [**Known lastname **] II (son) - [**Telephone/Fax (1) 67589**]; [**Name (NI) **]
[**Last Name (NamePattern1) **] (daughter-in-law) [**Telephone/Fax (1) 67590**]. Citrus [**Hospital 107**] Hospital,
[**Location (un) 67591**] FL ([**Telephone/Fax (1) 67592**]
.
# DNR/DNI. Confirmed with patient and family.
Medications on Admission:
ASA 81mg qD
Lasix 40mg qAM
Digitek 0.125mg qD
Coreg 12.5mg [**Hospital1 **]
Klor-con M20tab qD
Norvasc 5mg qD
Glipizide 5mg qD
Warfarin 5mg qD
Simvistatin 20mg qD
Lantus 10mg qHS
MVI
.
ALL: NKDA
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale sliding scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
Non Small Cell Lung Carcinoma
GI Bleed
Atrial Fibrillation
Diastolic CHF
CAD s/p CABG
Chronic Renal Insufficiency
DM2 Uncontrolled
Chronic Obstuctive Lung Disease
Discharge Condition:
stable
Discharge Instructions:
Please continue your medications as listed. Please make sure you
follow up for your PET/CT scan for staging of your tumor on the
9th. You will need to drink one bottle of clear scan 3 hours
prior to your appointment. Please make sure you or someone reads
the instructions with the bottles of clear scan regarding
dietary instructions the day prior. Please also make sure you
follow up for your appointment with your new oncologist Dr.
[**Last Name (STitle) **] on the 11th as well.
Followup Instructions:
1. Please make sure you or someone at your rehab reads the
directions for your PET/CT scan. Make sure you drink one bottle
of clear scan 3 hours prior to your study. Make sure you make it
to your PET/CT tumor staging study on [**2183-2-3**] at 9am on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. You can call [**Telephone/Fax (1) 2103**] if you
have questions.
2. Please follow up with your new oncologist as follows:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2183-2-6**] 3:00pm
Provider: [**Name10 (NameIs) 10341**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2183-2-6**] 3:00pm. This will be located on the [**Location (un) **]
of the [**Hospital Ward Name 23**] Building.
3. Please also follow up with your PCP in the next 2-4 weeks.
|
[
"041.4",
"585.9",
"599.0",
"428.0",
"285.1",
"790.92",
"414.00",
"250.02",
"428.30",
"578.9",
"V45.81",
"584.9",
"496",
"427.31",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.26"
] |
icd9pcs
|
[
[
[]
]
] |
8140, 8282
|
4508, 6468
|
266, 304
|
8489, 8498
|
2841, 4485
|
9028, 9884
|
2311, 2331
|
6713, 8117
|
8303, 8468
|
6494, 6690
|
8522, 9005
|
2346, 2822
|
223, 228
|
332, 1491
|
1513, 1833
|
1849, 2295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,519
| 127,788
|
54673
|
Discharge summary
|
report
|
Admission Date: [**2148-7-16**] Discharge Date: [**2148-8-1**]
Date of Birth: [**2092-1-10**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Right ICH
Major Surgical or Invasive Procedure:
[**2148-7-17**]: Diagnostic Cerebral Angiogram
[**2148-7-17**]: Right Hemicraniectomy for decompression
[**2148-7-17**]: Diagnostic Cerebral Angiogram
[**2148-7-18**]: Cerebral Angiogram with onyx embolization of R MCA
aneurysm
History of Present Illness:
56 y/o female with a PMH significant for mitral valve
prolapse, migraine headaches, a lung abscess who was admtted to
[**Hospital **] Hospital on [**2148-7-14**] with new onset afib with rapid
ventricular response. She received Plavix, Aspirin and Lovenox.
She was discharged on Lovenox.
She attended a dinner party today at 5:30 pm, was complaining of
a severe headache which she thought was a migraine, layed down
until 8 pm at which time she woke up, vomited and was found to
have left sided weakness and a facial droop.
She was taken to [**Hospital **] Hospital where A CT of the head was
obtained and showed a right frontal parietal intracerebral
hemorrhage. She was transferred to [**Hospital1 18**]. In our ED she
received Dilantin 1gm IV x1 and Mannitol 50mg IV x1.
Past Medical History:
mitral valve prolapse, migraine headaches, lung abscess,
newly diagnosed afib with rapid ventricular response.
Social History:
Smokes 1 PPD x >30 years. She denies the use of
alcohol or illicit drugs.
Family History:
unknown
Physical Exam:
on ADmission:
O: T: BP:118 /91 HR:135 R 19 O2Sats 100RA
Gen: WD/WN, lethargic
HEENT: NCAT reaction sluggis,
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: irregular, afib with RVR
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
Cranial Nerves:
I: Not tested
II: with left facial droop. Pupils: Right pupil larger than
left. Right pupil reactive to light 3mm-2mm; left pupil
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Left facial droop.
VIII: Hearing intact to voice.
IX, X: Palatal elevation : unable to asses.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius : unable to asses.
XII: left deviation.
Mental status: Drowsy, opens eyes to voice, follows commands;
cooperative with examination.
Orientation: Oriented to person, place, and date.
.
Language: Slurred Speech, labored and slow.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Moves right UE and LE extremity freely on command. No
spontaneous movement of the left UE or LE.
Sensation: Intact on the right UE and LE. Decreased sensation in
the left UE and LE.
Handedness: Right
Discharge exam:
AVSS
NAD
speech normal and full with moderate word finding difficulty
comprehension intact
Right gaze preference, neck spasmotic toward left.
follows commands on right
Full strength in Right delt/[**Hospital1 **]/tri/IS/quad/ham/GS/TA
Hemiplegic on Left. Withdraws to noxious stimuli.
Craniotomy flap is soft and full
Incision c/d/i, no erythema, edema or drainage. Absorbable
sutures in place.
Pertinent Results:
[**7-16**] ECG: Irregular supraventricular tachycardia. There is
organized atrial activity. This could be atrial fibrillation,
atrial flutter with variable block, multifocal atrial
tachycardia. There is leftward axis, left ventricular
hypertrophy, and intraventricular conduction delay of left
bundle-branch block type pattern. No previous tracing available
for comparison. Clinical correlation is suggested.
[**7-16**] CTA Head: IMPRESSION:
1. Large right frontal intraparenchymal hemorrhage, with
significant
peri-hemorrhagic edema and subarachnoid hemorrhage, with
approximately 4-mm shift of midline.
2. CTA images show a 4 x 5 mm hyper-attentuating focus, arising
from a distal MCA branch, highly concerning for a mycotic
aneurysm given the location.
[**2148-7-17**] echo: IMPRESSION: Suboptimal image quality. Critical
aortic valve stenosis. Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function.
[**7-17**] ECG: Irregular supraventricular tachycardia. Since the
previous tracing the rate is faster and there is now more
prominent aberration with single more leftward axis. Since the
previous tracing the rate is faster and ST-T wave abnormalities
are more prominent. Clinical correlation is suggested.
[**7-17**] ECG: Sinus bradycardia. Left ventricular hypertrophy. ST-T
wave abnormalities. Intraventricular conduction delay of left
bundle-branch block type. Since the previous tracing sinus
bradycardia is now present, axis is less leftward, ST-T wave
abnormalities less prominent, QTc interval more prolonged.
[**7-17**] CT Head: IMPRESSION: Overall, stable extent of right
frontal parenchymal and extensive subarachnoid hemorrhage, with
approximately 5 mm leftward shift of midline structures,
previously was 4 mm.
NOTE ADDED IN ATTENDING REVIEW: Noted is early formation of a
blood/fluid
level within the large hematoma (2:24), which may relate to
anticoagulation. Also, again noted (as on the preceding CTA) is
apparent retained contrast material within a rounded structure
in the distal aspect of the right sylvian cistern (2:15-16),
which may represent a partially-thrombosed aneurysm of the M3
segment of the MCA, as suggested by the CTA.
[**7-17**] CT Head: IMPRESSION:
1. Immediately status post extensive right frontovertex
craniectomy with
expected post-surgical changes. There is herniation of the
abnormal brain through the craniectomy defect, with some
improvement in the degree of leftward subfalcine herniation.
2. Large right frontal parenchymal hematoma is slightly larger,
with stable associated edema.
3. Internal blood/fluid level and overlying and cisternal
subarachnoid
hemorrhage, as before.
[**7-17**] CXR: ET tube tip is in standard position, 4.8 cm above the
carina. Left subclavian catheter tip is at the cavoatrial
junction. NG tube tip is in the stomach, out of view. Cardiac
size is top normal, is accentuated by the projection. Left
lower lobe opacity is likely atelectasis. Aspiration or
pneumonia cannot be totally excluded.
[**7-17**] CTA Head:
IMPRESSION:
1. Post-status right fronto-vertex craniectomy. Similar large
intraparenchymal right frontal intraparenchymal hemorrhage,
without evidence of interval hemorrhage. Minimal residual 1-mm
leftward shift, unchanged.
2. Unchanged 5 mm likely-mycotic aneurysm at the distal right
MCA branch.
[**7-17**] Angio:
IMPRESSION: [**Known firstname **] [**Known lastname 52932**] underwent single vessel diagnostic
angiography, which reveals recanalization of a right M3 division
5 mm x 4 mm pseudoaneurysm. Given the recent history of Surgery,
heparing could not be administered. Due to the high risk of
thrombosis, further therapy could not be provided at this time.
These findings were discussed with the [**Hospital 228**] healthcare
proxy, [**Name (NI) **], and the patient's son [**Name (NI) **] immediately
following the procedure.
[**7-18**] CXR: FINDINGS: In comparison with the study of [**7-17**], the
monitoring and support devices remain in place. Cardiac
silhouette again is at the upper limits of normal in size
without definite vascular congestion or pleural effusion.
Retrocardiac opacification is consistent with some volume loss
in the left lower lobe.
[**7-18**] Angio:
IMPRESSION: Ms. [**Known firstname **] [**Known lastname 52932**] underwent cerebral angiography
and Onyx
embolization of a right M3 branch dissecting pseudoaneurysm with
complete
exclusion of the aneurysm from flow. There is spontaneous
retrograde
dissection of the distal cervical internal carotid artery, which
was observed over a period of thirty minutes and seen to remain
unchanged. Aspirin 325 mg was also administered for this.
[**7-19**] CT Head
FINDINGS: Patient is status post right frontal craniectomy with
stable
pneumocephalus along the right frontal convexity. Again noted
is a large
intraparenchymal hemorrhage centered at the right frontal
region. The size of the hemorrhage is approximately unchanged
from previous study. The Onyx material is seen within the
hemorrhage from Onyx aneurysm embolization which is new from
previous exam. There is persistent perihemorrhagic edema and
adjacent subarachnoid hemorrhage. There is persistent partial
effacement of the right lateral ventricle and right-sided sulci
with minimal residual leftward shift. No intraventricular
hemorrhage extension is noted. Visualized paranasal sinuses are
clear. The globes are unremarkable.
CONCLUSION: Interval Onyx aneurysm embolization with stable
appearance of
right frontal intraparenchymal hemorrhage and stable
post-craniectomy changes.
[**7-21**] CTA Head
IMPRESSION:
1. There is no evidence of vasospasm.
2. Post-surgical changes consistent with right frontal
craniotomy with
slightly decreased pneumocephalus along the right frontal
convexity.
3. Slightly increased perihemorrhagic edema with greater
extracalvarial
expansion of the right frontal parenchyma, consistent with
transgaleal brain herniation. Stable minimal residual leftward
shift. There is no evidence of intraventricular hemorrhage.
[**7-23**] Cerebral Angiogram:
Ms. [**Known firstname **] [**Known lastname 52932**] underwent diagnostic cerebral angiography,
selective catheterization of a superior division of the M2, and
infusion of 10 mg of verapamil for further treatment of
vasospasm with some resultant improvement. There is an
unchanged appearance of cervical segment ICA dissection.
[**7-23**] ABD XR - Dobbhoff tube with distal tip in the stomach.
[**7-25**] - Dobbhoff tube has been pulled back and the tip is in the
distal
stomach/antrum. Evaluation of the lungs is limited due to the
projection.
Still diffuse opacities in the left perihilar region and lower
lobes
bilaterally, left greater than right, are present and unchanged.
These
opacities have wide radiologic differential diagnosis include
aspiration
pneumonia and asymmetric pulmonary edema. The component of
pulmonary edema has minimally improved prior study.
[**2148-7-29**] ECG
Sinus bradycardia. Since the previous tracing no significant
change
Brief Hospital Course:
Pt was admitted to the Neurosurgical Service, ICU for close
neurological observation. She recieved protamine to reverse her
elevated INR. She was taken to the angio suite for a cerebral
angiogram. No aneurysm was found. The patient was
hemodynamically unstable during the procedure and the anesthesia
team consulted cardiology. She was started on a dilt drip for
her afib RVR, which was eventually converted to PO.
On [**7-17**] she was taken to the operating room and underwent a right
decompressive hemicraniectomy. This was performed without
complication. She had TCD's for vasospassm monitoring and an
echo per cards request. The TEE revealed critical AS but stable
EF. She also underwent a CTA which was suggestive of a right MCA
aneurysm. She returned for another cerebral angiogram but the
attempt at coiling was unsuccessful. She was again
hemodynamically unstable at times during the procedure and was
started on pressors and amiodarone.
On [**7-18**] she was neurologically stable. She was seen by the
cardiology team who did not recommend valvuloplasty at this time
and suggested a cardioversion. Prior to this being performed the
patient converted on her own to NSR. She was again taken for a
cerebral angiogram and the aneurysm was successfully embolized
using onyx. She was started on aspirin 325mg and her BP was
liberalized. Daily TCD's were ordered.
on [**7-19**] she was successfully extubated in the afternoon. She
recieved one unit of blood for a HCT of 25.
On [**7-20**], patient was febrile and placed on a cooling blanket.
Blood, urine, and sputum cultures were sent along with a BAL.
Gram positive rods and cocci were seen in the sputum sample and
the patient was treated with Vancomycin and Zosyn for presumed
VAP.
On [**7-21**]% and Mannitol were discontinued. Her I/Os were
grossly positive and her IVF were decreased to reduce her
cardiac/ respiratory risk. A CTA head that showed mild vasospasm
in the right MCA. One bottle from blood cultures sent [**7-20**] grew
gram positive cocci and rods. In the afternoon she had an
episode of increased secretions, desat to 87%, HR up to 90's
(from 60's) requiring bagging and suctioning. The patient
returned to baseline and remained stable.
On [**7-23**], Patient was taken to the angio suite for evaluation of
for vasospasm and she recieved intra-arterial Verapamil to her
right MCA for spasm.
On [**7-24**], pt again had episodes of AFIB which responded to
lopressor IV. On [**7-25**], patient was extubated without incident.
She remained stable and was transferred to floor in stable
condition. on [**7-26**], Cardiology was consulted and they
recommended decrease amio from 400 mg to 200 mg, Dilt from 30
mg->15 QID. On [**7-27**], cardiology recommended diltiazem to be
discontinued.
On [**7-29**] patient had had several episodes of bradycardia with
borderline hypotension,cardiology recommended decreasing
Amiodrone to 200mg daily. She will have a follow up appointment
with Dr. [**Last Name (STitle) **] in 3 weeks.
On [**7-30**] through [**8-1**], patient's vital signs were stable. Pt
continued to report discomfort in the neck related to the spasm.
Flexeril and tizanidine were started and helped relieve the
symptoms partially. Rehab screening was begun and the patient
was discharged in stable condition to rehabilitation on [**8-1**].
All questions were answered and the patient expressed readiness
for discharge.
Medications on Admission:
Atenolol
ASA
Lovenox
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN temp>99
2. Amiodarone 200 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Cyclobenzaprine 10 mg PO QID tortacolis
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC TID
8. LeVETiracetam Oral Solution 500 mg PO BID
9. Nimodipine 30 mg PO Q2H
hold for SBP<90
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Senna 1 TAB PO HS
12. Tizanidine 4 mg PO TID torticollis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right frontal IPH
Cerebral edema with compression
MCA aneurysm
Critical Aortic Stenosis
Afib with RVR
LVH
Hemiparesis
VAP
Sepsis
respiratory failure
vasospasm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily. Howevery, you
must Hold Aspirin therapy 7 days prior to your second stage
surgery which is planned for [**2148-8-30**] at 7:30am.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
- Do not take any Aspirin, plavix, ibuprofen, Naproxen, Motrin
starting 7 days prior to your scheduled surgery as these drugs
can contribute to bleeding.
- Heparin SC should be held the night and morning before
surgery.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
Followup Instructions:
- You have an appointment in the Cardiology clinic with Dr.
[**Last Name (STitle) **]:
[**Telephone/Fax (1) 62**] Date/Time:[**2148-8-15**] 4:00. Their clinic is on the
[**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**].
- You should return to clinic with Dr. [**First Name (STitle) **] in on [**8-22**], [**2147**] at 11am. You will need a CT Head prior to your
appointment and it is scheduled for 10am that same day. At that
time, discussion regarding the second stage of your procedure
will take place.
- Currently your cranioplasty surgery for replacement of the
bone flap is scheduled for [**8-30**] at 7:30am. You should
not have anything to eat or drink after midnight the night
before and you should arrive at 6am on the day of surgery. You
must hold your Aspirin therapy 7 days prior to surgery.
Appointments and Radiology listed below:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2148-8-15**] 4:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2148-8-22**] 10:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2148-8-22**] 11:00
Completed by:[**2148-8-1**]
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Discharge summary
|
report
|
Admission Date: [**2151-6-9**] Discharge Date: [**2151-6-13**]
Date of Birth: [**2129-10-28**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Syncope, altered mental status
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
21 year old Male h/o EtOH and marijuana abuse, EtOH
pancreatitis, and multiple sports-related concussions who
presents with syncope and mental status change. He had a head
injury 2 days prior to admission at work after hitting his head
on a refrigerator door. He experienced confusion and amnesia but
did not have loss of consciousness. The patient then suffered a
MVC one day prior to admission, car vs pole, and it was unclear
if he had head trauma or LOC. He was evaluated at [**Hospital 13056**]
Hospital, where he had a negative head CT per report. On the day
of admission he experienced headache, confusion, and an episode
of syncope while hyperventilating, and was caught by his mother
prior to hitting the floor. He was unconscious and unresponsive
to painful stimuli for 5 mins, however did not have convulsions.
When he awoke, he was even more confused and unable to respond
to questions. He did not complain of neck pain chest pain or
abdominal pain or other extremity pain. Per his family, today
was supposed to be a reunion, but may have proven to be more
stressful for him than anticipated. His father found a bottle of
gin in his backpack.
In the [**Hospital1 18**] ED, initial VS: HR 72, BP 110/65, RR 18, T 97.8. He
was initially only oriented to self, and intermittently became
combative. After sedation with Versed, he was calm, able to
answer questions, and was AO x3. Labs were notable for AST 63,
lactate 2.5, Blood Alcohol was 305. He was placed in a c-collar
and then intubated for altered mental status. ABG after
intubation 7.38/46/425/28 on CMV 510/100/14/5. FAST exam
negative, he had a laceration on posterior shoulder which his
mother attributes to a cut while shaving. CT torso showed no
acute injuries to the chest, abdomen or pelvis. NCHCT showed no
acute intracranial process. CT C-spine showed no acute fracture
or malalignment. Neurosurgery was consulted but felt there was
no need for intervention, atributing his delerium to
intoxication and concussion, and did not recommend Dilantin.
Surgery was consulted and saw no injuries on exam, will follow.
He was given fentanyl, midazolam, propofol. He was admitted to
the MICU for extubation and frequent neuro checks.
Ultimately he was extubated and transferred to the floor, where
he continued in alcohol withdrawal.
Past Medical History:
- EtOH and marijuana abuse.
- EtOH pancreatitis in [**2148**], hospitalized for 3 days
- ADHD (unclear diagnosis)
- h/o multiple sports-related concussions
- chronic HA and periodic episodes of "confusion"
Social History:
Works at Olive Garden. Separated from family Drinks EtOH, uses
marijuana. Has played football since high school. Has been with
same girlfriend since high school. Has a brother, healthy.
Family History:
- Father with hypertension
- Mother with lupus, s/p kidney transplant
- EtOH abuse in multiple family members
Physical Exam:
Vitals: HR 69, BP 113/68, RR 17, T 97.5
General: Well Apearing, no acute distress.
HEENT: Pupils: 2.5->2 BL, sclera anicteric, oropharynx clear
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: large tattoo on right body/flank, abd soft, non-tender,
non-distended, bowel sounds present, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CAOx3, CNII-XII grossly intact, Motor [**3-27**] UE/LE Flex/Ext,
grossly normal sensation, 2+ reflexes bilaterally, gait normal,
finger-to-nose intact
Pertinent Results:
[**2151-6-11**] 09:12AM BLOOD WBC-7.1 RBC-4.51* Hgb-14.6 Hct-43.5
MCV-97 MCH-32.4* MCHC-33.6 RDW-12.6 Plt Ct-296
[**2151-6-11**] 07:05AM BLOOD WBC-8.1# RBC-4.49* Hgb-14.6 Hct-43.1
MCV-96 MCH-32.5* MCHC-33.9 RDW-12.5 Plt Ct-289
[**2151-6-10**] 02:44AM BLOOD WBC-5.2 RBC-3.94* Hgb-12.6*# Hct-37.8*
MCV-96 MCH-32.1* MCHC-33.4 RDW-12.8 Plt Ct-300
[**2151-6-9**] 07:05PM BLOOD WBC-7.6 RBC-4.91 Hgb-15.9 Hct-47.0 MCV-96
MCH-32.4* MCHC-33.9 RDW-12.5 Plt Ct-363
[**2151-6-11**] 07:05AM BLOOD Neuts-72.7* Lymphs-14.5* Monos-6.5
Eos-5.9* Baso-0.4
[**2151-6-9**] 07:05PM BLOOD PT-10.1 PTT-30.3 INR(PT)-0.9
[**2151-6-10**] 02:44AM BLOOD Glucose-82 UreaN-9 Creat-0.8 Na-143 K-3.6
Cl-112* HCO3-22 AnGap-13
[**2151-6-9**] 07:05PM BLOOD Glucose-87 UreaN-9 Creat-1.1 Na-144 K-3.9
Cl-102 HCO3-27 AnGap-19
[**2151-6-10**] 02:44AM BLOOD ALT-23 AST-39 TotBili-0.4
[**2151-6-9**] 07:05PM BLOOD ALT-36 AST-63* AlkPhos-50 TotBili-0.8
[**2151-6-9**] 07:05PM BLOOD Lipase-47
[**2151-6-11**] 09:12AM BLOOD Albumin-4.2 Calcium-9.5 Phos-2.9 Mg-1.9
[**2151-6-10**] 02:44AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.8
[**2151-6-9**] 07:05PM BLOOD ASA-NEG Ethanol-305* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2151-6-10**] 03:03AM BLOOD Type-[**Last Name (un) **] Temp-36.4 Rates-16/ Tidal V-500
PEEP-5 FiO2-40 pO2-53* pCO2-42 pH-7.35 calTCO2-24 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2151-6-9**] 08:16PM BLOOD Type-ART Rates-14/ Tidal V-510 PEEP-5
FiO2-100 pO2-425* pCO2-46* pH-7.38 calTCO2-28 Base XS-1
AADO2-238 REQ O2-48 -ASSIST/CON Intubat-INTUBATED
[**2151-6-10**] 03:03AM BLOOD Lactate-2.0
[**2151-6-9**] 07:14PM BLOOD Lactate-2.5*
[**2151-6-9**] 07:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.001
[**2151-6-9**] 07:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2151-6-9**] 07:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2151-6-10**] 2:44 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2151-6-12**]**
MRSA SCREEN (Final [**2151-6-12**]): No MRSA isolated.
ECG Study Date of [**2151-6-9**] 7:02:56 PM
Normal sinus rhythm. Prominent voltage in the precordial leads
may be normal variant for age. No previous tracing available for
comparison.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 166 96 [**Telephone/Fax (2) 112118**] 15
CHEST (PORTABLE AP) Study Date of [**2151-6-9**] 7:10 PM
FINDINGS: A nasointestinal tube is seen ending in the corpus of
the stomach. Endotracheal tube is seen ending 5.6 cm above the
carina. The lungs are clear.
CT C-SPINE W/O CONTRAST Study Date of [**2151-6-9**] 7:22 PM
intubated state of the patient. There is no large neck hematoma.
IMPRESSION: No acute fracture or malalignment.
CT HEAD W/O CONTRAST Study Date of [**2151-6-9**] 7:22 PM
IMPRESSION: No acute intracranial process.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2151-6-9**] 7:23 PM
CT CHEST W/CONTRAST
IMPRESSION:
1. No evidence of acute injury of the chest, abdomen or pelvis.
2. Small nodule in the left lobe of the thyroid; evaluation
with ultrasound is recommended when clinically appropriate.
Brief Hospital Course:
21 male with history significant of alcohol abuse, with syncope
in the setting of intoxication and recent head trauma. He was
intubated for altered mental status and admitted to the ICU, and
then transferred to medicine for further care.
1. Alcohol Dependence with Acute Intoxication, Alcohol
Withdrawal
- He began to have active alcohol withdrawal which required
increased dosing of valium to keep his CIWA < 10.
- He recieved Thiamine, Folate and a MVI
- He was seen by social work and plans were made for him to
transfer from [**Hospital1 18**] directly to an inpatient alcohol treatment
center.
- Patient was medically stable for transfer at time of discharge
2. Post-Concussive Sydrome
- Headache treated with tylenol
- By report the patient has had multiple concussions, and may
benefit from a neurologic evaluation as an outpatient, but this
is a chronic issue to best be addressed by his PCP
3. Anxiety
- Patient treated with ativan 1mg Q8H
4. Thyroid Nodule
- The incidental thyroid nodule noted on CT of the chest, was
communicated to the patient and PCP via letters. He will require
an outpatient ultrasound that can be arranged by the PCP
Full Code
Medications on Admission:
Adderral - dose unknown upon admissionPreadmissions medications
listed are incomplete and require futher investigation.
Information was obtained from Family/Caregiver.
1. Adderall *NF* (amphetamine-dextroamphetamine) unknown Oral
unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain/fever
Max 2g
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Acute alcohol intoxication
Acute alcohol withdrawal
Concussion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
See below
Followup Instructions:
Please call your Primary Care Physician after you are discharged
from rehabilitation
Name:O'[**Last Name (LF) **],[**First Name3 (LF) **] J
Location:[**Hospital **] MEDICAL ASSOCIATES
Address:[**Street Address(2) 112119**] #2A, [**Location (un) **],[**Numeric Identifier 90865**]
Phone:[**Telephone/Fax (1) 95599**]
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8761, 8776
|
7165, 8333
|
302, 313
|
8883, 8883
|
3882, 7142
|
9068, 9388
|
3094, 3206
|
8623, 8738
|
8797, 8862
|
8359, 8600
|
9034, 9045
|
3221, 3863
|
231, 264
|
341, 2646
|
8898, 9010
|
2668, 2875
|
2891, 3078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,547
| 140,486
|
8396
|
Discharge summary
|
report
|
Admission Date: [**2176-11-29**] Discharge Date: [**2176-12-7**]
Date of Birth: [**2112-1-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Sigmoidoscopy
TIPS?
History of Present Illness:
HPI: 64 y/o man with h/o cirrhosis and ulcerative colitis has
been experiencing lower GI bleed in the last 10 days. He notices
bright red blood per rectum with 3 bowel movements a day.
Yesterday he started experiencing BRBPR with diarrhea every
hour. He started experiencing dizziness while getting out of the
bed to the bathroom starting yesterday, worse today AM. He also
felt tired while walking. He was able to walk 1 mile without any
limiting symptoms few weeks ago. He decided to come to the
Emergency Department. His bowel movement stopped this morning at
5 am after taking Immodium.
He denies any chest pain, shortness of breath, palpitations,
fever, chills, nightsweats, cough, cold, dysuria, nausea,
vomitting or abdominal pain. He otherwise feels fine.
In the ED his vitals were 111/64 with HR 94. Patient started
receiving the first unit of blood. On arrival to the floor he
was asymptomatic with T 96.6 BP 111/47 HR 64 RR 19 with 100%
oxygen saturation in room air.
Past Medical History:
HTN
DMII
Cirrhosis
Tonsillectomy
Ulcerative colitis
Social History:
Lives alone, wife died in [**2168**]. Smoked for 33yrs X1ppd quit
[**2160**]. Does not drink alcohol, no drugs.
Family History:
HTN, Pancreatic CA
Physical Exam:
PE: T 96.6 BP 111/47 HR 64 RR 19 with 100% oxygen saturation in
room air.
Gen: Pleasant, well appearing gentleman with no apparent
distress
HEENT: Conjunctiva pallor. No icterus. MMM. OP clear.
NECK: Supple, JVP not elevated.
CV: RRR. nl S1, S2. I/VI systolic murmur best heard at RUSB
LUNGS: CTAB, good BS BL, No W/R/C
ABD: BS present, Distended with fluid waves. soft and nontender.
EXT: WWP, 3+ BLE edema
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2176-11-29**] 08:09AM PT-17.3* PTT-27.7 INR(PT)-1.6*
[**2176-11-29**] 08:09AM PLT COUNT-246#
[**2176-11-29**] 08:09AM WBC-19.1*# RBC-1.91*# HGB-6.0*# HCT-17.9*#
MCV-94 MCH-31.5 MCHC-33.6 RDW-18.7*
[**2176-11-29**] 08:09AM ALBUMIN-2.2*
[**2176-11-29**] 08:09AM LIPASE-88*
[**2176-11-29**] 08:09AM ALT(SGPT)-27 AST(SGOT)-30 ALK PHOS-103 TOT
BILI-1.7*
[**2176-11-29**] 08:09AM GLUCOSE-276* UREA N-38* CREAT-1.9* SODIUM-135
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-20* ANION GAP-13
[**2176-11-29**] 03:47PM WBC-18.1* RBC-2.21* HGB-6.9* HCT-20.2* MCV-92
MCH-31.5 MCHC-34.3 RDW-17.7*
[**2176-11-29**] 11:34PM WBC-5.3# RBC-2.29* HGB-7.3* HCT-20.3* MCV-89
MCH-31.7 MCHC-35.8* RDW-17.4*
[**2176-12-3**] 06:55AM BLOOD WBC-2.7* RBC-2.27* Hgb-7.6* Hct-21.5*
MCV-95 MCH-33.3* MCHC-35.2* RDW-17.5* Plt Ct-42*
[**2176-12-3**] 06:55AM BLOOD Plt Ct-42*
[**2176-12-3**] 03:25AM BLOOD PT-19.5* PTT-35.6* INR(PT)-1.8*
[**2176-12-3**] 03:25AM BLOOD Glucose-200* UreaN-48* Creat-1.9* Na-137
K-3.8 Cl-107 HCO3-23 AnGap-11
[**2176-12-3**] 03:25AM BLOOD Calcium-7.7* Phos-4.4 Mg-2.0
.
[**11-29**] CXR: CONCLUSION: No acute cardiopulmonary process.
.
TIPS: pending
[**2176-12-3**] 03:45PM BLOOD WBC-3.2* RBC-2.87*# Hgb-9.2* Hct-26.9*#
MCV-94 MCH-31.9 MCHC-34.1 RDW-18.0* Plt Ct-41*
[**2176-12-4**] 04:08AM BLOOD WBC-2.7* RBC-2.73* Hgb-8.9* Hct-25.2*
MCV-92 MCH-32.4* MCHC-35.2* RDW-17.3* Plt Ct-33*
[**2176-12-4**] 04:08AM BLOOD PT-20.4* PTT-34.3 INR(PT)-1.9*
[**2176-12-4**] 04:08AM BLOOD Plt Ct-33*
[**2176-12-4**] 04:08AM BLOOD Glucose-185* UreaN-42* Creat-1.7* Na-142
K-3.9 Cl-108 HCO3-26 AnGap-12
[**2176-12-4**] 04:08AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.9
.
Ultrasound [**2176-12-6**]: 1. Patent TIPS shunt with wall-to-wall flow.
Flow within the left portal vein is hepatopetal which is not in
the direction of the TIPS shunt and this is an unexpected
finding. Flow could not be documented in the anterior right
portal vein. Because of this a short-term followup ultrasound in
six weeks is recommended to re-assess TIPS patency. 2.
Cirrhotic-appearing liver. 3. Moderate ascites. 4. Splenomegaly.
Brief Hospital Course:
A/P: 64 y/o man with h/o cirrhosis and ulcerative colitis has
been experiencing lower GI bleed in the last 10 days.
.
# GI bleed: Known Ulcerative colitis. Had multiple oozing
lesions on sigmoidoscopy and it was thought that his oozing
would not stop until his portal HTN was relieved. His Hct was
17.9 on presentation, he recieved 6U PRBCs and his HCT went up
to 26 and then dropped back to 22. He was given 2 more U PRBC's.
His UOP dropped on [**11-30**] to 20cc/hr and he was given several
boluses of fluid and his UOP improved. Is no longer having
bloody bowel movements, Got TIPS done [**12-3**]. During procedure
found to have portal vein clot. Had 3L removed during para with
TIPS. Given 25g albumin and 3L IVF. After tips HCT drop from
27.2 to 22.2, to 21.5. Felt to be dilutional, no further bloody
BM, no abd pain to suggest subcapsular bleed. Liver no longer
suspect UC flare, finished steroids course. Per liver d/ced
cipro and Flagyl as does not have UGI bleed in need of ppx. IR
reccomends consider US abd to access for subcapsular bleed if
HCT does not stabilize. Received 2 U pRBC, with 20 IV lasix
prior and 20 IV lasix after infusion w/good urine output. Hct
stable 12h post-transfusion and patient is asymptomatic >24h
post-TIPS procedure.
.
# Cirrhosis [**2-3**] NASH: Patient with ascites and coagulopathy.
Underwent TIPS [**12-2**] to correct portal hypertension. Stopped
Octreotide post procedure. Per liver to Cointinue on mesalamine,
ursodiol.
- Started Lactulose, Lasix and Spironolactone
- Patient to start eval for liver transplant as an outpatient
**** Ultrasound [**2176-12-6**] demonstrated left portal vein flow is
hepatopetal which is not in the direction of the TIPS shunt -
recommended f/u ultrasound in 6 weeks ****
.
# SOB: Increased oxygen requirement after TIPS and 3L IVF. CXR
c/w fluid overload, patient with anasarca. Started nebs and gave
Lasix boluses. Breathing improved with lasix boluses, but still
requiring 3L NC O2 to maintain O2 sat in 90's. Resolved with
diuresis, stable on room air.
.
# Thrombocytopenia: Baseline is 50-70s, likely secondary to
NASH/cirrhosis/splenomegaly. Plt downtreanding to 33. Hold
transfusion unless signs of active bleeding.
.
# Elevated INR: likely due to cirrhosis. Given several units of
FFP before TIPS procedure with INR never dropping below 1.8. 24h
post procedure, INR is 1.9.
.
# CRI: BL Cr 1.8-2.1. Currently at baseline, decreased to 1.9.
.
# DM2: Last HbA1c on [**10-9**] was 7.1. Elevated finger sticks.
ISS and long-acting insulin titrated up during patient's stay.
Added 15U Glargine QHS on [**12-4**].
.
# Constipation: lactulose held b/c of GI bleeding, patient with
poor PO intake for last few days, likely contributing to
constipation. KUB w/out evidence for obstruction.
- started lactulose
.
# R medial ankle ulcer: Likely due to friction from footwear as
per patient. Good DP pulses, should heal well. Wound care
consulted. Patient discharged with VNA wound care.
Medications on Admission:
Dutasteride 0.5 mg daily
Mesalamine DR 1600 mg daily
Pantoprazole 40 mg twice a day
Finished prednisone taper yesterday
Propanolol 20 mg twice a day
Tolterodine sustained release 4 mg daily
Ascorbic acid
Ferrous sulfate 325 mg daily
MVI with iro
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): hold for > 1 BM daily .
Disp:*qs 1 month supply 15 ml syrup* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. Insulin
Please continue to take your Insulin as directed by your doctor
prior to admission. We have made no changes.
10. Lab Chem-7, Phosphate, HCT
Chem-7 + Phosphate + HCT Wednesday [**2176-11-11**]. Patient
started on Lasix and Spironolactone, important to follow K and
Creatinine. Phosphate low during admission. Forward results to
Dr. [**First Name4 (NamePattern1) **] [**First Name8 (NamePattern2) 3037**] [**Doctor Last Name 349**], [**Hospital1 18**] GI fellow, phone number
[**Telephone/Fax (1) 463**], fax number([**Telephone/Fax (1) 29644**].
11. Dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
12. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
13. Propranolol 20 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Commercial wound cleanser
qs
15. Moisture barrier ointment
qs
16. Duoderm Gel
qs
17. Gauze Bandage 4 X 4 Bandage Sig: One (1) Topical once a
day.
Disp:*30 gauze* Refills:*2*
18. Kerlix wrap
qs
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary:
Portal Colopathy s/p TIPS
Cirrhosis - portal HTN, portal colopathy, esophageal varices
Ascites
Secondary:
Chronic renal failure
Ulcerative colitis
Diabetes
Discharge Condition:
Good, ambulating, blood count stable.
Discharge Instructions:
You were admitted to the ICU for a lower GI bleed. You had a
sigmoidoscopy which demonstrated vascular congestion caused by
portal hypertensive colopathy. Consequently, you had a TIPS
procedure [**2176-12-2**].
.
We have started the following new medications: Lactulose, Lasix,
Spironolactone. Otherwise take your medications as directed and
review your discharge medications closely.
.
Your recommended diet: Low salt, diabetic.
.
Attend all your follow-up appointments.
.
Return to the ER if you experience bleeding, lightheadness, fast
heart rate, confusion, fever, chills, nausea, vomiting or any
other concerning symptoms.
Followup Instructions:
The liver center will call you for an appointment in [**Month (only) 1096**]
for transplant evaluation with Dr. [**Last Name (STitle) 696**]. If you do not hear
from them in 1 week, please call [**Telephone/Fax (1) 2422**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2177-1-7**] 8:45
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2177-1-15**] 1:00
Completed by:[**2176-12-9**]
|
[
"286.9",
"280.0",
"585.9",
"403.90",
"578.9",
"571.5",
"287.5",
"572.3",
"707.13",
"584.9",
"250.00",
"789.59",
"556.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.23",
"54.91",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
9490, 9546
|
4387, 7360
|
321, 342
|
9755, 9795
|
2269, 4364
|
10472, 10985
|
1571, 1591
|
7656, 9467
|
9567, 9734
|
7386, 7633
|
9819, 10449
|
1606, 2250
|
276, 283
|
370, 1350
|
1372, 1425
|
1441, 1555
|
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