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16,314
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7484
|
Discharge summary
|
report
|
Admission Date: [**2190-8-13**] Discharge Date: [**2190-8-21**]
Date of Birth: [**2137-9-2**] Sex: M
Service: cARDIAC [**Doctor First Name **]
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Hypertension.
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Coronary artery disease.
PAST SURGICAL HISTORY: Status post tonsillectomy and
adenoidectomy.
ALLERGIES: Shellfish and dye.
MEDICATIONS ON ADMISSION:
1. Levothyroxine 100 mcg p.o. once daily.
2. Atorvastatin 10 mg p.o. once daily.
3. Insulin NPH 26 units q.a.m.
HISTORY OF PRESENT ILLNESS: The patient is a 52 year old
diabetic man who has been told to have routine ETT over
years. The study from [**2189-2-25**], revealed moderate defect in
the apical wall, apical portion of anterior wall, apical
portion of septal wall, partially reversible. The ejection
fraction was 50%. Symptomatically, the patient denied any
chest discomfort or shortness of breath. In [**2190-1-22**],
he had a cardiac catheterization. Left anterior descending
had a long segment with 90% stenosis which was treated with
stents. The circumflex had 70% stenosis which was also
treated with stent and ramus and right coronary artery had no
disease.
Several months ago, the patient began to notice some mild
shortness of breath after climbing one flight of stairs. He
does not report any chest pain, but felt occasional
epigastric discomfort that involved significant exertion,
i.e. playing basketball with his children. Stress
echocardiogram from [**2190-7-29**], was stopped due to fatigue.
Imaging revealed ischemia of the distal septum extending to
apex. Ejection fraction was noted to be 53%.
PHYSICAL EXAMINATION: On admission, the patient is a
pleasant, cooperative male in no acute distress.
Cardiovascular - regular rate and rhythm, no murmurs.
Respiratory - Crackles at the bases bilaterally. The abdomen
is soft, nontender, nondistended. Extremities are warm and
well perfused. Blood pressure is 110/60, pulse 90. Blood
sugar 110 to 457.
LABORATORY DATA: Hematocrit 35.9, blood urea nitrogen 16,
creatinine 1.9, potassium 4.5.
HOSPITAL COURSE: The patient had a cardiac catheterization
on [**2190-8-13**], which showed total occlusion of left anterior
descending proximal to the stent and collaterals distant to
stent, diffuse 95% in-stent stenosis of left circumflex. The
patient was admitted to Medicine Service and preoperatively
was afebrile, pain free and vital signs were stable.
The patient was taken to the operating room on [**2190-8-16**],
where coronary artery bypass graft times two with left
internal mammary artery to left anterior descending and
saphenous vein graft to OM was performed. The operation went
without complications. Pacing wires as well as chest tubes
were placed intraoperatively. The patient was transferred to
Cardiac Surgery Intensive Care Unit in stable condition.
Postoperative day number one, the patient was extubated
successfully without complications. He was afebrile. He was
started on Lopressor and transferred to regular floor in
stable condition. Postoperative day number two, the patient
had a low grade fever of 100.9. His wires were removed
without complication. He is ambulating. He is complaining
of intermittent nausea and occasional vomiting which were
relieved by Zofran. His liver function tests and amylase and
lipase were all within normal limits. His abdominal
examination was unremarkable.
The patient's blood sugar is running between 300 and 400 on
24 units of NPH. His NPH was increased to 40 units in the
morning and [**Last Name (un) **] consultation was requested. He was put on
more strict regular insulin sliding scale with blood checks
every four hours.
Postoperative day number three, the patient was afebrile with
stable vital signs. He still has some occasional nausea and
vomiting. The patient stated that he recently quit smoking
abruptly and he was started on Nicoderm patch which relieved
some of his symptoms.
Postoperative day number three, the patient's blood sugar was
between 70 and 210. He required very little sliding scale
insulin. Postoperative day number five, the patient was
afebrile with stable vital signs. His blood sugar is running
between 100 and 200. His nausea and dizziness has resolved.
No concerns and no active issues at this point.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged home.
FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) 70**]
in six weeks. The patient will follow-up with [**Last Name (un) **]
Diabetes Center for his diabetic education and insulin
management.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. twice a day.
2. Enteric Coated Aspirin 325 mg p.o. once daily.
3. Levothyroxine 100 mcg p.o. once daily.
4. Atorvastatin 10 mg p.o. once daily.
5. Reglan 10 mg p.o. three times a day.
6. Nicotine Patch 14 mg transdermal once daily.
7. Percocet one to two tablets p.o. q4-6hours p.r.n.
8. Motrin 400 mg p.o. q8hours p.r.n.
9. Tylenol 650 mg p.o. q6hours p.r.n.
10. Docusate 100 mg p.o. twice a day.
11. Insulin NPH 40 units subcutaneous q.a.m.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Diabetes mellitus.
3. Hypertension.
4. Hyperlipidemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2190-8-21**] 11:21
T: [**2190-8-21**] 11:38
JOB#: [**Job Number 27384**]
|
[
"250.00",
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"414.00",
"412",
"305.1",
"244.9"
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icd9cm
|
[
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[]
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icd9pcs
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|
4373, 4647
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,885
| 172,355
|
41941
|
Discharge summary
|
report
|
Admission Date: [**2157-9-5**] Discharge Date: [**2157-9-16**]
Date of Birth: [**2078-7-28**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Found down after fall, right hemiparesis
Major Surgical or Invasive Procedure:
[**2157-9-5**]: Left Craniotomy for evacuation of subdural hematoma
[**2157-9-15**]: PEG
History of Present Illness:
This is a 79 year old man who was found at the bottom of a
flight of stairs after last being seen that afternoon. He was
awake and responsive,though unable to speak or move his right
side. EMS responded, and the patient was taken to an OSH where
he was intubated for airway protection and a CT scan was
performed showing a 2 cm left hemispheric subdural hematoma. He
was
transferred to [**Hospital1 18**] for further care.
He was administered 10 mg vitamin K, weight based profilline,
and 2 units FFP per coumadin rx with an INR of 2.4. He was
unable to give any history, arrived from OSH intubated/sedated.
Past Medical History:
Prior stroke
a-fib
b12 defy
dementia
HTN
anemia
EtOH
Social History:
Daily EtOH use, 10oz of wine per reports. Lives independently.
Family History:
NC
Physical Exam:
On Admission:
BP: 150's systolic HR:85 Intubated/vented
Pupils equally round and reactive to light
Unable to elicit corneal reflexes
Gags to ETT manipulation
c-collar in place
w/d left upper ext to deep stim
w/d left lower ext to deep stim
no movement right upper/lower ext to deep stim
At discharge: <<<<<<<<<<<<<<<<<<
Pertinent Results:
[**2157-9-5**] 08:40PM PT-24.2* PTT-26.7 INR(PT)-2.3*
[**2157-9-5**] 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2157-9-5**] 08:40PM WBC-11.4* RBC-3.59* HGB-12.9* HCT-38.6*
MCV-108* MCH-35.8* MCHC-33.4 RDW-13.1
[**2157-9-5**] 09:52PM PT-14.8* PTT-20.1* INR(PT)-1.3*
[**9-5**] CXR: Portable chest radiograph was obtained with patient
positioned
semi-upright. The endotracheal tube tip resides approximately
3.7 cm above the carina. The NG tube courses into the left upper
quadrant. There is mild left basilar plate-like atelectasis.
There is subtle nodular opacity projecting over the right upper
lung which could represent costochondral calcification though
the possibility of a true pulmonary nodule is difficult to
exclude. The cardiomediastinal silhouette appears grossly
unremarkable. Old left-sided rib fractures are noted.
[**9-5**] CT head: IMPRESSION: Large left hemispheric subdural
hematoma with 13 mm of rightward shift of midline structures,
not significantly changed from the OSH study.
[**9-6**]: CT head: IMPRESSION: Status post evacuation of large left
subdural hematoma with persistent 12 mm of rightward subfalcine
herniation, extensive pneumocephalus, but no new sites of
hemorrhage.
[**9-6**] CT head: FINDINGS: Patient is status post left-sided
craniotomy for subdural evacuation with extensive pneumocephalus
and hyperdense subdural collection once again visualized.
Improvement of rightward shift of approximately 7 mm of the
normally midline structures. No right-sided hemorrhage or new
foci of hemorrhages are seen. No infarction or edema is seen.
[**2157-9-7**] MRI Cervical spine: No signs of ligamentous disruption
or acute trauma to the cervical spine identified. Chronic
compressions of T4 and T5 vertebral bodies are noted. No
abnormal signal within the spinal cord or intraspinal hematoma.
Multilevel degenerative changes.
[**2157-9-7**] CT head
Minimal change since the examination at 12:01PM. No new
hemorrage or large
vascular territorial infarct detected. No new mass effect.
Improved moderate pneumocephalus.
[**2157-9-8**] CXR
Interval extubation. Unchanged left lung basilar atelectasis
[**2157-9-8**] CXR
Appropriate Dobbhoff line placement
[**2157-9-8**] EEG: left temporal slowing, no epileptiform waves
[**2157-9-10**]: CT head noncontrast: Stable left subdural collection
status post left craniotomy
[**9-11**] portable CXR: Cardiomediastinal contours are stable in
appearance. Subtle heterogeneous opacities in the left mid and
lower lung have been somewhat waxing and [**Doctor Last Name 688**] for serial
radiographs since [**2157-9-6**] and could potentially be due
to aspiration considering the clinical suspicion for this
entity. Minor atelectasis is present at the right lung base.
[**2157-9-12**] KUB: A nasogastric tube is seen traversing the stomach
with angulation of its distal portion, with its tip most likely
in the body of the stomach (post pyloric location of the tip is
felt less likely due to the horizonal course of the distal
portion of the tube). There is a nonspecific gas pattern. There
is no free air. There is a screw seen in the right femoral head.
There are degenerative changes of the lumbar spine.
[**9-12**] portable CXR:
[**9-12**]: Lower extremity dopplers: Negative for DVT
Brief Hospital Course:
Mr [**Known lastname 3827**] was taken for emergent craniotomy on [**9-5**] for
evacuation of acute left sided subdural hematoma.
Postoperatively he remained intubated and was transferred to the
ICU for frequent neuro checks and systolic blood pressure
control less than 140. Postoperative head CT demonstrated good
evacuation of clot with postcraniotomy pneumocephalus for which
he was maintained on 100% FIO2 for 24 hours. Wound care was
consulted for evaluation of his right shoulder and trochanter
wounds/ulcers from his initial injury. They made dressing
recommendations and will continue to follow.
Repeat Head CT on [**9-6**] demonstrated improved midline shift and
the patient's exam improved significantly. He started to follow
commands in all extremities except for the right arm however he
did demonstrate antigravity strength in the right arm. He
remained intubated in order to obtain an MRI of his cervical
spine to rule out ligamentous injury. MRI was performed
overnight on [**9-6**]. It showed no signs of ligamentous
disruption, acute trauma to the cervical spine or signs of
spinal cord injury and subsequently on [**9-7**] the cervical collar
was removed.
The patient's exam continued to improve and on [**9-7**], POD 2, and
the patient was extubated. He developed some agitation in the
evening and was unable to follow commands and was mroe
dysphasic.
CT head was repeated and there was no new hemorrhage. The
pneumocephalus was resolving. He required 0.5 mg ATivan for the
CT imaging. He was also given morphine for tachycardia in the
event that this was pain related. This helped with HR and
behavior for about 2 hours. He was then again agitated and
tachycardic and Haldol was given prn.
On [**9-8**], patient was more lethargic on examination, but
following simple commands. His morphine dosing was decreased and
he was transferred to the step down unit. Speech and swallow
evaluation was unable to be completed due to patient
participation and patient will require a dobhoff.
On [**9-9**] he was placed on continuous EEG monitering for rule out
seizure in the setting of persistent lethargy. This showed no
epileptiform waveforms but left temporal slowing. Neuro exam
was unchanged. He had an episode of tachycardia associated with
a SBP of 168. This resolved with one dose of Metoprolol 5gm IV.
Dilantin level was 8 with an albumin level of ***
On [**9-10**] his corrected dilantin was 7.6 and so he received 500mg
IV dilantin bolus. Noncontrast Head CT was stable. Digoxin
level was 0.5. His neurological exam remained stable.
On [**9-11**] he was able to get OOB to chair with max assist. FS
blood sugars were stable ranging 130 to 150 and RISS was
discontinued. Tube feeds were advanced to gaol at 70.
Corrected dilantin level 10.2. As patient remained seizure
free, 24 hour EEG monitering was discontinued. The patient
developed tachypnea and coarse Lung sounds on [**9-11**] into [**9-12**].
Portal CXR demonstrated increased interstitial markings
indicating fluid overload. He responded to a one-time dose of
Lasix 20mg IV with improved breathing and urinary output of 2
liters. He pulled out his NG tube and a Dobhoff tube was
replaced, confirmed to be in the stomach by KUB.
On [**9-12**] the patient's mental status was signifincantly
improved. He remained attentive thoughout the evaluation, was
AOx2 to self and "hospital", antigravity in right upper
extremity. Lower extremity doppler ultrasounds were negative
for DVT bilaterally. His corrected Dilantin was 7.2 and so he
received a 300mg IV bolus of Dilantin and his dose was adjusted
to 200 [**Hospital1 **]. Although he was able to participate more than in
past exams, he failed a speech and swallow evaluation.
Discussion was held with the healthcare proxy about the utility
of PEG placement and the proxy agrees to consent. General
surgery was consulted for PEG placement.
The Medicine team was consulted on resuming coumadin for Afib in
the setting of a fall with significant acute SDH. They
recommending holding coumadin for 4 weeks and deferred
decision-making to the patient's PCP. [**Name10 (NameIs) **] the meantime they
recommended placing the patient on ASA 325mg daily once cleared
from a neurosurgical perspective as the patient does have
history of CVA.
On [**9-15**], patient's exam remained stable, he was taken to the OR
for placement of a PEG. This was un-complicated. The patient's
dilantin level was subtherapeutic therefore he was given a bolus
of dilantin and increased his standing dose.
On [**9-16**] his tube feeds were restarted and his foley catheter
was discontinued. A plastics consultation was requested for
evaluation of his right trochanter wound per the wound care
nurse. They recommended continue with current dressing care, no
debridement is necessary at this time and that the patient can
follow up in clinic at a later time. At this time he was cleared
for discharge to a rehab facility.
Medications on Admission:
warfarin
lopressor
fosamax
b12
digoxin
ocuvite
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. oxycodone 5 mg/5 mL Solution Sig: Five (5) ml PO Q4H (every 4
hours) as needed for pain.
10. phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO BID (2 times a day).
11. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days: discontinue after dose on [**9-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] [**Hospital **] Hospital of [**Location (un) 246**]
Discharge Diagnosis:
Left Acute Subdural hematoma
Delirium
dysphagia
[**Hospital **]
Hospital aquired pneumonia
right troachanter decubitus / unstageable from evaluation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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.
?????? You may wash your hair
?????? 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 were on a medication Coumadin (Warfarin), prior to your
injury. We are recommending that you do not take this medication
for 4 weeks. You should follow up with your PCP and discuss the
risks and benefits of restarting this medication after 4 weeks.
?????? 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**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast.
We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]
?????? You were seen by the Plastic Surgery for your right
trochanter wound while in house. They recommended following up
with them in their clinic. This can be arranged by calling ([**Telephone/Fax (1) 29379**].
Completed by:[**2157-9-16**]
|
[
"852.26",
"707.04",
"285.9",
"707.25",
"784.3",
"784.59",
"486",
"733.00",
"785.0",
"266.2",
"E880.9",
"427.32",
"V58.67",
"780.09",
"342.90",
"401.9",
"276.69",
"294.20",
"427.31",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"43.11",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11025, 11121
|
4960, 9916
|
348, 439
|
11313, 11313
|
1619, 2511
|
13381, 14145
|
1256, 1260
|
10014, 11002
|
11142, 11292
|
9942, 9991
|
11489, 13358
|
1275, 1275
|
1579, 1600
|
268, 310
|
467, 1081
|
2896, 4937
|
1289, 1565
|
11328, 11465
|
1103, 1158
|
1174, 1240
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,917
| 185,345
|
5973
|
Discharge summary
|
report
|
Admission Date: [**2102-12-13**] Discharge Date: [**2102-12-16**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Alcohol withdrawal
.
Major Surgical or Invasive Procedure:
None.
.
History of Present Illness:
46 year old man with a history of alcohol abuse, HTN, HCV,
alcoholic cardiomyopathy (LVEF 25%), and bilateral cavitary
pulmonary lesions who is admitted to the MICU for management of
alcohol withdrawl and hypertension. Per the patient, he was
recently hospitalized at [**Hospital1 2177**] for shortness of breath and was
discharged on [**2102-12-9**]; during this admission, per the patient,
he was ruled out for TB and was diagnosed with having "fluid in
my lungs"; he reports being put on a completely new regimen of
"heart medications". Following his discharge on [**2102-12-9**], he
reports that he went home and took all of his new medications.
After this he fell asleep and he reports waking up 24 hours
later. At this point, he was feeling very anxious because he
couldn't find his keys, so he went out and bought a gallon of
vodka which he proceeded to consume. Per the patient, this was
his first time drinking in several months. He was later found
outside his home by someone who called EMS. Per EMS reports, the
patient had alluded to suicidal thoughts (which he is currently
denying). His last drink was reportedly around 2pm on [**2102-12-12**].
.
Upon arrival to the [**Hospital1 18**] ED, he was afebrile, HR 104, BP
100/66. His labs were notable for a serum ethanol level of 407
with an anion gap of 20 and a creatinine of 1.5 (up from a
baseline of 0.9). He was given normal saline for hydration and
diazepam per a CIWA scale. Throughout the day today, he has
become progressively more tremulous with increasing diazepam
requirements (by report, 50 mg IV over the past 3 hours). He has
also become increasingly hypertensive with a peak BP of 230/115
requiring IV hydralazine. Currently, his only complaint is of
feeling anxious and tremulous. He denies SI/HI and denies AH/VH.
.
Past Medical History:
Past Medical History:
- EtOH abuse
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy (EF 25%)
- cocaine abuse (last use ~ 3 weeks ago)
- hypothyroidism
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated Aspergillous
fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]
- h/o C. diff colitis
- h/o IVDA per OSH records (pt denies)
.
Social History:
Smokes < [**1-3**] ppd recently; prior to that he smoked 1 ppd x30
years. Heavy EtOH use (usually >1 gallon vodka per day). Sober
x10 years up until ~2 years ago; more recently, reports several
months of sobriety. +Cocaine abuse; last use several wks ago. He
denies IVDA. Sexually active with his girlfriend.
.
Family History:
Mother with CAD. Sister with h/o CVA.
.
Physical Exam:
Physical Examination:
T 96.2 BP 168/99 HR 112 RR 15 Sat 99% on ra
General: tremulous but cooperative
[**Month/Day (2) 4459**]: symmetric periorbital edema; no icterus, conjunctival
erythema, pupils 5mm and symmetric
Neck: supple; s/p resection of left SCM muscle
Chest: clear to auscultation throughout
CV: rrr, II/VI systolic murmur at RUSB
Abdomen: soft, NTND, normal BS, no HSM
Extr: no edema, 2+ PT pulses
Skin: no rashes or jaundice
Neuro: alert, oriented, cooperative; CN 2-12 intact; [**5-6**]
strength in both arms and legs
.
Pertinent Results:
Pertinent labs:
[**2102-12-12**] GLUCOSE-114* UREA N-16 CREAT-1.5* SODIUM-141
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-23
[**2102-12-12**] WBC-7.6 (N-57.2 L-35.7 M-3.0 E-2.4 B-1.7) HGB-13.8
HCT-40.4 PLT-253
[**2102-12-13**] ALT(SGPT)-58* AST(SGOT)-99* ALK PHOS-67 TOT BILI-0.9
ALBUMIN-3.9
.
[**2102-12-12**] serum tox screen ASA-NEG* ETHANOL-407* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
.
CXR ([**2102-12-13**]):
Known upper lobe cavitary lesions with mycetomas are less well
seen than on CT but cavitary lesions with air are unchanged in
appearance from [**2102-11-23**]. [**Hospital1 **]-apical, right greater than left,
pleural thickening with hilar retraction likely represent old
granulomatous disease. Otherwise the lungs are well expanded and
clear. No pneumothorax or pleural effusions are present. The
heart size, mediastinal and hilar contours, and pulmonary
vessels are unremarkable. Bony thoracic cage appears intact.
.
Brief Hospital Course:
Alcohol withdrawal: Upon admission, the patient was tremulous,
started on a CIWA scale with valium q2 hours. He was admitted
to the MICU overnight for blood pressure control. Over the first
24 hours, he received 20mg valium ever 2 hours. After coming to
the regular medical floor, he was transitioned to valium every 4
hours. On hospital day 3, valium was discontinued. He was
started on thiamine/MVI/folic acid. SW was consulted. He was
discharged to home and stated that he would pursue inpatient
rehab.
.
Hypertension: His home regimen is unknown. He was started on
lisinopril and metoprolol here, and received IV hydral x1 on
admission. His blood pressure was well controlled on discharge.
.
Dilated Cardiomyopathy (EF 25%): He appeared euvolemic on exam.
As above, his outpatient regimen was unknown. He was started on
aspirin and a beta blocker.
.
Acute renal failure: His creatinine was elevated to 1.5 on
admission but improved to 0.8 with IVF. This was most likely
pre-renal renal failure.
.
Hypothyroidism: He was continued on levothyroxine per his
outpatient regimen.
.
Pulmonary mycetomas: Stable from prior imaging studies; no need
for further workup/treatment at this time.
.
He was full code for this admission.
.
Medications on Admission:
Home Medications (per [**11/2102**] OMR discharge summary; pt reports
that his "heart medications" were changed around last weekend at
[**Hospital1 2177**] but doesn't know his new regimen):
levothyroxine 75 mcg daily
folic acid 1 mg daily
thiamine 100 mg daily
aspirin 81 mg daily
lisinopril 30 mg daily
buspirone 10 mg [**Hospital1 **]
omeprazole
.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Alcohol withdrawal
Secondary:
1) Anxiety
2) Hypertension
3) Alcoholic cardiomyopathy
.
Discharge Condition:
Vital signs stable.
.
Discharge Instructions:
You were admitted to the hospital for alcohol withdrawal. You
should continue to abstain from drinking. You were also started
on a medication regimen for your anxiety and your high blood
pressure. Please take all medications as prescribed.
.
If you develop chest pain, shortness of breath, persistent fever
> 101, please return to the nearest emergency room.
.
Followup Instructions:
You will need to schedule follow-up with a primary care
physician in the next two weeks. Please call [**Telephone/Fax (1) 250**] to
schedule an appointment with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 23537**].
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"425.5",
"303.01",
"291.81",
"244.9",
"305.60",
"070.70",
"584.9",
"V10.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
6889, 6895
|
4546, 5779
|
337, 347
|
7035, 7059
|
3579, 3579
|
7468, 7835
|
2969, 3010
|
6181, 6866
|
6916, 7014
|
5806, 6158
|
7083, 7445
|
3025, 3025
|
3047, 3560
|
277, 299
|
375, 2174
|
3595, 4523
|
2218, 2625
|
2641, 2953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,389
| 171,935
|
20241
|
Discharge summary
|
report
|
Admission Date: [**2160-12-19**] Discharge Date: [**2160-12-29**]
Date of Birth: [**2108-6-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of breath. Referred for bronchoscopy
Major Surgical or Invasive Procedure:
1. Bronchoscopy on [**2160-12-20**]
2. Chest tube placment for pneumothorax on [**2160-12-20**]
3. Chest tube re-placement for expanding pneumothorax on [**2160-12-23**]
History of Present Illness:
52 yo female with advanced pulmonary emphysema on home oxygen
therapy through a transtracheal catheter placed four months ago
transferred from [**Hospital3 **] Hospital for evaluation of increased
SOB and bronchoscopy by IP. Pt was admitted to [**Hospital3 **] Hospital
on [**2160-12-9**] with increased SOB for approximately one week. She
reports that she was in her normal state of health until that
time. At baseline, she could walk half a block at a normal pace
without becoming SOB. However, one week PTA the pt became
acutely SOB at rest and with any exertion. On [**2160-12-7**] she had
a CT scan of the chest to evaluate the increasing SOB. It showed
increased soft tissue thickening of the peribronchilar perihilar
tissues on the right extending toward the right middle lobe and
a 1 cm spiculated density in the posterior segment of the right
upper lobe. This has strands of density extending posteriorly
and laterally to the pleural surfaces and anteriorly toward the
right hilum. There were chronic emphysematous changes and cysts
in the uppler lobes. On the morning of admission, the pt noted a
singificant increase from her baseline SOB. In addition, she had
a cough productive of a small amount of brown, yellow sputum. Pt
felt febrile but did not check her temperature. She denies
orthopnea, PND, CP, and hemoptysis.
.
On admission to the [**Name (NI) **], pt's labs included a WBC count of
[**Numeric Identifier 7923**], Ht of 40, and troponin of 0.1. She was treated with a
seven day course of deftin which was completed today, IV
steroids, and nebs. A bone scan was obtained which was negative
for evidence of metastatic disease. It did show some mild
degenerative changes of the right knee. On [**2160-12-16**], the pt
developed severe respiratory distress with concern for impending
respiratory failure. An ABG was obtained while the pt was on 4L
o2 by transtracheal catheter showed a pH of 7.2, pO2 of 113, and
pCO2 of 91. The pt's pH normalized quickly with aggressive
bronchodilator therapy and diuresis. Bronchoscopy was performed
at this time to evaluate for upper airway obstruction. This
showed extensive debris within the distal trachea concerning for
retained secretions, granulation tissues, or obstruction. The
carinae and main stem bronchi coing not be visualized. Biopsies
and washings of the area was obtained. The decision was then
made to transfer the pt to [**Hospital1 18**] so Dr.[**Last Name (STitle) **] could further
evaluate the airway with repeat ripid bronchoscopy.
.
On arrival, pt was resting comfortably in bed. She continues to
have some intermitten brown sputum production. She feels that
her SOB is not better. Occasional chest pain with coughing but
not at rest or with exertion. No abdominal pain, nausea, or
vomiting. Good appetite. No diarrhea or blood in her stools, No
dysuria or hematuria.
Past Medical History:
1.COPD
2. Small cell lung CA s/p chemotherapy and radiation in [**2155**]. Pt
has metastasis to her spine. On evaluation by oncology in
[**1-/2160**], the patient was felt to be cancer free.
3. Radiation fibrosis of the right lower lung
4. Osteoporosis
5. Chronic back pain
6. Type 2 DM
7. Depression
Social History:
Pt is married and lives with her husband and dog. She has an
involved family including a daughter, brother, and sister in
law. Former smoker but quit in [**2154**]. No ETOH or drugs.
Family History:
non-contributory
Physical Exam:
PE: P 108 bp 140/77 RR 20 Pox 99%/transtracheal 4L O2 NC and 2L
NC O2
Gen- Alert and oriented. NAD. Able to speak in complete
sentences without becoming SOB
HEENT- NC AT. PERRL. EOMI. MMM. No lesions in the OP.
Neck- Transtracheal catheter in place.
Cardiac- Distant heart sounds. RRR.
Chest- R sided sm caliber chest tube in place, R ant chest wall
Pulm- Coarse, decreased breath sounds thoughout. Bronchial BS
upper fields, prolonged expiratory phase.
Abdomen- Obese. Soft. NT ND. Positive bowel sounds.
Extremities- Trace BLE, warm, no palpable cords. 2+ DP pulses
bilaterally.
Pertinent Results:
[**2160-12-19**] 09:18PM WBC-16.5*# RBC-4.02* HGB-13.2 HCT-39.2 MCV-98
MCH-32.7* MCHC-33.6 RDW-13.1
[**2160-12-19**] 09:18PM PLT COUNT-241
[**2160-12-19**] 09:18PM NEUTS-94.1* LYMPHS-3.1* MONOS-2.5 EOS-0.1
BASOS-0.2
[**2160-12-19**] 09:18PM PT-12.8 PTT-23.0 INR(PT)-1.0
.
[**2160-12-19**] 09:18PM GLUCOSE-120* UREA N-26* CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-35* ANION GAP-10
[**2160-12-19**] 09:18PM CALCIUM-9.4 PHOSPHATE-2.7 MAGNESIUM-2.2
.
[**2160-12-19**] EKG: Sinus tachycardia @100
Poor R wave progression - ? lead placement
Since previous tracing, QRS changes in V3 - ? lead placement
.
[**2160-12-19**] CXR: Emphysema most marked in upper lobes. No change in
right basilar density since prior study of [**2160-9-9**]. No
new lung lesion. old healed fracture left 6th rib.
.
[**12-29**] CXR: FINDINGS: A single AP upright image. Comparison study
dated [**2160-12-28**]. There is again evidence of generalized
pulmonary emphysema, slightly worse on the right side. This is
associated with lung hyperinflation and vascular attenuation. No
focal pulmonary infiltrate is identified. No definite effusion
is seen. A small bore tracheostomy catheter is noted. No right
apical pneumothorax could be appreciated.
IMPRESSION: Severe emphysema. No focal pulmonary or pleural
abnormalities.
Brief Hospital Course:
1. Shortness of breath: Pt with very complicated pulmonary
picture. Severe underlying emphysema with a history of small
cell lung CA. Pt also has radiation fibrosis of the right lower
lobe. Pt underwent bronchoscopy on [**12-19**] with removal of a large
amount of mucous. Following this, pt had an episode of
repiratory distress and was found to have a right sided
pneumothorax. A chest tube was placed and the pt was transferred
to the MICU for closer monitoring. Her respiratory status
stabalized and she was transferred back to the floor on the
following day. She remained stable from a respiratory standpoint
with a good oxygen saturation on nasal canula and transtracheal
catheter. Chest tube was pulled on [**12-22**]. On [**12-23**], pt had an
expanding pneumo so chest tube was replaced. Pt improved with
this and the chest tube was pulled on [**12-26**] with an X-ray
confirming re-expanding lung and pt has been doing well since.
She was gradually weaned off the nasal canula and is currently
relying only on 4L via her transtracheal catheter.
During the hospital course, she was started and continued
on Levofloxacin 500mg a day for treatment of a likely pneumonia,
presumed by the appearance of the mucous plugs. Today she is on
day [**9-26**] of the antibiotic course. She will need to take one
more dose.
The pt was continued on her outpatient COPD medications
which include spiriva, salmeterol, albuterol and atrovent nebs.
She was continued on Prednisone 40mg. She will follow-up with
her pulmonologist in a week. Pt needs to have the 1cm right
upper lobe spiculated mass seen on Chest CT followed up as an
outpatient.
Patient received aggressive pulmonary care throughout her
hospital course, with catheter washings and changings twice a
day. She received aggressive teaching about how she could do
this herself and was feeling comfortable about changing her own
[**Last Name (un) **] on discharge.
*
2. Anxiety:Pt had several episodes of anxiety which contributed
to her respiratory distress. She was given Lorazepam with good
effect during these episodes. She takes Lorazepam at home as
well as needed for her anxiety.
.
3. Chronic back pain- Pt with a long history of chronic back
pain for which she takes multiple narcotics. She was continued
on Acetominophen and acetominophen/oxycodone as needed and has
not complained of her back pain.
*
4. Type 2 DM- Metformin was held during this admission and pt's
glucose was covered with regular insulin on a sliding scale. Her
fingersticks showed good sugar contol throughout the admission.
*
5. Depression- Zoloft was continued during this admission.
*
6. Nutrition: Pt. was maintained on a diabetic diet which she
tolerated well throughout the admission
.
7. Prophylaxis: Pt received Heparin subcutaneously to prevent
DVT.
8. Code- Patient was DNR/DNI during this admission. There was an
extensive discussion with the pt during which she confirmed her
code status.
Medications on Admission:
Medications on transfer:
1. Quinine sulfate 60 mg PO daily
2. Spiriva 18 mcg inhaled daily
3. Serevent 1 puff [**Hospital1 **]
4. Flovent 220 2 puffs [**Hospital1 **]
5. Metformin 500 mg PO daily
6. Percocet 1 tab PO QID PRN
7. Albuterol nebs Q4H
8. Regular insulin SS
9. [**10-26**]. Ceftin 500 mg PO QD (seven day course started on [**2160-12-13**])
11. Zoloft 50 mg PO daily
12. Atrivent 0.5 mg Q4H
13. Lasix 20 mg PO daily
14. Prednisone 40 mg PO daily
15. MS contin 15 mg PO Q12H
16. Morphine sulfate 4 mg Q1H PRN
17. Ativan 1 mg PO Q4H PRN
18. Tussinex 5 mg PO Q8H PRN
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) inhalation Inhalation Q12H (every 12 hours).
Disp:*1 disk device* Refills:*2*
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
Disp:*180 neb* Refills:*2*
6. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
8. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
10. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Give sliding scale as directed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary diagnosis:
Emphysema
Secondary diagnosis:
S/P small cell lung CA of right lung
Radiation fibrosis of right lower lung
Depression
Type 2 DM
Discharge Condition:
Stable. Pt on chronic oxygen therapy.
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fevers, chest pain, shortness of
breath, or other concerning symtpoms.
Followup Instructions:
Primary care follow up with Dr. [**Last Name (STitle) 54356**] on Monday, [**1-12**], at 11:15.
Pulmonary follow-up on [**1-7**] @ 3pm with [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **].
Please have your physicians follow up on the 1cm mass seen in
your right upper lobe.
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2161-3-10**]
9:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"198.5",
"162.8",
"250.00",
"492.8",
"934.1",
"311",
"E879.2",
"E912",
"512.1",
"E878.4",
"508.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"98.15",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
11094, 11206
|
5908, 8860
|
339, 513
|
11398, 11437
|
4566, 5885
|
11677, 12278
|
3930, 3948
|
9487, 11071
|
11227, 11227
|
8886, 8886
|
11461, 11654
|
3963, 4547
|
253, 301
|
541, 3390
|
11278, 11377
|
11246, 11257
|
8911, 9464
|
3412, 3714
|
3730, 3914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,622
| 158,463
|
26611
|
Discharge summary
|
report
|
Admission Date: [**2157-7-11**] Discharge Date: [**2157-7-26**]
Date of Birth: [**2088-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
generalized swelling and respiratory discomfort
Major Surgical or Invasive Procedure:
intubation [**7-14**]
extubation [**7-16**]
History of Present Illness:
CC: admitted to MICU [**7-11**] for hyponatremia, called out to the
floor [**7-12**], back to MICU [**7-14**] for altered mental status,
respiratory stress and fever
.
HPI
Please see the MICU note for more details. Briefly, Mr. [**Known lastname 65646**]
is
a 69 yo man with hx of schizophrenia, COPD, Prostate CA on
suppresive therapy since [**2154**], cryptogenic cirrhosis, large
ingunoscrotal hernia, and long-standing scrotal edema who
presented from his group home with increased LE and scrotal and
was admitted to MICU for hyponatremia on [**7-11**]. Hyponatremia
improved with lasix diuresis and he was sent to the floor the
next day [**7-12**]. He was doing well for the next 2 days but then was
found to minimally responsive, obtunded, febrile and hypoxic to
the 70s (came back to low 90s on NRB) when he was receiving an
infusion of albumin, so he was transfered back to the MICU on
[**7-14**]
for hypoxia and altered mental status.
.
On transfer to MICU on [**7-14**], he was noted to be obtunded with
thick secretions. His O2 requirement escalated to 100% NRB to
maintain sats in the high 80s. ABG at that point showed
respiratory acidosis with hypercarbia and the decision was made
to intubate him for hypoxic/hypercarbic respiratory failure. Pt
was successfully extubated on [**7-16**], and has been requiring 4-6
liters of O2 since.
.
Sputum culture grew streptococcus pneumoniae on [**7-14**]. Pt was
bronched on [**7-15**] which revealed thick plugs throughout right
airways with purulent drainage distally; BAL and washings were
sent but no microorg seen on gram stain or in culture.
.
Currently, pt complains of some shortness of breath on 5 liters
of oxygen. No chest pain or palpitations. No pain anywhere. He
is
complaining of increased lower extremity edema, and said his
scrotal edema has been stable for many years.
Past Medical History:
- Schizophrenia (followed by psychiatrist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**]
[**Telephone/Fax (1) 65647**])
- Prostate Ca on lupron since [**2154**]
- Anemia of chronic disease with macrocytosis.
- Cryptogenic cirrhosis, followed by the liver center until
recently, but he no longer wishes to see hepatology. It is
thought to be probably secondary to prior alcohol abuse.
Appt w/ Dr [**Last Name (STitle) 10285**] made for thurs [**7-28**]
- COPD
- obesity
- prostate cancer
- compression fracture status post vertebroplasty.
- very large inguinoscrotal hernia, for which he has deferred
surgery. (loops of bowel are in his scrotum)
- Pyruvate kinase deficiency
- splenomegaly
- status post cholecystectomy
Social History:
Lives at a group home for his schizophrenia ([**Street Address(1) 65648**])
which has help daily, but not at night. Ex-wife [**Name (NI) 2411**] is still
quite involved. Smokes 1 PPD for "a long time". Denies alcohol
use, but past history of alcohol use is noted. Denies other
drugs.
Family History:
He has 4 sisters that he does not keep in regular contact with.
Unsure of what his parents died from.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.4 BP: 119/50 P: 96 R: 18 O2: 91% on 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera mildly icteric, MMM, oropharynx clear
Neck: supple, JVP 10 cm, no LAD
Lungs: Diminished breath sounds bilaterally, also with wheezes,
but without rales or ronchi.
CV: Regular rate with frequent premature beats, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, Obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly noted. Large
umbilical hernia, easily reducible.
GU: Extensive scrotal swelling to the size of a basketball
Ext: warm, well perfused, 2+ DP pulses palpated through edema,
3+ edema to mid thigh and extensive scrotal edema as above.
Physical Exam On Transfer:
Vitals: T: 98.3 BP: 106/71 P: 85 R: 15 O2: 93 on 5L FM
General: NAD, FM in place, Alert and oriented x3
HEENT: Sclera mildly icteric, MMM
Neck: supple
Lungs: Diminished breath sounds bilaterally, mild wheezing and
crackles in the bases bilaterally
CV: RRR, normal S1, S2, no murmurs, rubs, gallops
Abdomen: Large umbilical hernia, easily reducible. Normoactive
bowel sounds. Soft, non-tender, no rebound tenderness or
guarding, no organomegaly noted.
GU: Extensive scrotal swelling.
Ext: WWP, 2+ edema to knee level with b/l lower extremity
erythema. 2+ DP and PT pulses palpated through edema
Pertinent Results:
Chemistries:
[**2157-7-11**] 11:30AM GLUCOSE-108* UREA N-9 CREAT-0.7 SODIUM-118*
POTASSIUM-4.6 CHLORIDE-82* TOTAL CO2-31 ANION GAP-10
[**2157-7-11**] 05:46PM GLUCOSE-107* UREA N-9 CREAT-0.8 SODIUM-122*
POTASSIUM-4.3 CHLORIDE-86* TOTAL CO2-31 ANION GAP-9
[**2157-7-11**] 11:10PM SODIUM-120*
[**2157-7-11**] 11:30AM ALBUMIN-3.7
[**2157-7-11**] 11:30AM proBNP-2207*
[**2157-7-11**] 11:30AM LIPASE-20
[**2157-7-11**] 11:30AM ALT(SGPT)-18 AST(SGOT)-30 ALK PHOS-79 TOT
BILI-3.5*
[**2157-7-11**] 11:31AM LACTATE-0.9
[**2157-7-11**] 05:46PM CORTISOL-13.3
[**2157-7-11**] 05:46PM TSH-0.89
Hematology:
[**2157-7-11**] 11:30AM WBC-7.7 RBC-3.32* HGB-11.4* HCT-33.4*
MCV-101* MCH-34.4* MCHC-34.3 RDW-17.3*
[**2157-7-11**] 11:30AM NEUTS-86.4* LYMPHS-8.1* MONOS-4.7 EOS-0.4
BASOS-0.3
[**2157-7-11**] 11:30AM PLT COUNT-247
[**2157-7-11**] 05:46PM PT-13.5* PTT-28.0 INR(PT)-1.2*
Urine Studies:
[**2157-7-11**] 01:25PM URINE HOURS-RANDOM UREA N-355 CREAT-67
SODIUM-15 CHLORIDE-24
[**2157-7-11**] 01:25PM URINE OSMOLAL-282
[**2157-7-11**] 01:25PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2157-7-11**] 01:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
[**2157-7-12**] CT ABD/PELV: IMPRESSION:
1. No hyperenhancing hepatic mass.
2. Findings consistent with cirrhosis and portal hypertension,
as described above.
3. Stable left adrenal nodule, likely a fat-containing adrenal
nodule.
4. Stable diffuse right adrenal thickening, likely related to
hyperplasia.
[**7-13**] CXR: IMPRESSION:
Moderate new right sided pleural effusion and diffuse middle and
lower lobe consolidation is most likely due a developing
pneumonia secondary to aspiration with a diagnosis of
assymetrical edema less likely
Brief Hospital Course:
69 yo man with hx of schizophrenia, COPD, prostate ca, and
cryptogenic cirrhosis presents with anasarca and profound
scrotal edema.
.
Pneumonia: Patient was febrile with tachycardia and hypoxia on
[**2157-7-13**] prompting transfer to the MICU. Patient with new
infiltrates on CXR c/w pneumonia. He required intubation for
hypoxic hypercarbic respiratory failure. He was started on
vanc/zosyn/levo, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1066**] showed extensive mucous plugging
which was cleared out with resolution of atelectasis and
mediastinal shift. He was extubated after 2 days and quickly
weaned to 4 L NC. Evaluated by speech and swallow who
recommended
continuing PO diet of thin liquids (single sips), regular
solids, whole pills with puree, and strict aspiration
precautions. Vanc was discontinued on [**2157-7-18**] due to concern for
leukopenia and as MRSA screen negative. He completed an 8-day
course of cefepime for hospital acquired v. aspiration pneumonia
on [**2157-7-21**].
.
Lower Extremity Edema: Likely related to liver cirrhosis. BNP
elevated at 2207 but no evidence of pulmonary edema.
Echocardiogram showed moderate pulmonary systolic hypertension
which could be an etiology of right sided failure. He has known
cryptogenic cirrhosis (unclear etiology) which could lead to
elevated portal pressures. Dopper ultrasound without evidence
of portal/splenic venous thrombosis. Lower extremity
ultrasounds negative for DVT. TSH and cortisol are within
normal limits. Albumin is also within normal limits. FeNa of
0.1% in the setting of total body volume overload favors cardiac
or liver etiology. CT abd without hepatoma.
MICU had held further diuresis, this was changed to 40mg PO
lasix daily and 100mg Spironolactone daily on the floors for
goal negative 0.5 to 1 Liter daily. Strict I's and O's were
measured and daily weights were followed. He diuresed well, leg
edema markedly improved upon discharge. his weights trended as
follows: [**7-23**] 90.2kg--> [**7-24**] 89kg--> [**7-24**] 88.2kg
- aldactone 50 mg daily given evidence of cirrhosis
.
Hyponatremia: Hypervolemic as above. Urine Na of 15 and FeNa of
0.1% on presentation suggesting cirrhosis as etiology.
Psychiatric medications also can cause hyponatremia including
risperdal. This started to resolve with lasix diuresis and fluid
restriction. On the floor, we monitored strict I's and O's and
conducted free H2O restrict to 1.5 L.
Scrotal edema: Patient with knowed inguinoscrotal hernia for
which he has refused surgery in the past. There are loops of
bowel herniating into his scrotum. [**Name8 (MD) **] RN and aides at Group
home, edema is much worse over past several days. Hx of prostate
ca on lupron therapy. Scrotal U/S with large free fluid. Urology
placed foley catheter without difficulty. Foley was D/C on [**7-20**]
and pt was voiding well on his own.
***Would readdress inguinal hernia repair when acute issues
stable; has refused in past
.
Leukopenic: Slowly declining WBC count thought [**2-7**] to
antibiotics. Vanc discontinued.
Has a macrocytic anemia but B12 and folate levels were checked
on discharge which were WNL.
.
Schizophrenia: Currently appears appropriate although slightly
tangential during interview.
- received risperdol consta dose on [**2157-7-15**] (q2 week dosing)
- continue ativan HS
. will need Risperdal consta on [**2157-7-29**] (sees [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] for
psych)
COPD: Severe by PFTs in [**2155**] with FEV1 33% and FVC 51% of
predicted
- continue spiriva and advair discus
- albuterol nebs PRN
**would recommend getting outpatient PFT's to assess changes in
pulmonary function and home oxygen requirement.
**would strongly encourage smoking cessation especially given
home O2.
.
S/p vertebral fracture: Currently without pain.
- continue vit D/calcium
- fosamax dosing unknown gets it monthly
.
Cryptogenic Cirrhosis: Previously followed at the liver center.
Likely thought to be due to ETOH abuse in past. Followed by
Liver team.
- pt refusing Liver f/u and screening EGD at this time; cont to
readdress
- have scheduled appointment w/ Dr [**Last Name (STitle) 10285**] in liver clinic for
11:45 am on Thursday [**7-28**].
.
FEN: No IVF, replete electrolytes, regular diet with fluid
restriction 1.5 L
.
Prophylaxis: Subutaneous heparin
Access: PICC
Code: DNR but okay to re-intubate (discussed with patient and
with HCP). Followed by SW and Palliative Care.
Communication: Patient, [**Name (NI) 41293**] and HCP [**Name (NI) 2411**] [**Telephone/Fax (1) 65649**] (H)
[**Telephone/Fax (1) 65650**] (C), Program RN [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65651**] [**Telephone/Fax (1) 65652**]
Medications on Admission:
MVI
Folate 1 mg daily
Thiamine 100 mg daily
Cogentin 1 mg HS
Vit D 400 mg [**Hospital1 **]
CaCO3 500 mg [**Hospital1 **]
Senna PRN
Spiriva 1 cap daily
Fosamax 70 mg Qweek
Ativan 1 mg HS
Lupron Q 3 months
Risperdol Consta Q2weeks (unknown when his last dose was)
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
3. Risperidone Microspheres 37.5 mg/2 mL Syringe Sig: One (1)
Syringe Intramuscular Q2W (FR).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**1-7**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
12. Cogentin 1 mg/mL Solution Sig: One (1) Injection at
bedtime.
Disp:*30 * Refills:*2*
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
15. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
17. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Disp:*5 Tablet(s)* Refills:*2*
18. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
19. Lupron Depot 7.5 mg Syringe Sig: One (1) Intramuscular
q3months.
Disp:*1 * Refills:*2*
20. Risperdal Consta Intramuscular
21. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
PRIMARY: Anasarca, pneumonia, respiratory distress
SECONDARY: cryptogenic cirrhosis,schizophrenia, prostate cancer,
pyruvate kinase deficiency
Discharge Condition:
stable
HE WILL NEED A LESS THAN 30 DAY STAY AT THE SKILLED NURSING
FACILITY
Discharge Instructions:
You were admitted to the hospital on [**7-11**] with generalized body
swelling. Because your sodium got very low on [**7-12**] you were
transfered to the Intesive Care Unit (ICU). This improved with
water pills (diuretics) so you went back to the floor the same
day. You did well over the next 2 days, however you spiked a
fever and your oxygen was low on [**7-14**]. Because of this you went
back to the ICU and had to have a breathing tube because you had
a bacterial infection in your lungs that made it hard for you to
breathe. You got antibiotics, did well and the tube came out on
[**7-16**]. You were monitored in the intesive care unit did well, and
went back to the medicine floor on [**7-19**] where you were stable.
You had one episode of low oxygen on the night of [**7-21**]. You
continued to do well on the general medical floors, where we
diuresed you (gave you water pills) to help decrease the
swelling in your legs. You did very well with the diuresis so we
discharged you to a skilled nursing facility on [**7-26**].
Please return to the hospital if you have any of the following
symptoms: crushing chest pain, severe shortness of breath,
fevers/chills, intractable nausea and/or vomiting, and blood in
your stool or urine.
.
Your medications have changed as follows:
1. Furosemide (lasix) 40mg PO once daily
2. Spironolactone 100mg PO once daily
OUR DIURESIS PLAN IS AS FOLLOWS: daily spironolactone and lasix
(hold if SBP <100) for a goal of -0.5 to -1 L daily. strict I's
and O's and daily weights.
Followup Instructions:
- f/u in liver clinic w/ Dr. [**Last Name (STitle) 10285**] on Thursday [**7-28**] at 11:45 am
Please call them if you need to cancel or reschedule
([**Telephone/Fax (1) 1582**]
-will need Risperdal consta IM on Fri [**7-29**] dose unknown)
Completed by:[**2157-7-26**]
|
[
"282.3",
"518.81",
"571.5",
"295.62",
"572.3",
"185",
"496",
"518.0",
"782.3",
"486",
"608.86",
"285.29",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13740, 13792
|
6667, 11406
|
363, 408
|
13979, 14058
|
4844, 6644
|
15629, 15903
|
3367, 3470
|
11719, 13717
|
13813, 13958
|
11432, 11696
|
14082, 15606
|
3510, 4825
|
276, 325
|
436, 2280
|
2302, 3046
|
3062, 3351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,557
| 173,656
|
27356
|
Discharge summary
|
report
|
Admission Date: [**2130-9-29**] Discharge Date: [**2130-10-1**]
Date of Birth: [**2058-11-17**] Sex: F
Service: MEDICINE
Allergies:
Shellfish / Percocet / Zosyn / Amiodarone
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Placement of central venous line
Tracheal intubation
History of Present Illness:
71 year old female, chronically trach'ed and vented, h/o
multiple hospitalizations since [**4-10**], h/o multiple psedomonal
PNAs, ARDS, COPD, chronic hypercarbia, presented to the ED after
being discharged from the ICU to rehab 2 days ago.
.
The patient has had extensive recent hospitalizations. Last hosp
was for 1 month from [**Month (only) **] to mid [**Month (only) **]. During the most recent
admission, she was tx'd for hypotension, hypercarbic respiratory
failure, recurrent multi-drug resistant pseudomonal pneumonia,
(for which she completed a 21 day course of meropenem, altered
mental status and rapid atrial fibrillation. When the patient
was discharged, she was stable on PSV 10/5 FIO2 0.4, pulling
normal tidal volumes. Although a chronic CO2 retained, pt left
the hospital in no respiratory distress.
.
Reportedly, last night, while on SIMV mode, the patient was
anxious, agitated, awake the whole night and was medicated with
ativan total of 1.5mg, and then fell asleep. Per rehab notes, at
7am, the patient was not arousable, and ABG done, pCO2 92 (80s
baseline) with O2 sats in the high 80s. Pt was switched back to
AC, given 80 IV lasix w/o improvement, pCO2 on re-check was 132.
Pt was then sent to [**Hospital1 18**] ED.
.
Upon arrival to the [**Hospital1 18**] [**Name (NI) **], pt's abg was 7.34/90/112. Her UA
was also + and Ucx was sent. The patient was admitted to the
MICU for lethargy, hypercarbic resp failure.
Past Medical History:
1. Influenza A in [**4-10**] complicated by ARDS eventually leading to
intubation, ventilatory support, and tracheostomy.
2. Remote history of pneumonia.
3. Status post left eye cataract surgery.
4. Anxiety
5. DMII
Social History:
no significant tobacco or alcohol use.
Family History:
non-contributory.
Physical Exam:
T: 97.8 BP:110/45P: 70 (AFib) RR: 23 O2 sats: 98%
Gen: Cachexic elderly female with tracheostomy in mild resp
distress, slightly tachypneic
HEENT: OP clear. track in place
CV: +s1+s2 irregular No Murmurs
Resp: Coarse air movement anteriorly.
Abd: Tender over umbilicus and to the right of the umbilicus. +R
CVA angle tenderness
There is some guarding. No rebound tenderness.
Back: Scoliotic
Ext: 2+ pretibial/pedal edema
Neuro: A&O x 3
Pertinent Results:
[**2130-10-1**] 04:40AM BLOOD WBC-7.7 RBC-2.72* Hgb-8.3* Hct-24.0*
MCV-88 MCH-30.5 MCHC-34.6 RDW-17.3* Plt Ct-25*
[**2130-10-1**] 12:24AM BLOOD WBC-6.4 RBC-2.30* Hgb-6.8* Hct-20.5*
MCV-89 MCH-29.4 MCHC-33.0 RDW-16.9* Plt Ct-35*
[**2130-9-30**] 05:30PM BLOOD WBC-5.4 RBC-2.31* Hgb-6.8* Hct-20.9*
MCV-91 MCH-29.5 MCHC-32.5 RDW-16.7* Plt Ct-34*
[**2130-9-30**] 04:42AM BLOOD WBC-5.7 RBC-2.86* Hgb-8.6* Hct-25.6*
MCV-89 MCH-30.0 MCHC-33.5 RDW-16.6* Plt Ct-47*
[**2130-9-29**] 11:45AM BLOOD WBC-8.8 RBC-2.97* Hgb-9.1* Hct-27.2*
MCV-92 MCH-30.6 MCHC-33.4 RDW-16.5* Plt Ct-84*#
[**2130-9-29**] 11:45AM BLOOD Neuts-91.5* Bands-0 Lymphs-6.4*
Monos-1.2* Eos-0.7 Baso-0.2
[**2130-10-1**] 04:40AM BLOOD PT-26.1* PTT-42.5* INR(PT)-2.7*
[**2130-10-1**] 04:40AM BLOOD Glucose-96 UreaN-80* Creat-1.4* Na-138
K-4.7 Cl-92* HCO3-38* AnGap-13
[**2130-9-29**] 11:45AM BLOOD Glucose-148* UreaN-64* Creat-1.0 Na-137
K-4.2 Cl-88* HCO3-47* AnGap-6*
[**2130-10-1**] 04:40AM BLOOD ALT-790* AST-865* AlkPhos-120* Amylase-48
TotBili-2.2*
[**2130-10-1**] 04:40AM BLOOD Calcium-7.5* Phos-6.5*# Mg-2.8*
[**2130-10-1**] 10:17AM BLOOD Hgb-7.5* calcHCT-23 O2 Sat-92
[**2130-10-1**] 10:17AM BLOOD freeCa-1.16
.
CXR: : Comparison is made to previous study from [**2130-9-29**].
The tracheostomy tube and left-sided central venous catheter are
unchanged in position and appropriately sited. There is
cardiomegaly, unchanged. There are again seen diffuse airspace
opacities throughout both lungs, which have worsened and have
more confluent opacification within the left mid-to-lower lung
field. There is a prominent retrocardiac opacity. There is also
increased density seen in the lung apices. This may represent
loculated fluid. The patient has severe scoliosis. These diffuse
airspace opacities are nonspecific and could be due to a
combination of extensive pulmonary edema versus
infectious/inflammatory process. Alveolar hemorrhage would also
have a similar appearance.
.
CT abd / pelvis: IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. No evidence of hydronephrosis or hydroureter.
3. Continued pulmonary consolidations consistent with pneumonia.
4. Cholelithiasis.
Brief Hospital Course:
71F with chronic respiratory failure secondary to
influenza/ARDS, reccurent pseudomonal pneumonias, afib,
bronchiectasis admitted with changes in mental status and
hypercarbic respirator failure.
She placed back on AC ventilation, and was treated with steroids
and inhalers. Her respiratory status was continuing to decline,
and she also developed acute renal failure (oliguric), as well
as thrombocytopenia and coagulaopathy. Her BP was trending
downward, and she was requiring medications to maintain MAP of
55. It was unclear the etiology of her thrombocytopenia, and
there was concoern for HIT or DIC. There were multiple family
meetings with the MICU team, including Dr. [**Last Name (STitle) **]. The decision
was made to make her comfort measures only, which was amenable
to the entire family. She expired in the presence of her
family, peacefully, and in no apparent distress. THe family
declined an autopsy.
Medications on Admission:
lansoprazole
sertraline 50qd
tylenol prn
sotalol 40qd
diltiazem 30 qid
atrovent inh
albuterol inh
hydral 25 q 6h
epogen [**2124**] u sc q mo we fri
senna
colace
warfarin 4mg qd
prednsione 60qd (to be started on a taper week of [**10-7**])
lasix 120 iv qd
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
THromobctopenia
UTI
Acute renal failure
Discharge Condition:
na
Discharge Instructions:
na
Followup Instructions:
na
|
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icd9cm
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[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,835
| 129,744
|
4523
|
Discharge summary
|
report
|
Admission Date: [**2201-10-29**] Discharge Date: [**2201-11-16**]
Date of Birth: [**2164-5-10**] Sex: M
Service: SURGERY
Allergies:
Shellfish / Topamax / Augmentin
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
increasing abdominal pain
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
[**2201-11-3**]: Extensive lysis of adhesions; External drainage of
pancreatitis pseudocysts with debridement; Gastrojejunostomy and
placement of a feeding jejunostomy tube
History of Present Illness:
Pt is a 37M well know to Dr. [**First Name (STitle) **] & the Gold Surgery service for
his history of complicated pancreatitis requiring tracheostomy
and now gastric outlet obstruction [**2-7**] pancreatic pseudocyst.
He has been at rehab since [**2201-10-21**] NPO on TPN and is scheduled
for a cystjejunostomy on [**2201-10-24**]. He was doing
well until last night when he developed nausea & vomiting. Then
developed acutely worsening abdominal pain this morning. He was
subsequently transfered to the [**Hospital1 18**] ED.
An NGT was placed prior to his transfer to the ED. He reports
his breathing is okay and does not think he aspirated while
vomiting. His mother reports he was with him until yesterday
evening. He had been up walking around during the day, and laid
down for a nap when she left. Patient reports he has been
passing gas & having bowel movements. His abdominal pain is the
same has his
pancreatitis pain but much worse.
Past Medical History:
PMH/PSH:
- Tracheostomy [**2201-9-14**] (emergent)
- Multiple episodes of alcoholic pancreatitis; history of ARDS
requiring intubation in the setting of severe pancreatitis in
[**2194**], recent admission as above
- Splenic hematoma s/p splenectomy. Tail of pancreas was
densely adherent to spleen hilum, had distal pancreatectomy
- GERD
- HTN
- Sleep apnea tried on CPAP, biPAP but hasn't tolerated
- Hypercholesterolemia
- Chronic pain (L abdomen & shoulder) on methadone
- Alcoholism/Alcohol withdrawal; several admissions for DTs and
intubations
- Right upper quadrant abscess, status post percutaneous
catheter drainage in [**2192-5-5**].
- Fatty liver and hepatomegaly on US [**2191**]
- Hypertriglyceridemia
- Migraine HA/cluster HAs
- Asthma
- Depression - multiple suicide attempts
- False positive RPR
Social History:
SocHx: Tobacco: quit smoking over a year ago, used to smoke 1
ppd
EtOH: started drinking 7th grade, drank 30 beers a night plus
few shots of alcohol in his 20's, abstinent since [**2194**], attended
AA but found it boring. Drugs: remote hx MJ, cocaine. Denies
IVDA. Denies recent drug use. Living: Previously lived with
mother. Currently at rehab. On disability for chronic pain.
Family History:
Father CAD (1st MI in 40's), EtOH. Mother type 2 DM, 3
sisters: 1 with seizure d/o, 1 with migraines, + family hx
alcoholism (father, 2 sisters)
Physical Exam:
On admission:
PE: 99.9 115 175/102 22 100% 50% TM
Looks unwell and uncomfortable. Not as well appearing as at
time
of last discharge.
No jaundice or icterus
Breathless when talking, breathing labored. CTA b/l
Tachy
Abd soft, sl distended, TTP diffusely, worst in RLQ/RMQ. No
rebound or guarding. no shake or tap tenderness
No LE edema
Pertinent Results:
[**2201-11-15**] 12:47PM BLOOD WBC-21.6*# RBC-3.13* Hgb-8.9* Hct-28.0*
MCV-89 MCH-28.3 MCHC-31.7 RDW-14.8 Plt Ct-1225*
[**2201-11-13**] 04:35AM BLOOD WBC-13.6* RBC-2.71* Hgb-7.6* Hct-23.9*
MCV-88 MCH-28.1 MCHC-32.0 RDW-15.3 Plt Ct-998*
[**2201-11-12**] 06:21PM BLOOD WBC-17.2* RBC-2.94* Hgb-8.3* Hct-25.7*
MCV-87 MCH-28.3 MCHC-32.4 RDW-14.9 Plt Ct-1061*
[**2201-11-12**] 04:08AM BLOOD WBC-18.1* RBC-2.79* Hgb-8.0* Hct-24.3*
MCV-87 MCH-28.9 MCHC-33.2 RDW-15.0 Plt Ct-970*
[**2201-11-11**] 02:49AM BLOOD WBC-19.5* RBC-2.55* Hgb-7.2* Hct-22.1*
MCV-87 MCH-28.1 MCHC-32.4 RDW-14.8 Plt Ct-973*
[**2201-11-11**] 12:01AM BLOOD WBC-19.6* RBC-2.45* Hgb-6.9* Hct-21.6*
MCV-88 MCH-28.2 MCHC-31.9 RDW-14.9 Plt Ct-951*
[**2201-11-10**] 04:40AM BLOOD WBC-24.0* RBC-2.88* Hgb-8.1* Hct-24.8*
MCV-86 MCH-28.1 MCHC-32.7 RDW-15.6* Plt Ct-1037*
[**2201-11-9**] 03:57AM BLOOD WBC-20.0* RBC-2.56* Hgb-7.2* Hct-22.6*
MCV-88 MCH-28.1 MCHC-31.9 RDW-15.1 Plt Ct-838*
[**2201-11-8**] 04:30AM BLOOD WBC-20.2* RBC-2.63* Hgb-7.4* Hct-23.1*
MCV-88 MCH-28.1 MCHC-32.1 RDW-14.6 Plt Ct-796*
[**2201-11-7**] 04:46AM BLOOD WBC-15.1* RBC-2.75* Hgb-8.0* Hct-24.6*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.8 Plt Ct-778*
[**2201-11-6**] 03:51AM BLOOD WBC-19.3* RBC-2.56* Hgb-7.3* Hct-22.4*
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.7 Plt Ct-711*
[**2201-11-5**] 04:13PM BLOOD Hct-23.5*
[**2201-11-5**] 06:37AM BLOOD WBC-21.1* RBC-2.65* Hgb-7.7* Hct-23.2*
MCV-87 MCH-28.9 MCHC-33.1 RDW-14.8 Plt Ct-690*
[**2201-11-4**] 04:30AM BLOOD WBC-26.0*# RBC-3.31* Hgb-9.4* Hct-28.7*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.2 Plt Ct-858*
[**2201-11-3**] 08:10PM BLOOD Hct-27.9*
[**2201-11-3**] 03:51PM BLOOD Hct-25.2*
[**2201-11-3**] 05:45AM BLOOD WBC-14.8* RBC-2.92* Hgb-8.4* Hct-26.4*
MCV-91 MCH-28.8 MCHC-31.8 RDW-14.2 Plt Ct-896*
[**2201-10-30**] 02:40AM BLOOD WBC-14.4* RBC-2.68* Hgb-7.8* Hct-23.7*
MCV-89 MCH-29.1 MCHC-32.8 RDW-14.2 Plt Ct-763*
[**2201-10-30**] 02:27PM BLOOD Hct-24.1*
[**2201-10-31**] 02:00AM BLOOD WBC-12.8* RBC-2.66* Hgb-7.5* Hct-23.7*
MCV-89 MCH-28.4 MCHC-31.8 RDW-14.0 Plt Ct-765*
[**2201-10-29**] 10:22AM BLOOD Neuts-86.4* Lymphs-9.7* Monos-3.1 Eos-0.7
Baso-0.1
[**2201-11-16**] 11:34AM BLOOD PTT-74.0*
[**2201-11-16**] 05:06AM BLOOD PT-18.2* PTT-76.0* INR(PT)-1.7*
[**2201-11-15**] 09:50PM BLOOD PT-17.3* PTT-64.1* INR(PT)-1.6*
[**2201-11-15**] 12:47PM BLOOD Plt Ct-1225*
[**2201-11-15**] 12:47PM BLOOD PT-16.6* PTT-56.1* INR(PT)-1.5*
[**2201-11-15**] 04:02AM BLOOD PTT-67.6*
[**2201-11-14**] 08:13PM BLOOD PT-15.7* PTT-58.3* INR(PT)-1.4*
[**2201-11-14**] 11:00AM BLOOD PT-14.6* PTT-53.1* INR(PT)-1.3*
[**2201-11-14**] 02:49AM BLOOD PT-14.5* PTT-50.9* INR(PT)-1.3*
[**2201-11-13**] 07:36PM BLOOD PT-14.1* PTT-44.3* INR(PT)-1.2*
[**2201-11-12**] 06:21PM BLOOD PT-13.9* PTT-52.6* INR(PT)-1.2*
[**2201-11-12**] 12:32PM BLOOD PTT-55.9*
[**2201-11-12**] 04:08AM BLOOD PT-14.7* PTT-142.4* INR(PT)-1.3*
[**2201-11-11**] 02:49AM BLOOD Plt Ct-973*
[**2201-11-11**] 02:49AM BLOOD PT-14.4* PTT-40.6* INR(PT)-1.3*
[**2201-11-11**] 12:01AM BLOOD Plt Ct-951*
[**2201-11-10**] 04:40AM BLOOD Plt Ct-1037*
[**2201-11-4**] 04:30AM BLOOD Plt Ct-858*
[**2201-11-3**] 05:45AM BLOOD Plt Ct-896*
[**2201-11-3**] 05:45AM BLOOD PT-15.0* PTT-44.3* INR(PT)-1.3*
[**2201-11-1**] 05:30AM BLOOD Plt Ct-887*
[**2201-11-1**] 05:30AM BLOOD PT-15.6* PTT-47.9* INR(PT)-1.4*
[**2201-11-13**] 04:35AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-138 K-4.1
Cl-101 HCO3-29 AnGap-12
[**2201-11-12**] 06:21PM BLOOD Glucose-137* UreaN-8 Creat-0.7 Na-138
K-4.4 Cl-99 HCO3-30 AnGap-13
[**2201-11-12**] 04:08AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139
K-3.4 Cl-97 HCO3-35* AnGap-10
[**2201-11-11**] 02:49AM BLOOD Glucose-143* UreaN-18 Creat-0.8 Na-138
K-3.2* Cl-92* HCO3-39* AnGap-10
[**2201-11-11**] 12:01AM BLOOD Glucose-186* UreaN-17 Creat-0.9 Na-136
K-3.3 Cl-90* HCO3-38* AnGap-11
[**2201-11-9**] 10:28AM BLOOD Glucose-85 UreaN-14 Creat-0.5 Na-142
K-4.0 Cl-101 HCO3-33* AnGap-12
[**2201-11-8**] 04:30AM BLOOD Glucose-115* UreaN-15 Creat-0.6 Na-141
K-4.0 Cl-103 HCO3-27 AnGap-15
[**2201-11-7**] 04:46AM BLOOD Glucose-135* UreaN-19 Creat-0.6 Na-142
K-3.8 Cl-103 HCO3-30 AnGap-13
[**2201-11-11**] 12:01AM BLOOD CK(CPK)-31*
[**2201-11-7**] 01:45AM BLOOD CK(CPK)-85
[**2201-11-3**] 09:50PM BLOOD CK(CPK)-96
[**2201-10-30**] 02:40AM BLOOD ALT-133* AST-125* AlkPhos-847*
TotBili-0.6
[**2201-10-29**] 10:22AM BLOOD ALT-72* AST-53* AlkPhos-925* TotBili-0.9
[**2201-10-30**] 02:40AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.8 Mg-1.8
[**2201-10-31**] 02:00AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8
[**2201-11-13**] 04:35AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
[**2201-11-12**] 06:21PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9
[**2201-11-10**] 11:52PM BLOOD Type-ART Temp-36.3 FiO2-90 pO2-97
pCO2-48* pH-7.53* calTCO2-41* Base XS-15 AADO2-520 REQ O2-84
Intubat-NOT INTUBA
[**2201-10-29**] 06:36PM BLOOD Type-ART pO2-75* pCO2-35 pH-7.53*
calTCO2-30 Base XS-6
[**2201-11-3**] 09:41AM BLOOD freeCa-1.13
[**2201-10-29**] 10:35AM BLOOD Glucose-300* Lactate-2.5* Na-140 K-3.9
Cl-99*
Brief Hospital Course:
Location of care: Mr. [**Known lastname 19280**] was admitted to the [**Known lastname **] ICU
on admission for further management and stabilization. On
hospital day 3, the patient was transferred to the floor. The
patient was taken to the OR on [**11-3**] for an uncomplicated
extensive lysis of adhesions, external drainage of pancreatitis
pseudocysts with debridement, and gastrojejunostomy and
placement of a feeding jejunostomy tube. He was then additted to
back the ICU and was transferred to the floor on post-op day 3.
Overnight on post-op day 7, the patient was transferred back to
the ICU after a trigger for low O2 and low blood pressure. This
subsequently resolved and he was transferred back to the floor
on POD 9.
FEN/GI: TPN was started on hospital day 2. The patient's NG tube
was self d/c'd several times during the hospitalization. Tube
feeds were started and advanced to goal with recommendations
from nutrition. TPN was discontinued on post-op day 5.
An UGI swallow study with gastrograffin was performed to assess
anastomosis and stomach emptying time. Normal transit of
contrast through the [**Month/Year (2) **] anastomosis
without evidence for leak, obstruction, or other abnormality was
noted. Once NGT output met criteria for removal, the NG tube was
removed by the [**Month/Year (2) **] team on post-op day 7. Bedside swallow
analysis was performed on [**11-12**]. Intake of thin liquids and
reulgar solids was recommened. The patient continued on tube
feeds at goal and was able to tolerate a regular diet. Calorie
counts approximated at 700daily at the time of discharge. Upon
discharge, pt met criteria to begin cycling of tubefeeds to
regain appetite. This will commence at rehab.
ID: staph, coagulase negative in 1 set of blood cultures was
identified on [**10-29**]. Also, gram positive cocci were identified
from blood cultures drawn from the right ij central line. The
line was discontinued. The patient was also + for MRSA pneumonia
in teh past. The patient was treated with vancomycin and will
continue prophylactically for at least 2 weeks.
Heme: Serial HCTs were performed on admission for a question of
a cystic bleed. HCTs remained stable. Due to a low HCT, he was
transfused on post-op day 8.
Pulmonary: Mr. [**Known lastname 19280**] experienced a desaturation on O2 on POD7.
He was transferred to the ICU and CTA revealed a pulmonary
embolism. He was anticoagulated with heparin. Lower extremity
ultrasounds were negative for clots. He was transitioned to
coumadin and continued on heparin drip until with a therapeutic
INR.
Neuro: On admission, pain was maintained with a dilaudid PCA,
with IV medication for breakthrough. Post-op, the pain service
was consulted recommending a modificatication of methadone dose
and a dilautid PCA and continued to make recommendations on pain
management. The pt was ultimately transitioned to PO oxycodone
and methadone.
Cardio: The patient triggered to for low blood pressure on
post-op day 4 and responded to a fluid bolus.
Renal/GU: The foley was removed on post-op day 6.
General: Physical therapy evaluated the patient and deemed the
patient appropriate for discharge to home with physical therapy.
Medications on Admission:
[**Last Name (un) 1724**]:
1. Acetaminophen 650 mg PO Q4H as needed.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization q6hr prn
3. Docusate Sodium 100 mg PO BID
4. Lovenox 40mg SQ daily
5. Tizanidine 2 mg PO BID
6. Tizanidine 6 mg PO [**Last Name (un) **]
7. Methadone 60 mg PO TID
8. Dilaudid 4mg IV q4hrs prn pain
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release (2) Cap PO QIDWMHS
10. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
11. Bupropion 100 mg PO TID
12. Quetiapine 100 mg PO [**Last Name (un) **]
13. Aspirin 81 mg Tablet PO DAILY
14. Metoprolol Tartrate 12.5 mg PO BID
15. prilosec 20 mg PO Q24H
16. Metoclopramide 20 mg PO QIDACHS
17. Senna 8.6 mg PO BID prn
18. Polyethylene Glycol 3350 PO DAILY
19. oxycodone liquid 20mg po qhrs prn pain
20. zofran 4mg IV prn N/V
21. ferous gluconate 325mg po BID
22. novolin sliding scale
23. TPN
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
3. Warfarin dosing goal INR [**2-8**]
4. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWEEK ().
5. Metoclopramide 20 mg IV Q6H
6. Vancomycin 1000 mg IV Q 12H
Plse do vanc trough after the 3rd dose.
7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO [**Month/Day (3) **] (once a
day (at bedtime)).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
9. Tizanidine 2 mg Tablet Sig: Three (3) Tablet PO [**Month/Day (3) **] (once a
day (at bedtime)).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast.
14. Ondansetron 4 mg IV Q8H:PRN
15. Lorazepam 1-2 mg IV Q4H:PRN anxiety
hold for Respiratory rate<10
16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1200 (1200) Units Intravenous drip per hour: GOAL
PTT 60-80; use to bridge until therapeutic INR x 2-3 days.
Disp:*qs Units* Refills:*2*
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Pancreatitis (acute on chronic)
pancreatic pseudocyst
Pulmonary embolism; ARDS, Emergent Trach
E. Coli bacteremia, MRSA pneumonia
Discharge Condition:
Stable
Discharge Instructions:
You were seen for pancreatitis, pancreatic pseudocyst, and had
complications which resulted in an ICU stay, a tracheostomy, and
thinning of your blood for a blood clot.
Incision Care: Keep clean and dry.
Staples out 14 days after surgery. Monitor for infection.
.
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 see blood or dark/black material when you vomit or have a
bowel movement.
* 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 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.
* Continue to ambulate several times per day.
* No heavy ([**10-21**] lbs)lifting until your follow up appointment.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in [**2-8**] weeks ([**Telephone/Fax (1) 6347**]
Completed by:[**2201-11-16**]
|
[
"338.29",
"272.1",
"577.2",
"493.90",
"401.9",
"458.9",
"415.19",
"577.1",
"577.0",
"V15.82",
"568.0",
"327.23",
"303.93",
"311",
"790.7",
"V44.0",
"571.0",
"272.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"46.01",
"38.93",
"54.59",
"99.04",
"52.09",
"44.39",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
14064, 14144
|
8241, 11437
|
14318, 14327
|
3263, 8218
|
16076, 16210
|
2744, 2891
|
12437, 14041
|
14165, 14297
|
11463, 12414
|
14351, 14521
|
14537, 16053
|
2906, 2906
|
254, 514
|
542, 1494
|
2920, 3244
|
1516, 2329
|
2345, 2728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
791
| 170,658
|
11563+11564
|
Discharge summary
|
report+report
|
Admission Date: [**2141-12-1**] Discharge Date:
Date of Birth: [**2071-10-17**] Sex: F
Service:
NO DICTATION
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2141-12-4**] 16:53
T: [**2141-12-4**] 19:54
JOB#: [**Job Number 36788**]
Admission Date: [**2141-12-1**] Discharge Date: [**2141-12-5**]
Date of Birth: [**2071-10-17**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 1637**] is a 7-year-old
female with known coronary artery disease, status post
percutaneous transluminal coronary angioplasty of a stent to
the left anterior descending as recently as [**Month (only) 359**] of this
year who presented with four to five pounds of typical chest
discomfort and low level exertion consistent with new onset
and unstable angina.
The patient has a past medical history significant for a
retinopathy, hypertension, diabetes mellitus, has no history
of transient ischemic attack,no history of stroke,
Gastrointestinal bleeding. She has hyperlipidemia and has
known coronary artery disease as previously stated. No
history of myocardial infarction is present.
Due to her progressive four bouts of typical chest pain,
discomfort at low levels of exertion she presented to her PCP
who ultimately admitted her to the [**Hospital1 190**] for cardiac catheterization.
Electrocardiogram on admission showed no acute changes. Her
Troponins were borderline and her CPKs were ultimately
negative. She had normal hemodynamic profile. In the
catheterization laboratory she underwent a left heart
coronary artery catheterization that revealed the following.
Left ventriculography showed a mitral regurgitation with left
ventricular ejection fraction to be "normal." There was a
right heart dominant circulation with left main coronary
artery disease within normal however, there was 90% in-stent
restenosis in the proximal left anterior descending. Left
circumflex is small but normal. Right coronary artery was
80% distal right coronary artery. Given the aggressive
in-stent restenosis of the proximal left anterior descending
in a diabetic female with a right coronary artery lesion the
recommendation was to go forward with coronary artery bypass
grafting.
Subsequently the patient was admitted to the hospital, placed
on nitrates, no Plavix, Heparin, beta-blockade. The patient
has no known drug history, no history of dye allergy.
MEDICATIONS ON ADMISSION:
1. Plavix 75 mg q day.
2. Lopressor 75 mg q AM, 50 mg p.o. q PM.
3. Zestril 40 mg q day.
4. Aspirin 81 mg q day.
5. NPH 20 units subcutaneously q AM, 6 units subcutaneously
q PM.
6. Humilog sliding scale.
7. Eyedrops, which she takes three separate brands, not
otherwise specified.
ADMISSION LABS: Crit of 9, BUN and creatinine of 18 and .6.
She was well nourished, well developed female, sinus with
160/70 blood pressure, lungs clear. Heart was regular, no
murmur. Peripheral pulses were palpable. Dorsalis pedis and
posterior tibial bilaterally. Ultimately on [**2141-12-1**], the
same day of admission the patient was taken electively to
coronary artery bypass with Dr. [**Last Name (STitle) 70**]. She underwent
coronary artery bypass graft times two including Left
internal mammary artery to left anterior descending and a
right saphenous vein graft to the right coronary artery,
posterior descending. She left the operating room with
pericardium opened. She has a right radial A-line, Central
venous pressure, right atrial catheter, two ventricular
wires, one atrial, one ground wire, one mediastinal, one
right pleural and one left pleural tube was also present.
Upon transfer to the Intensive Care Unit the patient was
neurologically intact. Neo-Synephrine was being utilized for
blood pressure support and was weaned off, started on Lasix
and Lopressor. Respiratory wise she was extubated. She was
encouraged to use incentive spirometry with coughing, deep
breathing and also to immobilize early. Gastrointestinal:
She was put on cardiac diet. BUN and creatinine were 10.4,
acceptable heme. She was started on aspirin and then
subsequently transferred to the floor.
While on the floor she was noted to have no real significant
events. She was afebrile throughout her hospital course.
Lopressor was titrated to effect heart rate persistently at
90's and at present there are not any readings that are lower
at this time.
HOSPITAL COURSE: Unremarkable. She had hematocrit of 34,
BUN 23 and creatinine of .7 on day of discharge. Blood
pressure was however, hypertensive on postop day three she
reached systolics of 200/palp which was able to precipitate
chest discomfort, chest pressures, electrocardiogram done at
this time shows sinus tachycardia with no ST-T segment
changes. Additionally she has chest x-ray that showed
bilateral apical pneumothoraces that were stable from
previous x-ray seen after chest tube removal.
DISCHARGE MEDICATIONS:
1. Humilog sliding scale, please see Page 1 for
comprehensive details of sliding scale as well as
NPH 20 units subcutaneously q AM, NPH 6 units
Subcutaneously q PM.
2. Percocet 5/325 mg one to two q 4 to 6 hours p.r.n.
3. Lasix 20 mg p.o. q AM times seven day.
4. K-Dur 20 mEq p.o. q day times seven days.
5. Protonics 40 mg p.o. q day.
6. Aspirin 325 mg p.o. q day.
7. Lopressor 50 mg p.o. b.i.d.
8. Zestril 10 mg
Additional medications include aforementioned Colace,
Zestril, Lopressor.
CONDITION ON DISCHARGE: Stable, afebrile. Sternum is
intact. 98.1 for temperature, 84 sinus, 130/70 blood
pressure. Crit and BUN previously stated. Cardiac was
stable with no drainage. Regular rate and rhythm. Clear to
auscultation. There were crackles at the basis. Abdomen is
benign. Extremities: Right saphenous vein graft patent.
Intact, well approximate, no evidence of erythema or exudate.
Discharge is to rehabilitation.
FOLLOW-UP: See Dr. [**Last Name (STitle) 70**] in four weeks. See PCP in
three weeks. She can have wound check, blood pressure
monitoring, physical rehabilitation at rehabilitation
facility.
DIAGNOSIS:
1. Significant and aggressive in-stent restenosis, 80%
distal or mid-right coronary artery lesion status post
Coronary artery bypass graft times two,
Left internal mammary artery to left anterior descending
and right saphenous vein graft to posterior tibial
artery.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2141-12-4**] 17:03
T: [**2141-12-4**] 20:03
JOB#: [**Job Number **]
|
[
"411.1",
"362.01",
"414.01",
"250.50",
"V45.82",
"272.4",
"401.9",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"39.61",
"36.15",
"37.22",
"88.55",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5129, 5640
|
2637, 2935
|
4618, 5106
|
597, 2611
|
2952, 4600
|
5665, 6876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,442
| 103,523
|
52742
|
Discharge summary
|
report
|
Admission Date: [**2151-1-4**] Discharge Date: [**2151-1-14**]
Service:
ADMISSION DIAGNOSES:
1. Coronary artery disease.
2. Aortic stenosis.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Aortic stenosis.
3. Status post coronary artery bypass graft times one with
saphenous vein graft and left radial artery composite, atrial
valve replacement with 19 mm [**Last Name (un) 3843**]-[**Known firstname **] valve.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
man with known coronary artery disease. He reports having
shortness of breath with exertion since [**2148**], but this has
gotten worse over the past month. He states that he has
dyspnea after climbing one flight of stairs, with carrying
ten pound trash barrels. He denies any chest pain. He
denies claudication, orthopnea, paroxysmal nocturnal dyspnea,
edema or lightheadedness. The patient is now referred for
cardiac catheterization. A previous cardiac catheterization
had shown a 70% apical LAD lesion, 90% circumflex lesion with
a subtotally occluding OM2, a 40-80% proximal RCA lesion and
a 60% MRCA lesion. The patient had stenting of the OM1,
distal circumflex/OM3 and PTCA of the small OM2.
Persantine/Myoview in [**2150-7-26**] was negative for angina
and an uninterpretable EKG. Negative for perfusion defects
with a calculated ejection fraction of 50-55%.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Nonhealing left foot ulcer.
3. Nephrolithiasis.
4. Small bowel obstruction.
5. Left superficial femoral artery to posterior tibial
bypass [**2149-4-1**].
6. Vein patch angioplasty of bypass [**2150-8-13**].
7. Laparoscopic cholecystectomy [**2145**].
MEDICATIONS:
1. Accupril 10 mg q. day.
2. Lopressor 25 mg b.i.d.
3. Glucophage 1000 mg b.i.d.
4. Aspirin 325 mg q. day.
5. Insulin NPH 52 units q. a.m., 22 units q. p.m.
6. Insulin regular 8 units q. a.m.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is an elderly gentleman in
no acute distress. Vital signs are stable, afebrile. HEENT
is atraumatic, normocephalic. Extraocular movements intact.
Pupils equal, round and reactive to light. Anicteric.
Throat is clear. Neck is supple, midline with no masses or
lymphadenopathy. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm without murmur, rub
or gallop. Abdomen is soft, non-tender, non-distended
without mass or organomegaly. Extremities are warm,
noncyanotic, nonedematous. There are venous stasis changes
in the legs. The patient also has scars consistent with his
left SFA to PT bypass grafts. Neuro is grossly intact.
LABS ON ADMISSION: CBC: 9.4/12.2/35.9/159. Chemistries:
142/4.6/104/27/22/0.9. INR 1.1.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization which revealed calculated ejection fraction
of approximately 50% and normal wall motion. Findings showed
codominant coronary artery system with severe two vessel
coronary artery disease and severe aortic valve stenosis.
There was also found to be biventricular diastolic
dysfunction and moderate pulmonary hypertension. The patient
was recommended for urgent revascularization surgery.
On [**2151-1-5**], the patient was taken to the Operating
Room for coronary artery bypass graft times one with
composite saphenous vein graft of the left radial artery to
the left posterior descending artery, he also had aortic
valve replacement performed with a 19 mm pericardial
[**Last Name (un) 3843**]-[**Known firstname **] valve. The patient tolerated the
procedure well with no complications. On postoperative day
zero, the patient was transfused two units of packed red
blood cells for an hematocrit of 21.7 in the CSRU. The
patient was also noted to have increased chest tube outputs
for which he was given protamine, four units packed red blood
cells and two units of platelets. The patient remained
intubated and had very thick secretions which were frequently
suctioned. The patient was extubated on postoperative day
one, but reintubated subsequent to difficulty with
respiration. The patient was again extubated on
postoperative day two and seemed to tolerate this well.
Levophed and dobutamine were both weaned off. On
postoperative day four, the patient was transferred to the
floor without further complication. He was noted to be quite
edematous and his remaining hospital course essentially dealt
with his diuresis. He was initially found to be poorly
responsive to Lasix and his Lasix dose was increased to 8 mg
b.i.d. He remained unresponsive to this with only slightly
negative I&O balance. Chest x-ray showed the patient was
moderately wet and a bedside echocardiogram revealed that
there was a high transaortic gradient but no wall motion
abnormalities. Mild mitral regurgitation was also detected
at that time. Lasix was increased to 120 mg b.i.d. on
postoperative day seven and a formal echocardiogram was
performed. Formal echocardiogram again showed a high
transaortic gradient as well as very mild global hypokinesis
of the left ventricle. No focal wall motion abnormalities.
Aggressive diuresis was continued at 120 mg of Lasix p.o.
b.i.d. The patient responded to this well and had
improvement in his clinical symptoms of extremity edema as
well as wheezing. The patient continued to work with
physical therapy and was ultimately discharged on
postoperative day nine tolerating a regular diet, adequate
pain control on p.o. pain medications and showing improvement
in his clinical symptoms of volume overload. The patient had
no further anginal symptoms during his hospital stay or at
the time of discharge.
PHYSICAL EXAMINATION ON DISCHARGE: General: No acute
distress. Vital signs are stable, afebrile. Chest clear to
auscultation bilaterally. Cardiovascular is regular rate and
rhythm with a 2/6 systolic ejection murmur. The patient's
abdomen is soft, non-tender, non-distended. The patient does
have 1+ peripheral edema. There is no sternal click or
sternal discharge. There is mild serosanguinous drainage
from the right lower extremity saphenous vein graft wound.
There is only minimal erythema.
CONDITION AT DISCHARGE: Good.
DISPOSITION: To home.
DIET: Cardiac and diabetic.
MEDICATIONS:
1. Lopressor 50 mg b.i.d.
2. Lasix 120 mg b.i.d. times ten days.
3. Keflex 500 mg b.i.d. times ten days (renal dose).
4. Potassium chloride 20 mEq b.i.d. times ten days.
5. Colace 100 mg b.i.d.
6. Aspirin 325 mg q. day.
7. Glucophage 500 mg b.i.d.
8. Percocet 5/325 one to two q. 4h. p.r.n.
9. Amiodarone 400 mg b.i.d.
10. Isosorbide mononitrate 60 mg q. day.
11. NPH insulin 15 units q. a.m. and 10 units q. p.m.
DISCHARGE INSTRUCTIONS: The patient is to continue elevating
his legs at rest and ambulating and incentive spirometry. He
is to follow up with Cardiology in one to two weeks' time and
address the need for continued diuresis as well as adjustment
of cardiac medications at that time. The patient should
follow up in four weeks with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2151-1-14**] 16:28
T: [**2151-1-14**] 15:46
JOB#: [**Job Number 107068**]
|
[
"443.9",
"V45.82",
"250.00",
"412",
"424.1",
"428.0",
"416.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"39.61",
"35.21",
"88.56",
"88.53",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
176, 434
|
2756, 5678
|
6710, 7331
|
104, 155
|
1959, 2650
|
6187, 6685
|
5693, 6172
|
463, 1370
|
2665, 2738
|
1392, 1936
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,037
| 149,150
|
15693
|
Discharge summary
|
report
|
Admission Date: [**2179-3-6**] Discharge Date: [**2179-3-8**]
Date of Birth: [**2146-1-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2179-3-6**] s/p BMS in LAD/
History of Present Illness:
Mr. [**Known lastname 45245**] is a 33 year-old smoker male with a history of
premature multivessel CAD status post IMI in [**2173**] treated with
LCx stent, cocaine use, and a strong family history of premature
CAD, who presents with chest pain. Of note, he was recently
evaluated at [**Hospital1 18**] [**2179-2-26**] for chest pain following cocaine use
3 hours prior, at which time his cardiac biomarkers revealed
CK-MB 24 (MBI 12.2) and troponin 0.29. He left AMA prior to
further work-up.
.
This AM, he awoke with chest pain at 0900 AM, substernal in
location with occasional radiation to the left shoulder. He
endorses associated shortness of breath. No N/V, no diaphoresis.
He denies cocaine use since [**2179-2-26**]. His chest pain persisted,
and he presented to an OSH.
.
There, EKG showed anterolateral ST elevations. He was given ASA
325 mg, NTG SL X3 without improvement, then nitroglycerin drip,
and Heparin IV bolus then drip. He was transferred to [**Hospital1 18**] for
further care.
.
In the ED, initial vitals were T 97.8, HR 68, BP 124/66, 02
99%3L, RR12. He was given metoprolol 5 mg IV, 25 mg PO, Plavix
300 mg PO, Ativan 1 mg IV, and Fentanyl 50 mcg x2. He was taken
directly to the cath lab for coronary angiography.
.
Coronary angiography revealed patent LMCA, LAD 95%
mid-thrombotic lesion and 40% distal stenosis, patent LCx
including stent, proximally occluded RCA with perfusion from
left collaterals. He was treated with export thrombectomy,
direct bare-metal stenting X2, with good angiographic results.
He is being admitted to the CCU for further care.
Past Medical History:
1. Premature multivessel CAD, status post IMI in [**2173**], status
post LCx stent in [**2173**]. See anatomy below and most recent
exercise MIBI.
2. Depression, previously on antidepressant currently off
therapy
3. Substance abuse
4. Hypercholesterolemia
Social History:
He has 3 young children from a prior relationship. He lives at
home with his mother, sister and brother. [**Name (NI) **] does not have a
close relationship with his mother or siblings. He continues to
smoke. As noted above, recent cocaine use, last on [**2179-2-26**].
Family History:
Per OMR, his father had a first MI at 18, and died at 36 from an
MI. Many males on paternal side with premature CAD. Mother with
DM, HTN, throat, breast and uterine CA.
Physical Exam:
VS: Afebrile, BP 117/72, HR 60 RR 10 O2 97% on RA
Gen: Male in NAD. Oriented x3. Tearful.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP not elevated.
CV: RR, normal S1, S2. + Extra heart sound, unclear if S3 or S4.
No murmur appreciated. No thrills, lifts.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Right groin cath site without
hematoma, good distal pulses.
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+
.
MEDICAL DECISION MAKING:
EKG pre-cath demonstrated NSR, rate 70 bpm, indeterminate axis,
ST elevation in V2-5, T wave flattening I, aVL. New TWI in V2-4.
Post-procedure EKG unchanged versus pre-cath.
Pertinent Results:
[**2179-3-6**] 04:20PM BLOOD WBC-8.6 RBC-4.11* Hgb-12.5* Hct-34.9*
MCV-85 MCH-30.3 MCHC-35.7* RDW-14.6 Plt Ct-261
[**2179-3-8**] 04:05AM BLOOD WBC-13.2* RBC-4.90 Hgb-14.6 Hct-42.0
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.7 Plt Ct-331
[**2179-3-6**] 04:20PM BLOOD Neuts-67.2 Lymphs-26.6 Monos-4.8 Eos-1.0
Baso-0.4
[**2179-3-6**] 04:20PM BLOOD Plt Ct-261
[**2179-3-6**] 10:21PM BLOOD PT-12.1 PTT-33.5 INR(PT)-1.0
[**2179-3-6**] 04:20PM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-133
K-3.6 Cl-103 HCO3-26 AnGap-8
[**2179-3-8**] 04:05AM BLOOD Glucose-127* UreaN-7 Creat-0.6 Na-136
K-4.3 Cl-103 HCO3-24 AnGap-13
[**2179-3-6**] 04:20PM BLOOD CK(CPK)-259*
[**2179-3-6**] 10:21PM BLOOD CK(CPK)-1112*
[**2179-3-7**] 07:16AM BLOOD CK(CPK)-1056*
[**2179-3-8**] 04:05AM BLOOD CK(CPK)-364*
[**2179-3-6**] 04:20PM BLOOD CK-MB-34* MB Indx-13.1* cTropnT-0.28*
[**2179-3-6**] 10:21PM BLOOD CK-MB-136* MB Indx-12.2* cTropnT-1.95*
[**2179-3-7**] 07:16AM BLOOD CK-MB-58* MB Indx-5.5 cTropnT-1.04*
[**2179-3-7**] 07:16AM BLOOD Calcium-9.9 Phos-2.8 Mg-2.3
[**2179-3-6**] 04:20PM BLOOD Triglyc-87 HDL-37 CHOL/HD-5.1
LDLcalc-136*
.
Cardiac Catherization:
(Report not completed in OMR yet)
Coronary angiography revealed patent LMCA, LAD 95%
mid-thrombotic lesion and 40% distal stenosis, patent LCx
including stent, proximally occluded RCA with perfusion from
left collaterals. He was treated with Export thrombectomy,
direct bare-metal stenting X2 to the LAD, with good angiographic
results.
Brief Hospital Course:
ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS: Mr. [**Known lastname 45245**] is a 33 year-old male with
premature multivessel CAD status post IMI [**2173**], status post LCx
stent, admitted with anterolateral ST elevation MI, status post
LAD bare metal stents X2 on [**3-6**].
.
1) Anterior STEMI: Found in the ED to have an STEMI. He was
immedicately taken to the catherization lab and found to have a
patent LMCA, LAD 95% mid-thrombotic lesion and 40% distal
stenosis, patent LCx including stent, proximally occluded RCA
with perfusion from left collaterals. He then had Export
thrombectomy and two bare metal stents were placed in the LAD.
In the hours after the procedure he still had residual (but
improved) chest pain with persistent ST elevations. However,
after the sheath was pulled he became very agitated and wanted
to leave AMA. He was thought not to be competent to leave and
kept with security sitter. At this time, he continued to have
bleeding at the groin site, but vitals were stable and he would
not lie flat as instructed or permit dressing changes.
Additionally, he pulled his IVs and could not be continued on
integrillin/heparin (received approx 4 hours after PCI). The day
after the procedure he continued to have ST elevations
consistent with concern for a possible LV aneurysm. However, his
chest pain resolved by 12 hours after stenting and he remained
chest pain free for the remainder of the hospitalization.
Medically he was kept on aspirin, plavix, statin. Additionally
he was started on carvedilol and titrated up to 25 mg [**Hospital1 **] while
inpatient with plan to transition to coreg CR.
Patient left prior to an echo being performed.
Patient has been set up with outpatient follow up with Dr.
[**Last Name (STitle) 171**] and will be seeing the patient [**4-28**] (left message at
home).
.
2) Rhythm: NSR pre and post-cath. Carvedilol increased to keep
heart rate 50-60s.
.
3) Pump: Not assessed, no signs of volume overload.
.
4) Hyperlipidemia: Goal LDL <70 (admission labs showed elevation
at 136) Started high-dose statin (Lipitor 80 mg daily).
.
5) Psych: As mentioned, patient was very agitated approx [**1-24**]
hours after catherization wanting to leave AMA. Intial
evaluation by psychiatry felt that the patient was not competent
to make medical decisions and was kept with security sitters in
room. He was also given haldol and ativan as needed for
agitations but never required mechanical restraints. On day 3
of hospitalization, he was found to be competent to make medical
desicions and left AMA. He understood clearly the risks of
leaving and the importance of taking medications. He also was
counselled on not using illicit drugs and seeking treatment.
Apparently on presentation he voiced some thoughts of
suicidality but clearly stated in the days prior to leaving that
he had no thoughts or plans of hurting himself.
.
6) Substance abuse/heroin withdrawal: He reported using heroin
the day prior to admission but had not used cocaine in approx a
week (urine tox confirmed this). He began to show signs of
heroin withdrawal and was placed on a clonidine patch to treat
this as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale with methadone. Additionally
social work discussed heroin use with the patient and
recommended resuming methadone treatment. Patient expressed
interest in methadone clinic but said that if he could not
arrange this he would start using again.
Additionally given his high risk for HIV/Hep these serologies
were sent and risk factors were discused. He will follow up
with his PCP for the results.
.
7) Dispo: Patient left AMA clearly understanding the risks of
further heart attacks, death or other complications. He also
stated understanding that he must take aspirin and plavix.
Medications on Admission:
He describes intermittent use of ASA in the past 2 months, about
once every other day. He has not been taking his other
medications for at least 2 months.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**11-24**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for Chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Captopril Oral
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for agitation/anxiety.
10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSUN (every Sunday) as needed for opiate
withdrawal.
11. Carvedilol 6.25 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
Disp:*240 Tablet(s)* Refills:*2*
12. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
13. Methadone 10 mg/5 mL Solution Sig: One (1) PO Q2H PRN () as
needed for [**Doctor Last Name **] >10.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: ST Elevation Myocardial Infarction.
.
Secondary Diagnoses:
Hypercholesterolemia
Depression
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambultating
without assistance.
Discharge Instructions:
You were admitted with a heart attack and had removal of a clot
from your heart, and a bare metal stent placed in one of the
main arteries supplying blood to your heart. Not all of the
tests were completed to fulfill your workup and it is essential
that you take your medications as prescribed. It is also
pertinent that you follow-up with your PCP [**Name Initial (PRE) 176**] 7 days of
discharge and that you call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] within 2 weeks.
Followup Instructions:
Please call your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] to follow-up
within 7 days
.
Please call the number for the [**Hospital 2514**] Clinic in [**Location (un) **], MA
[**Telephone/Fax (1) 45246**] immediately following discharge
.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], Dept. of Cardiology [**Telephone/Fax (1) 45247**]
for an appointment within the next 2 weeks. When you call please
tell them that you need to have an echocardiogram at the
appointment.
|
[
"272.0",
"V45.82",
"412",
"410.11",
"V17.3",
"305.50",
"311",
"414.01",
"305.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.56",
"36.06",
"00.46",
"00.40",
"00.66",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
10844, 10850
|
5335, 9169
|
322, 379
|
11004, 11084
|
3853, 5312
|
11639, 12218
|
2578, 2748
|
9374, 10821
|
10871, 10871
|
9195, 9351
|
11108, 11616
|
2763, 3834
|
10949, 10983
|
272, 284
|
407, 1995
|
10890, 10928
|
2017, 2275
|
2291, 2562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,915
| 198,555
|
47085
|
Discharge summary
|
report
|
Admission Date: [**2178-4-7**] Discharge Date: [**2178-4-7**]
Date of Birth: [**2110-2-23**] Sex: M
Service: MEDICINE
Allergies:
Metoprolol
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
hypotension,fever
Major Surgical or Invasive Procedure:
CVL placement
History of Present Illness:
68 yo male brought to the ED after being found unresponsive at
dialysis. BP 70's systolic on arrival to the ED. He recently
underwent a right [**First Name3 (LF) 6024**] 2 weeks ago at the VA for osteomyelitis
after presenting in septic shock.
.
In the ED, he was found to have a lactate of 3.6 and GDT was
initiated. He received 5 liters of fluids, a CVL was placed, and
he was started on Levophed. He received a dose of both Vanc and
Zosyn. Blood sugar on arrival found to be in the 50's, given
glucose and octreotide. Vascular surgery evaluated surgical
wound, did not think likely source of sepsis.
.
On arrival to the floor, the patient denies pain or difficulty
breathing. Able to follow commands, cannot recall events
preceding admission. Asking to "just let me go."
Past Medical History:
(per VA DC summary):
Insulin dependent diabetes
PVD, s/p R [**First Name3 (LF) 6024**] 2 weeks ago
ESRD, on HD Tue/Thurs/Sat schedule- failed renal tx in [**2174**]
immunoblastic B-cell lymphoma (s/p 6 cycles of CHOP)last dose of
chemo [**2177-12-31**]
multiple admissions for fever and neutropenia, pseudomonal
sepsis
MRSA, VRE (culture locations unknown)
anemia
HTN
CHF (last echo in [**2176**] w/ preserved EF)
Social History:
Lives with his daughter, denies tobacco and ETOH
Family History:
unknown
Physical Exam:
vitals: temp 99.6/ bp 111/52/ CVP 9/ HR 105/ 94% on 4L NC
GEN: awake, responsive
HEENT: normocephalic, PERRLA, ? fluid pocket in L eye, EOMI,
whitish coating on tongue, dry mucosa
NECK: RIJ in place, no JVD
CV: tachy, no murmurs or rubs appreciated
LUNGS: bronchial breath sounds B/L, slight wheeze, no crackles,
no accessory muscle use
ABD: soft, nt, nd, hypoactive BS
EXT: R knee s/p [**Year (4 digits) 6024**]. Wound dressed, bleeding through bandage.
Sutures in place, black eshcar, no frank pus. LLE without edema,
warm, palpable DP pulse. UE cool.
NEURO: A/O x2 (time and self). Muscle tone normal, strength 4/5
in UE. Follows commands, answers questions
SKIN: dry, papular non-blancing rash on axilla B/L
Pertinent Results:
[**2178-4-7**] 12:10PM WBC-7.9 RBC-3.09* HGB-9.2* HCT-28.9* MCV-94
MCH-29.9 MCHC-32.0 RDW-27.9*
[**2178-4-7**] 12:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2178-4-7**] 12:10PM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-1.5*
MAGNESIUM-1.7
[**2178-4-7**] 12:10PM CK-MB-NotDone cTropnT-0.93*
[**2178-4-7**] 12:10PM ALT(SGPT)-17 AST(SGOT)-252* CK(CPK)-72 ALK
PHOS-66 AMYLASE-59 TOT BILI-0.8
[**2178-4-7**] 12:21PM LACTATE-3.6*
[**2178-4-7**] 07:13PM CORTISOL-8.1
[**2178-4-7**] 07:13PM GLUCOSE-105 UREA N-12 CREAT-3.9* SODIUM-142
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2178-4-7**] 07:31PM LACTATE-3.8*
[**2178-4-7**] 09:30PM TYPE-[**Last Name (un) **] TEMP-38.6 O2 FLOW-3 PO2-43* PCO2-49*
PH-7.33* TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
.
[**2178-4-7**] knee films:FINDINGS: Two views are provided, with no
comparisons on record. The patient is status post below-knee
amputation with the proximal tibial and fibular margins, sharp
and regular. The soft tissue stump is, overall, unremarkable in
appearance. There may be a small superficial ulcer, anteriorly,
with no evidence of deeper subcutaneous emphysema or gas-filled
tract reaching the underlying bone. There is amorphous
radiodense material in the deep soft tissues between the stump
margin and the fibular resection site, which may represent
heterotopic ossification, dressing material within the deep
ulcer, or less likely, retained surgical material. The knee
joint, itself, is unremarkable, with no effusion or acute
osseous abnormality. Noted is vascular calcification.
IMPRESSION: Status post below-knee amputation, with sharp
surgical margins. There remains probable ulceration, anteriorly,
and amorphous radiodense material may represent implanted
dressing/sponge, but should be closely correlated clinically.
There is no definite evidence of osteomyelitis.
.
[**2178-4-7**] CXR: Study is markedly limited secondary to significant
patient rotation. There is a hemodialysis catheter, with the tip
in the SVC. There is a right pleural effusion, an area of
increased opacity in the right lower lobe which is difficult to
assess due to the marked rotation. No definite pneumothorax
seen.
IMPRESSION: Limited study secondary to patient rotation. Right
pleural effusion, and questionable opacity in the right lower
lobe
.
EKG:Sinus tachycardia. Modest low amplitude lateral T waves are
non-specific and may be within normal limits. No previous
tracing available for comparison
Brief Hospital Course:
68 yo male with multiple medical problems, recent sepsis and R
knee [**Name (NI) 6024**] who was admitted to the MICU for hypotension and
unresponsiveness.
.
Given the patient's elevated lactate, it was thought that his
hypotension was most likely due to sepsis. Early goal-directed
therapy was initiated in the ED and continued on arrival to the
ICU. The patient was given broad spectrum antibiotics including
Vancomycin, Levofloxacin, and Zosyn given recent instrumentation
and possible new opacity on chest x-ray. Vascular surgery was
consulted in the ED to evaluate his surgical wounds. It was
felt by the surgery team that his wound was most likely not the
source of infection as the site appeared relatively clean, with
no frank pus. Plain films were done and did not show any
evidence of osteomyelitis, emphysema, or effusion. Renal was
also consulted as he was a dialysis patient. It was felt that
he did not require acute HD at that time, and it was recommended
to pursue CVVH overnight if the patient became more overloaded
with fluid resuscitation. His elevated troponin in the setting
of ESRD and hypotension was thought to be from demand rather
than ACS, as his CK enzymes were flat and his EKG did not have
any ST changes suggestive of ischemia. An echo was ordered to
assess for any wall motion abnormalities and it was planned to
obtain his medical record from the VA to better understand his
cardiac history.
Although the patient was found to be unresponsive in the ED, he
was awake and oriented x 2 on arrival to the ICU. He was able
to follow commands and answer some questions. He repeatedly
remarked "just let me go". The need for the IVF, antibiotics,
and possible pressors was explained to the patient multiple
times. His daughter and HCP was [**Name (NI) 653**] by phone and she
arrived to the ICU about two hours after the patient was
admitted. She explained that the patient was DNR/DNI and that
we "should listen to him and just let him go". She stated that
she did not want central line placement, pressors, or
antibiotics. She explained that he had endured a prolonged
hospitalization at the VA, and that he had wanted to stop all
care at that point, but that she pushed him to hold on and
continue. She said now she just wanted to honor his wishes.
Another daughter was also present for the conversation, and it
was discussed with both family members and the patient about
what the cause of his hospitalization was thought to be, what
role the antibiotics and IVF played in treating him, and that if
these measures were to be stopped, he would most likely die.
Both the patient and the family expressed understanding of these
risks, but still wanted to stop care and make him comfortable.
The overnight intensivist was notified of the patient and his
family's wishes and the plan to withdraw care; agreed with the
decision as the patient and family were competent. The patient
was given a dose of morphine to help with his progressing
respiratory distress.
The patient became apneic, bradycardic, and eventually
asystolic. He was pronounced dead at 10:17 pm. His family
members were present at the bedside. The overnight intensivist
was notified. An autopsy was offered and declined.
Medications on Admission:
(per VA DC summary):
allopurinol
gabapentin
nephrocaps
EPO w/ HD
advair
NPH 18 units qam/ 16 units qpm
simvastatin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
1. respiratory failure
2. pneumonia
3. ESRD
4. diabetes
5. CHF
Discharge Condition:
expired
Discharge Instructions:
none
|
[
"403.91",
"V49.75",
"250.00",
"486",
"285.21",
"585.6",
"038.9",
"202.80",
"V58.67",
"995.92",
"428.0",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8391, 8400
|
4959, 8196
|
287, 302
|
8506, 8515
|
2384, 4936
|
1627, 1636
|
8362, 8368
|
8421, 8485
|
8222, 8339
|
8539, 8546
|
1651, 2365
|
230, 249
|
330, 1107
|
1129, 1545
|
1561, 1611
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,353
| 107,212
|
21582
|
Discharge summary
|
report
|
Admission Date: [**2160-9-5**] Discharge Date: [**2160-9-11**]
Date of Birth: [**2091-3-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6029**]
Chief Complaint:
bloody stool and dizziness
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 69yo M h/o peripheral vascular disease, chronic renal
insufficiency, type II diabetes, recurrent DVT on Coumadin and
diastolic CHF who presented to the ED on [**2160-9-4**] after noting
black tarry stools x 2 days and experiencing an episode of
dizziness in which he fell to the floor in his kitchen. Patient
denies LOC on falling. He did not hit his head, and remembers
event well.
.
On arrival to the ED, VS were T: [**Age over 90 **]F, BP 107/32, HR 58, RR 20,
SaO2 97% RA. Orthostatics were done, demonstrating supine BP
115/80, upright 104/70. Initial labs were significant for hct
16.3 and INR 7.3, with grossly heme+ black stool. He refused NG
lavage. He was given 2U FFP, 10mg Vitamin K SC, 1L NS, and 2U
PRBC. After transfusion, hct had only increased from 16.3 to
17.8. ECG demonstrated NSR at 60bpm, nl axis and intervals, TW
flattening in inferior leads, TWI V6, no ST elevations; no
significant change from prior. CK was 170(6), with troponin of
0.09, which is his baseline in the context of chronic renal
insufficiency. He denied CP or SOB. He denied any new
medications or significant dietary changes, and stated that his
coumadin was last checked 1 week ago. He believes his coumadin
dose may have been increased, but is unsure.
.
In the MICU, FFP and Vitamin K was given for supertherapeutic
INR. EGD revealed multiple non-bleeding 2-5mm shallow ulcers
likely secondary to NSAID used. There was also a single
non-bleeding red lesion in the the proximal body of stomach with
minor erosions at the GE junction. During his MICU stay, blood
pressure was controlled with Hydralazine and Captopril. The
patient experienced some pulmonary congestion in the context of
aggressive fluid replacement and was managed with Lasix. As HCT
had stabilized, patient was transferred to the floor ternoon for
further management.
Past Medical History:
Recurrent BL DVT on Coumadin
Chronic Stasis Dermatitis with leg ulcers
PVD – Right tibial arterial disease on arterial dopplers
HTN
L tib-fib osteomyelitis s/p vanco x 6 weeks in [**11-30**]
Mild diastolic CHF
borderline DMII
Social History:
Former smoker (1pack per month), former light EtOH user (1 pint
per month). Denies drug use. Retired security guard.
Lives alone with daily home health aide. No close family.
Family History:
NC
Physical Exam:
Vitals: T99.6 BP 1156/63 HR 75 RR 18 O2 Sat 94% RA
Appearance: comfortable, in supine in bed, well-kept, NAD
HEENT: NC/AT. Anicteric. Oropharynx clear and without
exudates/erythema.
Neck: Negative LAD. Supple neck. No carotid bruis.
Pulm: Diffuse minimal wheezes BL. No R/W/C.
Cardio: Distinct S1, S2. Slight decrescendo murmur immediately
after S1.
ABD: S/NT. + Distention. + BS.
EXT: Warm, well-perfused. No calf-tenderness. Intact pedal,
radial pulses. Dressing over LLE ulcer is clean, dry and intact.
NEURO: No focal defecits.
Pertinent Results:
[**2160-9-5**] 11:02PM HCT-23.0*
[**2160-9-5**] 08:15PM HCT-23.7*
[**2160-9-5**] 08:15PM PT-16.2* INR(PT)-1.5*
[**2160-9-5**] 04:40PM TYPE-ART TEMP-36.7 PO2-60* PCO2-36 PH-7.42
TOTAL CO2-24 BASE XS-0 INTUBATED-NOT INTUBA
[**2160-9-5**] 04:40PM LACTATE-2.2*
[**2160-9-5**] 04:25PM WBC-9.9 RBC-3.02*# HGB-8.0*# HCT-24.4*
MCV-81* MCH-26.4* MCHC-32.7 RDW-16.6*
[**2160-9-5**] 04:25PM PT-18.3* PTT-27.2 INR(PT)-1.7*
[**2160-9-5**] 02:25PM HCT-21.4*
[**2160-9-5**] 07:53AM WBC-10.2 RBC-2.37* HGB-6.2* HCT-18.8* MCV-79*
MCH-26.0* MCHC-32.8 RDW-17.1*
[**2160-9-5**] 07:53AM PT-23.6* PTT-24.4 INR(PT)-2.4*
[**2160-9-5**] 02:00AM HGB-5.9* HCT-17.8*
[**2160-9-4**] 06:54PM WBC-11.8* RBC-2.03*# HGB-5.0*# HCT-16.3*#
MCV-80* MCH-24.8* MCHC-30.9* RDW-17.9*
[**2160-9-4**] 06:54PM PT-57.4* PTT-32.8 INR(PT)-7.3*
.
EGD: [**2160-9-5**]: multiple non-bleeding 2-5mm shallow ulcers in 1st
and second portion of duodenum. Single non-bleeding red lesion
in proximal body of stomach, and minor erosions at the GE
junction. The gastric lesion was of unclear significance and
would not bleed upon provocation.
Brief Hospital Course:
.
1.GI Bleeding: Given EGD, bleeding likely due to NSAID-induced
duodenal ulcers or gastritis with ulceration at GE junction in
setting of an INR of 7.3 on [**2160-9-4**]. Warfarin was held; patient
was started on a pantoprazole 40 mg [**Hospital1 **]. HCT was monitored
closely and patient was discharged after it had stabilized for
greater than 48 hrs. He did not have a colonoscopy while
in-patient; he will be having one as an out-patient. This was
discussed with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
.
2. History of multiple DVTs: INR 7.3 ([**9-4**])--> 1.2 ([**9-11**]).
Bilateral LENIs on [**2160-9-5**] were negative for DVT.
Anti-coagulation held initially given GI bleeding. Given h/o
multiple DVT's and concern about potential for clot, warfarin
was restarted prior to discharge. At time of discharge INR was
not yet therapeutic. He will have his INR followed by his PCP as
he usually does.
.
3.HTN: Patient had been hypertensive in MICU despite GI bleed.
He was started on captopril for blood pressure control.
Eventually he was transitioned over to lisinopril and
metoprolol. He will continue to have his blood pressure
monitored by daily home care nurse and his PCP; medications will
be further titrated if necessary.
.
4. L lower extremity leg ulcer: No obvious infection. Evaluated
by podiatry service -daily application of aquacel and dry kerlex
was recommended. Patient will be seen daily by wound care nurse
following discharge.
.
Medications on Admission:
Lopressor 200 mg [**Hospital1 **]
Lasix 40 mg [**Hospital1 **]
nifedipine ER 90 mg qd
coumadin 3 mg qhs
lisinopril 40 mg qd
Iron 325 mg qd
nexium 40 mg qd
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*59 Tablet(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*80 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
caregroup
Discharge Diagnosis:
1.Upper GI Bleed, likely from duodenal ulcers.
2. HTN
3. Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at your residence.
Please discuss with him the following issues:
1. Management of your duodenal ulcers
2. Outpatient colonoscopy
3. INR management - you will need to have your INR checked on
Monday [**9-15**]
4. Ongoing blood pressure control - we have restarted you on all
of your usual blood preesure medications - metoprolol and
lisinopril - and we restarted your Lasix as well. We held your
nifedipine while you were here and have not yet restarted it.
Please talk to Dr. [**Last Name (STitle) **] about restarting the nifedipine when
you see him on Monday [**9-15**].
Followup Instructions:
Please follow-up with your PCP as suggested above.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]
|
[
"578.9",
"532.90",
"428.0",
"453.40",
"250.00",
"707.10",
"401.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6929, 6969
|
4388, 5880
|
342, 348
|
7079, 7086
|
3252, 4365
|
7799, 7945
|
2680, 2684
|
6086, 6906
|
6990, 7058
|
5906, 6063
|
7110, 7776
|
2699, 3233
|
275, 304
|
376, 2217
|
2239, 2472
|
2488, 2664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,730
| 195,438
|
41132
|
Discharge summary
|
report
|
Admission Date: [**2113-3-29**] Discharge Date: [**2113-4-25**]
Date of Birth: [**2051-3-21**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
postcoital headache,nausea, and vomiting
Major Surgical or Invasive Procedure:
[**2113-3-29**] Right external ventricular drain placement
[**2113-3-29**] Angiogrm and Coiling of PICA Aneurysm
[**2113-4-3**] Reinsertion of External Ventricular drain
[**2113-4-6**] Cerebral Angiogram with use of verapamil
[**2113-4-19**] Cerebral Angiogram
History of Present Illness:
This is a 62 right handed Male who presents with one day of
postcoital headache, nausea, and vomiting after showering the
night prior to admission. He was difficult to arouse this
morning and was then seen at an outside hospital where CT of the
head without contrast showed blood in the third and fourth
ventricles. He was transferred to [**Hospital1 18**] for further evaluation.
Upon arrival to the [**Hospital1 18**] ED he was lethargic but arousable. CTA
of the head showed AVM with associated high flow aneurysm.
Past Medical History:
Denies
Social History:
Lives with wife and has an adult son who lives at college,The Pt
works as a software designer. He is a non smoker and denies
EtOH or recreational drug use. He routinely bikes 17 mi to work
twice weekly and long distances on weekends.
Family History:
NC
Physical Exam:
Physical Examination
97.0 41 123/70 18 100% 2L NC
Gen: Comfortable, NAD.
HEENT: Pupils: 3 to 1.5 mm bil EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic but arousable, cooperative with exam,
normal affect.
Orientation: Oriented to person only.
Language: Monosyllabic with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 1.5 mm
bilaterally. Visual fields intact
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus or diplopia.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline with fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-4**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: mild dysmmetria on finger-nose-finger
EXAM ON DSICHARGE:Awake alert oreinted x [**2-2**] / this does
fluctuate. Speech is clear / thought process is tangential, no
facial, no drift, follows commands, pupils [**3-1**] bilaterally.
Pertinent Results:
CTA Head [**3-29**]
IMPRESSION:
1. Arteriovenous malformation and 8-mm high flow aneurysm
arising from an
enlarged right PICA.
2. Subarachnoid and intraventricular hemorrhage.
3. Obstructive hydrocephalus.
CT Head [**3-30**] - Interval decrease in the size of the lateral
ventricles with essentially unchanged bilateral occipital [**Doctor Last Name 534**]
and fourth ventricular hemorrhage. Small amount of
pneumocephalus as expected status post a right frontal approach
ventriculostomy catheter.
Femoral vascular u/s [**3-30**] - No pseudoaneurysm and no measurable
hematoma identified.
[**2113-3-29**] Cerebral angiogram
IMPRESSION:
[**Known firstname **] [**Known lastname 20473**] underwent cerebral arteriography and coiling of
right distal PICA aneurysm. This was complicated by a rupture;
however, the patient suffered no adverse consequences secondary
to this, there was also a pial AVM measuring approximately 2.5 x
2.5 x 2.5 cm in the vermian region on the right side with a
single large draining vein into the right transverse sinus.
[**2113-3-30**] femoralUS
IMPRESSION: No pseudoaneurysm and no measurable hematoma
identified.
[**2113-4-3**] CT brain
IMPRESSION:
1. Successful re-positioning of a right EVD, now at the right
foramen of
[**Last Name (un) 2044**].
2. Persistent dilatation of the right lateral ventricle and
intraventricular
hemorrhage.
[**2113-4-11**] CEREBRAL ANGIOGRAM
IMPRESSION: [**Known firstname **] [**Known lastname 20473**] underwent cerebral angiography which
revealed
moderate spasm of both anterior cerebral arteries in its
proximal A1 segment.
5 mg of verapamil was instilled intra-arterially in the right
internal carotid artery and in the left internal carotid artery.
[**2113-4-18**] LOWER EXTREMITY DOPPLER
CONCLUSION:
Low velocity venous flow is noted particularly on the right
greater than the left, but there is no evidence of DVT
[**2113-4-19**] angio:
No vasospasm.
[**2113-4-21**] CTA Head:
FINDINGS:
CT HEAD:
A ventriculostomy catheter from right frontal approach
terminates in the right
lateral ventricle, unchanged in position. Hypodensities along
its course
likely represent gliosis. Minimal confluent hypodensities in
periventricular distribution likely reflect transependymal
migration of CSF. In comparison to [**2113-4-11**] exam, there is mild
increase in ventricular size. The anterior horns of the lateral
ventricles currently measure 3.4 cm, previously 2.5 cm (2:19).
The third ventricle measures 1.1 cm in diameter, previously 0.7
cm (2:18). The temporal horns of the lateral ventricles also
appear more prominent from prior exam. Small amount of blood
products are seen layering in the occipital horns of lateral
ventricles, unchanged. There is no acute intracranial
hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation appears well
preserved. There is no large vascular territorial infarction.
Post-surgical changes related to left PICA coiling are noted
with extensive metallic streak artifacts that limit evaluation
of the posterior fossa.
Round densities projecting over right maxillary sinus likely
represent
retention cysts. Right sphenoid sinuses and posterior ethmoid
cells are
completely opacified. The wall of the right sphenoid sinus
appears thickened, suggestive of chronic nature of inflammation.
The mastoid air cells appear well aerated. No acute fracture is
seen. Visualized soft tissues are unremarkable.
CTA HEAD:
Moderate diffuse narrowing involving the principal vessels of
circle of [**Location (un) 431**] noted on [**2113-4-5**] CT exam has resolved.
However, left PCA vasospasm persists. The relative narrowing and
irregularity of the basilar artery, seen on prior exam, is not
visualized on current study. Residual filling of coiled left
PICA aneurysm is apparent measuring 2.7 mm and is concordant
with findings of most recent angiogram of [**2113-4-19**]. The right
cerebellar AVM is redemonstrated.
IMPRESSION:
1. In comparison to [**2113-4-11**] exam, there is mild interval
increase in the
size of ventricles. A small amount of blood layering in
occipital horns of
the lateral ventricles persists. There is no new intracranial
hemorrhage or infarction.
2. Vasospasm involving the basilar artery, middle and anterior
cerebral
arteries appears resolved from prior exam. However, moderate
left posterior cerebral artery narrowing persists.
3. Residual filling of the coiled left PICA aneurysm measures
2.7 mm.
4. Stable appearance of the right cerebellar AVM.
5. Sinus disease, as detailed above.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Patient was intubated at the time of admission and taken to the
the ICU for EVD placement. Patient subsequently went to
angiogram for coiling of the aneurysm,During the case there was
a sudden rise in the ICP and the EVD started draining bright red
blood indicating the aneurysm had ruptured. We were able to
secure the aneurysm and transferred the patient in stable
condition to the ICU. Mr. [**Known lastname 20473**] was extubated on [**3-30**] with a
stable and non focal exam. There was a question of right groin
hematoma no pseudoaneurysm and no measurable hematoma
identified. He continued to have his EVD at 5cmH20. It
continued to drain accordingly. [**3-31**] and [**4-3**] TCDS demonstrated no
evidence of vasospasm. In the early morning of [**4-3**] his EVD
became dislodged. He was brought to the OR for replacement of
the EVD without complication. Post operatively he was noted to
have a right sided seizure.
On [**4-5**] there was a slight change in his mental status and he was
noted to be confused. He had a CTA which showed moderate spasm,
we treated this by elevating his systolic blood pressure and
increasing his IVF. He underwent an angiogram on [**4-6**] and had
intra arterial Verapamil. On [**4-7**] his blood pressure perameters
were decreased to 160-180.
On [**4-11**], he had an angiogram and recieved 5mg of verapamil in
the bilateral ICA's due to vasospasm. On [**4-12**], Dr. [**First Name (STitle) **]
considered a repeat angiogram but held off due to stable
neurologic status. His sheathe was removed. He received a PICC
and his central line was discontinued. The SICU stopped his
fludrocortisone. His CSF sample was finalized as no growth. His
EVD was at 20.
On [**4-13**], his drain remained at 20. On [**4-14**], exam remained
unchanged and drain at 20 and open. His blood pressure
parameters were changed to 140-160 systolic.
His ICU continued to remain stable. EVD remained at 20cmH2O
with minimal drainage on low ICPs. On [**2113-4-19**] patient went for
a cerebral angiogram in which his AVM was unable to be completly
embolized. Operative planning was delayed. He was cleared for
transfer to the SDU but no bed was available so he remained in
the ICU. On [**4-20**], it was noted that the urine output had
increased but his serum NA was stable. Urine NA/OSM were checked
and stable. His IVF were decreased. On [**4-21**], he continued to
have increased urine output but his lab values remained stable.
A Head CTA was done which was stable and his EVD was removed.
His Nimodipine was also discontinued as it was day 23. His
Keppra was weaned to off.
He was transferred to the floor and remained stable. He was
evaled by PT OT and deemed appropriate for acute rehab. He was
discharged to [**Hospital1 **] / [**Location (un) 86**].
Medications on Admission:
Supplements
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain/fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
AVM
RIGHT PICA ANEURYSM
SEIZURE
DELERIUM
CEREBRAL ARTERY VASOSPASM A1 SEGMENT REQUIRING VERAPAMIL
INTRAVENTRICULAR HEMORRHAGE
OBSTRUCTIVE HYDROCEPHALUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
as well as Mental Status: Confused - sometimes.
Discharge Instructions:
*****PLEASE REMOVE PATIENTS STAPLES ON [**2113-4-28**]
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.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
Clearance to drive and return to work will be addressed at your
post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
YOUR CASE IS BEING MANAGED BY DR [**First Name (STitle) **] / NEUROSURGEON AT
[**Telephone/Fax (1) **]
WE WOULD LIKE YOU TO FOLLOW UP WITH DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] AT [**Hospital3 **] [**Hospital3 **] 3 WEEKS AFTER DISCHARGE. Phone: [**Telephone/Fax (1) 89617**]
PLEASE CALL TO SCHEDULE AN APPOINTMENT TO BE SEEN
Completed by:[**2113-4-25**]
|
[
"430",
"331.4",
"998.2",
"276.1",
"E879.8",
"293.0",
"998.11",
"747.81",
"780.39",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.75",
"96.71",
"99.29",
"02.39"
] |
icd9pcs
|
[
[
[]
]
] |
11105, 11175
|
7402, 10187
|
347, 610
|
11371, 11371
|
2775, 4742
|
13007, 13431
|
1454, 1458
|
10249, 11082
|
11196, 11350
|
10213, 10226
|
11570, 12984
|
1473, 1662
|
267, 309
|
638, 1157
|
1894, 2755
|
4752, 7379
|
11522, 11546
|
1179, 1187
|
1203, 1438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,120
| 166,555
|
53688
|
Discharge summary
|
report
|
Admission Date: [**2167-5-2**] Discharge Date: [**2167-5-2**]
Date of Birth: [**2114-12-14**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
Patient is a 52 M who was found wandering in the [**Doctor Last Name 6641**] confused,
walking around barefoot. Per ED, his family reports that he was
last seen when had rode out his motorcycle however EMS notes
state patient himself reports he had been out on his motorcycle.
He was seen by bystanders who called EMS. There were no signs of
his motorcycle or of accident. He was found with white paste vs
paint around lips. Patient denied substance abuse at the scene.
He had blood on feet from walking around barefot and on tips on
fingers but no other evidence of trauma.
In the ED, initial VS were BP 118/90, HR 90, 16, 98% on RA. He
was AAOx3, but inattentive, did not appear intoxicated. He was
initially directable in the trauma bay. His labs were positive
for amphetamines but negative for other substances. He initially
received 5 mg iv haldol. He became agitated during transfer to
CT and he received 10 mg iv haldol, 4 mg iv lorazepam and was
intubated with 20 mg iv etomidate, 120 mg iv succinylcholine,
100 mg iv ketamine, 10 mg iv vecuronium, propofol, then versed/
fentanyl. CT head/ torso was unremarkable. Trauma evaluation was
negative. Vital signs prior to transfer were: 63, 112/54, CMV
FiO2 60%, TV 500, PEEP 5.
On arrival to the MICU, patient remains intubated/ sedated/
paralyzed
.
Review of systems:
(+) Per HPI, unable to obtain [**1-15**] intubation
Past Medical History:
numerical dyslexia
ADHD
h/o leg injury following shooting
bipolar depression
Social History:
smokes pot on occasion from his friend
denies alcohol
denies tobacco
Family History:
mother has depression
no family history of heart disease or seizure disorder
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.5 BP: 118/54 P: 62 R: 12 O2: 99% on RA
General: intubated, sedated
HEENT: blood seen in ET tube, pupils pinpoint and sluggist
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: equal breath sounds bilaterally with scattered coarse
breath sounds
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace edema
SKIN: puntacte lesion seen in right forearm, suspicious for
IVDU, multiple tattoos
Neuro: patient winces to pain but does not localize
Physical Exam on Discharge:
Vitals: T: 98.4 BP: 121/51 P: 79 R: 15 O2: 97% on RA
General: extubated, off sedation
HEENT: PERRL, MMM
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: equal breath sounds bilaterally with scattered coarse
breath sounds
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: foley removed
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace edema
SKIN: puntacte lesion seen in right forearm, suspicious for
IVDU, multiple tattoos
Neuro: A+Ox3, no focal deficit
Pertinent Results:
Lab Results:
[**2167-5-2**] 12:48AM BLOOD WBC-13.2* RBC-5.12 Hgb-16.8 Hct-50.0
MCV-98 MCH-32.7* MCHC-33.5 RDW-12.4 Plt Ct-218
[**2167-5-2**] 06:10AM BLOOD WBC-11.3* RBC-4.77 Hgb-15.4 Hct-47.3
MCV-99* MCH-32.2* MCHC-32.6 RDW-12.4 Plt Ct-178
[**2167-5-2**] 12:48AM BLOOD PT-11.0 PTT-29.2 INR(PT)-1.0
[**2167-5-2**] 12:48AM BLOOD Fibrino-303
[**2167-5-2**] 12:48AM BLOOD Glucose-112* UreaN-25* Creat-1.3* Na-138
K-4.1 Cl-100 HCO3-23 AnGap-19
[**2167-5-2**] 06:10AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-139
K-4.3 Cl-107 HCO3-24 AnGap-12
[**2167-5-2**] 12:48AM BLOOD ALT-33 AST-44* LD(LDH)-276* CK(CPK)-545*
AlkPhos-78 TotBili-0.8
[**2167-5-2**] 06:10AM BLOOD CK(CPK)-856*
[**2167-5-2**] 12:48AM BLOOD Calcium-10.3 Phos-4.5 Mg-2.6
[**2167-5-2**] 06:10AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.5
[**2167-5-2**] 06:10AM BLOOD Osmolal-295
[**2167-5-2**] 12:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2167-5-2**] 02:24AM BLOOD Type-[**Last Name (un) **] Rates-16/20 Tidal V-500 FiO2-100
pO2-359* pCO2-59* pH-7.27* calTCO2-28 Base XS-0 AADO2-295 REQ
O2-55 -ASSIST/CON Intubat-INTUBATED
[**2167-5-2**] 06:52AM BLOOD Type-ART pO2-182* pCO2-43 pH-7.39
calTCO2-27 Base XS-1
[**2167-5-2**] 12:56AM BLOOD Glucose-98 Na-139 K-4.0 Cl-100 calHCO3-30
[**2167-5-2**] 08:27AM BLOOD PHENCYCLIDINE-PND
[**2167-5-2**] 01:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2167-5-2**] 01:50AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2167-5-2**] 01:50AM URINE RBC-6* WBC-4 Bacteri-NONE Yeast-NONE
Epi-0
[**2167-5-2**] 01:50AM URINE CastHy-32*
[**2167-5-2**] 01:50AM URINE Mucous-RARE
[**2167-5-2**] 01:50AM URINE Hours-RANDOM
[**2167-5-2**] 01:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS mthdone-NEG
ECG:
Cardiovascular Report ECG Study Date of [**2167-5-1**] 2:16:36 AM
Sinus rhythm. Compared to the previous tracing of [**2167-4-21**]
criteria for
low limb lead voltage are not met on the current tracing.
IMAGING:
Radiology Report TRAUMA #3 (PORT CHEST ONLY) Study Date of
[**2167-5-2**] 12:42 AM
FINDINGS: Examination is limited by motion and overlying
structures. Lungs are low in volume, but clear. There is no
pleural effusion or pneumothorax. Heart is normal in size with
normal cardiomediastinal contours. The study and the report were
reviewed by the staff radiologist.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2167-5-2**] 1:42
AM
IMPRESSION: No acute intrathoracic process.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
[**2167-5-2**] 3:01 AM
IMPRESSION:
1. No acute traumatic injury to the torso.
2. NG tube in the distal esophagus, should be advanced.
3. Dense round 2.6-cm scrotal structure may reflect testicular
prosthesis,
correlate with exam findings.
Radiology Report CT CHEST W/CONTRAST Study Date of [**2167-5-2**] 3:01
AM
IMPRESSION:
1. No acute traumatic injury to the torso.
2. NG tube in the distal esophagus, should be advanced.
3. Dense round 2.6-cm scrotal structure may reflect testicular
prosthesis,
correlate with exam findings.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2167-5-2**]
3:01 AM
IMPRESSION: No acute fracture or subluxation, with degenerative
change
causing moderate canal narrowing.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2167-5-2**]
3:01 AM
IMPRESSION: No acute intracranial process with mild soft tissue
swelling
along the right aspect of the vertex.
Radiology Report ANKLE (AP, MORTISE & LAT) RIGHT Study Date of
[**2167-5-2**] 3:09 AM
IMPRESSION: No fracture or dislocation with multiple radiopaque
foreign
bodies in the lateral leg.
Radiology Report TIB/FIB (AP & LAT) RIGHT Study Date of [**2167-5-2**]
3:09 AM
IMPRESSION: No fracture or dislocation with multiple radiopaque
foreign
bodies in the lateral leg.
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a 52 M with
history of bipolar disorder and ADHD who presented with altered
mental status and confusion following taking marijuana and
zolpidem. He required intubation for agitation and radiologic
studies to eval for trauma. He was found not to have a C-spine
fracture and his neck was later cleared clinically when awake.
He was intubated and sedated overnight, and was extubated and
discharged the next day with recovery of mental status and no
significant traumatic injury with instruction to discontinue
ambien and marijuana use.
ACUTE CARE:
1. THC and zolpidem intoxication: Patient was found wandering in
his underwear in the [**Doctor Last Name 6641**] in the middle of the night with
superficial lesions on his feet and hands. He was confused and
talking about a motorcycle. The last thing he remembers prior to
the event was going to bed after taking ambien smoking marijuana
grown by a friend. When found he was disoriented and talking
about a motorcycle. He was taken to the ED where he was alert
and oriented x 3 (per report), but agitated and tangential. He
was sent for CT scans for a trauma evaluation (CTs head /
C-spine / torso), but became agitated in the CT scanner. He was
then intubated and sedated and the CT scans were obtained. He
tested + for amphetatmines but he takes Adderall at home. No
hypertension or hyperthermia were noted by EMS, in the ED, or in
the MICU. His EKG without changes. The following morning he was
satting 100% on minimal PSV settings, following all commands,
and given he was only intubated in the ED for agitation (and not
for any acute pulmonary process), he was extubated without
issue. Post-extubation, his mental status was entirely normal
(completely oriented, normal speech, normal content of speech,
and able to reason fully and clearly). Given there was no
clinical evidence of any serious or on-going process
contributing to his presentation, he was discharged home. His
overall presentation was thought to be related to somnambulation
related to the combination of alcohol, marijuana, and Ambien. He
was strongly advised to not use Ambien in the future, to avoid
marijuana, and to use alcohol only in moderation (and never in
combination with his prescribed medications.) He endorsed
understanding of these recommendations.
2. Question trauma: There were no clinical signs of trauma aside
from abrasions on patient's feet and hands. His C-spine was
without fracture on CT and cleared clinically upon regaining
mental status. CT head, chest, and abdomen revealed no acute
trauma as well. He was discharged with instructions for PCP
[**Last Name (NamePattern4) 702**].
3. HTN: patient normotensive on this admission. Recommended
taking home medication on discharge.
4. ADHD/numerical dyslexia: defer to outpatient providers for
management.
TRANSITIONS IN CARE:
-stopped ambien and recommended avoiding illicit drugs
-recommended 1 week PCP followup
[**Name9 (PRE) 110235**] not change patient's on-going home medications
Medications on Admission:
1. Adderall Oral
2. duloxetine Oral
3. lisinopril-hydrochlorothiazide Oral
4. tramadol Oral
5. Ambien prn insomnia
Discharge Medications:
1. Adderall Oral
2. duloxetine Oral
3. lisinopril-hydrochlorothiazide Oral
4. tramadol Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 916**],
You were admitted to the hospital because you were found
wandering and confused and with signs of potential injury. While
in the hospital, you were sedated and placed on a breathing
machine because you were unable to cooperate with tests to show
that your spine was not damaged. You were on the breathing
machine overnight but came off of it quickly when your mental
state returned to [**Location 213**]. We examined your cervical spine and
coupled with the CT scan of your neck, we felt you do not need
the neck collar.
Please make an appointment for follow up with your primary care
physician following discharge.
Please make the following changes to your medications:
1. Stop taking Ambien
Please avoid taking recreational drugs.
Followup Instructions:
Please make an appointment to see your primary care physician
[**Name Initial (PRE) 176**] 1 week of discharge.
|
[
"401.9",
"314.01",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10579, 10585
|
7258, 10289
|
306, 330
|
10652, 10652
|
3364, 7235
|
11603, 11717
|
1940, 2018
|
10458, 10556
|
10606, 10631
|
10315, 10435
|
10802, 11486
|
2033, 2047
|
2742, 3345
|
11516, 11580
|
1685, 1738
|
245, 268
|
358, 1666
|
2061, 2713
|
10667, 10778
|
1760, 1838
|
1854, 1924
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,566
| 172,605
|
9968
|
Discharge summary
|
report
|
Admission Date: [**2194-6-6**] Discharge Date: [**2194-6-21**]
Date of Birth: [**2115-9-30**] Sex: M
Service: MEDICINE
Allergies:
Cytarabine
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
High WBC count (relapsed AML)
Major Surgical or Invasive Procedure:
Placement and subsequent removal of pheresis line
History of Present Illness:
Mr. [**Known lastname 20904**] is a 78 yo Cantonese speaking man with AML s/p 7+3
induction chemotherapy in [**2194-2-16**], who presents from clinic
with relapsed AML. He had been in peripheral remission for about
3 months. Patient interview was conducted with the help of
interpreter via telephone.
.
He was diagnosed with AML in [**2194-2-16**] when he presented to the
hospital with dizziness. He was found to be neutropenic and
anemic, and BM biopsy was consistent with AML. His 6[**Hospital **]
hospital stay included a brief ICU stay for respiratory distress
while receiving idarubicin for 7+3 induction, and then his
post-chemo course was complicated by C. [**Hospital 563**] candidemia.
Echo and eye exam were normal. He was initially started on
Micafungin for the candidemia, however LFTs were noted to rise
with a new abdominal pain. MRI was performed which ruled out
hepatosplenic involvement. Although it was felt unlikely that
micafungin caused the LFT elevation, it was switched to
anidlofungin per ID recs and was discharged home with 2 more
weeks of anidlofungin.
.
Since discharge from the hospital in [**2194-3-16**], pt reports
feeling "okay." His lower back has been bothering him since he
"fell back in the winter time," and he feels weak in the legs on
prolonged ambulation. He also endorses swelling in the lower
legs, but it's not new. Otherwise, his ROS is negative;
specifically, he denies fevers, chills, URI symptoms, nausea,
vomiting, abdominal pain, diarrhea, dysuria.
Past Medical History:
1. AML as above
2. Diabetes Mellitus; followed by Dr. [**First Name (STitle) 3636**] at [**Hospital **] Clinic; was
started on insulin during last admission in Efb [**2194**] however it
was stopped on [**2194-5-13**] per patient request (did not like the
[**Last Name (un) **] of checking FS and giving injections)
3. HTN
Social History:
Lives with wife. Married for 30+ years. Denies smoking, alcohol
or drug use history ever.
Family History:
No one in family has hx of cancer/blood disorders
Physical Exam:
Vitals: T: 97.8 BP: 123/70 HR: 97 RR: 20 O2: 94% RA
Appearance: NAD
Eyes: EOMI, PERRL, dentures in place, no oral lesions. MMM
Neck: supple. No thyromegaly
Lymph node: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy
Heart: Borderline tachycardic, no murmurs/rubs/gallops
Lungs: CTAB no rhonchi, crackles or wheezes
Abd: Soft, NDNT. +normoactive bowel sounds
Ext: [**1-17**]+ pitting edema bilaterally to upper ankles
Neuro: Alert and oriented x3, no focal deficits
Skin: warm, no rash, no ulcer
Pertinent Results:
Admission labs
135 98 14
-------------- glu not done
4.3 27 0.9
Ca: 9.0
ALT: 55 AP: 189 Tbili: 0.3
AST: 51 LDH: 846
WBC 107.2 (N:1 Band:0 L:0 M:1 E:0 Bas:0 Other (blasts): 98)
Hbg 12.8
Hct 38.8
Plt 71
[**6-11**] ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is mild global
left ventricular hypokinesis (LVEF = 50 %). There is no
ventricular septal defect. Right ventricular chamber size is
normal with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. 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. Mild to moderate ([**1-17**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2194-4-4**],
biventricular systolic function is now borderline/mildly
depressed. The degree of MR has slightly increased. Pulmonary
hypertension is now detected.
Brief Hospital Course:
Pt was admitted in good condition despite WBC count of 100,000
until ~ 6 pm on [**6-7**] when he started to become dyspneic, hypoxic
to 88% on RA with drop in UOP. There was a concern for
leukostasis and pt was transferred to MICU for urgent pheresis.
MICU course: On [**6-6**] he spiked a temperature to 102.8F
overnight, with SVT to the 140's responsive to diltiazem, and
cefepime was started given functional neutropenia. He was doing
well on [**6-7**] with heart rates ~100, sats 92-95% on room air, and
respiratory rates in the 20's, until 6pm, when he was noted to
be more tachypneic (to the 30's), tachycardic (to the 150's),
and hypoxic (88% on room air). His urine output dropped off, and
a chest xray showed mild hilar prominence. LDH had doubled, and
white count had not dropped substantially. Given concern for
leukostasis, preparations for initiation of pheresis were made.
Given his likely tumor lysis, early DIC, likely leukostasis, and
tenuous respiratory and hemodynamic status, he was transferred
to the [**Hospital Unit Name 153**].
In the ICU, constellation of symptoms, including low urine
output and worsening respiratory status concerning for
leukostasis. Pheresis line was placed and leukoreduction therapy
undertaken. Hypoxia was thought to be secondary to leukostasis,
and he maintained his O2 Sat on 2L NC. Hydroxeaurea and
hydration were contineud to protect against tumor lysis. He was
afebrile but was given levaquin + vancomycin + zosyn for recent
fevers and functional neutropenia.
Pt underwent pheresis without incident and was transferred to
the floor. He was continued on Decitabine chemo per protocol
(total 5 days) and high dose hydroxyurea. He was on allopurinol
to reduce risk of hyperuricemia. Tumor lysis and DIC labs were
checked frequently. The patient appeared to be in early DIC
during the acute stage of needing leukopheresis however it did
not progress further. Pt had occasional fevers with no evidence
of infection. He was continued on Vanc, Cefepime, Acyclovr and
Fluconazole as he was neutropenic, but his fevers were thought
to be most likely due to disease process.
Summary of other issues:
# SVT/ Flash Pulm Edema: Pt went into SVT especially when
febrile. It responded well on Dilt IV (5 mg very slowly as BP
would transiently drop). Pt was maintained on Dilt 30 mg PO QID
with holding parameters. Lasix IV bolus was effective in
managing his respiratory distress. As his home hospice service
was unable to provide this, he was discharged on daily po lasix.
.
# Diabetes: He is followed by [**Last Name (un) **]. Pt was deemed to require
insulin however pt refused it at home due to the rigors of
checking blood sugars and giving appropriate doses of insulin.
Thus he was on glyburide instead at home.
- Held glyburide during hospital stay.
- FS QID and HISS
.
# Past hepatitis B exposure: HBV surface antigen negative, HBV
surface antibody positive, HBV core antibody (IGM) positive
- Pt was started on Lamivudine for concern of HBV reactivation
during prior admission. It was continued.
=======================================
GOALS OF CARE:
Several meetings were held with the team and the patient and his
family to discuss goals of care given his advanced age and grave
prognosis. The decision was made to make pt DNR/DNI, but to
complete a course of decitabine. On the BMT service, his WBC
initially seemed to respond to this therapy, but his peripheral
counts ulitmately demonstrated a recurrence of his disease. This
was discussed with him and his family; they chose to make him
CMO and be discharged home with hospice.
Medications on Admission:
Doxazosin 2 mg QHS
Glyburide 10 mg QDay
Lamivudine 100 mg QDay
Omeprazole 20 mg QDay
Aspirin 325 mg QDay
Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: 5-15 mg PO q2-3h
as needed for pain/shortness of breath.
Disp:*30 ML* Refills:*0*
2. MED
LIQUID ATIVAN; GIVE 0.5mg po/SL Q4H prn anxiety. dispense 50mg.
3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1)
Sublingual every four (4) hours as needed for secretions.
Disp:*50 tablets* Refills:*3*
4. Acetaminophen 650 mg Suppository Sig: One (1) Rectal every
four (4) hours.
Disp:*50 suppositiories* Refills:*2*
5. Compazine 25 mg Suppository Sig: One (1) Rectal every eight
(8) hours as needed for nausea.
Disp:*50 Suppository* Refills:*3*
6. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation.
Disp:*30 Suppository* Refills:*0*
10. OXYGEN
oxygen 2L nasal cannula PRN
11. LINE FLUSH
10cc saline flush and 2cc 10% heparin flush DAILY and PRN in
each PICC port
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2188**]
Discharge Diagnosis:
Acute Myelogenous Leukemia
Discharge Condition:
Hemodynamically stable. Poor Oncologic prognosis. Comfort
measures only.
Discharge Instructions:
Dear Mr. [**Known lastname 20904**],
You were admitted to [**Hospital1 18**] for treatment of your leukemia.
Unfortunately, this treatment was not effective. As per
discussion with you and your family, we focused on making you
comfortable. Arrangements were made for you to receive hospice
care at home.
You and your family should now that if it becomes too difficult
to take care of you when you become more ill at home, you are
welcome to return to the hospital.
Followup Instructions:
None
Completed by:[**2194-6-25**]
|
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icd9cm
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[
[
[]
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[
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23,506
| 136,571
|
14051
|
Discharge summary
|
report
|
Admission Date: [**2158-2-24**] Discharge Date: [**2158-3-3**]
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 16462**] is an 86 year old man
with coronary artery disease who was in his usual state of
health until [**2-24**] when around 4 AM he began to complain
of feeling gassy pain in his lower abdomen. His wife gave
him some Pepcid, he burped and then said he wanted to walk it
off. At his urging his wife returned to bed but was awakened
again around 5 AM when she noticed that he was in the
bathroom sitting on the toilet, with the seat down and was
complaining of pain in his abdomen. The pain was below his
umbilicus and radiated to the flank and back on both sides.
He was severely diaphoretic, his wife said his pajamas were
soaked. He appeared severely ill. He denied chest pain,
palpitations, shortness of breath, nausea and vomiting or
diarrhea. He was afebrile but had shaking chills. At this
time, emergency help was called and he was taken to [**Hospital6 23267**]. He was seen by his cardiologist who felt
that his presentation might be unstable angina. He was
hypotensive and a right subclavian line was inserted to
deliver pressors. Heparin was also started. He was
discharged to the [**Hospital6 256**] for
urgent catheterization. On route it was noticed that the
right central line was actually in the subclavian artery. It
was removed and pressure was applied. Heparin was
discontinued. At the [**Hospital6 256**]
line was placed in the left internal jugular.
On presentation to the [**Hospital6 256**]
the patient was found to have no changes on electrocardiogram
and normal CK and troponin levels. He was hemodynamically
labile but stabilized after a short time on Dopamine. Of
note, he was combative and confused, alert and oriented only
to self. This was thought secondary to Phenergan and/or
Morphine administration. His wife had said that this has
happened before with narcotic administration. He was sent to
the Critical Care Unit. At baseline he is only slightly
forgetful according to his wife.
The patient was treated empirically for abdominal sepsis with
Levofloxacin and Metronidazole. Abdominal computerized
tomography scan revealed the left perinephric hematoma
tracking to the groin. There were cystic lesions on the
kidneys bilaterally. General Surgery was consulted and
deferred to Urology. Urology recommended supportive therapy
with fluids and red blood cell replacement to keep hematocrit
greater than 30. The patient was made NPO. The patient's
creatinine was to 2.1 from an unknown baseline which was felt
to be prerenal. The next creatinine was falling with fluid
hydration. His baseline creatinine was later found to be in
the mid 1s according to his primary care physician. [**Name10 (NameIs) **] on
[**2-24**] and again at noon on [**2-25**] he was found to
have temperatures to 101. Blood cultures and urine cultures
were seen. The peripheral cultures had no growth and
cultures off the central line 1 out of two revealed anaerobic
gram positive cocci in pairs and clusters. Vancomycin was
started. Central line was discontinued after this result.
The tip was sent for culture. Chest x-ray was concerning for
a lower lobe process on the left, either retrocolic
consolidation or atelectasis. Levofloxacin and Metronidazole
were continued as coverage for aspiration pneumonia. The
patient remained NPO. In the Critical Care Unit the patient
was afebrile and hemodynamically stable through the afternoon
and evening on [**2-25**] and was transferred to the floor on
[**2-26**]. On presentation to the floor the patient is
comfortable but confused. He denies chest pain,
palpitations, shortness of breath, back pain, flank pain,
urination symptoms, abdominal pain, bright red blood per
rectum, melena, nausea, vomiting and diarrhea. The patient
does complain of a nonproductive cough and a sore throat.
REVIEW OF SYSTEMS: On review of systems the patient denies
headache or dizziness. He denies penis or testicle pain. He
denies rash.
PAST MEDICAL HISTORY: Coronary artery disease, status post
left anterior descending stent in [**2152**], following 90%
occlusion, catheterization in [**2154**] showed a patent stent with
proximal left anterior descending 56 to an occlusion, right
coronary artery okay, left circumflex 40% occlusion, it was a
right dominant system. He had normal ejection fraction.
Transient ischemic attack in fall, [**2156**]. Benign prostatic
hypertrophy.
PAST SURGICAL HISTORY: Left knee surgery, unknown time and
nature of surgery. Left total hip replacement.
ALLERGIES: Penicillin, he gets a rash.
MEDICATIONS: As an outpatient
Aspirin 81 mg q.d.
Atenolol 25 mg q.d.
Plavix 75 mg q.d.
Ditropan 5 mg q.h.s. prn
FAMILY HISTORY: No history of renal disease or coagulopathy.
His brother died of liver cancer.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] has one
son who is healthy. He has several grandchildren and a great
granddaughter who are all healthy. He is normally quite
active. He has no history of smoking, alcohol or drug use.
PHYSICAL EXAMINATION: On [**2-26**], on transfer to the
floor the patient had a temperature of 98.2??????, heartrate 70,
blood pressure 131/59, respiratory rate 16 and 100%
saturation on 4 liters of oxygen via nasal cannula. The
patient in general appears well and is lying in bed in no
acute distress. Head, eyes, ears, nose and throat
examination is unremarkable. On neck examination the patient
has no lymphadenopathy, no thyromegaly, 10 cm of jugulovenous
distension. He has no carotid bruits and 2+ carotid pulses.
On lung examination the patient has sparse crackles
bilaterally to the mid shaft as well as hollow breathsounds
in the left lower lung. Heart is regular rate and rhythm
with a normal S1 and S2, no murmurs, rubs or gallops.
Abdomen is soft, nontender, nondistended. He has some
voluntary guarding but no tap tenderness, no shake
tenderness. He has no masses or hepatosplenomegaly. Bowel
sounds are present. The patient has no costovertebral angle
tenderness bilaterally. Extremity examination: The patient
has no cyanosis, clubbing or edema. Femoral pulses are 2+
bilaterally, dorsalis pedis and posterior tibial pulses are
2+ bilaterally. Neurological examination: The patient is
awake, oriented only to name. He thinks he is in [**Location (un) 12017**]
and does not know that he is in the hospital. He had 0 out
of 3 recall at five minutes and 0 out of 3 with prompts.
Unable to assess his mental status further due to severe
confusion. Cranial nerves II through XII are within normal
limits. Sensation was normal to light touch. Motor
examination was [**5-21**] in all extremities. Reflexes were 2+
throughout with downgoing toes. Coordination was normal by
finger-to-nose test. Gait was not assessed due to the
patient is on bedrest. On skin examination, the patient has
ecchymosis at the right clavicle as well as the scrotum and
penis.
LABORATORY DATA: On imaging studies, the patient had a KUB
on [**2158-2-24**]. This was a limited study because the
patient was moving. The entire abdomen was not viewed. From
what was seen there were no dilated loops of bowel, however,
a left lower lobe consolidation/atelectasis was seen. Chest
x-rays on [**2-24**], [**2-25**] and [**2-26**] showed a
left lower lobe opacity which was read as atelectasis versus
consolidation. An abdominal computerized tomography scan on
[**2158-2-25**] showed a left perinephric hematoma tracking
into the groin. There were renal cysts in the mid lower pole
on the left lateral border of the left kidney as well as on
the upper pole of the right kidney. There were no stones.
There was no hydronephrosis. Bilateral pleural effusions
were seen, left greater than right.
An magnetic resonance imaging scan with gadolinium contrast
of the abdomen was performed on [**3-1**]. This magnetic
resonance imaging scan revealed some hyperintense region
within the left kidney which were thought to be consistent
with hemorrhage. There was some other abnormality which were
thought to be related to hemorrhagic cysts, however, soft
tissue neoplasm could not be excluded.
LABORATORY DATA: On presentation to the hospital on [**2-24**], the patient's complete blood count showed a white count of
18, hematocrit 33.6, platelets 156. Electrolytes showed a
sodium of 141, potassium 4.2, chloride 111, bicarbonate 20,
BUN 25, creatinine 1.7, glucose 124. CK was 114, troponin
was less than 0.3. Arterial blood gases showed
7.41/35/192/100% nonrebreather. On presentation to the floor
on [**2-26**], the patient's laboratory data showed a white
count of 12.9, hematocrit 31.5, platelets 118, and MCV of 88.
The differential showed 61% polys, 32% lymphocytes and 6%
monocytes and no bands. Electrolytes showed sodium 145,
potassium 4.2, chloride 115, bicarbonate 20, BUN 27,
creatinine 1.6, down from a maximum of 2.1 on [**2-25**].
Glucose was 82, calcium 7.9, phosphate 2.4, magnesium 1.5.
Liver function tests on [**2-24**] showed an AST of 20, ALT
10, lipase 20 and amylase of 52. Urinalysis showed protein
level of 30, no nitrites, otherwise unremarkable. The urine
culture from [**2-24**] showed no growth. Blood cultures
from [**2-24**] showed no growth on the peripheral draw, 1
out of 2 anaerobic gram positive cocci in pairs and cultures
off of the central line draw. The central venous line tip
culture did not grow anything. The anaerobic gram positive
cocci were later found to be Staphylococcus coagulase
negative sensitive to the Quinolones.
Electrocardiogram on admission showed normal sinus rhythm at
72, left anterior vesicular block, normal intervals, no ST
changes.
HOSPITAL COURSE: The [**Hospital 228**] hospital course from
admission to the Emergency Department through the Critical
Care Unit stay is described in the history of present
illness. Addition information to note is that the patient
required two units of packed red blood cells on [**2-24**]
and one unit on [**2-25**] to keep his hematocrit greater
than 30. He has not required any packed red blood cells
since. The remainder of the hospital course will be
presented from the time of presentation to the medicine team
on the floor [**2-26**].
1. Perinephric hematoma - The hematoma remained stable
clinically throughout his time on the floor. His hematocrits
were checked q.i.d. for one day and then b.i.d. for one day
and then q.d. since that time. They have remained
consistently in the low 30s. The creatinine has remained
steady in the 1.5 to 1.8 which was found to be at his
baseline according to his primary care provider. [**Name10 (NameIs) **] was
followed by Urology for his hematoma. They reviewed the
magnetic resonance imaging scan with the radiologist and
discussed the findings with the family. They have judged the
patient to be stable from their standpoint. He is instructed
to follow up with his primary care provider and home
urologist in two to three weeks for a repeat scan and further
evaluation. They are available to the family for further
help if needed, otherwise the urologic problem will be
handled by the patient's own urologist in [**Location (un) 7658**]. The
patient was on bedrest at the time he came to the Medical
Floor and was cleared to be out of bed to chair by Urology on
[**3-2**]. They have asked that his anticoagulation with
Aspirin and Plavix for his carotids, for gastrointestinal
short prophylaxis be held for a minimum of two weeks until
the bleed is stable.
2. Infectious disease - The patient's left lower lobe
infiltrate was either atelectasis or pneumonia. It was
unable to tell from the x-ray. Clinically although he did
spike a fever to 101 on the first day in the unit, he never
again spiked a temperature that high. He did not use any
Tylenol for it. The culture from the line was thought to be
contaminate, however, he was treated with Vancomycin once the
organism was identified. The Vancomycin was discontinued
once the sensitivity for the Staphylococcus came back as
Quinolone sensitive. He was initially put on Levofloxacin
and Metronidazole at admission due to a question of abdominal
sepsis. This was never lifted and covered him for his
possible left lower lobe pneumonia. It was decided to do a
ten day course. At the time of discharge, the patient is on
day 8 of 10. He will complete the course of Levofloxacin and
Metronidazole as he left to rehabilitation. It was thought
that the lower lobe consolidation might be pneumonia due to
aspiration. The patient was advanced to a soft solid, clear
liquid diet on presentation to the floor. He did well with
this. There was no evidence of any aspiration.
3. Cardiac - The patient was continued on his Atenolol for
blood pressure control once he reached the floor.
Hydralazine was added as the Atenolol was unable to achieve
good blood pressure control while at hospitalization. With
Hydralazine 10 mg t.i.d. the patient was able to keep his
systolic pressure below 140. His Aspirin and Plavix were
held as described above per Urology.
4. Mental status change - The patient's mental status change
initially was felt simply due to the narcotics, however, even
after these had gone off the patient continued to remain
confused. A 1:1 sitter was kept for the patient until
[**3-2**]. The patient's confusion tended to wax and wane,
being better while his family was around and worse when he
was alone. It was thought that this might be due to
infection so this was treated with antibiotics as described
earlier. This could also perhaps be due to hypoxia from the
hemorrhage. Neurology was not consulted. It was thought
that this could, however, be a shocked liver, however, liver
function tests were normal. Folate, B12, TSH and RPR were
sent and all came back normal or in the case of RPR negative.
Upon speaking with his wife it was found out that he tends
to become confused and agitated when he is in the hospital.
I also spoke with his primary care provider who confirmed
that he tended to become confused when hospitalized. This
happened on a prior admission for his hip replacement
surgery. The primary care provider suggested using Xanax
because this had worked successfully in the past with Mr.
[**Known lastname 16462**]. He also said that the confusion tends to resolve
fairly quickly once the patient returns home. So, to control
his confusion and agitation the patient was given Xanax 0.25
mg t.i.d. He was also given Haldol prn. The nurses tended
to give him the Haldol approximately once per day.
At the time of discharge the patient remains confused. He
does know his name and realize that he is in the hospital,
however, he is unable to remember which city the hospital is
in or the name of the hospital. He is alert and oriented to
the month and year. It is hoped that his mental status will
improve dramatically once he gets home.
5. Fluids, electrolytes and nutrition - The patient was NPO
during this time in Critical Care Unit, however, he was
switched to soft solid and clear liquid diet upon arrival to
the floor. He did well with this diet. Since he was not
tolerating good p.o the first couple of days he was started
on intravenous fluids, however, by [**3-2**] his
intravenous fluids were discontinued and the patient was
eating a good diet. Boost was added three times a day
between meals. His magnesium phosphate tended to be low and
were repleted as indicated by the laboratory results.
CONDITION ON DISCHARGE: Guarded.
DISCHARGE STATUS: The patient will be discharged to
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Left perinephric hematoma
2. Coronary artery disease
3. Benign prostatic hypertrophy
MEDICATIONS ON DISCHARGE:
Atenolol 25 mg q.d.
Levofloxacin 250 mg p.o. q.d. for three more days
Metronidazole 500 mg p.o. t.i.d. for three more days
Toprazole 40 mg p.o. q.d.
Xanax 0.25 mg p.o. t.i.d.
Hydralazine 10 mg p.o. t.i.d.
Ditropan XL 5 mg q.h.s. prn
Droperidol 1 to 2 mg q. 4 hours prn
DR.[**Last Name (STitle) **],[**First Name3 (LF) 7853**] C. 12-869
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2158-3-2**] 19:54
T: [**2158-3-2**] 21:04
JOB#: [**Job Number 41921**]
|
[
"507.0",
"331.0",
"275.2",
"275.41",
"785.59",
"276.5",
"593.2",
"593.81",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4779, 4859
|
15644, 15736
|
15762, 16271
|
9751, 15518
|
4522, 4762
|
5138, 9733
|
3936, 4052
|
112, 3916
|
4075, 4498
|
4876, 5115
|
15543, 15623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,126
| 161,056
|
21254
|
Discharge summary
|
report
|
Admission Date: [**2181-6-18**] Discharge Date: [**2181-6-25**]
Date of Birth: [**2105-3-7**] Sex: F
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 61-year-old female who
had a routine echocardiogram done in [**2181-4-17**] which revealed
an ascending aortic aneurysm with a mildly depressed left
ventricle function. The patient underwent cardiac
catheterization which showed no coronary artery disease and
the patient was referred to Dr. [**Last Name (Prefixes) **]
For operative repair.
PAST MEDICAL HISTORY: Hypertension.
Hypothyroidism
Status post hysterectomy
Status post cholecystectomy
Status post knee arthoscopy.
PREOPERATIVE MEDICATIONS:
1. Synthroid 0.1 mg p.o. q day.
2. Zestril 20 mg p.o.q day.
3. Triamterene/Hydrochlorothiazide 37.5/25 mg p.o. q day.
4. Alprazolam .25 mg p.o. p.r.n.
ALLERGIES: No known drug allergies.
HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital1 346**] on [**2181-6-18**] and was taken to the
operating room with Dr. [**Last Name (Prefixes) **] for repair of the
ascending aortic aneurysm with a 26 mm [**Last Name (un) **] Leaf graft.
Cardiopulmonary bypass time was 140 minutes, cross clamp time
was 94 minutes and circulatory arrest time was 20 minutes.
Please see operative note for full details. The patient was
transferred to the ICU in stable condition. The patient was
weaned and extubated from mechanical ventilation on postop
day one, the patient had a persistent hypoxia thought to be
due to the patient's quitting smoking approximately one month
prior to admission. Also the patient was noted on postop day
one to have a mildly elevated creatinine of 1.5, this
subsequently decreased to 1.0. The patient was asymptomatic
from her mild hypoxia.
On postop day two the patient was transferred from the
intensive care unit to the regular part of the hospital.
Chest tubes were removed without difficulty. The patient
continued to have moderate oxygen requirement, diuretics were
increased. Chest x-ray showed small bilateral pleural
effusion left greater than right. The patient responded well
to Lasix. On postop day three the patient began working with
physical therapy. It was recommended that the patient would
benefit from [**Hospital 3058**] rehabilitation.
Postop day four, the patient's hematocrit was noted to be
25.6. This in conjunction with he hypoxia and decreased
exercise tolerance it was decided to transfuse the patient
with one unit of packed red blood cells, this was given with
additional diuretics. The patient responded well and the
post transfusion hematocrit was 27. The patient continued to
improve however continued to require oxygen. By
postoperative day seven, the patient was cleared for
discharge to rehabilitation. Of note, the patient had a
mildly elevated TSH in the postoperative course at 6.4 it was
recommended the patient have it rechecked by her primary care
physician.
CONDITION ON DISCHARGE: Temperature 98.6, pulse 76 in sinus
rhythm, blood pressure 100/46, respiratory rate 16, oxygen
saturation 93% on four liters nasal cannula. Neurologically
the patient is awake, alert, oriented times three, nonfocal.
Heart is regular rate and rhythm without rub or murmur.
Respiratory: Breath sounds are clear, decreased at bilateral
basis. Gastrointestinal: Positive bowel sounds, soft,
nontender, nondistended. Sternal incision is clean, dry and
intact. Sternum is stable.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. twice a day times ten days.
2. Potassium chloride 10 mEq p.o. twice a day times ten days.
3. Colace 100 mg p.o. twice a day.
4. Synthroid 100 mcg p.o. q day.
5. Lopressor 25 mg p.o. twice a day.
6. Zantac 150 mg p.o. twice a day.
The patient is to have oxygen therapy via nasal cannula to
maintain oxygen saturation greater than 92%, wean as
tolerated, Combivent MDI two puffs q 6 hours. The patient
has to be discharged to rehabilitation in stable condition.
She is to follow-up with her primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 24642**] in one to two weeks. She is to follow-up with her
Cardiologist in one to two weeks and she is to follow-up with
[**Last Name (Prefixes) **] in three to four weeks.
The patient will be discharged to Life Care of [**Location (un) 17886**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2181-6-25**] 09:23:36
T: [**2181-6-25**] 10:08:28
Job#: [**Job Number 56253**]
|
[
"424.1",
"305.1",
"272.0",
"401.9",
"441.2",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.04",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
3491, 4586
|
705, 2962
|
563, 679
|
2987, 3468
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,331
| 120,294
|
29463
|
Discharge summary
|
report
|
Admission Date: [**2142-11-2**] Discharge Date: [**2142-11-7**]
Date of Birth: [**2069-12-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
cardiac arrest at home
Major Surgical or Invasive Procedure:
cardiac catheterization
intubation
Mechanical ventilation
central venous catheterization
arterial catheterization
History of Present Illness:
72 year old male with unceratin PMH presents after being found
unresponsive and not breathing at home. Family reported that
patient had been wheezing for the past few days. He saw his PCP
and was given ?abx and inhalers, had CXR on [**10-31**] with extensive
chronic changes with nodular interstitial changes but nothing
acutely seen. He had been heard wheezing in bed this a.m. as
early as 7:30a.m. on morning of admission. Sometime between 8
and 8:30 a.m., he was found by family to be unresponsive, blue,
and not breathing but still warm. EMS was called. He was found
to be in either asystolic or PEA arrest, intubated in field and
coded. He got atropine x 2, Epi x 2 and was brought to [**Hospital1 18**] ED
where he receivd more epi/atropine, levoflox, flagyl, 1 amp
calcium gluconate, 10 u insulin, 1 amp D50 and ASA 325 x 1. He
received CPR both in transport and in the ED. EKG showed diffuse
ST depressions. Given this he was emergently cathed. On arrival
in the cath lab, he was again pulseless and coded. Cath with PA
saturations in the 90's with high PCWP but clean coronaries;
this was likely due to a failure of peripheral/mitochondrial
ability to extract oxygen. He was on levophed and epinephrine
and intermittently dropping his blood pressures to 50's,
requiring frequent boluses of epinephrine.
At transfer to the ICU, the patient was unresponsive, difficult
to ventilate, in shock, and anuric. He continued to have
episodes of hypotension requiring boluses of epi every 10 mins.
A subclavin line placed for additional access.
Past Medical History:
history of tobacco use: ?COPD
no other known history
Social History:
[**12-11**] ppd smoker
Family History:
Non-contributory
Physical Exam:
Vitals: HR 109 BP 125/58 on multiple vasopressors RR 22 100% A/C
400x14/peep 5 with high PIPs and Plateaus
Gen: Intubated, sedated
HEENT: MMM, pupils dilated.
Neck: supple
CV: tachy with episodes of irregular tachy. no r/m/g
Pulm: Wheezing bilaterally
Abd: soft, nt
Ext: no edema, cool, clamped. distal pulses not palpable.
Neuro: unresponsive. dilated pupils.
.
Pertinent Results:
Labs:
[**2142-11-2**] 09:35AM BLOOD WBC-16.0* RBC-4.29* Hgb-12.5* Hct-39.0*
MCV-91 MCH-29.2 MCHC-32.1 RDW-13.5 Plt Ct-253
[**2142-11-3**] 05:00AM BLOOD WBC-51.1* RBC-3.83* Hgb-11.3* Hct-35.0*
MCV-91 MCH-29.4 MCHC-32.2 RDW-13.2 Plt Ct-130*
[**2142-11-4**] 05:36AM BLOOD WBC-60.2* RBC-3.99* Hgb-11.8* Hct-33.3*
MCV-84 MCH-29.5 MCHC-35.4* RDW-13.8 Plt Ct-79*
[**2142-11-5**] 05:48AM BLOOD WBC-57.4* RBC-3.29* Hgb-9.8* Hct-28.1*
MCV-85 MCH-29.7 MCHC-34.8 RDW-14.2 Plt Ct-107*
[**2142-11-7**] 05:02AM BLOOD WBC-43.8* RBC-3.12* Hgb-9.2* Hct-25.7*
MCV-82 MCH-29.6 MCHC-35.9* RDW-14.6 Plt Ct-33*#
[**2142-11-2**] 09:35AM BLOOD PT-16.1* PTT-50.6* INR(PT)-1.5*
[**2142-11-3**] 05:00AM BLOOD PT-32.1* PTT-84.7* INR(PT)-3.4*
[**2142-11-4**] 05:36AM BLOOD PT-30.1* PTT-73.4* INR(PT)-3.2*
[**2142-11-5**] 05:48AM BLOOD PT-25.7* PTT-53.1* INR(PT)-2.6*
[**2142-11-7**] 07:56AM BLOOD PT-16.5* PTT-41.4* INR(PT)-1.5*
[**2142-11-2**] 09:35AM BLOOD Fibrino-475*
[**2142-11-2**] 12:12PM BLOOD Fibrino-265#
[**2142-11-3**] 05:00AM BLOOD Fibrino-62*#
[**2142-11-3**] 06:11PM BLOOD Fibrino-60*
[**2142-11-2**] 09:35AM BLOOD Glucose-208* UreaN-24* Creat-1.4* Na-134
K-7.3* Cl-89* HCO3-23 AnGap-29*
[**2142-11-3**] 05:00AM BLOOD Glucose-674* UreaN-35* Creat-2.3* Na-130*
K-3.7 Cl-91* HCO3-16* AnGap-27*
[**2142-11-5**] 05:48AM BLOOD Glucose-196* UreaN-73* Creat-4.9* Na-131*
K-6.3* Cl-96 HCO3-16* AnGap-25*
[**2142-11-6**] 05:01AM BLOOD Glucose-152* UreaN-95* Creat-6.3*# Na-133
K-5.4* Cl-98 HCO3-21* AnGap-19
[**2142-11-7**] 05:02AM BLOOD Glucose-151* UreaN-112* Creat-7.2* Na-135
K-4.9 Cl-100 HCO3-21* AnGap-19
[**2142-11-2**] 12:12PM BLOOD ALT-3848* AST-4451* LD(LDH)-7310*
CK(CPK)-483* AlkPhos-122* Amylase-79 TotBili-0.5
[**2142-11-3**] 05:00AM BLOOD ALT-6320* AST-[**Numeric Identifier **]* LD(LDH)-[**Numeric Identifier **]*
AlkPhos-144* TotBili-1.2
[**2142-11-4**] 08:15PM BLOOD ALT-4870* AST-3267* LD(LDH)-2463*
TotBili-1.8*
[**2142-11-2**] 12:12PM BLOOD CK-MB-23* MB Indx-4.8 cTropnT-0.42*
[**2142-11-2**] 12:12PM BLOOD Albumin-2.4* Calcium-7.5* Phos-10.3*
Mg-3.1*
[**2142-11-4**] 05:36AM BLOOD Calcium-7.8* Phos-5.8* Mg-2.0
[**2142-11-5**] 05:48AM BLOOD Calcium-7.6* Mg-2.1
[**2142-11-7**] 05:02AM BLOOD Calcium-6.2* Phos-8.6* Mg-2.5
[**2142-11-2**] 09:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Imaging:
CHEST (PORTABLE AP) [**2142-11-2**] 12:25 PM
IMPRESSION:
1) Repositioning of endotracheal tube, now in standard position;
however, the cuff is likely over distended.
2) Swan-Ganz catheter tip overlies lateral aspect of right hilar
pulmonary artery.
3) Questionable evolving bilateral upper lobe opacities
superimposed upon changes of prior granulomatous infection.
These findings may be due to acute aspiration, infectious
pneumonia including reactivation TB, or asymmetrical edema.
Findings communicated to Dr. [**Last Name (STitle) 11180**] by telephone on [**11-2**], [**2141**].
.
Cardiology Report C.CATH Study Date of [**2142-11-2**]
COMMENTS:
1. Selective coronary angiography of this left dominant system
revealed
no angiographically apparent coronary artery disease. The LMCA,
LAD,
LCX, and RCA were all patent with only minimal disease.
2. Resting hemodynamics demonstrated elevated right and left
sided
pressures (mean RA pressure was 33mmHg, mean PCWP was 36mmHg).
There was
severe pulmonary hypertension (mean PAP was 53mmHg). The cardiac
index
was elevated at 7.4 L/min/m2. No significant gradient across the
aortic
valve was noted up on pullback of the pigtail catheter from the
left
ventricle.
3. Echocardiography in the lab revealed normal ventricular
function
and no signiicant valvular disease and no pericardial effusion
or
evidence of intracardiac shunt.
4. Severe systemic hypotension to 50 mm Hg systolic responding
to
boluses of epinephrine.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Non-cardiogenic shock.
.
Cardiology Report ECHO Study Date of [**2142-11-2**]
Conclusions:
At the beginning of this study, left an right ventricular
contractile function
appeared normal to hyperdynamic. At the end of ther study,
during hypotension,
with high dose epinephrine, there was at least moderate global
biventriculart
hypokinesis. The mitral valve leaflets are mildly thickened.
There is no
mitral valve prolapse. There is moderate pulmonary artery
systolic
hypertension. There is no pericardial effusion.
.
CHEST (PORTABLE AP) [**2142-11-3**] 11:03 PM
IMPRESSION:
1. Swan-Ganz catheter from inferior approach with distal tip in
right ventricle. This finding was relayed in a preliminary
report to Dr. [**Last Name (STitle) 4281**] at 11:45 p.m. on [**2142-11-3**] by Dr. [**Last Name (STitle) **].
2. There is scarring in the right apex and laterally in the left
upper lung. There may be increased density in the left apex,
which may be indicative of a developing pneumonia. Correlate
clinically.
.
Neurophysiology Report EEG Study Date of [**2142-11-6**]
IMPRESSION: This is an abnormal EEG due to the extremely severe
encephalopathy. No electrographic activity of cerebral origin
was
noted. The usual EEG parameters for brain death protocol were
utilized.
Brief Hospital Course:
The patient was a 72 yr old male who was admitted after being
found down for an unknown period of time, with full
cardiopulmonary arrest.
He required very aggressive hemodynamic and ventilatory support
during his first days in the ICU. Once his shock had
stabilized, formal testing revealed brain death. The clinical
examination was confirmed at different times by three
physicians. An apnea test was confirmatory. An EEG revealed no
cortical activity.
Because the family had obtained a restraining order preventing
discontinuation of supportive devices, his body was maintained
in the ICU for several days after his death. Monks from his
religion came and performed rituals several times. After
resolution of the legal issues, we discussed particular
specifics of the method of discontinuation of support with his
family's attorney. The court's guardian ad [**Name2 (NI) 5352**] was present in
person; the hospital's attorney was present by conference call;
the judge in the case was notified and agreed. All details were
followed: his intravenous mediations were allowed to run out;
several hours later, his heart stopped beating. The ventilator
was then disconnected and the nasal and oral tubes removed. The
family and attorneys were immediately notified after the
cessation of heartbeat. The family was contact[**Name (NI) **] several times.
No one from the family came to perform post-mortem rituals, so
the CCU nursing staff followed documents (provided by the
family) which detailed some of these practices. In particular,
the patient was left on the ICU, undisturbed, for a full eight
hours after cessation of the heartbeat. Recorded chants played
at all times. After eight hours, he was transferred to the
morgue with the chants still playing.
Medications on Admission:
inhalers (started by PCP this week)
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac arrest
brain death
COPD
Discharge Condition:
Deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2142-12-6**]
|
[
"584.9",
"995.92",
"038.9",
"286.6",
"570",
"348.1",
"416.8",
"276.7",
"305.1",
"578.0",
"782.5",
"427.5",
"276.2",
"790.29",
"785.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.23",
"88.56",
"99.60",
"00.17",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9616, 9625
|
7729, 9501
|
339, 454
|
9700, 9868
|
2582, 6382
|
2165, 2183
|
9587, 9593
|
9646, 9679
|
9527, 9564
|
6399, 7706
|
2198, 2563
|
277, 301
|
482, 2032
|
2054, 2109
|
2125, 2149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,829
| 113,515
|
44152
|
Discharge summary
|
report
|
Admission Date: [**2199-11-22**] Discharge Date: [**2199-12-6**]
Service: MEDICINE
Allergies:
Captopril / Erythromycin Base / Ampicillin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
PEG tube placement
NG tube placement
History of Present Illness:
Patient is a 84 yo female with h/o diastolic CHF who presents
with dyspnea and lower extremity edema. The patient states that
she has been having increasing lower extremity edema for the
past 3 weeks. Last night, she woke up in the middle of the
night to go to the bathroom and experienced abdominal cramping.
She called the nurse [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab, who evaluated the patient
and found her to be dyspneic and satting 94% on room air. Ms.
[**Known lastname 94752**] denies orthopnea, as she states she now always sleeps on
an incline because of her C2-C4 fusion in [**Month (only) 359**]. The patient
also denies PND and states that she never felt subjectively
dyspneic. Of note, the patient states that she takes Lasix 40
mg daily and has been compliant with her medications. She also
denies eating many salty foods, but admits to frequent
consumption of soups.
.
In the ED, the patient's VS were BP 189/86, P 76, R 20, O2 74%
on 4L. She was placed on Bipap and received Lasix 80 mg IV, ASA
325 mg, was placed on a nitro gtt. An ECG demonstrated that the
patient is in AFib, which is altered from her previous baseline.
The patient diuresed 1.1L and her O2 requirement decreased to
2L. She was then admitted to [**Hospital Ward Name 121**] 3 for further workup and
evaluation.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. He denies exertional buttock or calf pain. All of the
other review of systems were negative. Cardiac review of
systems is notable for absence of chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
HTN
Diastolic CHF
Gout
Barrets
Polymyositis
Bell's Palsy (Rt)
Massive PE s/p Trendy procedure, IVC filter placement
TAH
Appendectomy
T4, T8 vertebroplasty [**2196-10-11**]
C4-C5 disectomy and hardware placement
3.9 cm infrarenal AAA
Recent BM biopsy from iliac crest
Social History:
40 pack year hx of tobacco, quit over 20 years ago, no
etoh/illict drug use; was living independently until recently;
now in [**Hospital 100**] Rehab after recent surgery; does not have much
family - is close with friends; good friend [**Name (NI) 2184**] [**Name (NI) 951**] is her
HCP
Family History:
mom with osteoporosis and heart disease, died at age 79; no
other history of heart disease
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.8, BP 160/80, P 57, R 22, O2 94% on 2L
Gen: Elderly woman, pleasant, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: R sided facial droop and ptosis. PERRL, Sclera
anicteric. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
Neck: Supple with JVD to base of ear.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 systolic murmur best heard at L lower
sternal border. No thrills, lifts. No S3 or S4.
Chest: Kyphosis. Resp were unlabored, no accessory muscle use.
Diffuse crackles to mid-lung bilaterally
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: 3+ pedal edema bilaterally. Skin darkening in lower
extremities bilaterally. No femoral bruits.
Skin: + stasis dermatitis, no ulcers, scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2199-11-22**] 05:20AM BLOOD WBC-12.7* RBC-3.61* Hgb-10.1* Hct-31.8*
MCV-88 MCH-28.1 MCHC-31.9 RDW-15.7* Plt Ct-456*
[**2199-11-22**] 05:20AM BLOOD Neuts-82.8* Lymphs-12.3* Monos-2.9
Eos-1.9 Baso-0.2
[**2199-11-22**] 05:20AM BLOOD PT-31.2* PTT-26.3 INR(PT)-3.2*
[**2199-11-22**] 05:20AM BLOOD Glucose-85 UreaN-28* Creat-1.5* Na-143
K-4.6 Cl-105 HCO3-30 AnGap-13
[**2199-11-22**] 05:20AM BLOOD CK(CPK)-32
[**2199-11-22**] 05:20AM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-9136*
[**2199-11-22**] 02:43PM BLOOD cTropnT-0.03*
[**2199-11-23**] 07:38AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
[**2199-11-26**] 09:44PM BLOOD Lactate-1.9
.
[**2199-12-2**] EKG - Sinus bradycardia. Left axis deviation likely due
to left anterior fascicular block. Lateral ST-T wave changes are
non-specific. Compared to the previous tracing of [**2199-11-29**] the
findings are similar.
.
[**2199-12-2**] echo - The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. 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 are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: No intracardiac shunt identified. Mild aortic valve
stenosis. Mild mitral regurgitation. Mild pulmonary artery
systolic hypertension.
.
[**12-1**] - echo - IMPRESSION: No hydronephrosis. Bilateral simple
renal cysts.
.
[**12-1**] PA/Lateral chest x-ray - FINDINGS: Comparison is made to
prior study of [**2199-11-27**]. There is again seen bibasilar
atelectasis and small pleural effusions. There are no signs of
overt pulmonary edema. No focal consolidation is seen. The
filter and spinal fixation hardware is again seen.
.
[**2199-11-24**] - CT chest - IMPRESSION:
1. New centrilobular "tree-in-[**Male First Name (un) 239**]" and nodular opacities in the
lower lobes and right middle lobe consistent with infection or
aspiration.
2. Moderate centrilobular upper lobe predominant emphysema.
3. Extensive moderate aortic valve calcifications of uncertain
physiologic
significance.
.
[**12-2**] - echo with bubble study - IMPRESSION: No intracardiac
shunt identified. Mild aortic valve stenosis. Mild mitral
regurgitation. Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
#. Hypoxia: With pulmoary engorment on CXR and elevated BNP of
9000 and new AF, the etiology of the patient's hypoxia was felt
to be acute exacerbation of diastolic dysfunction. Over the
course of her 4 day admission, the patient had been diureesed
with IV lasix with removal of 6 liters. The patient had
continued to be hypoxic during the hospitalization, and a chest
CT was obtained, showing a question of right middle and lower
lobe infitrate vs. aspiration. The patinet was started on
levofloxacin/vanc/flagyl to treat a potential pneumonia. The
patiet triggered after being noted to be hypoxic at 76% on 4L
NC, 82% on 6L NRB despite the aggressive diuresis. The patient
was transfered to the CCU for futher care.
Differential for patient's hypoxia included blossoming PNA
vs. aspiration pneumonitis vs. flash pulmonary edema with dCHF
and AF vs. PE. The patient had been significantly diureesed
during the course of the hospitalization, and on exam appeared
euvolemic to dry. Patient was not acutly hypertensive during
inciting event. Chest XR was without evidence of acute
pulmonary edema. The patient was being treated for pneumonia
and had been afebrile. Chest CT showed dependent area of
nodular opacities which could be consistent with likely
aspiration pneumonia. Patient has a history of severe
aspiration on swallow study, and felt that this would be most
likely explanation of patinet's hypoxia. PE seems less likely
given supratherapeutic INR throughout hospitalization and IVC
filter in place.
The patient's O2 requirement improved over three days. She
was given supportive nebs and a course of solumendral given
wheezes on physical exam. With high O2 requirement, pulmonary
was consulted, who agreed that aspiration pneumonitis likely
etiology to patient's hypoxia with element of chronic bronchitis
from aspiration. At the time of transfer from the unit, the
patient's antibiotics were reduced to levofloxacin/flagyl with
negative cultures, to complete a 5 day course. Her prednisone
was increased to 60 mg daily every other day.
On the floor patient was made NPO given her severe aspiration.
She completed a total of 10 day course of antibiotics for
aspiration pneumonia/pneumonitis. She underwent a PEG tube
placement to reduce the risk of aspiration which was
uncomplicated. In addition, her steroids are being decreased
back to her home dose. Patient underwent an echo with bubble
that showed no evidence of intracardiac shunt. Of discharge
patietn saturatin 94% on 4L. Goal O2 sats are 90-92% and oxygen
should continued to be adjusted to meet this goal.
.
# Coronaries: The patient has no history of coronary artery
disease, and last PMIBI without any defects. No complaints if
chest pain and no iscemic changes on EKG.
.
# Diastolic Congestive Heart: The patient presented with
elevated BNP, hypoxia, and lower extremity edema. Patient
initially was diagnosed over 6L, with continued hypoxia thought
to be secondary to aspiration as described above. Patient came
in with new atrial fibrillation possibly secondary to worsening
heart failure, with possible insufficient lasix dose or poor
dietary compliance. [**Last Name (un) **] being held in the setting of elevated
Cr. Patient was started on a CCB to help supress ionotropic
activity. Her beta blocker was continued and titrated up as
tolerated. Patient underwent a TTE with a bubble study to
evaluate for left to right shunt which was negative.
.
#. Atrial Fibrillation: The patient's ECG on admission
demonstrates atrial fibrillation, which is a new diagnosis. She
has been in and out of AF since admission, and is currently in
sinus. Likely contributing to element of acute diastolic heart
failure. She was continued on metoprolol and diltiazem was
started, both were titrated up to improve blood pressure
control. She is already anticoagulated for PEs. Coumadin was
continued with goal INR [**1-20**]. Coumadin was held in the setting of
needing to get PEG placed, however patient was transitioned with
IV heparin drip and will go back to [**Hospital1 100**] with IV heparin
bridge until INR is therapeutic again for 48 hours.
.
#. Hypertension: The patient has a history hypertension and had
BP 189/86 on admission. She was continued on metoprolol. Her
home amlodpine was held, and diltiazem was started as described
above. Her [**Last Name (un) **] was being held in the setting of ARF.
.
# Acute Renal Failure: Patient with Cr of 1.2 on admission, and
had risen to 2.1 after aggressive diuresis. Cr on day of
discharge was 1.4. Renal ultrasound demonstrated no evidence of
hydronephrosis. [**Last Name (un) **] was held secondary to rising Cr. Would
continue to hold Losartan until she follows up with her primary
care provider.
.
#. Polymyositis: The patient has a history polymyositis, for
which she takes 20 mg prednisone every other day. Her
prednisone had been increased to treat concern for COPD
exacerbation in the setting of chronic fibrotic changes
secondary to chronic aspiration after treatment with IV
solumedrol. She is being weaned back to home dose on discharge.
Currently patient recieving 40 mg PO QOD. In addition, she is on
bactrim for PCP [**Name Initial (PRE) 1102**].
.
# Hypercholesterolemia:
Continued simvastatin 10mg daily
. .
#. Aspiration. The patient is a known sevear aspirater, and has
failed passed swallow studies. The patient had been
non-compliant with restricted diet in [**Hospital **] rehab. The patient
had declined PEG in the past, but agreed on this admission given
the severity of her aspiration. Patient had PEG placed [**2199-12-5**]
with interventional radiology. Patient will continue to be NPO
on discharge with tube feeding and free water flushes through
her PEG to maintain her free water needs.
.
#. PPx: DVT: IV heparin drip until INR therapeutic for 48
hours. Goal INR [**1-20**]. If INR > 3 please hold coumadin and lower
dose by 0.5 mg. If INR between [**1-20**] do not change dosing. If INR
is < 2 for 2 days would increase dose by 0.5 mg. Continue PPi.
Colace and senna.
.
#. Code: Full Code
Medications on Admission:
Acetaminophen 325-650 mg
Simvastatin 10 mg daily
Folic Acid 1 mg daily
Calcium Carbonate 500 mg [**Hospital1 **]
Losartan 25 mg TID
Metoprolol Tartrate 50 mg TID
Furosemide 40 mg daily
Multivitamin daily
Fluoxetine 10 mg daily
Pyridoxine 50 mg daily
Prednisone 20 mg qod
Oxycodone 5-10 mg q3h prn for pain
Vitamin D 400 unit daily
Cortisone 1 % Cream TID prn
Warfarin 2 mg daily
Ipratropium Bromide INH q6h prn
Docusate Sodium 50 mg [**Hospital1 **] (liquid)
Fluticasone 110 mcg 2 puffs [**Hospital1 **]
Lidocaine 5 %(700 mg/patch) Adhesive Patch, daily
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-19**]
Drops Ophthalmic Q8H (every 8 hours) as needed.
Albuterol nebulization q6h prn
Senna 8.6 mg [**Hospital1 **]
Benzonatate 100 mg TID
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
please hold for BP < 100 HR < 55.
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for dyspnea.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain, headache, fever.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day: please hold
for BP < 100, HR < 55.
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 days: please give 40 mg dose, only [**12-8**].
13. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER
DAY (Every Other Day): please start patient on this dose at
[**12-10**].
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day:
please hold for BP < 100 HR < 55.
15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane TID (3 times a day).
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: for
goal INR [**1-20**].
17. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for 3 days.
18. 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.
19. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Ativan 0.5 mg Tablet Sig: 0.5 Tablet PO three times a day as
needed for anxiety, insomnia: please hold for sedation or RR <
12.
21. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
22. Heparin (Porcine) Injection
23. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**3-24**]
hours as needed for pain: please hold for sedation or RR < 12.
24. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
25. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
26. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day.
27. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Hypoxia secondary to aspiration pneumonia, diastolic
heart failure
Secondary:
gout
Bell's palsy
polymyositis
massive PE and IVC filter placement
3.9 infrarenal AAA in [**2197**]
Discharge Condition:
afebrile, vital signs stable, saturing 94% on 4L
Discharge Instructions:
You were admitted to the hospital with worsening hypoxia and
lower extremity swelling. You were diagnosed with aspiration
pneumonia and treated with IV antibiotics. You were evaluated
by speech and swallow who felt that you were extremely high
aspiration risk. Given this you had a PEG tube inserted in
order to feed you more safely. While you were eating nothing by
mouth you were kept on IV fluids for maintence. You will be
able to start using your new PEG tube tonight and we have
consulted nutrition for tube feeding reccomendations for you in
the meantim. We are going to reccomend that you keep your ins
and out roughly even and adjust your lasix dose as needed to do
this. We are currently holding one of your medications which
can worsen renal function. We would reccomend that you continue
to hold this medication until you see your primary care doctor.
For your safety, we reccomend that you take NOTHING BY MOUTH as
you are at high risk to put this into your lungs. You can use
oral swabs if your mouth feels dry however you will get all of
your fluids/water through your feeding tube.
.
You should continue on the IV heparin drip until your INR > 2
for at least 48 hours. We have increased your lasix dose in
order to help maintain your urine output. This lasix dose can be
adjusted while you are at [**Hospital 100**] Rehab in order to meet goals
ins and outs even. You need to continue oxygen, and will likely
need oxygen on discharge home from rehab. Currently you are on
4L of NC. Our goal oxygen saturation for you in between 90-92%
so your oxygen can be adjusted down accordingly.
.
IV heparin drip until INR therapeutic for 48 hours. Goal INR
[**1-20**]. If INR > 3 please hold coumadin and lower dose by 0.5 mg.
If INR between [**1-20**] do not change dosing. If INR is < 2 for 2
days would increase dose by 0.5 mg.
Followup Instructions:
You should follow up with your primary care provider as
previously scheduled on discharge from [**Hospital 100**] Rehab. You should
regardless have an appointment within one month. Your PCP
number Dr. [**Last Name (STitle) 2204**], [**First Name3 (LF) **] ([**Telephone/Fax (1) 2941**].
.
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2200-6-30**] 10:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2200-6-30**] 11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2199-12-6**]
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icd9cm
|
[
[
[]
]
] |
[
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"93.90",
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] |
icd9pcs
|
[
[
[]
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|
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211, 220
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324, 2187
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|
2494, 2783
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,143
| 189,921
|
33203
|
Discharge summary
|
report
|
Admission Date: [**2189-12-9**] Discharge Date: [**2189-12-24**]
Date of Birth: [**2142-11-15**] Sex: F
Service: MEDICINE
Allergies:
Benadryl
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Transfer from [**Hospital 6136**] hospital for a portex tracheostomy.
Major Surgical or Invasive Procedure:
[**2189-12-15**] Open tracheostomy, esophagoscopy, flexible
bronchoscopy, open gastrostomy tube.
History of Present Illness:
This is a 47 yo F smoker with hx of sleep apnea on CPAP at home,
obesity hypoventilation syndrome, and COPD who was initially
admitted to [**Hospital 77152**] hospital on [**2189-11-20**] for productive cough,
shortness of breath, and bilateral wheezing. Pt had low grade
fevers [**2189-11-21**] and was hypoxic to 84% on RA [**2189-11-21**] which improved
to 95% on 3LNC. She was started on levofloxacin, nebs, and
systemic steroids for treatment of COPD exacerbation with
suspected PNA. On [**2189-11-22**] she developed worsening hypoxia
w/lethargy on CPAP 5LO2, ABG at that time was 7.27/90/31 with
bicarb 41. She was transferred to the OSH MICU and she was
intubated. She had bronchoscopy [**11-22**] which showed secretions in
the airways BL and easily collapsible airway. Cultures of these
washings grew MRSA. Levofloxacin was changed to vancomycin and
systemic steroids were decreased. She continued on the vent
with frequent episodes of coughing and ??????fighting the vent?????? with
accompanying cyanosis. These episodes lasted ~1 minute, and
would require ambu-bag ventilation after which time it would
resolve. She never had to be paralyzed due to these events, but
she was continued on propofol gtt.
.
On [**2189-11-26**] pt had a repeat bronch showed mild erythema of the
airways. She was started on theophyline.
.
On [**2189-11-29**] blood cultures grew MRSA and coag negative staph. Pt
was continued on vancomycin.
.
Mutiple attempts at weaning off the vent were attempted but were
unsuccessful, leading the team at the OSH to consider
tracheostomy. General an thoracic surgery were consulted at the
OSH, and felt that the pt would require an extra-long
tracheostomy tube called a portex tracheostomy tube. Despite
multiple attempts, the OSH hospital was unable to obtain such a
tube, and the pt was transferred to [**Hospital1 18**] for placement
evaluation and possible placement of this tracheostomy tube.
.
Because of the MRSA bacteremia, the team at the OSH had
considered echocardiogram to r/o endocarditis. Due to the pt??????s
body habitus it was felt that she would require TEE. However,
the pt did not have the echo before being transferred to [**Hospital1 18**].
Past Medical History:
h/o childhood asthma
morbid obesity
obesity hypoventilation syndrome
sleep apnea
COPD
tobacco use
hyperlipidemia
DM2
HTN
Social History:
Tobacco: 1ppd
Other: lives w/husband
Family History:
non-contributory
Physical Exam:
Tmax: 36.5 ??????C (97.7 ??????F)
HR: 69 (69 - 80) bpm
BP: 126/76(89){123/88(75) - 144/81(95)} mmHg
RR: 18 (18 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
.
Respiratory
Ventilator mode: CMV/ASSIST
Vt (Set): 550 (550 - 550) mL
PEEP: 8 cmH2O
FiO2: 50%
PIP: 33 cmH2O
Plateau: 32 cmH2O
SpO2: 100%
ABG: 7.39/46/77.[**Numeric Identifier 71132**]//1
Ve: 13.7 L/min
PaO2 / FiO2: 156
.
General: obese female, Intubated, sedated, not following
commands
HEENT: NCAT, LSC central line in place with clean dressing,
PEERL, ETT tube in place, OG tube in place, neck obese and
unable to evaluate JVP
CV: Distant HS, no murmurs appreciated
Chest: Good air entry bilaterally, rales at bilateral bases
ABD: obese, soft, NT ND, distant BS
Ext: 2+ pitting edema of bil lower extremities and bilateral
upper extremity
Peripheral Vascular: DP and PT pulses Dopplerable
Skin: Hyperemic dorsal feet bilaterally c/w venous stasis
Pertinent Results:
ADMISSION LABS:
[**2189-12-9**] 02:51PM BLOOD WBC-5.5 RBC-4.22 Hgb-13.9 Hct-42.7
MCV-101* MCH-32.9* MCHC-32.5 RDW-12.6 Plt Ct-319
[**2189-12-9**] 02:51PM BLOOD Neuts-55.6 Lymphs-30.4 Monos-7.2 Eos-6.3*
Baso-0.5
[**2189-12-9**] 02:51PM BLOOD PT-12.4 PTT-23.2 INR(PT)-1.0
[**2189-12-9**] 02:51PM BLOOD Glucose-106* UreaN-9 Creat-0.7 Na-143
K-3.7 Cl-103 HCO3-31 AnGap-13
[**2189-12-11**] 04:37AM BLOOD ALT-31 AST-39 AlkPhos-69 TotBili-0.5
[**2189-12-9**] 02:51PM BLOOD Calcium-9.6 Phos-4.6* Mg-1.8
[**2189-12-16**] 12:48PM BLOOD %HbA1c-6.7*
[**2189-12-9**] 02:11PM BLOOD Type-ART pO2-78* pCO2-46* pH-7.39
calTCO2-29 Base XS-1 Intubat-INTUBATED
[**2189-12-9**] 02:11PM BLOOD Lactate-1.0
.
echo [**12-16**]
Technically limited study. The left ventricle is not well seen.
Overall RV systolic function appears normal. Suboptimal image
quality.
Brief Hospital Course:
47 yo morbidly obese female smoker with history of sleep apnea
presented to OSH with cough and pneumonia, went on to develop
respiratory distress requiring intubation. Despite weaning
attempts at the OSH pt has been unable to pass SBT, and came to
[**Hospital1 18**] for portex tracheostomy.
.
Acute on Chronic Resp failure: Pt is morbidly obese, tobacco
smoker with COPD/asthma, tracheobronchomalacia, sleep apnea and
obesity hypoventilation. On admission to OSH pt had elevated
bicarb suggesting pre-existing presence of obesity
hypoventilation syndrome. Then she developed acute worsening of
SOB and cough likely [**12-19**] MRSA PNA and required intubation.
Before intubation ABG was performed and showed hypercapnea in
the presence of high bicarb, suggesting that chronic obesity
hypoventilation syndrome had caused CO2 retention and
compensatory metabolic acidosis before the insult of PNA. Due
to prolonged vent requirement, Thoracics evaluated her for a
tracheostomy. Pt was treated with bronchodilators and inhaled
steroids. Patient was taken for trach by thoracics, with a
succesful operation. Please see seperate op report for full
details of that procedure. After that procedure the patient was
slowly weaned from the vent. She was successful on [**3-23**] hours
of trach mask trial and 1 day later she was successful on [**5-25**]
hours of trach trial. Complicating problem of abdominal wound
dehiscence requiring ex-lap and fascial closure, for which she
required AC mode briefly, but quickly was weaned to pressure
support at her previous settings. She was evaluated for a PM
valve but was unable to tolerate it secondary to bronchospasm.
On the day of discharge she was tolerating a trach mask very
well.
.
Obesity Hypoventilation Syndrome: as described above, pt has
obesity hypoventilation syndrome causing significant CO2
retention.
.
Tracheobronchomalacia: Pt was shown to have easily collapsible
airway on bronchoscopy. This is likely a chronic problem, but
is probably contributing to her respiratory distress.
Respiratory distress with Tracheobronchomalacia was managed as
described above.
.
Sleep Apnea: Pt has hx of severe sleep apnea. A trachestomy was
thought to offer some relief from nighttime apnea. Thoracics
team evaluated for tracheostomy and it was done as above.
.
COPD: Hx of asthma with smoking hx, contributing to underlying
chronic resp failure.
Pt was treated with bronchodilators and inhaled steroids as
described above.
.
MRSA Bacteremia/PNA: Pt had PNA with BAL cx showing MRSA and
subsequently had positive BCx. Vancomycin was continued to
complete a 14 day course. Pt did not have persistent fevers or
persistently positive Cx so it was felt that endocarditis was
unlikely and echocardiogram was therefore not obtained.
.
Diabetes Mellitus: continued Lantus 30/30 and HISS which had
been started at the OSH. This was insufficient for control of
her elevated blood sugars, and was elevated, eventually to a
level of 60/60. Intervally, she was on an insulin drip for
control of these elevated sugars. She was followed by the
[**Hospital **] clinic while in the hospital and it was felt that her
elevated blood sugars were secondary to infection (UTI and
pneumonia). On discharge she was on an insulin sliding scale
and glargine 60 [**Hospital1 **].
.
UTI: the patient developed a fever s/p trach that initially was
felt to be a ?VAP due to gram negative organisms on sputum.
However, these grew as OP flora and the patient actually had
improved respiratory status and decreased secretions. The
patient did have a dirty U/A, and her fevers resovled on
Zosyn/Vanc rapidly. It was decided to complete a 7d course of
zosyn/vanc for a presumed UTI.
.
Wound Dehiscence: Pt had a G tube placed in the OR. On the day
of planned discharge her wound was noted to be open and thoracic
surgery was called to evaluate. She went to the OR for
exploratory laparotomy and fasciotomy was done without event.
She recovered well from this. Tube feeds were started on POD 1
and she tolerated them well. Pain control was achieved with
morphine 4mg q 3 hours prn. Thoracics continued to follow her
and placed 2 penrose drains which were removed prior to
discharge. She will follow up with thoracics in one week.
.
PPX-was achieved with heparin SC, protonix
.
Full code
Medications on Admission:
heparin 5000 u sc tid
acetominophen 325-650 mg q4 prn
MVI po QD
miconazole powder to affected area
fentanyl and midazolam gtts
albuterol-ipratropium MDI 6 puffs q4
colace liquid 100 mg [**Hospital1 **]
lasix 40 mg IV QD
protonix 40 mg QD
chlorhexidine rinse
rosuvastatin 10 mg qd
senna 1 tab [**Hospital1 **]
bisacodyl 10 mg po/pr daily
insulin sliding scale and glargine 10 mg qam, 30 mg qhs
vancomycin 1500 mg q12
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000u
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10ml PO BID (2
times a day).
6. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) 80mcg Inhalation [**Hospital1 **] ().
8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
13. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: see SS
Subcutaneous four times a day: Fingerstick QACHS
*********
Insulin SC Fixed Dose Orders
--Breakfast
Glargine 60u
--Bedtime
Glargine 60u
***************
Insulin SC Sliding Scale
Q6H Regular Insulin Dose
---Glucose 0-60 mg/dL [**11-18**] amp D50
---61-110 mg/dL 0 Units
----111-160 mg/dL 30 Units
---161-200 mg/dL 33 Units
---201-240 mg/dL 36 Units
---241-280 mg/dL 39 Units
---281-310 mg/dL 42 Units
---311-350 mg/dL 45 Units
---351-400 mg/dL 48 Units
---> 400 mg/dL Notify M.D.
.
15. Morphine Sulfate 2-4 mg IV Q3HRS PRN pain
hold for sedation
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Hypercarbic respiratory failure
Wound Dehiscence s/p Exploratory Lap
Morbid Obesity
MRSA Pneumonia
UTI
Diabetes Mellitus
HTN
Hyperlipidemia
Tinea corporis
Discharge Condition:
stable, afebrile, tube feeds at goal (40cc/hr)
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
insertion of a portex tracheostomy, as you were intubated
because you had a bad pneumonia and it was expected that you
would need a breathing tube for an extended period of time. You
had the tracheostomy and a feeding tube (G tube) without event.
Your blood sugars were quite high and you were put on insulin in
addition to glargine. The wound near your G tube opened and you
had to go to the operating room to have it closed. You did well
after this surgery and were discharged to pulmonary
rehabilitation.
Please return to the hospital for any difficulty breathing,
bleeding, chest pain, cough, fever, drainage, nausea, vomiting,
diarrhea or any other symptoms that worry you or your family.
Followup Instructions:
(Thoracic Surgery) Dr. [**Last Name (STitle) 11482**] Pe??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 1504**]
[**Doctor First Name **] [**12-31**], 3:30, [**Location (un) 8661**] [**Location (un) **] [**Hospital1 827**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2189-12-24**]
|
[
"250.00",
"482.41",
"599.0",
"998.31",
"V09.0",
"493.22",
"518.84",
"780.57",
"278.01",
"519.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.61",
"96.72",
"33.23",
"96.6",
"42.23",
"31.1",
"43.19",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11295, 11356
|
4725, 9048
|
341, 440
|
11555, 11604
|
3864, 3864
|
12394, 12817
|
2889, 2907
|
9515, 11272
|
11377, 11534
|
9074, 9492
|
11628, 12371
|
2922, 3845
|
232, 303
|
468, 2675
|
3880, 4702
|
2697, 2819
|
2835, 2873
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,500
| 174,832
|
13093
|
Discharge summary
|
report
|
Admission Date: [**2163-8-26**] Discharge Date: [**2163-9-10**]
Date of Birth: [**2084-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Cortisone / Adhesive Tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Unstable angina, shortness of breath.
Major Surgical or Invasive Procedure:
[**2163-9-5**] AVR(19 mm [**Company 1543**] Mosaic Porcine) / cabg x2 (LIMA to
LAD, SVG to OM)
History of Present Illness:
78 yo female with known coronary artery disease, s/p PCI/stent
who presented to an outside hospital with one weeks of angina.
She r/o for MI and underwent left and right heart
catheterization with coronary angiography.
This demonstrated a 75% left main stenosis, luminal
irregularites of the LAD, RCA and circumflex, 50% 2nd diagonal
lesion and a patent distal RCA stent. Right sided pressures were
PA 38/16, CVP 12 and the [**Location (un) 109**] was 0.7cm2, with a 35mm gradient.
The CI was 2.49l/min.
She was transferred to this institution for surgical treatment.
Past Medical History:
Diabetes
hypercholesterolemia
s/p appendectomy
s/p hysterectomy
depression
s/p cholecystectomy
s/p PCI/Stent
Social History:
remote smoker ( 30 yrs ago)
lives with husband who suffers from [**Name (NI) 2481**] disease
Denies ETOH use
Retired
Family History:
No cardiac history
Physical Exam:
Vitals:Temp 99.1 Tmax:99.4 P:59 BP:120/52 RR:18
Vent:97%
General: aaox3, no acute distress
HEENT: perrl, op clear, mmm
Neck: supple. no lad. no thyromeg.
Respiratory: cta bilaterally w/out wheezes/rhonchi/rales
Cardiovascular: III/IV systolic murmur best heard on the right
upper sternal border. cresc/decresc.
Back: no ST tenderness
Gastrointestinal: +bs, soft, NT, ND, no organomegaly appreciated
Genitourinary: WNL
Musculoskeletal:WNL
Skin:A 5cm by 5x5cm rash in the left gluteal region. There are
multiple small pustules on an erythematous base. Another
similar
smaller rash 2x2cm 3cm superior to this rash. Along S2 vs S3
dermatome.
Dermatographic erythematous plaques on chest in shape of
telemetry leads.
Neurological: WNL
Psychiatric:WNL
Pertinent Results:
[**2163-8-26**] 09:21PM PT-13.5* PTT-21.5* INR(PT)-1.2*
[**2163-8-26**] 09:21PM PLT COUNT-274
[**2163-8-26**] 09:21PM WBC-6.6 RBC-3.88* HGB-12.0 HCT-35.6* MCV-92
MCH-30.8 MCHC-33.6 RDW-13.5
[**2163-8-26**] 09:21PM ALT(SGPT)-15 AST(SGOT)-19 LD(LDH)-160 ALK
PHOS-40 AMYLASE-37 TOT BILI-0.3
[**2163-8-26**] 09:21PM GLUCOSE-156* UREA N-20 CREAT-1.0 SODIUM-138
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
[**2163-8-29**] Carotid Duplex Ultrasound
Bilateral 1-39% ICA stenosis. Bilateral vertebral antegrade
flow.
[**2163-9-5**] ECHO
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
7. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2163-9-5**] at 930am.
Post bypass
1. Patient is being AV paced .
2. Biventricular systolic function is unchanged.
3. Mitral regurgitation is 2+
4. Bioprosthetic va;lve seen in the aortic position. Leaflets
move well and the valve appears well seated. Peak gradient
across the aortic valve is 17 mm Hg.
5. Aorta intact post decannulation.
Brief Hospital Course:
Ms. [**Known lastname 40009**] was transferred from [**Hospital3 417**] Hospital to the
[**Hospital1 18**] on [**2163-8-26**] for definitive surgical treatment of her aortic
stenosis and coronary artery disease. She underwent routine
preoperative testing including a carotid duplex ultrasound which
showed bilateral 1-39% internal carotid artery stenosis. She had
a brief episode of CP after admission which resolved without
intervention. Herpes zoster was noted on exam for which
acyclovir was started. An infectious disease consult was
obtained who obtained a culture which was positive for herpes
simplex virus type 2 and agreed with antiviral treatment.
Augmentin was started for moraxella catarrhalis in her sputum.
On [**2163-9-5**], Ms. [**Known lastname 40009**] was taken to the operating room where
she underwent an aortic valve replacement (porcine valve) and
coronary artery bypass grafting to two vessel. Please see
operative not for details. Postoperatively she was taken to the
cardiac surgical intensive care unit for monitoring. She was
later extubated without difficulty. Her vasoactive drips were
weaned and her chest tubes removed. She was transferred to the
step down floor. Her wires were removed. [**9-10**] she was
ambulating well, her sternal wound was improved. She will be
discharged today on keflex for 5 days.
Medications on Admission:
Avapro 150mg/D
Glyburide 7.5mg/D
ASA 325mg/D
Plavix 75mg/D
Protonix 40mg/D
Zoloft 50mg/D
Metformin500mg [**Hospital1 **]
Lipitor 40mg/D
Imdur 60mg/D
ToprolXL 25mg/D
Discharge Medications:
Glyburide 5mg/D
Irbesartan 150 mg Tablet/d
Metoprolol 25 mg po BID
pantoprazole EC 40 mg/d
sertraline 50 mg po/d
atorvastatin 40mg po daily
Fenofibrate Nanocrystallized [Tricor]145mg po/d
ASA 81 mg po/d
Furosemide 20mg iv q12hrs
Docusate 100mg po bid
plavix 75 mg po daily
Glucophage 500mg po bid
cephalexin 500mg po q6hrs X 5days
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
aortic stenosis
coronary artery disease
diabete mellitus
hypertension
s/p MI
dyslipidemia
s/p PCI/ stent
depression
GERD
herpes zoster
Pneumonia
Discharge Condition:
good
Discharge Instructions:
take all medications as prescribed
no lifting more than 10 pounds for 10 weeks
keep wounds clean and dry, ok to shower daily, no baths or
swimming
no creams, lotions or powders to incisions
report any drainage or redness of incisions
report any temperature greater than 101
no driving for one month AND off all narcotics
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] M. in [**1-16**] weeks ([**Telephone/Fax (1) 3183**])
Completed by:[**2163-9-10**]
|
[
"707.03",
"272.0",
"276.52",
"482.83",
"411.1",
"414.01",
"496",
"054.9",
"424.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5677, 5732
|
3764, 5106
|
359, 456
|
5920, 5927
|
2154, 3741
|
6296, 6542
|
1336, 1356
|
5321, 5654
|
5753, 5899
|
5132, 5298
|
5951, 6273
|
1371, 2135
|
282, 321
|
484, 1053
|
1075, 1185
|
1201, 1320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,032
| 110,103
|
51294
|
Discharge summary
|
report
|
Admission Date: [**2121-4-23**] Discharge Date: [**2121-5-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
SOB, abdominal pain. In the [**Name (NI) **] Pt. was found to be in
A.flutter, cardioverted, became hypotensive/SOB. Transferred to
the CCU for further monitoring and eval for further treatment of
A.flutter.
Major Surgical or Invasive Procedure:
temporary pacer
intubation
central venous line
arterial line
History of Present Illness:
85 yo M w/ hx. of hyperlipidemia and HTN presented to his PCP
with [**Name Initial (PRE) **]/o abd pain and DOE and SOB x 2-3 days. Found to
tachycardic (140's) with RA 02 sats were 93%. Pt. reports
flu-like symptoms 2-3 weeks prior, but has otherwise been
healthy. He does not report any change in his excercise
tolerance. He can walk up to a quarter mile which has not
changed. He does report intermittent DOE over the past several
years. He also noticed his abdomen has distended and
uncomfortable since Sunday.
ROS: denies HA, chest pain, N/V. He reports constipation (small
BM this AM) and diffuse abdominal pain since Sunday. All other
ROS as above.
.
In the ED: initial VS 98.8 HR 140 BP 162/88 RR 18 02 92% RA to
96% on 4L NC
Presented with a rapid rate. Given adenosine 6mg x2, flutter
waves noted on EKG, given Dilt 20 x ?2, lopressor 10 iv, esmolol
60mg. ASA 81mg, lasix, NTG SL, NTG ointment, he was cardioverted
(DCC synchronized 50J w/fentanyl 50mcg&propofol 30mcg) with
conversion to NSR following a long pause. However, following
cardioversion he became bradycardic to the 50's and hypotensive
80/50 given 1L NS and placed on a NRB and given 1 amp of calcium
gluconate. He became hypotensive and SOB, a CXR showed failure
and he was given 120 IV lasix. In the ED his intial ABG was
7.39/23/103 with a lactate of 4.3. of He was started on a
heparin GTT and transferred to the CCU.
.
In the CCU he progressively became SOB and complained of
worsening abdominal pain, diaphoretic, appeared to go into
respiratory arrest then went into asystolic arrest, CPR was
initiated. He was given Epi x3, bicarb x2, atropine x2, he was
intubated and resuscitated after approximately 7 min of CPR.
When his pulse returned, his rhythm with a.fib/RVR of 140 with
SBP of 200's. He was given 5 IV lopressor and a temporary pacing
wire was placed by cardiology.
.
REVIEW OF SYSTEMS:
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. 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,
He did report dyspnea on exertion as discussed above.
Past Medical History:
History of bladder cancer
S/P Prostatectomy
Prostatic stone
SPINAL STENOSIS
HIATAL HERNIA, W/ REFLUX
PSORIASIS
BASAL CELL CANCER
HYPERCHOLESTEROLEMIA
S/P CARPAL TUNNEL SURGERY- RIGHT.
HYPERTENSION, BENIGN ESSENTIAL
COLON ADENOMAS
Social History:
lives alone
works part time
drives independently
Family History:
Noncontributory.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 92.9 (oral) 98.9 (rectal) BP 103/70 HR 78 RR 28 O2 99RA
Gen: Elderly gentleman. Oriented x3. Mild distress from diffuse
abdominal discomfort. Can complete full sentances.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVP detected
CV: Distant heart sounds, RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Slightly barrel chested. intermitently tachypneic, no accessory
muscle use. decreased breath sounds at the bases.
Abd: diffusely tender to palpation and distended. Hyperactive
BS. could not assess HSM. Abd aorta not enlarged by palpation.
No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
CXR: (portable [**4-23**]) IMPRESSION: Interstitial edema with small
bilateral pleural effusions consistent with CHF/volume overload.
More dense opacity within the right infrahilar region likely
represents alveolar edema; however, consolidation cannot be
excluded
and repeat radiographs are recommended.
.
LABORATORY DATA:
CK 153
Troponin 0.07
CK-MB 9
Anion GAP 15
CBC with 2 bands
Bicarb 20, crt. 1.6
Initial ABG 7.39/23/103
.
Abdominal/Pelvic CT:
1. Bilateral pleural effusions, right greater than left and
compression atelectasis.
2. Left exophytic heterogeneous renal cyst concerning for renal
cell carcinoma. MRI is recommended for further characterization.
Right intracortical hypodensity not fully characterized, could
also be evaluated with MRI.
4. Foley catheter with its balloon inflated in the prostatic
urethra. Repositioning is recommended.
5. Bilateral minimally displaced acute rib fractures.
6. Cholelithiasis without evidence of cholecystitis.
7. L3 lytic lesion just inferior to the superior endplate, could
be degenerative in nature, however, cannot rule out metastatic
disease.
8. Atherosclerotic changes.
.
TTE [**2121-4-24**]:
The left atrium is elongated. The estimated right atrial
pressure is
11-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left
ventricular cavity size is normal. There is moderate to severe
global left ventricular hypokinesis (ejection fraction 30
percent) with some regional
variation (apex appears somewhat more hypocontractile than base,
and posterior wall appears somewhat more hypocontractile than
the rest of the ventricle). Right ventricular chamber size is
normal. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
MRI abdomen/pelvis [**2121-4-28**]:
1. Bilateral simple renal cyst. Exophytic left renal lesion seen
on CT scan of [**2121-4-24**] corresponds to a simple renal cyst.
2. Bilateral pleural effusions with atelectasis/consolidation.
3. Aortoiliac atherosclerosis.
Brief Hospital Course:
Hospital course: this patient is a 85M with a history of HTN and
hyperlipidemia who presents with SOB and abd pain x 3 days,
found to be in new onset A.flutter. In the ED s/p cardioversion
(50 J), pt. became hypotensive and hypoxic with a lactic
acidiosis. Soon after transfer to the CCU, he had a asystolic
arrest, he was resucitated and intubated he was extubated on
[**4-26**]. Incidentally, a CT scan of the abdomen shows a left renal
mass c/w RCC.
.
1. Respiratory/cardiac arrest: It was unclear why this occured,
possible secondary to respiratory failure and lactic acidosis.
Initially there was suspicion of sepsis due to an elevated WBC
and complaints of abdominal pain. However, abdominal workup did
not reveal a source of infection and cultures have remained
negative. The patient was in asystolic arrest for approximately
9 minutes. ACLS was initiated immediately, spontaneous rhythm
was re-established after epinephrine/atropine/bicarb were
administered. HE was intubated and a temporary pacing wire
placed. A follow up head CT did not show any evidence of
ischemic injury. The patient pulled out his temporary pacer. He
was extubated and his respiratory status was stable throughout
his stay.
.
2. Metabolic acidosis: the patient initial ABG 7.39/24/103 with
a lactic acid of 4.3. The etiology of his lactic acidosis is
unclear although it could be secondary to hypoperfusion, as the
patinet was hypotensive in the ED. Other possibilities
entertained were ischemic bowel, given the patients complaints
of abdominal pain also sepsis as discussed above. He was given
bicarb, and ventilator adjustments were made as needed. his
lactic acidosis resolved.
.
3. Presumed sepsis: Patient presented with an elevated WBC
count, was tachycardia and hypotension on admission. He was
started on empiric vanco/zosyn. However, no source was
identified, cultures remained negative and abx. were stopped.
.
4. abdominal pain: Mr. [**Known lastname 14**] c/o of [**2-23**] days of abd. pain
prior to admission. He also reports distension and constipation.
Obstruction or perforation were ruled out and a surgical
evaluation was negative for an acute abdominal process.
.
5. Left renal mass: CT shows a L renal exophytic mass with
characteristics of a RCC. However, a renal MRI for further eval
on [**2121-4-28**] showed b/l simple renal cysts.
.
6. Pump: No prior TTE on record. After his cardiac arrest, a TTE
showed left ventricle hypokinesis. his prior cardiac function is
unknown. He was started on heparin for prophylaxis against
thrombus formation and for his atrial flutter. He was
transitioned to coumadin on discharge.
.
7. CHF: pt has no known history of CHF, in the ED a CXR showed
signs consistent with failure. It is unclear if this is of acute
onset or has been undiagnosed. The pt. has an unclear hx. of
intermittent DOE. A echo showed an EF of 30%, however, this was
also in the setting of asystolic arrest. He was discharged on
standing lasix, which should be stopped by his primary care
physician as appropriate.
.
8. Rhythm: New onset atrial flutter, s/p cardioversion in the ED
at which time he converted to NSR but became hypotensive and
bradycardic. A temporary pacer was accidentally
self-discontinued by the patient. However, the patient did not
have any significant pauses since then. He was started on a
heparin drip with transition to coumadin. His INR was 2.4 on
discharge. EP was following the patient throughout the hospital
stay, they did not feel a pacemaker was indicated.
.
9. Hypertension: At home the patient was on HCTZ. As pt. was
initially hypotensive, antihypertensives were held. While
intubated, pt. became hypertensive and was started on
hydralizine iv which was transitioned to po. In addition,
lopressor was added after extubation. On discharge, his blood
pressure was well controlled with toprol xl and hydralazine. His
hydralazine should be transitioned to an ace inhibitor once his
renal failure resolves.
.
10. ARF- baseline Cr = 1.2, presented with a creatinine of [**12-28**].
Possible pre-renal [**1-24**] to poor perfusion due to hypotension.
After the cardiac arrest his creatinine rose to 4.1 due to ATN.
He continued to produce urine. His creatinine stabalized at 4.
and began to trend down, on discharge his creatinine was 3.2.
.
11. Anemia- baseline Hct of 35. Remained stable without
requirement for transfusion.
.
12. FEN: cardiac diet.
.
15. Code: Full
Medications on Admission:
VITAMIN B-12 TAB 1000 TR 1 QD
ASPIRIN TAB 81MG qday
PRILOSEC CAP 20MG CR 1 po qday
HCTZ 12.5 mg qday
TIZANIDINE HCL 4 MG TABS 1 tab po qd
CLOBETASOL PROPIONATE 0.05 % CREAM
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain for 2 weeks.
5. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
1. atypical atrial tachycardia
2. congestive heart failure, EF 30%
3. spinal stenosis
4. rib fractures
Secondary diagnosis:
History of bladder cancer
S/P Prostatectomy
Prostatic stone
SPINAL STENOSIS
HIATAL HERNIA, W/ REFLUX
PSORIASIS
BASAL CELL CANCER
HYPERCHOLESTEROLEMIA
S/P CARPAL TUNNEL SURGERY- RIGHT.
HYPERTENSION, BENIGN ESSENTIAL
COLON ADENOMAS
Discharge Condition:
stable. ambulating.
Discharge Instructions:
You presented with an abnormal heart rhythm for which you
underwent electrical cardioversion. Your hospital course was
complicated by a cardiac arrest and intubation.
- Important: on your abdominal CT, a left renal mass was noted.
Further workup of this mass showed this to be a simple cyst.
However, your primary care physician should be made aware of
this finding.
- please continue to take your medications as prescribed.
your new medications are: toprol XL, coumadin, hydralazine,
lasix
- your hydrochlorothiazide was stopped, discuss with your
primary care physician prior to restarting.
- once your kidney function normalizes your hydralazine should
be stopped and you should be started on an ACE-inhibitor to be
decided by your primary care physician
- if you again have symptoms of shortness of breath or chest
pain or other worrisome symptoms, please seek medical attention.
- please follow up with your appointments as below
Followup Instructions:
follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-24**] weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**]
Completed by:[**2121-5-1**]
|
[
"584.9",
"553.3",
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"276.2",
"518.0",
"458.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"99.61",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
11983, 12060
|
6627, 6627
|
470, 532
|
12459, 12481
|
4237, 6604
|
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|
3216, 3234
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3249, 3249
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3271, 4218
|
2441, 2879
|
221, 432
|
560, 2422
|
12206, 12438
|
2901, 3133
|
3149, 3200
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,098
| 193,565
|
4368
|
Discharge summary
|
report
|
Admission Date: [**2197-11-9**] Discharge Date: [**2197-11-27**]
Date of Birth: [**2144-7-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
seizure, unresponsiveness, hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 53-year-old woman with a history of type II
DM, HTN, seizure disorder, PFO, TIA, remote history of viral
encephalitis, who was transferred from [**Hospital3 **] after
being found at home with a generalized tonic-clonic seizure.
.
Per EMS, she was found by her family actively seizing for about
1 min, but post-ictal at the time of EMS arrival. HR 110s, BP
140s/80s, O2 sat 92%. No recording of FS. En route to [**Hospital1 **], she had 3 seizures with unclear details, was given
diazepam 5 mg IV x 2. She was noted to have numbness in her R
arm over the past week.
.
On arrival to [**Hospital3 3583**] ED, T 98.0, BP 141/101, HR 132, RR
16. Serum glucose was 526 with Na 138, K 4.0, Cl 95, CO2 28,
BUN 15, Cr 1.13--AG 15. U/a notable for glucosuria and
ketonuria. Phenytoin level was < 2.5 and her NH4 was 20. ABG
was 7.30/58/350. Her chemistry showed an AG of 15. CEs negative
x 1. Her head CT and CXR showed no acute process. Was given
lorazepam 2 mg then 3 mg then 0.5 mg. Also recieved fosphenytoin
1900 mg, insulin 10 units x 2, ondansetron 8 mg x 1. She was
intubated with succ 120mg and etominatae 20mg. Started on
propofol.
.
On arrival to [**Hospital1 18**] ED, T 101.8, HR 117, BP 167/71, RR 15, 100%
on AC with undocumented settings. WBC 10.9 with 79%N, 17%L, no
bands. Hct 31.2. Glucose decreased to 264 with a normal anion
gap, with K 3.7 and Cr 0.8. Her u/a showed 1000 glucose and 15
ketones. Serum and urine tox screens were negative. LP showed
WBC 3, protein 162, glucose 240, with HSV PCR pending. C-spine
CT showed no traumatic injury. She was seen by neuro. A RIJ was
placed. She was given empiric ceftriaxone 2 gm, vancomycin 1 gm,
acyclovir 800 mg IV. She was started on an insulin gtt and given
2L of NS.
.
Of note, her records include an elder abuse report describing
her living conditions to be "unhealthy and unfit for current
health status". There was also "many foul odors inside the home
along with structural failures.". The report also describes that
the family has been unable to afford her medications and she has
been without medicine for 8 months, only receiving insulin but
without tester strips to monitor her BS.
.
ROS: unable to obtain due to patient's being intubated
.
Past Medical History:
- DM
- HTN
- HLD
- Sz
- CAD
- MI
- "Herpetic encephalopathy", hx of viral encephalitis treated
with acylovir in [**2-/2196**], presented with status
- CVA
- PFO, hx of TIA, on Coumadin
- Anemia
- Diabetic neuropathy
- toe amputations, hx of osteomyelitis in [**2195**]
- migraines
- orthostatic hypotension (seen by Dr. [**First Name (STitle) **] in Neurology in
[**2186**]-99)
.
Social History:
Lives with 2 sons and with a friend of their's in a mobile home
in [**Location (un) 18825**]. According to the transfer notes pt's living
condition was unhealthy and unfit. Home had structural failures
and foul odors. It was also reported that pt has been not taking
her meds for the past 8 months because unable to afford them.
Family History:
NC
Physical Exam:
Vitals: stable
GEN: middle-aged woman, intubated
HEENT: PERRL, sclera anicteric, ET tube in place
NECK: No JVD, no cervical lymphadenopathy
COR: Nl rate, reg rhythm, nl S1/S2, no m/r/g
PULM: Lungs with bilateral aeration from anterior, no crackles
or wheezes
ABD: Soft, obese, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, 1+ DP pulses bilateraly
NEURO: intubated, withdraws to painful stimuli, normal bulk and
tone
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
[**2197-11-9**] 02:15PM WBC-10.9 RBC-3.54* HGB-11.2* HCT-31.2* MCV-88
MCH-31.6 MCHC-35.8* RDW-13.2
[**2197-11-9**] 02:15PM NEUTS-78.6* LYMPHS-17.1* MONOS-3.9 EOS-0.1
BASOS-0.3
[**2197-11-9**] 02:15PM PLT COUNT-340
.
[**2197-11-9**] 02:15PM PT-12.5 PTT-18.6* INR(PT)-1.1
.
[**2197-11-9**] 02:15PM GLUCOSE-306* UREA N-15 CREAT-0.8 SODIUM-139
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
[**2197-11-9**] 02:15PM ALT(SGPT)-13 AST(SGOT)-20 LD(LDH)-270*
CK(CPK)-115 ALK PHOS-70 TOT BILI-0.4
[**2197-11-9**] 02:15PM LIPASE-23
.
[**2197-11-9**] 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2197-11-9**] 02:15PM ACETONE-MODERATE OSMOLAL-302
.
[**2197-11-9**] 02:15PM CK-MB-3 cTropnT-<0.01
.
[**2197-11-9**] 05:30PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-0 POLYS-11
LYMPHS-19 MONOS-56 MACROPHAG-14
[**2197-11-9**] 05:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-162*
GLUCOSE-240
.
[**2197-11-9**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
.
[**2197-11-9**] CXR: IMPRESSION:
1. High positioning of the nasogastric tube with tip at the
gastroesophageal junction. A wet read has been placed in CCC
regarding this finding.
2. Satisfactory position of endotracheal tube
.
[**2197-11-9**] CT C-spine: IMPRESSION: No cervical spine trauma
identified. Mild degenerative change centered at C5-C6. Support
tubes as above. Consider advancing endotracheal tube 2 cm for
optimal placement.
.
[**2197-11-10**] EEG: IMPRESSION: No cervical spine trauma identified.
Mild degenerative change centered at C5-C6. Support tubes as
above. Consider advancing endotracheal tube 2 cm for optimal
placement.
.
[**2197-11-10**] MRI Brain: IMPRESSION: Small subdural in the left
parietal region. There is no mass effect on the underlying
brain. No evidence for acute ischemia.
Brief Hospital Course:
53-year-old woman with a history of type II DM, seizure
disorder, HTN, PFO, TIA, remote history of viral encephalitis,
who was admitted after being found at home with a generalized
tonic-clonic seizure, also found to have hyperglycemia and
glucosuria with a normal anion gap.
.
Plan:
# Seizure: likely triggered by antiepileptic non-compliance.
Patient was intubated for airway protection and extubated on day
2 of ICU stay. Meningitis/encephalitis, DKA were also
considered as potential causes. Patient's intial LP showed
elevated glucose and protien, but this was in the setting of
hyperglycemia - CSF had only 3 WBC and patient remained
afebrile. EEG was abnormal (see above). Antibiotics were d/c'ed
except for acyclovir which was kept until HSV PCR was negative.
Hyperglycemia treated as below. Patient was given phenytoin 100
mg tid with goal serum conc of 15-20 and neuro was consulted.
MRI with small subdural hematoma, neuro exam was non-focal, head
CT 3 days later which showed stable hematoma. She was placed on
aspirin 81 mg daily per neurology recs. She should not receive
any further anticoagulation.
.
#. Subdural hematoma: Given her subdural hematoma and her
history of falls and noncompliance with medications, her
coumadin was not started. She had not been taking her
medications as an outpatient.
.
# Hyperglycemia: with history of DM2. FS 500s on presentation to
[**Hospital1 46**], with ketonuria, but has never had an anion gap--could be
due to good renal clearance of ketoacids. Arterial pH 7.47.
Likely due to recent medication non-compliance. Patient given
aggressive IVF with Insulin gtt until gap closed.
Patient required significant insulin titration, with resulting
improvement in glycemic control. Pt was noted to have
significant dietary indiscretions, resulting in difficult
control. This was discussed with the patient on multiple
occasions, however, pt stated that she will "probably always
cheat" on her diabetic diet. Patient will require close
outpatient for insulin titration.
.
# Anemia - Baseline not known. H/H stable here but low.
B12/folate wnl. PCP to follow up.
# Altered mental status: most likely due to seizure coupled with
possible DKA. Could also be due to infections, metabolic
derangements. [**Month (only) 116**] be due to encephalopathy. MRI with Small SDH
as above. Unclear what her MS is at baseline and family issues
contribute to her non-compliance. Social work, psychiatry, and
legal were consulted regarding her poor care and neglect at
home. She was seen by protective services who evaluated the home
as well. Psychiatry reevaluated (please see note dated [**11-24**]),
with determination that pt is competent to make decisions.
Therefore, the team discontinued pursuing guardianship, and
efforts were made to ensure patient had a safe environment to
return to.
.
# Right shoulder pain: Patient with R shoulder pain upon
awakening from seizures. Pain with point tenderness and with
Passive motion. Tx with tylenol. Imporved over course of
hospitalization.
.
# FEN: Diabetic diet
.
#. Social issues. Patient was noted to have been unkempt. At
home she lives in a trailer with her sons. She has been unable
to afford her medications for several months. Multiple people
expressed concern about the safety of her return to her home
situation. Social work was consulted.
.
Guardianship paperwork in progress as intiated, however, with
repeat psychiatric evaluation pt now considered to be competent.
Will not pursue guardianship. Working with protective services
to ensure safe environment to return home. Will d/c to home with
services and will be followed by protective services when able
to verify safe environment.
Case management appreciated; total cost/month for meds/supplies
less than $20/month.
Medications on Admission:
- Insulin 50/50 50 units (frequency unknown)
- Humulin 70/30 50 units (frequency unknown)
- Coumadin 5mg on Wednesday, 7mg PO all other days
- Metoprolol 50mg PO QD
- Simvastatin 40mg PO QD
- dilantin 300mg PO (frequency unknown) and 200mg (frequency
unknown)
- Tylenol 650mg (frequency unknown)
.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: One (1) vial
Subcutaneous AS DIR: Dose as per insulin dosing schedule
provided.
Disp:*1 vial* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) vial
Injection AS DIR: as per insulin dosing schedule.
Disp:*1 vial* Refills:*2*
9. Insulin Syringe-Needle U-100 1 mL 29 x [**1-11**] Syringe Sig: One
(1) box (100 syringes) Miscellaneous four times a day.
Disp:*1 box of 100 syringes* Refills:*2*
10. One Touch Test Strip Sig: One (1) box In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care
Discharge Diagnosis:
# Seizures
# Medication non-compliance
# Subdural hematoma
# Type II diabetes, uncontrolled with complications
# Anemia, NOS
Discharge Condition:
Stable
Discharge Instructions:
Please take all of your medications as prescribed and follow a
diabetic diet. Please check your sugars at least 4 times per
day.
Please follow up with your primary care provider within the next
week.
Please return to the emergency room if you develop seizures,
very low blood sugars, confusion, severe headaches, or any other
concerns.
Followup Instructions:
Pt to have protective services follow patient after discharge.
Please follow up with your primary care physician within the
next week. You may need to have your insulin doses titrated
further.
Please fax discharge summary to [**Telephone/Fax (1) 18826**] attention [**Doctor Last Name **] she
is the secretary for Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**]
|
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icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71"
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icd9pcs
|
[
[
[]
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11108, 11169
|
5844, 7968
|
357, 363
|
11338, 11347
|
3942, 5821
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3056, 3387
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,266
| 174,975
|
48430
|
Discharge summary
|
report
|
Admission Date: [**2113-2-9**] Discharge Date: [**2113-2-16**]
Service: MEDICINE
Allergies:
Cisatracurium
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
2 episodes of dark brown stools
Major Surgical or Invasive Procedure:
NG Lavage [**2113-2-9**]
EGD [**2113-2-14**]
Colonoscopy [**2113-2-14**]
Central Venous Line [**2113-2-11**]
History of Present Illness:
Mr. [**Known lastname 83312**] is an 88M with CAD, afib on warfarin, AS, and h/o
GIB who presented on [**2-9**] with melena x2. In the ED, VS: 96.2,
54, 136/69, 96% RA. He was trace guiac positive on rectal exam.
He was started on protonix and admitted for further workup.
.
Since admission, Hcts have trended down from 31.3->27.1, for
which he received 1 units PRBCs this AM. NG lavage was negative.
He was taken to EGD today but unable to get the procedure [**2-20**]
acute onset of low back pain. Per his daughter this has not
happened before. He was given 2mg of dilaudid which made him
very groggy.
.
Back on the floor, he was hypotensive to the 70's initially with
improvement to the 80's systolic following NS boluses. With
time, his mental status did improve back to baseline. MICU was
called to evaluate given persistent hypotension. Of note, urine
culture obtained [**2-9**] has grown >100,000 E coli. SBPs improved
from 80's to low 100's overnight following IVF resuscitation.
.
On floor eval, patient denied any further chest, back, or
abdominal discomfort, cough, diarrhea. He had some recent
dysuria and hematuria.
Past Medical History:
1. Hypertension
2. Permanent atrial fibrillation
-on coumadin
3. Chronic renal insufficiency
-Baseline creatinine 1.5-1.7
4. Hypercholesterolemia
5. Multiple knee replacements
6. Aortic stenosis
- moderate echo [**6-24**]
7. Coronary artery disease
-OM BMS [**2103**]
-neg P-MIBI [**6-24**]
-EF >55%
8. Elevated homocysteine
9. Hematuria (S/p TURP)
10. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]
11. Arthritis
12. Gout
13. GI bleeding
14. Dementia
Social History:
Mr. [**Known lastname 83312**] grew up in the [**Hospital3 4414**] in [**Location (un) 86**]. He was the 3rd
of 7 children in a very tight-knit family. He has been working
in a pharmacy since the age of 12, and after graduating from
high school ([**Location (un) 86**] English High School) and college, he
attended [**State 350**] College of Pharmacy and was a pharmacist
in [**Location (un) 86**] for 56 years and retired 10-12 years ago. He was very
happily married for 61 years, and has 2 daughters and 3
grandchildren. His wife passed away last year following a fall
and leg injury that became infected. He presently lives in an
apartment that joins the home of his younger daughter and
son-in-law in [**Name (NI) 16848**], MA. He uses a walker to navigate the
house and outside, although he is able to climb up and down
stairs. He has never used tobacco, and drinks 3-4 oz of wine
once a week (Sunday) and holidays. He is active both physically
through gardening and intellectually through [**Location (un) 1131**] and writing
avidly. He follows a salt-free diet and eats vegetables he grows
in his garden seasonally in addition to a well-balanced diet.
Family History:
1. Father was a smoker who died in his 60s of lung cancer
2. Mother suffered from chronic peripheral edema and died in her
80s of MI
3. a sister died of liver cancer
4. another sister had a blood disorder: patient could not recall
the name
Patient reports no family history of colon cancer, prostate
cancer, diabetes, CAD, or depression.
Physical Exam:
Vitals - T:97 BP:142/60 sitting and 130/60 standing HR: 45
sitting 59 standing (asymptomatic) RR: 18 02 sat: 99%RA
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. L eye
red, No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= 9cm
LUNGS: good air movement biaterally, crackles heard b/l bases
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or 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. [**1-20**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2113-2-9**] 08:16PM CK(CPK)-277*
[**2113-2-9**] 08:16PM CK-MB-6 cTropnT-0.11*
[**2113-2-9**] 08:16PM WBC-4.8 RBC-3.23* HGB-10.9* HCT-30.8* MCV-95
MCH-33.8* MCHC-35.4* RDW-15.6*
[**2113-2-9**] 08:16PM PLT COUNT-120*
[**2113-2-9**] 05:50PM WBC-5.4 RBC-3.48* HGB-11.7* HCT-33.6* MCV-97
MCH-33.8* MCHC-34.9 RDW-15.6*
[**2113-2-9**] 05:50PM PLT COUNT-132*
[**2113-2-9**] 02:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2113-2-9**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-2-9**] 11:30AM GLUCOSE-97 UREA N-50* CREAT-1.8* SODIUM-141
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-34* ANION GAP-13
[**2113-2-9**] 11:30AM cTropnT-0.11*
[**2113-2-9**] 11:30AM proBNP-6332*
[**2113-2-9**] 11:30AM WBC-5.6 RBC-3.26* HGB-11.0* HCT-31.3* MCV-96
MCH-33.7* MCHC-35.1* RDW-15.4
[**2113-2-9**] 11:30AM NEUTS-78.8* LYMPHS-14.4* MONOS-5.5 EOS-1.2
BASOS-0.3
[**2113-2-9**] 11:30AM PLT COUNT-135*
[**2113-2-9**] 11:30AM PT-19.5* PTT-31.1 INR(PT)-1.8*
[**2113-2-8**] 10:40AM GLUCOSE-90
[**2113-2-8**] 10:40AM UREA N-52* CREAT-1.7* SODIUM-139
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-34* ANION GAP-11
[**2113-2-8**] 10:40AM estGFR-Using this
[**2113-2-8**] 10:40AM ALT(SGPT)-32 AST(SGOT)-41* ALK PHOS-82 TOT
BILI-1.1
[**2113-2-8**] 10:40AM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-2.4*
CHOLEST-148
[**2113-2-8**] 10:40AM HDL CHOL-50 CHOL/HDL-3.0 LDL([**Last Name (un) **])-89
[**2113-2-8**] 10:40AM TSH-13*
[**2113-2-8**] 10:40AM FREE T4-1.0
[**2113-2-8**] 10:40AM [**Doctor First Name **]-NEGATIVE
[**2113-2-8**] 10:40AM WBC-5.1 RBC-3.20* HGB-10.6* HCT-31.4* MCV-98
MCH-33.1* MCHC-33.7 RDW-14.8
[**2113-2-8**] 10:40AM NEUTS-75.0* LYMPHS-15.4* MONOS-8.1 EOS-1.2
BASOS-0.3
[**2113-2-8**] 10:40AM PLT COUNT-122*
[**2113-2-8**] SPEP normal
Cryoglobulins pending
.
Micro:
[**2113-2-13**] IMMUNOLOGY HCV VIRAL LOAD-not detecctedFINAL
INPATIENT
[**2113-2-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negativeFINAL INPATIENT
[**2113-2-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2113-2-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2113-2-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-2-9**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
.
Studies:
[**2113-2-9**] CXR:
Patchy opacity within the left lower lobe which could represent
atelectasis or aspiration with associated small pleural
effusion. Developing infection is not excluded.
.
[**2113-2-10**] CT GU:
1. Normal kidneys without hydronephrosis or calculi.
2. Pancreatic head calcifications, which can be seen as sequelae
of chronic pancreatitis. No evidence of acute pancreatitis.
2. Extensive diverticulosis of the sigmoid colon, without
evidence of acute diverticulitis.
3. Unchanged cholelithiasis without evidence of acute
cholecystitis.
4. Splenic calcifications consistent with prior granulomatous
infection.
5. Redemonstration of atherosclerotic calcification throughout
the aorta and major branches.
.
[**2112-2-13**] Echo:The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The aortic valve
leaflets (?#) are severely thickened/deformed. There is moderate
aortic valve stenosis (area 1.1cm2). Mild to moderate ([**1-20**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-20**]+) mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior report (images unavailable for
comparison) of [**2110-12-3**], the ventricle is less vigorous, but
without definite regional dysfunction. The severity of aortic
stenosis, aortic regurgitation, and mitral regurgitation are
similar.
CLINICAL IMPLICATIONS:
Based on [**2111**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2113-2-13**] CXR: Consolidation at the left lung base has progressed
with a persistent small left pleural effusion. The right lung
remains clear, and there is no pneumothorax. The pulmonary
vascularity remains stable. A right jugular central venous line
ends in the lower SVC, unchanged.
.
[**2112-2-14**] EGD: small dulefoy lesion coiled
colonoscopy:2 sessile polyps removed, pathology pending
Brief Hospital Course:
This 88M with h/o afib on warfarin, CAD, AS, and GIV presented
with 2 dark BM worked up for GI bleed with complicated hospital
course by urosepsis.
.
# GI bleed: Admitted with 2 dark guiac positive stools on
coumadin. Had been worked up prior for massive GI bleeds with no
etiology found. Hct trended down slightly, HD stable, GI was
consulted with plan to scope him. Cdiff negative stools. Started
IV PPI [**Hospital1 **], held coumadin. Initially q6 hcts, 2 large bore IVs,
maintained active T+S. Given 2 units of PRBCs and 2 FFP prior to
scope to reverese INR. First scope attempt was [**2113-2-8**] but
patient developed acute back pain. Likely [**2-20**] renal stones, UTI,
early presentation of sepsis. Transferred to MICU for sepsis
treatment as below. When called out of MICU, underwent
colonoscopy which showed two polyps that were removed and an EGD
which showed dulefoy lesion likely accounting for guaic positive
stools, subsequently clipped. Hct stable post procedure. Changed
PO PPI 40mg to daily.
.
#Bacteremia/hypotension: Most likely secondary to E coli
urosepsis(Blood and urine cultures positive) Patient transferred
to MICU where CVL was placed and Ceftriaxone was started.
Hypotension resolved with IVF resuscitation. There was concern
over pneumonia on CXR but the L lung base opacity was stable and
more likely to represent atelectasis vs. small pleural effusion.
He does have any upper resp symptoms or fever with improving
leukocytosis so more likely to be atelectasis, possibly volume
overload more likely than pneumonia. Ceftrixone would cover most
PNA bacteria. Survellience Blood cultures negative to date.
Switched to PO levaquin to complete 2 week course.
.
# CHF: Echo from [**11-24**] LVEF 55%, slightly volume overloaded by
exam, BNP in 6000s which is at baseline. Repeat echo "the
ventricle is less vigorous, but without definite regional
dysfunction. The severity of aortic stenosis, aortic
regurgitation, and mitral regurgitation are similar" EF 50-55%,
held lasix. Monitored I/Os, monitored daily weights. Remained
mostly euvolemic except some trace pretibial edema which
improved with elevation.
.
# Blue fingers: likely vasoconstriction, concern for cold blue
but blanching fingers for ischemia, but no signs of embolic
lesions, consider cryoglobulinemia which was pending upon
discharge. HEPC VL not detected. Gloves for comfort.
.
#CKD: Patient has Cr baseline 1.5, continued gentle hydration,
renally dosed meds, followed urine output. Held lasix and can be
restarted as outpatient.
.
#Afib:rate controlled without nodal agents, previously on
coumadin, tele picking up ~2 sec pauses. EP consulted for
concern over pacemaker but will hold off for now as he is
asymptomatic and pauses <3sec. Will follow with cards as
outpatient. Coumadin was discontinued indefinitely as he now has
GI bled multiple times.
.
#CAD: no chest pain, no acute EKG change, cardiac enzymes
stable, monitored on tele.
.
#BPH: continued home medication regimen
.
#hypothyroid: TSH elevated, followed as outpatient, continued
current synthroid at current dose.
.
#General Care: IVF for gentle hydration, replete lytes prn,
clear cardiac diet advanced to regular after GI bleed
stabilized, PPX: PPI, pneumoboots, ACCESS: PIV, CVL into R IJ,
CODE: full, confirmed, CONTACT: dtr [**Name (NI) **] [**Telephone/Fax (1) 101962**], [**Name2 (NI) **]rged
home with PT.
Medications on Admission:
Allopurinol 100 daily
Calcitriol 0.25 mcg MWF
Warfarin
Darbepoetin 60mcg q2 wk
Donepezil 10 daily
Finasteride 5 daily
Tamsulosin 0.4 daily
Lasix 60 daily
Levothyroxine 25 daily
Protonix 40 daily
Kcl 10meq daily
Pravastatin 40 daily
Pyridostigmine 60 TID
Tramadol 50mg q8h
Ferrous sulfate 160 [**Hospital1 **]
Folate
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
6. Levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q8H
(every 8 hours).
9. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
8 days.
Disp:*8 Tablet(s)* Refills:*0*
13. Aranesp (Polysorbate) 60 mcg/0.3 mL Syringe Sig: One (1)
Injection q2weeks.
14. Ultram Oral
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
GI bleed
bradycardic atrial fibrillation
urosepsis
.
Secondary Diagnosis:
Myasthenia [**Last Name (un) **]
Discharge Condition:
Stable, ambulating
Discharge Instructions:
You were admitted after your had a large dark bowel movement
which was concerning for bleeding from your GI tract. We
monitored you and had the gastroenterologists follow you. We
checked your stool and made sure you did not have C.Difficle in
your stool. After another dark bowel movement, the GI doctors
decided to [**Name5 (PTitle) **] in side your stomach to see if there was any
evidence of bleed. They found a small area in your upper GI
tract that may have explained your symptoms. You also had 2
polyps removed on your colonoscopy. We then monitored your
blood counts and found you to be stable. We also had the
cardiologist come assess you because of your slow rhythm. They
believe that you do not currently need a pacemaker but you
should continue to follow up with your cardiologist so they can
asses if you will need one in the future. You also stayed in
the intensive care unit because you developed a urinary tract
infection and bacteria got into your blood stream. We treated
this with antibiotics and your infection improved. You were
cleared by physical therapy to go home but you will still need
some physical therapy when you go home.
.
Please stop your lasix and potassium until your primary care
doctor or cardiologist resumes them. Please continue to take
Levaquin for 8 more days for your infection. We stopped your
coumadin since you have now had multiple episodes of recurrent
GI bleeding and the risks to bleed again are much greater than
your overall risk for stroke. Please continue with your Aranesp
injections.
.
Please follow up with your primary care doctor to adjust your
synthroid dose.
.
Please continue to follow up with your primary care doctor and
your cardiologists as scheduled.
.
If you develop any of the following, chest pain, shortness of
breath, dizziness, fever, chills, nausea, vomiting, or
increasing dark bowel movements please call your doctor or go to
your local emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2113-3-1**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2113-3-2**] 8:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2113-8-8**] 10:20
Completed by:[**2113-2-16**]
|
[
"294.8",
"403.90",
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"458.29",
"V45.82",
"427.81",
"272.0",
"414.01",
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"358.00",
"455.3",
"995.92",
"562.10",
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"V43.65",
"244.9",
"584.5",
"287.5",
"038.42",
"274.0",
"455.0",
"443.89",
"211.3",
"427.31",
"285.1",
"V58.61",
"486",
"600.00",
"424.1",
"518.0",
"785.52",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"44.43",
"96.07",
"99.04",
"45.42",
"96.33",
"38.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
14515, 14590
|
9635, 13015
|
252, 363
|
14760, 14781
|
4470, 8952
|
16767, 17209
|
3205, 3544
|
13382, 14492
|
14611, 14611
|
13041, 13359
|
14805, 16744
|
3559, 4451
|
8975, 9612
|
181, 214
|
391, 1522
|
14704, 14739
|
14630, 14683
|
1544, 2011
|
2027, 3189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,344
| 150,713
|
4914
|
Discharge summary
|
report
|
Admission Date: [**2185-4-23**] Discharge Date: [**2185-5-1**]
Date of Birth: [**2120-1-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2344**]
Chief Complaint:
Flank Pain
Major Surgical or Invasive Procedure:
Attempt at IR guided embolization
History of Present Illness:
65yo male with h/o [**Doctor Last Name 933**], hyperlipidemia presenting with left
flank pain; CT with bilateral pulmonary emboli.
.
Per report patient had been in USOH when developed acute onset
left sided flank pain. Pain described as a burning is
non-radiating and localized to left flank. Reports associated
pleuritic component and difficulty breathing when pain severe.
Aggravating factors: sitting upright
Alleviated factors: lying flat, deep breaths
Pertinent +/-: no personal or family of DVT/clotting disorder,
no long trips, no recent surgery, no fevers, weight loss, night
sweats, no abdominal pain, no melena, no hematchezia, no h/o
colonscopy
.
Persistent pain prompted presentation to the ED. On arrival VS:
97.2 107 120/80 16 100% RA. Ed labs notable for an elevated
Ddimer: 1381 EKG showed NSR 99 with no sign of R heart strain.
.
CTA of chest/abd/pelvis obtained with prelim read concerning for
bilateral PE's of basal segments with no sign of strain or
pulmonary infarct. Patient received Dilaudid 0.5IV for pain
control and was started on heparin per weight based protocal (wt
151): bolus 5500 and 1250 infusion to start. Vitals on transfer
afeb 110 118/78 20 98% on 2L NC.
.
On the floor, patient with persistent left flank pain, was
initially [**7-10**]. Reports breathing is comfortable. The patient
was started on heparin gtt in the ED. This was continued until
heparin was discontinued on [**4-24**] in the PM. On [**4-24**] PM the
patient was started on lovenox and coumadin in anticipation for
discharge. However at 1530 the patient became hypotensive to the
70s. He was also pale and diaphoretic with tachycardia. The
patient was triggered. He complained of abdominal pain and had
tenderness so went emergently to CT scan which showed
intra-abdominal hemorrhage.
.
ROS: otherwise negative
Past Medical History:
[**Doctor Last Name 933**] Disease
Dyslipidemia
Hypertension
Social History:
Married, lives with wife. [**Name (NI) **] involved in care
Occupation: Retired; previously worked with animals and
livestock; denies h/o pesticide exposure or factory work
Tobacco: Denies
EtoH: Denies
Drugs:Denies
Family History:
No history of clotting disorders
No history malignancy
Physical Exam:
ADMISSION PHYSICAL:
VS: 99.2 132/96 97Reg 16 99%2L
Gen: Alert, oriented, Portugeuse speaking male in NAD
HEENT: hypopigementation of left eyebrow; EOMI, PERRLA, OP clear
without exudates, lesion, MMM
NECK: supple, no appreciable thyromegaly or nodules.
CV: RRR, nl S1, S2 no m/r/g, no edema
RESP: shallow breaths, CTA-B, decreased bs at left base
ABD: soft, mildly distented, non-tender, +BS, no palpable
masses, no HSM
EXT: WWP, 2+ pulses, no calf swelling, asx, or tenderness, no
palpable cords
LYMPH: no cervical, supraclavicular, submandibular, axillary or
inguinal LAD.
NEURO: II-XII intact, motor and sensation intact
.
DISCHARGE PHYSICAL:
Vitals: 98.6 125/85 69 18 96%RA
Gen: Alert, oriented, Portugeuse speaking male in NAD
HEENT: hypopigementation of left eyebrow; EOMI, PERRLA, OP clear
without exudates, lesion, MMM
NECK: supple, no appreciable thyromegaly or nodules.
CV: RRR, nl S1, S2 no m/r/g, no edema
RESP: CTA-B, decreased bs at bilateral bases
ABD: soft, mildly distented, non-tender, +BS, no palpable
masses, no HSM
EXT: WWP, 2+ pulses, no calf swelling, asx, or tenderness, no
palpable cords
LYMPH: no cervical, supraclavicular, submandibular, axillary or
inguinal LAD.
NEURO: II-XII intact, motor and sensation intact
Pertinent Results:
ADMISSION LABS: [**4-23**]
CBC
WBC-12.2*# RBC-5.56 Hgb-15.7 Hct-46.2 MCV-83 MCH-28.2 MCHC-33.9
RDW-14.0 Plt Ct-197
Diff
Neuts-81.5* Lymphs-12.0* Monos-5.1 Eos-0.8 Baso-0.6
.
[**Name (NI) **]
PT-12.9 PTT-24.1 INR(PT)-1.1
.
Chem
Glucose-98 UreaN-15 Creat-1.2 Na-135 K-7.7* Cl-102 HCO3-24
AnGap-17
[**2185-4-24**] 05:20AM BLOOD Glucose-117* UreaN-18 Creat-1.2 Na-139
K-4.5 Cl-100 HCO3-27 AnGap-17
.
BLOOD TSH-2.4
.
DISCHARGE LABS:[**2185-5-1**] 05:50
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
11.5* 4.00* 12.1* 34.4* 86 30.4 35.2* 14.5 232
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
93 19 0.9 137 3.7 104 23 14
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
64* 37 80 1.2
.
MICRO:
[**2185-4-28**] 12:34 pm CATHETER TIP-IV Source: Left Subclavian.
**FINAL REPORT [**2185-4-30**]**
WOUND CULTURE (Final [**2185-4-30**]): No significant growth.
.
[**2185-4-26**] 4:35 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2185-4-28**]**
GRAM STAIN (Final [**2185-4-26**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2185-4-28**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
Blood Cx: NGTD
.
Urine Cx: NGTD
.
.
STUDIES:
CTA:
IMPRESSION:
1. Bilateral segmental pulmonary emboli with small associated
pleural
effusions. There is no right heart strain or pulmonary infarct.
2. 1-cm cyst within the neck/body of the pancreas probably
represents a side branch IPMN.
.
CTAP:
IMPRESSION:
1. Large right heterogeneously hyperdense subcapsular liver
hematoma with
active extravasation. Possible extravasation from a posterior
inferior right liver branch; unable to definitively identify
vessel of origin. Extracapsular extension of hemorrhage into the
peritoneal cavity along the right paracolic gutter and adjacent
to the spleen. Large amount of hemorrhage within the dependent
pelvis.
2. Heterogeneous hypoenhancement of the liver adjacent to the
subcapsular
hematoma is likely related to mass effect. If clinical
suspicision remains for an underlying subcapsular liver lesion,
multiphasic CT would be useful to assess.
3. Prostate enlargement.
4. Enlarging left pleural effusion with worsening left lower
lobe atelectasis and/or consolidation.
.
CXR:
IMPRESSION:
1. New left lower lobe atelectasis and possible left pleural
effusion.
2. Position of new left subclavian central venous catheter as
described.
3. No evidence of post-insertion pneumothorax.
.
TEE:
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is no
pericardial effusion.
IMPRESSION: Extremely limited study. Globally-preserved
biventricular systolic function. Aerated saline contrasted study
was performed at rest, but its results are uninterpretable. If
clinical question regarding valvular disease or possible
intracardiac shunting persists, would recommend a
transesophageal study.
Compared with the report of the prior study (images unavailable
for review) of [**2171-11-25**], biventricular function still appears
normal overall.
.
CXR [**2185-4-26**]:
FINDINGS: As compared to the previous radiograph, the patient
has been
intubated. The tip of the tube projects 8 cm above the carina,
the tube
should be advanced by approximately 2 to 3 cm. The venous
introduction sheath over the left subclavian vein is in constant
position. There is no evidence of complications, notably no
pneumothorax. In the interval, the patient has received a
nasogastric tube. The course of the tube is unremarkable.
No evidence of pulmonary edema, the cardiac silhouette is
unchanged.
Unchanged right retrocardiac atelectasis. Newly appeared mild
volume loss in the middle lobe, repeat radiograph should be
performed to exclude early
pneumonia. Tip of an inferior vena cava filter is included on
the image.
.
CXR: [**4-29**]
There is slight interval improvement of preexisting interstitial
pulmonary
edema. There is no change in bilateral, left most likely more
than right,
pleural effusions and bibasilar areas of consolidation. There is
no
pneumothorax.
Brief Hospital Course:
Mr [**Known lastname 1794**] is a 65yo male with history of [**Doctor Last Name 933**] disease
presenting with left sided chest/flank pain found to have
bilateral pulmonary emboli with hospital course complicated by
spontaneous intra-hepatic hematoma requiring massive transfusion
protocal activation and MICU transfer
.
# Intra-abdominal hemorrhage: Likely secondary to
anticoagulation. Interesting admission CT abdomen without
obvious hepatic anatomic abnl. CT scan demonstrates intrahepatic
hematoma with extravasation. Pt taken to IR, and no active
extravasation discovered, nothing embolized. Pt received 4 units
PRBC's initially with massive transfusion protocol, in addition
to 1 unit of platelets. Pt received add'l 2 units PRBC's on day
1 of MICU stay for hypotension attributed to hemorrhage.
Transplant surgery followed, but recommended conservative
management. Serial Hcts were checked. Calcium was repleted.
Bleed stabilized without intervention.
.
# Bilateral Pulmonary Emboli: Etiology of emboli unclear.
Inherited hypercoagulable states vs malignancy. He has not had
age appropriate screening, primarily c-scope and PSA. No
evidence of RHS on ECG. LENI??????s not done prior to hemorrhage as
discussed above. IR placed IVC filter [**4-25**] as anti-coagulation
contraindicated. OUTPATIENT ISSUES:
-- Will likely need outpatient malignancy work-up with c-scope
and PSA and possible thyroid US/work-up; of note no lab data
suggestive of MM therefore SPEP, UPEP
.
# Hypoxic respiratory distress: Likely multifactorial given
PE??????s, volume overloaded in setting of transfusions, and possible
flash pulmonary edema given likely diastolic dysfunction, vs.
intrabdominal distension. TRALI also a possibility given recent
transfusions, though relatively quick timing make this unlikely
and CXR not supportive. Pt was weaned to pressure support and on
[**4-27**] patient was successfully extubated. On the medical floor
patient with signs of volume overload and intermittent
diuresised with 20mg IV Lasix with good response. On discharge
patient saturating well on RA and with ambulation
.
# Fever: DDx includes PE, vs. infectious source. On admission to
ICU, cultures were sent. Pt grew out GPC??????s in sputum. CXR
suggestive of infiltrate vs. fluid. Pt was started on Vancomycin
though due to low clinical suspicion for infection vancomycin
stopped. Patient afebrile for >48hr on the floor with
downtrending WBC.
.
# Transaminitis: likely [**2-2**] decreased perfusion in setting of
hypotension vs. inflammation associated with intrahepatic bleed.
LFT??????s were trended daily and normalized prior to discharge.
Simvastatin was held in the MICU and decision made to hold at
time of discharge.
.
# History of [**Doctor Last Name 933**] Disease. Previously followed by Endocrine at
[**Hospital1 18**]. Per patient not receiving any treatment. Denies symptoms
or hyper/hypothyroid at this time.
.
# Dyslipidemia: Held Simvastatin 10mg qhs given transaminitis.
Medications on Admission:
Advil
Simvastatin 10mg qhs
Lisinoril 10mg QD
Discharge Medications:
1. lisinopril 10 mg 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.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bilateral Pulmonary Emboli
Spontanous Hepatic Hematoma
.
Secondary:
Hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 1794**] it was a pleasure taking care of you.
.
You were admitted to [**Hospital1 18**] due to treatment and evaluation of
left flank and were found to have clot in the blood vessels
supplying your lungs. It is unclear what triggered the formation
of the clots however your primary care doctor will continue to
explore for potential causative factors. To prevent propogation
of clot you were started on anticoagulation: Lovenox and
Coumadin. Unfortunately shortly after starting these medications
you experienced a spontaneous bleed in your liver. This bleed
[**Hospital 20470**] transfer to the ICU. There you received multiple
blood transfusions with stabilization of your blood counts. The
interventional radiologists attempted to find the source of
bleed but could not identify it. It was decided that you could
no longer take anticougulation safely so an IVC (inferior vena
cava) filter was placed to prevention new pulmonary emboli.
.
Of note while hospitalized you labs demonstrated inflammation of
your liver. Simvastatin, a cholersterol lowering medication, can
also irritate the liver so the decision was made to hold this
medication until your liver functions return to normal.
.
At time of discharge you were without pain and oxygenating well
without need for supplemental oxygen.
.
CHANGES TO YOUR MEDICATIONS
DISCONTINUE SIMVASTATIN until seen by primary care doctor and
liver function test rechecked.
Take over the counter stool softners and laxatives as needed to
faciliate regular bowel movements.
.
Again it was pleasure taking care of you. Please contact us with
any questions or concerns
Followup Instructions:
Please call PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] at Uphams Corner to schedule a
follow-up appt within the next week.
Completed by:[**2185-5-5**]
|
[
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"573.8",
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"415.19",
"272.4",
"401.9",
"577.2",
"E934.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"38.91",
"38.7",
"88.51",
"96.71",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
11622, 11628
|
8290, 11265
|
314, 349
|
11775, 11775
|
3867, 3867
|
13584, 13801
|
2530, 2586
|
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264, 276
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377, 2196
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3883, 4279
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11790, 11902
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2218, 2281
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2297, 2514
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,708
| 197,245
|
52298+52299
|
Discharge summary
|
report+report
|
Admission Date: [**2178-2-8**] Discharge Date: [**2178-2-14**]
Date of Birth: [**2120-6-4**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 57-year-old gentleman
with human immunodeficiency virus, end-stage renal disease
(on hemodialysis), hepatitis B, hepatitis C, cirrhosis,
history of IV drug use (currently on methadone), history of
history of pancreatitis, who is status post a recent [**Hospital1 1444**] admission from [**1-13**]
through [**1-22**] for hypotension and found to have markedly
decreased left ventricular ejection fraction compared to
three years ago. This was attributed to human
immunodeficiency virus cardiomyopathy. Following the past
admission, the patient was started on captopril. Highly
had been off of that therapy for approximately 10 months
secondary to pancreatitis.
Admission in [**2177-2-22**] was for pancreatitis which was
attributed to antiretroviral medications. The patient was
discharged to [**Hospital1 **] two weeks ago for cardiac rehabilitation.
The patient has complained of chest pain and abdominal pain times
two weeks. Today, the patient returned from hemodialysis and
complained of mild abdominal pain for which he took Tylenol.
Several hours later the patient complained of
lightheadedness, worsening chest pain especially with
inspiration. The patient was found to be in rapid wide
complex tachycardia at 150 beats per minute, systolic blood
pressure of 60, treated with lidocaine 100 mg times one and
then 4 mg lidocaine drip and converted to normal sinus rhythm
at the [**Hospital1 69**].
Cardiology was consulted in the emergency department, the
ventricular tachycardic strip was interpreted as probably
atrial flutter with 2:1 conduction, at which time the
lidocaine was discontinued. The patient described nausea,
vomiting, fever, chills, and dark/loose stool earlier in the
day. He was found to have elevated amylase and lipase, and
his laboratories were also hemolyzed. In the emergency
department the patient was given aspirin, Kayexalate for a
potassium of 5.8, started on levofloxacin 250 mg p.o.,
Flagyl 500 mg p.o., vancomycin 1 g IV times one, and
morphine 4 mg IV times two, and a clot was sent to the blood
bank. The patient was in normal sinus rhythm and tachycardic
at 100 to 110 with a temperature of 100.5, blood pressure
of 116 to 130/78 to 83, oxygen saturation 93% to 96% on
4 liters. The patient was transferred from the emergency
department to the medical intensive care unit for
observation. He also had a right femoral catheter placed at
the time of admission.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus diagnosed in [**2159**] with a
cardiomyopathy revealing severe left ventricular global
hypokinesis, right ventricular hypokinesis described on
echocardiogram on [**2178-1-13**]. This was a new finding
compared to previous studies. His human immunodeficiency
virus was with a CD4 count of 139; most recent viral load
of 31,429 off antiretroviral treatment secondary to
pancreatitis in [**2177-2-22**]. Those medications, however,
were restarted on [**2177-1-14**], at the time of admission
he was taking antiretroviral medication.
2. History of IV drug use, on methadone.
3. End-stage renal disease, on hemodialysis times two
years. The renal disease was secondary to membranoproliferate
glomerulonephropathy versus IGA nephropathy.
4. The patient also has chronic lung disease and
hypoventilation times four years on 4 liters oxygen by nasal
cannula.
5. He has a history of PE and deep venous thrombosis, on
Coumadin, dose ranging from 2.5 mg to 5 mg.
6. History of hepatitis B and hepatitis C.
7. Cirrhosis.
8. Splenomegaly.
9. Pancreatitis (two episodes of acute pancreatitis in the
past).
10. Anemia.
11. Hemorrhoidal bleeds.
12. Benign prostatic hypertrophy.
13. Depression.
14. History of methicillin-resistant Staphylococcus aureus
and vancomycin-resistant enterococcus.
15. History of thrush.
16. PPD positive treated for four months with INH.
17. History of peptic ulcer disease.
MEDICATIONS ON ADMISSION: Compazine 10 mg p.o. q.6h.,
Coumadin 8 mg p.o. q.d. (as documented in the medical
intensive care unit admission note), Senokot 2 tablets p.o.
q.h.s., Lanoxin 0.125 mg p.o. q.o.d. on even days,
Tylenol 650 mg p.o. q.6h., Epogen 6000 units subcutaneous
twice a week at hemodialysis, Tums [**2176**] mg p.o. t.i.d. with
meals, Anusol ointment p.r.n., methadone 50 mg p.o. q.d.,
captopril 12.5 mg p.o. t.i.d., diazepam 10 mg p.o. q.i.d.
p.r.n., Colace 100 mg p.o. b.i.d., multivitamin with
minerals 1 tablet p.o. q.d., Prevacid 30 mg p.o. q.d.,
Percocet 2 tablets q.4-6h. p.r.n., Zoloft 50 mg p.o. q.d.,
Bactrim 1 tablet every Monday, Wednesday and Friday,
3-TC 25 mg p.o. q.d., D4T 20 mg p.o. q.d., Neoflex 1 tablet
b.i.d., and lactulose 20 cc p.o. p.r.n.
ALLERGIES: HALDOL gives him a rash. THORAZINE causes
anaphylaxis. CODEINE causes unknown adverse reaction as does
STELAZINE. H2 BLOCKERS cause thrombocytopenia. CLINDAMYCIN
gives him a rash.
SOCIAL HISTORY: He is married with two daughters and one
son. [**Name (NI) **] lives with his wife and son. Former IV drug use
(heroin). Past history of ethanol abuse. Smoked two packs
per day times 20 years; quit 10 years ago. On methadone
since [**2162**].
FAMILY HISTORY: His father passed away of unknown causes.
Mother passed away of myocardial infarction at age 75.
Brother was killed in [**Country 3992**]. Sister is alive and well.
PHYSICAL EXAMINATION ON ADMISSION: On admission to the
medical intensive care unit with a temperature was 100.5,
blood pressure 116/74, heart rate 100, respiratory rate 18,
oxygen saturation 96% on 4 liters. In general, a thin
chronically ill-appearing 57-year-old gentleman in no acute
distress. HEENT revealed pupils were equal, round and
reactive to light. Extraocular movements were intact.
Sclerae were icteric. Thrush seen on the tongue. Neck was
supple. No lymphadenopathy. No jugular venous distention.
Cardiovascular revealed tachycardic with a systolic ejection
murmur heard at the right lower sternal border. Chest had
fine crackles, left greater than right, at the bases. No
wheezes. Abdomen was soft and nondistended, generalized
tenderness especially in the epigastric area. No rebound,
active bowel sounds. Liver and spleen both palpable.
Extremities revealed no cyanosis, clubbing or edema.
Palpable dorsalis pedis pulses. Neurologically, alert and
oriented times three. Cranial nerves were grossly intact.
No asterixis.
LABORATORY DATA ON ADMISSION: White blood cell count 6.3,
hematocrit 33.5, platelets 104 with 74% polys and
19% lymphocytes. PT 20.3, INR 2.7, PTT 35.8.
Fibrinogen 277, albumin 2.6. Calcium 8.8, phosphate 4.3,
magnesium 2. ALT 142, AST 623, LDH 3700, alkaline
phosphatase 147, total bilirubin 1.4, lipase 2170,
amylase 896. First creatine kinase was 94. Troponin was
sent and was pending. Sodium 138, potassium 5.8,
chloride 101, bicarbonate 23, BUN 44, creatinine 6.4, and
glucose 89. Digoxin level was also sent and was pending.
Arterial blood gas was 7.29, lactate 3.1, free calcium 1.14,
DAT was sent off. Blood cultures sent times two.
Chest x-ray showed no congestive heart failure, no
infiltrates.
Electrocardiogram showed sinus tachycardia, left atrial
dilatation, right bundle-branch block with new Q waves in III
and aVF. No ST changes.
HOSPITAL COURSE: This 57-year-old gentleman with human
immunodeficiency virus, end-stage renal disease, hepatitis B,
hepatitis C, cirrhosis, cardiomyopathy, presented with
ventricular tachycardia following hemodialysis as well as
hypotension and was initially admitted to the medical
intensive care unit for observation and was subsequently
transferred the next morning to the [**Hospital Ward Name **]. His
hospital course by issue is as follows.
1. CARDIOVASCULAR: The patient had no further episodes of
his wide complex tachycardia which was thought to be more
likely atrial flutter with aberrancy; however, ventricular
tachycardia could not be ruled out. He also had a positive
troponin to 13.5 with flat creatine kinases. There were
electrocardiogram changes, but the overall opinion from
cardiology was that the troponin leak as well as
electrocardiogram changes could all be consistent with a
cardiomyopathy. The digoxin was discontinued. The captopril
was held. Telemetry was continued, and the patient continued
to show ventricular bigeminy and trigeminy with some
premature ventricular contractions on telemetry, but did not
have any further tachy arrhythmias.
2. GASTROINTESTINAL: The patient was had pancreatitis by
elevated amylase and lipase in the setting of restarting his
human immunodeficiency virus medications. He was kept n.p.o.
with low maintenance IV fluids. His human immunodeficiency
virus medications were held. A CAT scan of the abdomen was
done which showed a small stone in the gallbladder with no
evidence of biliary obstruction, atrophic kidneys, small
bilateral pleural effusions as well as fat stranding
surrounding the tail of the pancreas, and a small amount of
fluid collecting around the liver and anterior left renal
fascia. Findings were determined to be consistent with early
pancreatitis, and the patient was treated as previously
mentioned. Also, an MRCP was obtained and gastrointestinal
was consulted. The MRCP showed choledocholithiasis without
any obstruction, most likely the cause of his intermittent
pancreatitis. He declined ERCP and was started on ursodiol.
3. RENAL: The patient was continued on hemodialysis every
other day. He had minimal fluid intake with maintenance
fluids, and his electrolytes were followed closely. He
required only one dose of Kayexalate to normalize his
potassium, and otherwise did not require any other
adjustments in his electrolytes.
4. HEMATOLOGY: The patient had multiple blood draws that
were hemolyzed. He was Coombs antibiotic positive with
decreased haptoglobin and increased LDH. The source of his
hemolysis was thought to be due to medications; possibly the
captopril or the Bactrim or the human immunodeficiency virus
medications. His hemolysis laboratories progressively
continued to improve with the LDH and the haptoglobin
normalizing. His reticulocyte count was 3.3, and his
hematocrit dropped to 25 but increased to 30 after 1 units of
packed red blood cells.
A hematology consultation was obtained, and they proposed
doing a bone marrow biopsy to rule out a lymphoproliferative
disorder or a lymphoma in this human immunodeficiency virus
positive patient; however, the patient declined that
procedure. The patient's INR increased to 8. He was given
one dose of vitamin K at which time it came down to 1.8. He
was restarted on 2.5 mg of Coumadin and increased to 5 mg of
Coumadin. The patient received 8 mg of Coumadin in the
medical intensive care unit, after which time his INR
increased significant; however, after the patient received
vitamin K and was restarted on the Coumadin the INR was
followed to try to achieve a level of between 2 and 3 for
adequate anticoagulation.
5. PULMONARY: The patient has obstructive sleep apnea and
a chronic oxygen requirement, chronic deep venous thrombosis
and PE. He was continued on supplemental oxygen throughout
the hospitalization, and his oxygen saturation was stable.
6. PE/DEEP VENOUS THROMBOSIS: Again, the Coumadin was
restarted at 2.5 mg and then 5 mg with a goal INR of 2 to 3.
7. INFECTIOUS DISEASE: HAART medications were held, as was
the Bactrim, in the setting of hemolysis. The patient had
[**2-25**] blood culture bottles positive for Staphylococcus
coag-negative. Two bottles were oxacillin resistant, and two
were oxacillin sensitive. The patient received seven days of
vancomycin dosed by level due to his renal failure.
Surveillance cultures were sent times two. At the time of
this dictation, those cultures showed no growth to date.
The plan was to restart his Bactrim once he is taking better
p.o. following resolution of the pancreatitis and once the
hemolysis has resolved. The patient was also known to have
methicillin-resistant Staphylococcus aureus as well as
vancomycin-resistant enterococcus and precautions were in
place during his hospitalization.
8. PSYCHIATRY: The patient has a history of depression and
IV drug use. He was continued on methadone. The Zoloft and
the diazepam were held while his was n.p.o., and he was
maintained on Valium p.r.n.
DISCHARGE DISPOSITION: The patient was ultimately
transferred to the [**Hospital **] Rehabilitation facility in good
condition with the following discharge diagnoses.
DISCHARGE DIAGNOSES:
1. Human immunodeficiency virus.
2. Cardiomyopathy.
3. End-stage renal disease.
4. Pancreatitis.
5. History of IV drug use, on methadone.
6. Chronic lung disease.
7. Status post tachy arrhythmia with hypotension.
8. History of pulmonary embolus/deep venous thrombosis.
9. Hepatitis B.
10. Hepatitis C.
11. Cirrhosis.
12. Splenomegaly.
13. Anemia.
14. Benign prostatic hypertrophy.
15. Depression.
16. History of methicillin-resistant Staphylococcus aureus
and vancomycin-resistant enterococcus.
17. Peptic ulcer disease.
MEDICATIONS ON DISCHARGE:
1. Prilosec 20 mg p.o.
2. Bactrim-DS 1 tablet every Monday, Wednesday and Friday.
3. Methadone 50 mg p.o. q.d.
4. Valium 5 mg to 10 mg p.o. q.6h. p.r.n.
5. Oxycodone one to two tablets q.4-6h. p.r.n.
6. Coumadin 5 mg p.o. q.h.s.
7. Aspirin.
At the time of this dictation he had not been restarted on
his captopril or on a beta blocker, but the hope that this
will happen if his blood pressure can tolerate it.
Additional discharge medications will be dictated separately
in a discharge summary addendum.
CONDITION AT DISCHARGE: The patient was discharged in good
condition.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 29450**]
MEDQUIST36
D: [**2178-2-12**] 17:09
T: [**2178-2-12**] 17:39
JOB#: [**Job Number 108127**]
Admission Date: [**2178-2-8**] Discharge Date: [**2178-2-17**]
Date of Birth: [**2120-6-4**] Sex: M
Service: [**Hospital1 3253**]
DISCHARGE MEDICATIONS: Prilosec 20 mg po q.d., Coumadin 2.5
mg q.h.s. q.d., Bactrim DS one tablet q Monday, Wednesday and
Friday, methadone 50 mg po q.d., Roxicet 5/325 one tab q 6
hours prn, aspirin 325 q.d., Colace 100 mg b.i.d., Epogen
6000 units two times a week with hemodialysis, multi vitamin
prn, Tums [**2176**] mg t.i.d. with meals, Senna two tablets po
q.h.s. prn, Compazine 10 mg po q 6 hours prn, Captopril 625
po b.i.d., Fentanyl patch 25 micrograms per hour q 72 hours,
Miconazole cream to feet t.i.d. Ursodiol 300mg [**Hospital1 **], metoprolol
25mg [**Hospital1 **].
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 29450**]
MEDQUIST36
D: [**2178-2-16**] 14:19
T: [**2178-2-16**] 14:29
JOB#: [**Job Number 57191**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
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12492, 12637
|
5303, 5491
|
12659, 13206
|
14278, 15125
|
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|
7403, 12468
|
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145, 2569
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2592, 4041
|
5036, 5285
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,835
| 166,037
|
50007
|
Discharge summary
|
report
|
Admission Date: [**2188-3-12**] Discharge Date: [**2188-3-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Left subclavian central line placed and removed
History of Present Illness:
This is an 84 y/o female with a PMH significant for recurrent
upper abdominal discomfort, GERD, PUD, gastroparesis, IBS,
depression, presenting with worsening of her chronic upper
abdominal pain for the last 3-4 days. Sees Dr. [**Last Name (STitle) **] for GI
issues, GI consulted on patient. She states the pain is
mid-epigastric in location without any radiation. For the last
few weeks, she has been experiencing dry heaves w/o vomiting and
decreased po intake over the last 3 days due to the dry heaves
and worsening abdominal pain. The pain is currently a [**7-7**] and
is constant, with a "squeezing" feeling. At her baseline, the
pain is at a [**4-7**]. She says the pain feels "heavier" after
eating, but does not associate the feeling with any particular
types of food. Nothing makes her pain better. She is constipated
at her baseline and uses an over-the-counter stool softener.
Last BM was this morning. No change in stool caliber, color. No
BRBPR, hematochezia, or melena. No recent weight changes. Does
report generalized fatigue, weakness, and increased sleepiness
over the last few days. Denies increased feelings of
depressions, any SI or HI. No recent changes in medications.
Patient used to be on Reglan and Domperidone in the past for
gastroparesis, but it was stopped due to concern of Parkinsonian
features. Per patient, had low BS this morning in the 50's, so
she drank some OJ. In the ED, BS was in 300's and she was given
10 units of regular insulin.
.
ROS - In addition to the above, patient denies any f/c/s,
dizziness/lightheadedness, chest pain, SOB, palpitations,
dysuria, decreases/increases in voiding amount, swelling in
extremities, focal weakness, numbness/tingling/loss of
sensation.
Past Medical History:
1. GERD
2. PUD
3. IBS
4. Lactose intolerance
5. Depression
6. Constipation
7. HTN
8. Hyperlipidemia
9. Hypothyroidism
Social History:
Lives alone in an apartment with an aide to help with
medications, shopping, groceries. Has children in the area. No
tobacco, EtOH, or illicits.
Family History:
NC
Significant for DM, no h/o cancer.
Physical Exam:
VS: Tc 98.0, BP 117/41, HR 78, RR 18, sats 100%/RA
General: Pleasant, eldery female appearing fatigued in NAD. AO x
3. Comfortable and not in severe pain.
HEENT: NC/AT, PERRL, EOMI. MM slightly dry, OP clear.
Neck: supple, no JVD or TMG appreciated
Chest: CTA-B, no w/r/r
CV: RRR, s1 s2 normal, no m/g/r
Abd: soft, ND, NABS. Tenderness to deep palpation in the
epigastric region, without any peritoneal signs. Guiac negative
in ED.
Ext: no c/c/e, pulses 2+ b/l
Neuro: AO x 3, CN II-XII intact. MS [**5-2**] throughout with
sensation intact grossly. Downgoing toes b/l. No tremors or
rigidity.
Pertinent Results:
[**2188-3-12**] 12:45PM GLUCOSE-272* UREA N-30* CREAT-1.4*
SODIUM-131* POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-16
[**2188-3-12**] 12:45PM ALT(SGPT)-52* AST(SGOT)-47* ALK PHOS-161*
AMYLASE-31 TOT BILI-0.5
[**2188-3-12**] 12:45PM LIPASE-17
[**2188-3-12**] 12:45PM ACETONE-NEGATIVE
[**2188-3-12**] 12:45PM WBC-9.8# RBC-3.73* HGB-10.6* HCT-32.3* MCV-87
MCH-28.6 MCHC-33.0 RDW-16.1*
[**2188-3-12**] 12:45PM NEUTS-84.5* BANDS-0 LYMPHS-9.3* MONOS-5.7
EOS-0.2 BASOS-0.4
[**2188-3-12**] 12:45PM PLT COUNT-201.
.
Abd CT:
1. Nephroptosis with interval low lying right kidney, which
still appears well perfused.
2. Small left pleural effusion and bibasilar atelectasis.
3. Calcified fibroid uterus.
4. Stable thickening of distal stomach.
.
Renal US:
No evidence of hydronephrosis or proximal hydroureter.
.
RUQ U/S: Single gallstone is seen that is mobile with no
evidence of acute cholecystitis.
.
CXR: Probable aspiration pneumonia - radiographic followup is
recommended after treatment and if radiographic appearances
persist a CT should be considered.
.
MRCP: 1. Limited study in a patient unable to breath-hold
optimally. No pancreatic lesions evident with mildly atrophic
pancreas unchanged. No pancreatic ductal dilatation. If there is
continued clinical concern, a breath-hold study could be
performed when the patient's condition improves.
2. Anasarca with increased pleural effusions, ascites, and
subcutaneous edema since [**2188-3-12**] CT.
3. Ptotic right kidney that is otherwise normal.
.
U/S of left upper ext: neg for DVT
Brief Hospital Course:
Patient is an 84 y/o female with h/o GERD, gastritis, PUD,
chronic abdominal pain, presenting with worsening abdominal
pain.
.
1. Abdominal pain: Patient with history of chronic abdominal
pain, has had thorough workup by Dr. [**Last Name (STitle) **] and his team in the
past. GI was consulted and followed the patient while-in house.
CT Abdomen done in the ER showed single gallstone, with
transient elevation in liver enzymes that then tapered down;
impression was that acute worsening of pain was secondary to
passed stone. An MRCP was done to evaluate her biliary system
given this theory and because of the atrophic pancreas seen on
EGD with EUS done last year. Because of this atrophic pancreas,
she was started on Pancrease prior to each meal. The MRCP was a
suboptimal study but showed no abnormalities. The ddx also
included gastritis, PUD so she was continued on her [**Hospital1 **] PPI.
Another possibility is chronic mesenteris ischema. She had an
MRA of her abdomen in [**2185**] which showed some stenosis. GI
recommended that the pt have another MRA of her abdomen when her
respiratory status is more stable. At the time of discharge, pt
was tolerating po with minimal pain. She has a follow up
appointment with Dr. [**Last Name (STitle) **]. Both Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 141**]
agree that the pt should be placed back on Domperidone as an
outpatient. Due to thought that she likely had no parkinsonism
features, her sinemet was stopped.
.
2. Diabetes: Pt is a type I diabetic and very brittle. She is
followed by [**Last Name (un) **] and Joslinwas consulted for help with
management of her sugars. On admission, the pt reported the
incorrect insulin dosage so she was only receiving short acting
insulin. Due to the lack of long acting insulin, the pt slipped
into DKA requiring a short ICU stay for an insulin drip. Her
insulin was changed from am NPH to bedtime Lantus and her sugars
became easier to control. The scale or Lantus will likely need
to be titrated up as the pt's appetite increases.
.
3. Pneumonia: On admission, pt spiked a low grade fever and had
an oxygen requirement. She was found to have a small pneumonia
and started on a 10-day course of Levaquin. This will finish on
[**3-22**]. She received combivent nebs to help with her cough and
wheezing.
.
4. Acute and Chronic Renal Failure: During pt's episode of DKA,
her creatinine increased from 1.3 to 2.5. With aggressive fluid
hydration, her creatinine improved back down to 1.3 on
discharge. She was started on a low dose ACE-I on discharge.
.
5. Anemia: Likely in setting of her chronic renal failure. She
was continued on iron and will start epogen as an outpatient.
Baseline hct 27-30.
.
6. HTN: Pt with several episodes of SBP>150. Her carvedilol was
increased to 25mg [**Hospital1 **] and she was started on Lisinopril. If her
creatinine rises, she should stop the Lisinopril.
.
7. Hypothyroidism: continue synthroid. TSH wnl.
.
8. Depression - continue Celexa
.
9. Upper ext swelling: noted 3 days after placement of central
line (left subclavian). U/S neg for DVT. Line pulled on day of
discharge.
Medications on Admission:
1. Synthroid 50 mcg qd
2. Nexium 40 mg [**Hospital1 **]
3. Coreg 6.25 mg [**Hospital1 **]
4. ASA 81 mg qd
5. Lipitor 20 mg qd
6. Folic acid 1 mg qd
7. Avandia 4 mg qd
8. Celexa 40 mg qhs
9. Humalog 17 U qAM
10. Humulin SS
11. Fluodricort 0.1 mg qd
12. Sinemet 25/100 as directed
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO QOD ().
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed.
15. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at bedtime.
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
as directed Subcutaneous four times a day: as directed by
sliding scale.
17. Levaquin 250 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Last dose on [**3-22**].
18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. Epogen 3,000 unit/mL Solution Sig: 3000 (3000) units
Injection QMOWEFR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
PRIMARY
1. Acute on chronic abdominal pain
2. Type I Diabetes Mellitus s/p DKA
SECONDARY
1. PUD
2. IBS
3. Lactose intolerance
4. Depression
5. Constipation
6. HTN
7. Hyperlipidemia
8. Hypothyroidism
Discharge Condition:
feeling well, tolerating PO, abdominal pain improved
Discharge Instructions:
1. Please take all medications as prescribed
- your carvedilol was increased to 25mg [**Hospital1 **]
- you will get epogen injections for your chronic anemia
- continue taking Levaquin for your pneumonia until [**3-22**]
- you have been started on a low dose of ACE-I for your kidney
and blood pressure
- continue to take pancrease before meals
2. Please go to all follow-up appointments
3. If you develop fever, chills, nausea, vomiting, difficulty
breathing, or any other concerning signs/symptoms, please
contact your PCP or report to the Emergency Department
immediately
4. Please discuss with Dr. [**Last Name (STitle) 141**] the possibility of
restarting your Domperidone. You have an appointment scheduled
with him on [**2188-3-26**]
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2188-6-19**] at
3:30
.
Please keep your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11793**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2188-3-26**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2188-4-1**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
Completed by:[**2188-4-21**]
|
[
"271.3",
"533.90",
"536.3",
"401.9",
"244.9",
"250.10",
"530.81",
"250.40",
"272.4",
"285.21",
"507.0",
"362.01",
"564.1",
"V58.67",
"583.81",
"250.50",
"585.9",
"574.20",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9911, 9996
|
4640, 7802
|
277, 326
|
10239, 10294
|
3064, 4617
|
11085, 11713
|
2396, 2435
|
8132, 9888
|
10017, 10218
|
7828, 8109
|
10318, 11062
|
2450, 3045
|
223, 239
|
354, 2076
|
2098, 2218
|
2234, 2380
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,838
| 137,759
|
19322
|
Discharge summary
|
report
|
Admission Date: [**2139-3-17**] Discharge Date: [**2139-4-8**]
Date of Birth: [**2084-3-11**] Sex: F
Service:
ADMITTING DIAGNOSES:
1. Necrotizing fasciitis - Fournier's gangrene - status post
debridement times three.
2. Type II Diabetes mellitus.
3. Chronic obstructive pulmonary disease.
4. Coronary artery disease.
5. Morbid obesity.
6. History of diverticulitis.
7. Depression.
8. Anxiety disorder.
9. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
10. Status post appendectomy.
11. Status post G-tube/TEF repari as a child.
DISCHARGE DIAGNOSES:
1. Necrotizing fasciitis - Fournier's gangrene - status post
exploratory laparotomy with lysis of adhesions, repair of
ventral/umbilical hernia, sigmoid colostomy, status post open
gastrostomy tube placement, status post feeding jejunostomy
tube placement, status post rigid sigmoidoscopy, status post
necrotic tissue debridement.
2. Pleural effusions.
3. Diabetes mellitus.
4. Chronic obstructive pulmonary disease.
5. Coronary artery disease.
6. Morbid obesity.
7. History of diverticulitis.
8. Depression.
9. Anxiety disorder.
10. Status post bilateral buttocks debridements.
11. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
12. Status post appendectomy.
13. Status post G-tube/TEF as a child.
ADMISSION HISTORY AND PHYSICAL: Ms. [**Known lastname **] is a 54-year-old
female with an extensive past medical history as noted above
who was transferred to the [**Hospital1 188**] on [**2139-3-17**], after she had initially
presented to an outside hospital with complaints of bilateral
buttock pain. When she was seen and examined at the outside
hospital she underwent CT scan of the abdomen and pelvis
which showed soft tissue air bilaterally extending around the
rectum and into the retroperitoneal tissue. She was
subsequently taken on that same day for debridement in the
Operating Room and underwent subsequent serial debridements
on [**3-14**] and 22nd. She remained intubated
postoperatively after this and a repeat CT scan on the 23rd
showed persistent peritoneal gas; therefore, the patient was
transferred to the [**Hospital1 69**] for
further management.
When she arrived at [**Hospital1 69**] her
T-max was 100.1 degrees; otherwise, patient was intubated and
her heart rate was in the 70's to 80's with a systolic
pressure from the 100's to 140's and, as noted, patient was
intubated. She did respond to voice. Otherwise she had some
crackles at the bases of her lungs bilaterally. The heart
was regular. The abdomen was otherwise soft. In terms of
the buttocks, there were bilateral 10 cm areas which were
open with pus which tracked deep into the pelvis lateral to
the rectum and, as noted, a significant amount of purulence
was seen. The extremities were otherwise warm.
In terms of an electrocardiogram from the outside hospital,
it was only notable for sinus tachycardia but no ischemic
changes. She had a chest x-ray also from that outside
hospital which did not evidence any infiltrate and the CT
scan findings as noted above.
ADMISSION LABORATORY: When she arrived her white count was
23.1 with an hematocrit of 33. Otherwise, her electrolytes
were notable for potassium of 4.7, BUN and creatinine of 15
and 0.7.
HOSPITAL COURSE: Given the nature of the patient's extensive
infection, it was determined that she needed to be taken to
the Operating Room somewhat urgently for surgical debridement
of this deep seated infection. The case was discussed with
the patient's husband who agreed. As noted on [**2139-3-17**], patient was taken to the Operating Room and underwent
exploratory laparotomy with lysis of adhesions. A ventral
and umbilical hernia were found which were both reduced and
repaired primarily and sigmoid colostomy was created. Also a
G-tube and J-tube were placed along with the extensive
debridement of the necrotic tissue. The patient tolerated
the procedure and there was no note of excessive blood loss.
It was actually estimated to be about 400 cc. She remained
intubated in the Operating Room and was subsequently taken to
the Intensive Care Unit postoperatively. Notably, the
Infectious Disease service did consult along the course of
the [**Hospital 228**] hospital stay.
In terms of [**Hospital 228**] hospital course from a neurologic
standpoint, patient did relatively well. She did have one to
two episodes of mental status changes late in the course of
her hospitalization while patient was on the floor. These
did actually resolved within just a few minutes of being
re-oriented to her surroundings and were felt to be secondary
to patient's being in a foreign location. Otherwise, aside
from standard sedation when the patient was intubated and
postoperative pain control with narcotics, the patient really
had no neurologic issues.
From a respiratory standpoint, the patient was, as noted,
intubated when she arrived and actually remained intubated
for some time postoperatively when she was in the Intensive
Care Unit for respiratory support. It was felt that her
prolonged weaning may have been secondary to the severity of
her infection and it was not until postoperative day five the
patient was actually taken off pressure support and changed
over to CPAP although she did remain on CPAP for some time up
until postoperative day eight when she again required some
additional pressure support which she stayed on until
postoperative day 11 at which time again she was converted
back to CPAP. By postoperative day 13 the patient was
actually off any additional support which had been keeping
her in the Intensive Care Unit. Otherwise, she did have some
small pleural effusions develop during the course of her
hospitalization but the time of her discharge patient had no
oxygen requirements, actually satting in the high 90's
without any sort of oxygen support. On examination there
were only a few crackles at the bases indicating these had
essentially resolved.
From a cardiac standpoint, there was a question of whether
patient had suffered any sort of ischemic event while at the
outside hospital as noted by troponin-I of 0.6 but there were
no electrocardiogram changes and an echocardiogram there
showed preserved left ventricular systolic function. While
she was hospitalized here she was again ruled out for any
sort of myocardial infarction. She was otherwise maintained
on beta blockade and by the time of discharge was doing well
on a course of Lopressor 37.5 mg p.o. b.i.d. which allowed
her to maintain rate at around 70 with pressures of 130's
over 70's.
From a gastrointestinal standpoint, the patient's colostomy
that was created did quite well and was viable. Prior to
discharge the patient's stoma looked viable and was working
well. She was given Protonix during her hospitalization as
ulcer prophylaxis. The J-tube that was placed for tube feeds
intraoperatively was removed three days prior to patient's
discharge.
In terms of patient's fluid, electrolytes and nutrition
status, electrolytes were repleted as needed but, notably, in
terms of her nutritional status given the knowledge the
patient would require excellent nutritional support
postoperatively, she did have a feeding jejunostomy placed.
She was actually on total parenteral nutrition
postoperatively and also subsequently given Impact tube
feeds. We were able to actually conduct calorie counts six
days prior to patient being discharged in order to assess her
meeting adequate nutritional needs. Given the fact that she
had good p.o. intake we were able to stop the TPN and tube
feeds and patient was able to meet her caloric requirements.
From a renal standpoint, as noted, patient's creatinine when
she came in was about 0.7. She never really had any episodes
of oliguria or renal insufficiency. She did quite well in
terms of making urine and mobilizing all the intravenous
fluids that she had been given. Prior to discharge her BUN
and creatinine were around their baseline at 13 and 0.9. We
did keep the Foley catheter in place in order to keep the
wound relatively clean. The patient was relatively
non-ambulatory but otherwise patient had no significant
issues with renal dysfunction.
From a hematologic standpoint, patient did require blood
transfusion on postoperative day two of two units given low
hematocrit and her history of coronary artery disease.
Subsequent to this patient's hematocrit was actually pretty
stable and prior to discharge was 29.3. She had always
ranged between about 27 and 29 during her hospitalization
except as noted when she came in when her hematocrit was
between 30 and 33 which was felt partially to be secondary to
dehydration. As noted, she was given the previously
mentioned two units. Otherwise, she was on heparin subcu and
Venodyne's for deep venous thrombosis prophylaxis and there
was never any evidence of deep venous thrombosis during the
course of her hospitalization.
In terms of patient's hospitalization from an infectious
disease perspective, the Infectious Disease service was
consulted. From the outside hospital their cultures were
noted to grow Clostridium perphringens and Bacteroides
fragilis. When she was at the outside hospital she was on
vancomycin, levofloxacin and clindamycin. The choice of this
was also noted based on her allergies to a number of
medications which include Demerol, Keflex, Valium,
phenobarbital, Flagyl and meperidine, as per the patient.
Otherwise, as noted, intraoperatively cultures were also
obtained. These intraoperative cultures from our institution
showed notable growth of Bacteroides fragilis, Gram positive
rods, horny bacterium, Staphylococcus which was coag negative
and Gram negative rods. Further subsequent characterization
was not carried out. Given the extent of patient's infection
and species as noted, patient's broad spectrum antibiotics
including levofloxacin, Pen-G and clindamycin were carried on
as per Infectious Disease recommendations. She continued
this course from postoperative day one up until postoperative
day ten at which time vancomycin was added for the following
combination of vancomycin, clindamycin, Pen-G and
levofloxacin. Patient did well on this course although a
significant amount of purulence was noted at times from the
wound. During the course of her hospitalization only one
blood culture bottle grew coag negative Staph and all other
blood cultures were otherwise negative. Her Clostridium
difficile's were negative and urine cultures never evidenced
any sort of urinary tract infection. The patient never
evidenced any sort of pneumonia. In terms of management of
her infected wound, initially after the debridement the wound
was again cared for aggressively with dressing changes.
Plastic Surgery recommended Dakin's solution which was
carried out for some time though prior to discharge she was
back to normal saline wet-to-dry dressing changes with
irrigation of the drain placed in order to irrigate any sort
of purulent material. There was question as to whether a Vac
would be appropriate for the patient but after extensive
consultation with Plastic Surgery, their recommendation was
to continue with wet-to-dry dressing changes. Patient's
white count had normalized prior to discharge to 9.0. Once
the patient had stabilized in the Intensive Care Unit and had
transferred to the floor, the Infectious Disease
recommendations were to continue on vancomycin, levofloxacin
and Zosyn in terms of antibiotic coverage. These were
continued and their recommendation was for a total of six
weeks. Therefore, she was continued on these for four weeks
from the time of discharge. She did have a PICC line placed
for the intravenous antibiotics.
In terms of the patient's overall condition at the time of
discharge, she had been afebrile and otherwise
hemodynamically stable with sats in the high 90's on room
air. She was otherwise making excellent urine and taking
excellent p.o. intake to maintain her caloric needs. The
wound looked good with good viable tissue and, therefore, it
was felt that she could be discharged to an extended care
rehabilitation facility for b.i.d. dressing changes.
DISCHARGE MEDICATIONS: She was sent to the facility on the
following:
1. Nicotine patch 21 mg topically q. day.
2. Heparin 5,000 units subcu q. 8h.
3. Albuterol inhaler.
4. Miconazole powder p.r.n.
5. Protonix 40 mg p.o. q. day.
6. Lopressor 25 mg p.o. b.i.d.
7. Levaquin 500 mg p.o. q. day for four weeks.
8. Vancomycin 1000 mg b.i.d. for four weeks.
9. Zosyn 4.5 grams IV q. 6h. for four weeks.
10. Dilaudid p.r.n. dressing changes.
11. Paxil 20 mg p.o. q. day.
12. Tylenol with codeine p.r.n. pain.
13. Regular insulin sliding scale as needed.
FOLLOW-UP INSTRUCTIONS: The patient was advised to return to
her surgeon or call her surgeon's office for a temperature
above 101.5 degrees, any worsening drainage from the wound or
increasing redness of the wound.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Last Name (NamePattern1) 13262**]
MEDQUIST36
D: [**2139-4-7**] 14:14
T: [**2139-4-7**] 14:19
JOB#: [**Job Number 52612**]
|
[
"518.5",
"728.86",
"496",
"566",
"250.00",
"553.1",
"276.5",
"278.01",
"553.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.59",
"99.15",
"43.19",
"93.90",
"48.23",
"53.49",
"96.6",
"96.72",
"38.93",
"46.39",
"86.22",
"46.11"
] |
icd9pcs
|
[
[
[]
]
] |
607, 3297
|
12223, 12758
|
3315, 12199
|
12783, 13248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,220
| 163,685
|
37054
|
Discharge summary
|
report
|
Admission Date: [**2113-11-24**] Discharge Date: [**2113-12-10**]
Date of Birth: [**2039-11-5**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Percocet
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
S/p esophageal stent placment admitted to [**Hospital Unit Name 153**] for respiratory
distress
Major Surgical or Invasive Procedure:
EGD with esophageal stent placement
History of Present Illness:
This is a 74 year old female with recently diagnosed gastric CA,
s/p resection transfered from [**Hospital3 **] on [**2113-11-24**] to
the [**Hospital1 18**] for esophageal stenting.
The follow history is taken from [**Hospital1 2436**] and [**Hospital1 3278**] notes. The
patient [**Hospital1 1834**] EGD in [**2113-9-30**] for w/u anemia. She was found
to have a gastric mass, poorly differentiated adenocarinoma. On
[**11-1**], she [**Month/Year (2) 1834**] partial proximal gastrectomy and
pylorplasty with J-tube placment. She was discharged home on
[**11-9**] but returned to the ED later that day for hematemasis. EGD
was done showing some clots in the stomach but no active
bleeding. The follwing day she had another episode of
hematemasis, was transfered to the ICU and electively intubated
for airway protection. She [**Month/Year (2) 1834**] repeat endoscopy which
showed a small separtion in one portion of the esophagastric
anatomosis with oozing. She then [**Month/Year (2) 1834**] exploratory
laparotomy on [**11-11**] where a tear in the capusle of the spleen
was found, but was not able to be repaired given concerns with
disrupting the anastomosis. Tear was controlled with
thombin-soaked Gel foam, bleeding stopped. She then [**Month/Day (4) 1834**] an
arteriogram showing a 6mm splnic pseudoaneurysm. She was
transfused multiple units during these few days, HCT around 26.
She was on Zosyn and fluconazol 200mg IV daily.
She was transfered to [**Hospital1 3278**] SICU for treatment on the
pseudoaneurysm. She was taken to IR for stenting of of splenic
artery aneursym. She was weaned off the ventilator. However, she
was noted to be on 3L NC during ambulance transport. Lasix was
given. There was a question of vomiting enroute. She was then
reintubated on [**11-18**] for respiratory distress and hypotension on
[**11-18**]. She was diuresed for the following two days and then
extubated on [**11-20**]. On [**11-20**], she [**Month/Day (4) 1834**] CT chest, which only
showed moderate pleural effusions. On [**11-22**], she was switched
from Zosyn to Cefepime.
During this time a CT abdomen, demonstrated perforation of the
GE junction by the NG tube. NGT was pulled back and secured.
Gastrografin swallow on [**2113-11-23**] showed a contained anastomotic
leak to the left of the remaining stomach measuring approx
6x3cm. She was then transfered to [**Hospital1 18**] for esophagastric
stenting.
Here she [**Hospital1 1834**] ERCP with placement of esophagastric metal
9cm x10mm stent proximal clipping. She stent placement was
verified by a pediatric scope. She had been electively intubated
prior to the procedure and was extubated post ERCP. Post
proceedure, she was ordered 125ml/hr NS; she likely received
400cc LR during the procedure. She then developed respiratory
distress with respiratory rates in 40's, no documented hypoxia.
She was then reintubated in the PACU. She was given lasix 20mg
IV in the PACU. She was transfered to the [**Hospital Unit Name 153**] on AC 500x 14,
FI02 50%, PEEP 5.
In the [**Hospital Unit Name 153**], the patient was aggressively diuresed with
furosemide because of flash pulmonary edema. The patient's
respiratory condition improved and pt subsequently extubated on
[**2113-11-26**]. An echocardiogram performed revealed an EF 40%, severe
diastolic dysfunction, moderate mitral regurgitation, akinesis
of the septum and hypokinesis of the inferior wall which could
suggest recent MI. Serial troponins were negative.
The patient was to return to [**Hospital3 **], but the
admitting surgeon, Dr. [**Last Name (STitle) 64258**], does not have ICU admitting
privileges, so the patient is to be transferred to the floor and
then have transfer reattempted.
Past Medical History:
Gastric CA s/p resection
Breast ca s/p mastectomy
Partial thyroidectomy for thyroid CA
Bladder CA s/p transurethral resection
HTN
Splenic artery aneurysm s/p stenting
Social History:
Married and lives with her husband, children live nearby, she is
a former smoker of less than one pack per day, she drinks wine
occasionally.
Family History:
Breast ca, sister with gastric CA, a sister with lung CA, CAD
and COPD in various family members
Physical Exam:
Exam upon presentation on Medicine Floor:
Vitals: T 98.6 HR 85 BP 160/88 RR 22 SaO2: 97 on 2L NC
General: NAD
HEENT: EOMI, anicteric sclerae, MMM, oropharynx clear, neck
supple
Pulmonary: CTAB
Cardiac: RRR, normal s1 and s2, no murmurs
Abdomen: soft, nontender, nondistended, bowel sounds present
Extremities: No edema. Warm.
Skin: No rashes or lesions noted.
Neurologic: Alert and oriented x 4. Fluent speech. Strength 5/5
BUE and BLE. Sensory intact throughout. No dysmetria.
Psych: Appropriate, calm
Pertinent Results:
Blood:
[**2113-11-27**] 04:28AM BLOOD WBC-13.0* RBC-3.41* Hgb-9.9* Hct-30.8*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.4 Plt Ct-479*
[**2113-11-27**] 04:28AM BLOOD Neuts-89.9* Lymphs-6.1* Monos-3.7 Eos-0.1
Baso-0.1
[**2113-11-27**] 04:28AM BLOOD PT-13.3 PTT-29.1 INR(PT)-1.1
[**2113-11-25**] 08:51PM BLOOD CK(CPK)-14* CK-MB-2 cTropnT-0.02*
[**2113-11-25**] 04:40AM BLOOD CK(CPK)-18* CK-MB-2 cTropnT-0.02*
[**2113-11-24**] 10:30PM BLOOD proBNP-[**Numeric Identifier **]*
[**2113-11-27**] 04:28AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
Microbiology:
[**2113-11-24**] MRSA swab: negative
[**2113-11-25**] Central venous line tip culture: No significant growth
[**2113-12-4**] and [**2113-12-5**] Sputum culture:
STAPH AUREUS COAG +. SPARSE GROWTH.
[**2113-12-7**] JP Drain Fluid
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
GRAM NEGATIVE ROD(S). MODERATE GROWTH STRAIN 2.
[**2113-12-8**] C Diff Toxin: Negative
Studies:
CT abdomen w/ contrast [**2113-11-28**]:
1. Extraluminal gas collection to the left of the body of the
somach, NG tubes through an area of surgical clips in the GE
junction into this extraluminal gas collection, findings
compatible with perforation at the GE junction
2. Retroperitoneal hematoma in the right anterio pararenal space
3. J-tube in place
Bilateral LENI's [**11-20**]: No DVT above the knees
Abdominal Flouroscopy [**2113-11-24**]: A metal stent is visualized
projecting over the GEJ, extending from the T9 vertebral body to
the L1 vertebral body. There is dense material in the T9
vertebral body likely secondary to prior vertebroplasty. There
is a small left pleural effusion and retrocardiac opacity. Chest
radiograph is recommended for further work-up.
CT Chest [**11-20**]: no PE, bilateral moderal pleural effusion L>R
CXR (Portable AP) [**2113-11-24**]: New esophageal stent. Mild pulmonary
edema, left lower lobe atelectasis.
CXR (Portable AP) [**2113-11-25**]: The esophageal stent, right-sided IJ
venous catheter and endotracheal tube are unchanged since stable
in position. There is a tortuous thoracic aorta and some mild
cardiomegaly. There is a unchanged left retrocardiac opacity and
bilateral pleural effusions. There is mild fluid overload as
evident by mild pulmonary interstitial marking prominence.
EGD [**2113-11-24**]: A large defect was seen at the esophagogastric
anastamosis. The endoscope was passed into the stomach. A 10.5cm
by 23mm Wallflex fully covered metal stent was placed
successfully across the defect. The position was verified
endoscopically and fluoroscopically. An endoclip was
successfully deployed to clip the proximal end of the stent to
the esophageal wall to maintain stent position. ref 1673 Lot
[**Numeric Identifier 83544**] (stent placement) Post surgical gastric anatomy was
noted.
EKG [**Hospital1 2436**] [**11-6**]: sinus tachy at 106, left axis, deep TWI in
V2-V3, TWF in V4-V6, I, AVL, ? q waves in III, AVF, no ST
elevations or depressions EKG [**Hospital1 18**]: TWI in V2-V6
ECHO [**11-27**]:
IMPRESSION: Moderate regional left ventricular systolic
dysfunction consistent with coronary artery disease. Severe
diastolic dysfunction. Moderate mitral regurgitation.
[**2113-11-28**] GI Bleeding Study: Brisk bleeding in the left upper
quadrant with spread of activity consistent with the know
retroperitoneal location.
Brief Hospital Course:
Ms. [**Known lastname 83545**] is a 74 year-old lady with recently diagnosed
gastric adenocarcinoma, s/p [**2-14**] gastric resection who was
transfered from [**Hospital3 **] for esophageal stenting,
admitted to [**Hospital Unit Name 153**] after intubation for respiratory distress from
pulmonary edema, with a hospital course complicated by pulseless
VTach/Vfib arrest while on the floor and massive splenic
hemorrhage requiring splenic artery embolization. Due to
prolonged ICU course, her problems are addressed chronologically
in detail below:
[**Hospital Unit Name 13533**] [**Date range (3) 83546**]:
Ms. [**Known lastname 83545**] [**Last Name (Titles) 1834**] EGD which showed a large defect at the
esophagogastric anastamosis. A 10.5cm by 23mm Wallflex fully
covered metal stent was placed successfully across the defect.
Post-procedure, she remained strictly NPO, with feeding through
her J-tube. Fluconazole and Cefepime were continued. She was
electively intubated for EGD. She was extubated after the
procedure but developed respiratory distress in the PACU,
requiring reintubation which was felt to be secondary to
pulmonary edema. She was diruesed with Lasix, her sedation was
weaned, and she was successfully extubated on [**2113-11-26**]. The
patient [**Date Range 1834**] transthoracic echocardiogram on [**2113-11-27**] to
evaluate why she developed pulmonary edema. TTE showed Moderate
regional left ventricular systolic dysfunction consistent with
coronary artery disease. Severe diastolic dysfunction and
moderate mitral regurgitation.
Hypokinesis and akinesis seen on Echocardiogram suggested recent
MI. Serial cardiac enzymes were checked and had been negative.
She was transferred to the general medical floor, alert and
conversant on [**2113-11-27**] in hemodynamically stable condition.
[**Hospital Unit Name 13533**] [**Date range (3) 83547**] :
On [**2113-11-28**] on the general medical floor, a code blue was called
as Ms. [**Known lastname 83545**] was in VT/VF arrest. As per her floor RN, she
was in the solarium and afterwards was moved back to her room.
Shortly thereafter, she became unresponsive in bed. A code blue
was called. She initially had a pulse but quickly lost it. CPR
was begun. Her rhythm was noted to be VT/VF and a single shock
was administered with return of pulse and blood pressure. No
medications were administered. She was breathing spontaneuously
but her respirations were felt to be feeble and she was
intubated for airway protection following femoral line placement
and administration of etomidate and succynylcholine. An ABG at
the time showed 7.50/42/128. Sedation was given with midazolam
and fentanyl. EKG showed sinus tachycardia with premature beats
and stable TWIs in the anterior precodial leads. She was then
brought to the ICU.
Access was obtained, she became hypotensive and hematocrit
steadily dropped from 33.5-> 24.1->19.8 so she was transfused 5
units pRBCs, 1 unit FFP, 1 bag platelets repeat HCT 33. CT
Abdomen revealed large hematoma of spleen. Tagged RBC scan was
done showing active bleed of the spleen. She was given multiple
additional units of blood, 1 unit of platelets and taken to
interventional radiology for splenic artery embolization. Broad
spectrum antibiotics were initiated and patient was pan-cultured
as she started to spike fevers on and off during this time. She
was aggressively diuresed initially, for goal TBB -1.0 to -1.5 L
but lasix drip was stopped in the setting of hypotension and
increasing creatinine. Increasing creatinine was also thought to
be secondary to contrast dye needed for CT.
[**Hospital Unit Name 13533**] [**Date range (3) 83548**]:
Sputum culture grew MRSA, but patient was already being treated
with vancomycin. Due to increasing leukocytosis and fevers, she
was pan-cultured again. Repeat CT abdomen and pelvis revealed a
large left-sided pleural effusion with collapse of the left
lower lobe, small right pleural effusion with associated
atelectasis, stable splenic JP drain and infrasplenic fluid
collection/hematoma, percutaneous J-tube without evidence of
intestinal obstruction and no definitive abscesses. Right upper
extremity ultrasound was performed and was negative for DVT. Due
to no identifiable source of infection in the setting of
leukocytosis and fever, interventional pulmonology was called to
perform thoracentesis of pleural effusion to rule out empyema.
600cc of serosanguinous turbid fluid was drained but was
negative for microorganisms and cytology revealed no malignant
cells. Her abdomen continued to be rigid and bilious fluid was
emerging from her J-tube site. Additonally, she started having
bilious emesis. After speaking with Dr. [**Last Name (STitle) 64258**], her surgeon from
[**Hospital3 2783**], a possible source of infection could be
splenic necrosis from inadequate blood supply as splenic artery
was embolized and patient did not have adequate collateral
supply due to alterations of her vasculature from gastric
resection. [**Hospital1 18**] surgical team, [**Hospital Unit Name 153**] attending spoke with
patient's family regarding goals of care and splenectomy was not
an option given patient was a poor surgical candidate. Multiple
family meetings were held and ultimately the family decided that
comfort-directed care was the best option for the patient. She
was made comfort-measures only and extubated. She expired on
[**2113-12-10**] at 8:10pm in the presence of her family.
Medications on Admission:
Home Medications:
Arimidex 1mg daily
Diovan 80mg daily
ASA 81mg daily
Prilosec 20mg da day
Carafate 1 gram per day
Calcium
Vit D
Toprol Xl 50mg daily
Medications on Transfer:
Albuterol
Ipratropium
Cefepime 1gram q12
Fluconazole 200mg IV once a day
Heparin 5000 units TID
hydromorphine 0.6mg -1,g q2-4hrs PRN pain
Reglan 5mg IV q 6hrs
lopressor 75mg [**Hospital1 **]
Zofran 5mg IV q 6hrs
Percocet 5mg
protonix 40mg q12hrs
Insulin sliding scale
Diovan 80mg qhs via j-tube
ASA 81mg via J-tube
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest
Sepsis
Gastroesophageal anastamotic leak s/p gastrectomy
Gastric cancer
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"V10.87",
"401.1",
"428.41",
"427.1",
"414.01",
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"038.9",
"424.0",
"276.7",
"428.0",
"427.41",
"285.1",
"998.2",
"V10.3",
"518.81",
"151.9",
"511.9",
"E878.6",
"482.42",
"276.0",
"995.92",
"902.23",
"427.5",
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icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.72",
"38.93",
"42.81",
"96.04",
"96.71",
"96.6",
"00.14",
"88.47",
"38.91",
"99.60",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
14831, 14840
|
8799, 14258
|
383, 420
|
14978, 14987
|
5174, 8776
|
15043, 15053
|
4537, 4635
|
14799, 14808
|
14861, 14957
|
14284, 14284
|
15011, 15020
|
4650, 5155
|
14302, 14435
|
248, 345
|
448, 4172
|
14460, 14776
|
4194, 4362
|
4378, 4521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,641
| 102,091
|
21197
|
Discharge summary
|
report
|
Admission Date: [**2103-6-2**] Discharge Date: [**2103-6-8**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 83-year-old female with a
history of interstitial pulmonary fibrosis on six liters of
oxygen and 10 mg of prednisone at baseline, congestive heart
failure, hypertension, was found by primary care physician on
[**5-29**] to have ambulatory sats of 70 percent. The patient
was admitted to [**Hospital 1562**] Hospital and started on Solu-Medrol
and levofloxacin. The patient underwent CT of chest at
outside hospital which showed ground glass opacities
bilaterally and no PE. The patient was transferred to [**Hospital1 1444**] for lung biopsy and
intubated. Lung biopsy only showed pulmonary congestion
consistent with congestive heart failure and interstitial
pulmonary fibrosis. The patient was eventually extubated on
[**6-5**] and a transesophageal echocardiogram was performed
which showed severe left ventricular global hypokinesis,
ejection fraction 20 percent, 1 plus mitral regurgitation, PA
pressure not estimated because of size of patient. In the
Medical Intensive Care Unit the patient was empirically
treated for PCP with Bactrim and pneumonia with Levaquin and
diuresed with modest improvement in breathing. The patient
states she still gets very short of breath with any movement
such as moving in bed. The patient cannot move to commode
without shortness of breath. The patient also just denies
any chest pain, no cough or fever, no abdominal or urinary
symptoms.
PAST MEDICAL HISTORY: Interstitial pulmonary fibrosis since
[**2097**]. Requires six liters of oxygen at home. Essentially
any movement makes the patient desaturate. Chronically on
steroids. Congestive heart failure. Had clean cardiac
catheterization in [**2086**]. Question of viral etiology of
cardiomyopathy. Hypertension. Hyperlipidemia.
ALLERGIES: Procardia, Voltaren.
PHYSICAL EXAMINATION: Afebrile, 80, 127/51, 22, 94 percent
on six liters face mask. No apparent distress. Alert and
oriented times three. Moist mucus membranes. Oropharynx
clear. Jugular venous pressure difficult to assess because
of neck size. Regular rate without murmur. Distant S1, S2.
Diffuse crackles and bronchial sounds in upper airways. No
wheezes. Soft, obese, positive bowel sounds, non-tender, non-
distended. No clubbing, cyanosis or edema, warm.
She gave sputum, oropharynx on [**6-3**]. Biopsy consistent with
IPF and pulmonary edema.
LABORATORY: White count 11.8, hematocrit 30.9, platelet
count 202,000. Electrolytes unremarkable.
HOSPITAL COURSE: Respiratory failure: The patient's biopsy
was consistent with end-stage interstitial pulmonary fibrosis
that might have been exacerbated by congestive heart failure.
The patient was also empirically treated for PCP and
pneumonia with ten days of Levaquin and Bactrim. The patient
was on 40 mg of prednisone and this should be tapered down to
10 mg q. day which is her home dose. After discussions with
the patient and her family, the Pulmonary team felt that this
was end-stage interstitial pulmonary fibrosis that would have
a progressive course regardless of any treatment modalities.
The patient and family then spoke with the Palliative Care
team at [**Hospital1 69**] and it was felt
that she should go to rehab for one week to try to build up
strength and ability to walk and then to go home with hospice
care. The patient felt that bronchodilators were of no
benefit so these were discontinued upon her discharge.
Morphine sulfate IV was used as needed for shortness of
breath and dyspnea. She will be sent out on oxycodone 5 mg
to 10 mg orally q. 4h. as needed for dyspnea. This may be
increased upward as you see fit to treat her dyspnea.
Cardiovascularly, cardiomyopathy with ejection fraction of 20
percent most likely viral etiology with clean cardiac
catheterization in [**2096**]. She will be restarted on her Bumex
0.5 mg q. day as diuresis. She appeared slightly dry on
discharge. An ACE inhibitor was also initiated here in the
hospital 10 mg q. day.
Code Status: After discussions with the family she will
become DNR. Her code status was changed to DNR/DNI. The
patient has elected that with no further treatment modalities
to enter hospice after rehab.
DISPOSITION: Discharge to rehab and then to hospice care.
DISCHARGE STATUS: Poor. Unable to do any activities of
daily living. Saturations 98 percent with six liters oxygen
but decreases upon minimal movement including her activities
of daily living.
DISCHARGE MEDICATIONS:
1. Oxazepam 15 mg q. hs. as needed for sleep.
2. Zoloft 100 mg q. day.
3. Protonix 40 mg q. day.
4. Prednisone 40 mg q. day that should be tapered over one
week to 10 mg q. day.
5. Lisinopril 10 mg q. day.
6. Oxycodone 5-10 mg q. 4h., save for shortness of breath or
wheezing.
7. Bumex 0.5 mg q. day.
FOLLOW UP: The patient after rehab stay will be discharged
to hospice care.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 14382**]
MEDQUIST36
D: [**2103-6-8**] 13:13:46
T: [**2103-6-8**] 13:51:34
Job#: [**Job Number 56154**]
|
[
"515",
"518.81",
"425.4",
"493.90",
"428.0",
"136.3",
"401.9",
"285.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"99.04",
"88.72",
"33.28",
"97.41",
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4544, 4853
|
2578, 4521
|
4865, 5201
|
1918, 2560
|
116, 1509
|
1532, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,339
| 166,862
|
35365
|
Discharge summary
|
report
|
Admission Date: [**2134-1-16**] Discharge Date: [**2134-1-19**]
Date of Birth: [**2064-3-19**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
69M with history of laryngeal cancer s/p new tracheostomy (done
at [**Hospital3 15402**] 2 weeks ago), COPD; sent from [**Hospital1 1501**] with dyspnea and
hypoxemia. Patient noted to have desat to 60s with
hypoventilation (RR 4-6), of unclear etiology. Briefly required
bagging and then sent to [**Hospital3 15402**]. Temp reportedly 103 at OSH
with WBC 11.5K and bandemia of 9%. Received nebs, levaquin,
vanco, lasix, decadron 10 mg IV, and aspirin at OSH. Bandemia
present at OSH. Transferred to [**Hospital1 18**] for possible need for ENT
if further decompensates (do not have at OSH per notes). ABG at
OSH 7.26/54/250 on 100%.
.
In the [**Hospital1 18**] ED, vitals T97.6, HR 90s-120s, 173/86, R20, 100% on
TC. No pneumonia on CXR, ?vascular fullness. No source for
infection found. Treating like COPD exacerbation. Given
Solumedrol 125. ECG without concerning findings but troponins
slightly elevated. Episode of acute resp distress in ED. Bagged
briefly, then eventually placed on vent but difficulty
tolerating. In CT scanner (obtained due to fever and previous
complaint of abdominal pain), patient also became more anxious
then stridorous and tachypneic. Got benadryl and continuous
nebs.
.
Upon arrival to ICU, patient with significatn difficulty
ventilating via trach on own and with bag and vent. 2 mg ativan
IV given followed by propofol gtt for improved tolerance with
vent. Anaesthesia called for ?difficulties with trach and need
for endotracheal intubation. Patient unable to provide further
history. Per wife, patient has had gradually worsening
respiratory status since trach.
Past Medical History:
-Recurrent laryngeal papillomas s/p removals (as recently as
[**2133-11-26**]).
- Laryngeal cancer (invasive squamous cell)- diagnosed after
found to have fixed L vocal cord. ?in [**12-4**]. Discussion of
future laryngectomy. Not entirely clear if has had chemo/XRT
thus far.
- s/p tracheostomy at [**Hospital3 15402**] ([**2133-12-31**]) - "performed
emergently" earlier this month after presented with shortness of
breath to rad onc office. Reportedly was intubated but was
difficult intubation.
- COPD
- CAD
- Diabetes type II
- Hyperlipidemia
- Gout
- s/p lumbar laminectomy
Social History:
Married. Lives at rehab facility. Wife denies recent EtOH or
smoking, unclear of use in past.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM ON DISCHARGE:
Vitals: T: 98.4 BP: 140/60 P: 78 R: 8 O2: 94% on 35% humidified
air
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear anteriorly, diminished breath sounds difficult to
auscultate over supplemental O2 sounds, scattered wheeze
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended w/ bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
bilateral edema, pneumoboots in place
Pertinent Results:
[**2134-1-16**] 08:00PM BLOOD WBC-9.3 RBC-3.76* Hgb-11.6* Hct-36.0*
MCV-96 MCH-30.8 MCHC-32.2 RDW-14.6 Plt Ct-490*
[**2134-1-18**] 04:12AM BLOOD WBC-13.2*# RBC-3.15* Hgb-9.5* Hct-29.1*
MCV-92 MCH-30.1 MCHC-32.6 RDW-14.5 Plt Ct-454*
[**2134-1-16**] 08:00PM BLOOD PT-16.0* PTT-33.7 INR(PT)-1.4*
[**2134-1-17**] 01:48AM BLOOD PT-16.4* PTT-34.5 INR(PT)-1.5*
[**2134-1-18**] 04:12AM BLOOD PT-15.2* PTT-28.7 INR(PT)-1.3*
[**2134-1-16**] 08:00PM BLOOD Glucose-253* UreaN-16 Creat-1.2 Na-145
K-5.0 Cl-102 HCO3-23 AnGap-25*
[**2134-1-17**] 01:48AM BLOOD Glucose-344* UreaN-19 Creat-1.2 Na-141
K-4.6 Cl-101 HCO3-20* AnGap-25*
[**2134-1-18**] 04:12AM BLOOD Glucose-169* UreaN-24* Creat-1.0 Na-146*
K-3.6 Cl-111* HCO3-26 AnGap-13
[**2134-1-16**] 08:00PM BLOOD cTropnT-0.13*
[**2134-1-17**] 01:48AM BLOOD CK-MB-7 cTropnT-0.11*
[**2134-1-17**] 01:24PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2134-1-17**] 04:55AM BLOOD Type-ART Temp-37.7 Tidal V-350 PEEP-15
FiO2-50 pO2-237* pCO2-27* pH-7.46* calTCO2-20* Base XS--2
Intubat-INTUBATED
[**2134-1-17**] 04:00PM BLOOD Type-ART pO2-164* pCO2-38 pH-7.46*
calTCO2-28 Base XS-3
[**2134-1-18**] 04:13AM BLOOD Type-ART Temp-37.6 Rates-/18 pO2-137*
pCO2-37 pH-7.47* calTCO2-28 Base XS-4 Intubat-NOT INTUBA
Comment-AXILLARY=9
[**2134-1-17**] 02:04AM BLOOD Lactate-2.4* K-3.6
[**2134-1-17**] 04:55AM BLOOD Lactate-2.1*
[**2134-1-17**] 04:00PM BLOOD Lactate-1.4
CT of abdomen:
CT OF THE ABDOMEN WITH INTRAVENOUS AND ORAL CONTRAST:
Please note the exam is limited due to respiratory motion.
Limited evaluation of the lung bases is unremarkable. The liver,
gallbladder
which is moderately distended, spleen, stomach, small bowel,
pancreas, adrenal
glands, and kidneys appear unremarkable. No free air, free
fluid, or
pathologically enlarged lymph nodes are identified. Small type 1
hiatal
hernia.
CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: Air is
noted within a
Foley-containing urinary bladder. Evaluation of the intrapelvic
large bowel
is limited due to respiratory artifact but appears within normal
limits. No
free fluid or pathologically enlarged lymph nodes are present.
Bilateral
(left greater than right) fat-containing inguinal hernias are
noted.
BONE WINDOWS: No malignant-appearing osseous lesions are
identified.
Bilateral healing rib fractures are noted as well as
post-surgical changes
from prior posterior fusion spanning from L2 to L4 where there
is also
laminectomy. Additionally laminectomy is also noted at L5. Wedge
compression
deformity involving L2 with mild grade 1 retrolisthesis of L2 on
L3 is of
indeterminate age. Scattered benign vertebral body hemangiomas
are noted.
IMPRESSION:
No etiology for leukocytosis or abdominal pain identified.
Brief Hospital Course:
# Respiratory failure. Initially described to have seemingly
hypoventilatory failure with low respiratory rate; in ED patient
with increased respiratory effort but distressed. Differential
initially included COPD exacerbation or other cause of acute
bronchospasm (allergic reaction/anaphylaxis from ?CT contrast),
pneumonia (no infiltrate on CXR), mucous plugging, ACS or CHF
exacerbation (elevated BNP with small increase in troponin).
After bronch appeared to be related to airway edema and
obstruction of trach tube. IP replaced trach [**2134-1-17**] and patient
was able to be weaned off the ventilator onto trach mask. With
the fever there was concern also of pna playing a role in his
respiratory distress. A follow up CXR showed a worsened RML
infiltrate and he was started on levofloxacin. Then on [**2134-1-18**]
his sputum grew GPCs in clusters and he was started on
vancomycin. He was continued on the steroid taper for
inflammation per interventional pulmonology recs as well as prn
bronchodilators and benadryl to decrease airway edema and treat
a possible COPD exacerbation. His primary MD at [**Hospital 13128**]
was contact[**Name (NI) **] and requested transfer to their facility for
further care and once stabilized the patient was transferred
there.
# Leukocytosis and fever. T 103 with leukocytosis and bandemia
at OSH. On arrival here had neutrophil predominence without
bands and after receiving steroids had a leukocytosis. Blood,
urine, and sputum cultures (endotracheal) were obtained and the
sputum grew GPCs as above.He had a CT abd without evidence of
source. He was started on levofloxacin and then switched to
vancomycin when the sputum sample came back. His first dose of
vancomycin was on [**2134-1-18**]. First dose of levofloxacin on [**2134-1-17**]
# Laryngeal cancer. s/p trach with difficulting passing
bronchoscopy through cords.
Received steroids/benadryl as above.
# Elevated troponin. No chest pain or concerning ECG findings,
?demand in setting of hypoxia/acute respiratory failure. A
repeated EKG was normal. Troponins trended down likely in the
setting of less demand with better ventilation.
# Hypernatremia: Repleted with IVF as patient unable to take POs
# Diabetes type II: Insulin sliding scale with QID FSG
# FEN: IVFs for now, replacing free water. Surgery was
consulted for GT placement but were unable to place the doboff
tube.
# Anemia: Patient had Hct drop from 36->29 over 24 hours and
then remained stable at 29 over the next 24 hours. Was given PPI
QD, 2 PIVs placed, T&C sent. Likely diluational with IVF being
given for hypernatremia. Will be monitored daily on discharge at
OSH.
Medications on Admission:
MEDICATIONS AT HOME:
albuterol neb QID and Q1H prn shortness of breath
ipratroprium neb QID
lorazepam 1 mg PO Q6H prn anxiety
oxycodone 5mg Q4prn pain
prednisone 2.5 mg daily (recently tapered from 5 mg daily)
lasix 40 mg IV daily x 5 days (started [**1-15**])
tylenol prn
morphine 2mg IV on [**2134-1-16**] at 815am
zolpidem 5 mg prn insomnia
allopurinol 100 mg PO daily (on hold)
flovent 220 [**Hospital1 **]
fragmin [**Numeric Identifier 3301**] units daily
lopressor 37.5 mg Q8H (on hold [**12-28**] no PO access)
omeprazole 20 mg daily (on hold)
Kcl 40 mEq [**Hospital1 **]
theophylline 300 mg TID (on hold since [**1-13**])
xalatan gtts 1 drop to right eye HS
nepralin solution swish and spit TID
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
4. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
5. Insulin Regular Human 100 unit/mL Solution Sig: AS DIR
Injection ASDIR (AS DIRECTED): Per sliding scale.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
7. Pantoprazole 40 mg IV Q24H
8. MethylPREDNISolone Sodium Succ 20 mg IV Q24H Duration: 1 Days
Start: [**2134-1-19**]
9. Vancomycin 1000 mg IV Q 12H
10. IV fluids
Please continued D5W at 100mL/hour on discharge.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Obstruction of tracheostomy tube
COPD exacerbation
Health-care associated pneumonia
Discharge Condition:
The patient was afebrile X 24 hours, hemodynamically stable, and
satting 94% on humidified air.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. The
tube in your wind pipe was obstructed. This was replaced. You
also had a pneumonia. This was treated with antibiotics
(vancomycin). You also had a flare of your chronic lung disease.
This was treated with steroids.
Followup Instructions:
Completed by:[**2134-1-19**]
|
[
"519.02",
"790.5",
"414.01",
"E878.1",
"272.4",
"491.21",
"276.0",
"250.00",
"518.81",
"V58.65",
"274.9",
"285.9",
"482.42",
"161.9",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"97.23",
"33.21",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10296, 10311
|
6063, 8718
|
304, 318
|
10439, 10537
|
3339, 6040
|
10868, 10896
|
2679, 2697
|
9472, 10273
|
10332, 10418
|
8744, 8744
|
10561, 10842
|
8765, 9449
|
2712, 2712
|
2741, 3320
|
257, 266
|
346, 1947
|
1969, 2550
|
2567, 2662
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,088
| 191,740
|
7692
|
Discharge summary
|
report
|
Admission Date: [**2171-10-23**] Discharge Date: [**2171-10-30**]
Date of Birth: [**2124-9-27**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 47-year-old white male has
a history of type 1 diabetes, chronic renal insufficiency,
hypertension, depression and MRSA infection of his foot in
the past and presented to the Emergency Room with chest pain
and shortness of breath for the past four days. He was found
to have ST elevation MI in the inferior leads and underwent
cardiac catheterization. A balloon pump was placed and he
was transferred to the CCU.
PAST MEDICAL HISTORY: History of type 1 diabetes with
peripheral neuropathy.
History of chronic renal insufficiency.
History of depression.
History of MRSA lower extremity infection and osteomyelitis
status post foot surgeries bilaterally and debridement for
MRSA.
History of hyperlipidemia.
History of hypertension.
MEDICATIONS ON ADMISSION:
1. Humulin N 35-40 units qam, 10 units qpm.
2. Augmentin.
3. Humulin R 5 units at lunch, 10 units at dinner.
4. Prinivil.
5. Viagra.
6. Celexa.
7. Zyvox.
ALLERGIES: He has no known allergies.
SOCIAL HISTORY: He quit smoking 20 years ago and has a 10
pack history. He does not drink alcohol.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: He is a well developed, well nourished
white male in no apparent distress. Vital signs stable,
afebrile. HEENT exam: Normocephalic, atraumatic,
extraocular movements intact. Oropharynx benign. Neck was
supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids 2 plus and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular exam: Regular rate and rhythm, normal S1, S2
with no rubs, murmurs or gallops. Abdomen was soft,
nontender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities were without clubbing,
cyanosis or edema. Neuro exam was nonfocal.
He was admitted and underwent cardiac cath which revealed 90
percent LAD lesion, 90 percent left circumflex lesion with a
small nondiseased RCA. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] was consulted and
on [**10-24**] the patient underwent a CABG x3 with LIMA to the
LAD, a reverse saphenous vein graft to the OM and right PDA.
Cross clamp time was 61 min. Total bypass time was 73 min.
He was transferred to the CSIU on Neo-Synephrine and propofol
in stable condition. He had a stable postop night and was
extubated.
Postop day one, he had his intraaortic balloon pump
discontinued.
Postop day two he had his chest tubes discontinued and he was
seen by Renal for a creatinine that went up to 2.7. He did
continue to urinate and was followed.
On postop day three he had two units of packed cells for a
hematocrit of 23. He continued to diurese with IV Lasix.
On postop day four his creatinine came down to 1.9. He was
transferred to the floor in stable condition. His epicardial
pacing wires were discontinued. He continued to have a
stable postop course.
On postop day number six, he was discharged to home in stable
condition.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg po bid for ten days.
2. Colace 100 mg po bid.
3. Zantac 150 mg po qday.
4. Aspirin 325 mg po daily.
5. Lopressor 50 mg po bid.
6. Percocet one to two po q4-6h prn pain.
7. Plavix 75 mg po daily.
8. Celexa 40 mg po daily.
9. Flomax 0.4 mg po daily.
10. Glargine 44 units at bedtime subcutaneously.
11. Novolog sliding scale.
LABS ON DISCHARGE: Hematocrit 29.5, white count 8700,
platelets 313, sodium 132, potassium 5.2, chloride 99, C02
27, BUN 45, creatinine 1.7, blood sugar 212.
DISCHARGE DIAGNOSES: Insulin dependent diabetes.
Hypertension.
Chronic renal insufficiency.
Depression.
Methicillin resistant Staph aureus osteomyelitis.
He will be followed by Dr. [**First Name (STitle) **] in one to two weeks, Dr.
[**Last Name (STitle) 27963**] of [**Hospital **] Clinic on [**11-6**] at 1:30 pm in three to four
weeks by Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2171-10-30**] 16:49:01
T: [**2171-10-31**] 01:17:46
Job#: [**Job Number 27964**]
|
[
"401.9",
"410.71",
"584.9",
"784.7",
"414.01",
"593.9",
"250.61",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"37.61",
"36.15",
"88.56",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1253, 1268
|
3738, 4369
|
3205, 3556
|
938, 1134
|
1326, 3179
|
1288, 1303
|
3576, 3716
|
167, 588
|
611, 912
|
1151, 1236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,145
| 193,705
|
9354
|
Discharge summary
|
report
|
Admission Date: [**2125-1-23**] Discharge Date: [**2125-2-16**]
Date of Birth: [**2069-5-14**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 55 yoF with h/o cirrhosis secondary to EtOH abuse who
was recently hospitalized in the [**Hospital1 18**] ICU for GI bleed treated
with EGD banding of esophageal varicies, also dx'd with c. diff
colitis at that hospitalization and treated with Flagyl. Since
discharge diarrhea has continued, amounting to about 1 Liter per
day over past few days. Pt has had frequent discussions with
Dr. [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 7307**], who states she seemed to be compliant with
the Flagyl. However, per [**Name (NI) **], pt was recently seen as outpt and
provider who saw her was concerned regarding Ms. [**Known lastname 31956**]'
awareness as to which bottles of medicine she should be taking
since discharge.
.
Per pt diarrhea has been continuous since discharge, no blood or
melena, no nausea or vomitting, no sick contacts. She denies
fever, chills. Pt does have a mild abdominal cramping as a band
across lower abdomen - no RUQ pain. She denies increased abd
girth.
.
Past Medical History:
Past Medical History:
1. cirrhosis secondary to etoh - Child's B
2. UGI bleed -- last EGD [**5-21**] w/ grade I esophageal varices, ?
gastric varix, portal gastropathy
3. asthma
4. PTSD secondary to abuse and battery
5. etoh abuse, h/o multiple detoxes
6. depression
7. c. diff colitis x 3 episodes, most recently diagnosed in
[**2125-1-12**]
8. diminished hearing
9. h/o head injuries
10. h/o ascites
11. h/o SBP
Social History:
Denies tobacco use, drug use.
States last drink in [**2124-11-16**].
Family History:
No liver disease, h/o breast cancer, no IBD, no heart
disease or diabetes.
Physical Exam:
Tc 97.8 HR 115 BP 90/palp RR 24 Sat 97 % on NRB
Gen: thin appearing female, tachypneic, jaundiced and icteric
HENNT: dry MMM
Neck: no LAD, no JVD
CV: RRR, nl S1S2, No M/R/G
Lungs: decreased BS at bases
Abd: soft, NT/ND, +BS, no rebound/guarding, ascitic with minimal
fluid wave.
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: A&Ox3
Pertinent Results:
US RUQ: [**2125-1-23**]:
FINDINGS: The gallbladder is decompressed. There is an ovoid
focus of sludge within the lumen. The liver is coarse in
echotexture. No focal lesions are identified. Again demonstrated
is reversal of portal venous flow. Ascites is again identified.
.
IMPRESSION:
1. Sludge within the gallbladder. No evidence of cholecystitis.
2. Redemonstration of reversal of portal venous flow.
3. Coarse echogenic liver consistent with cirrhosis.
4. Moderate amount of ascites.
.
[**2125-1-24**]: Abdomen - supine and erect:
FINDINGS: Note is made of diffuse increase in radiodensity of
the abdomen, suggestive of ascites noted on the prior
ultrasound. Bowel gas pattern is unremarkable, without evidence
of significant obstruction. Note is made of normal haustral
pattern in the ascending colon. No evidence of free air is seen.
.
IMPRESSION: Ascites. No evidence of obstruction or dilatation of
the bowel gas.
.
[**2125-1-25**] Liver/GB u/s-Appearances are consistent with hepatopetal
flow secondary to portal hypertension in a cirrhotic liver.
.
[**2125-1-25**]: LENI: No evidence of DVT
.
[**2125-1-30**]: ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis with near akinesis of the septum
and inferior wall. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-18**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion
.
[**2125-1-31**]: US Abdomen
COMPARISON: Reference is made to examination from [**2125-1-25**].
.
REPORT:
Again the liver parenchyma is somewhat coarsened consistent with
cirrhosis. The gallbladder is relaxed, but there is gallbladder
wall thickening and sludge within the gallbladder, both likely
reflecting background chronic liver disease. The patient has
moderate ascites. No intra- or extra-hepatic biliary dilatation.
The portal vein is patent, but again demonstrates hepatopetal
flow. This is identified in the anterior branch of the right
portal vein and the left portal vein also. The hepatic veins are
patent and normal waveforms are returned from right middle and
left hepatic veins. The hepatic arteries are similarly patent.
Kidneys are normal size, shape, and echogenicity. Symmetrical
flow is identified to both kidneys. No evidence of renal vein
thrombus identified on either side.
.
CONCLUSION: Cirrhosis with portal hypertension as described. No
evidence of renal or hepatic vein thrombus
.
[**2125-2-6**]: CXR:
IMPRESSION:
1. ETT tip too close to the carina. This finding was discussed
with Dr. [**Last Name (STitle) **] at 11:00 a.m.
2. Improved but still suboptimal position of the tip of the left
PICC line.
3. Worsening right lower lobe pneumonia.
4. Increasing pulmonary edema.
.
[**2125-1-23**]: Stool Cultures:
FECAL CULTURE (Final [**2125-1-26**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2125-1-25**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2125-1-24**]):
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2125-1-26**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2125-1-26**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2125-1-26**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2125-1-24**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
Sputum Culture:
GRAM STAIN (Final [**2125-1-31**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2125-2-3**]):
OROPHARYNGEAL FLORA ABSENT.
SERRATIA LIQUEFACIENS. SPARSE GROWTH.
Brief Hospital Course:
On admission to [**Hospital1 18**], patient continued to have copious
diarrhea of approximately 1L per day. An extensive workup
looking for potential causes of her diarrhea inlcuding:
- stool cultures : these were negative
- paracentesis: negative for SBP, malignancy
- TTG: negative
- C Diff cultures - were negative
- GI service was consulted and followed patient while on floor.
- abdominal imaging including ultrasound and plain films did not
identify any potential causes.
.
Despite an extensive workup, no clear cause of her diarrhea was
identified. She was supported with IVF and electrolyte repletion
while on the floor.
.
On the night of [**1-29**], patient lost all access (had an EJ only),
and was unable to take IVF as per usual. In the AM, she was
found to be relatively [**Name2 (NI) 24420**] (sbp in the 70's and tachy to
the 115 range) and to have increased o2 requirement (was on 2
lpm, but was 91% on 4 L now on NRB). She was transferred to the
MICU for central access in the setting of coagulopathy (INR
1.5), the need for closer monitoring of volume status and fluid
repletion, as well as a diagnostic and therapeutic paracentesis.
After approximately 1.5L of fluid resuscitation, patient's blood
pressure returned to SBPs in the 90s.
.
Later in the evening of [**1-30**], she was found to be in respiratory
distress and felt to be in acute pulmonary edema. Hence, she was
intubated on [**1-30**]. This repiratory compromise was felt to also
be [**1-18**] increasing abdominal ascites. She did not respond to
lasix. However, on [**1-31**] paracentesis removed 2.6L ascites fluid
-> her bladder pressure improved from 32 to 17 and her ABGs
showed improving ventilation.
.
During her intubation on the evening of [**1-30**], patient became
[**Date Range 24420**] with SBPs in the low 70s. Hence, she was started on
levophed. It was speculated that propofol used for sedation may
have contributed to her drop in BP. Cultures were sent, but were
negative. She was weaned off of the levophed on [**2125-2-1**].
.
Over the course of the first few days of her MICU admission,
patient's Cr began to rise from - 1.2->1.8->2.2->2.9->3.1 and
at the same time, her urine output started to decline. The
creatinine rose despite giving about 10L of IVF from [**Date range (1) 31957**]
and her urine output continued to decline to near anuria. It was
felt that this ARF was likely ATN from her transient hypotensive
episodes vs. Hepatorenal syndrome. Urine studies could not be
helpful in this setting because lasix was used in an attempt to
diurese her and FeUrea is not useful in the setting of HRS. She
was started on Octreotide and Midodrine [**1-31**] and [**2-1**]
respectively in setting of possible HRS. Given that she was not
a liver transplant candidate, dialysis was not an appropriate
option per renal.
.
.
# Elevated bilirubin: In regards to this, there was no evidence
of CBD dilation by ultrasound. However, in cirrhosis, the CBD
may not demonstrate dilation in obstruction. This elevation was
likely in the setting of worsening hepatitis from volume
depletion. Discussed option of ERCP with GI service; however
they saw no imminent need for an ERCP of MRCP.
- in addition, the potential of cholangitis was discussed, and
it was decided that in the event of worsening clinical status,
that there would be a need to cover for cholangitis.
.
# ESLD/ETOH Cirrhosis: Initially Held nadolol [**1-18**] relative
hypotension,however restarted nadolol [**2-1**] in setting of
increasing SBP and discontinuation of pressors.
-started on Rifaximin per Liver service for 3 week course
-started on Octreotide/Midodrine
-Lactulose
.
#. Leukocytosis: UA neg, cxr with infiltrates. Continue to send
stool for C Diff. oral vancomycin switched to IV for broader
coverage in setting of increasing WBC, temp, ?sepsis, and no
clear source identified. Her Sputum from [**2-2**] did grow out GNR
which grew out to be pansensitive serratia liquifasciens.
- she was continued on rifamixin, and Ceftriaxone was added [**1-31**]
- Tap negative for SBP - continued Ceftriaxone for SBP
prophylaxis
.
# Depression. Continued Paxil
.
# Code status:
Patient was a full code on admission to the MICU. However, [**First Name4 (NamePattern1) 16901**]
[**Last Name (NamePattern1) **], who stated that she was the patient's HCP (and confirmed
by her mother) wanted the patient to be DNR and DNI once she
could be extubated.
.
However, there was a difficulty with her proxy (long time
friend) [**Name (NI) 16901**] [**Name (NI) **] producing a Power of attorney. She and her
lawyer did not have a copy of this document. Despite the fact
that the patient's mother was alive and in good senses, she
could not be the HCP, as per [**Hospital1 18**] legal, because there was
precedent that the patient chose another person to be HCP
despite her mother being alive and in good senses. Her former
guardian [**Name (NI) 3608**] [**Name (NI) 4334**] was also contact[**Name (NI) **] regarding the
situation. After much investigation, it was determined that
[**First Name4 (NamePattern1) 3608**] [**Last Name (NamePattern1) 4334**] was still legally the patient's HCP. As it turns
out, Ms [**Name13 (STitle) 4334**] was legally Ms [**Known lastname 31958**] HCP when she was her
guardian; however, this edict was never legally reversed upon Ms
[**Name13 (STitle) 4334**] no longer being her guardian. We obtained documentation of
this fact. And after collaborating with [**First Name4 (NamePattern1) 16901**] [**Last Name (NamePattern1) **], patient's
mother and [**Name (NI) 3608**] [**Name (NI) 4334**], patient was made CMO upon her
extubation. She was placed on a morphine drip and other
medicines geared towards comfort. She remained comfortable on
these medications.
Medications on Admission:
1. Protonix 40 mg PO daily
2. Metronidazole 500 mg PO TID
3. Nadolol 10 mg PO daily
4. Carbamazepine 100 mg PO q12h
5. Multivitamin
6. Thiamine HCl 100 mg PO DAILY
7. Folic Acid 1 mg PO DAILY
8. Paroxetine HCl 20 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Furosemide 20mg PO daily
11. Spironolactone 25mg PO daily.
11. Ferrous Gluconate 300 PO daily
12. Florastor 250 mg PO BID
Discharge Medications:
1. Morphine 50 mg/mL Solution Sig: 1-75 mg/hr Injection
INFUSION (continuous infusion).
2. Morphine Sulfate 10 mg IV Q15MINS:PRN
3. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours).
4. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for agitation.
5. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
End Stage Renal Disease
Alcoholic Cirrhosis
End Stage Liver disease
Congestive Heart Failure
Discharge Condition:
Poor - Comfort Measures only
Discharge Instructions:
Please continue all medications for comfort.
Followup Instructions:
Please call the primary care physician (Dr. [**First Name (STitle) **]
[**Telephone/Fax (1) 4775**]if there are further questions.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"584.9",
"428.0",
"572.3",
"008.45",
"456.21",
"572.4",
"288.8",
"486",
"585.6",
"303.91",
"403.91",
"276.2",
"790.92",
"424.0",
"311",
"276.1",
"576.8",
"783.7",
"796.3",
"537.9",
"309.81",
"571.2",
"518.81",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.72",
"54.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13500, 13573
|
6887, 12642
|
281, 288
|
13710, 13741
|
2326, 6864
|
13834, 14062
|
1875, 1951
|
13079, 13477
|
13594, 13689
|
12668, 13056
|
13765, 13811
|
1966, 2307
|
233, 243
|
316, 1334
|
1378, 1772
|
1788, 1859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,957
| 196,602
|
2849
|
Discharge summary
|
report
|
Admission Date: [**2128-6-6**] Discharge Date: [**2128-6-10**]
Date of Birth: [**2042-11-13**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
aphasia -> code stroke
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
HPI: Ms. [**Known lastname **] is an 85yo woman with a PMHx significant for
afib on coumadin, DM2, HTN, dilated cardiomyopathy and recently
diagnosed PNA and E Coli UTI (on abx) who presented to [**Hospital1 18**]
with "aphasia" concerning for stroke. She had been in her USOH
(lives at the [**Hospital3 2558**]) until one hour prior to
presentation when she was last seen well. She was then found to
unresponsive there. Further details are not known. She was
then transferred
to [**Hospital1 18**] for further evaluation. Of note, she had been
diagnosed with PNA (unknown location in lung) as well as an E
Coli UTI and was treated with levaquin for the PNA and augmentin
for the UTI. In addition, her coumadin was held on [**6-5**] [**2-5**] an
INR of 5.09 on [**6-4**] (she was also given vitamin K to reverse her
INR). In the ambulance, initial VS were: BP: 80/50 RR: 16 T: 97
93% RA FS: 331.
Upon arrival to the ED a Code STROKE was called. However, she
had left gaze deviation with myoclonic jerking of her LLE which
progressed to pursing movements of her lips. Concerned about
seizure, she was loaded with 2mg of IM LZP twice (five minute
interval) with no resolution of sx. 20mg/kg of PHT was
ordered and she ceased to clinically seize afterwards, though
had persistently decreased responsiveness and left gaze
deviation. NCHCT showed global atrophy, but no acute process.
Past Medical History:
- Paroxysmal atrial fibrillation on Coumadin
- Hypertension/moderate left ventricular hypertrophy
- Hyperlipidemia, previously on atorvastatin
- Nonischemic cardiomyopathy, EF 35%, s/p biventricular/ICD
pacer.
- Type 2 diabetes c/b retinopathy, neuropathy, nephropathy
- Chronic kidney disease: baseline Cr 1.9 in [**6-13**]
- Rheumatic fever as a child
- s/p hysterectomy
- Stable 10x15x17cm cystic structure in left pelvis
Seen two weeks ago for diarrhea and subsequently discharged
Social History:
Had previously been living in [**Hospital3 **] at Foley House but
was moved to [**Hospital3 2558**] for rehab 2 weeks PTA given general
medical deterioration . Son recently died in [**Month (only) 958**] and she has
been gradually declining per her daughter since then.
Daughter is health care proxy. Also has four grandchildren,
three great grandchildren
Tobacco: 15-pack-year smoker, quit in [**2087**].
ETOH: Former heavy alcohol use, quit in [**2109**]
Family History:
unknown/non-contributory
Physical Exam:
Physical Examination on Admission:
VS: (exact VS unavailable) afebrile, 110s/70s, HR: 100s-110s,
100% RA
Genl: Unresponsive, non-verbal.
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: irregularly irregular rate and rhythm, otherwise Nl S1, S2,
no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen
Ext: +ace bandages over b/l LE.
Skin: petechiae covering torso
Neurologic examination:
Mental status: Non-verbal, though stated name once during
examination. Left gaze preference. Rarely followed commands
initially, now does not follow commands.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. No blink to threat. Face appears symmetric,
+cough and gag. +corneals b/l.
Motor: Normal bulk but increased tone bilaterally. occasional
myoclonus noted on left UE and LE.
Sensation: withdraws to pain in all four extremities.
Reflexes: 1+ and symmetric throughout. Toes mute bilaterally.
Coordination: unable to assess.
Gait: deferred
********************
Physical Examination on Discharge:
???????
Pertinent Results:
[**2128-6-6**] 04:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-137
[**2128-6-6**] 04:45PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-2*
POLYS-85 LYMPHS-7 MONOS-6 EOS-1 NUC RBCS-1
[**2128-6-6**] 03:00PM GLUCOSE-141* UREA N-67* CREAT-2.6* SODIUM-140
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2128-6-6**] 03:00PM CALCIUM-7.7* PHOSPHATE-6.4* MAGNESIUM-2.0
[**2128-6-6**] 03:00PM WBC-9.7 RBC-3.99* HGB-10.3* HCT-31.9* MCV-80*
MCH-25.7* MCHC-32.2 RDW-17.5*
[**2128-6-6**] 03:00PM PLT COUNT-120*
[**2128-6-6**] 03:00PM PT-16.9* PTT-34.8 INR(PT)-1.6*
[**2128-6-6**] 11:11AM PT-17.1* PTT-53.7* INR(PT)-1.6*
[**2128-6-6**] 09:22AM PHENYTOIN-13.9
[**2128-6-6**] 03:33AM GLUCOSE-284* UREA N-66* CREAT-2.6* SODIUM-139
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20
[**2128-6-6**] 03:33AM ALBUMIN-3.0* CALCIUM-7.9* PHOSPHATE-6.7*
MAGNESIUM-1.7
[**2128-6-6**] 03:33AM WBC-10.4 RBC-4.11* HGB-10.6* HCT-33.5* MCV-82
MCH-25.9* MCHC-31.7 RDW-17.1*
[**2128-6-6**] 03:33AM NEUTS-94.1* LYMPHS-3.7* MONOS-2.1 EOS-0.1
BASOS-0
[**2128-6-6**] 03:33AM PLT COUNT-158
[**2128-6-6**] 03:33AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2128-6-6**] 03:33AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2128-6-6**] 03:33AM URINE RBC-36* WBC-46* BACTERIA-FEW YEAST-NONE
EPI-1
[**2128-6-6**] 03:33AM URINE HYALINE-4*
[**2128-6-6**] 03:33AM URINE MUCOUS-RARE
[**2128-6-5**] 11:40PM URINE HOURS-RANDOM
[**2128-6-5**] 11:40PM URINE HOURS-RANDOM
[**2128-6-5**] 11:40PM URINE GR HOLD-HOLD
[**2128-6-5**] 11:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2128-6-5**] 11:40PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2128-6-5**] 11:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG
[**2128-6-5**] 11:40PM URINE RBC-4* WBC->182* BACTERIA-MOD YEAST-NONE
EPI-0
[**2128-6-5**] 11:40PM URINE HYALINE-10*
[**2128-6-5**] 11:40PM URINE AMORPH-RARE
[**2128-6-5**] 11:40PM URINE WBCCLUMP-MANY MUCOUS-RARE
[**2128-6-5**] 09:57PM LACTATE-3.5*
[**2128-6-5**] 09:52PM TYPE-[**Last Name (un) **] PO2-31* PCO2-43 PH-7.26* TOTAL
CO2-20* BASE XS--8
[**2128-6-5**] 09:40PM GLUCOSE-288* UREA N-69* CREAT-2.6* SODIUM-139
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
[**2128-6-5**] 09:40PM estGFR-Using this
[**2128-6-5**] 09:40PM CALCIUM-8.3* PHOSPHATE-6.9*# MAGNESIUM-1.8
[**2128-6-5**] 09:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-6-5**] 09:40PM NEUTS-94.0* LYMPHS-4.2* MONOS-1.6* EOS-0.1
BASOS-0
[**2128-6-5**] 09:40PM NEUTS-94.0* LYMPHS-4.2* MONOS-1.6* EOS-0.1
BASOS-0
[**2128-6-5**] 09:40PM PLT COUNT-144*
[**2128-6-5**] 09:40PM PT-16.8* PTT-29.8 INR(PT)-1.6*
CT head [**2128-6-5**]:
IMPRESSION:
1. No acute intracranial process. If there remains a high
clinical concern for acute ischemia, MRI could be considered for
more sensitive examination.
2. Moderate prominence of the ventricles, out of proportion to
sulci,
denoting central atrophy, correlate with any clinical history
for NPH.
3. Opacification of the left sphenoid sinus.
4. Soft tissue lesions within the subcutaneous fat posterior to
the upper
cervical neck, also seen on the [**2125**] study.
EEG [**2128-6-5**]:
IMPRESSION: This is an abnormal portable EEG because of severe
diffuse
background slowing and attenuation of faster frequencies. Much
of the
EEG is obscured by diffuse EMG artifact. These findings are
indicative
of severe diffuse cerebral dysfunction which is etiologically
non-
specific. No electrographic seizures are present.
CXR [**2128-6-5**]:
IMPRESSION: More dense opacity at the left lung base,
silhouetting the
hemidiaphragm likely in part due to pleural effusion with
underlying
consolidation not excluded. Pulmonary vascular congestion as on
prior and
cardiomegaly.
CXR [**2128-6-7**]:
Mild-to-moderate pulmonary edema which developed between [**6-5**]
and [**6-6**] has improved, though severe cardiomegaly has not.
Moderate left pleural effusion is unchanged. There is no
pneumothorax. Transvenous atriobiventricular pacer
defibrillator leads are unchanged in their respective positions
since [**2127-5-21**].
Brief Hospital Course:
85-year-old woman with atrial fibrillation on chronic
anticoagulation, diabetes, hypertension, and dilated
cardiomyopathy, recent pneumonia and UTI treated with Levaquin,
who initially presented with aphasia concerning for stroke. Upon
arrival to the ED a code stroke was called, however upon exam
she was noted to have left gaze deviation with myoclonic jerking
of her LLE which progressed to pursing movements of her lips.
Due to concern for seizure, she was loaded with 2mg of IM LZP
twice (five minute interval) with no resolution of sx. She was
then loaded with 20mg/kg of PHT and she ceased to clinically
seize afterwards, though she had
persistently decreased responsiveness and left gaze deviation.
NCHCT showed global atrophy, but no acute process. EEG
posttreatment showed no evidence of recurrent seizure activity.
She was admitted to the ICU for close monitoring.
ICU course:
# Neuro:
She was continued on LTM EEG monitoring. She was initially
maintained on phenytoin 100mg TID which was subsequently changed
to keppra 250mg [**Hospital1 **]. She had no further evidence of clinical
seizure activity although remained very lethargic, oriented x 1
only and not consistently following commands. LP was performed
to rule out meningitis or encephalitis; preliminary results
showed protein 47, glucose 127, WBC 4, RBC 2. Gram stain
negative, cx preliminarily negative. She was continued on
empiric coverage with Vanc, Ceftriaxone, Ampicillin, and
Acyclovir until cx and HSV PCR came back negative. Stroke was
also considered as a potential etiology for her seizures,
particularly in the setting of a fib with a subtherapeutic INR.
Initial NCHCT showed no evidence of focal abnormality. She was
maintained on a heparin drip for bridging. INR was initially 1.6
but rose to 4.3 and heparin gtt was stopped. Coumadin was held.
.
Code status transition to comfort measures:
Her family indicated that she should be DNR/DNI upon her
admission. Her daughter expressed a desire to pursue palliative
care given her overall deterioration and poor mental status.
Palliative care was consulted. Per discussion with her daughter
and PCP it was decided that the patient would want to be made
comfort measures only. The patient was transferred to the floor
and then discharged back to her home skilled nursing facility.
.
CV: She was maintained on telemetry monitoring. She was
continued on her home medications enalapril, furosemide, and
simvastatin. She had several brief episodes of VT overnight
[**Date range (1) 7218**]. Pacemaker was interrogated on [**6-8**] and showed a fib with
intermittent RVR resulting in short runs of VT. PM was
functioning appropriately.
.
Pulm: Respiratory status remained stable on RA. CXR showed a LLL
opacity concerning for possible aspiration pneumonia.
.
ID: She remained afebrile with no leukocytosis. UA was positive
for GNR which is being treated with ceftriaxone. CXR showed a
LLL opacity, atelectasis vs. infiltrate.
Medications on Admission:
torsemide 5 mg Tab 1 Tablet(s) by mouth once a day
Humulin N 100 unit/mL Susp, Sub-Q Inj 20 units s/c twice a day
cyanocobalamin (vitamin B-12) 1,000 mcg/mL Injection 1000 mcg/ml
s/c q month
cholecalciferol (vitamin D3) 1,000 unit Cap 1 Capsule(s) by
mouth
once a day
acetaminophen 500 mg Tab 2 Tablet(s) by mouth three times a day
as needed for pain
calcitriol 0.25 mcg Cap 1 Capsule(s) by mouth every other day
enalapril maleate 2.5 mg Tab 1 (One) Tablet(s) by mouth once a
day
Alendronate 70 mg Tab 1 (One) Tablet(s) by mouth weekly
simvastatin 10 mg Tab 1 Tablet(s) by mouth at bedtime
meclizine 12.5 mg Tab 1 Tablet(s) by mouth once a day
sertraline 50 mg Tab 1 [**1-5**] Tablet(s) by mouth once a day
ferrous sulfate 325 mg (65 mg iron) Tab 1 Tablet(s) by mouth
twice a day
metoprolol succinate ER 25 mg 24 hr Tab 1 Tablet(s) by mouth
once
a day
Discharge Medications:
1. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for seizures.
Disp:*4 Tablet(s)* Refills:*0*
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2-10 mg PO Q2H (every 2 hours) as needed for resp distress,
pain for 3 weeks: 2-10 mg every 2 hours as needed for resp
distress or pain. .
Disp:*21 dose* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Status epilepticus
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Bedbound.
Level of Consciousness: Lethargic and minimally arousable.
Discharge Instructions:
Ms. [**Known lastname **] was admitted in status epilepticus without a clear
etiology. An aggressive work-up was discussed with the family
and ultimately declined in favor of making the patient comfort
measures only. The patient is being discharged back to her
skilled nursing facility for hospice care.
Followup Instructions:
None
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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|
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|
328, 345
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,141
| 100,403
|
52259
|
Discharge summary
|
report
|
Admission Date: [**2113-8-19**] Discharge Date: [**2113-8-30**]
Service: NEUROSURGICAL
HISTORY OF PRESENT ILLNESS: This is a 76-year-old man
brought into [**Hospital3 **] Emergency Department after an
unwitnessed syncopal episode. The patient recalled going for
a walk in the afternoon and then no memory of events until he
was brought to the Emergency Room on [**2113-8-19**]. He was
reportedly found down by bystanders on the sidewalk
"confused". EMS was called and they found the patient alert
with stable vital signs, unremarkable exam and no complaints.
In the Emergency Department, exam was remarkable only for
systolic murmur which was old. Electrocardiograms were
unchanged from prior. A head CT with and without contrast,
however, revealed a large left frontal parietal mass presumed
to be metastases given his history of small cell lung cancer.
He was given then Dilantin 300 mg p.o. and Solu-Medrol 85 mg
intravenous. He initially presented with the right lower
lobe lung nodule in [**2112-7-26**] and a cough with weight
loss. In addition, he had postobstructive pneumonia. A
bronchoscopic biopsy revealed small cell lung cancer. Bone
scan and head CT in [**2112-8-26**] were negative. He was
billed as a limited stage and underwent four cycles of
carboplatin and etoposide between [**2112-9-25**] and [**2112-12-26**], resulting in resolution by radiologic studies at least
of his mass. Subsequent surveillance chest x-rays every
three months have all been negative. The last one was on
[**8-9**].
PAST MEDICAL HISTORY:
1. Type 2 diabetes x30 years
2. Hypertension x10 years
3. Status post stroke 10 years ago with loss of his left
peripheral vision
4. Left upper extremity weakness
5. Dysphagia
6. Benign prostatic hypertrophy
7. Hypercholesterolemia
8. Peripheral vascular disease
9. Hypertension
10. Penile prosthesis
11. Small cell lung cancer as described above
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS FROM OLD DISCHARGE SUMMARY:
1. Lasix 20 mg b.i.d.
2. Toprol XL 50 q.d.
3. Aspirin 325 q.i.d.
4. Ramipril 5 mg b.i.d.
5. Pravachol 20 q.d.
6. Flomax 0.4
7. Insulin 70/30 10 units in the a.m., 12 units q p.m., now
15 units q p.m. as per patient
REVIEW OF SYSTEMS: No chest pain, no palpitations, no bowel
or bladder incontinence, no nausea, vomiting or shortness of
breath. No acute bloody stools.
s
SOCIAL HISTORY: Married. He is a retired accountant. He
smokes three packs a day for 35 years and he does drink.
FAMILY HISTORY: Significant for diabetes.
EXAM ON ADMISSION:
VITAL SIGNS: Temperature 97.6??????, pulse 70, pressure 100/58,
respirations 17, 97% on room air.
GENERAL: He is a pleasant man in no acute distress.
HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic,
atraumatic. Mucous membranes moist, anicteric. No evidence
of tongue laceration.
NECK: Supple, no lymphadenopathy, no carotid bruits.
CARDIOVASCULAR: Regular rate and rhythm, 2/6 systolic murmur
in the left upper sternal border.
CHEST: Clear bilaterally.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds, no palpable hepatosplenomegaly. He was guaiac
negative.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Alert and oriented to person, place, but not
time. He said it was [**2114-6-25**]. Motor [**3-30**] extensors, left
upper extremity wrist [**4-29**], otherwise. Light touch was
grossly intact. Cranial nerves II through XII grossly intact
with a left homonymous hemianopsia which is old. Finger to
nose, heel to shin slow but intact. No pronator drift. Deep
tendon reflexes were symmetric and toes were downgoing
bilaterally.
LABORATORIES AND IMAGING: White count 4.5, hematocrit 37,
platelet count 133. His chem-7 was significant for a
creatinine of 1.7. His baseline is between 1.2 and 1.6.
Electrocardiogram was not changed from prior and a head CT on
admission showed a 4.1 x 3.7 cm enhancing mass in the left
frontal lobe extending to the frontal [**Doctor Last Name 534**] of the left
ventricle with effacement of sulci on the right consistent
with metastatic disease, new since the [**12-26**] exam. In
addition, a chronic right occipital infarct which is
unchanged.
HOSPITAL COURSE: The patient was admitted to the O-Med
service. He was ruled out by CKs, continued on aspirin and
beta blockers. In addition, he was started on intravenous
steroids and put on seizure precautions, as well as given
Dilantin. The patient, in addition, his p.o. intake was
encouraged and his creatinine returned to baseline. In
conjunction with his oncologist, neurosurgery was consulted
in addition radiation oncology was consulted, as well. The
patient underwent work up to determine extent of his
metastatic disease, including an MRI of his head which was
again consistent with metastatic disease as well as a CT of
his lung, abdomen and pelvis, which showed no metastatic
disease in the abdomen or pelvis. No liver lesions, adrenal
lesions, however his lung mass appeared to have increased in
size.
In conjunction with oncology, radiation oncology and
neurosurgery, it was decided that the patient would go for
resection of the brain metastasis. He was transferred to the
neurosurgical service on [**2113-8-24**] and underwent craniotomy on
[**2113-8-24**] with resection of the left frontal brain lesion.
Surgery proceeded without any complications. A surgical
drain was put in which was left there and the drain was
pulled [**2113-8-26**]. The patient continued to do well and
transferred from the Intensive Care Unit to the floor where
he remained stable neurologically. At that time, the patient
remained alert and awake, arousable, oriented to person with
good strength in all extremities, no pronator drift, looking
in all directions. On the floor, had some problems with
[**Name2 (NI) **] pressure control. His Toprol was changed to Lopressor
75 t.i.d., did well with that. He was seen by physical
therapy and the plan was to discharge this patient with
inpatient rehabilitation.
DISCHARGE DIAGNOSES:
1. Brain metastases of small cell lung cancer
2. Status post resection mass
DISCHARGE MEDICATIONS:
1. Decadron 0.5 mg po q8h x1 day
2. Lopressor 75 mg po t.i.d.
4. Insulin 70/30 15 units subcutaneous q a.m.
5. Boost shakes b.i.d.
6. Regular insulin sliding scale
7. Dilantin 100 mg po t.i.d.
8. Zantac 150 mg po b.i.d.
9. Lasix 20 mg po b.i.d.
10. Ramipril 5 mg po b.i.d.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Discharge to rehabilitation
FOLLOW UP in Brain [**Hospital 341**] Clinic
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 8853**]
MEDQUIST36
D: [**2113-8-29**] 09:58
T: [**2113-8-29**] 10:11
JOB#: [**Job Number 108076**]
|
[
"780.2",
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icd9cm
|
[
[
[]
]
] |
[
"01.32",
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icd9pcs
|
[
[
[]
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] |
6448, 6831
|
2525, 2557
|
6042, 6121
|
6144, 6426
|
4219, 6021
|
2253, 2391
|
128, 1537
|
2571, 4200
|
1559, 2233
|
2408, 2508
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,024
| 179,030
|
49074
|
Discharge summary
|
report
|
Admission Date: [**2176-10-9**] Discharge Date: [**2176-10-17**]
Service: MEDICINE
Allergies:
Ambien / Valium
Attending:[**First Name3 (LF) 56857**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
central line placement, arterial line placement
History of Present Illness:
[**Age over 90 **]-year-old female with advanced Alzheimer's dementia who
presented to the ED with altered mental status. Pt's family
notes that she was less interactive than baseline this morning.
At the ED, initial vitals were 99.7 70 88/61 16 95% ra. U/A was
grossly positive with >182WBC and many bacteria. She was
covered empirically with vancomycin and cefepime. Other
significant labs included Na of 171, Cr of 2.0 (baseline
normal), WBC 14.7, Hct of 48.7, lactate of 3.0, trop of 0.05.
She was given a total of 3L NS upon arrival to the MICU.
Of note, she was last hospitalized with UTI on [**2175-11-5**].
Urine culture grew <[**2164**] enterococcus and she was discharged on
total 14 day course of amoxicillin
On arrival to the MICU,
HR 68 BP 118/55 RR 16 98% on RA. Pt. responding only to noxious
stimuli with incoherent vocalizations.
Review of systems:
Unable to obtain
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Shingles - [**2169**]
4. Depression
5. Anxiety
6. Advanced Dementia - Behavioral issues in the past with
paranoia. No recent behavioral issues.
7. Status post GI bleed - The patient has a history of bleeding
ulcers with significant bleeds in [**2151**] and [**2167**]. She no longer
takes aspirin for this reason.
8. Falls
9. Insomnia
10. Constipation
11. Urinary retention
Social History:
Lives with daughter and her 3 grandchildren. Has 24 hour
supervision and family is extremely supportive. Dependent for
ADL's. Quit tobacco 60 years ago. Denies alcohol or IVDA.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: HR 68 BP 118/55 RR 16 98% on RA
General: Somnolent, arouses minimally to sternal rub
HEENT: Sclera anicteric, dry mucus membranes, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: significant skin tenting present. 1cm ulcer over right hip
w/ minimal surrounding erythema.
Neuro: moans and opens eyes to sternal rub. withdraws from
painful stimuli. Unintelligible vocalizations. Moving all 4
extremities. Uncooperative with neuro exam.
DISCHARGE PHYSICAL EXAM:
VS 98.5/99.4 HR 78-94 BP 106/60 (100s-130s/50s-60s) RR 16-18 O2
98-99%RA
GEN: somnolent, non-verbal, not following commands, NAD
HEENT: NCAT. EOMI. PERRL. dry MM. no LAD. no JVD. neck supple.
CV: RRR, normal S1/S2, no murmurs, rubs or gallops.
LUNG: exam very limited [**2-29**] poor inspiratory effort [**2-29**]
cognitive impairment from advanced dementia, no rales, wheezes
or rhonchi appreciated
ABD: soft, ND, does not grimace to palpation, +BS. no rebound or
guarding. neg HSM.
EXT: W/WP, trace edema, no C/C. 1+ DP/PT pulses bilaterally.
SKIN: W/D/I
NEURO: Unable to perform exam [**2-29**] severe dementia & pt unable to
cooperate
Pertinent Results:
Admission labs:
[**2176-10-9**] 01:45PM BLOOD WBC-14.7*# RBC-4.96 Hgb-14.6 Hct-48.3*#
MCV-97# MCH-29.5 MCHC-30.3*# RDW-15.7* Plt Ct-114*
[**2176-10-9**] 01:45PM BLOOD Neuts-71.1* Lymphs-24.5 Monos-4.1 Eos-0.1
Baso-0.3
[**2176-10-9**] 07:59PM BLOOD Neuts-69.9 Lymphs-26.6 Monos-3.3 Eos-0.1
Baso-0.2
[**2176-10-9**] 07:59PM BLOOD WBC-13.5* RBC-3.66*# Hgb-10.9*# Hct-36.1#
MCV-99* MCH-29.9 MCHC-30.3* RDW-15.7* Plt Ct-95*
[**2176-10-9**] 01:45PM BLOOD PT-12.6* PTT-25.8 INR(PT)-1.2*
[**2176-10-9**] 07:59PM BLOOD PT-14.0* PTT-23.0* INR(PT)-1.3*
[**2176-10-9**] 01:45PM BLOOD Glucose-92 UreaN-54* Creat-2.0*# Na-171*
K-4.8 Cl-133* HCO3-26 AnGap-17
[**2176-10-9**] 07:59PM BLOOD Glucose-113* UreaN-47* Creat-1.5* Na-169*
K-3.8 Cl-140* HCO3-26 AnGap-7*
[**2176-10-9**] 10:12PM BLOOD Glucose-185* UreaN-43* Creat-1.4* Na-168*
K-3.2* Cl-140* HCO3-23 AnGap-8
[**2176-10-9**] 01:45PM BLOOD cTropnT-0.05*
[**2176-10-9**] 01:45PM BLOOD Calcium-9.7 Phos-4.2 Mg-3.0*
[**2176-10-9**] 07:59PM BLOOD Calcium-7.8* Phos-2.8 Mg-2.4
[**2176-10-9**] 10:12PM BLOOD Calcium-7.2* Phos-2.1* Mg-2.2
[**2176-10-10**] 02:15AM BLOOD Type-ART Temp-36.7 pO2-83* pCO2-33*
pH-7.33* calTCO2-18* Base XS--7 Intubat-NOT INTUBA
[**2176-10-10**] 10:49AM BLOOD Type-[**Last Name (un) **] pO2-90 pCO2-29* pH-7.37
calTCO2-17* Base XS--6
[**2176-10-9**] 02:41PM BLOOD Glucose-90 Lactate-3.0*
[**2176-10-9**] 08:11PM BLOOD Lactate-2.1*
[**2176-10-10**] 02:15AM BLOOD Lactate-1.0 Na-160* K-2.8* Cl-138*
[**2176-10-10**] 04:07AM BLOOD Glucose-98 Lactate-1.1 Na-159* K-3.2*
Cl-141*
[**2176-10-10**] 07:40AM BLOOD Glucose-84 Lactate-1.8 Na-157* K-3.8
Cl-141*
[**2176-10-10**] 10:49AM BLOOD Glucose-74 Lactate-1.5 Na-156* K-3.7
Cl-141*
[**2176-10-10**] 04:07AM BLOOD freeCa-1.10*
[**2176-10-10**] 10:49AM BLOOD freeCa-1.05*
Discharge labs:
Imaging:
[**2176-10-9**] CXR: No acute intrathoracic process.
[**2176-10-10**] IR Guided PICC Placement:
Successful PICC exchange, with placement of a new 36 cm
double-lumen PowerPICC. The tip is within the distal SVC. The
line is ready to use.
[**2176-10-14**] CXR:
In comparison to prior radiograph, a new right-sided PICC
terminates in the mid SVC. Left lower lobe opacities could
represent aspiration versus pneumonia. The right lung is
grossly clear. Extensive vascular clips are noted. Cardiac
size is normal without any signs of heart failure.
Brief Hospital Course:
[**Age over 90 **]-year-old female with advanced Alzheimer's dementia who
presented to the ED with altered mental status and hypotension,
found to have a leukocytosis, positive UA, hypernatremia to 171,
and ARF.
# Sepsis: Pt. met [**3-2**] SIRS criteria (WBC 14.7 and HR 100) and
has evidence of infection, likely urinary source, based on UA
with positive LE, >182 WBCs, and many bacteria. Initially
presented with hypotension 88/61, which improved with 2L NS.
Lactate on presentation was 3.0. At the MICU, she was started
on vancomycin and cefepime while awaiting urine culture results.
She was also on levophed to maintain MAP > 65. With treatment
of her infection and with IVFs (see below), she was able to be
weaned off the pressor and was transferred to the medical floor.
# Hypernatremia: Pt presented with Na of 171. Her family
endorsed that she had been refusing food and drink for several
days. This degree of hypernatremia most likely represents a
significant free water deficit caused either by decreased PO
intake of free water, or increased urinary losses, i.e. diabetes
insipidis. Calculated free water deficit was 6.2L on admission.
We must assume this hypernatremia has been present for at least
24 hours, and therefore we corrected her serum Na at a rate no
greater than 10mEq per day in order to avoid iatrogenic cerebral
edema. Renal consult was obtained and with their guidance,
patient was placed on IVFs that were adjusted based on her rate
of correction. She was initially on 1/2NS, then D5W and NS and
briefly on hypertonic saline to prevent overcorrection.
Electrolytes were monitored every 2 hours initially and spaced
out as electrolytes normalized. Sodium level eventually
normalized to the low 140 range and she was maintained on D5 [**1-29**]
normal saline as she was taking PO.
# Altered mental status: Caretaker reported that she was less
responsive than baseline. Likely multifactorial. Primary
contributor is likely her profound hypernatremia. This may be
exacerbated by underlying UTI/sepsis as well as baseline severe
dementia. She was continued on memantine and mirtazapine.
# [**Last Name (un) **]: Pt.'s severe hypernatremia and evidence of volume
depletion on exam argue strongly for a pre-renal etiology. Cr
returned to baseline with IVFs.
# UTI: Patient with evidence of UTI on urinalysis, but culture
was without growth. She was initially started on vanco/cefepime
given likely sepsis (above) and later transitioned to
ampicillin. She continued to spike low grade fevers, so was
transitioned back to cefepime and ultimately transitioned to PO
ciprofloxacin to complete a 7 day total course on [**2176-10-17**].
# LLL consolidation: Patient with evidence of pneumonia vs.
aspiration pneumonitis on CXR from [**10-14**]. She was without cough
and leukocytosis had resolved and patient remained afebrile. She
is on ciprofloxacin for UTI (above) and will complete course on
[**10-17**]. She was seen by speech and swallow given aspiration risk
and they felt she could eat with precautions and recommended
pureed solids and nectar thick liquids.
# HTN: Patient was initially hypotensive from sepsis (above) and
home atenolol was held on admission. This can be restarted as
patient can tolerate PO medications.
# HLD: Stable, continued home simvastatin.
# Advanced Dementia, Goals of care: Pt was initially full code
when admitted to the MICU. Discussion was held regarding goals
of care in light of her advanced dementia. Her caretaker
(daughter [**Name (NI) **], HCP) made the decision to make her DNI/DNR.
She requested that procedures that would cause pain not be
performed. The hospice team was consulted and helped arrange
hospice care for the patient including pain medication
prescriptions and a hospital bed will be delivered to the
patients home address.
# Transitional issues:
- Patient is now home hospice, she was provided with
prescriptions for pain medications and a hospital bed will be
delivered to her home
- Several medications were discontinued on discharge, including
memantine and simvastatin in order to simplify medicine regimen
- Patient to complete a course of ciprofloxacin on [**2176-10-22**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Simvastatin 10 mg PO DAILY
2. Senna 1 TAB PO BID:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Mirtazapine 7.5 mg PO HS
5. Memantine 10 mg PO BID
6. Calcitriol 0.25 mcg PO DAILY
7. Atenolol 50 mg PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO DAILY
2. Mirtazapine 7.5 mg PO HS
3. Senna 1 TAB PO BID:PRN constipation
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*9 Tablet Refills:*0
5. Atenolol 50 mg PO DAILY
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
Flush with 10mL Normal Saline followed by Heparin as above daily
and PRN per lumen Daily Disp #*30 Each Refills:*0
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.
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % Flush 3 mL
IV every eight (8) hours Disp #*60 Syringe Refills:*0
8. PICC line care
Please provide PICC line care and dressing changes 3 times per
week.
9. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN
moderate to sever pain or shortness of breath
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25 mL by mouth
every four (4) hours Disp #*4 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary diagnoses:
- Sepsis from a urinary source
- Hypernatremia to 171
- Metabolic encephalopathy
- Pneumonia
Secondary diagnoses:
- Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and somnolent, not
interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 66673**],
You were admitted to the hospital because your sodium level was
very high and you were less interactive than your baseline. You
were treated with IV fluids and your sodium level came back to
normal. You were also found to have an infection in your blood,
urine and possibly in your lungs as well. You were treated with
IV antibiotics and you were changed to oral antibiotics
(ciprofloxacin) which you should continue taking as prescribed
through [**10-22**].
You were also seen by the hospice team and your family including
your daughter [**Name (NI) **] who is your health care proxy decided to
move forward with hospice care. You will be provided with
prescriptions for pain as needed and a hospital bed will be
delivered to your home.
Followup Instructions:
Hospice team will be visiting you at home.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1239**] DO 12-ASV
Completed by:[**2176-10-17**]
|
[
"263.9",
"276.8",
"276.2",
"486",
"276.50",
"995.91",
"780.52",
"599.0",
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"E878.9",
"584.9",
"427.1",
"300.4",
"996.1",
"331.0",
"038.0",
"564.00",
"V15.82",
"273.8",
"294.10",
"272.4",
"348.31",
"V49.86",
"275.41",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11481, 11539
|
5744, 7574
|
247, 296
|
11728, 11728
|
3369, 3369
|
12684, 12900
|
1883, 1901
|
10302, 11458
|
11560, 11673
|
9956, 10279
|
11881, 12661
|
5162, 5721
|
1941, 2684
|
11694, 11707
|
1198, 1217
|
186, 209
|
324, 1179
|
3385, 5145
|
11743, 11857
|
9595, 9930
|
1239, 1670
|
1686, 1867
|
2709, 3350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,408
| 150,957
|
5422+55670+55671
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2163-8-26**] Discharge Date:
Date of Birth: [**2087-5-9**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 21991**] is a 75-year-old male
with a history of restrictive lung disease admitted for an
elective anteroposterior cervical fusion on [**2163-8-26**]. Patient initially noted to have tangential speech on
the [**8-27**], and it was believed to be related to
the Morphine PCA.
On [**2163-8-28**], the patient was noted to be diaphoretic and
agitated and confused with an elevated blood pressure of
220/102 and an oxygen saturation of 85%. He received 2
oxygen via nasal cannula and 5 mg of IV Lopressor and a 1 mg
of lorazepam. He had a chest x-ray that showed bilateral
atelectasis. Patient became increasingly somnolent, and was
transferred to the Medicine service from the Orthopedic
service for further management of his mental status changes.
At the time of transfer, the patient denied chest pain,
shortness of breath, palpitations, fevers, chills, melena,
bright red blood per rectum. He did complain of a headache
in the left occiput nonradiating. He was evaluated by
Neurology, who reported no focal signs, but evidence of
perseveration suggesting diffuse encephalopathy or frontal
syndrome.
Patient later developed progressive respiratory distress
requiring intubation for hypercarbic respiratory failure. He
was transferred to the MICU for further management. On the
hospital floor, the patient had received levofloxacin and
Flagyl for a potential aspiration.
PAST MEDICAL HISTORY:
1. Restrictive lung disease with paralyzed right diaphragm.
2. Type 2 diabetes.
3. Mild chronic renal insufficiency secondary to diabetes
with a baseline creatinine of 1.5 to 1.9.
4. Hypertension.
5. History of syncope.
6. History of multiple small infarcts on CT and MRI.
7. Cervical spondylosis status post cervical fusion.
8. Right cervical C5 polyradiculopathy and axonal
polyneuropathy.
MEDICATIONS:
1. Insulin.
2. Aspirin 325 mg p.o. q.d.
3. Baclofen 10 mg p.o. t.i.d.
4. Hydrochlorothiazide 25 mg p.o. q.d.
5. Zoloft 50 mg p.o. q.d.
6. Lipitor 20 mg p.o. q.d.
7. Lisinopril 10 mg p.o. q.d.
8. Lopressor 50 mg p.o. b.i.d.
9. Megestrol 20 mg p.o. q.d.
10. Viagra prn.
11. Amitriptyline 30 mg p.o. q.h.s.
12. Hectorol 50 mg b.i.d.
ALLERGIES:
1. Thorazine.
2. Compazine.
3. Taluir.
SOCIAL HISTORY: Patient is a retired mail man who lives with
his wife in [**Name (NI) 1268**]. He quit tobacco 35 years ago half
pack per day habit. Positive EtOH two drinks per day. No
history of IV drug use. Patient has a daughter and a
grandchild from an earlier marriage.
EXAM ON TRANSFER TO THE MICU: Vital signs: Temperature
95.0, blood pressure 207/104, respiratory rate 14, and 95%
ventilated on AC with a tidal volume of 600, respiratory rate
of 14, FIO2 of 1.00. In general, the patient was sedated
with protocol, intubated. Moved all four extremities
occasionally. HEENT: Pupils are equal, round, and reactive
to light. EOMI. Neck brace in place, anicteric, no JVD, and
no LAD. Cardiac: Regular, rate, and rhythm, no murmurs,
rubs, or gallops. Pulmonary: Decreased breath sounds at the
bases bilaterally without crackles, wheeze, or rhonchi.
Abdomen: Normoactive bowel sounds, soft, nontender, no
masses. Extremities: No clubbing, cyanosis, or edema, cool
with palpable pulses bilaterally. Neurologic: Heavily
sedated on propofol, opens eyes and responds to pain.
PERTINENT LABORATORY DATA: The patient had multiple chest
x-rays and imaging while in the hospital. Most notably, a
head CT from [**8-28**] showed no evidence of intracranial
hemorrhage or recent infarction.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 2706**]
MEDQUIST36
D: [**2163-9-8**] 21:27
T: [**2163-9-9**] 04:24
JOB#: [**Job Number 21992**]
Name: [**Known lastname 3659**], [**Known firstname 3660**] Unit No: [**Numeric Identifier 3661**]
Admission Date: [**2163-8-26**] Discharge Date: [**2163-9-12**]
Date of Birth: [**2087-5-9**] Sex: M
Service:
HOSPITAL COURSE:
1. ORTHOPEDIC: The patient underwent cervical spine fusion
anterior and posterior on [**2163-8-26**]. There were no
immediate complications post procedure and the patient was
extubated without difficulty.
2. NEUROLOGIC: The patient was noted to be confused on
[**8-27**], with increased tangential speech and increased
agitation. The patient was evaluated by the Neurology
Service on [**2163-8-28**]. At that time, it was felt that the
patient's change in mental status was most likely secondary
to a diffuse encephalopathy versus a more frontal syndrome.
Neurology recommended a metabolic and endocrinologic work-up
which was negative.
3. RESPIRATORY: On the evening of [**2163-8-28**], the patient
developed hypercarbic respiratory failure requiring
intubation and was transferred to the Medical Intensive Care
Unit for further management. Chest x-ray at that time showed
small lung volumes with a questionable infiltrate in the left
lower lobe. The patient's hypercarbic respiratory failure was
felt to be secondary to an acute exacerbation of chronic
right diaphragmatic paralysis. This acute exacerbation was
believed secondary to either manipulation of cervical nerve
roots at the time of cervical spine surgery versus pneumonia
versus congestive heart failure.
The patient was intubated until [**2163-9-1**], at which time
sedation was weaned down and the patient was extubated;
however, approximately four hours post extubation, the
patient was noted to have increased respiratory rate to the
high 30s with decreased total volumes, although saturation
was at 100%. The patient was placed on a BiPAP at settings
of 15 out of 5 at which time his arterial blood gas was 7.34
/ 42 / 119. The patient also was noted to have markedly
elevated blood pressures with a systolic blood pressure
maximum of 240. Given that the patient appeared in danger of
complete respiratory failure, the patient was re-intubated.
The patient remained re-intubated for several days while
attempts were made to better control his blood pressure to
improve his chance of success following a second trial at
extubation. The patient was extubated for a second time on
[**2163-9-6**], and transitioned directly to BiPAP with pressure
support of 12 and PEEP of 5. The patient tolerated
extubation well although he continued to produce copious
amounts of oral and pulmonary secretions requiring frequent
suctioning.
Over the next several days, the patient was alternated
between a BiPAP and shovel mask until at the day of
discharge, the patient was tolerating being off of BiPAP all
day to rest on BiPAP overnight from 10 p.m. until 06:00 a.m.
The patient was noted post-extubation to have poor gag and
cough response, although his gag and cough improved over the
course of the next several days. The patient was not felt to
be able to handle his own secretions or to safely swallow
pills or food.
An nasogastric tube was placed on [**2163-9-8**], through which
the patient received tube feed boluses, 250 cc five times a
day, and medications. The patient was scheduled for a speech
and swallow evaluation on the day of discharge.
The patient will require swallowing retraining at the
pulmonary rehabilitation center.
4. HYPERTENSION: The patient remained persistently
hypertensive throughout the course of hospital stay. After
frequent readjustments of medications and dosing, the patient
will be discharge on Metoprolol, Captopril, and Hytrin. It
is believed that there is a large component of anxiety
contributing to the patient's hypertension and although the
patient had received benzodiazepines and Fentanyl to control
his hypertensive spikes, his agitation appeared to settle
down post extubation and at the time of discharge the patient
was not requiring benzodiazepines or Fentanyl boluses.
5. ANEMIA: Prior to transfer to the Medical Intensive Care
Unit, the patient received one unit of packed red blood cells
for a hematocrit of 27.6 post surgery. The patient's
hematocrit initially bumped to 34.5, but continued to drift
downward over the course of the hospital stay. The patient
remained guaiac negative without any evidence of bleeding at
his incision site.
The patient's baseline hematocrit runs between 28 and 32. He
has been worked up in the past with findings consistent with
anemia of chronic disease. The patient's hematocrit
continued to be monitored throughout the course of hospital
stay with a transfusion threshold of less than 21.
6. STAPHYLOCOCCUS AUREUS BACTEREMIA: On [**2163-9-8**], the
patient was noted to have low grade temperature to 100.4 F.,
with increased white blood cell count to maximum of 13.6.
Blood cultures were drawn at this time which grew two out of
four bottles positive for Gram positive cocci in clusters,
later identified as Staphylococcus aureus. Sensitivities of
Staphylococcus aureus cultures were pending at time of
discharge.
The patient was initiated on Vancomycin given prolonged
hospital stay with intubation and the patient is planned for
a 14 day course of Vancomycin and a PICC line was placed on
day of discharge.
7. PNEUMONIA: The patient was diagnosed on initial chest
x-ray on [**2163-8-28**], with a possible left lower lobe
pneumonia which appeared to worsen over the course of the
next several days. The patient completed a 14 day course of
Levofloxacin.
DISCHARGE STATUS: Discharged to an acute rehabilitation
facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325 to 650 mg p.o. q. four to six hours
p.r.n.
2. Bisacodyl 10 mg p.o. or p.r. q. day p.r.n.
3. Atorvastatin 40 mg p.o. q. day.
4. Sertraline 25 mg p.o. q. day.
5. Docusate sodium 100 mg p.o. q. day.
6. Senna two tablets p.o. twice a day.
7. Terazosin 4 mg p.o. twice a day.
8. Captopril 75 mg p.o. three times a day.
9. Pantoprazole 30 mg p.o. q. day.
10. Metoprolol 100 mg p.o. twice a day.
11. NPH 7 units q. a.m. and 8 units q. p.m. with a regular
insulin sliding scale.
12. Vancomycin 500 mg intravenously q. 12 for a total of a 15
day course to end on ten days post discharge.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with primary care physician
within one week of discharge from acute rehabilitation
facility.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**]
Dictated By:[**Last Name (NamePattern1) 3663**]
MEDQUIST36
D: [**2163-9-10**] 15:32
T: [**2163-9-10**] 19:22
JOB#: [**Job Number 3664**]
Name: [**Known lastname 3659**], [**Known firstname 3660**] Unit No: [**Numeric Identifier 3661**]
Admission Date: [**2163-8-26**] Discharge Date: [**2163-9-23**]
Date of Birth: [**2087-5-9**] Sex: M
Service: MICU [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Please see the prior dictation summary for the history of
present illness, past medical history, social history, and
family history as well as the hospital course through
[**2163-9-12**].
Hospital course [**2163-9-12**] through [**2163-9-23**]:
Pulmonary: On [**2163-9-11**], Mr. [**Known lastname **] had an episode of
bradycardia secondary to hypoxia with mucus plugging with
newly more copious secretions. Patient was emergently
reintubated for the third time since admission. Patient was
also treated with a 10 day course of Vancomycin for MRSA in
sputum and blood (ending [**2163-9-19**]) and a seven day course of
Zosyn (ending [**2163-9-20**]) for gram-negative rods on sputum Gram
stain in the setting of increased sputum production (although
the rods never grew out in the sputum).
The patient received a trache [**2163-9-14**]. The trache was
changed for a #1 Shiley, nonfenestrated, [**9-22**] as the #6 was
too flexible and would [**Doctor Last Name **] out with patient movement.
However, the new trache may not allow adequate speech
production - may require alteration. The patient did not
tolerate a trial of trache mask [**9-18**] (acidemic) and [**9-21**]
(acidemic, hypoxic, bradycardic, and hypotensive, required 1
mg of atropine to revive). Patient is stable and PFV is [**6-30**]
(10 on a.m. of discharge) and PEEP of 5.
Infectious disease: The patient received a 10 day course of
Vancomycin for MRSA and blood in sputum (ended [**2163-10-19**]) and
seven day course of Zosyn (ended [**2163-9-20**]) for gram-negative
rods on sputum Gram stain in the setting of increased sputum
production (although, again, the rods never grew out in the
sputum). Patient also grew Enterococcus in urine which was
also sensitive to Vancomycin. Finally, patient is day [**7-31**]
in a course of Flagyl for Clostridium difficile. Patient is
afebrile during the period from [**2163-9-13**] to [**2163-9-23**]; patient
was febrile to 103.3 in the a.m. of [**2163-9-12**].
Gastrointestinal: Patient's bowel function was maintained
using Colace, Senna, and lactulose (standing hold for loose
BMs). Patient received PEG on [**2163-9-20**] without complication.
Cardiovascular: Patient's hypertension controlled with
metoprolol, captopril, and Hytrin. Patient occasionally
hypotensive for second dose of captopril, hold for systolic
blood pressure less than 100.
Endocrine: Patient's diabetes mellitus type 2. Serum
glucose well controlled with 4 units of NPH q.a.m., 5 units
of NPH q.p.m. with regular insulin-sliding scale.
F/E/N: Patient maintained on continuous tube feeds through
his PEG. Patient has diminished gag reflex and is not - as
of time of discharge - taking p.o.
Renal: Patient without known renal pathology. Creatinine
ranged from 1.0 to 1.4 through this period. Medications
renally dosed depending on creatinine level.
Psychiatric: Patient has baseline depression treated at home
on sertraline. Patient also had continued delirium agitation
particularly at night after [**2163-9-12**]. Patient was originally
treated with propofol, Zyprexa, and Ativan. However, due to
sedation, propofol was weaned and Zyprexa increased [**9-15**],
with Ativan prn. Trazodone was also added q.h.s. on
[**2163-9-16**], with Fentanyl added [**9-17**], for continued agitation.
Finally psychiatric consult was sought and recommended
discontinuing all psychiatric medications - including
sertraline - and controlling delirium with Haldol 5 t.i.d.
with prn doses offered q.1h. Patient's agitation well
controlled on this regimen, with a few prn doses required.
Patient is much more alert and oriented; avoid oversedation.
DISPOSITION CONDITION: Fair.
DISPOSITION: [**Hospital3 2975**] Rehab.
DISCHARGE MEDICATIONS:
1. Acetaminophen 325-650 mg p.o. q.4-6h. prn.
2. Dulcolax 10 p.r. q.d. prn.
3. Atorvastatin 40 p.o. q.d.
4. Colace liquid 100 mg p.o. b.i.d.
5. Senna two tablets p.o. b.i.d.
6. Terazosin HCL 4 mg p.o. b.i.d.
7. Captopril 75 p.o. t.i.d., hold for systolic blood pressure
less than 100.
8. Lansoprazole 30 mg q.d.
9. Metoprolol 100 p.o. b.i.d.
10. Albuterol nebulizers prn.
11. Atrovent nebulizers prn.
12. Metronidazole 500 p.o. t.i.d. x2 more days.
13. Lactulose 30 prn constipation.
14. Insulin sliding scale.
15. Morphine sulfate 1-4 mg IV q.4h. prn pain.
16. Nystatin oral suspension 5 mL p.o. q.i.d. swab in the
oropharynx.
17. Haldol 5 mg p.o. t.i.d.
18. Haldol 1-3 mg IV q.1h. prn not to exceed a total of 40
mg/day.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Last Name (NamePattern1) 3665**]
MEDQUIST36
D: [**2163-9-23**] 11:50
T: [**2163-9-26**] 06:08
JOB#: [**Job Number 3666**]
|
[
"997.3",
"518.89",
"486",
"041.11",
"519.4",
"599.0",
"518.5",
"041.04",
"721.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"31.1",
"81.03",
"81.63",
"81.02",
"80.51",
"38.93",
"33.21",
"96.04",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14773, 15772
|
4210, 9626
|
10318, 14750
|
148, 1551
|
1573, 2361
|
2378, 4193
|
9652, 9661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,753
| 167,996
|
24927
|
Discharge summary
|
report
|
Admission Date: [**2134-12-13**] Discharge Date: [**2135-1-1**]
Date of Birth: [**2071-8-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Prinivil
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Type A dissection
Major Surgical or Invasive Procedure:
Graft replacement of ascending aorta (26mm gelweave), aortic
valve replacement(25mm Porcine) [**2134-12-13**]
Right leg fasciotomies- [**2134-12-15**]
L arm PICC line placement [**12-27**]
Rt groin debridment [**12-25**]
Vac wound dressing placement [**12-31**]
History of Present Illness:
This 63 year old male with a history of hypertension presented
to an outside hospital with the acute onset of chest pain
radiating to the back. A CTA revealed a Type A dissection
extending into the left iliac artery, and involving the right
internal carotid artery. He was transferred here for emergency
repair.
Past Medical History:
gastric reflux
hypertension
Social History:
Nonsmoker
denies alcohol use
Family History:
Father died of cardiac disease at age 65
Physical Exam:
98.4 118/64 95 18 100% RA
General: pleasant, sleaks with heavy accent
Chest: lungs clear, sternum stable
COR: Normal s1S2
Sternal incision: dry, no erythema
Abdomen: soft and nontender. Diffuse rash on belly, legs, arms.
R Groin: s/p wound debridment with wet to dry dressing in place
extremities: warm without edema
Pertinent Results:
[**2134-12-13**] 01:53PM FIBRINOGE-169
[**2134-12-13**] 01:53PM PLT COUNT-162
[**2134-12-13**] 01:53PM PT-13.1 PTT-26.2 INR(PT)-1.1
[**2134-12-13**] 01:53PM WBC-9.1 RBC-4.11* HGB-12.5* HCT-34.7* MCV-85
MCH-30.4 MCHC-35.9* RDW-13.4
[**2134-12-13**] 01:53PM LIPASE-58
[**2134-12-13**] 01:53PM UREA N-26* CREAT-1.2
[**2134-12-13**] 01:59PM GLUCOSE-121* LACTATE-3.5* NA+-138 K+-4.3
CL--108 TCO2-22
[**2134-12-13**] 06:45PM PLT COUNT-129*
[**2134-12-31**] 05:54AM BLOOD WBC-7.0 RBC-3.21* Hgb-9.4* Hct-27.5*
MCV-86 MCH-29.4 MCHC-34.3 RDW-14.6 Plt Ct-434
[**2134-12-29**] 05:24AM BLOOD Neuts-74.0* Lymphs-13.9* Monos-5.7
Eos-6.0* Baso-0.4
[**2134-12-31**] 05:54AM BLOOD Plt Ct-434
[**2134-12-18**] 01:55AM BLOOD PT-12.3 PTT-22.6 INR(PT)-1.0
[**2134-12-31**] 05:54AM BLOOD Glucose-92 UreaN-28* Creat-1.0 Na-136
K-4.5 Cl-101 HCO3-25 AnGap-15
[**2134-12-31**] 05:54AM BLOOD ALT-25 AST-22 LD(LDH)-399* AlkPhos-95
Amylase-86 TotBili-0.6
[**2134-12-31**] 05:54AM BLOOD Lipase-58
[**2134-12-28**] 09:30PM BLOOD CRP-32.1*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 62669**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 62670**] (Complete)
Done [**2134-12-13**] at 3:26:05 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2071-8-15**]
Age (years): 63 M Hgt (in): 66
BP (mm Hg): / Wgt (lb): 180
HR (bpm): BSA (m2): 1.91 m2
Indication: Aortic dissection. Left ventricular function.
Preoperative assessment.
ICD-9 Codes: 441.00, 424.0
Test Information
Date/Time: [**2134-12-13**] at 15:26 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *4.2 cm <= 3.4 cm
Aorta - Arch: *3.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated ascending aorta. Mildly dilated aortic
arch. Ascending aortic intimal flap/dissection.. Aortic arch
intimal flap/dissection. Descending aorta intimal flap/aortic
dissection.
AORTIC VALVE: Three aortic valve leaflets. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Physiologic 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
Pre Bypass:
1- Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
2- The ascending aorta is moderately dilated. The aortic arch is
mildly dilated.
3- The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation (trace
possible). There is no aortic valve stenosis.
4- The mitral valve appears structurally normal with trivial
mitral regurgitation.
5- There is no pericardial effusion.
6- Aortic dissection origin at r. sinotubular junction, extended
throughout the extent of observable descending aorta.. The flap
prolapses to level of aortic valve but not through the valve.
There is no extension to the aortic root and the coronaries are
intact.
Post Bypass:
Preserved biventricular function, LVEF >55%. MR remains mild.
There is a bioprosthetic Aortic valve insitu which is well
seated (#25 mosaic per surgeons). Peak gradient 10, mean 5 mm
Hg, no perivalvluar leaks. The ascending aortic contours
appeared regular without visible dissection. A dissection flap
could still be seen in the arch and descending aorta. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2134-12-13**] 20:30
[**Known lastname 62669**],[**Known firstname **] [**Medical Record Number 62671**] M 63 [**2071-8-15**]
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2134-12-28**] 8:55 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2134-12-28**] SCHED
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 62672**]
Reason: 53cm R basilic picc: please evaluate placement of tip
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with newly placed PICC
REASON FOR THIS EXAMINATION:
53cm R basilic picc: please evaluate placement of tip
Final Report
REASON FOR EXAM: Assess right PICC.
Comparison is made with prior study, [**2134-12-21**].
New right PICC tip is in the cavoatrial junction. Left lower
lobe opacity has
resolved. The lungs are grossly clear. There is no pneumothorax.
A small
right pleural effusion is unchanged. Sternal wires are aligned.
Cardiomediastinal contour is unchanged with mild cardiomegaly.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2134-12-29**] 9:56 AM
[**Known lastname 62669**],[**Known firstname **] [**Medical Record Number 62671**] M 63 [**2071-8-15**]
Radiology Report CHEST (PA & LAT) Study Date of [**2134-12-21**] 1:20 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2134-12-21**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 62673**]
Reason: eval for ptx/atx/infiltrate
Final Report
INDICATION: 63-year-old man status post repair of type A aortic
dissection.
Evaluate for pneumothorax or infiltrate.
COMPARISON: [**2134-12-17**].
A right internal jugular catheter tip terminates over the mid
right atrium.
The cardiomediastinal silhouette is stable. Lung volumes are
low. There is
stable small bilateral pleural effusions with likely mild
bilateral associated atelectasis. There is no new consolidation.
IMPRESSION: Stable bilateral small effusions and mild
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**First Name8 (NamePattern2) **] [**2134-12-21**] 7:43 PM
Brief Hospital Course:
Following transfer, during which he required intubation, he went
emergently to the Operating Room where a type A aortic
dissection repair was effected as noted. The right femoral
artery was cannulated for bypass. Hypothermic circulatory arrest
for 30 minutes was utilized.
He weaned from bypass on propofol and Phenylephrine.
Postoperatively he weaned from pressor and was hypertensive,
requiring IV NTG. He was kept sedated to allow clearance of
myoglobin, which peaked at over 20,000. He was kept polyuric
and a sodium bicarbonate infusion was utilized to alkalinize
urine for renal protection.
Two compartment fasciotomies were performed on [**12-15**] with the
finding of ischemic muscle. The skin was closed at that time.
Myoglobinemia improved with a fall to less than 9600 on [**2134-12-16**].
He was awakened, remained stable and antihypertensives were
begun to wean IV NTG. He was extubated on POD 3.
On [**12-18**] he complained of blurring of the vision in his right eye.
Ophthalmologic consultation was obtained, along with neurology
and rheumatology. On Ophth. exam a small retinal hemorrhage was
noted on the optic disc of the right eye. CRP and ESR were
elevated. A MRA was requested, but the patient was rather
agitated and confused the night of [**12-19**] and was unable to
cooperate for the duration of the procedure.
POD#7 Dental consultation performed as Mr.[**Known lastname **] was being
treated preop on antibiotics for a dental abscess with
Clindamycin, which was resumed [**12-17**]. Per Dental the antibiotics
were discontinued with referral to follow up as an outpt. with
his dentist.
POD#8 MRA of the head and neck was performed which showed "Acute
'embolic shower' from a central source, likely related to recent
aortic repair." Neurology recommendation is to maintain aspirin
therapy.
The patient developed erythema at his fasciotomy sites.
Cefazolin treatment was initiated, leg was elevated and Ace wrap
applied. The wounds improved with this conservative management.
Right groin cannulation site dehisced with serosanguinous
fluid. Dry sterile dressings were applied, and Vancomycin
bejun. A PICC line was placed for antibiotic therapy. An ID
consult was obtained. After several days therapy the patient
developed a rash and refused any further treatment with
Vancomycin. His antibiotic regime was switched to Clindamycin
per ID recommendations.
On POD 16/14 his fasciotomy site opened and 2 days later were
primarily closed by the vascular surgery service. On POD19/17 a
VAC dressing was placed in the groin wound.
On POD 20/18, he was cleared to go home with IV clindamycin and
a wound vac to his right groin wound.
Medications on Admission:
Atenolol
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2)
Drop Ophthalmic Q4H (every 4 hours).
9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
10. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs 1 tube* Refills:*2*
11. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical DAILY
(Daily) for 7 days.
Disp:*1 tube* Refills:*0*
12. Benzoyl Peroxide 10 % Gel Sig: One (1) Appl Topical DAILY
(Daily).
Disp:*1 tube* Refills:*2*
13. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
14. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*2*
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous daily and prn as needed for line flush: Heparin
Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen. .
Disp:*qs ML(s)* Refills:*0*
16. Clindamycin Phosphate 150 mg/mL Solution Sig: Six Hundred
(600) mg Injection Q8H (every 8 hours): thru [**2-5**].
Disp:*qs mg* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Type A aortic dissection
Discharge Condition:
stable hemodynamically but deconditioned; requires PT to recover
function of right leg post fasciotomies
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming for 6 weeks
no lotions, creams or powders to incisions
report any fever greater than 100.0
report any redness of, or drainage from incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5263**] in [**12-17**] weeks ([**Telephone/Fax (1) 59410**])
If dermatological issues persist, can follow-up with Dr. [**Last Name (STitle) 62674**]
[**Name (STitle) 2161**] at ([**Telephone/Fax (1) 34896**]
Please call for appointments
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2135-1-19**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2135-1-14**] 10:30
Completed by:[**2135-1-1**]
|
[
"E878.2",
"377.39",
"362.30",
"401.1",
"736.79",
"998.59",
"424.1",
"368.16",
"278.00",
"998.89",
"729.72",
"441.01",
"682.6",
"276.3",
"530.81",
"997.02",
"117.9",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"35.21",
"86.22",
"96.71",
"39.61",
"38.93",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
13761, 13810
|
8890, 11560
|
292, 556
|
13879, 13986
|
1409, 6836
|
14402, 15099
|
1011, 1053
|
11619, 13738
|
6876, 6915
|
13831, 13858
|
11586, 11596
|
14010, 14379
|
1068, 1390
|
235, 254
|
6947, 8867
|
584, 898
|
920, 949
|
965, 995
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,044
| 134,722
|
23531
|
Discharge summary
|
report
|
Admission Date: [**2133-10-27**] Discharge Date: [**2133-10-29**]
Date of Birth: [**2069-3-21**] Sex: M
Service: MEDICINE
Allergies:
Avapro / Zetia / Heparin Agents
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Hypercarbic Respiratory Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 yo male with PMH CAD (s/p CABG), AF (on coumadin), DM, HTN,
recent admission for presumed drug-induced
rhabdomyolysis/weakness resulting in hypercarbic respiratory
failure (s/p trach and PEG) and ARF presents with hypercarbic
respiratory failure.
.
Pt was recently admitted at [**Hospital1 18**] from [**Date range (1) 60244**] with elevated
LFTs, rhabdomyolysis with CK 13,000 and weakness presumed
secondary to a combination of zetia and avapro. Muscle biopsy
suggested a metabolic myopathy induced by toxic agents and drugs
(i.e cholesterol lowering agents). No evidence of inflammatory
myositis. Medications were held.
Hepatitis serologies negative. Pt developed hypercarbic
respiratory failure secondary to muscle weakness and was
intubated, then got trach and PEG for failure to extubate in
setting of persistently low NIFs. Course was complicated by
contrast nephropathy and was temporarily on HD; creatinine on
discharge was 1.0.
.
Recently, pt was being weaned off the vent: Trach was capped
during the day and put on Bipap at night. Per wife, pt was
having difficulty tolerating Bipap. PEG removed one week ago; pt
is eating by mouth. Per the pt's wife, pt expressed generalized
malaise for the past 3 days. On the morning of admission, pt was
noted to be less responsive and A&O x 1 (at baseline A&O x 3 and
appropriate). ABG was 7.15/117/65. Pt was given Lasix 200 IV x1,
put on mechanical ventilation, and transferred for further mgmt.
.
Of note, per wife, pt was coded two weeks ago. [**Month (only) 116**] have
preceding hypercarbic respiratory failure. He was pulseless and
received CPR without any shocks. Pt was admitted to [**Hospital 8**]
Hospital for one day. No neurologic complications.
.
ROS: [**Name (NI) 1094**] wife denies recent fever, GU sx. Pt has had some
secretion from trach. + nausea, abominal discomfort,
constipation. Denies vomiting, hematachezia, BRBPR, hematemesis.
.
In the [**Name (NI) **], pt was continued on AC 600/16/5/.4. ABG was
7.29/66/414.
Past Medical History:
Rhabdomyolosis (presumed [**2-26**] drug toxicity)
Respiratory Failure (s/p Trach and PEG)
ARF ([**2-26**] contrast nephropathy)
IDDM
HTN
AF on coumadin
Gout
Hypercholesterolemia
Arthritis
CAD (s/p CABG)
.
PSH:
s/p L 5th ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]
Social History:
Retired postal worker, married, 4 children, no tobacco, no drugs
use, prior ETOH qweek, wife involved
Family History:
Mother died of liver cancer in her 70's
Physical Exam:
VS: t99.9, p72, 110/36, rr25, 95% AC 600/16/5/.4,
Gen: intubated, able to whisper
HEENT: clear OP, MMM
Neck: unable to assess JVP
CVS: irreg irreg, nl s1 s2, no m/g/r
Lungs: CTAB anteriorly
Abd: obese, soft, NT, ND, +BS
Ext: 3+ pitting edema of bilateral lower/upper extremities
Neuro: A&O x3, able to appropriately answer questions, [**3-1**]
bilateral upper extremities, unable to move bilateral lower
extremities
Pertinent Results:
Laboratory Data:
[**2133-10-27**] 08:15PM CK(CPK)-744*
[**2133-10-27**] 08:15PM CK-MB-32* MB INDX-4.3 cTropnT-2.35*
[**2133-10-27**] 03:29PM URINE HOURS-RANDOM CREAT-48 TOT PROT-9
PROT/CREA-0.2
[**2133-10-27**] 01:28PM CK(CPK)-734*
[**2133-10-27**] 01:28PM CK-MB-31* MB INDX-4.2 cTropnT-2.03*
[**2133-10-27**] 10:11AM TYPE-ART PO2-84* PCO2-44 PH-7.46* TOTAL
CO2-32* BASE XS-6
[**2133-10-27**] 10:11AM freeCa-1.13
[**2133-10-27**] 09:48AM URINE HOURS-RANDOM UREA N-365 CREAT-106
[**2133-10-27**] 05:00AM URINE HOURS-RANDOM
[**2133-10-27**] 05:00AM URINE GR HOLD-HOLD
[**2133-10-27**] 05:00AM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2133-10-27**] 05:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-MOD
[**2133-10-27**] 05:00AM URINE RBC-[**3-29**]* WBC-[**7-4**]* BACTERIA-OCC
YEAST-NONE EPI-0
[**2133-10-27**] 05:00AM URINE HYALINE-<1
[**2133-10-27**] 05:00AM URINE AMORPH-OCC
[**2133-10-27**] 05:00AM URINE EOS-NEGATIVE
[**2133-10-27**] 04:00AM GLUCOSE-153* UREA N-65* CREAT-2.0* SODIUM-133
POTASSIUM-5.6* CHLORIDE-91* TOTAL CO2-31 ANION GAP-17
[**2133-10-27**] 04:00AM ALT(SGPT)-89* AST(SGOT)-73* LD(LDH)-347*
CK(CPK)-892* ALK PHOS-98 TOT BILI-0.5
[**2133-10-27**] 04:00AM CK-MB-63* MB INDX-7.1* cTropnT-1.29*
[**2133-10-27**] 04:00AM ALBUMIN-3.8 PHOSPHATE-6.7*# IRON-57
[**2133-10-27**] 04:00AM calTIBC-273 FERRITIN-91 TRF-210
[**2133-10-27**] 04:00AM WBC-11.2* RBC-3.09*# HGB-9.8*# HCT-29.1*#
MCV-94 MCH-31.5 MCHC-33.5 RDW-16.3*
[**2133-10-27**] 04:00AM NEUTS-88.7* LYMPHS-7.2* MONOS-3.8 EOS-0.1
BASOS-0.1
[**2133-10-27**] 04:00AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2133-10-27**] 04:00AM PLT COUNT-208
[**2133-10-27**] 04:00AM RET AUT-4.6*
[**2133-10-27**] 03:17AM TYPE-ART PO2-414* PCO2-66* PH-7.29* TOTAL
CO2-33* BASE XS-3
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2133-10-29**] 05:12AM 7.4 2.83* 9.0* 26.2* 93 31.8 34.4
15.8* 149*
[**2133-10-28**] 03:37AM 9.7 2.79* 8.9* 26.0* 93 32.0 34.4
16.1* 169
[**2133-10-27**] 04:00AM 11.2* 3.09*# 9.8* 29.1*# 94 31.5 33.5
16.3* 208
.
PT/PTT/INR: [**2133-10-29**]: 27.8/33/2.9
.
Retic Count: [**2133-10-27**]: 4.6
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2133-10-29**] 05:12AM 97 66* 1.9* 137 3.2* 92* 36* 12
[**2133-10-28**] 03:37AM 84 66* 2.0* 133 4.0 90* 31 16
[**2133-10-27**] 01:28PM 65* 2.0* 4.7
[**2133-10-27**] 04:00AM 153* 65* 2.0* 133 5.6* 91* 31 17
.
CPK ISOENZYMES CK-MB MB Indx cTropnT proBNP
[**2133-10-29**] 05:12AM 33* 3.4 1.77*1
[**2133-10-28**] 03:37AM 39* 4.0 2.75*1
[**2133-10-27**] 08:15PM 32* 4.3 2.35*1
[**2133-10-27**] 01:28PM 31* 4.2 2.03*1
[**2133-10-27**] 04:00AM 63* 7.1* 1.29*1
.
.
Imaging:
CXR: [**2133-10-27**]: INDICATION: 64-year-old male status post NG tube
placement.
COMPARISON: Comparison is made to radiograph performed in the
same day, approximately one hour earlier.
FINDINGS: There is interval placement of the NG tube with the
tip lying within the stomach. Otherwise, the appearance of the
chest is unchanged.
.
[**2133-10-27**]: EKG: AF @72, nl axis, nl QTc, low voltages, diffuse
TWF, 1mm STD in V2-4 (new)
.
[**2133-10-27**]: TTE ECHO:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is moderately dilated. There is
hypokinesis of the basal half of the right ventricular free wall
preserved apical systolic function. There is abnormal systolic
septal motion/position consistent with right ventricular
pressure overload. The aortic root is mildly dilated. The aortic
valve leaflets (3) are moderately thickened. There is no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2133-8-28**], the
findings are similar. The prominent RV cavity enlargement and
free wall hypokinesis are similar and underestimated on the
prior study and suggestive of a primary pulmonary process
(pulmonary embolism, pneumonia, bronchospasm, etc.). The
estimated pulmonary artery systolic pressure is similar.
.
Brief Hospital Course:
This is a 64 yo male with recent drug induced
rhabdomyolosis/hepatitis complicated by respiratory failure (s/p
Trach/PEG) and ARF who is re-admitted with hypercarbic
respiratory failure.
.
Hypercarbic respiratory failure: On initial presentation, this
was most likely of mutifactorial etiology. Possibilites included
secondary to recent weaning off vent, continued respiratory
muscle weakness, increased abdominal girth (compressing
diaphragm), and standing sedating medications. Also, pt has RLL
opacity on CXR which may be aspiration pneumonitis vs. early
pneumonia. We held all sedating medications, diuresed the
patient and maintained him on standing nebulizers. 24 hours into
his admission, the patient's mentation and respiratory status
improved substantially. His vent was changed from AC to PS and
then taken off. His ABG improved from
His ABG improved from 7.29/66/414 to 7.46/44/84 as him mentation
improved. He was not empirically started on antibitics because
of lack of fever or increased WBC count. Pt was on trach mask
during the day and bipap at night. Diuresis was achieved with
10mg zaroxolyn followed by 140mg IV lasix. On day of discharge,
pt was started on Diamox, given his rising bicarb from 31 to 36.
Pt should be continued on 2 more days of diamox.
.
# Anasarca: Most likely secondary to right heart failure. Urine
protein to creatinine ratio was 0.2 with a serum albumin of 3.8
- no evidence for nephrotic syndrome. Echo showed worsened RV
function. Pt was diuresed with lasix and zaroxyln.
.
# RH failure: Unknown etiology. Most likely secondary to
pulmonary disease - DDx includes intermittent pulmonary
vasoconstriction 2/2 episodes of apnea, chronic thromboembolic
disease, pulmonary edema. Less likely secondary to LV
dysfunction, given disproportionate RV dysfunction on echo. Pt
needs a right heart cath at some point, once his renal function
improves and is stable. [**Month (only) 116**] also benefit from a Chest CT with
contrast.
.
# Elevated Tn: Pt had a Tn of 1.3 on admission, which increased
to 2.75. CK MB index was negative. This is most likely secondary
to demand ischemia (more likely RV than LV). Pt needs to be
aggressively diuresed. He may benefit from pMIBI and potential
cardiac cath as an outpatient.
.
# ARF: Most likely secondary to pre-renal state from being
intravascularly dry and underlying diabetic nephropathy. Pt's Fe
Urea was 11%, which is consistent with pre-renal status. Urine
eosinophils were negative. Creatinine remained stable with
diuresis. Pt should have his creatinine and lytes followed
daily.
.
# Anemia: Most likely dilutional in setting of significant total
body overload. No evidence of active bleeding; guiac negative.
Iron studies suggestive of iron deficiency anemia. Pt was
started on iron supplementation. Pt needs continued outpt w/u of
anemia.
.
#. Afib: Pt was continued on BB for rate control. Coumadin was
held in setting of supratherapeutic INR. INR on discharge was
2.9. Coumadin should be restarted tomorrow.
.
# DM: ISS
.
# HTN: continue hydralazine and lopressor
.
# CAD: continue asa, bb
.
# Depression: continue citalopram
Medications on Admission:
albuterol inh
Ascorbic acid 500mg qd
Citalopram 20mg qd
Lasix 140mg IV bid
Gabapentin 100mg qd
Hydralazine 20mg qid
Insulin ss
Metolazone 5mg qd
Lopressor 100mg [**Hospital1 **]
Miconazole powder
MVI qd
Olanzapine 2.5mg qd
Protonix 40mg qd
Papain/urea ointment
Warfarin qd
Zinc 220mg qd
Tylenol
ASA 325mg qd
Bisacodyl 10mg qd
ativan 0.5mg qhs
Nitroglycerin prn
Ondansetron 4mg q4h prn
Percocet prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
15. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Furosemide 10 mg/mL Cartridge Sig: One [**Age over 90 11578**]y (180)
mg Injection twice a day: please give 30 minutes after zaroxyln.
19. Acetazolamide Sodium 500 mg Recon Soln Sig: Two Hundred
Fifty (250) mg Injection once a day for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Hypercarbic respiratory failure
Anasarca
RH Failure
ARF
Demand ischemia vs. NSTEMI
Anemia
Discharge Condition:
Stable respiratory status.
Discharge Instructions:
Please return to the ED if you develop altered mental status or
respiratory distress.
Please follow up with your PCP.
Please continue all of your medications.
Followup Instructions:
Follow up with your primary care doctor as needed.
Follow up with cardiology within 1 month. Call ([**Telephone/Fax (1) 2037**] to
schedule an appointment.
|
[
"V58.61",
"410.71",
"707.05",
"V44.0",
"428.0",
"427.31",
"250.40",
"428.33",
"V45.81",
"518.81",
"583.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13184, 13263
|
7958, 11075
|
326, 332
|
13397, 13426
|
3388, 7935
|
13635, 13795
|
2895, 2936
|
11523, 13161
|
13284, 13376
|
11101, 11500
|
13450, 13612
|
2951, 3369
|
255, 288
|
360, 2354
|
2376, 2758
|
2774, 2879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,622
| 183,996
|
14522
|
Discharge summary
|
report
|
Admission Date: [**2176-9-29**] Discharge Date: [**2176-10-25**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
S/P Fall at Nursing Home now unresponsive on Coumadin, has hx of
subdural hematoma
Major Surgical or Invasive Procedure:
Left side craniotomy for evacuation of subdural hematoma
History of Present Illness:
Dr. [**Known lastname 13662**] is and 86 year old woman with a history of atrial
fibrillation, type II diabetes, and hypothyroidism who initially
presented to [**2176-8-5**] [**Hospital1 18**] for a subdural hematoma, drained by
neurosurgery. She was then transferred to [**Hospital1 **] for
rehabilitation on [**8-12**] on levaquin for ?UTI. On [**8-13**] she was
started on cefepime for presumed pneumonia. She was then
re-admitted to the to the medicine service on [**2176-8-14**] for mental
status changes that were attributed to both a pneumonia and a
UTI. She was treated initially with zosyn and vanco and then
cefepime and was treated through [**8-23**]. MRI also showed L
insular and L pca infarctions. She was re-started on her
coumadin for her afib. She was readmitted in [**Month (only) 216**] for mental
status changes and a thigh hematoma then transferred back to
[**Hospital1 **] for continued care she had been restarted on Coumadin
and reportably neurologically doing well. On [**9-28**] she had a fall
at the nursing home and became progressively less responsive.
Of note Ms [**Known lastname 13662**] was DNR/DNI and health care proxy Mrs [**Name (NI) **]
overturned the order and wished to proceed with the surgery
Past Medical History:
Subdural hematoma s/p craniotomy ([**7-/2176**]) w/ residual left-sided
hemiparesis.
Atrial fibrillation
Type II diabetes
Hypothyroidism
Hypertension
Congestive heart failure
UTI
Thigh Hematoma
Social History:
single, former professor [**First Name (Titles) **] [**Last Name (Titles) **]-linquistics at [**University/College **]
Universtiy. Healthcare proxy is [**Name (NI) 1494**] [**Name (NI) 42891**] [**Telephone/Fax (1) 42892**].
Family History:
NC
Physical Exam:
VS: 97.4 144/77, HR 92
Pul: Clear bilaterally
Card: RRR
Abdomen: soft non distended
Neuro: Did not follow commands, eyes do not track, withdraws to
pain in bilateral lower extremeties and left upper extremeties
no withdrawl of RUE
Pertinent Results:
[**2176-9-29**] 09:16AM TYPE-ART PO2-210* PCO2-42 PH-7.40 TOTAL
CO2-27 BASE XS-1 COMMENTS-ADD ON ABG
[**2176-9-29**] 09:16AM O2 SAT-98
[**2176-9-29**] 09:12AM GLUCOSE-184* UREA N-19 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-19
[**2176-9-29**] 09:12AM WBC-17.1* RBC-3.64*# HGB-11.0* HCT-31.9*#
MCV-88 MCH-30.3 MCHC-34.5 RDW-14.3
[**2176-9-29**] 02:45AM PT-20.7* PTT-30.2 INR(PT)-2.8
[**2176-9-29**] 07:00AM PT-15.2* PTT-29.4 INR(PT)-1.5
[**2176-9-29**] 09:12AM PT-14.0* PTT-27.8 INR(PT)-1.3
Brief Hospital Course:
Ms. [**Known lastname 13662**] was brought to the Operating room and underwent a
left sided craniotomy after her INR was reversed to 1.3.
Post-operatively she brought to the surgical ICU where her BP
was kept less than 140, INR less than 1.3. She had a subdural
drain in place.
On [**9-30**] an MRI was done that showed an acute infarction
involving the left MCA (posterior branch and portions of the
anterior branches), left PCA, and left basal ganglia. These
findings suggest compromise, likely embolic, of the M1 branch.
Stable left temporal hemorrhagic contusion. Acute hemorrhagic
extension of the previously known subacute right PCA infarction.
Stable appearance of bilateral subdural hematomas.
Neurologically her exam was poor, she would withdraw lower
extremeties to painful stimuli, toes were upgoing. On [**10-2**] she
was noted to be deceberate posturing in upper extremeties which
progessed to posturing of all extremeties, pupils were larger
4.5 and 4.0. Her JP drain was discontinued on [**10-4**].
On [**10-3**] Ms [**Known lastname 13662**] developed a fever a full fever work up
including a bilateral lower extremetity ultrasound which showed
bilateral DVT's for which she had a IVC filter placed on [**10-5**].
She was also treated for a left lower pneumonia and had a 10 day
treatment of Levo and Cefapime and Fluconazole for yeast in
urine.
Immediate discussions were started with [**Hospital **] [**Known lastname 13662**] health care
proxy, Dr [**First Name4 (NamePattern1) 1494**] [**Last Name (NamePattern1) 42891**] and [**Name (NI) **] [**Last Name (un) **] about the severity
of Ms [**Known lastname 13662**] brain injury and that she would most likely remain
in a persistent vegitative state and not regain consciousness
needing 24 hour nursing care. Given this information Ms
[**Name13 (STitle) 42891**] wanted to proceed caring for Ms [**Known lastname 13662**] requesting a PEG
and trach.
A head CT on [**10-11**] showed evolution of left middle cerebral
artery infarct. No evidence of new hemorrhage. Residual
bilateral subacute/chronic subdural hematomas. Chronic right
posterior cerebral artery infarct.
Ethics committee was involved however Ms [**Name13 (STitle) 42891**] would not meet
with our team and ethics team, she continued to want full care
to continue.
During the last 2 weeks of her hospital course she would open
her eyes to noxious stimuli and deceberate posture to
suctioning. She was treated for Staph aureus coag + blood
cultures and needs 14 days total of Vancomycin ends [**10-31**].
She was also treated for C-Diff for 14 days with Flagyl ends
[**11-2**].
Her tube feeds are at goal of Promote with fiber at 60 hr and
vent settings of CPAP 10 pressure support and 5 of Peep and FiO2
of 40%
Medications on Admission:
Medications prior to admission:
- Coumadin 5 QD
- Keppra 1000 qAM and 1500qHS
- Digoxin 0.125 QD
- Zestril 7.5 QD
- Lantus 12 qHS and SSI
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subdural Hematomas with Left MCA infarct and chronic right
posterior cerebral artery infarct
Discharge Condition:
Neurologically poor exam, deceberate postures will open eyes to
stimulation, pupils reactive
Discharge Instructions:
Return to ER for any changes
Followup Instructions:
No further neurosurgical follow up needed
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2176-10-25**]
|
[
"008.45",
"434.11",
"041.11",
"250.00",
"518.5",
"112.2",
"V58.61",
"453.8",
"438.20",
"427.31",
"244.9",
"E884.4",
"428.0",
"790.7",
"486",
"783.7",
"852.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"38.93",
"99.07",
"96.6",
"38.7",
"01.31",
"43.11",
"88.65"
] |
icd9pcs
|
[
[
[]
]
] |
5935, 6014
|
2985, 5746
|
350, 408
|
6151, 6246
|
2429, 2962
|
6324, 6493
|
2159, 2163
|
6035, 6130
|
5772, 5772
|
6270, 6301
|
2178, 2410
|
5804, 5912
|
228, 312
|
436, 1682
|
1704, 1899
|
1915, 2143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,623
| 108,897
|
20655+20656
|
Discharge summary
|
report+report
|
Admission Date: [**2150-2-21**] Discharge Date: [**2150-3-6**]
Date of Birth: [**2107-10-10**] Sex: M
Service:
This dictation covers hospital stay through [**2150-3-6**].
Remainder of hospital course will be dictated by subsequent
intern.
HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old
male with no significant past medical history who presents
with 3 weeks of fevers, diarrhea, and abdominal pain. The
patient was in his usual state of health until approximately
3 weeks prior to admission when he noted the onset of left
lower quadrant abdominal pain. He described it as a
squeezing or wringing sensation, which did not radiate. He
also noted profuse diarrhea with approximately 5 to 8 bowel
movements per day. He described his stool as tan and watery
and intermittently greenish in color. He also noted high
fevers as high as 102 at home. He then went to an outside
hospital emergency department for evaluation. He was
admitted for workup. He had an abdominal CT, which did note
some large lymph nodes in his abdomen, but otherwise no
focality. He also had an upper GI series with a small bowel
followthrough study, which showed some duodenal thickening,
and otherwise was unremarkable. The patient was started on
antibiotics, initially Cipro and then switched to Flagyl. He
was discharged on a regimen of p.o. Flagyl to be taken for 10
days. Initially, he had several days without diarrhea on
this regimen and also improvement in his fevers for several
days; however, then his diarrhea returned as above. In
addition to his loose green stools, which he noted to be foul
smelling, and he also had increased flatulence. He denied
any bright red blood per rectum or melena. His abdominal
pain continued as noted as above. He also continued to have
high fevers to 102 for approximately the week prior to
admission. He also noted some chills and night sweats with
these fevers. He had approximately a 10-pound weight loss
over the previous few weeks. He also noted general fatigue
and weakness and malaise since his symptoms began.
REVIEW OF SYSTEMS: Review of systems are positive and are as
per above. He also notes mild anorexia over the previous few
weeks. No history of similar symptoms. No nausea or
vomiting. No shortness of breath, cough, chest pain,
headache, dizziness or other complaints.
PAST MEDICAL HISTORY: Herniated disc, status post discectomy
in [**12-13**].
History of abnormal LFTs, approximately 6 years prior to
admission, reportedly with negative liver biopsy.
History of mononucleosis in [**8-14**].
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No alcohol, drug or tobacco use. No recent
travel. No pets.
PHYSICAL EXAMINATION: On admission, VITAL SIGNS:
Temperature 102.2 degrees, pulse 103, blood pressure 116/76,
and respirations 20. GENERAL: A cachectic and ill-appearing
male, appearing mildly uncomfortable. HEENT: Pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements intact. Sclerae anicteric. Bilateral
temporal wasting and dry mucous membranes. CARDIOVASCULAR:
Regular rate. No murmurs, rubs or gallops. LUNGS: Clear to
auscultation and equal bilaterally. ABDOMEN: Positive bowel
sounds and soft. Minimally tender to palpation in the left
lower quadrant without any rebound tenderness or guarding.
No hepatosplenomegaly. EXTREMITIES: Warm and dry. No
clubbing, edema or cyanosis. NEUROLOGICAL: Nonfocal. SKIN:
Very faint trace maculopapular rash on bilateral upper
extremities with dry skin.
LABORATORY DATA: White count 9.8, hematocrit 39.9, and
platelets 441,000. Differential, 83 neutrophils, 14
lymphocytes, and 2 monocytes. Sodium 135, potassium 3.5,
chloride 96. BUN 10 and creatinine 0.7. ALT 62, AST 96,
amylase 43, alkaline phosphatase 397, and total bilirubin
0.7.
HOSPITAL COURSE: Abdominal pain. The patient admitted with
approximately 3 weeks of left lower quadrant abdominal pain
in concurrence with high-grade temperatures and profuse
diarrhea. He had had abdominal imaging at an outside
hospital and an empiric course of antibiotics without any
focal findings nor any improvement in his symptoms. At the
time of presentation, the patient did not have any focal
findings on his abdominal exam, however, there was concern
for underlying pathology. Given his ill-appearance, high-
temperatures, and constellation of clinical symptoms, there
was concern for an acute infection following attainment of
cultures. He was then started empirically on Levaquin and
Flagyl. Repeat abdominal CT was obtained, which again showed
diffuse lymphadenopathy in the mesentry with the largest node
seen in the left lower quadrant measuring approximately 2.9 x
2.0 cm. There were, otherwise, no focal findings on the CT.
Multiple laboratory studies were sent. These were
significant only for an elevated LDH, which was found to be
394. On admission, his LFTs were otherwise markedly
elevated. On initial presentation, a GI consult was
obtained. The patient continued to have progressive
abdominal pain and was somewhat tender on exam. Given his
some abnormal findings on CT and continued diarrhea, the
patient underwent an exploratory laparotomy. Upon opening of
the abdomen, we noted to have thick purulent fluid in his
abdomen, and he was then converted to an open abdominal
surgery. He was found to have approximately 20 masses in his
abdomen and 4 areas of microperforation, which were resected.
Multiple biopsies were also obtained. These biopsies later
came back showing celiac sprue associated T-cell lymphoma; in
addition, his anti-TIG antibody was positive.
Hematology/Oncology consult was obtained with plans for the
patient to begin chemotherapy following clinical
stabilization. He did complete a 10-day course of
antibiotics given the findings in his abdomen. He did
continue to spike fevers following antibiotics. Repeat
cultures and other infectious workup was nonrevealing and
thought his fevers were most likely related to his oncologic
diagnosis as opposed to any active infection. He also
continued to have diarrhea, which also was attributed to his
oncologic diagnosis.
Celiac sprue associated T-cell lymphoma. The patient newly
diagnosed with lymphoma at this hospitalization as per above.
An Oncology consult was obtained. At the time of dictation,
the patient was to be transferred to the Bone Marrow
Transplant Service for initiation of chemotherapy.
Celiac sprue. The patient newly diagnosed with celiac sprue.
He was placed on a low-gluten diet and had multiple nutrition
counseling sessions. Multiple vitamin levels were sent
including calcium and vitamin D levels, and all of these came
back normal. Given his weight loss and uncompromised
clinical status, he was started on TPN for supplemental
nutrition. His TPN was cycled in the evenings with the
patient taking orals during the day.
Infection. The patient was status post abdominal exploratory
laparotomy, which was then converted to open surgery given
normal findings on exam. The patient developed an abdominal
wound infection at the site of surgical closure, this was
also complicated by wound dehiscence. Surgery Service, which
had performed the abdominal surgery, continued to follow
this. Following completion of IV antibiotics and dressing
changes, his wound did slowly heal. At the time of
dictation, his wound infection continues to resolve.
Tachycardia. The patient was sinus tachycardic throughout
the hospitalization, which was more pronounced in the setting
of his fevers. He had multiple EKGs, which showed that he
was in sinus tachycardia. He also underwent an echo.
Initially, there had been concern for a pericardial effusion
following a CT; however, on echo found this to be an artifact
and there was no evidence of a pericardial effusion. His
tachycardia was thought to be most likely due to his
underlying malignancy. He continued to receive supportive
care and had no symptoms or hemodynamic compromise related to
his tachycardia.
Infectious Disease. The patient was febrile throughout the
hospital stay. Multiple blood cultures were obtained as well
as urine. Chest x-ray and CT scans with no other foci of
infection noted. He did complete empiric antibiotics given
bowel perforations. Given the negative infectious workup,
his fevers were thought to be most likely due to his
underlying malignancy. He continued to receive Tylenol,
cooling blankets and other supportive care as needed for his
fevers.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 33899**]
Dictated By:[**Last Name (NamePattern1) 14186**]
MEDQUIST36
D: [**2150-5-18**] 10:25:52
T: [**2150-5-18**] 18:28:23
Job#: [**Job Number 55186**]
Admission Date: [**2150-2-21**] Discharge Date: [**2150-3-12**]
Date of Birth: Sex:
Service:
SERVICE: The patient was initially admitted to the medicine
service and then discharged from the bone marrow transplant
service.
HISTORY OF PRESENT ILLNESS: This is a 42-year-old male with
no significant past medical history who presented after 3
weeks of intermittent fevers, diarrhea, and left lower
quadrant abdominal pain. On [**2150-2-2**], the patient began to
experience abdominal pain, fever, nausea, vomiting, and
diarrhea. The patient went to the [**Hospital1 2436**] ED and was
admitted there. At the ED, he had a CT, which showed large
lymph nodes in the abdomen. He has also done upper GI
series, which was negative and a small bowel follow through,
which showed some thickened bowel. The patient was initially
started on Cipro and then switched to Flagyl. The patient
states his fevers lasted for 8 days and his diarrhea slowed
at about the same time. He continued Flagyl at home for
another 10 days. He described his diarrhea as loose, green,
and extremely foul smelling, no blood or melena, but
increased gas. On Monday, prior to admission, the patient
began to experience fevers again. His temperature broke with
Tylenol. The patient also noted to have rash at this time.
He experienced abdominal pain again in the left lower
quadrant. On the 10th, he began to experience increasing
chills and fevers and by the 11th, he was experiencing night
sweats and making up temperatures. He also admits to some
weight loss over the last 3 weeks, approximately 10 pounds.
He has had some weakness. The patient has had no history of
GERD or history of H. pylori. He has had no dysphagia or
early satiety, but decreased appetite. The patient has no
history of IVD and no HIV risk factors.
PAST MEDICAL HISTORY: Disc surgery.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married, with several
children. He works at an office job. He is a nonsmoker,
nondrinker, and no history of IV drug use.
PHYSICAL EXAMINATION: Temperature currently was 98.6, T-
maximum 102.2, pulse 103, blood pressure 116/74, and
respiratory 20. In general, in no acute distress, resting
comfortably, and appears anxious. PERRL, EOMI. Mucous
membranes dry. Neck, no JVD. Trachea midline. Thorax clear
to auscultation bilaterally. No wheezes, crackles, or rales.
Cardiovascular, tachycardic, no murmurs, rubs, or gallops.
Abdomen, bowel sounds present, tender to palpation on left
lower quadrant. Nondistended. No tympany. Guaiac negative.
Extremities, warm and well perfused. No cyanosis, clubbing,
or edema. A 2 plus dorsalis pedis and radial pulses
bilaterally. Neuro, no focal deficits. Cranial nerves
intact.
LABORATORY DATA: Significant for white count of 9.8, 83
percent neutrophils, 14 percent lymphs, 2 percent monos,
hematocrit of 39.9, and platelets of 421. LFTs significant
for alkaline phosphatase of 397 and total bilirubin of 0.7.
UA showed small amounts of blood with moderate bacteria. CT
showed mesenteric lymphadenopathy.
HOSPITAL COURSE: GI was consulted on admission. The patient
had multiple tests sent, an LDH was initially sent, which was
396. The patient's LFTs were followed. His alkaline
phosphatase trended down, and his transaminases were never
really elevated. The differential was for malignancy,
inflammatory bowel disease, or some kind of infection. The
patient was tested for HIV initially. Surgery was consulted
for lymph node biopsy. On [**2150-2-22**], the patient went for
lymph node biopsy. At the time of surgery, the surgeons
found in a small bowel multiple perforations and masses
adhered to the bowel, and this required four resections. The
patient also had an omental biopsy and a lymph node biopsy.
The patient was hemodynamically stable during his course in
the OR and went to the trauma SICU following surgery. The
patient was then transferred to the Surgery service and
followed there, as well as in addition followed by Medicine.
The pathology eventually returned as a T-cell lymphoma and
celiac sprue. At that time, Hematology-Oncology was
consulted. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] saw the patient and immediately
recommended TPN for aggressive nutrition control following
the LDH and for chemotherapy. The patient was transferred to
the BMT service on approximately [**2150-3-7**]. While on the BMT
service, the patient continued to be followed by surgery and
was also followed by ID notes below. The patient was started
on chemo on [**2150-3-10**]. He was started on CHOP. He tolerated
well without problems, and plans were made for the patient to
have further CHOP in the future. However, the patient's
prognosis with this aggressive disease was relatively poor
even with aggressive chemotherapy.
Infectious disease. The patient had fevers prior to
admission and then persistently had fevers. In addition, the
patient had a wound infection following his laparotomy. The
patient continued on the surgery service; when transferred to
BMT, an ID consult was obtained. The patient had multiple
blood cultures, all of which were gram negative in addition
to urine cultures and fungal cultures. He had hepatitis
serologies sent as well as multiple Clostridium difficile and
ova and parasites. The patient had received ampicillin,
levofloxacin, Flagyl following his surgery, and several days
after surgery did have one time bandemia. ID felt that the
patient was not currently infected, however, were concerned
about bacterial seeding into the abdomen when his tumor
shrinks from CHOP. Therefore, ID recommended prophylactic
antibiotics with Unasyn while starting chemotherapy and as an
outpatient to switch to an oral antibiotic. Following CHOP,
the patient defervesced significantly, and it was felt that
his fevers were consistent with his severe lymphoma.
Cardiac. The patient was persistently tachycardic during the
entire hospital course. He did receive an echo one time,
which showed a small pericardial effusion though this was
read as possibly an artifact. The patient did have CTA
during his hospital course, which demonstrated no pulmonary
embolism. The tachycardia was cleared to be compensatory to
his fever and malignancy, and Cardiology consultation did not
feel that treatment of this sinus tachycardia was necessary
despite having persistent tachycardia to the 150s. Again,
the patient's heart rate did decrease following CHOP.
Nutrition. The patient's albumin was quite low even on
admission and on discharge, his albumin was 2.7. He was
started on TPN while in-house and then cyclic TPN on
discharge and this was to continue at least for the present
time. The patient was also educated about a gluten-free diet
given his celiac sprue disease.
DISCHARGE DIAGNOSES: T-cell lymphoma.
Celiac sprue.
Small bowel perforation.
DISCHARGE CONDITION: Stable.
FOLLOW-UP: The patient is to follow up with Dr. [**First Name (STitle) **] on
[**2150-3-6**], R.N. [**Doctor Last Name **] on [**2150-3-6**].
DISCHARGE MEDICATIONS:
1. Allopurinol 100 mg p.o. q.d.
2. Dilaudid 2 mg 1 to 2 tablets p.o. q.4-6h. p.r.n. pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 36051**]
Dictated By:[**Last Name (NamePattern1) 2864**]
MEDQUIST36
D: [**2150-6-17**] 16:47:47
T: [**2150-6-18**] 07:45:17
Job#: [**Job Number **]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,611
| 171,161
|
29183
|
Discharge summary
|
report
|
Admission Date: [**2122-12-6**] Discharge Date: [**2122-12-21**]
Date of Birth: [**2056-4-30**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Ceftriaxone
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Fever, Anemia
Major Surgical or Invasive Procedure:
Tunneled dialysis catheter removed, VIP triple lumen temporary
dialysis catheter placed
History of Present Illness:
This is a 66yo female with MMP including Lupus, ESRD on HD, and
peptic ulcer disease s/p Billroth gastrectomy in [**2118**] who was
discharged from [**Hospital1 18**] on [**11-27**] after an admission for e.coli
infection of right loop graft who now presents with fever to
101, relative hypotension (SBP 90s) and acute drop in hematocrit
from 26 -> 19 and guiaic positive stools. The patient was
discharged on ceftriaxone for her wound infection and oral vanc
for history of c.diff colitis. On [**12-5**] patient noted to be
febrile and hypotensive following hemodialysis. Pt switched from
ceftriaxone to cefepime. This am patient patient was found to
have a hematocrit of 19.1 down from 26.2 on [**12-3**] and a platelet
count of 27 down from 107 on [**12-3**]. In setting of acute
hematocrit drop with guiaic positive stools and difficult IV
access, pt was transferred back to [**Hospital1 18**] for further management.
.
In the ED, the pt's vitals were T: 101.1 BP: 98/56 P: 122 RR: 16
O2: 95% RA. Patient given 1L NS, 1gm Vanc IV, 1 unit pRBCs and
650 mg Tylenol and 25mg Benadryl IV for itchiness. Pt's temp
went as high as 102.1. Stools in diaper were not noted to be
grossly bloody but were guiaic positive. Pt transfered to the
ICU for further management.
.
ROS: Positive for non-productive cough, itching for the last 2
weeks, intermittent chest pain, and some abdominal discomfort.
Pt states that she has had diarrhea for the last 2 weeks. Pt
states that she feels depressed.
Past Medical History:
1. s/p CVA ([**5-3**], with left facial drop)
2. HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin,
PF4+ in [**4-4**])
3. TTP (s/p plasmapheresis *10)
4. ESRD on HD (first HD, [**2121-9-5**], HD three days/week)
5. VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid)
6. C. difficile colitis with h/o failed flagyl
7. SLE (diagnosed [**2119**])
8. HTN
9. ACD (baseline Hct from [**Date range (1) 70208**], 26---37)
10. Bowel and bladder incontinence
11. Peripheral vascular disease
12. Diverticulosis
13. Peptic ulcer disease
14. s/p Billroth II gastrectomy ([**2118**])
15. Gout
16. ETOH abuse
17. Depression
18. s/p hysterectomy
19. h/o PE
Social History:
She came from [**Hospital1 **] this admission. Prior to going to nursing
home/rehab she was living alone. Her husband died 3 years ago.
she has a son and 2 daughter, [**Name (NI) 24592**] and [**Name (NI) **]. Her son lives
locally with his wife. they are supportive. used to work as [**Name8 (MD) **]
RN. Smoked for 8 years about [**1-31**] cig a day. quit about 40 years
ago. Alcohol states
quit 1 year ago, previous heavy use. Her daughter is her HCP.
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.5 BP: 93/60 HR: 120 RR: 12 O2sat: 100%
GEN: restless, lip smacking and dyskinesia of mouth
HEENT: NC, AT, PERRL, anicteric, MM dry
RESP: some crackles at bases, difficult to examine as pt in
constant motion
CV: tachycardic, S1 and S2 wnl, difficult to examine as pt in
constant motion
ABD: nd, +b/s, soft, nt
EXT: no c/c/e, warm
SKIN: healing wound on right arm with health-appearing
granulation tissue
NEURO: able to answers questions, tardive dyskinesia, constant
motion
Pertinent Results:
[**2122-12-6**] 11:30AM WBC-3.1* RBC-2.17* HGB-6.8* HCT-20.5* MCV-95
MCH-31.1 MCHC-32.9 RDW-19.1*
[**2122-12-6**] 11:30AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
STIPPLED-1+
[**2122-12-6**] 11:30AM PLT SMR-LOW PLT COUNT-125*#
[**2122-12-6**] 11:30AM calTIBC-133* FERRITIN-GREATER TH TRF-102*
[**2122-12-6**] 11:30AM PHOSPHATE-1.3* IRON-36
[**2122-12-6**] 11:30AM GLUCOSE-110* UREA N-43* CREAT-3.8*
SODIUM-130* POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-29 ANION GAP-11
[**2122-12-6**] 11:41AM LACTATE-1.4 K+-5.4*
.
CXR: [**12-6**] - Opacity within the right lung base is concerning for
pneumonia.
Brief Hospital Course:
A/P: This is a 66yo female with a PMH significant for Lupus,
ESRD on HD, HIT, and and recent e.coli wound infection.
.
1. Acute Hematocrit Drop - hct from 26 -> 19 from [**12-3**] to [**12-6**].
The patient had melanotic stools and was guiaic positive. Pt
anticoagulated on coumadin. INR 1.7. Pt has a history of peptic
ulcer disease s/p Billroth procedure. The patient received 2
units of PRBCs while in the [**Hospital Unit Name 153**] and was followed by the GI
consult team. She was on anticoagulation at the time for LUE
clots however this was stopped. Given her tenuous condition and
the stabilization of hematocrit it was decided to hold on
endoscopy during the interim. Plan for outpt endoscopy. The
patient was discharged off coumadin due to significant GI bleed
on presentation.
On outpatient basis, would reconsider risk benefit analysis
for anticoagulation for LUE clots if patient does not have any
further GI bleeding or significant thrombocytopenia. Outpatient
scope.
Patient discharged off coumadin.
2. Fevers - Pt febrile on presentation to 102.5 with hypotension
concerning for sepsis. The patient had a history of E coli graft
infection in [**2122-10-29**]
s/p removal of the graft [**11-20**] with culture growing E coli who
was admitted [**12-6**] with fever. She had been admitted [**11-18**] for
fever and had an old loop graft removed [**11-20**] as it was thought
to have been infected. She was discharged to [**Hospital1 **] with plans
to complete a course of antibiotics through [**12-18**] with
ceftriaxone. At the rehab on the day prior to admit was febrile
and hypotensive so was switched to cefepime, however had
persistent fever, pancytopenia and GI bleeding so transferred.
She was thought to have possible pneumonia and so was given
vancomycin and she was admitted to the MICU and initially her GI
bleed was managed without endoscopy. She was thought to have C
diff though her toxin assays were all negative. She was started
onto vancomycin orally and IV flagyl on [**12-7**]. As she had a
marked eosinophilia, she was switched from ceftriaxone to
cefepime for coverage of her E coli graft infection. The rash
persisted and she was switched to Zosyn on [**12-9**]. She remained
afebrile with a normal white count and was transferred to the
floor on [**12-11**].
She was improving overall, maintained on a regimen of oral
vancomycin, IV flagyl, Zosyn and IV vancomycin. On [**12-18**], the
day
she had her temporary catheter changed to a tunneled catheter,
she was noted to have a temperature to 101.2. Given that she
had been adequately treated for one month for the e coli
infection and 10 days for the PNA, it was decided to stop all
antibiotics and monitor for signs of infection.
On discahrge, the patient was afebrile for over 36 hours after
discontinuation of all abx. Patient had [**12-20**] blood cxs drawn
in dialysis, NGTD.
3. ESRD - h/o of lupus, on HD [**Name (NI) 12075**], pt appeared very dry,
hypophosphatemic and hyponatremic at presentation. These issues
resolved after renal management with dialysis and tunnel line
placement.
Next dialysis session scheduled for [**12-23**].
# Eosinophilia - NEW, differential includes drug reaction v.
parasitic v. heme/bone marrow malignancy v vasculitis v adrenal
insufficiency. Cephalosporins and BBlockers can cause
eosinophilia. Time frame of pruritis correlates with
administration of ceftraixone. Resolved following
discontinuation of cefriaxone and high dose steroids.
# Pruritis - 2 week time course, whole body, consider allergic
drug reaction v. uremic pruritus v. cholestatic v. other. Has
responded best to atarax.
.
# H/O DVTs and PE - on coumadin, however, Pt developed DVTs and
PE insetting of supratherapeutic INR. per records pt has an IVC
filter, h/o of HIT
-patient to restart coumadin on day after discharge (was off it
for several days before for tunnel line placement and
thrombocytopenia).
# Thrombocytopenia - long history of thrombocytopenia, h/o HIT,
TTP and ITP. likely due to lupus or marrow suppressive drugs
- no schistos on smear
- resolving, on discharge 138K.
.
Neutropenia - neutropenic at baseline, however, never before
below 2. Could be due to marrow suppressive drugs v. known
autoimmune disease. Last bone marrow biopsy [**8-4**]. Likely due to
cephalosporin use
Resolved during hospital course.
.
# Tardive Dyskinesia - Followed by neurology as an outpatient.
Onset ~ 6 weeks ago. Have d/c'd zofran as associated with
extrapyramidal movements
- continue benztropine and clonazepam
-patient discharged on haldol 1.5 mg po tid.
Medications on Admission:
1. Cholestyramine-Sucrose 4 gram Packet [**Month/Year (2) **]: One (1) Packet PO
DAILY
2. White Petrolatum-Mineral Oil Cream [**Month/Year (2) **]: One (1) Appl
Topical [**Hospital1 **]
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY
5. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H as
needed.
7. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
8. Mirtazapine 15 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS
9. Ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One Tablet,
Rapid Dissolve PO TIDAC
10. Clonazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS
11. Benztropine 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
12. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Hospital1 **]:
One (1) Intravenous Q24H: Continue through
[**2122-12-18**].
13. Morphine 1 mg/mL Solution [**Month/Day/Year **]: [**12-30**] Injection q4hrs PRN as
needed for pain.
14. Metamucil Powder [**Month/Day (2) **]: One (1) packet PO once a day.
15. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: 1 PO twice a
day.
16. Protonix 40 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (3) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
.
Discharge Medications:
1. Haloperidol 0.5 mg Tablet [**Telephone/Fax (3) **]: Three (3) Tablet PO TID (3
times a day).
2. B-Complex with Vitamin C Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO
DAILY (Daily).
3. Mirtazapine 15 mg Tablet [**Telephone/Fax (3) **]: 0.5 Tablet PO HS (at bedtime).
4. Clonazepam 0.5 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Benztropine 1 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO TID (3 times a
day).
6. Zinc Oxide-Cod Liver Oil 40 % Ointment [**Telephone/Fax (3) **]: One (1) Appl
Topical PRN (as needed).
7. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
[**Telephone/Fax (3) **]: One (1) Powder in Packet PO DAILY (Daily).
8. Cortisone 1 % Cream [**Telephone/Fax (3) **]: One (1) Appl Topical QID (4 times a
day) as needed for pruritis.
9. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID
(2 times a day).
10. Hydroxyzine HCl 25 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
11. Camphor-Menthol 0.5-0.5 % Lotion [**Telephone/Fax (3) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for pruritis.
12. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection
ASDIR (AS DIRECTED): TO BE ADMINISTERED DURING DIALYSIS PER
[**Hospital1 18**] DIALYSIS GUIDELINES.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
14. Amlodipine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
16. Sodium Citrate Liquid [**Last Name (STitle) **]: Three (3) ML Miscellaneous
ASDIR (AS DIRECTED) as needed for dialysis use only: PER RENAL
DURING DIALYSIS.
1. Haloperidol 0.5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3
times a day).
2. B-Complex with Vitamin C Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
3. Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime).
4. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Benztropine 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
6. Zinc Oxide-Cod Liver Oil 40 % Ointment [**Last Name (STitle) **]: One (1) Appl
Topical PRN (as needed).
7. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
[**Telephone/Fax (3) **]: One (1) Powder in Packet PO DAILY (Daily).
8. Cortisone 1 % Cream [**Telephone/Fax (3) **]: One (1) Appl Topical QID (4 times a
day) as needed for pruritis.
9. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID
(2 times a day).
10. Hydroxyzine HCl 25 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
11. Camphor-Menthol 0.5-0.5 % Lotion [**Telephone/Fax (3) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for pruritis.
12. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection
ASDIR (AS DIRECTED): TO BE ADMINISTERED DURING DIALYSIS PER
[**Hospital1 18**] DIALYSIS GUIDELINES.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
14. Amlodipine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
16. Sodium Citrate Liquid [**Last Name (STitle) **]: Three (3) ML Miscellaneous
ASDIR (AS DIRECTED) as needed for dialysis use only: PER RENAL
DURING DIALYSIS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
e coli bacteremia
PNA
diarrhea
tardive dsykinesia
ESRD on HD
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
You were admitted with an infected graft and placed on
antibiotics. You were treated for pnuemonia and presumed C.diff
infection. You were continued on your HD.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2123-3-22**] 1:00
PATIENT NEEDS TO SCHEDULE F/U APPT WITH PCP [**Last Name (NamePattern4) **] 2 WEEKS to
DISCUSS ANTICOAGULATION.
|
[
"288.3",
"V12.51",
"V45.1",
"698.8",
"582.81",
"V58.61",
"710.0",
"578.9",
"333.85",
"E947.8",
"287.5",
"274.9",
"263.9",
"285.1",
"585.6",
"790.7",
"443.9",
"041.4",
"787.91",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14152, 14231
|
4313, 8898
|
304, 393
|
14335, 14355
|
3629, 4290
|
14566, 14824
|
3089, 3107
|
10358, 14129
|
14252, 14314
|
8924, 10335
|
14379, 14543
|
3122, 3610
|
251, 266
|
421, 1910
|
1932, 2599
|
2615, 3073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 168,943
|
51960
|
Discharge summary
|
report
|
Admission Date: [**2157-11-16**] Discharge Date: [**2157-11-21**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Fluid overload and Electrolyte abnormalities
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 107485**] is a 61 year-old man with a history of DM2, HTN,
ESRD on HD (T/Th/Sat), atrial tachycardia, cocaine abuse. He
was recently admitted [**9-/2157**] for pneumonia complicated by afib
with RVR into the 190s. He was discharged to complete 10 days
of levofloxacin and return to his previous doses of amiodarone
and diltiazem. It is unclear if he was taking these. He has
been actively using crack cocaine, most recently yesterday. He
missed two HD sessions and then developed palpitations so he
activated EMS. He is unable to provide any further history.
.
In the ED, initial VS: HR 150, RR 24, BP 200/90, o2 Sat 98% RA
EKG showed SVT. He was given 12 mg adenosine x 1 with no effect.
He then received amiodarone 150 mg x 2 followed by an
amiodarone gtt. With this his HR fell into the 120s. He was
also given 25 mg captopril and 2 g magnesium. Labs were notable
for hyperkalemia without EKG changes. He was given 1 amp of
calcium gluconate and 1 amp of bicarb. Eventually, a diltiazem
gtt was started. With this his HR fell into the 80s, reportedly
sinus. He was also given dilaudid 1 mg IV and Ativan 1 mg IV.
VS prior to transfer: HR 88, BP 154/82, RR 22, 100% on 2L
Access: 20g in hand and 18g EJ.
.
In the ICU, the patient denies pain including chest pain. He
also denies shortness of breath. Other review of systems
difficult to interpret.
Past Medical History:
1. ESRD on HD T/Th/Sa at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] [**Last Name (NamePattern1) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**],
[**Telephone/Fax (1) 69669**]
2. Type 2 diabetes mellitus c/b peripheral neuropathy
3. CAD: On review of records, he had demand ischemia in [**9-/2155**]
with no flow-limiting stenoses on cardiac cath. MIBI in [**11/2152**]
showed reversible defects inferior/lateral. Baseline troponin
0.2-0.4. Cath in [**2155**] - normal coronaries.
4.Chronic systolic CHF with EF 30% ([**10/2156**] TTE)
5. Atrial fibrillation/AFlutter s/p ablation [**2153**]; h/o atrial
tachycardia s/p EPS [**9-21**] and ablation x 2. not on coumadin due
to history of GIBs.
6.Hypertension
7. Dyslipidemia: [**9-/2155**] TC 101, LDL 54, HDL 29, TG 112
8. History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p
thermal therapy; diverticulosis throughout colon
9. Chronic pancreatitis
10. Possible Hepatitis C infection, HCV Ab + [**10/2150**], but neg
[**2154**]
- GERD
- Gout
- s/p arthroscopy with medial meniscectomy [**5-/2149**]
- Depression with multiple hospitalizations due to SI
- Polysubstance abuse: crack cocaine, EtOH, tobacco
- frequent bouts of chest pain following crack/cocaine use
- Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
- H/o C diff in [**2156-8-14**]
Social History:
Per previous notes, patient reports a 42 pack-year smoking
history. He currently smokes [**2-16**] cigarettes per day. He has a
history of alcohol abuse, with DTs and detoxification, with last
drink reportedly > 1 year ago. Pt has used crack cocaine for
years, approx 2-3x/wk. Lives with his girlfriend.
Family History:
Mother had ESRD on HD, died from MI at the age of 58. 4 Brothers
and 2 sisters, nearly all with DM2.
Physical Exam:
BP 148/92, HR 87, RR 20, O2 90% on 5L
Gen: Middle aged man lying in bed, intermittently falling asleep
and unable to consistently answer questions, intermittently
shaking entire upper body without provocation
HEENT: Supple neck without lymphadenopathy.; JVP not
visualized.
Chest: lungs diffusely rhonchorus and wheezing
Heart: regular, no murmur
Abdomen: soft, nontender, nondistended. Normal bowel sounds.
Extremities: No edema. LUE fistula with palpable thrill.
Nontender.
Skin: Nodular rash on anterior chest and arms
Pertinent Results:
[**2157-11-16**] 11:40PM GLUCOSE-290* UREA N-67* CREAT-12.4*
SODIUM-135 POTASSIUM-6.3* CHLORIDE-98 TOTAL CO2-20* ANION
GAP-23*
[**2157-11-16**] 11:40PM CALCIUM-10.7* PHOSPHATE-5.3* MAGNESIUM-3.2*
[**2157-11-16**] 11:40PM WBC-8.1 RBC-4.02* HGB-12.4* HCT-37.4* MCV-93
MCH-30.9 MCHC-33.2 RDW-17.2*
[**2157-11-16**] 11:40PM PLT COUNT-208
[**2157-11-16**] 06:57PM LACTATE-2.0
[**2157-11-16**] 06:50PM ALT(SGPT)-28 AST(SGOT)-27 ALK PHOS-177* TOT
BILI-0.4
[**2157-11-16**] 06:50PM cTropnT-0.25*
[**11-16**] CXR: There is markedly worsened mild-to-severe pulmonary
edema. Mild-to-moderate cardiomegaly is stable. A small right
pleural effusion is unchanged. A small left pleural effusion has
increased or is new.
[**11-17**] CXR:
Mild-to-moderate cardiomegaly is unchanged. There has been
interval mild
improvement in the moderate pulmonary edema. Mild-to-moderate
cardiomegaly is stable. Small right pleural effusion is
unchanged. Small left pleural
effusion has minimally increased. Dense opacity in the right
upper lobe could be due to asymmetric edema, but aspiration or
infection cannot be excluded. Attention on follow up studies is
recommended. Increased opacity in the left lower lobe is
consistent with increasing atelectasis and left pleural
effusion.
Brief Hospital Course:
Mr. [**Known lastname 107485**] is a 60 year-old man with ESRD on HD and a history
of atrial tachycardia who presents with tachycardia,
hypertension, hyperkalemia, and hypoxia in the setting of
missing 2 sessions of HD.
.
# Hypoxia: Mr. [**Known lastname 107485**] developed significant hypoxia shortly
after admission to the intensive care unit. This was concerning
for rapidly progressive pulmonary edema in the setting of an
inability to excrete volume renally. He was found to have marked
pulmonary edema and received emergent hemodialysis with the
removal of 3.5L. His hypoxia improved significantly. Mr.
[**Known lastname 107485**] received two additional session of hemodialysis during
his admission with weaning of his 6L NC oxygen requirement to
sating well on room air. Mr. [**Known lastname 107485**] was to resume his
outpatient hemodyalisis schedule as an outpatient.
.
# Atrial tachycardia: Mr. [**Known lastname 107494**] EKG revealed an atrial
tachycardia with 2:1 conduction. He was placed on an amiodarone
drip and a diltiazem drip on admission to the ICU. It was likely
that he was not taking his amiodarone or diltiazem at home
because of his cocaine use. He was transitioned to his home
doses of oral amiodarone 200mg daily and diltiazem 360mg daily
(90 QID) with maintenance of his heart rate in the 90-100 range.
In an effort to provide improved rate control, his diltiazem was
increased to 120 QID. This change decreased his blood pressure
but failed to reduce his heart rate, thus he was discharged on
his home dose of diltiazem 360mg daily.
.
# Hyperkalemia: He was hyperkalemic to 6.3 on admission. This
was likely secondary to his renal failure in the setting of
having missed two session of [**Known lastname 2286**]. His EKG was determined to
be stable without QRS widening or peaked T wave. He received
calcium gluconate and bicarbonate in the ED and 30mg of
kayexalate and insulin with glucose. His hyperkalemia was
ultimately treated with hemodialysis.
.
# ESRD: T/Th/Saturday Hemodialysis - He had missed two session
of hemodialysis and required emergent hemodialysis in the ICU.
He ultimately received three session of HD prior discharge.
.
# Polysubstance abuse: He spoke with the substance abuse social
worker prior to discharge to discuss his substance abuse
treatment options.
.
# DM2: Glucose was well controlled on SSI
.
# Hyperlipidemia: He was continued on his home does of
simvastatin 20 mg po daily
.
# Hypertension: He was well controlled on his home
antihypertensives
.
# GERD: He was continued on pantoprazole
Medications on Admission:
albuterol hfa prn
amiodarone 200 mg daily
atorvastatin 20 mg daily
cinacalcet 30 mg daily
diltiazem SR 360 mg daily
gabapentin 100 mg [**Known lastname **]
hydroxyzine 25 mg tid prn
insulin glargine 14 units [**Known lastname **] (not needed)
insulin lispro 2-10 units per ss
lisinopril 40 mg daily
NTG SL prn chest pain
oxycodone-acetaminophen prn
pantoprazole 40 mg daily
selenium sulfide 2.5%
sertraline 50 mg daily'
sevelamer 2400 mg tid ac
ASA 81 mg daily
docusate 100 mg [**Hospital1 **]
senna [**Hospital1 **] prn
Discharge Medications:
1. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. sertraline 50 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 Q24H (every 24 hours).
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for itching.
9. Insulin
Please take as advised by you PCP
10. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at
bedtime.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
Inhalation
12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. nitroglycerin Sublingual
14. oxycodone-acetaminophen Oral
15. selenium sulfide Topical
16. diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
End Stage Renal Disease
Atrial Tachycardia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of a fast heart rate
and difficulty breathing. You had also missed two sessions of
hemodialysis. You were evaluated and treated by the medicine
service. You received three session of hemodialysis while
admitted and restarted on you home medications. Please do not
use cocaine anymore as this is very hazardous to your health.
Please inquire at your hemodialysis center about outpatient
cocaine abuse rehabilitation to help you quit.
No changes were made to your home medications.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
Department: DERMATOLOGY
When: FRIDAY [**2157-11-25**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16424**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2157-11-29**] at 2:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"V45.11",
"305.60",
"250.60",
"530.81",
"427.89",
"274.9",
"403.91",
"585.6",
"E854.3",
"577.1",
"970.81",
"428.32",
"427.31",
"518.81",
"357.2",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9716, 9722
|
5448, 8008
|
315, 330
|
9822, 9822
|
4153, 5425
|
10603, 11283
|
3488, 3590
|
8580, 9693
|
9743, 9801
|
8034, 8557
|
9973, 10580
|
3605, 4134
|
231, 277
|
358, 1752
|
9837, 9949
|
1774, 3151
|
3167, 3472
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,871
| 139,855
|
49214
|
Discharge summary
|
report
|
Admission Date: [**2170-1-5**] Discharge Date: [**2170-1-10**]
Date of Birth: [**2089-8-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
[**2170-1-7**] Central venous catheter placement
[**2170-1-9**] Sigmoidoscopy
History of Present Illness:
Ms. [**Known lastname 32713**] is a 80 year-old Spanish speaking female with HTN,
DM, autoimmune cirrhosis c/b variceal bleeding, s/p CCY with a
recent admission [**Date range (1) **] for colitis who presents now with
multiple episodes of BRBPR. Her initial illness began
approximately one week ago with N/V, watery diarrhea (no blood
at that time), bloating, and abdominal pain exacerbated after
eating. No blood initially in stool or emesis. CT scan showed
new findings consistent with an infectious colitis. She was
treated with cipro/flagyl for presumed infectious colitis (stool
studies were not sent) and improved. Since being home, she has
had no further N/V. Diarrhea initially improved but then
worsened again over last 24 hours, with multiple loose/watery
BM. Stool had been yellowish-brown. Abdominal pain has
definitely improved from last admission but still has some
diffuse tenderness and a feeling like bloating/gas. She had
low-grade fevers with her original illness and today felt cold
again so questions whether she may have been febrile (although
daughter says heat was accidently turned off in her apartment,
so that may have been responsible). She also reports feeling
some LH for the last 1-2 days which is a change from prior.
.
Today, she had an episode of diarrhea where she noticed BRB in
the toilet. Difficult for her to determine whether it was mixed
in with the stool or separate. She has had milder rectal
bleeding in the past (known hemorrhoids) but none recently.
After this episode, her granddaughter brought her into the [**Name (NI) **].
While here, she had a few more episodes of rectal bleeding, the
first of which seemed to be promted by rectal exam per ED
resident, who estimate ~50cc of dark red blood mixed with stool.
Did not appear melenotic per report.
.
In the ED, initial vs were: 97.7 64 178/74 20 100% 3L NC.
Hepatology team was consulted and recommended admission to ET
service. Her admission vitals were 98.6 56 180/55 16 100%.
.
On the floor, patient appears well. She is with her
granddaughter who helps to translate (speaks very limited
English). She endorses some continued abdominal pain and a
little headache, but otherwise feeling OK right now.
.
Review of systems: Per HPI. Denies sinus tenderness, rhinorrhea
or congestion aside from usual allergies. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Cirrhosis secondary to auto-immune hepatitis. History of
variceal bleeding, with obliteration of varices through
endoscopy, last done [**2166-2-20**]. Followed by Drs. [**Last Name (STitle) 7033**] and
[**Doctor Last Name **]
- Anemia, baseline HCT ~30, with h/o transfusions when Hct <25
(recently baseline has been stable in upper 20s)
- Diabetes, on insulin, diagnosed in [**2132**]
- Thyroid nodule
- Hypertension
- Depression
- Status-post cholecystectomy and cataract surgery
- History of positive PPD, never treated
- Glaucoma
Social History:
Originally from [**Country 3594**]. Worked at [**Hospital1 18**] for many years in
housekeeping. Now lives alone but with family close by. Attends
adult day care. Never used tobacco/ETOH/illicit drugs.
Family History:
Non-contributory
Physical Exam:
Upon admission:
V/S: 96.7 52 165/67 12 95%RA
GEN: Appears well, resp nonlabored
HEENT: Dry MM
NECK: No JVD
CV: reg rate nl S1S2 no m/r/g
PULM: clear bilat
ABD: soft, mild bilateral lower abdominal pain, no
rebound/guarding, +BS
EXT: warm, dry no edema
NEURO: awake, alert, conversing appropriately; no asterixis
Upon discharge: pertinent changes only
ABD: no abdominal pain, no further hematochezia
Pertinent Results:
Labs upon admission:
.
[**2170-1-5**] 04:00PM BLOOD WBC-2.8* RBC-3.10* Hgb-8.7* Hct-27.4*
MCV-89 MCH-28.1 MCHC-31.7 RDW-14.5 Plt Ct-202
[**2170-1-5**] 04:00PM BLOOD Neuts-69.6 Lymphs-20.5 Monos-7.2 Eos-2.2
Baso-0.6
[**2170-1-5**] 04:00PM BLOOD PT-14.6* PTT-29.6 INR(PT)-1.3*
[**2170-1-6**] 11:17PM BLOOD Fibrino-367
[**2170-1-5**] 04:00PM BLOOD Glucose-231* UreaN-18 Creat-1.2* Na-136
K-4.1 Cl-104 HCO3-27 AnGap-9
[**2170-1-6**] 04:50AM BLOOD ALT-20 AST-33 AlkPhos-84 TotBili-0.2
[**2170-1-6**] 04:50AM BLOOD Albumin-2.8* Calcium-7.8* Phos-3.2 Mg-1.8
[**2170-1-6**] 10:43AM BLOOD Lactate-1.4
.
Labs upon discharge:
.
[**2170-1-10**] 05:00AM BLOOD WBC-4.1 RBC-4.19* Hgb-12.1 Hct-35.3*
MCV-84 MCH-28.9 MCHC-34.3 RDW-14.7 Plt Ct-176
[**2170-1-10**] 05:00AM BLOOD PT-15.8* INR(PT)-1.4*
[**2170-1-10**] 05:00AM BLOOD Glucose-54* UreaN-12 Creat-1.1 Na-139
K-4.2 Cl-105 HCO3-28 AnGap-10
[**2170-1-10**] 05:00AM BLOOD ALT-15 AST-26 AlkPhos-94 TotBili-0.4
[**2170-1-10**] 05:00AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.7
.
Microbiology:
[**2170-1-10**] and [**2170-1-5**]: Cdiff: negative
[**2170-1-8**]: CMV viral load: undetectable
[**2170-1-6**]: Urine culture: <10,000 organisms
[**2170-1-5**]: Stool culture: negative for Campylobater, Salmonella,
Shigella, ova/parasites
.
Imaging:
.
[**2170-1-7**]: CXR: IMPRESSION: Right jugular sheath in place.
Subsegmental atelectasis. There may be mild vascular congestion.
Repeat study with a better inspiratory effort is recommended.
.
[**2170-1-6**]: ECG: Sinus bradycardia. Q-T interval is mildly
prolonged. Compared to the previous tracing of [**2169-12-31**] the R wave
transition is more delayed and the Q-T interval is more
prolonged on today's tracing.
.
[**2170-1-9**]: Flex sig: Impression: Rectal varices were found that
were non-bleeding. Poorly visualized due to feces. Otherwise
normal sigmoidoscopy to splenic flexure.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 32713**] is a 80 year old female with autoimmune
hepatitis/cirrhosis with recent admission for possible
infectious colitis who presented with bilateral lower abdominal
pain and hematochezia.
Hematochezia: Likely ischemic colitis versus rectal variceal
bleed. Infectious workup was negative. NG lavage was negative
for upper GI source of bleeding. She was transferred to the
MICU (night of [**2170-1-6**]) due to a brief episode of hypotension
(SBP 160-190 dropped to 110s) in the setting of a large bloody
bowel movement. She rapidly became hemodynamically stable with
transfusion (received total 4 units PRBC) and was transferred
back to the floor [**2170-1-7**]. She received a flexible
sigmoidoscopy [**2170-1-9**], however the source of bleeding was not
identified. She had been admitted on cipro/flagyl from prior
admission. She was continued on these antibiotics to complete
her original 7 day course. Ciprofloxacin alone was extended for
another 7 days from onset of her hematochezia for SBP
prophylaxis.
Hypertension: Blood pressure was difficult to control (SBP
160-190). She did not have hypertensive urgency. She was
restarted on her home medications once hemodynamic stability was
ensured and hematocrit was stable. She will follow up with her
PCP for dosage adjustments as needed.
.
Cirrhosis/autoimmune hepatitis: Continued on home ursodiol. She
is not on chronic immunosuppression.
.
Diabetes: She had intermittently low glucose likely secondary to
poor PO intaker. Her lantus dose was decreased to 12 units
during admission. Her diet was advanced and she was sent home
on her home dose of Lantus 48 units nightly.
.
She was full code for this admission.
Medications on Admission:
Cipro 500 [**Hospital1 **]
Flagyl 500 TID
Ursodiol 300 mg Cap QAM, Q2PM, and 600 mg QHS
Bactroban Nasal 2 % Ointment intranasally daily, as needed
Lantus 48 units once a day in AM (recently decreased from 60u)
Humalog SS 8u TID with meals
Lexapro 10 mg Tab qam
Vitamin D 1,000 unit Cap
Nadolol 40 mg Tab (one MD thinks 30, one 40...actually takes 40)
Ativan 1 mg Tab by mouth at bedtime
Hydrochlorothiazide 25 mg Tab by mouth once a day
Lisinopril 40 mg Tab by mouth once a day
Timolol Maleate 0.5 % Eye Drops 1 drop both eyes twice a day
Omeprazole 20 mg Cap 2 (Two) Capsule by mouth once a day
CARMOL 40 40 % Topical Cream apply to affected areas twice a day
(to feet; not using recently)
Docusate Sodium 100 mg Tab one Tablet(s) by mouth three times a
day as needed for prn constipation
Ferrous Sulfate 325 mg (65 mg Iron) Tab by mouth twice a day
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day): in the morning and at 2 PM.
2. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
11. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
12. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
14. Lantus 100 unit/mL Solution Sig: Forty Eight (48) units
Subcutaneous once a day.
15. insulin lispro 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous TID with meals.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Lower gastrointestinal bleeding
Pancolitis
Acute blood loss anemia
Cirrhosis secondary to autoimmune hepatitis
Esophageal and rectal varices
Diabetes type II
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with GI bleeding. You received
4 red blood cell transfusions and your blood counts remained
stable. No source of bleeding was identified on sigmoidoscopy.
You were treated for a possible infection in the large intestine
(colitis).
Please continue the prescribed antibiotic for two more days to
prevent additional infection around the time of the bleeding
episode.
The following medication changes were recommended:
1) START ciprofloxacin 250 mg once daily through [**Last Name (LF) 2974**], [**1-11**].
Please continue to check your blood sugars before meals and at
bedtime. Please keep a record of these numbers to show your
doctors.
Followup Instructions:
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2170-1-25**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: LIVER CENTER
When: THURSDAY [**2170-1-25**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NUTRITION
When: TUESDAY [**2170-2-6**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 3679**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3680**], RD [**Telephone/Fax (1) 3681**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Hospital 1422**]
Campus: EAST Best Parking: Main Garage
Completed by:[**2170-1-12**]
|
[
"241.0",
"557.9",
"250.80",
"428.32",
"571.5",
"311",
"V58.67",
"285.1",
"428.0",
"571.42",
"455.8",
"458.9",
"456.21",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
9934, 9992
|
6002, 7731
|
316, 396
|
10207, 10207
|
4111, 4118
|
11055, 12146
|
3656, 3675
|
8634, 9911
|
10013, 10186
|
7757, 8611
|
10358, 11032
|
3690, 3692
|
2647, 2861
|
264, 278
|
4726, 5979
|
424, 2628
|
4132, 4710
|
10222, 10334
|
2883, 3421
|
3437, 3640
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,228
| 102,859
|
7635
|
Discharge summary
|
report
|
Admission Date: [**2112-7-28**] Discharge Date: [**2112-8-4**]
Date of Birth: [**2034-8-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
chest pain, atrial fibrillation, fever, mental status changes,
hypotension, dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
77 year old man with history of atrial fibrillation during a
previous hospitalization which was converted to NSR and was
followed up with a good performance on a stress test who
presented to the ED [**2112-7-28**] with chest pain. He was in his
usual state of health until two days prior to admission when he
developed a "cold" consisting of a dry cough and fevers to 37.8
in addition to chest pain. He described the chest pain as a
[**5-7**], dull and intermittent located in his mid-chest and
radiating to his right shoulder. He also noted loss of appetite
and diaphoresis. He reports that he gets this same combination
of fever, chest pain, and diaphoresis every Fall.
No recent fatigue, no dysuria, no diarrhea. No recent travel, no
leg swelling. No recent weight loss. In the ED he was noted to
have a temperature of 101 and hypotension to 83/53 which
improved with 2 L IVF.
Past Medical History:
-hypertension
-hyperlipidemia
-atypical chest pain (ETT and stress test [**8-31**] normal)
-anxiety
-s/p fall with multiple facial fractures ([**2107**])
-s/p removal infected mandibular hardware ([**2108**])
-remote h/o afib controlled with amiodarone; d/c by cards([**2107**])
-hemorrhoids
-colonic polyps (colonoscopy [**2107**])
-glaucoma
Social History:
Moved from [**Country 532**] about 14 years ago, traveled 3 years ago to
[**Country **] but no other travel. H/o tobacco in [**2045**], none recently.
Uses EtOH socially on weekends ([**1-1**] drinks/week); denies IVDU.
Lives with his wife.
Family History:
No CAD.
Physical Exam:
VS: 97.3; BP: 146/82; P:97; RR: 22, labored; O2 Sat: 100% on 2L
GEN: resting in bed watching TV, labored breathing using
accessory muscles but NAD, able to speak in full sentences, RR
of 22, patient is very uncooperative and refuses to be
interviewed
HEENT: PERL
NECK- supple, no cervical or supraclavicular LAD. No bruits. No
JVD.
CV- Irregular, tachycardic, no murmur appreciated.
CHEST- expiratory wheezes noted bilaterally
ABD- taut, possibly distended, non-tender, no masses, no
organomegaly
EXT: warm, well perfused, no edema
Neuro: limited exam, seems to have no focal findings
Pertinent Results:
[**2112-7-28**] 10:18PM CK-MB-3 cTropnT-<0.01
[**2112-7-28**] 10:18PM CK(CPK)-194*
[**2112-7-28**] 08:53PM LACTATE-2.8*
[**2112-7-28**] 04:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2112-7-28**] 04:55PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2112-7-28**] 04:55PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2112-7-28**] 04:10PM GLUCOSE-151* UREA N-19 CREAT-1.2 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
[**2112-7-28**] 04:10PM cTropnT-<0.01
[**2112-7-28**] 04:10PM CK(CPK)-104
[**2112-7-28**] 04:10PM CK-MB-2 proBNP-1598*
[**2112-7-28**] 04:10PM WBC-16.0*# RBC-4.85 HGB-13.4* HCT-38.7*
MCV-80* MCH-27.7 MCHC-34.8 RDW-14.3
[**2112-7-28**] 04:10PM NEUTS-95.0* BANDS-0 LYMPHS-2.9* MONOS-1.9*
EOS-0 BASOS-0.1
[**2112-7-28**] 04:10PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-3+
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2112-7-28**] 04:10PM PLT SMR-NORMAL PLT COUNT-174
[**2112-7-28**] 04:10PM PT-13.5* INR(PT)-1.2*
Brief Hospital Course:
He was admitted to CC7. On the medicine floor, he was ruled out
for myocardial infarction with serial enzymes. He was
orthostatic and his hypotension initially improved with fluid
rehydration. A fever work up including UA, cultures, CXR, and LP
was started and has so far been inconclusive. Serum tox screen
negative. He had a head CT without any obvious intracranial
bleed or mass; some maxiallary sinus mucosal thickening was
noted. He was started on antibiotics the evening of [**2112-7-29**], when
he was spiking fevers with altered MS; he was started
empirically on vanco/levo/flagyl. His WBC had trended down and
his fevers were intermittent (Tmx: 102). He developed atrial
fibrillation with RVR on the floor; his rate was controlled with
lopressor, at the expense of his BP. He also became more
tachypnic, breathing 40/min while sleeping, with ABG 7.41/29/91
on 3L nc.
He was transferred to the MICU. A work up for his change in
mental status resulted in a repeat negative head CT, an abnormal
EEG which showed changes consistent with metabolic
abnormalities, infection, ischemia or anxiety, an unrevealing
second LP, a negative RPR, B12 of 289 and TSH of 1.0. He was
treated with Zyprexa and Ativan for agitation and placed on the
CIWA protocol. His Atrial Fibrillation was treated with
Lopressor, Amiodarone, and Heparin and Warfarin. An
Echocardiogram showed no vegetations. Due to increased wheezing,
he was started on albuterol nebs and inhaled fluticasone with an
improvement in his tachypnea and wheezing. His WBC continued to
trend downwards and his blood pressure stabilized. Antibiotics
were continued.
On [**2112-8-2**] he was transferred to [**Hospital Ward Name 121**] 7 for further
management.
1. ATRIAL FIBRILLATION
The patient's atrial fibrillation with RVR has remained stable
with HR ranging from 90-125. He was started on Amiodarone HCl
400 mg PO starting [**2112-8-1**], and his home dose of Metoprolol was
increased from 25 mg [**Hospital1 **] to 75 mg [**Hospital1 **]. Heparin on and sliding
scale and Warfarin 2.5 mg PO were begun [**2112-8-2**] with an
increase in Warfarin to 5 mg PO daily on [**2112-8-4**] since the INR
remained low at 1.3. Lovenox 90 mg [**Hospital1 **] SC was begun [**2112-8-4**] at
6 PM and heparin discontinued in anticipation of discharge. INR
upon discharge 1.3. Home VNA will help administer Lovenox.
2. CHANGES IN MENTAL STATUS
A work up for his change in mental status resulted in a negative
head CT, an abnormal EEG which showed changes consistent with
metabolic abnormalities, infection, ischemia or anxiety, two
unrevealing LPs, a negative RPR, B12 of 289 and TSH of 1.0. He
was treated with Zyprexa and Ativan and placed on the CIWA
protocol for concerns about possible alcohol withdrawal. The
patient's mental status improved during his hospital stay with
more difficulties at night. He was fully alert and oriented
with a mini-mental status score of 27/30 with only some
difficulty on fine points of orientation including the floor of
the hospital he was on, the county we were in, and the date the
day before discharge.
3. FEVER OF UNKNOWN ORIGIN
At discharge, the patient was afebrile with a WBC of 9.4, down
from 16.0 upon admission. ID believes he had a viral infection
which has resolved. He was treated with Levofloxacin for 6 days,
and Vancomycin and Flagyll for 5 days during his
hospitalization.
4. DYSPNEA
The patient improved with a RR of 22, an oxygen saturation of
95% on room air, and lungs CTAB upon discharge. The dyspena is
believed to be due to COPD although the patient only has a
remote history of smoking. A Chest/Abdominal/Pelvic CT
concluded "1.Prominent mediastinal fat likely corresponds to the
widened appearance of the mediastinum on chest radiograph. On
this study limited by patient motion
artifact and suboptimal contrast bolus timing, there is no
evidence of aortic
dissection, aneurysm, or central pulmonary embolism. 2.
Posterior dependent atelectatic changes and minimal bilateral
pleural, effusions. 3. Right renal lesions incompletely
characterized, but likely cysts. 4. Prostatic enlargement. 3.8
cm cystic area of right prostate is of uncertain signficance and
clinical correlation is suggested."
During this hospitalization he was treated with Albuterol 0.083%
nebs every four hours, fluticasone propionate 110 mcg 4 puffs
inhaled [**Hospital1 **] and Albuterol 0.083% 1-2 nebs inhaled every [**1-30**]
hours PRN. He will be discharged on Spiriva, Combivent and
Albuterol for presumed COPD.
5. HYPOTENSION
The patient's blood pressure has remained stable since his
return to the medical floor.
6. HEMATURIA
The patient had one episode of blood tinged urine. A UA showed
only large amount of blood and RBC >1000. His Is and Os have
been excellent.
7. CHEST PAIN
His chest pain resolved soon upon admission. EKGs do not show
ischemic changes and his cardiac enzymes were negative x3.
Echocardiogram performed [**2112-8-2**] concluded: left ventricular
systolic function is low normal, mild to moderate ([**11-30**]+) mitral
regurgitation, Moderate [2+] tricuspid regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
8. MICROCYTIC ANEMIA
The patient had a microcytic anemia with a HCt in the low 30s
and an MCV of 79 which was not fully worked up. He was placed
on 1000 mcg of B12 due to a low normal B12 value, B12: 289.
At the time of discharge, pt had no further chest pain and was
rate-controlled. His systolic pressures were excellent and he
was discharged with followup plans discussed with his primary
care provider.
Medications on Admission:
fluoxetine 20mg daily
ativan 0.25mg tid prn
lipitor 10mg daily
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day.
Disp:*qs inhaler * Refills:*2*
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
Disp:*qs inhaler+caps* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
q4-6 hours PRN as needed for shortness of breath or wheezing.
Disp:*qs 1 inhaler* Refills:*0*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 7 days.
Disp:*14 syringes* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family and Children Services
Discharge Diagnosis:
1. Atrial fibrillation with Rapid Ventricular Response
2. Atypical chest pain
3. Hypertension
4. Hypercholesterolemia
5. Anxiety
6. Changes in mental status
7. Probable COPD
8. Probable Alcohol withdrawal
9. Acute on Chronic Renal Insufficiency
Discharge Condition:
Stable no further rapid ventricular response.
Discharge Instructions:
1. Please take your medications as prescribed.
2. Please return to the hospital or call your PCP if you develop
shortness of breath, chest pain, fevers or other worrisome
symptoms.
3. You will need to continue taking Enoxaparin (lovenox) for the
next 5 days. Also continue taking warfarin as directed by your
doctor's office. You have also been started on a number of new
medications for your breathing difficulty.
Followup Instructions:
Please followup with your primary care doctor: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**],
MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-8-10**] 11:30
Recommend pulmonary function tests as outpatient as baseline for
amiodarone therapy.
|
[
"424.0",
"280.9",
"272.4",
"079.99",
"427.31",
"276.1",
"585.9",
"401.9",
"291.81",
"397.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10508, 10584
|
3678, 9268
|
356, 363
|
10873, 10921
|
2547, 3655
|
11388, 11667
|
1916, 1925
|
9415, 10485
|
10605, 10852
|
9294, 9392
|
10945, 11365
|
1940, 2528
|
233, 318
|
391, 1274
|
1296, 1642
|
1658, 1900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,753
| 144,029
|
44598
|
Discharge summary
|
report
|
Admission Date: [**2130-9-21**] Discharge Date: [**2130-10-4**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2130-9-24**] extraction of teeth #6 #7 #8 #19 #21 #22 under MAC
[**2130-9-28**] Aortic valve replacement with 21 mm Biocor Epic
tissue valve.
History of Present Illness:
Mr. [**Known lastname 95459**] is an 88 yo male with severe aortic stenosis who
presents with signs and symptoms of congestive heart failure,
including worsening dyspnea on exertion, JVD, lower extremity
edema, and crackles at the bases of his lungs. The patient was
seen by Dr. [**Last Name (STitle) 16794**] today, and there was concern for critical AS.
A TTE showed valve area of .6 cm squared. The patient has
experienced worsening dyspnea on exertion for the past two
weeks. He was able to walk from the parking lot to the entrance
of the emergency department without stopping (per his daughter).
He has had some shortness of breath upon lying down but it is
unclear if he has had PND. He has more shortness of breath when
walking on an incline. He has not had chest pain or pressure.
He was admitted for evaluation
Past Medical History:
Aortic stenosis
Diabetes Mellitus
Gout
Low back pain
hypercholesterolemia
colon CA s/p colostomy
Social History:
Lives with: wife, who is currently in rehab for broken leg
Occupation:retired
Cigarettes: Smoked no [x]
ETOH: < 1 drink/week [x]
Denies illicit drug use
Family History:
Non-contributory
Physical Exam:
VS: 97.9, 147/95, 53, 18, 97% RA
GENERAL: Well-appearing man in NAD, comfortable supine,
appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, JVD 5cm to the mid-neck, no
carotid bruits.
HEART: RRR, high pitched systolic murmur at upper sternal border
radiating to carotids and heard throughout precordium, nl S1-S2.
LUNGS: CTA bilat, crackles 1/3 up lung bases bilaterally, good
air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, trace pitting edema in lower extremities
bilaterally, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-13**] throughout
Pertinent Results:
Admit Labs:
[**2130-9-21**] 02:20PM BLOOD WBC-3.9* RBC-3.86* Hgb-13.0* Hct-36.2*
MCV-94 MCH-33.7* MCHC-36.0* RDW-15.7* Plt Ct-79*
[**2130-9-21**] 02:20PM BLOOD PT-12.9 PTT-29.7 INR(PT)-1.1
[**2130-9-21**] 02:20PM BLOOD Glucose-112* UreaN-17 Creat-0.9 Na-142
K-4.2 Cl-101 HCO3-33* AnGap-12
[**2130-9-21**] 02:20PM BLOOD proBNP-1152*
[**2130-9-21**] 02:20PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
.
CXR [**2130-9-21**]:
FINDINGS: Frontal and lateral views of the chest are obtained.
The cardiac
silhouette is mildly enlarged. The aorta is calcified and
tortuous. There is slight indistinctness and prominence of the
hila which may be due to pulmonary vascular engorgement without
overt pulmonary edema. No definite focal consolidation is seen.
There is no pleural effusion or pneumothorax.
IMPRESSION: Possible mild pulmonary vascular engorgement without
overt
pulmonary edema.
.
[**2130-9-23**] CT Chest
FINDINGS:
Dense aortic valvular calcifications are noted. There is mild
coronary artery calcification noted. The heart is at the upper
limits of normal in size. There is trace pericardial
fluid/thickening.
Aortic measurements are as follows:
Sinus: 3.5 cm.
Sinotubular junction: 2.9 cm.
Proximal aortic arch: 3.5 cm.
Mid aortic arch, just distal to left subclavian artery: 3.1 cm.
Distal aortic arch: 3.2 cm.
Mid descending thoracic aorta: 3.1 cm.
Distal thoracic aorta: 2.7 cm.
Mild atherosclerotic calcified plaque is present within the
aortic arch.
The thyroid gland is unremarkable. There is no axillary,
mediastinal, or
hilar lymphadenopathy. Note is made of calcified mediastinal and
right hilar lymph nodes.
Calcified pleural plaque is noted, particularly on the left.
There is minimal pleural thickening on the right anteriorly
(2:30). At the right base, adjacent to the dome of the right
hemidiaphragm, there are multiple
nodular-appearing densities which, on coronal reformatted
images, represent areas of pleural thickening consistent with
additional pleural plaques. There are no pulmonary nodules.
Linear strand of atelectasis or scar is present in the middle
lobe. Ground-glass nodular opacity in the right lower lobe
(3:34) measures approximately 3 mm and is of uncertain, if any,
clinical significance. The airways are patent.
Visualized portions of the upper abdomen reveal cholecystectomy
clips, a left adrenal 1.4-cm adenoma, a splenule, and bilateral
low-density renal lesions in the mid-to-lower pole on the right
kidney and mid portion of the left kidney. In the right kidney,
the low-density lesion measures 1.2 cm and has Hounsfield units
consistent with simple fluid. On the left, the hypodense lesion
measures 1.5 cm and also has Hounsfield units consistent with
simple fluid.
Degenerative changes are present throughout the thoracic spine.
There are no destructive osseous lesions. Bilateral glenohumeral
degenerative changes are also noted.
IMPRESSION:
1. Significantly calcified aortic valve consistent with provided
history of aortic stenosis.
2. Mild dilatation of the ascending aortic arch measuring up to
3.5 cm.
3. Calcified pleural plaques and noncalcified pleural thickening
at the right base.
4. Calcified mediastinal and right hilar lymph nodes are
consistent with
sequelae of prior granulomatous disease.
5. Bilateral hypodense renal lesions are stable and likely
represent simple
cysts.
.
TTE [**2130-9-25**]:
The left atrium is mildly dilated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are severely thickened. There is
severe aortic valve stenosis (valve area 0.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral leaflets are mildly
thickened. There is no systolic prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Severe aortic stenosis. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild pulmonary artery systolic
hypertension. Increased PCWP.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on [**2124**]
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
symptomatic (angina, syncope, CHF) and a surgical candidate,
surgical intervention has been shown to improve survival.
.
Carotid Doppler [**2130-9-25**]
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is mild heterogeneous plaque seen
in the ICA. On the left there is mild heterogeneous plaque seen
in the ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 51/13, 44/16. 62/28,
cm/sec. CCA peak systolic
velocity is 75 cm/sec. ECA peak systolic velocity is 67 cm/sec.
The ICA/CCA ratio is .83 These findings are consistent with <40%
stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 79/34, 89/36, 88/28, cm/sec. CCA peak
systolic
velocity is 88 cm/sec. ECA peak systolic velocity is 74 cm/sec.
The ICA/CCA ratio is 1.0. These findings are consistent with
<40% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
.
Echocardiogram
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four
pulmonary veins not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Dilated sinuses of Valsalva.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
thickening of mitral valve chordae. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: Very small pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. 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. The right ventricular cavity is
mildly dilated with normal free wall contractility. The sinuses
of Valsalva are dilated. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
moderate thickening of the mitral valve chordae. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is a very small pericardial effusion.
POSTBYPASS:
The patient is AV paced on low dose phenylephrine nfusion. While
separating from CPB, RV was hypokinetic but responded to low
dose epinephrine infusion & supplemental boluses. There is a
well seated prosthetic valve in the aortic position. There is no
stenosis. There is mild AI. The remaining valves are unchanged.
The aorta remains intact. LV function is unchanged.
EKG
Atrial fibrillation with relatively slow ventricular response
with intermittent fast responses. No significant change compared
to previous tracing of [**2130-9-30**].
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 0 92 400/408 0 -16 48
[**2130-10-3**] 05:40AM BLOOD WBC-5.8 RBC-3.29* Hgb-10.4* Hct-31.0*
MCV-94 MCH-31.8 MCHC-33.7 RDW-16.2* Plt Ct-131*
[**2130-10-4**] 06:00AM BLOOD PT-15.9* INR(PT)-1.4*
[**2130-10-3**] 05:40AM BLOOD Glucose-104* UreaN-29* Creat-1.0 Na-137
K-4.8 Cl-97 HCO3-31 AnGap-14
[**2130-9-22**] 08:10AM BLOOD ALT-13 AST-26 LD(LDH)-179 AlkPhos-50
TotBili-1.7*
[**2130-9-22**] 08:10AM BLOOD cTropnT-<0.01
[**2130-10-3**] 05:40AM BLOOD Mg-2.5
[**2130-9-22**] 08:10AM BLOOD %HbA1c-5.8 eAG-120
[**2130-9-24**] 07:35AM BLOOD Valproa-31*
Brief Hospital Course:
Mr. [**Known lastname 95459**] is an 88M with hx of Aortic stenosis, DM, HLD,
colon CA s/p colectomy who presented to hospital with HF
exacerbation and evaluation of Aortic Stenosis now s/p RHC/LHC
[**2130-9-22**], who was then evaluated for AVR. As patient was
admitted, and known to have severe aortic stenosis, he was
continued on gentle diuresesis only in attempt to maintain his
preload. Patient denied history of syncope, but had worsening
DOE prior to his presentation. The patient was evaluated by the
Cardiac Surgery team and after pre-op evaluation deemed a
surgical candidate for AVR.
His Acute on Chronic Diastolic Heart Faliure Exacerbation in
setting of Critical AS he presented with mild lower extremity
edema, elevated JVP, and crackles in lungs. He was placed on a
low sodium diet, had daily weights monitored, and had careful
diuresis. He was continued on his home dose of metoprolol. In
relation to thrombocytopenia and anemia on admission he had a
low platelet count at 79. Hematology was consulted, who
evaluated patient. They did not have a specific concern for MDS,
and did note that the patietn's Divalproex could be the cause of
his thrombocytopenia. Patient actually had a rise in his
platelet counts throughout his stay up into the low 100's, but
day prior to scheduled surgery on [**9-26**] had platelet drop to 81
for which his AVR was postponed. Psychiatry was consulted and
his Divalproex was titrated down and off post operatively due to
thrombocytopenia.
On [**9-24**] he was brought to the operating room for dental
extraction in preparation for valve surgery which he tolerated
without complications
On [**2130-9-28**] he was brought to the operating room for aortic
valve replacement. See operative report for further details. He
was brought to the intensive care unit post operatively for
management. He remained intubated until postoperative day one
and then was extubated without complications and neurologically
intact. He required neosynphrine for his blood pressure which
was progressively weaned off. Of note he had thrmobocytopenia
post op and based on hematology recommendations psychiatry was
consulted and his Divalproex was titrated down and off. He was
started on betablocker when rhythm was stable in sinus rhythm
however he did develop atrial fibrillation. He was initially
treated with amiodarone however became bradycardic and
amiodarone was stopped. He remains in atrial fibrillation with
rate controlled and betablockers being titrated. Additionally
he was started on coumadin for atrial fibrillation. Physical
therapy worked with him on strength and mobility. He continued
to progress slowly, his platlet count continued to trend up and
he remained in atrial fibrillation with rate control. He was
placed on soft diet as he was unable to chew post teeth
extraction and will need follow up as outpatient with dentist
for dentures/partials. He was ready for discharge on post
operative day [**9-14**] to rehab at Newbridge on the [**Doctor Last Name **] -
[**Location (un) 1411**].
Medications on Admission:
allopurinol 150mg daily
divalproex 250mg [**Hospital1 **]
glipizide 10mg [**Hospital1 **]
metoprolol tartrate 50mg daily
asa 81mg daily
Vitamin b12
spironolactone 25mg MWF
bumetanide 1mg MWF .
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain, fever.
2. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
150 mg daily .
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
5. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): increase to home dose of 10 mg [**Hospital1 **] as oral intake improves
.
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. warfarin 4 mg Tablet Sig: One (1) Tablet PO [**10-5**]: please
give 4 mg on [**10-5**] then check INR on [**10-6**] for further dosing -
goal INR 2-2.5 for atrial fibrillation .
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Outpatient Lab Work
LFT (new statin) in 1 month
14. discontiued med
valproate stopped due to thrombocytopenia
15. diabetic medication
Glipizide home dose 10 mg po BID - currently on 5 mg - please
increase as blood glucose will tolerate
then will need Januvia 100 mg added back - he currently had BG
80-140 on glipizide 5 mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
Atrial Fibrillation
Acute on chronic diastolic heart failure
Thrombocytopenia question secondary to medication
Diabetes Mellitus type 2
Mood disorder
Hypertension
hypercholesterolemia
Gout
Colon cancer
Prostate cancer s/p radiation seeds
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with tylenol prn
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1 bilateral LE (TEDS bilateral LE)
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2130-11-8**] at 1:00 pm
Cardiologist: Dr [**Last Name (STitle) 11679**] on [**2130-10-24**] at 1:30pm
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**3-14**] weeks [**Telephone/Fax (1) 30837**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2-2.5
First draw [**10-6**]
Please check INR Monday, Wednesday and Friday for the first two
weeks and then decrease per physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] physician to
monitor INR and adjust coumadin while at rehab. Please set up
with PCP for continued management of coumadin after discharge to
rehab prior to leaving rehab
Completed by:[**2130-10-4**]
|
[
"V10.46",
"521.00",
"V10.05",
"272.0",
"424.1",
"427.31",
"428.0",
"250.00",
"296.90",
"523.40",
"287.5",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.09",
"39.61",
"23.19",
"35.21",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
15723, 15817
|
10910, 13963
|
277, 424
|
16123, 16325
|
2389, 6770
|
17165, 18145
|
1581, 1599
|
14207, 15700
|
15838, 16102
|
13989, 14184
|
16349, 17142
|
8947, 10887
|
1614, 2370
|
6793, 8908
|
218, 239
|
452, 1274
|
1296, 1394
|
1410, 1565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,873
| 119,636
|
3477
|
Discharge summary
|
report
|
Admission Date: [**2147-7-10**] Discharge Date: [**2147-7-14**]
Service: MEDICINE
Allergies:
Levofloxacin / Codeine
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
upper endoscopy
History of Present Illness:
The patient is a 84 yo F w/ h/o GERD, AFib, CAD, COPD, HTN, TIA,
PVD, w/J tube recently admitted ([**Date range (1) 16006**]) with J-tube
dysfunction. The patient was admitted [**2147-7-10**] because she
awoke and vomited bright red blood two times (each approxmiately
1 cup). In the ED, the patient was afebrile and normotensive.
She was found to be in Afib with rates to the 120s. A NG lavage
showed 150cc coffee grounds, and the patient had melena from
below. Pt. not clearing completely after 500 cc NS and was
transfused 1 Unit. The patients hct was 28 from a baseline of
approximately 30. GI was called and wanted to admit to ICU for
EGD. Also, troponin elevated to 0.06. Per cardiology likely
demand ischemia and recommeneded transfusing PRBC.
.
The patient was in the ICU and her brief hospital course is
listed below. Her EGD showed friable esophag. mucosa and
[**Last Name (un) **]. For her drop in hct from 28.4-27.7, she was given 2
Units of PRBC and responded appropriately (hct 35.8). She was
maintained on a PPI, carafate, and her ASA was held per GI
consult. For her UTI, she was started on bactrim, and had no
issues. For her afib, her digoxin and metoprolol were held, in
the setting of the GIB. In addition to the above issues, she
was found to have a troponin leak, but this was attributed to
demand ischemia, and no intervention was required. The
patient's rheumatoid medications were held during her course as
well. Finally, per imaging her G tube was found to be displaced
and surgery will be notified.
.
On the floor, the patient denied increased SOB, CP, dizziness,
increased weakness, back pain, suprapubic tenderness. Unchanged
dysuria.
Past Medical History:
1) paraesophogeal hernia
2) GERD
3) CAD/MI/CABG
4) A-Fib
5) COPD
6) HTN
7) h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear w/ dilatation
8) TIAs
9) DMII
10) dyslipidemia
11) RA
12) PVD
13) ?Hepatitis C
14) CHF w/ preserved EF 50-55%. Mod-severe MR/TR
Social History:
Lives alone and has help from granddaughter, home health aid and
a homemaker. Quit tobacco 1 year ago (40 pack years).
Occasional alcohol use. No recreational drugs. From NH - family
lives nearby.
Family History:
Famhx: brother died of heart attack, and pt. thinks mother had
heart disease.
Physical Exam:
On floor:
T: 98.3, BP 128/78, P 117, RR 24, 97% RA
gen: cachectic female, in bed, NAD
HEENT: mmm, oropharynx clear, no sclerae icterus
neck: no [**Doctor First Name **], no JVD
CV: irregular, tachycardic, [**3-13**] murmur noted
lungs: crackles at base
abd: s/nd/+BS. Tenderness to palp at GJ site(LUQ), some
erythema (unsure if this is baseline as just replaced).
neuro: AAOx3, CN intact, strength 5/5, sensation intact
ext: no c/c/e and no calf tenderness.
Pertinent Results:
CXR [**7-10**]: IMPRESSION:
1. No evidence of free intraperitoneal air.
2. Improvement of the congestive heart failure and left lower
lobe
atelectasis
.
EGD: Grade 4 esophagitis in the GE junction and distal lower
third of esophagus. Patchy erythema in the stomach body. G
tube in place with distal end near cardia.
.
[**2147-4-28**] ECHO (most recent):
1.The left atrium is markedly dilated. The left atrium is
elongated. The right atrium is markedly dilated.
2.There is mild global left ventricular hypokinesis. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Though the views are limited, it appears that there might be a
small area of distal septal hypokinesis.[Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
3.The ascending aorta is mildly dilated.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild to moderate ([**1-9**]+) aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen.
6.Moderate to severe [3+] tricuspid regurgitation is seen.
7.There is moderate pulmonary artery systolic hypertension.
8.There is a small pericardial effusion. No tamponade is
present.
9. There is a large pleural effusion present.
.
Micro:
UA: moderate leuk esterase, > 50 WBC and bacteria. Culture
negative
.
Labs on admission:
[**2147-7-10**] 10:00AM WBC-9.7 RBC-3.16* HGB-9.6* HCT-28.4* MCV-90
MCH-30.3 MCHC-33.8 RDW-17.2*
[**2147-7-10**] 10:00AM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2147-7-10**] 10:00AM CK-MB-4 cTropnT-0.06*
[**2147-7-10**] 10:00AM GLUCOSE-138* UREA N-41* CREAT-0.8 SODIUM-138
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-34* ANION GAP-12
[**2147-7-10**] 02:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2147-7-10**] 02:10PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
.
Labs on discharge:
[**2147-7-14**] 05:30AM BLOOD WBC-6.1 RBC-3.64* Hgb-11.3* Hct-33.2*
MCV-91 MCH-31.0 MCHC-34.0 RDW-17.0* Plt Ct-179
[**2147-7-14**] 05:30AM BLOOD Glucose-105 UreaN-13 Creat-0.6 Na-141
K-3.8 Cl-109* HCO3-26 AnGap-10
[**2147-7-11**] 04:51AM BLOOD CK-MB-4 cTropnT-0.04*
Brief Hospital Course:
The patient is an 84 year old female with history of reflux,
atrial fibrillation, coronary artery disease (CAD), COPD,
hypertension, TIA, PVD, who presents with Upper GI bleed due to
esophagitis, and urinary tract infection.
.
1) Upper GI Bleed - The source of the patient's GI bleed was
likely from her friable esophageal mucosa, we continued to
monitor her hematocrit, until it was stable. Once she was
stable, we restarted her home medications through her GJ tube.
We continued her on a proton pump inhibitor [**Hospital1 **], carafate and
held her ASA. After being in the ICU, she did not require any
further transfusion. We stopped her IVF, once she was stable
and she did well with her diet being advanced as tolerated.
.
2) Atrial Fibrillation - The patient was having afib with rate
up to 150's in ED, and up to 120's in ICU. Once on the floor,
she was not actively bleeding so we restarted her home
medications of digoxin and metoprolol, and maintained her on
telemetry. She remained stable on these medications, and her
tachycardia improved.
.
3) Troponin Leak - This was likely demand ischemia, in the
setting of a GI bleed, so we continued to check her hematocrit
to keep her stable. She did well and her tropinins improved.
She would likely benefit from seeing her outpatient cardiologist
once she is out of rehab.
.
4) Urinary tract infection - Her UA was positive, so we sent
urine cultures. She was started on bactrim, but when her urine
culture was negative we stopped her antibiotic. She remained
afebrile, and did not have signs of symptoms of infection.
.
5) Coronary artery disease - The patient was stable, and as
above her troponins improved. Per the GI service, we restarted
her metoprolol and lipitor through her GJ tube. We held her ACE
and lasix, to avoid hypotension and the patient did well. Her
aspirin was held due to her bleed and this as well as her ACE
and Lasix should likely be restarted by her primary care
physician.
.
6) Diabetes - We held her home medications of metformin and
glipizide. She was given sliding scale insulin and had one
episode of hypoglycemia which responded well to half an amp of
dextrose. She did well once we halved her dose of sliding scale
insulin.
.
7) Rheumatoid arthritis - In the ICU, her hydroxychloroquine,
prednisone and sulfasalazine, were held initially. She was
stable on the floor, so we restarted these medications through
her GJ tube and she had no problems.
.
8) LUQ tenderness (at GJ site) - The patient had just had her GJ
readjusted, so this was likely normal. She remained afebrile
and her pain improved, but we notified Dr. [**Last Name (STitle) **] the
physician who placed the tube) about this and the suboptimal
placement of the tube. No intervention was necessary and the
patient's pain improved. Dr. [**Last Name (STitle) **] said her tenderness is
normal, and both tubes are able to be used. Her G tube is the
foley and the J tube is the pigtail.
.
9) Nutrition - Patient is tolerating oral diet. She should
continue this with shake supplements at meals. If she has
problems, she can be fed through her [**Name (NI) **] tube and this could be
addressed with her outpatient.
Medications on Admission:
1. Digoxin 125 mcg QD
2. Metoprolol Tartrate 100 mg TID
3. Prednisone 10 mg QD
4. Lansoprazole 30 mg QD
5. Metformin 500 mg [**Hospital1 **] (when TF's on)
6. Ferrous Sulfate 300 mg/5 mL Liquid 5ml QD
7. Aspirin 81 mg QD
8. Tylenol 325 mg PRN
9. Lasix 40 mg QHS
10. Lasix 20 mg QAM
11. Glipizide 2.5 mg SR [**Hospital1 **]
12. Trandolapril 2 mg QD
13. Hydroxychloroquine 200 mg [**Hospital1 **]
14. Atorvastatin 10 mg QD
15. Sulfasalazine 500 mg [**Hospital1 **]
16. Albuterol 90 mcg/Actuation Aerosol 1-2 Puffs Q6H PRN
17. Ipratropium Bromide 17 mcg/Actuation Aerosol 2 Puffs QID
18. ISS
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 14 days.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day:
through J tube please (lower red port).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day): through J tube (red port).
7. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
through J tube red port.
8. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): through J tube please.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): through J tube please.
11. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): through J tube please.
12. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO twice a day.
13. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Primary
1. Upper GI bleed due to grade 4 esophagitis
.
Secondary
1. Atrial fibrillation
2. Diabetes
Discharge Condition:
stable, tolerating PO, afebrile
Discharge Instructions:
1. Please take all your medications as prescribed.
2. Please return if you develop fevers, vomiting, uncontrolled
pain and inability to take medications.
3. Do not take aspirin till your doctor restarts it.
Followup Instructions:
1) Please follow-up with Dr. [**Last Name (STitle) 16004**] ([**Telephone/Fax (1) 3183**]) [**7-18**] at
8:20 am. He should readress if you need to restart tube feeds
and restart your lasix and trandopril which were held.
2) Please follow-up with GI (Dr. [**Last Name (STitle) 2427**] Friday [**9-15**]
for 10:00 am ([**Hospital3 **] hospital [**Hospital Ward Name 23**] building [**Location (un) 436**]
medicine specialty phone # [**Telephone/Fax (1) 1954**]).
3) Please attend your endoscopy appointment For monday [**8-28**]
8:30 am (# [**Telephone/Fax (1) 463**] [**Hospital3 **] hospital [**Hospital Ward Name 121**] bldg [**Location (un) **]). Do not eat or drink from midnight on (nothing in
stomach before procedure, can call # above for more details)
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"530.81",
"427.31",
"530.19",
"714.0",
"496",
"250.80",
"443.9",
"530.20",
"285.1",
"428.0",
"414.00",
"401.9",
"V45.81",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10462, 10527
|
5387, 8573
|
246, 263
|
10670, 10703
|
3097, 4517
|
10958, 11843
|
2523, 2602
|
9213, 10439
|
10548, 10649
|
8599, 9190
|
10727, 10935
|
2617, 3078
|
190, 208
|
5097, 5364
|
291, 1967
|
4531, 5078
|
1989, 2291
|
2307, 2507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,317
| 150,323
|
6402
|
Discharge summary
|
report
|
Admission Date: [**2134-2-2**] Discharge Date: [**2134-2-7**]
Date of Birth: [**2053-8-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization and angioplasty to SVG to LAD [**2134-2-5**]
History of Present Illness:
80M with CAD s/p CABG, PVD, DM, HTN, hyperlipidemia, CRI, GERD
who presented to ED with ~6 days of diarrhea. Pt was in his
usual state of good health & on vacation in [**State 108**] when the
diarrhea began on [**1-27**]. Describes diarrhea as loose, watery,
brown, no BRBPR, 3-5x/day. +Sweats (sometimes soaking through
clothes), subjective fevers, and "shakes" (lasting ~30 minutes)
occurring a few times per day since the diarrhea began. Does
remember eating lobsters, oysters, & other seafood at a buffet
the night before the diarrhea began, so he attributed it to
possibly eating undercooked or contaminated food. Unaware of
anyone else at restaurant or other friends/family becoming sick.
Tried immodium without any change in his diarrhea. Denies any
recent Abx use. Denies any nausea, vomiting, or abdominal pain.
Pt reports poor PO intake since diarrhea began but was able to
take flight back to [**Location (un) 86**] 3 days ago. Tonight, patient's family
was concerned about his continued symptoms, lightheadedness, and
dehydration so brought him to ED.
In the ED, initial VS HR 88, BP 82/48 -> 70/37, sat 96% RA so
started on IVF (rec'd total 6L in ED) with some improvement in
SBP to 85-100. Central line placed and CVP ~[**8-29**]. Lactate 2.1.
WBC 8.8 w/65N, 13bands.
Also in the ED, the patient developed epigastric burning and
then, separately, sudden-onset severe substernal chest pain with
radiation to his L-arm. Pt stated that the SSCP was similar to
his previous angina. Pt was lying in stretcher at that time and
receiving IVF for SBP in 80s. ECG was A-V paced and unchanged
from prior. Chest pain resolved after 1 mg morphine. Rec'd 325
mg ASA in ED.
On ROS, patient denies DOE, orthopnea, or urinary Sx. Reports
good excercise tolerance including walking many blocks and
biking 20 minutes per day at the gym. Denies any swimming while
in [**State 108**].
Past Medical History:
-CAD s/p MI, s/p 5-vessel CABG in [**2109**]. Most recent cath [**9-22**]
w/PTCA of the PDA ostium and drug-eluting stenting of the distal
RCA into the PLB & DES to prox SVG-RCA, Patent SVG->D1/LAD and
SVG->OM.
Severe SVG->dRCA disease in proximal graft and distal to graft.
Moderate diastolic left ventricular dysfunction.
-PVD, s/p bilat femoral endarterectomy [**2133-6-19**]
-DM on insulin
-S/p pacemaker placement ([**Company 1543**]) in [**2133-11-19**] for 2:1 AV
block
-Hypercholesterolemia
-Hypertension
-CRI, baseline ~1.0-1.2
-History of GERD, gastritis
-Anemia, baseline Hct 30-34
-Dyspnea: w/u by Dr. [**Last Name (STitle) 575**], pulmonary, smoking h/o vs.
asbestos exposure; last CT scan [**2133-9-3**]: 3-mm diameter
noncalcified peripheral right lower lobe lung nodule f/u
[**2-/2134**]
-S/p bilateral carotid endarterectomy [**6-23**]
-S/p multiple colonoscopies with polyp removal
-Multiple orthopedic procedures on back and knees
Social History:
Lives with wife (she has h/o CVAs & he is her primary
caregiver). >80 pack-yr hx, quit >40 yrs ago. Occasional EtOH
when cooking. Retired but previously worked in Navy & as a
police officer.
Family History:
Strongly positive for premature heart disease.
Physical Exam:
VS: T 98.8, HR 90, BP 95/50, Sat 99-100% on 2L NC
-Gen: pleasant elderly M in NAD
-Skin: C/D/I, old surgical scars sternum, LEs; no rashes apprec
-HEENT: OP clear, dry MM,
-Neck: no JVD
-Heart: distant heart sounds, S1S2, no M appreciated
-Lungs: CTA B, no crackles appreciated, good air movement
-Abdom: soft, obese, NT, somewhat distended, hyperactive BS
-Rectal: dark brown, green stool, guaiac + in ED
-Extrem: 1+ pitting edema, L>R ankle; trace DP pulses
-Neuro/Psych: A&Ox3, conversant, appropriate, CN2-12 intact, [**4-23**]
strength throughout
Pertinent Results:
[**2134-2-1**] 10:20PM GLUCOSE-175* UREA N-40* CREAT-1.9* SODIUM-134
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-15* ANION GAP-18
Glucose UreaN Creat Na K Cl HCO3
[**2134-2-7**] 06:08AM 134* 13 0.9 137 4.5 104 26
.
[**2134-2-1**] 10:20PM WBC-8.8# RBC-3.77* HGB-12.6* HCT-35.0* MCV-93
MCH-33.3* MCHC-35.9* RDW-15.5
[**2134-2-2**] hct 26.9, repeat 27.6
[**2134-2-3**] hct 25.3
[**2134-2-4**] hct 29.2 (after 2 units PRBCs), repeat in pm 35.9
[**2134-2-5**] hct 28.8 (after 1 unit PRBC)
[**2134-2-6**] hct 30.7, repeat 32.1
[**2134-2-7**] hct 33
[**2134-2-7**] 06:08AM WBC 7.2 HCT 33.0* PLT 166
.
[**2134-2-1**] 10:20PM cTropnT-<0.01
[**2134-2-2**] 03:51AM cTropnT-<0.01
[**2134-2-2**] 05:50AM cTropnT-0.02*
[**2134-2-2**] 03:22PM CK-MB-17* MB INDX-10.9* cTropnT-0.28*
[**2134-2-3**] 03:33AM cTropnT-0.46*
[**2134-2-3**] 02:06PM cTropnT-0.25*
[**2134-2-4**] 06:26AM cTropnT-0.35*
[**2134-2-4**] 12:50PM cTropnT-0.04*
[**2134-2-4**] 07:50PM cTropnT-0.39*
[**2134-2-5**] 05:35AM cTropnT-0.40*
[**2134-2-6**] 05:48AM cTropnT-0.49*
[**2134-2-7**] 06:08AM cTropnT-0.37*
.
[**2134-2-2**] 03:51AM BLOOD CK(CPK)-37*
[**2134-2-2**] 05:50AM BLOOD CK(CPK)-53
[**2134-2-2**] 03:22PM BLOOD CK(CPK)-156
[**2134-2-3**] 03:33AM BLOOD CK(CPK)-96
[**2134-2-3**] 02:06PM BLOOD CK(CPK)-60
[**2134-2-4**] 06:26AM BLOOD CK(CPK)-46
[**2134-2-4**] 12:50PM BLOOD CK(CPK)-56
[**2134-2-5**] 05:35AM BLOOD CK(CPK)-40
[**2134-2-5**] 09:05PM BLOOD CK(CPK)-47
[**2134-2-6**] 05:48AM BLOOD CK(CPK)-37*
[**2134-2-7**] 06:08AM BLOOD CK(CPK)-51
.
[**2134-2-1**] ECG: Atrial sensed ventricular paced rhythm at 88 beats
per minute, unchanged compared to the previous tracing of
[**2133-11-28**].
.
[**2134-2-2**] ECG: Atrial sensed ventricular paced rhythm at 80 beats
per minute. Compared to the previous tracing of [**2134-2-2**] no
diagnostic interval change
.
[**2134-2-4**] ECg: Atrial sensed ventricular paced rhythm. Compared to
the previous tracing of [**2134-2-3**] no significant change
.
[**2134-2-5**] ECG: Baseline artifact makes interpretation difficult.
Probable atrial sensed and ventricular paced rhythm. Compared to
the previous tracing of [**2134-2-4**] no significant change, except
for artifact.
.
[**2134-2-6**] ECG:Ventricular pacing. Pacemaker rhythm - no further
analysis. Compared to the previous tracing of [**2134-2-5**] no
significant change.
.
[**2134-2-2**] 8:43 am STOOL CONSISTENCY: LOOSE Source:
Stool.
FECAL CULTURE (Final [**2134-2-4**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2134-2-4**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final [**2134-2-4**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2134-2-4**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2134-2-3**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2134-2-2**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2134-2-2**] TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic root 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. Mild to moderate ([**12-21**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Mild-moderate
mitral regurgitation. Pulmonary artery systolic hypertension.
Dilated ascending aorta.
.
[**2134-2-5**] Cardiac Cath:
1. Selective coronary angiography revealed native three vessel
disease,
patent SVG to PDA and SVG to OM and 70% stenosis of the SVG to
LAD. The
LMCA was occluded proximally. The native LAD was backfilled by
the SVG
but the distal native LAD was also occluded (similar to prior
cath). The
SVG to LAD and D1 had a 70% stenosis in an extremely tortuous
segment
just prior to the anastomosis. This was balloon angioplastied
(see
below). The native LCx was occluded proximally. A SVG to large
OM2 was
patent. The native RCA was occluded proximally, the distal RCA
was
supplied by a widely patent SVG with patent stents in the SVG
and the
PLV branch.
2. Limited hemodynamics revealed elevated central aortic blood
pressures.
3. Left ventriculography was not performed.
4 . The SVG touch down to the LAD was angioplastied with a 2.0 X
15mm
Voyager and a 2.5 X 15mm Maverick balloon with lesion reduction
from 70%
to 30%. the final angiogram showed no dissection and no
embolisation.(see PTCA comments)
FINAL DIAGNOSIS:
1. Severe native three vessel CAD
2. Patent SVG to PDA, patent SVG to OM.
3. 70% stenosis of SVG to LAD/D1
4 Successful angioplasty of the touch down lesion of the SVG to
the LAD.
.
[**2134-2-6**] U/S of R groin: Grayscale and Doppler son[**Name (NI) 1417**] of the
right groin including right external iliac artery and vein as
well as right common femoral artery and vein demonstrate normal
flow and waveforms in these vessels and no evidence of
pseudoaneurysm, hematoma or thrombus.
IMPRESSION: No evidence of pseudoaneurysm in the right groin.
.
Brief Hospital Course:
80M with CAD s/p CABG, PVD, DM, HTN, hyperlipidemia, CRI, GERD
a/w diarrhea, hypotension and poor POs x 1 wk.
.
# Hypotension: Was from dehydration [**1-21**] diarrhea and poor
intake. All his antihypertensives were held initially. After
receiving IVF (6L NS) in the MICU, hypotension resolved.
.
# Diarrhea: This began after seafood buffet. The patient had
guaiac + stools but the stool cultures were negative. The
patient was on levofloxacin briefly while in the MICU but was
discontinued on the floor. The patient's diarrhea improved
gradually then resolved. The patient did have guaiac positive
stools during this hospitaliziation (h/o hyperplastic polyps and
last colonoscopy in [**9-23**]) and recommended outpatient f/u
colonoscopy in 6 weeks.
.
# Coronary artery disease/non-ST elevation myocardial
infarction: Was concerning for cardiac origin with ECG changes
and troponin rise. Initially thought to be secondary to demand
ischemia [**1-21**] hypotension and was given IVF and continued on ASA,
plavix, statin, and restarted BB and ACEI as BP tolerated. The
patient was also transfused to keep his hct >30. The patient
remained asymptomatic until the night of [**2-4**] when he developed
chest pain in the setting of emotional distress with the
unchanged ECG and troponin rise, then the patient was taken to
the cath lab on [**2-5**] and found to have a 70% stenosis of SVG to
LAD/D1 and angioplasty of the touch down lesion of the SVG to
the LAD was performed. The patient did not receive any heparin
before or after cath due to guaiac positive stools. The patient
tolerated the cath well and did not have any complications.
Right fem u/s at cath site was obtained because of a new bruit
but was negative for pseudoaneurysm, hematoma or thrombus.
.
# Diastolic dysfunction: Was volume-overloaded after IVF
resuscitation in the MICU and on the floor, pt was restarted on
lasix home dose once BP normalized/stablized and also received
IV lasix after blood transfusion. His lower extremity edema
improve with lasix and the patient did not require any
supplement O2 on the floor. The patient was advised to monitor
his daily weights and continue lasix as outpatient and call his
primary care physician if weight gain of 3 lbs or more occurs.
.
# Anemia: The patient had guaiac positive stools but never gross
blood in stools during the hospitalization. Given his NSTEMI,
the patient was transfused with a total of 3 units of PRBCs to
keep his hct above 30. The patient was advised to get a repeat
colonoscopy in 6 weeks after cardiac catheterization as has a hx
of hyperplastic polyps.
.
# DM II on insulin: The patient was restarted on lower dose NPH
(8 am/8 pm)than at home dose (14 am and 13 NPH and humalog 13 at
dinner) due to poor intake and nausea which eventually resolved.
The patient has a follow-up PCP appointment with [**Name9 (PRE) **] to
titrate up his insulin regimen. His FS was in 100s-200s at the
time of discharge.
.
# Acute renal insufficiency: Creat normalized after fluid
resuscitation.
.
# Restrictive lung dz/smoking/wheezes: ws stable and continued
nebs. The patient has outpatient CT chest follow-up in [**5-25**] as
an outpatient.
.
# FEN: Received IVF and advanced to regular, cardiac, diabetic
diet as tolerated. The patient tolerated po without problem at
the time of discharge. The mag and K were repleted/prn to keep
mag at 2 and K at 4.
- Nongap Metabolic Acidosis: bicarb 15 initially from diarrhea.
Resolved with resolution of diarreha.
.
# Prophyl: PPI, SC heparin
Medications on Admission:
Aspirin 325 mg daily, Clopidogrel 75 mg daily, Plendil 10 mg
daily; Insulin, NPH 14 units qAM, 13 units at dinner; Humalog 13
units at dinner; Metoprolol 100 mg Tablet [**Hospital1 **], Fosinopril 60 mg
daily, Isosorbide Dinitrate SR 60 mg Q12H; Furosemide 80 mg
daily, Atorvastatin 80 mg daily, Ezetimibe 10 mg daily, Spiriva
1 puff daily, Prilosec 20 mg daily, Albuterol 1-2 Puffs Q4H as
needed,
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Fosinopril 10 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eight
(8) units Subcutaneous in am and at dinner.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Diarrhea- resolved
Dehydration- resolved
Coronary artery disease s/p cardiac catheterization and
angioplasty
Secondary diagnoses:
Diabetes mellitus type 2 on insulin
peripheral vascular disease
Anemia
Congestive heart failure
Discharge Condition:
Stable, chest pain free.
Discharge Instructions:
Return to the emergency department if you develop chest pain,
shortness of breath, sweating, nausea, vomiting, abdominal pain,
jaw pain, bleeding from catheterization site, bright red blood
in your stools, lightheadedness, palpitations, or any other
concerning symptoms.
.
Please, take medications as instructed. We stopped amlodipine
because of your low blood pressure and decreased fosinopril and
metoprolol. We also decreased your insulin because of your poor
intake while in the hospital. Follow-up with your primary care
physician and increase your insulin and blood pressure
medications as needed. Please check your blood sugar as you
have been doing and record blood sugars and take the log to your
primary care physician. [**Name10 (NameIs) 357**], discuss with your primary care
physician about occult blood in your stools and you need a
repeat colonoscopy in 6 weeks.
.
Please monitor your weight daily and if weight increases 3lbs or
more, call your primary care physician to see if lasix needs to
be increased.
.
Please keep all your follow-up appointments as shown below.
.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 713**] at [**Last Name (un) **] (Dr. [**Last Name (STitle) **] left the
practice and referred you to Dr. [**Last Name (STitle) 713**] as your new primary care
physician) within 1-2 weeks. Phone number [**Telephone/Fax (1) 9979**]. The
office will call you with the earliest date.
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2134-2-15**] 12:30
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2134-5-20**] 10:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2134-5-20**] 10:10
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2134-5-20**] 9:15
|
[
"787.91",
"401.9",
"285.9",
"428.0",
"428.33",
"250.00",
"276.2",
"276.51",
"530.81",
"996.72",
"V58.67",
"585.9",
"424.0",
"414.01",
"443.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"99.04",
"99.20",
"88.52",
"00.40",
"00.66",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
14813, 14819
|
9833, 13361
|
331, 402
|
15108, 15135
|
4153, 9242
|
16275, 17172
|
3516, 3564
|
13809, 14790
|
14840, 14968
|
13387, 13786
|
9259, 9810
|
15159, 16252
|
3579, 4134
|
14989, 15087
|
272, 293
|
430, 2317
|
2339, 3292
|
3308, 3500
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,979
| 112,699
|
30660
|
Discharge summary
|
report
|
Admission Date: [**2184-10-27**] Discharge Date: [**2184-11-19**]
Date of Birth: [**2119-12-26**] Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture
PICC line placement
PEG tube placement
History of Present Illness:
Patient is a 64 yo male with recent renal transplant on
[**2184-9-22**], diabetes mellitus, HTN, admitted [**2184-10-27**] with 24-48
hours of confusion and aphasia. The patient was doing well
post-transplant and was off of dialysis, with improving kidney
transplant.
.
On [**2184-10-25**], the patient's VNA thought he was a little more
confused than usual. The patient was seen in nephrology on
[**2184-10-26**], and had a fall on the way to the car, without head
trauma. He then presented to [**Hospital6 3105**], where he
was felt to have a toxic metabolic encephalopathy. Urine showed
119 RBC and 14 WBC. Urine tox was negative. Non-contrast head CT
showed small vessel ischemic change and atrophy with no acute
process. He was given a dose of levofloxacin for question of
UTI. Given his recent renal transplant, he was transferred to
[**Hospital1 18**] for further management.
.
According to the patient's wife, the patient became more
confused [**10-26**], and his speach became incomprehensible, with
impaired naming. No other symptoms. The only recent medication
change was a decrease in tacrolimus dose several days ago. The
patient took oxycodone 2.5 mg x 2 for knee pain during the
weekend, with some sleepiness but no change in mental status.
.
He was admitted to the renal service for further work-up. LP was
unremarkable, viral studies pending, on empiric acyclovir. MRI
showed no infarct or hemorrhage. He was started on acyclovir per
ID recs. Creatinine is stable at 1.5. On [**2184-10-31**], he was found
to be in non-convulsive status epilepticus and was started on
keppra. He was monitored with EEG.
.
On [**2184-11-1**] at 12:30 am, he was triggered for worsened AMS. His
VS were AF, P: 96, BP: 166/56, RR: 45, 98% on RA. He has been
able to open his eyes to name. At midnight, she was
non-responsive to sternal tub with RR in the 40s. He was also
having shaking movements. EEG showed slow waves with occasional
spikes not correlated with seizure activity. He was given ativan
1 mg iv x 2 without improvement. He was transferred to the MICU
for further management.
Past Medical History:
ESRD from diabetic nephropathy, s/p deceased donor kidney
transplant [**2184-9-21**]
Diabetes mellitus
HTN
SDH after fall, resolved
actinic keratosis
RUE AV fistula creation
CAD
Social History:
Married. Lives with wife.
-Tobacco: none
-EtOH: None
-Drugs: None
Family History:
HTN
Physical Exam:
General: tachypneic, non-responsive, occasionally opens eyes to
sternal rub
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: tachypneic, Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: sl. tachy, reg 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: AV fistula in place in RUE, +thrill; LUE-
Neuro: pupils 6 mm->3 mm sluggish but responsive bilaterally,
unable to fully assess CNII-XII as patient was not following
commands
Pertinent Results:
[**2184-10-26**] 01:35PM BLOOD WBC-9.4 RBC-3.25* Hgb-10.6* Hct-33.8*
MCV-104* MCH-32.5* MCHC-31.3 RDW-14.6 Plt Ct-216
[**2184-10-27**] 07:30PM BLOOD WBC-7.3 RBC-2.75* Hgb-9.1* Hct-27.9*
MCV-101* MCH-33.0* MCHC-32.6 RDW-14.6 Plt Ct-198
[**2184-10-28**] 05:40AM BLOOD WBC-7.7 RBC-2.86* Hgb-9.1* Hct-28.9*
MCV-101* MCH-31.9 MCHC-31.5 RDW-14.7 Plt Ct-184
[**2184-10-29**] 05:50AM BLOOD WBC-6.5 RBC-2.66* Hgb-8.6* Hct-27.5*
MCV-103* MCH-32.3* MCHC-31.3 RDW-14.0 Plt Ct-192
[**2184-10-30**] 07:25AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE
TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-UNABLE TO
[**2184-10-30**] 10:40AM BLOOD WBC-9.5 RBC-2.85* Hgb-8.9* Hct-29.2*
MCV-103* MCH-31.4 MCHC-30.6* RDW-13.8 Plt Ct-192
[**2184-10-31**] 06:20AM BLOOD WBC-10.8 RBC-3.13* Hgb-9.9* Hct-31.4*
MCV-100* MCH-31.7 MCHC-31.6 RDW-14.2 Plt Ct-178
[**2184-11-1**] 02:14AM BLOOD WBC-12.3* RBC-3.07* Hgb-9.7* Hct-30.0*
MCV-98 MCH-31.7 MCHC-32.5 RDW-14.2 Plt Ct-211
[**2184-11-2**] 03:51AM BLOOD WBC-9.8 RBC-2.75* Hgb-8.8* Hct-27.1*
MCV-99* MCH-32.0 MCHC-32.4 RDW-14.0 Plt Ct-205
[**2184-10-27**] 07:30PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+
[**2184-11-1**] 02:14AM BLOOD PT-13.5* PTT-30.6 INR(PT)-1.3*
[**2184-10-26**] 01:35PM BLOOD UreaN-31* Creat-1.9* Na-137 K-5.7* Cl-102
HCO3-18* AnGap-23*
[**2184-11-2**] 03:51AM BLOOD Glucose-201* UreaN-16 Creat-1.3* Na-138
K-4.2 Cl-104 HCO3-28 AnGap-10
[**2184-10-26**] 01:35PM BLOOD ALT-9 AST-15 TotBili-0.5
[**2184-11-1**] 02:14AM BLOOD ALT-7 AST-14 LD(LDH)-268* AlkPhos-81
TotBili-0.6
[**2184-11-2**] 03:51AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
[**2184-10-29**] 05:50AM BLOOD VitB12-1675*
[**2184-10-28**] 05:40AM BLOOD TSH-0.94
[**2184-11-2**] 03:51AM BLOOD CRP-87.4* antiTPO-PND
[**2184-11-1**] 02:36AM BLOOD Type-[**Last Name (un) **] Temp-39.1 pO2-61* pCO2-49
pH-7.39 calTCO2-31* Base XS-3 Comment-AXILLARY T
[**2184-11-1**] 01:24AM BLOOD Glucose-221* Lactate-1.4 Na-135 K-3.8
Cl-101
[**2184-11-1**] 01:24AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-96 COHgb-1
MetHgb-0
Brief Hospital Course:
Patient is a 64 yo male with recent renal transplant on
[**2184-9-22**], diabetes mellitus, HTN admitted with confusion and
aphasia now with worsened AMS after being found to have
non-convulsive status epilepticus this am.
# Altered Mental Status: Likely toxic metabolic given extensive
work-up including negative LP and MRI. He was found to be in
non-convulsive status epilepticus on the floor and was
transferred to the ICU. He was treated with keppra and his
seizures have resolved. He was placed on continuous EEG which
showed persistent encephalopathy. EEG is not suggestive of
further seizure activity at this time and no dose adjustment of
his anti-epileptic medications were made. Tacrolimus is thought
to be contributing to his new onset encephalopathy. Tacrolimus
was stopped and he was started on sirolimus and prednisone.
Tacrolimus levels in his blood have been undetectable now for
several days and very little mental status improvement has been
seen. Neurology has been involved and feel that the pt's
recovery will be a slow process and he will require in patient
rehabilitation. Infectious Disease has also been consulted and
his infectious workup has all been negative to date including a
lumbar puncture with cultured CSF.
.
#Fever / Leukocytosis- During this hospital admission the pt
developed fever, tachypnea and leukocytosis. A CXR was obtained
which showed right and left opacities that were consistent with
either a new pneumonia or aspiration pneumonitis. Vancomycin and
Zosyn were started. He again spiked a fever through the
anitbiotics the next day and Ciprofloxacin was added for double
coverage of pseudomonas. Blood and urine cultures were obtained.
Two of fourteen bottles were positive for Coagulase Negative
Staph. The PICC line was removed and he completed a 7 day course
of Zosyn, cipro was discontinued after three days of treatment.
He has remained afebrile with negative blood cultures now for
over 48 hours. A new PICC line was placed and we will continue
Vancomycin for 14 days with a start of [**2184-11-14**]. Vancomycin
should be stopped on [**2184-11-27**].
.
# Renal Transplant: On admission to the hospital the patient's
creatinine was elevated to 1.9. He was administered IV fluids
and a tacrolimus level was checked and found to be elevated.
Tacrolimus was held due to the elevated level and because it was
though to be contributing to his altered mental status. she
instead was started on prednisone and sirolimus. we also
continued CellCept Bactrim and valganciclovir for prophylaxis as
well. His creatinine improved with increased oral intake and IV
fluids and at the time of discharge was within normal limits.
.
#Right knee effusion: on admission the patient had a right knee
effusion. It was tender to palpation On exam. The joint
aspiration was performed for which was positive for inflammatory
cells only without evidence of infection. It was felt that this
was due to a gout flare.
.
# Hypertension: The patient was noted to be hypertensive during
this hospital stay. We increased his dose of metoprolol and
added amlodipine and lisinopril for better blood pressure
control.
.
#DMII: He was placed on an insulin sliding scale.
.
#Gout: We continued allopurinol.
.
#Transitional: the patient was discharged to a [**Hospital 4820**] rehab
facility. He has follow-up appointments with the kidney
transplant center and neurology. You will also need a urology
appointment for your stent removal. He should have labwork drawn
on [**2184-11-24**] and faxed to Dr. [**Last Name (STitle) 6729**] office at [**Telephone/Fax (1) 697**].
Medications on Admission:
Mycophenolate Mofetil 1000 mg PO BID
Acyclovir 700 mg IV Q8H HSV encephalitis
Metoprolol Tartrate 37.5 mg PO/NG [**Hospital1 **]
Allopurinol 100 mg PO/NG DAILY
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
Amlodipine 5 mg PO/NG DAILY
Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Quetiapine Fumarate 12.5 mg PO/NG QHS
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Famotidine 20 mg PO/NG DAILY
Senna 1 TAB PO/NG [**Hospital1 **]
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Sulfameth/Trimethoprim SS 10 mL PO/NG DAILY
Insulin SC (per Insulin Flowsheet)
ValGANCIclovir 900 mg PO Q24H
LeVETiracetam 1000 mg IV Q12H
Discharge Medications:
1. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution
Sig: Five (5) ml PO BID (2 times a day).
2. senna 8.8 mg/5 mL Syrup Sig: [**11-30**] ml PO BID (2 times a day).
3. valganciclovir 50 mg/mL Recon Soln Sig: Eighteen (18) ml PO
Q24H (every 24 hours).
4. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig:
Ten (10) ML PO DAILY (Daily).
5. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
8. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2
times a day).
13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. sirolimus 1 mg/mL Solution Sig: Five (5) ml PO DAILY
(Daily).
17. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. insulin glargine 100 unit/mL Cartridge Sig: Twenty Five (25)
units Subcutaneous in am and at bedtime.
19. insulin lispro 100 unit/mL Cartridge Sig: One (1) as
directed Subcutaneous as directed : please see attached sliding
scale.
20. Outpatient Lab Work
Please obtain a CBC, Chem 7, Sirolimus trough on [**11-30**] and
fax results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 697**]
21. vancomycin 500 mg Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 9 days.
22. Outpatient Lab Work
Please draw a sirolimus trough (prior to am dose) and vancomycin
trough on [**2184-11-20**] and fax results to Dr. [**Last Name (STitle) **] @
[**Telephone/Fax (1) 697**]
23. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY:
Metabolic encephalopathy
Status Post Kidney Transplant
hypertension
diabetes mellitus
gout
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 **]. You admitted to the hospital with confusion. We
believe your confusion was caused by one of the
immunosuppressive medications that you were previously taking
called tacrolimus. We have stopped tacrolimus and started you on
a new medication called sirolimus along with prednisone instead.
We have determined that your altered mental status is not due to
a stroke or infection. We would like you to continue to
follow-up with neurology as an outpatient.
The following changes have been made your medications:
STOP:
Tacrolimus
Nortriptyline
Gabapentin
Zantac
CHANGE:
Valganciclovir 900mg daily
Metoprolol Tartrate 150mg every 8hrs
Vitamin D 1000IUs daily
START:
Nystatin 5ml swish in mouth up to four times per day as needed
for thrush
Miconazole Powder 2% apply twice per day to groin
Heparin 5000Units inject subcutaneously three times per day
Levetiracetam 500mg twice per day
Amlodipine 10mg daily
Polyethylene Glycol 17grams daily
Famotidine 20mg daily
Sirolimus 6mg daily
Prednisone 5mg daily
Lisinopril 40mg daily
Vancomycin 500mg IV twice per day last day [**2184-11-27**]
Glargine Insulin inject 25units in the am and at bed time
Humalog Insulin sliding scale please see attached sheet
See below for follow-up appointments have been made on your
behalf.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital **] MEDICAL & WALK IN CENTER, LLC
Address: [**Last Name (un) 39144**], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 72680**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.**
Department: TRANSPLANT
When: TUESDAY [**2184-11-16**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2184-11-17**] at 2:00 PM
With: [**Name6 (MD) 2341**] [**Last Name (NamePattern4) 2342**], M.D. [**Telephone/Fax (1) 2343**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
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45,180
| 184,821
|
31429
|
Discharge summary
|
report
|
Admission Date: [**2171-6-26**] Discharge Date: [**2171-7-7**]
Date of Birth: [**2116-11-20**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. Distal pancreatectomy with splenectomy.
2. Extended adhesiolysis.
3. Portal vein repair, Dr. [**Last Name (STitle) **] primary surgeon, Dr.
[**Last Name (STitle) **] assistant surgeon.
4. Placement of gold fiducial seeds for CyberKnife
radiotherapy.
History of Present Illness:
This 54-year-old woman previously underwent a Whipple
resection 6 months ago. She originallypresented with tumor in
the pancreatic head and during the Whipple operation she had an
atypical neck margin which was cutback farther on the body of
the pancreas. Both the frozen
section and the final margin on the second excision was
negative for malignancy. However, interestingly she comes
back at this point in time with evidence of another tumor in
the pancreatic remnant just at the pancreaticojejunal site.
This is causing duct obstruction downstream and clear-cut
pancreatitis. It is assumed that this is residual microscopic
disease that was unrecognized at the first operation which
has blossomed at the site of the pancreaticojejunostomy. The
rest of her workup was completely negative for metastatic
disease and the tumor appeared as if it was resectable on the
CAT scan in terms of the vascular involvement.
Past Medical History:
PMHx: multiple episodes of acute pancreatitis [**12-17**] pancreatic
divisum (stented [**2168**]), pancreatic cysts, multiple liver
hemangiomas, HTN, hypothyroid, depression
PSHx: CCY [**11/2168**], C-Section x2 (remote)
Social History:
SocHx: married, grown children
Family History:
FHx: non-contributory
Physical Exam:
Temp 96.7 BP 130/80 HR 67 RR 16 O2 sat 100%
General: Well-appearing and in no apparent distress. She is
accompanied by her husband. ECOG performance status 0.
HEENT: Sclera anicteric, oropharynx clear.
Chest: Clear to auscultation and percussion.
Heart: Regular without murmur.
Abdomen: Soft, nondistended. She is status post Whipple
procedure with a well-healed abdominal scar. There are no
palpable masses, tenderness, or organomegaly noted.
Lymph nodes: No cervical, supraclavicular, axillary,
epitrochlear, or inguinal lymphadenopathy.
Extremities: No edema.
Pertinent Results:
[**2171-6-26**] 05:39PM WBC-15.5*# RBC-3.49* HGB-10.0* HCT-30.8*
MCV-88 MCH-28.6 MCHC-32.4 RDW-14.0
[**2171-6-26**] 05:39PM GLUCOSE-61* UREA N-10 CREAT-0.8 SODIUM-145
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-23 ANION GAP-14
[**2171-6-26**] 05:39PM CALCIUM-8.0* PHOSPHATE-4.0 MAGNESIUM-1.2*
[**2171-6-26**] 03:03PM HGB-10.5* calcHCT-32 O2 SAT-97
Brief Hospital Course:
Mrs. [**Known lastname 74009**] was admitted to the hospital and taken to the
Operating Room where a distal pancreatectomy was done. She
tolerated the procedure well and returned to the PACU in stable
condition. With the help of the pain service she was managed
with Ketamine and a Dilaudid PCA post op. She was subsequently
transferred to the Surgical floor for further management.
She was followed closely by the [**Last Name (un) **] Diabetic service for
management of her blood sugars following the completion
pancreatectomy. Her blood sugars were well controlled for the
first few days post op on low dose Lantus however as her intake
improved her insulin needs increasd. She was educated in
insulin administration as this is new for her and glucometer
checks were reinforced as she was instructed during her last
admission. She will have VNA services at discharge to continue
to review and educate.
From a surgical standpoint her wound was healing well without
evidence of erythema or drainage. She was started on clear
liquids 4 days post op and her diet was slowly advanced over a
twenty four hour period after bowel function returned. This was
tolerated well.
Following the cessation of Ketamine and Dilaudid PCA she was
managed with a Fentanyl patch 25 mcg/hr and Dilaudid 4-8 mg
orally for breakthrough pain. The recommendations from the pain
service include continuing the Fentanyl patch at 25 mcg/hr for 2
weeks post discharge and then decreasing to 12 mcg/hr for 2
weeks. At that time she should be managed with oral narcotics
for pain control.
After an uneventful post operative stay she was discharged home
with VNA services for diabetic teaching and insulin
administration and she will follow up with her PCP for further
pain medication adjustment. She will also follow up with Dr.
[**Last Name (STitle) **] in
2 weeks. Her staples were removed prior to discharge.
Medications on Admission:
Zoloft 0.5', Norvasc 5', Synthroid 0.137', Ambien, Albuterol,
Fent patch
Discharge Medications:
1. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 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 Q24H (every 24 hours).
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): For a total of 2 weeks then
decrease to 12mcg/hr every 72 hours.
Disp:*5 Patch 72 hr(s)* Refills:*0*
8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
11. Insulin Syringe Ultrafine [**11-16**] mL 29 x [**11-16**] Syringe Sig: One
(1) box Miscellaneous once a day.
Disp:*1 box* Refills:*2*
12. Amylase-Lipase-Protease 60,000-12,000- 38,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*200 Cap(s)* Refills:*2*
13. Alcohol Prep Pads Pads, Medicated Sig: Two (2) pads
Topical once a day.
Disp:*1 box* Refills:*2*
14. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) 12mcg/hr
Transdermal every seventy-two (72) hours: for 2 weeks then
discontinue and use oral pain medication alone.
Disp:*5 patches* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva Health Services
Discharge Diagnosis:
1. Pancreatic cancer in remnant pancreas.
2. Injury to coronary vein and portal vein.
3. Extensive adhesions of the upper abdomen.
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 [**3-24**] 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.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] for a follow up appointment in 2 weeks
([**Telephone/Fax (1) 1231**])
Call Dr. [**First Name (STitle) **] fora follow up appointment in [**11-16**] weeks
|
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4782, 4856
|
6843, 8301
|
8317, 8810
|
1885, 2464
|
274, 290
|
619, 1535
|
1557, 1781
|
1797, 1830
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,485
| 198,549
|
4463
|
Discharge summary
|
report
|
Admission Date: [**2179-8-23**] Discharge Date: [**2179-8-30**]
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2179-8-24**]: Right hip cemented hemiarthroplasty
History of Present Illness:
Ms. [**Known lastname 19130**] is an 87 year old female who had an unwitnessed fall
at her [**Hospital3 **] (reported trip and fall with no LOC).
She was initially placed in a chair by the staff and later
daughter was concern for pain and confusion. She was then
transferred to the [**Hospital1 18**] for further evaluation and care.
Past Medical History:
-Siezure disorder on Keppra (initial seizure [**2-/2179**])
-Multiple TIA and possible stroke with R side residual last [**Month (only) **]
-Hyperlipidemia
-Hypertension
-Colon CA s/p partial colon resection 6 years ago
-Hypothyroidism
-Bursitis
-Glaucoma
-Rheumatic fever during childhood
-Dementia: alzheimer's vs. vascular, was on aricpet but this was
thought to be contributing to syncopal events so was d/c
-GERD
-anxiety
-pelvic prolapse: has pessary
Social History:
Comes from [**Hospital3 **]. Has recently had stays in [**Hospital 100**]
Rehab. Previously worked as a secretary. Has 5 children, one of
whom is deceased. Denies tobacco, etoh, IVDU. Has a son, [**Name (NI) **]
[**Name (NI) **] [**Telephone/Fax (1) 19126**] who is her HCP and is an endocrinologist in
[**Name (NI) **]. Daughter, [**Name (NI) **], who lives close by and is
readily avalible.
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: RLE, shortended roatated,
+pulses/sensation/movement
Pertinent Results:
[**2179-8-23**] 02:25PM WBC-14.3*# RBC-4.65 HGB-13.6 HCT-40.8 MCV-88
MCH-29.3 MCHC-33.4 RDW-13.9
[**2179-8-23**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2179-8-23**] 02:25PM PT-12.5 PTT-23.4 INR(PT)-1.1
Brief Hospital Course:
Ms. [**Known lastname 19130**] presented to the [**Hospital1 18**] on [**2179-8-23**] after a fall at her
[**Hospital3 **]. She was evaluated by the orthopaedic surgery
service and found to have a right hip fracture. She was
admitted, consented, and prepped for surgery. On [**2180-8-23**] she
was taken to the operating room and underwent a right hip
hemiarthroplasty. She tolerated the procedure well, was
extubated, transferred to the recovery room, and then to the
floor. On the floor she was seen by physical therapy to improve
her strength and mobility. On [**2179-8-27**] she was seen by
speech/swallow evaluation and recommended a thin liquid with
moist ground solids and meds creshed with purees. Geriatrics
was consulted for help in the post operative periods as Ms.
[**Known lastname 19130**] was refusing to take food. The decreased oral intake was
thought to be due to delirum and dementia. On the day of
discharge she was taking good PO intake and was up out of bed
and into a chair most of the day.
The rest of her hospital stay was uneventful with her lab data
and vital sings within normal limits and her pain controlled.
She is being discharged today in stable condition.
Medications on Admission:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
Disp:*300 ML(s)* Refills:*0*
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*100 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
Disp:*30 Tablet(s)* Refills:*2*
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*28 syringes* Refills:*0*
15. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for Pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
s/p fall
Right hip fracture
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:
Continue to be weight bearing as toleratd on your right leg
Continue to take your lovenox injections for a total of 4 weeks
after surgery
Please take all your medication as prescribed
If you have any increased redness, draiange, 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: Ambulate twice daily if patient able
Right lower extremity: Full weight bearing
Treatments Frequency:
Staples out 14 days after surgery
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
months, please call [**Telephone/Fax (1) 1228**] to schedule that appointment
Appointments made at the [**Hospital1 18**] prior to your admission:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2179-8-31**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2179-9-13**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2179-9-21**] 11:00
|
[
"293.0",
"331.0",
"437.0",
"820.8",
"345.90",
"733.00",
"272.4",
"530.81",
"401.9",
"290.40",
"294.10",
"300.00",
"428.0",
"244.9",
"V10.05",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6217, 6294
|
2115, 3315
|
232, 288
|
6366, 6366
|
1806, 2092
|
7094, 7802
|
1561, 1566
|
4407, 6194
|
6315, 6345
|
3341, 4384
|
6549, 6903
|
1581, 1787
|
6921, 7014
|
7036, 7071
|
184, 194
|
316, 652
|
6381, 6525
|
674, 1133
|
1149, 1545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,071
| 171,539
|
32658
|
Discharge summary
|
report
|
Admission Date: [**2195-11-18**] Discharge Date: [**2195-11-26**]
Date of Birth: [**2174-6-22**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions, small bowel
resection
History of Present Illness:
21M w history of UC s/p TAC w jpouch and ostomy reversal [**12-8**]
complicated by recurrent SBOs s/p ex-lap LOA [**3-9**] returns with
abdominal pain and nausea/vomiting similar to prior SBOs.
Stated
he was feeling well until 4-5pm when he ate dinner, then had
sudden abdominal pain and nausea. Dry heaves at home, none
since
arrival to ED. No fevers or chills. Last BM today, normal, no
blood. No flatus since pain started. Pain was [**10-10**], now
improved after receiving morphine.
Past Medical History:
Ulcerative colitis, diagnosed in [**2193-4-30**]. He has been treated
with Asacol, prednisone, 6-mercaptopurine and most recently
Remicade.
Social History:
Freshman College student at [**University/College 5130**] [**Location (un) **]. He lives at
home with his family. He is no longer smoking, he is wearing a
nicotine patch
Family History:
He has 3 paternal uncles with [**Name2 (NI) 499**] cancer. Multiple family
members with ulcerative colitis or [**Name2 (NI) 499**] cancer.
Physical Exam:
AVSS
NAD
RRR no m/r/g
CTAB no w/r/r
Abd: soft NT ND +BS, incisions C/D/I no erythema
Ext: WWP
Pertinent Results:
AXR [**11-18**]: Single loop of dilated small bowel in the mid abdomen
with an
air-fluid level, with a paucity of small bowel gas elsewhere.
Findings are
non-specific, but abnormal, given the paucity of small bowel
gas, but are
suspected to reflect partial or early small bowel obstruction.
AXR [**11-21**]: Small bowel obstruction stable from prior.
[**2195-11-18**] 07:45AM WBC-6.3 RBC-4.02* HGB-7.9* HCT-26.7* MCV-66*
MCH-19.7* MCHC-29.6* RDW-14.5
[**2195-11-18**] 07:45AM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.8
[**2195-11-18**] 07:45AM GLUCOSE-71 UREA N-8 CREAT-0.8 SODIUM-139
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-10
Brief Hospital Course:
Pt. admitted for treatment of SBO on [**11-18**]; conservative
management with NPO, IVF, nasogastric decompression. Abdominal
exam remained stable with diffuse tenderness. On HD4 patient's
exam remained stable in the morning but became progressively
more concerning in the afternoon. He became increasingly
agitated and began exhibiting bizarre behavior. His urine output
dropped precipitously. The patient was taken to the operating
room emergently for an exploratory laparotomy revealing three
feet of necrotic small bowel. This bowel was resected and a
primary anastomosis was performed. The patient did well
post-operatively and on POD4 the nasogastric tube was removed
and the patient's diet was advanced given evidence of flatus and
return of bowel function. Due to a history of difficulty
voiding following foley catheter removal, the patient was
started on flomax prior to removal of the foley. At time of
discharge, the patient is tolerating a regular diet, pain is
well-controlled, the patient has voided following foley catheter
removal, and he is ambulating.
Medications on Admission:
Adderall
Discharge Medications:
1. Dilaudid 4 mg Tablet Sig: 0.5 -1 Tablet PO q3h as needed for
pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction, strangulated small bowel, Ulcerative
colitis, status post abdominal colectomy, ileostomy, [**Doctor Last Name **]
[**6-/2194**]; ileoanal pouch with diverting ileostomy [**9-/2194**],
ileostomy closure [**12/2194**], recurrent small bowel ostructions
status post exploratory laparotomy and lysis of adhesions [**3-9**]
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**1-2**] weeks. Call ([**Telephone/Fax (1) 9011**]
to schedule an appointment.
|
[
"556.9",
"V58.65",
"560.81",
"V15.82",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
3464, 3470
|
2200, 3278
|
306, 374
|
3857, 3864
|
1532, 2177
|
5287, 5418
|
1263, 1403
|
3337, 3441
|
3491, 3836
|
3304, 3314
|
3888, 4925
|
4940, 5264
|
1418, 1513
|
231, 268
|
402, 895
|
917, 1059
|
1075, 1247
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,004
| 190,954
|
36648
|
Discharge summary
|
report
|
Admission Date: [**2132-11-13**] Discharge Date: [**2132-11-26**]
Date of Birth: [**2064-2-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Dizziness, pleuritic chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
68M last CHOP for T-Cell 2 weeks ago, LLE dvt, h/o melanoma and
nephrolithiasis p/w fevers, joint aches, no localizing sx x 2
days. Patient reports that he was feeling "generally unwell" and
he took his temperature this afternoon and found it to be 101.7.
He called the oncology dept that advised her come into the ED.
Patient reports some subjective chills and dizziness, but no
other symptoms. He denies fevers, nausea, vomitting, diarrhea,
headaches, neck pain, abdominal pain, chest pain and shortness
of breath.
.
Review of systems is otherwise negative.
.
In the emergency department Labs were notable for leukocytosis.
Urinalysis and CXR were unremarkable. Patient had a transient
episode of hypotenstion to the 70s that responded with fluids to
the 90s. VS on transfer HR 85, RR 10, 97 2L, BP 95/49. Other
than 2L NS, patient received vanco 1gx1, aztreonam 2 g x1, and
tylenol.
Past Medical History:
Oncologic History:
Mr. [**Known lastname **] is a 68 yo male who developed left inguinal
swelling in [**5-17**] while in [**Country 4194**], where it was attributed to a
hernia. Upon his return to the US in early [**Month (only) 216**], his PCP
suspected left inguinal lymphadenopathy and arranged for
excisional biopsy of a part of a lymph node. This revealed
reactive changes. He was admitted to the [**Hospital1 18**] on [**2132-9-7**] with
worsening left groin swelling and pain related to worsening
lymphadenopathy, abdominal pain and nausea. Laboratory data
remarkable for elevated LDH and significant eosinophilia (as
high as 30%.) CT imaging demonstrated bilateral basilar
pulmonary nodules and significant lymphadenopathy involving the
retroperitoneal, pelvic, and left iliac chains. Infectious
disease work-up was unremarkable. The CT findings, along with
elevated LDH, raised concern about a lymphoproliferative
disorder. SPEP revealed monoclonal gammopathy, which was
comprised of IgG lambda and constituted 1600 mg/dl. PET scan
demonstrated intensely FDG avid in the left cervical (SUV 18),
right axillary (SUV 5), left supraclavicular (SUV 17), left
paratracheal (SUV 13), retroperitoneal (SUV 22,) and left
inguinal (SUV 25) lymph node groups.
.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] repeat excisional biopsy of an FDG-avid
inguinal lymph node on [**9-13**]. Flow cytometry revealed atypical
lymphohistiocytic infiltrate highly suggestive of peripheral
T-cell lymphoma NOS. On histological examination, the lymph node
architecture was completely effaced with a background of
epithelioid histiocyte granulomatoid aggregates. Intermingled
was an atypical lymphoid population that stained positive for
CD2, 3, and 5 with dual loss of CD4 and CD8 and loss CD7. The
combined morphologic and immunophenotypic picture was most
consistent with peripheral T-cell lymphoma, NOS. [**Last Name (un) **] staining
was negative. IgH gene rearrangement failed to show
monoclonality. TCR rearrangement, on the other hand, was
monoclonal.
.
OTHER PAST MEDICAL HISTORY:
1. Melanoma, right arm excised in [**2129**].
2. Question of history of histoplasmosis.
3. Right shoulder surgery for fracture and dislocation [**2129**].
4. Kidney stones 40 years ago.
Social History:
Typically splits his time between [**First Name9 (NamePattern2) 82914**] [**Last Name (un) **], [**Country 4194**] and
[**Last Name (un) 51768**]. Spent the majority of the past five years in
[**Country 4194**] where his wife of several years works as a physician. [**Name10 (NameIs) **]
frequently traveled to [**Country 4194**] over the past 25
years. Patient also has a strong social support network of
friends in [**Name (NI) 108**]. Patient has traveled to Western Europe; used
to smoke a pipe, 5 bowls per day x30 years. Currently living
with his son and [**Name2 (NI) 41859**] in law plus their children here in
[**State 350**]. He used to be an alcoholic but has been sober
since [**2098**]. He is a retired school teacher and used to teach in
[**Last Name (LF) 51768**], [**First Name3 (LF) 108**]. He has one healthy pet dog in [**Country 4194**]
who "plays rough" after roaming the streets/markets of [**Country 4194**].
His son and daughter in law have a dog he is not intimately
involved with and mainly licks.
Family History:
Breast cancer in mother, throat cancer in father, and coronary
artery disease in brothers.
Physical Exam:
T=100.5 BP= 85/53 HR=75 RR=17 O2= 94% RA
GENERAL: Pleasant, well appearing man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: crackles right base
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. chest midline in place c/d/i
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
Pertinent Results:
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2
.
GLUCOSE-109* UREA N-15 CREAT-1.0 SODIUM-131* POTASSIUM-4.6
CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
.
WBC-25.7*# RBC-3.73* HGB-11.8* HCT-34.2* MCV-92 MCH-31.6
MCHC-34.5 RDW-15.5
NEUTS-78* BANDS-3 LYMPHS-8* MONOS-4 EOS-0 BASOS-0 ATYPS-1*
METAS-3* MYELOS-2* PROMYELO-1* NUC RBCS-1*
PLT COUNT-277
.
PT-12.6 PTT-31.6 INR(PT)-1.1
.
[**2132-11-14**] 6:50 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2132-11-21**]):
CAPNOCYTOPHAGA SPECIES. PRESUMPTIVE IDENTIFICATION.
.
CTA, abdomen and pelvis:
IMPRESSION:
1. No evidence of acute pulmonary embolism.
2. Bilateral lower lobe consolidation, likely representing
pneumonia, right
more than left. Diffuse nodular and patchy opacities throughout
the lungs,
especially in the middle lobes, consistent with infectious or
inflammatory
etiology.
3. Emphysema.
4. Precarinal, left paratracheal and right hilar lymph nodes
measuring about
1.2 cm in short axis.
5. Left renal cyst.
6. Left inguinal partially imaged cystic lesion, this may
represent a
lymphocele. Clinical correlation is recommended.
7. left seminal vesicle with minimal surrounding fat stranding
which measures
up to 3.6 x 2.7 cm. Clinical correlation for acute pain is
recommended.
.
Chest Ultrasound:
IMPRESSION: Small bilateral pleural effusions, right greater
than left.
Superinfection cannot be excluded.
.
CT chest: 1. Increased size of mediastinal nodes likely
reactive. Pre-existing
micronodules have become more confluent and consolidative. This
is most
likely an infective process and the differential includes an
acute (bacterial)
on chronic (atypical - for example, atypical mycobacterial)
infection.
Recommend followup CT scan after treatment.
2. New small pericardial effusion.
Brief Hospital Course:
68 yo M with T cell lymphoma (+ monoclonal
gammopathy), recent LLE DVT (now on anticoagulation) presents
with fevers/chills, arthralgias/myalgias, headaches and now
diarrhea with epigastric pain and abnormal CXR. Patient was
hypotensive but responsive to fluids in the ED, called out of
the
[**Hospital Unit Name 153**] after uneventful overnight stay (spiked temp of 102.8).
.
While in the [**Hospital Unit Name 153**], the patient was started on Vancomycin,
aztreonam and oseltamavir. Oseltamavir was discontinued when the
patient's influenza swabs returned negative. Bactrim was
continued for PCP [**Name Initial (PRE) 1102**].
.
#. SIRS/Hypotension: Most likely infectious etiology given
fevers, myalgias/arthralgias, leukocytosis. Patient was likely
also hypovolemic in the ED, [**Hospital Unit Name 153**]. Patient was continued on
intravenous fluids as his blood pressures would dip into
SBP85-90s whenever intravenous fluids were discontinued. By
Wednesday, [**11-18**], patient's IVF were discontinued as he
had a new oxygen requirement the weekend prior felt partially
due to fluid overload. Patient was initially continued on
Vancomycin and Aztreonam. When he continued to spike
temperatures, his coverage was broadened to Voriconazole.
Patient continued to spike temperatures through Thursday,
[**11-19**] so Levofloxacin was added. On Friday, [**11-21**],
blood cultures drawn on the second day of hospitalization came
back positive for gram negative rods, likely Capnocytophaga.
Infectious Disease, who was already following the patient,
recommended Ceftriaxone or Clindamycin (given patient's
allergies to penicillin and keflex). Upon initiation of
Clindamycin, patient's fever curve decreased and resolved within
two days. Patient was sent home on Clindamycin and Levofloxacin.
Of note, Capnocytophaga is a gram negative rod organism found in
canines which has been found to cause fulminant sepsis in
asplenic patients. It has also been found to infect other
immunocompromised populations. Upon further questioning, the
patient has a dog at his son's home where he lives which he does
not interact much with; the dog mainly licks. The patient has a
dog in [**Country 4194**], however, who plays rough. It routinely roams the
city's meat/fish/fruit markets and then comes home to bite the
patient.
.
#. Pneumonia: Chest Xrays and CT chest confirmed evolving
pneumonia. It is unclear if Capnocytophaga was the cause of the
pneumonia, as only 20 such cases have been documented. Patient
developed tachycardia, hypotension, oxygen requirement and
low-grade temperatures on Saturday, [**11-15**]. CTA was negative
for pulmonary embolism and CT abdomen/pelvis did not show
interval change in lymphadenopathy suggestive of worsening
disease. Pulmonary was consulted and patient [**Month (only) 1834**]
bronchoalveolar lavage on Monday, [**11-17**] which did not yield
any infectious etiology. Patient was negative for fungi,
legionella, PCP [**Name Initial (PRE) **]. Chest ultrasound showed that the patient's
pulmonary effusions were trace/small and non-tappable. Patient
was continued on Levofloxacin with good effect and repeat CT
chest showed interval improvement in bibasilar consolidations.
.
# Visual disturbances/hallucinations: Patient was started on
Voriconazole for broad pulmonary infection coverage and the day
after initiation, he complained of bright white spots and auras
around black window frames, words etc. He also described
non-threatening visual hallucinations, such as people standing
by his bed. As patient continued to have these visual changes,
CT head was ordered which did not show any acute changes.
Neurology was consulted, who revealed a history of Ecstacy and
other illicit drug use. It was felt that Voriconazole and
possible, IV Morphine was causing patient's visual changes.
Voriconazole was discontinued with good effect. Patient's
morphine use was also minimized.
.
# Insomnia: Patient had frequent difficulty sleeping. After
trying various combinations of medications, patient appeared to
respond best to Ativan 1 mg and Oxycontin 10mg before bed.
.
#. Diarrhea: Given recent antibiotics use, chemotherapy and
elevated white count, concern for C.Diff. Patient was ordered
for CDiff stool toxin assays which were negative and patent's
diarrhea resolved.
.
#. DVT: Patient was continued on his home lovenox without any
issues.
.
#. T cell lymphoma: Patient received his fifth cycle of CHOP-14
on Tuesday, [**11-25**] after resolution of his infectious
process. Patient tolerated CHOP-14 well without any nausea.
.
CODE STATUS: FULL CODE, discussed with patient (would not want
prolonged intubation)
Medications on Admission:
ENOXAPARIN [LOVENOX] - 100 mg/mL Syringe - 1 Syringe(s) SC daily
LORAZEPAM - 0.5 mg Tablet - [**1-11**] Tablet(s) by mouth every 6 hours
as needed for Nausea
ONDANSETRON HCL [ZOFRAN] - 8 mg Tablet - 1 Tablet(s) by mouth
three times a day as needed for nausea
OXYCODONE - 5 mg Capsule - [**1-11**] Capsule(s) by mouth every 6 hours
as needed for Pain
PREDNISONE - 50 mg Tablet - 1.5 tablets with chemo
PROCHLORPERAZINE [COMPAZINE] - 10 mg Tablet - 1 Tablet(s) by
mouth every 6 hours as needed for Nausea
Medications - OTC
BISACODYL - 5 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day as needed for constipation
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
Twice per day as needed for constipation
SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 1
Tablet(s) by mouth twice a day
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
2. 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*
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Last day: Monday, [**12-1**].
Disp:*5 Tablet(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
6. Prednisone 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: Last day: Saturday, [**11-29**].
Disp:*3 Tablet(s)* Refills:*0*
7. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
8. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*12 Tablet(s)* Refills:*2*
9. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO four
times a day for 9 days: Last day: Thursday, [**12-4**].
Disp:*108 Capsule(s)* Refills:*0*
10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime))
as needed for insomnia.
Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Pneumonia, blood stream infection
Secondary diagnosis: Peripheral T cell lymphoma, history of
melanoma and histoplasmosis
Discharge Condition:
Improved. Vital signs are stable and patient has been afebrile.
Patient ambulating and taking PO.
Discharge Instructions:
-You were admitted with chills, shortness of breath, pain with
breathing and general aches. You were found to have a pneumonia
and an infection of the blood stream (capnocytophaga). You were
treated with antibiotics for both, with improvement in your
symptoms.
While you were in the hospital, we also gave you your fifth
cycle of your CHOP chemotherapy which you tolerated well.
.
-It is important that you continue to take your medications as
directed. Please resume your Lovenox injections, Bactrim DS
(taken every Monday/Wednesday/Friday), Protonix. We added the
following medications:
--> CONTINUE Prednisone 100mg daily for 3 more days (Last day:
Saturday, [**11-29**])
--> CONTINUE Levofloxacin 750mg daily, for 5 more days (Last
day: Monday, [**12-1**])
--> CONTINUE Clindamycin 450mg every 6 hours, for 9 more days
(Last day: Thursday, Novmber 26)
--> START Zofran 8mg three times a day, even if you are not
nauseated
--> START Compazine 10mg every 6 hours as needed for nausea
--> START Lorazepam 1mg before bed as needed to help you sleep
--> START Oxycontin 10mg before bed as needed to help you sleep
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
You have an appointment to with Drs. [**Last Name (STitle) 4613**] and [**Name5 (PTitle) **] on Friday,
[**2132-11-28**] at 11 am. You will get your Neulasta at that
appointment. The Heme/[**Hospital **] clinic is in the [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 436**]. You can reach their office at: [**Telephone/Fax (1) 447**].
.
You also have another appointment with Dr. [**Last Name (STitle) 4613**] on Tuesday,
[**12-2**] at 11 am. ** Please discuss with Dr. [**Last Name (STitle) 4613**] on Friday
if you need to make this appointment. **
|
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icd9cm
|
[
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[
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icd9pcs
|
[
[
[]
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322, 330
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14369, 14469
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14224, 14258
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3353, 3540
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3556, 4581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,307
| 150,695
|
51071
|
Discharge summary
|
report
|
Admission Date: [**2104-6-5**] Discharge Date: [**2104-6-10**]
Date of Birth: [**2045-6-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None on this hospital stay
History of Present Illness:
Mr. [**Name14 (STitle) 106073**] is a 58 yr old male who had an uncomplicated open
ventral hernia repair 3 days prior to admission. On day of
admission, he presented with abdominal pain without fever or
nausea/vomiting. He did have constipation and dehydration.
Past Medical History:
1. DM-2
2. HTN
3. Colon cancer s/p sigmoidectomy and adjuvant chemo
Physical Exam:
Temp 99.5 Pulse 94 B/P 122/54 RR 22
Heart regular
Lungs Clear
Abdomen: distended, non-localized tenderness, +bowel sound,
incision was
clean/dry/intact
Extremities: no edema
Pertinent Results:
[**2104-6-5**] 01:05AM GLUCOSE-294* UREA N-27* CREAT-1.4*
SODIUM-132* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
[**2104-6-5**] 01:05AM WBC-9.5# RBC-4.87 HGB-14.9 HCT-45.1 MCV-93
MCH-30.7 MCHC-33.1 RDW-13.5
Brief Hospital Course:
Patient was admitted for abdominal pain and distention. His
hospital course was complicated by high blood glucose ranging in
the 300's as well as acute respiratory distress, in which he had
to be admitted to the intensive care unit for monitoring. He
was placed on an insulin drip and nebulizer treatments and
responded well. He was then transferred back to the floor and
continues to improve. His diet was advanced from nothing per
oral/ iv fluids to regular diabetic diet. He began ambulating
and now has minimal pain. He was discharged in stable condition.
Medications on Admission:
glyburide, metformin, enalapril, norvasc, flomax, proscar
Discharge Medications:
1. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: [**12-16**] Capsules PO
every 4-6 hours as needed: PAIN.
Disp:*50 Capsule(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed: IF CONSTIPATION.
Disp:*20 Capsule(s)* Refills:*0*
3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution Sig: AS DIRECTED
Injection ASDIR (AS DIRECTED).
Disp:*5 INJ* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p open ventral hernia repair
Discharge Condition:
STABLE
Discharge Instructions:
If blood sugar becomes too high, please give insulin shots as
discussed. Continue to strip JP's and nonitor outputs.
Continue to take oral diabetic medications as well as other
medications as prescribed. Please follow-up with primary care
doctor within the next day or two. FOLLOW UP WITH DR.
[**Last Name (STitle) 106074**] WITHIN 1 WK. IF SUDDEN FEVER, INCREASED PAIN,
PUS-LIKE DISCHARGE, CALL OR GO TO THE ER.
Followup Instructions:
PLEASE CALL: Dr. [**Last Name (STitle) 5182**], M.D., Ph.D. [**Numeric Identifier 49859**] ([**Telephone/Fax (1) 15350**]
([**Telephone/Fax (1) 15350**] FOR FOLLOW UP WITHIN 1 WEEK.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-6-12**]
10:40
PLEASE FOLLOW UP WITH THE FOLLOWING DOCTORS:
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-9-11**] 9:00
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2104-6-10**]
|
[
"605",
"787.01",
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"564.00",
"V10.05",
"997.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
2753, 2759
|
1204, 1770
|
329, 357
|
2834, 2842
|
959, 1181
|
3307, 4069
|
1878, 2730
|
2780, 2813
|
1796, 1855
|
2866, 3284
|
756, 940
|
275, 291
|
385, 649
|
671, 741
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,661
| 163,813
|
25849
|
Discharge summary
|
report
|
Admission Date: [**2128-4-16**] Discharge Date: [**2128-4-23**]
Date of Birth: [**2049-12-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
supratherapeutic INR, rigors, delirium
Major Surgical or Invasive Procedure:
ERCP [**4-16**]
History of Present Illness:
Mr. [**Known lastname **] is a 78 year old man with h/o CAD s/p MI [**2095**], Afib
on Coumadin, CMP EF 45%, s/p AAA repair, PVD s/p fem-[**Doctor Last Name **] bypass,
cognitive impairment, HTN, HLD, biliary obstruction s/p biliary
stent placement and revision in [**2126**], who was admitted to [**Hospital1 **]
[**Location (un) 620**] with supratherapeutic INR, rigors, and confusion.
The patient was seen in [**Hospital 197**] clinic and noted to have a
supratherapeutic INR to 7. Also noted to have altered mental
status and rigors, so was transferred to the [**Hospital1 **] [**Location (un) 620**] ED. Wife
has noted increased confusion from baseline (typically mild
cognitive impairment and confusion when he moves from [**State 108**] to
[**State 350**]) x 1 week.
At [**Hospital1 **] [**Location (un) 620**], the patient was admitted to the ICU for further
workup of AMS, rigors, and low grade fevers (100.8). Initial
concern for UTI given recent instrumentation of the bladder
(bladder tear s/p repair in [**State 108**] recently) and dirty UA, but
UCx was negative. Patient noted to have elevated AP, as well as
biliary sludge on Abd U/S and ?obstruction on CT abdomen,
concerning for cholangitis, started on Zosyn for empiric
coverage. Patient had a biliary stent placed in the past for
obstruction that migrated and was replaced in [**1-3**]. According
to records, this was supposed to be removed in [**5-3**], but that
was not done. ERCP team at [**Hospital1 18**] was notified and will evaluate
his stent further.
Hospital course at [**Hospital1 **] [**Location (un) 620**] was complicated by hypotension
(SBP 90s), for which the patient was given some gentle IVF with
improvement of pressures. He developed flash pulmonary edema and
responded well to Lasix 20mg IV x1. Patient was also
delirious/agitated, given Ativan and Haldol prn.
On arrival to the MICU, patient's VS: T 97.4 P 96 BP 145/84 RR
33 O2sat 96%. Patient is confused, but denies pain, SOB, or any
other complaints.
Past Medical History:
CAD, s/p MI [**2095**]
Cardiomyopathy, EF 45%
Afib on Coumadin
HTN
HLD
Mild cognitive impairment
TIA - in the setting of low INR
Biliary obstruction - s/p biliary stent in the past with
migration, replaced by metal stent in [**1-3**], supposed to be
re-evaluated/possibly removed [**5-3**] but was not done
PVD s/p L fem-[**Doctor Last Name **] bypass [**2126**]
s/p bladder repair for tear [**3-4**]
s/p AAA repair [**8-2**]
Prostate ca - s/p radiation
Gout
UTIs
Social History:
Lives with his wife, also has a home in [**Name (NI) 108**]. History of
tobacco use, but quit in [**2114**]. Does not drink alcohol.
Family History:
Father with prostate problems. Mother died at age 89 after hip
fracture, ?clot.
Physical Exam:
ADMISSION EXAM:
Vitals: T 97.4 P 96 BP 145/84 RR 33 O2sat 96%
General: lethargic, arousable to voice, oriented x1, no acute
distress, Cheynes-[**Doctor Last Name **] breathing pattern
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregular, tachycardic, S1 + S2, no murmurs, rubs, gallops
Lungs: decreased breath sounds at bases, otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: orientedx1, moving all extremities.
DISCHARGE EXAM:
General: lethargic, arousable to voice, oriented x1, will have
episodes of apnea altered with tachypnea
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 8cm, no LAD
CV: irregular, tachycardic, S1 + S2, no murmurs, rubs, gallops
Lungs: decreased breath sounds at bases particularly R,
otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley
Ext: cold and clammy, pulses in LE dopplerable. NO edema
Neuro: orientedx1, moving all extremities. EOMI, perrla, will no
participate in most of the exam
Pertinent Results:
ADMISSION LABS:
[**2128-4-16**] 04:25PM BLOOD WBC-12.8* RBC-4.25* Hgb-11.4* Hct-36.1*
MCV-85 MCH-26.8* MCHC-31.6 RDW-16.0* Plt Ct-310
[**2128-4-16**] 04:25PM BLOOD PT-16.7* PTT-29.9 INR(PT)-1.6*
[**2128-4-16**] 04:25PM BLOOD Glucose-97 UreaN-34* Creat-1.4* Na-142
K-4.4 Cl-109* HCO3-18* AnGap-19
[**2128-4-16**] 04:25PM BLOOD ALT-35 AST-40 AlkPhos-666* TotBili-2.9*
[**2128-4-16**] 04:25PM BLOOD Albumin-2.6* Calcium-8.6 Phos-4.1 Mg-2.0
[**2128-4-16**] 04:29PM BLOOD Type-ART Temp-36.3 pO2-69* pCO2-23*
pH-7.51* calTCO2-19* Base XS--2 Intubat-NOT INTUBA
[**2128-4-16**] 04:29PM BLOOD Lactate-1.5
URINE:
[**2128-4-17**] 05:32AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2128-4-17**] 05:32AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2128-4-17**] 05:32AM URINE RBC->182* WBC-15* Bacteri-FEW Yeast-NONE
Epi-0
[**2128-4-17**] 05:32AM URINE Hours-RANDOM UreaN-720 Creat-78 Na-50
K-69 Cl-10
[**2128-4-17**] 05:32AM URINE Osmolal-542
MICRO:
[**2128-4-16**] MRSA screen: negative
[**2128-4-17**] UCx: yeast
[**2128-4-20**] UCx: yeast
STUDIES:
[**2128-4-16**] ERCP:
- A previously placed metal stent in the biliary duct that
migrated distally was found in the major papilla.
- Given the malposition of the stent decision was made to remove
the stent using a snare.
- Pus, sludge, and debris was seen coming out of the bile duct
after stent removal.
- Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
- Contrast medium was injected resulting in partial
opacification.
- Further contrast injection was not done given cholangitis.
- There were possible filling defects suggestive of sludge and
debris in the bile duct. However, this could not be fully
delineated given limited contrast injection.
- A previously placed plastic stent was noted that had migrated
well into the right hepatic duct/bilary tree - removal was not
attempted given concurrent cholangitis.
- A 5cm by 10FR double pig tail biliary stent was placed
successfully for decompression with the proximal end terminating
in the left hepatic duct. Good bile flow was seen after stent
deployment.
- Repeat ERCP in 4 weeks to attempt removal of previously placed
migrated stent from the right hepatic system and repeat biliary
evaluation.
.
[**2128-4-20**] CT head
Technically limited study. No acute hemorrhage or mass effect
.
[**2128-4-20**] CT abdomen pelvis
1. Bilateral pleural effusions with adjacent compressive
atelectasis.
2. Mild to moderate cardiomegaly with aortic and mitral valve,
coronary
artery calcifications, and calcification along the inferior
myocardial wall of the left ventricle.
3. Pneumobilia with double pigtail biliary stent with one end
of the stent
appearing to open within the duodenum and the other appears to
end in the
common bile duct.
4. Dilated pancreatic duct up to the ampulla with ill-defined
soft tissue
around the pancreatic head, unclear if this is secondary to
technique or due to recent procedure; however, recommend
dedicated imaging to rule out presence of pancreatic mass such
as multiphasic MR if the patient is able to optimally
breath-hold versus consideration of dedicated multiphasic CT.
5. Aortobifemoral stent with occlusion of the native aorta and
common iliac arteries.
6. Area of infarct along the upper pole of the right kidney.
.
CXR [**2128-4-20**]
1. Worsening vascular congestion, with possible mild edema.
2. Moderate right pleural effusion with right basal atelectasis.
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 year old man with h/o CAD s/p MI [**2095**], Afib
on Coumadin, CMP EF 45%, s/p AAA repair, PVD s/p fem-[**Doctor Last Name **] bypass,
cognitive impairment, HTN, HLD, biliary obstruction s/p biliary
stent placement and revision in [**2126**], who was admitted to [**Hospital1 **]
[**Location (un) 620**] with altered mental status and fevers. He was
transferred to [**Hospital1 18**] for ERCP given concern for ascending
cholangitis; he underwent ERCP (see below), and was stabilized.
ACTIVE ISSUES:
#. Ascending cholangitis: This was the most likely cause of his
sepsis, altered mental status, and fevers. Patient had a prior
h/o obstruction, s/p instrumentation with 2 stents currently in
place. He had elevated AP and e/o biliary sludge and possible
obstruction on abdominal imaging. He was originally supposed to
get a stent removed in summer [**2126**], but as the pt spends part of
the year in FL, this was lost to f/u. During ERCP, a previously
placed metal stent was removed; pus, sludge, and debris was seen
coming out of the bile duct after stent removal. A previously
placed plastic stent had migrated into the right hepatic
duct/bilary tree - removal was not attempted given concurrent
cholangitis; a 5cm by 10FR double pig tail biliary stent was
placed successfully for decompression with the proximal end
terminating in the left hepatic duct. Good bile flow was seen
after stent deployment. We continued antibiotics d1=[**4-16**] for a
14 day course, initially with zosyn and then with Augmentin
(stop date [**2128-4-29**]). As below he was transitioned back to zosyn
when his mental status worsened, concerning for active
infection. Before discharge, he was transitioned back to
augmentin.
# Intubation: Intubated for airway protection and ERCP, and was
extubated without event.
#. Acute renal failure: Cr 1.6 upon admission, up from baseline
1.0. Likely prerenal in etiology, but possible ATN from recent
hypotension as well. FeNa [**4-17**] was <0.7%. After callout to the
floor, his creatinine was 1.4. He received 250 cc of normal
saline and his creatinine improved slightly to 1.3. Patient
given another 250 cc of normal saline and his creatinine
improved to 1.2. Patient only given small boluses of iv fluids
given report that he developed flash pulmonary edema with gentle
hydration at [**Hospital1 **] [**Location (un) 620**]. At time of discharge, his creatinine
had bumped again to 1.5 but had remained stable.
#. Altered mental status: Patient with waxing and [**Doctor Last Name 688**] mental
status, with agitation at OSH requiring ativan and haldol.
Likely multifactorial etiology in an elderly patient with mild
cognitive impairment at baseline - infection, ICU delirium. Per
family report, he has had delirium at home, with falling asleep
mid-sentence, etc. This has been a gradual decline in the recent
year or two and they are thinking about housing options.
Physical therapy evaluated patient and determined he would
benefit from short term rehab. Patients mental status became
acutely worse on [**2128-4-20**]. Patient was noted to be confused,
lethargic and minimally responsive. The patient was also noted
to have a new leukocytosis concerning for infection. Head CT was
unremarkable. CT abdomen was without sign of abscess. CXR was
negative for pneumonia. UA was concerning for UTI which was the
presumed source of his confusion. He was transferred to the ICU
where he was started on broad spectrum antibiotics (vanc and
zosyn). Mental status improved and leukocytosis resolved.
Cultures were noteable only for yeast in his urine for which the
foley was replaced. Vancomycin was discontinued and the patient
remained afebrile.
# Pancreatic mass: CT of the patient's abdomen and pelvis was
concerning for a possible pancreatic mass vs changes consistent
with his previous ERCP. Pt has a planned repeat ERCP to be done
in 4 weeks.
CHRONIC ISSUES:
#. Acute on chronic CHF: Pt flashed after small fluid bolus at
OSH. We continued metoprolol, held his ACE I. His Ace-I was
restarted prior to discharge from the ICU. Given HTN, his dose
was increased to 10mg PO qday. After receiving IVF, pt was
found to have some intravascular cogenstion on CXR. He was
diuresed with 20IV lasix. AT time of discharge he was euvolemic
and was not started on lasix.
#. Afib: HR mostly 100-110s, although occasionally up to the
130-140s. Continued Metoprolol TID. He was noted to have a large
amount of ectopy and his dose was increased to 37.5 mg TID.
Coumadin was held for procedure, was restarted thereafter at a
decreased dose of 1mg by mouth daily given history of
supratherapeutic INR and concominant treatment with augmentin.
His dose of coumadin will likely need to be adjusted as an
outpt.
#. Anemia: at baseline throughout hospitalization.
#. CAD/PVD: Patient was off ASA since [**3-4**] for hematuria and
bladder tear. However, given his severe vascular disease,
benefits of ASA likely outweigh the risks. We continued BB and
restarted baby ASA after ERCP.
#. HTN: SBP 140-160s, improved from hypotension in the 90s at [**Hospital1 **]
[**Location (un) 620**]. Continued BB and held Lisinopril initially given recent
low BPs and [**Last Name (un) **]. He was then restarted on lisinopril 10mg by
mouth daily.
TRANSITIONS OF CARE:
-Pt's code status this admission was Full Code
-Patient will be contact[**Name (NI) **] by the ERCP team for repeat ERCP in 4
weeks for stent removal
-INR will need to be trended every other day given unstable INR
and concurrent use of augmentin.
- continue augmentin until [**2128-4-29**]
Medications on Admission:
Medications at home:
Metoprolol 25mg PO BID
Lisinopril 5mg PO daily
Coumadin 2.5mg PO daily x 6 days, 5mg PO daily Mondays,
currently held for supratherapeutic INR
MVI 1tab PO daily
Protonix 40mg PO daily
Flomax 0.4mg PO qhs
ASA - d/c'd in [**State 108**] recently
Medications on transfer:
Zosyn 3.375mg IV q8h
Metoprolol 25mg PO TID / 5mg IV q6h prn
Protonix 40mg IV daily
Xopenex 1inh q6h prn
Colace 100mg PO BID prn
Senna 2tabs PO daily
Bisacodyl 10mg daily
Lasix 20mg IV x1 [**2128-4-15**]
Tylenol 650mg PO q6h prn
Ativan 1mg IV x1 [**2128-4-16**]
Morphine 0.5mg IVx1 [**2128-4-16**]
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 13 doses: last day of
antibiotics is [**2128-4-29**].
3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Foxhill
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with an cholangitis, which is an infection in
your bile duct. You had your stent removed by ERCP. You will
need to stay on antibiotics through [**4-29**] (14 days total), and
will need to have another ERCP to remove your other stent in 4
weeks.
Medication changes:
1) Added augmentin 875mg by mouth every 12hrs through [**4-29**]
2) change warfarin to 1mg by mouth daily.
3) Increase metoprolol to 37.5mg by mouth three times daily
4) Increase lisinopril to 10mg by mouth daily.
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2128-5-5**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
You will need follow up with our GI department for a repeat ERCP
in 4 weeks. When this is scheduled, someone from the GI
department will call you with an appointment.
|
[
"584.5",
"276.4",
"285.9",
"443.9",
"425.4",
"995.92",
"V58.61",
"412",
"348.31",
"414.01",
"576.1",
"401.9",
"427.31",
"428.0",
"038.9",
"790.92",
"996.69",
"599.72",
"428.23",
"V10.46",
"E934.2",
"996.59",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.05",
"38.97",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
15130, 15233
|
8012, 8532
|
344, 362
|
15289, 15289
|
4442, 4442
|
15990, 16512
|
3048, 3129
|
14258, 15107
|
15254, 15268
|
13644, 13644
|
15467, 15731
|
13665, 13910
|
3144, 3791
|
3807, 4423
|
15751, 15967
|
266, 306
|
8548, 10501
|
390, 2394
|
4458, 7989
|
15304, 15443
|
13327, 13618
|
11943, 13306
|
13935, 14235
|
2416, 2882
|
2898, 3032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,183
| 194,783
|
37904
|
Discharge summary
|
report
|
Admission Date: [**2104-10-16**] Discharge Date: [**2104-10-23**]
Date of Birth: [**2051-9-28**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
Soft tissue sarcoma of the left ankle
Major Surgical or Invasive Procedure:
Left below knee amputation
History of Present Illness:
Mr. [**Known lastname 84743**] is a gentleman who presented with a mass in his
ankle region. On MRI, this did involve the ankle joint itself
with large masses extending
anteromedial, anterolateral as well as posterior. Needle biopsy
demonstrated an intermediate grade sarcoma not otherwise
specified. Based on this, our strongest
recommendation was for a below-the-knee amputation. We discussed
this at length in our multidisciplinary conference and made that
as a combined recommendation to the patient. He also sought
second opinion and that was the concurring with
ours. He thus wished to proceed. We discussed the risks,
benefits and alternatives and he was prepared with the informed
consent form signed.
Past Medical History:
Negative
Social History:
The patient is originally from [**Country 532**] and is [**Hospital1 **]. He is
currently not working. He smokes about half a pack per day and
drinks approximately two drinks a week.
Family History:
Notable for gynecologic cancers in his mother;
otherwise unremarkable.
Physical Exam:
Afebrile with stable vital signs
Adequate urine output
No acute distress, awake, alert, appropriate
Left lower extremity stump site with incision w/ mild discharge,
some mild surrounding erythema/resolving blistering. Able to
flex and extend knee.
Pertinent Results:
[**2104-10-18**] 05:30AM BLOOD WBC-12.3* RBC-4.50* Hgb-13.0* Hct-39.1*
MCV-87 MCH-28.9 MCHC-33.3 RDW-13.2 Plt Ct-308
[**2104-10-18**] 05:30AM BLOOD Plt Ct-308
[**2104-10-18**] 05:30AM BLOOD Glucose-126* UreaN-10 Creat-0.8 Na-138
K-4.3 Cl-102 HCO3-25 AnGap-15
Brief Hospital Course:
53 yo male admitted same day for left below knee amputation for
left ankle soft tissue sarcoma. Tolerated procedure well with
combined spinal epidural anesthesia. Generally uneventful
hospitalization. Post op labs remained stable. He was placed
in a splint postoperatively which was removed on postop day
number 2. At that time he was instructed in stump wrapping
subsequently seen by therapy for a stump shrinker. His epidural
was accidentally removed while up with PT causing him
significant pain and was thus replaced. The epidural was later
removed and he was transitioned to PO pain meds with good pain
relief. He had some blistering of his skin at his stump wound
which remained stable. His stump was wrapped daily with
xeroform gauze and a soft dressing + stump shrinker once it was
available. He was discharged to home in stable condition after
the epidural was removed and pain well controlled on po
medications.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for pain.
Disp:*60 Capsule(s)* Refills:*1*
4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q 4PM ().
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q MIDNIGHT ().
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*60 Tablet(s)* Refills:*0*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breakthru pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*14 Tablet(s)* Refills:*0*
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
Disp:*300 ML(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*90 Tablet(s)* Refills:*0*
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Synergy
Discharge Diagnosis:
Below knee amputation for soft tissue sarcoma of left ankle.
Discharge Condition:
Stable
Discharge Instructions:
Please re-wrap stump daily to decrease swelling. Elevate as
much as possible. You may shower. Pat wound dry (leave
steristrips) and re-wrap stump.
Please re-wrap stump daily to decrease swelling. Elevate as
much as possible.
Physical Therapy:
Non-weight bearing left lower extremity below knee amputation
site.
Treatments Frequency:
Assist patient w/ LLE dressing changes with xeroform, four by
fours or ABD pad and kerlix, followed by stump shrinking
compressive wrap.
Followup Instructions:
Please call to schedule followup appt with Dr. [**First Name (STitle) 4223**] in 2
weeks for wound check. Please call with any questions or
concerns.
Completed by:[**2104-10-23**]
|
[
"780.62",
"997.69",
"171.3",
"E878.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.15"
] |
icd9pcs
|
[
[
[]
]
] |
4801, 4839
|
2023, 2957
|
359, 388
|
4944, 4953
|
1738, 2000
|
5476, 5659
|
1381, 1454
|
3012, 4778
|
4860, 4923
|
2983, 2989
|
4977, 5206
|
1469, 1719
|
5224, 5292
|
5315, 5453
|
282, 321
|
417, 1129
|
1151, 1161
|
1177, 1365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,195
| 165,141
|
7387+7388+7409
|
Discharge summary
|
report+report+report
|
Admission Date: [**2185-6-14**] Discharge Date: [**2185-6-16**]
Date of Birth: [**2126-3-29**] Sex: M
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
man with history of coronary artery disease status post
multiple PCIs, prior non-Q-wave MI, hypertension,
hypercholesterolemia, panic disorder, peripheral vascular
disease, who was referred to [**Hospital1 188**] for outpatient cardiac catheterization. The patient
started developing whole-body numbness, particularly in his
hands and right side of his face about a week ago. On [**6-9**] while at the beach, the patient had felt lightheaded, had
bilateral transient blindness, and a syncopal event. Upon
recovery he had 1 out of 10 chest pain. The patient was
taken to [**Hospital3 3583**] for syncopal workup. He was ruled
out for combined myocardial infarction by cardiac enzymes and
at that time no arrhythmias or dysrhythmias were noted. He
was scheduled for stress test and discharged. In the ensuing
days, he stated developing increasing chest pain typical of
his previous angina. He went for his stress test. Myoview
showed mostly fixed inferior wall defect with very mild
inferior and lateral-wall reversibility. The patient had
intense chest pain. Stress test, procedure had to be
aborted. The patient refused to go to immediate
catheterization preferring to schedule an elective procedure
at [**Hospital1 69**] scheduled Tuesday,
[**6-14**]. When the patient went home he had increasing
angina at rest relieved with nitroglycerin. The patient also
described paroxysmal nocturnal dyspnea, two-pillow orthopnea.
He had CAD risk factors, high cholesterol, and hypertension.
He was a former smoker who quit in [**2181**] but still smokes a
pipe. There was no diabetes mellitus. The patient has an
extensive past CAD/catheterization history. He had stenting
of his distal RCA and proximal circumflex in [**2182-5-7**],
stenting of his marginal 2 and angioplasty of OM1 on [**2183-6-7**], angioplasty of inferior OM and superior branch OM [**2184-6-6**]. PTCA and stenting of PLV branch in [**2185-2-4**]. The
patient also had workup for TIA due to increasing numbness in
his hands bilaterally. At that time he had a carotid duplex
which showed no signs of flow abnormalities. He has also had
a MRI in the past, which revealed small vessel discharged and
an EEG performed in [**2181**], which showed no seizure activity.
The patient's syncopal episode had been observed and he had
no seizure activity or urinary incontinence. The patient
denies feeling diaphoretic prior to the syncopal episode.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Non-Q-wave MI.
5. Peripheral vascular disease status post right femoral
bypass in [**2181**].
6. Degenerative disk disease L1, L4, L5.
7. Transient ischemic attack.
8. Panic disorder.
ALLERGIES: The patient is allergic to PENICILLIN, CAUSING
NAUSEA AND VOMITING.
OUTPATIENT MEDICATIONS:
1. Aspirin.
2. Imdur 60 q.d.
3. Atenolol 50 b.i.d.
4. Paxil 40 q.d.
5. Prilosec 20 q.d.
6. Zocor 20 q.d.
7. Nitroglycerin sublingual p.r.n.
8. Ativan 1 mg p.r.n.
9. Trazodone 50 mg q.h.s.
SOCIAL HISTORY: The patient is an occasional pipe smoker.
The patient denies alcohol use.
FAMILY HISTORY: History revealed the patient's brother died
of a myocardial infarction at the age of 47. Father died of
a myocardial infarction at the age of 65.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] for catheterization.
Catheterization findings were normal left main, LAD with 50%
mid, 60% ostial diagonal 1, left circumflex 50% lower pole of
obtuse marginal 1, 70% upper pole, RCA with occluded PDA with
left to right collaterals, 90% stenosis in PLV stent.
Interventions were angiojet thrombectomy, only modest
improvement; balloon angioplasty with PDA stent to RCA beyond
PDA culprit lesion. During the procedure, the patient was
noted to have Wenckebach A-V block of varying degrees,
temporary transvenous pacing wire was left in place. Post
dilation, the EKG revealed first degree AV block. After
catheterization he was started on Integrilin for 18 hours and
also aspirin and Plavix. Plavix 75 mg for 30 days.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 97.4, blood pressure 109/41, pulse 66, normal
sinus rhythm, respiratory rate 14, pulse oximetry 95% on room
air. This is a middle-aged man lying in bed in no acute
distress. Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Sclerae were nonicteric.
Moist mucous membranes. NECK: Neck was remarkable for no
JVD, but right carotid bruit. He had regular rate and
rhythm, S1 and S2, [**1-12**] holosystolic low pitched murmur at the
apex and the left lower sternal border without radiation to
the axilla. LUNGS: Lungs were clear to auscultation
bilaterally. ABDOMEN: Soft, positive bowel sounds,
nontender. Femoral line showed no bleeding and no bruit.
EXTREMITIES: No edema, 2+ radial pulses, no DP or PT
palpable. NEUROLOGICAL: The patient was alert and oriented
times three. Cranial nerves II through XII grossly intact.
The motor was [**4-10**] in all extremities except for the proximal
left lower extremity secondary to femoral sheath. He had
decreased sensation on the dorsum of both feet bilaterally
and the medial aspect of his right thigh. Deep tendon
reflexes were 1+. Cerebellar function was grossly intact.
LABORATORY DATA: Initial labs showed the following:
Hematocrit of 35.1 down from 40.7 in the morning with
platelet count 238,000. PT was 12.9, INR 1.2, potassium 3.6.
HOSPITAL COURSE: The patient was kept on Integrilin for 18
hours without any events. Platelet count did not fall
substantially until the next morning. The patient also was
continued on aspirin and Plavix without any bleeding. He was
started on his outpatient medications including Zocor 20,
Atenolol 50 b.i.d., Imdur 30 b.i.d. He was also started on
Paxil 40. The patient had no ectopy, but occasional
bradycardia overnight, but transvenous pacer never paced. By
morning, the first degree heart block, which was observed
after catheterization was gone and the patient had normal pr
intervals.
NEUROLOGICAL: The patient had no episodes of syncope or
vasovagal events. He had no signs of arrhythmias, while
ischemic-induced arrhythmias are a possible cause for the
syncopal event. The patient did not show any signs of ectopy
or arrhythmias during the hospital course that would suggest
such an etiology. Further workup for syncope, such as MRI
and MRA should be done with the primary care physician on an
outpatient basis. The patient had no pulmonary issues. He
had no active renal issues. The BUN and creatinine were
stable. Potassium was repleted as necessary and he was
advanced to a regular diet. The hematocrit remained stable
initially following from 40 to 35.1, but stabilizing at 33.
The platelets stabilized at 201. He had no signs of
bleeding. The transvenous pacer was pulled and the femoral
line remained without signs of oozing, hematoma, or bruit.
The patient had no infectious disease issues or GI issues.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is to go home without
services. The patient is to followup with his primary care
physician in one to two weeks and with his cardiologist. The
patient may benefit from cardiac rehabilitation in four to
six weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post catheterization.
2. Syncope.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Plavix 75 mg q.d. times 30 days.
3. Imdur 30 mg q.d.
4. Atenolol 50 mg b.i.d.
5. Paxil 40 mg q.d.
6. Prilosec 20 mg q.d.
7. Zocor 20 mg q.d.
8. Sublingual nitroglycerin p.r.n.
9. Ativan 1 mg p.r.n.
10. Trazodone 50 mg q.h.s.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 20317**]
MEDQUIST36
D: [**2185-6-15**] 15:53
T: [**2185-6-15**] 16:39
JOB#: [**Job Number 27173**]
Admission Date: [**2185-6-14**] Discharge Date: [**2185-6-16**]
Date of Birth: [**2126-3-29**] Sex: M
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
man with history of coronary artery disease status post
multiple PCIs, prior non-Q-wave MI, hypertension,
hypercholesterolemia, panic disorder, peripheral vascular
disease, who was referred to [**Hospital1 188**] for outpatient cardiac catheterization. The patient
started developing whole-body numbness, particularly in his
hands and right side of his face about a week ago. On [**6-9**] while at the beach, the patient had felt lightheaded, had
bilateral transient blindness, and a syncopal event. Upon
recovery he had 1 out of 10 chest pain. The patient was
taken to [**Hospital3 3583**] for syncopal workup. He was ruled
out for combined myocardial infarction by cardiac enzymes and
at that time no arrhythmias or dysrhythmias were noted. He
was scheduled for stress test and discharged. In the ensuing
days, he stated developing increasing chest pain typical of
his previous angina. He went for his stress test. Myoview
showed mostly fixed inferior wall defect with very mild
inferior and lateral-wall reversibility. The patient had
intense chest pain. Stress test, procedure had to be
aborted. The patient refused to go to immediate
catheterization preferring to schedule an elective procedure
at [**Hospital1 69**] scheduled Tuesday,
[**6-14**]. When the patient went home he had increasing
angina at rest relieved with nitroglycerin. The patient also
described paroxysmal nocturnal dyspnea, two-pillow orthopnea.
He had CAD risk factors, high cholesterol, and hypertension.
He was a former smoker who quit in [**2181**] but still smokes a
pipe. There was no diabetes mellitus. The patient has an
extensive past CAD/catheterization history. He had stenting
of his distal RCA and proximal circumflex in [**2182-5-7**],
stenting of his marginal 2 and angioplasty of OM1 on [**2183-6-7**], angioplasty of inferior OM and superior branch OM [**2184-6-6**]. PTCA and stenting of PLV branch in [**2185-2-4**]. The
patient also had workup for TIA due to increasing numbness in
his hands bilaterally. At that time he had a carotid duplex
which showed no signs of flow abnormalities. He has also had
a MRI in the past, which revealed small vessel discharged and
an EEG performed in [**2181**], which showed no seizure activity.
The patient's syncopal episode had been observed and he had
no seizure activity or urinary incontinence. The patient
denies feeling diaphoretic prior to the syncopal episode.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Non-Q-wave MI.
5. Peripheral vascular disease status post right femoral
bypass in [**2181**].
6. Degenerative disk disease L1, L4, L5.
7. Transient ischemic attack.
8. Panic disorder.
ALLERGIES: The patient is allergic to PENICILLIN, CAUSING
NAUSEA AND VOMITING.
OUTPATIENT MEDICATIONS:
1. Aspirin.
2. Imdur 60 q.d.
3. Atenolol 50 b.i.d.
4. Paxil 40 q.d.
5. Prilosec 20 q.d.
6. Zocor 20 q.d.
7. Nitroglycerin sublingual p.r.n.
8. Ativan 1 mg p.r.n.
9. Trazodone 50 mg q.h.s.
SOCIAL HISTORY: The patient is an occasional pipe smoker.
The patient denies alcohol use.
FAMILY HISTORY: History revealed the patient's brother died
of a myocardial infarction at the age of 47. Father died of
a myocardial infarction at the age of 65.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] for catheterization.
Catheterization findings were normal left main, LAD with 50%
mid, 60% ostial diagonal 1, left circumflex 50% lower pole of
obtuse marginal 1, 70% upper pole, RCA with occluded PDA with
left to right collaterals, 90% stenosis in PLV stent.
Interventions were angiojet thrombectomy, only modest
improvement; balloon angioplasty with PDA stent to RCA beyond
PDA culprit lesion. During the procedure, the patient was
noted to have Wenckebach A-V block of varying degrees,
temporary transvenous pacing wire was left in place. Post
dilation, the EKG revealed first degree AV block. After
catheterization he was started on Integrilin for 18 hours and
also aspirin and Plavix. Plavix 75 mg for 30 days.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 97.4, blood pressure 109/41, pulse 66, normal
sinus rhythm, respiratory rate 14, pulse oximetry 95% on room
air. This is a middle-aged man lying in bed in no acute
distress. Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Sclerae were nonicteric.
Moist mucous membranes. NECK: Neck was remarkable for no
JVD, but right carotid bruit. He had regular rate and
rhythm, S1 and S2, [**1-12**] holosystolic low pitched murmur at the
apex and the left lower sternal border without radiation to
the axilla. LUNGS: Lungs were clear to auscultation
bilaterally. ABDOMEN: Soft, positive bowel sounds,
nontender. Femoral line showed no bleeding and no bruit.
EXTREMITIES: No edema, 2+ radial pulses, no DP or PT
palpable. NEUROLOGICAL: The patient was alert and oriented
times three. Cranial nerves II through XII grossly intact.
The motor was [**4-10**] in all extremities except for the proximal
left lower extremity secondary to femoral sheath. He had
decreased sensation on the dorsum of both feet bilaterally
and the medial aspect of his right thigh. Deep tendon
reflexes were 1+. Cerebellar function was grossly intact.
LABORATORY DATA: Initial labs showed the following:
Hematocrit of 35.1 down from 40.7 in the morning with
platelet count 238,000. PT was 12.9, INR 1.2, potassium 3.6.
HOSPITAL COURSE: The patient was kept on Integrilin for 18
hours without any events. Platelet count did not fall
substantially until the next morning. The patient also was
continued on aspirin and Plavix without any bleeding. He was
started on his outpatient medications including Zocor 20,
Atenolol 50 b.i.d., Imdur 30 b.i.d. He was also started on
Paxil 40. The patient had no ectopy, but occasional
bradycardia overnight, but transvenous pacer never paced. By
morning, the first degree heart block, which was observed
after catheterization was gone and the patient had normal pr
intervals.
NEUROLOGICAL: The patient had no episodes of syncope or
vasovagal events. He had no signs of arrhythmias, while
ischemic-induced arrhythmias are a possible cause for the
syncopal event. The patient did not show any signs of ectopy
or arrhythmias during the hospital course that would suggest
such an etiology. Further workup for syncope, such as MRI
and MRA should be done with the primary care physician on an
outpatient basis. The patient had no pulmonary issues. He
had no active renal issues. The BUN and creatinine were
stable. Potassium was repleted as necessary and he was
advanced to a regular diet. The hematocrit remained stable
initially following from 40 to 35.1, but stabilizing at 33.
The platelets stabilized at 201. He had no signs of
bleeding. The transvenous pacer was pulled and the femoral
line remained without signs of oozing, hematoma, or bruit.
The patient had no infectious disease issues or GI issues.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is to go home without
services. The patient is to followup with his primary care
physician in one to two weeks and with his cardiologist. The
patient may benefit from cardiac rehabilitation in four to
six weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post catheterization.
2. Syncope.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Plavix 75 mg q.d. times 30 days.
3. Imdur 30 mg q.d.
4. Atenolol 50 mg b.i.d.
5. Paxil 40 mg q.d.
6. Prilosec 20 mg q.d.
7. Zocor 20 mg q.d.
8. Sublingual nitroglycerin p.r.n.
9. Ativan 1 mg p.r.n.
10. Trazodone 50 mg q.h.s.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 20317**]
MEDQUIST36
D: [**2185-6-15**] 15:53
T: [**2185-6-15**] 16:39
JOB#: [**Job Number 27173**]
Admission Date: [**2185-6-14**] Discharge Date: [**2185-6-16**]
Date of Birth: [**2126-3-29**] Sex: M
Service: CCU
STAT ADDENDUM:
In addition to the hospital course addendum, echocardiogram
the next day after the procedure revealed an ejection
fraction of 50%. No pericardial effusion. Left ventricular
wall thickness and cavity size were normal. Mild regional
left ventricular systolic dysfunction and 1+ mitral
regurgitation.
The patient will be discharged with the additional
medications of lisinopril 2.5 mg qd and Percocet 1 to 2
tablets q6h prn for pain. He is being given enough pills for
the next seven days, at which time he will be evaluated by
his cardiologist and neurologist.
The patient has appointments with his cardiologist scheduled
for next week. He additionally has appointments with
neurology and he has been advised to make an appointment with
his primary care physician in the next one to two weeks. His
cardiologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15994**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ACC
Dictated By:[**Doctor Last Name 27212**]
MEDQUIST36
D: [**2185-6-16**] 11:43
T: [**2185-6-16**] 12:00
JOB#: [**Job Number 27213**]
cc:[**Numeric Identifier 27214**]
|
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"413.9",
"272.0",
"414.01",
"996.72",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"37.78",
"88.56",
"36.05",
"99.20",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
11399, 11547
|
15577, 15649
|
15672, 17458
|
13754, 15278
|
11092, 11290
|
12357, 13736
|
10721, 11068
|
11307, 11382
|
15304, 15556
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,138
| 101,308
|
12907
|
Discharge summary
|
report
|
Admission Date: [**2176-8-22**] Discharge Date: [**2176-8-25**]
Date of Birth: [**2100-5-7**] Sex: M
Service: MEDICINE
Allergies:
Percodan
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
direct admit for L carotid stenting
Major Surgical or Invasive Procedure:
L carotid stenting
History of Present Illness:
76 y/o man with PMH sig for DM2, HTN, hyperlipidemia, CAD (s/p
2vCABG, s/p PTCA w/ RCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]), carotid stenosis (severe
80-99% on R, moderate 60-70% on left), thought to be [**2-10**] rad
therapy for oropharyngeal cancer, now admitted for L carotid
artery senting by Dr. [**Last Name (STitle) **].
.
Prior to his R stent, the patient was having multiple TIAs with
unilateral blurry vision and one episode of syncope. The patient
underwent successful stenting of the right common and internal
carotid artery on [**2176-7-9**]. Since his discharge, he has not had
any dizziness, blurry vision, other visual disturbances,
headache, shortness of breath. He does admit to feeling a
generalized weakness and fatigue. Also, he has been diagnosed
with anemia with his last colonscopy being in [**2171**] which was
normal.
.
ROS: He denies any prior history of stroke, 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. Cardiac review of systems is
notable for absence of chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
All of the other review of systems were negative except says his
stools have been darker since he was started on the iron and he
has had periodic epistaxis that are not profound and resolved on
his own. In addition, the patient describes feeling depressed
for several months. He sleeps more and has less energy. He
takes part in fewer
activities. However, he does feel hopeful for the future.
.
Past Medical History:
Hypertension
Hyperlipidemia
Anemia of Chronic Disease
Diabetes
CAD:
- [**2161**]: LAD and RCA PTCA
- [**2163**]: 2 vessel CABG (LIMA-->LAD, SVG-->OM) (Dr. [**Last Name (STitle) 39668**] [**Hospital1 2025**])
Significant carotid artery disease per wife's report (records
requested from [**Hospital1 2025**])
[**2156**] malignant tumor involving the tonsil, s/p radical neck
surgery and radiation ([**Hospital1 2025**])
[**2167**] Hematuria related to kidney stone
GERD
Lap Cholecystectomy
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Social History: Patient is married with two children. Lives
with wife [**Name (NI) **] who is a nurse. He is retired and reviously
worked for [**Company 2676**]. Smoking: 40pack-year (quit 25 yrs ago),
ETOH: occasional,No drugs. Pt not very active anymore, but
independent in daily activities.
Family History:
Mother with heart disease, passing away in her late 70??????s. Father
with similar throat cancer. No family history of premature CAD,
DM.
Physical Exam:
VS - T 97.8 HR 66 BP 173/59 recheck later 138/50 RR 20 O2sat100%
Gen: WDWN middle aged male in NAD. Oriented x3. Mood depressed,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Evidence of previous tumor resection on the right, supple
with no JVD, no LAD, +L carotid bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 SEM over URSB, no r/g. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. Increased tympany on the LUQ.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, or xanthomas.
Neuro: no aphasia, no recall difficulty, CN 2-12 intact B/L,
strength 5/5 B/L upper and lower extremities, reflex 2+
throughout with negative Babinksi, coordination intact, fine
motor intact, vibratory sensation decrease in B/L LE, light
sensation intact B/L Upper and Lower Extremity. Non focal.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
ADMISSION LABS:
[**2176-8-22**] 03:51PM GLUCOSE-181* UREA N-34* CREAT-1.6* SODIUM-139
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2176-8-22**] 03:51PM estGFR-Using this
[**2176-8-22**] 03:51PM ALT(SGPT)-12 AST(SGOT)-16 LD(LDH)-162 ALK
PHOS-52 TOT BILI-0.1
[**2176-8-22**] 03:51PM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-4.0
MAGNESIUM-2.0 IRON-38*
[**2176-8-22**] 03:51PM calTIBC-283 VIT B12-590 FOLATE-16.3
HAPTOGLOB-228* FERRITIN-23* TRF-218
[**2176-8-22**] 03:51PM TSH-3.1
[**2176-8-22**] 03:51PM WBC-4.1 RBC-3.04* HGB-9.0* HCT-27.0* MCV-89
MCH-29.8 MCHC-33.6 RDW-14.7
[**2176-8-22**] 03:51PM PLT COUNT-170
[**2176-8-22**] 03:51PM PT-12.7 PTT-26.9 INR(PT)-1.1
.
.
PERTINENT LABS/STUDIES:
Hct: 27 -> 29.2 -> 29.3
Cr: 1.6 -> 1.3 -> 1.3
Glucose: 181 -> 116 -> 120
TIBC: 283
Vit B12: 590
Folate: 16.3
Hapto: 228
Ferritin: 23
TRF 218
TSH: 3.1
MICRO:
Urine Cx: No growth
Blood Cx x2: No growtn
CTA +/- contrast of head ([**2176-7-8**]): Severe atherosclerotic
disease in the bilateral carotid and right vertebral arteries.
There is suggestion of an acute thrombus in the distal right
cervical vertebral artery extending into the intradural portion.
Recommend
correlation with MRI to assess for acute ischemia.
Atherosclerotic stenosis in bilateral cervical ICAs and common
carotid arteries as detailed above. No significant abnormality
in the intracranial circulation is seen.
.
Carotid Doppler U/S ([**2176-5-1**])
1. B/l sig ICA stenoses which are severe on the right causing 80
to 99% luminal narrowing and moderate on the left where a 60 to
69% stenosis is present. 2. Suggestion of narrowing of the
proximal CCA bilaterally, right greater than left.
.
Cardiac catheterization ([**2176-4-30**]):
1. Three vessel coronary artery disease.
2. Patent LIMA-->LAD and SVG-->OM with 20% proximal ulceration.
3. Stenting of RCA with Drug eluting stent.
.
ETT w/ echo ([**2176-4-9**]): ischemia of the septum and inferior wall.
Abnormal septal motion. LVEF 51%.
EKG demonstrated TWI in 1 avL, and V4-V6 with no significant
change compared with prior dated 7/[**2176**].
TELEMETRY demonstrated:NSVT
.
.
DISHCARGE LABS:
[**2176-8-24**] 07:26AM BLOOD WBC-5.4 RBC-3.37* Hgb-9.8* Hct-29.3*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.4 Plt Ct-160
[**2176-8-24**] 07:26AM BLOOD Plt Ct-160
[**2176-8-24**] 07:26AM BLOOD Glucose-120* UreaN-25* Creat-1.3* Na-139
K-4.4 Cl-105 HCO3-28 AnGap-10
[**2176-8-22**] 03:51PM BLOOD ALT-12 AST-16 LD(LDH)-162 AlkPhos-52
TotBili-0.1
[**2176-8-24**] 07:26AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1
Brief Hospital Course:
Patient is a 76 year-old man with a h/o type 2 Diabetes, HTN,
hyperlipidemia, CAD, and carotid stenosis who presented for
stenting of his left carotid artery.
# Carotid stenosis: Patient underwent a stenting of his right
carotid artery on [**2176-7-9**]. He returned to [**Hospital1 18**] for an elective
stenting of his left carotid artery, which had a stenosis of
60-69%. Patient became hypotensive after the procedure and was
admitted to the CCU. This episode was thought to be a vagal
response, and the patient did not have any further episodes
while in the CCU. The patient was restarted on his home regimen
of Plavix and aspirin and did not have any acute events while in
the hospital.
.
# Coronary Artery Disease: Patient has a significant history of
CAD. He had a PTCA w/ a DES to the RCA in [**2176**] and a two-vessel
CABG in [**2163**]. Patient had an ECG performed on this admission,
which showed no significant interval changes since 7/[**2176**]. The
patient did not have any symptoms or signs of ongoing ischemia
during this admission. He was continued on his outpatient
regimen of Plavix, Aspirin, Metoprolol, Imdur, and Valsartan,
and he was monitored on tele for the duration of his hospital
stay.
.
# Systolic Congestive Heart Failure: Patient had an ECHO
performed in [**2176-4-9**] which showed ischemia of the septum and
inferior wall, abnormal septal motion, and a LVEF of 51%.
Patient did not appear volume overloaded on physical exam during
this hospital stay, but he has a history of periodic lower
extremity edema. He has been taking Lasix prn as an outpatient.
On this admission, was monitored for signs of volume overload.
It was recommended that the patient follow up with his
cardiologist for a repeat ECHO as an outpatient to assess for
interval change.
.
# Anemia- Patient's Hct was consistently low on this admission.
Iron studies and hemolysis labs were sent, and the results were
consistent with anemia of chronic disease. Patient was also
found to have a new systolic ejection murmur on this admission,
which may have been related to this anemia. Patient's stools
were guiaiced on this admission, and they were consistently
negative. Patient was transfused one unit of PRBCs before his
carotid stent placement, and his Hct increased appropriately
from 27.0 to 29.3. Patient was continued on his ferrous
sulfate, and he had no other acute events while in the hospital.
.
# Diabetes: Patient has a history of type 2 diabetes, and he
takes oral anti-glycemics as outpatient. His physical exam was
consistent with peripheral neuropathy with decreased vibratory
sensation in his lower extremities bilaterally. Patient was
started on a regular insulin sliding scale while in the
hospital, but he refused to take insulin injections. His blood
sugars remained relatively well controlled, with a range of
100-180. Patient was discharged on his home regiment of oral
anti-glycemics.
.
# Chronic Kidney Disease: Patient has a GFR of 53, which is
consistent with stage 3 CKD. This is most likely due to
diabetes. Patient had improvement in his BUN/Cr to 29/1.3 with
hydration and Mucomyst. Patient had no acute events during this
admission and was continued on Valsartan.
.
# Hypertension: Patient has a history of hypertension. He was
continued on his home doses of Metoprolol, Valsartan, and HCTZ,
and he had no acute events during this admission.
.
# Hyperlipidemia: Patient has a history of hyperlipidemia and
was continued on his outpatient statin.
.
# Code: Full Code
Medications on Admission:
Plavix 75 mg daily
Lasix 40 mg daily p.r.n.edema
Amaryl 4 mg b.i.d.
Imdur 60 mg q.h.s.
metformin 500 mg b.i.d.
metoprolol 25 mg q.h.s.
Prilosec 20 mg daily
Trental 400 mg t.i.d.
Actos 15 mg daily
Pravachol 40 mg q.h.s.,
losartan/hydrochlorothiazide 160/25 one tablet daily
aspirin 325mg daily
omega-3 fatty acids/vitamin E 1000 mg/5 unit capsule one capsule
t.i.d.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO TID
(3 times a day).
3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for fluid overload.
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
13. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Amaryl 4 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 39671**] Home Health Services of [**Location (un) **]
Discharge Diagnosis:
Primary:
1. carotid artery disease
.
Secondary:
Hypertension
Hyperlipidemia
Anemia of Chronic Disease
Diabetes
CAD:
- [**2161**]: LAD and RCA PTCA
- [**2163**]: 2 vessel CABG (LIMA-->LAD, SVG-->OM) (Dr. [**Last Name (STitle) 39668**] [**Hospital1 2025**])
Significant carotid artery disease per wife's report (records
requested from [**Hospital1 2025**])
[**2156**] malignant tumor involving the tonsil, s/p radical neck
surgery and radiation ([**Hospital1 2025**])
[**2167**] Hematuria related to kidney stone
GERD
Lap Cholecystectomy
Discharge Condition:
Vital signs stable, ambulatory without dizziness, tolerating PO
feeds and fluids.
Discharge Instructions:
You were admitted for a carotid artery stent, which was placed
successfully in the cardiac catheterization lab. You were able
to ambulate independently after the procedure. You were
discharged to home in stable condition.
You are advised to seek medical attention if you acquire chest
pain, shortness of breath, dizziness, nausea, or vomiting, or
any other concern that is out of the ordinary for you.
You are advised not to swim for a duration of at least one week
until you see your primary care physician.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2176-8-30**] 2:20
Completed by:[**2176-9-2**]
|
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"433.10",
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"250.00",
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icd9cm
|
[
[
[]
]
] |
[
"00.63",
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icd9pcs
|
[
[
[]
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12294, 12390
|
7000, 10530
|
303, 323
|
12971, 13055
|
4441, 4441
|
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|
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|
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228, 265
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351, 2080
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2683, 2963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,187
| 173,239
|
7993
|
Discharge summary
|
report
|
Admission Date: [**2132-12-17**] Discharge Date: [**2133-1-23**]
Date of Birth: [**2087-11-5**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 45 year old male
with a history of morbid obesity, diabetes mellitus, chronic
obstructive pulmonary disease with home O2, congestive heart
failure who was admitted to the [**Hospital1 **] [**Hospital3 **] for chronic obstructive pulmonary disease
exacerbation and improved with steroids. However, during
that hospitalization he developed severe abdominal pain and
evaluation with radiograph reveals free air under the
abdomen. His hospital course was significant for Kayexalate
for mild hyperkalemia. The patient was then transferred to
the [**Hospital1 69**] for further
management.
PAST MEDICAL HISTORY: Is significant for diabetes mellitus
with nephropathy, retinopathy and neuropathy. He has a
history of lower extremity ulcers. History of hypertension,
chronic obstructive pulmonary disease, congestive heart
failure with a recent ejection fraction of 50 percent,
anemia, morbid obesity, history of methicillin resistant
Staphylococcus aureus and pseudomonas pneumonia.
PAST SURGICAL HISTORY: Is significant for left below knee
amputation
MEDICATIONS AT HOME: Prior to admission were insulin sliding
scale, aspirin, OxyContin 80 q.i.d., Neurontin 600 t.i.d.,
Paxil 40 B.I.D., Klonopin 2 B.I.D., Lopressor 100 B.I.D.,
mexiletine 400 B.I.D., Singulair, lisinopril 10 daily,
Ambien, Flonase and Advair.
HOSPITAL COURSE: The patient was taken emergently to the
operating room and exploration revealed a perforated
transverse colon. The patient then underwent an exploratory
laparotomy, partial colectomy and transverse colostomy with
mucous fistula and a jejunostomy tube. Patient tolerated the
procedure well and immediately postoperatively in the
recovery room the patient underwent a percutaneous
tracheostomy for anticipated respiratory failure with the
history of severe chronic obstructive pulmonary disease,
morbid obesity and emergent abdominal exploration. The
patient's postoperative course was then significant for
respiratory failure, pneumonia due to pseudomonas and
methicillin resistant Staphylococcus aureus and
hyperglycemia. Postoperatively the patient was treated
empirically with Vancomycin and Zosyn and was supported with
mechanical ventilation. He was initially treated with tube
feeds and total parenteral nutrition for nutrition. Total
parenteral nutrition was weaned off as the tube feeds were
advanced. The patient then developed fever postoperatively
and the patient was continued on broad spectrum antibiotics.
Sputum cultures revealed pneumonia due to pseudomonas,
Citrobacter and methicillin resistant Staphylococcus aureus.
The patient had persistent fevers and central venous
catheters were removed and a pseudomonas line infection was
diagnosed and treated with antibiotics. Due to persistent
fevers the patient then underwent a CT of the chest and
abdomen which showed on postoperative day 16 that the patient
had a distended gallbladder that was concerning for
acalculous cholecystitis and a cholecystostomy tube was
placed. There were also moderate bilateral pleural effusions
and no evidence of intra-abdominal abscess.
The remainder of the [**Hospital 228**] hospital course was
significant for primarily respiratory failure as well as
hyperglycemia. The patient was slowly weaning from the
ventilator and ultimately a course of steroids was initiated
as well as aggressive diuresis which ultimately enabled Mr.
[**Known lastname **] to wean from the ventilator and remain on tracheostomy
collar for a significant period of time. The patient had
significant insulin resistance and hyperglycemia requiring an
insulin drip for a prolonged period of time which was
exacerbated with the steroids. At the time of discharge the
patient's condition by system is as follows:
1. Neurologic: Mr. [**Known lastname **] is comfortable and is being
adequately treated for pain with methadone and is on
gabapentin as well as Klonopin.
1. Pulmonary: Mr. [**Known lastname **] is now tolerated a tracheostomy
collar without ventilatory support within the last 24 to
48 hours. He is on a steroid taper as well as
bronchodilators.
1. Cardiac: The patient with a normal rate and rhythm on
Lopressor with adequate control of his hypertension with
Clonidine as well.
1. Gastrointestinal: Patient was tolerating his tube fees
and his cholecystostomy is being drained every six hours
and this bile is being replaced through the jejunostomy
tube.
1. Renal: He is aggressively diuresed to a BUN of 60.
However, this has plateaued and diuresis has been stopped
and his BUN is expected to come back down. His creatinine
has remained normal. His urine output has been adequate.
1. Heme: He is on Lovenox for deep venous thrombosis
prophylaxis. His hematocrits have been adequate.
1. Infectious Disease: He has been off antibiotics. He has
had no fever and a normal white count. He appears to be
colonized with pseudomonas and methicillin resistant
Staphylococcus aureus which is not causing an acute
infectious problem.
1. Endocrine: Mr. [**Known lastname **] is being weaned on a steroid taper.
He was started on steroids as Solu-Medrol 60 intravenous q
6 and is currently being weaned on half the dose every two
days. Mr. [**Known lastname **] is now off insulin drip and he is on
Lantus as well as insulin sliding scale and is maintaining
sugars under 130.
DISCHARGE DIAGNOSES:
1. Colon perforation.
2. Diabetes mellitus.
3. Nephropathy, retinopathy and neuropathy.
4. Hypertension.
5. Chronic obstructive pulmonary disease.
6. Home O2.
7. Home CPAP.
8. Congestive heart failure near 50 percent.
9. Anemia.
10. Morbid obesity.
11. Depression.
PROCEDURES:
1. Status post partial resection of transverse colon, end
transverse colostomy, mucus fistula, jejunostomy tube and
percutaneous tracheostomy on [**2132-12-16**].
2. Status post percutaneous cholecystostomy tube [**2134-1-1**].
MEDICATIONS ON DISCHARGE: Tylenol 650 mg P.O. q 4 to 6 PRN,
albuterol inhaler q 6 PRN, Combivent inhaler 1 to 2 puffs q
4, Atrovent inhaler q 6 PRN, Prevacid 30 mg P.O., daily,
Lantus 200 units subcutaneous at bedtime, Ativan 0.5 mg
intravenous PRN, Clonazepam 2 mg P.O. q 12, Clonidine 0.4 mg
P.O. q 8, enoxaparin 60 mg subcutaneous B.I.D., gabapentin
600 mg P.O. q 8, hydrochlorothiazide 12.5 mg P.O. daily,
hydralazine 20 mg intravenous q 6, insulin sliding scale,
Lopressor 100 mg P.O. B.I.D., Lopressor 5 mg intravenous q 4
PRN, methadone 30 mg P.O. jejunostomy tube t.i.d., Percocet
elixir 5 to 10 cc P.O. q 4 to 6 PRN, [**Location (un) 2452**] oil 1 vial q 6
PRN, paroxetine 40 mg P.O. q day, valsartan 80 mg P.O. q day
and prednisone 25 mg P.O. t.i.d. started on [**2133-1-22**] to be
tapered by [**1-4**] every two to three days as indicated.
DISCHARGE STATUS: Condition is fair.
FOLLOW UP: With Dr. [**Last Name (STitle) **] in two weeks.
DISPOSITION: Transfer to rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 11987**]
Dictated By:[**Name8 (MD) 26127**]
MEDQUIST36
D: [**2133-1-22**] 17:13:12
T: [**2133-1-22**] 18:01:29
Job#: [**Job Number 28629**]
cc:[**Hospital6 28630**]
|
[
"482.1",
"482.41",
"569.83",
"250.40",
"496",
"518.5",
"567.2",
"V58.67",
"401.9",
"357.2",
"428.0",
"278.01",
"V09.0",
"583.81",
"996.62",
"250.60",
"575.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"51.03",
"31.1",
"45.74",
"96.6",
"99.15",
"46.39",
"46.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5629, 6155
|
6182, 7048
|
1551, 5608
|
1292, 1533
|
1223, 1270
|
7060, 7433
|
184, 803
|
826, 1199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,862
| 181,900
|
3681
|
Discharge summary
|
report
|
Admission Date: [**2132-2-8**] Discharge Date: [**2132-2-19**]
Date of Birth: [**2054-5-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine / Ativan / Ace Inhibitors
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Black stool
Major Surgical or Invasive Procedure:
EGD on [**2132-2-12**]
History of Present Illness:
77M w/ history of atrial fibrillation, primary prevention ICD,
CAD s/p bypass grafting, s/p CABG, aortic valve replacement in
[**2116**], CHF (EF 40%), pulmonary HTN, parkinson-like syndrome
presenting with three to four days of dark, tarry stool. He had
had one episode of melena per day. He denies nausea, vomiting,
hematemesis, bright red blood per rectum. He has never had this
happen before. He is on coumadin and his most recent INR was
3.3 (INR generally ranges 3 - 3.5 given mechanical valve). No
dizziness, lightheadedness, chest pain. He has generally been
feeling fatigued since this started. Patient has also had
hemoptysis over the past two weeks. He and his wife are certain
he does not have hematemesis. He has had hemoptysis in the
past, but it has been worse. Patient coughed up frank blood
today as per his wife.
.
Of note, patient had multiple episodes of recurrent aspiration
pneumonia one year ago. He chose to go home with hospice in
[**2130-12-23**] following an admission for aspiration pneumonia,
but he improved and discontinued hospice several months ago.
Since that time, he has gradually been restarting his home
medications. He is currently taking coumadin, aspirin, but has
not been taking his beta blocker. As per wife patient had 40
pound weight loss over past year.
.
In the ED, initial vitals were: 97.9 79 109/62 18 100%. Patient
had melena on retal examination. Labs were significant for a
HCT of 28.2 down from 33.1 on [**2131-1-22**]. He had an EKG showing a.
fib at 80 BPM without evidence of ischemia. Patient had two 18
gauge peripheral IVs placed. GI saw patient in ED and
recommended endoscopy. Vitals at transfer were: Temperature
98.2, Pulse 81, Respiratory Rate 16, Blood Pressure 99/60, O2
Saturation 96 on RA.
.
On arrival to the MICU, patient was comfortable. He has some
fatigue, but generally is feeling well. No abdominal pain.
Patient had not had an episode of melena since day prior to
admission.
Past Medical History:
1. History of cough-variant asthma.
2. Status post aortic valve replacement ([**2116**], done with CABG#2)
3. Coronary artery disease (CAD) status post CABG ([**2112**], [**2116**]).
4. Atrial fibrillation, status post multiple cardioversions.
5. Ischemic cardiomyopathy with severely depressed ejection
fraction.
6. Pulmonary hypertension likely chiefly on the basis of
diastolic dysfunction seen on cardiac catheterization in [**2125**].
7. Sleep apnea.
8. Hyperlipidemia.
9. Post encephalitic Parkinson's disease.
10. Gout.
11. Recurrent pneumonia.
12. Abnormal CT scan (RLL lesion, decision previously made not
to biopsy/work-up lesion)
13. hip fracture [**2127**], after a fall treated with R
hemiarthroplasty
14. C. difficile colitis
15. Hypertension
16. s/p cholecystectomy and appendectomy
17. s/p colectomy with diversting colostomy, now repaired
Social History:
He grew up in the [**Location (un) 86**] area. Married with two grown adopted
children. Lives with his wife who is a retired nurse. He is
retired VP of [**Last Name (un) 1687**] College. He drinks [**12-24**] alcoholic beverages
per week. He denies any tobacco history.
Family History:
He has a strong family history of cancer. His mother died of
colon cancer, his father had lung cancer. He also had multiple
grandparents with colon cancer.
Physical Exam:
On Admission:
Vitals: T: afebrile BP: 114/61 P: 74 R: 13 O2: 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Irregular rhythm, regular rate, S1, mechanical S2, no
murmurs/rubs/gallops
Lungs: Bibasilar crackles, no wheezes/rhonchi, breathing
comfortably
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:
Admission labs:
[**2132-2-8**] 02:55PM BLOOD WBC-6.9 RBC-2.89* Hgb-9.5* Hct-28.2*
MCV-98# MCH-32.8*# MCHC-33.6 RDW-15.1 Plt Ct-284
[**2132-2-8**] 02:55PM BLOOD Neuts-68.1 Lymphs-21.7 Monos-4.5 Eos-4.9*
Baso-0.9
[**2132-2-8**] 02:55PM BLOOD PT-41.4* PTT-47.0* INR(PT)-4.1*
[**2132-2-8**] 02:55PM BLOOD Glucose-137* UreaN-32* Creat-1.0 Na-136
K-4.1 Cl-98 HCO3-27 AnGap-15
PA/lat CXR ([**2-8**]):
Findings: The study can be compared to [**2131-1-26**] and an
outside study from [**2131-3-3**]. The patient is status post
coronary artery bypass graft surgery. A dual-lead pacemaker/ICD
device is in place in a similar configuration. The cardiac,
mediastinal and hilar contours appear unchanged. The aortic
valve has been replaced. Right hilar prominence is stable and
may reflect mildly enlarged central pulmonary arteries. The
lungs appear clear. There are no pleural effusions or
pneumothorax. Mild degenerative changes are similar along the
thoracic spine.
Chest CT: Ground glass opacities likely areas of hemorrhage.
There are no
large soft tissue masses. Followup as clinically indicated or in
three
months. Small left pleural effusion. Mediastinal
lymphadenopathy. Evidence of pulmonary hypertension.
Gynecomastia.
Brief Hospital Course:
## Upper GI bleed: Patient was initially admitted to the ICU.
INR was not reversed as overt bleeding had abated on admission
to unit, and he had remained HD stable. He underwent EGD on
[**2132-2-12**] under GA where an 'inflammatory lesion' was found and
cauterized with cessation of bleeding. After discussion with
GI, it was decided to resume his Heparin gtt given his
mechanical valve and to observe for recurrent GI bleeding prior
to initiating any warfarin. He had no further episodes of GI
bleeding or anemia while on full anticoagulation. He was
discharged on a PPI.
.
## Mild hemoptysis: CT chest was performed and was notable for
diffuse ground glass opacities. In discussion with the patient,
his family, and Dr. [**Last Name (STitle) 575**] it was felt that further
evaluation with bronchoscopy would be unlikely to
therapeutically benefit patient and so this was deferred. His
hemoptysis slowly improved. He will follow up in Pulmonary
clinic per routine.
.
## s/p MVR: Upon resolution of bleeding, Coumadin was restarted.
However, since INR was still vastly subtherapeutic, he was
discharged home with Lovenox bridge until he has a therapeutic
INR 3-3.5. He is scheduled to have his INR drawn on [**2132-2-21**],
which was confirmed with the [**Hospital 191**] [**Hospital3 **].
.
## CAD, chronic systolic CHF EF 40%: He was ultimately restarted
on home ASA and Spironolactone. Bumex was held on discharge due
to persistent low blood pressure, although without suspicion for
active GI bleeding.
.
## R breast swelling: Breast US was remarkable only for
gynecomastia. No masses were identified.
.
## Parkinson's dz: Continued on home meds.
.
## DNR/DNI: confirmed during this admission.
Medications on Admission:
Allopurinol 200 mg PO daily
Aspirin 81 mg daily
Bumetanide 2 mg daily
Carbidopa-levodopa 25 - 100 mg TID
Gabapentin 100 mg [**Hospital1 **], 300 mg qHS
Nitroglycerin 0.4 mg SL PRN
Excelon patch 9.6 mg daily
Spironolactone 12.5 mg daily
Warfarin 6 mg daily
Cymbalta 20 mg daily
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 6 doses.
Disp:*6 injection* Refills:*0*
2. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): 8am and 4pm.
7. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
9. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal Daily ().
10. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Hemoptysis
Mechanical heart valve
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 black tarry stools. You
had a low blood count, which was monitored. Your Coumadin was
held and you were placed on a heparin drip. You decided to
undergo an EGD which showed an inflammatory lesion that was
bleeding. This bleeding was treated with thermal therapy with
control of bleeding. You also complained of coughing up blood,
and we decided to perform a CT of the chest which showed
enlarged lymph nodes but did not show discrete tumors.
MEDICATION CHANGES:
- You should NOT take Bumetanide (or Bumex) when you get home
since your blood pressure has been running low
- You will continue to take Lovenox until you are told to stop
by the [**Hospital3 **]
- You were started on Omeprazole to treat your GI bleeding
Followup Instructions:
You are scheduled to have your INR drawn on Thursday, [**2-21**],
which will be arranged through [**Hospital3 **].
Department: [**Hospital3 249**]
When: MONDAY [**2132-2-25**] at 1:40 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
Completed by:[**2132-2-19**]
|
[
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"414.8",
"327.23",
"274.9",
"416.9",
"332.0",
"428.0",
"V45.81",
"578.1",
"401.9",
"V58.61",
"611.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8692, 8698
|
5623, 7324
|
320, 344
|
8791, 8791
|
4379, 4379
|
9759, 10728
|
3525, 3684
|
7652, 8669
|
8719, 8770
|
7350, 7629
|
8974, 9460
|
3699, 3699
|
9480, 9736
|
269, 282
|
372, 2342
|
4395, 5600
|
3713, 4360
|
8806, 8950
|
2364, 3221
|
3237, 3509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,212
| 118,972
|
49610
|
Discharge summary
|
report
|
Admission Date: [**2132-8-27**] Discharge Date: [**2132-9-15**]
Date of Birth: [**2066-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Coumadin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Weight gain since discharge on [**8-25**] and rash
Major Surgical or Invasive Procedure:
Skin biopsy (right flank)
[**2132-9-4**] CABG x2 (LIMA to LAD, SVG to DIAG)/ pericardial
stripping
History of Present Illness:
Pt is a 66 year old male with PMH of HTN, s/p knee surgeries,
recently discharged from the hospital after treatment of
pericardial effusion and anasarca. He was treated with a
pericardial drain and diuresis with Lasix. He was discharged
with 3 more days of lasix and prescriptions for meloxicam and
omeprazole. He noted his weight was 1.5 lb heavier than
yesterday, with development of a new rash. Pt presented to hism
physician, [**Name10 (NameIs) 1023**] then referred him to the ED for evaluation.
.
The patient initially presented to [**Hospital1 18**] on [**8-19**] with left leg
and scrotal swelling. He was noted to have a pericardial
effusion and hypovolemic hyponatremia in the setting of poor
cardiac output. He was treated with a pericardial drain.
Hyponatremia slowly improved with fluids and treatment of
pericardial effusion. He first noted weight gain developing
after left knee replacement on [**2132-7-10**]. CTV done to eval for
thrombosis, not ideal timing of contrast to establish presence
of IVC clot, incidentally a large pericardial effusion, free
fluid in abdomen and pleural effusions were found. TTE without
tamponade physiology, large RA/RV, raised the question of
pulmonary embolism. He underwent CTA which was negative for PE
or aortic dissecction but showed persistent pericardial effusion
and bilateral pleural effusions. He was admitted to theICU for
pericardial drain, then transferred to the floor. Etiology of
pericarditis remained unclear.
Past Medical History:
Benign lesion removed from his right breast [**2125**]
s/p 3 knee surgeries, LTR [**2132-7-20**]
Normal stress test in [**2127**]
Hyperlipidemia
Pre-malignant skin lesions
Tendonitis
HTN
Social History:
Retired IRS attorney. Now runs own business as CPA/tax lawyer.
Lives with wife. 2 grown children.
[**Country 3992**] veteran.
No h/o incarceration or known TB exposures.
No IVDU.
Very distant smoking history.
2 glasses wine/day.
Family History:
He has a strong family history of coronary artery disease.
Father died of MI at age 51.
Physical Exam:
A & 0 x 3. VSS, afebrile. BP104/71
Cor- crisp heart sounds. SR @85.
Lungs- clear. Sternum stable, cleans dry and intact incision.
Abd- benign.
Exts- trace edema RLE. Scant serous drainage from JP site. EVH
incisions intact.
Pertinent Results:
Echo [**2132-8-27**]
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is dilated There is abnormal septal
motion suggestive of pericardial constriction. The aortic valve
leaflets (3) are mildly thickened. The mitral valve leaflets are
mildly thickened. There is a small pericardial effusion. The
effusion appears circumferential. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
The pericardium may be thickened. The echo findings are
suggestive but not diagnostic of pericardial constriction.
IMPRESSION: Smalll, circumferential, echo dense effusion. The
pericardium appears thickened. There is no evidence of
pericardial tamponade however the thickened pericardium and
septal "bounce" are suggestive of constriction. Mitral and
tricuspid inflows however do not confirm this possibility. If
constriction is being considered, a cardiac MR can help to
characterize the thickness of the pericardium and the presence
of constriction.
Compared with the prior study (images reviewed) of [**2132-8-25**],
the findings are similar. The mitral and tricuspid inflows are
not diagnostic of constriction on either study.
[**2132-9-15**] 05:35AM BLOOD WBC-12.3* RBC-2.98* Hgb-8.9* Hct-27.1*
MCV-91 MCH-30.0 MCHC-33.0 RDW-13.9 Plt Ct-612*
[**2132-9-15**] 05:35AM BLOOD Plt Ct-612*
[**2132-9-15**] 05:35AM BLOOD Glucose-85 UreaN-17 Creat-0.7 Na-135
K-4.6 Cl-101 HCO3-26 AnGap-13
[**2132-9-15**] 05:35AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
Brief Hospital Course:
Cardiac cath done [**9-2**] revealed LM and LAD dz. He was referred
for surgery and underwent cabg/pericardial stripping on [**9-4**] with
Dr. [**Last Name (STitle) 914**]. He was transferred to the CVICU in stable condition
on no pressors.
Within 24 hours, Mr. [**Known lastname **] awoke neurologically intact and was
extubated. Aspirin, a statin and beta blockade were resumed. His
chest tubes were left in place as he continued to drain from
them. On postoperative day three, he was trnasferred to the step
down unit for further recovery. he was gently diuresed towards
his preoperative weight. CTs were seperated and mediastinal
drains were removed. Pleural tubes and the right leg JP
continued to have copious outputs. Motrin was begun, Lasix dose
was increased and a fluid restriction was instituted. Nacl
tablets were given also to correct his low sodium level.
The physical therapy service was consulted for assistance with
his postoperative strength and mobility.
His edema improved, sodium rose and weight fell with these
treatments. The Left CTwas removed on POD6, the right drain on
POD9. Nacl tablets were stopped when sodium rose to 134 . The JP
drain was removed the day of discharge. POD 11 he was discharged
home with VNA. All follow-up appointments were advised.
Medications on Admission:
atorvastatin 10 mg daily
mobic 7.5 mg [**Hospital1 **]
lasix 20 mg PO x 3 days
Omeprazole 20 mg daily
benicar/HCTZ
(Mobic, lasix and omeprazole are new medications that were
started upon discharge on [**2132-8-25**])
Discharge Medications:
1. 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*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day for 4 weeks: with meals.
Disp:*84 Tablet(s)* Refills:*0*
5. 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*
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease
constrictive pericarditis
s/p cabg/pericardial stripping
s/p percardiocentesis [**8-8**]
biventricular diastolic heart failure secondary to constrictive
pericarditis
HTN
h/o basal cell skin CA
hyperlipidemia
s/p left TKR
s/p right THR
s/pleft breast lumpectomy
Discharge Condition:
good
Discharge Instructions:
no driving for one month AND until off narcotics
no lotions, creams, or powders on any incision
no lifting greater than 10 pounds for 10 weeks
shower daily ,no swimming or baths
call for fever greater than 100.5, redness or drainage
report weight gain of more than 3 pounds
take all medications as prescribed
Followup Instructions:
see Dr. [**First Name (STitle) 679**] in [**1-2**] weeks
see Dr.[**Doctor Last Name 3733**] in [**2-3**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
f/u with orthopedic surgeon as per postop instructions
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Completed by:[**2132-9-15**]
|
[
"428.0",
"V10.83",
"719.06",
"E947.9",
"416.8",
"693.0",
"276.1",
"401.9",
"428.31",
"414.01",
"423.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"86.11",
"36.15",
"37.31",
"37.23",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
7047, 7105
|
4295, 5583
|
325, 427
|
7434, 7441
|
2757, 4272
|
7798, 8166
|
2407, 2497
|
5852, 7024
|
7126, 7413
|
5609, 5829
|
7465, 7775
|
2512, 2738
|
235, 287
|
455, 1933
|
1955, 2143
|
2159, 2391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,906
| 141,543
|
47431
|
Discharge summary
|
report
|
Admission Date: [**2187-4-2**] Discharge Date: [**2187-4-11**]
Date of Birth: [**2110-3-27**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Hydrochlorothiazide / Ibuprofen / Zosyn
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Ischemic Left leg
Major Surgical or Invasive Procedure:
OPERATIONS PERFORMED:
1. Exploration of left common femoral artery.
2. Left common femoral artery endarterectomy.
3. Thrombectomy of left iliac artery.
4. Stenting of left common iliac artery.
5. Stenting of left profunda femoris artery.
6. Left iliofemoral arteriogram.
History of Present Illness:
Pt is 77 y/o F with h/o peripheral vascular disease, coronary
artery disease, and stroke 5 months ago who presents with cold,
painful left foot for past 3 days. Pt developed these symptoms
at a rehab facility 3 days ago and was transferred to [**Hospital 2586**] today for evaluation. Pt denies fevers or
chills. No chest pain, sob, abd pain, nausea/vomiting, or
diarrhea. Pt started on heparin gtt at OSH prior to transfer to
[**Hospital1 18**].
Past Medical History:
- Stroke L MCA infarct [**10-20**] s/p IV tPA, IA tPA+penumbra and s/p
PEG placement
- CAD and Infranodal Heart Block:
+MIBI [**12-12**] with reversible defects in inferior and
lateral walls. Cath [**12-12**]: LMCA: 30-40%, LAD: 50-60%, LCx:
50%, with OM1 T.O, 99% OM2; RCA: diffuse disease. No
percutaneous intervention done. [**12-12**] TTE: EF 70%, moderate
symmetric LVH
Echo [**10-14**] LVEF>55% No PFO; complex atheroma.
His/Purkinje block
- Bladder lesion under investigation: soft tissue density seen
on CT pelvis in bladder [**2186-10-25**]
- DMII (A1C 8.1 on [**11-10**]) on glargine
- PVD
- DVT in [**2157**]
- Hyperlipidemia - last LDL 64 on lipitor 80mg PO qD
- HTN
- Pancreatitis [**2181**], idiopathic
- Hemorrhoids
Social History:
Currently at [**Hospital3 **]. Prior to her CVA was living on [**Location (un) **] with her daughter living on floor below. She is a widow,
was working full time in accounting and finance. Former smoker,
40 pack year history. Denies EtOH or illicits.
Family History:
Mother with CAD. Parents with HTN.
Physical Exam:
Vitals: T 98.6 F BP 131/48 P 71 RR 20 SaO2 98 RA
General: NAD, well-nourished
HEENT: NC/AT, sclerae anicteric, MMM
Neck: no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: left foot slightly erythematous, pedal pulses difficult to
appreciate
Neurologic Examination:
Mental Status:
Sleepy, inattentive, repeatedly drifting back to sleep during
examination, appears abulic, states one-two words at most (can
occasionally state "yes" or "no"), seems to comprehend basic
examination commands (example, for strength testing) while
awake.
Seems to attend primarily to right space.
Cranial Nerves:
Fundi are difficult to appreciate, as she closes her eyes
forcefully. Pupils slightly irregular bilaterally but equally
reactive to light, ~3 to 2 mm bilaterally. Extraocular
movements
intact, no nystagmus. States that facial sensation to light
touch is symmetric. Right upper motor neuron facial droop.
Hearing intact conversational volume. Tongue protrudes midline,
but does not open mouth much further. Trapezii full on the left
and [**3-11**] on the right.
Motor:
Difficult to assess tone reliability given pain in extremities.
No tremor. She does not participate in formal testing, except
in
the left arm, due to pain. The left arm is full throughout,
except at the deltoid, which is 4+/5; the deltoid was tested
last
and some of the weakness may have been effort related. She is
able to weakly lift the right arm against gravity, but does not
participate further due to pain. She is able to wiggle her legs
in the plane of the bed, but again does not want to move much
more due to pain.
Sensation: She does states that sensation to light touch is
preserved and symmetric throughout, though the right side is
exquisitely painful to the touch, as noted above. I deferred
response to noxious given her pain.
Reflexes: B T Br
Right 2 1 2
Left 2 1 2
The reflexes in the lower extremities could not be elicited in
the setting of poor relaxation with pain. Toes were equivocal
bilaterally.
Coordination and gait could not be adequately or safely
performed
due to somnolence and weakness
Pertinent Results:
Cardiac Echo:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. No definite structural cardiac source
of embolism identified.
Compared with the prior report (images unavailable for review)
of [**2186-12-6**], the estimated pulmonary artery systolic pressure
and severity of mitral regurgitatio are now lower.
CTA:
Extensive vascular atherosclerotic dz with calcifications.
Non-occlusive
thrombus within common hepatic aa (3a,15), calcifications at the
ostia of all branches from the aorta. Left external iliac
thombus originating at the bifurcation (3a,88) with no flow
distally to the left lower extremity except for a short segment
of reconstitution at the proximal left superficial femoral aa.
?contrast in the left deep profunda aa- hard to visualize with
extensive calcifications. Minimal contrast opacification of the
right superficial femoral aa. Recons pending.
CT of Head:
There is no evidence of acute hemorrhage or shift of normally
midline structures. The ventricles and sulci are prominent
consistent with
age-related atrophy. Again identified is hypodensity in the left
frontal lobe consistent with prior MCA stroke. Bilateral basal
ganglia calcifications are noted. Study is limited due to slight
motion. The basilar cisterns are
patent. The visualized paranasal sinuses are clear.
Calcifications of the
carotid and vertebral arteries are noted.
[**2187-4-5**] 11:47 am URINE Source: Catheter.
URINE CULTURE (Final [**2187-4-6**]):
GRAM POSITIVE COCCUS(COCCI). ~1000/ML.
[**2187-4-11**] 06:32AM BLOOD
WBC-9.9 RBC-2.76* Hgb-7.7* Hct-23.4* MCV-85 MCH-27.9 MCHC-32.9
RDW-17.2* Plt Ct-559*
[**2187-4-11**] 06:32AM BLOOD
PT-21.9* PTT-79.5* INR(PT)-2.1*
[**2187-4-10**] 03:04PM BLOOD
Glucose-83 UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-108 HCO3-25
AnGap-11
[**2187-4-10**] 03:04PM BLOOD
Calcium-8.3* Phos-2.7 Mg-1.8
[**2187-4-5**] 11:47AM
URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.009
URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-15
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
URINE RBC->50 WBC-[**5-16**]* Bacteri-FEW Yeast-NONE Epi-0-2
Brief Hospital Course:
Mrs. [**Known lastname **],[**Known firstname 100336**] E was admitted on [**4-2**] with Ischemic cold
left leg. She was put in the CVICU. IV heparin started. She
agreed to have an elective surgery. Pre-operatively, she was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
Started on IV AB.
Mucomyst and bicarb given preoperatively for renal protection.
CTA:
Extensive vascular atherosclerotic dz with calcifications.
Non-occlusive
thrombus within common hepatic aa (3a,15), calcifications at the
ostia of all
branches from the aorta. Left external iliac thombus originating
at the
bifurcation (3a,88) with no flow distally to the left lower
extremity except
for a short segment of reconstitution at the proximal left
superficial femoral
aa. ?contrast in the left deep profunda aa- hard to visualize
with extensive
calcifications. Minimal contrast opacification of the right
superficial
femoral aa. Recons pending.
It was decided that she would undergo an emergent surgey:
OPERATIONS PERFORMED:
1. Exploration of left common femoral artery.
2. Left common femoral artery endarterectomy.
3. Thrombectomy of left iliac artery.
4. Stenting of left common iliac artery.
5. Stenting of left profunda femoris artery.
6. Left iliofemoral arteriogram.
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
IV heparin started, Goal PTT 60-80.
Mucomyst and bicarb given post operative period for renal
protection.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the CVICU for further recovery.
While in the CVICU she recieved monitered care.
POD # 1
She did recieve a central line without complications. Post CXR
showed no pneumothorax. She did have low urine output. Recieved
1 unit PRBC and LR bolus x 2. Adaquate response. BG covered with
SSI. Metformin held. Heparin IV continued.
POD # 2
Recived cardiac echo to rule aout thrombis and evaluate
function. BUN and creatine followed, slight elevation from
contrast nephropathy. OOB to chair. PT consult obtained. Serial
pulse check post operative period. Heparin IV continued. Poor PO
intake. Gabapentin started for pain control. Slight altered
mental status without acute deficit. Echo negative for thrombus.
Transfered to the VICU
POD # 3
Pt delined. Encourage PO. PT works with patient. Coumadin was
started with Heparin IV bridge. Geriatrics consult for
questionable depression obtained. Geriatrics concerned about
possible frontal [**Last Name 3630**] problem. [**Name (NI) 62847**] consulted.
She was stabalized from the acute setting of post operative
care, she was transfered to floor status. On the floor, she
remained hemodynamically stable with continued Pain. Pain
consult obtained for Ischemic Neuropathy.
Heparin IV continued. Coumadin. [**Name (NI) **] PTT and INR.
POD # 4
Pt was seen by neurology previous stroke. It was decided to get
stroke involved in her care. CT scan of head completed. Negative
for acute stroke. Has persistant encephalopathy. PO encouraged.
Continues to work with PT. Pain improves.
Heparin IV continued. Coumadin. [**Name (NI) **] PTT and INR.
Creatinine improves. Metformin restared. Ace an lasix on hold.
POD # 5
Persistant encephalopathy, Heparin IV continued. Coumadin,
serial pulse checks, Continue to moniter PO intake. Pt daughter
brings food. PO intake improves.
Heparin IV continued. Coumadin. [**Name (NI) **] PTT and INR.
Creatinine improves more. Home dose Lasix restarted. Ace on
hold.
POD # 6
Persistant encephalopathy but improved, Heparin IV continued.
Coumadin. serial pulse checks, Continue to moniter PO intake. Pt
daughter brings food. PO intake improves.
Heparin IV continued. Coumadin. [**Name (NI) **] PTT and INR.
Creatinine improves more. Ace still on hold, BP low. BB stopped
for HR of 50. BP stable.
Nutrition for calorie ccounts. Pt refuses DHFT.
POD # 7
She progressed with physical therapy to improve her strength and
mobility. She continues to make steady progress without any
incidents. Encephalopathy improved.
Heparin IV continued. Coumadin. [**Name (NI) **] PTT and INR.
BS good on metformin. BP good on lasix. ACE inhibitor started.
BB still on hold.
POD # 8
Pt c/o N/V. R/O for MI. No further issues. EKG showed. Atrial
fibrillation with slow responce.
Pt also with HCT 23. Recieved 1 untit PRBC. No active source of
bleeding identified.
POD # 9
Pt stable for DC, Heparin stopped on DC. Pt to go on coumadin
Lovenox Bridge. One dose given. Lovenox should be DC's when INR
2.5. Coumadin increased to 7.5 mg.
She was discharged to a rehabilitation facility in stable
condition.
Medications on Admission:
Norvasc 2.5, enalapril 20'', furosemide 40 qAM, 20 qPM, imdur
90, lipitor 80, metformin 500''', metoprolol xl 50, nitro prn,
plavix 75, asa 325, mvi, fish oil
Discharge Medications:
1. Amlodipine 2.5 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
[**Name (NI) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily).
6. Furosemide 40 mg Tablet [**Name (NI) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Furosemide 20 mg Tablet [**Name (NI) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Gabapentin 300 mg Capsule [**Name (NI) **]: One (1) Capsule PO BID (2
times a day).
9. Acetaminophen 500 mg Tablet [**Name (NI) **]: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
10. Tramadol 50 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Metformin 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times
a day).
12. Insulin
TO Insulin SC (per Insulin Flowsheet)
Sliding Scale
Fingerstick Q6 hrsInsulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**12-8**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
> 280 mg/dL Notify M.D.
13. Warfarin 7.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Once Daily at
4 PM: Check daily INR; goal 2.5-3.
14. Enalapril Maleate 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2
times a day).
15. Enoxaparin 100 mg/mL Syringe [**Month/Day (2) **]: 0.7 mL Subcutaneous [**Hospital1 **] (2
times a day): D/C once INR >2.5. Check INR daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Ischemic left leg
Depression
ARF secondary to contrast load
Anemia secondary to OR blood with low urine output loss
requiring PRBC
Encphalopathy
Ischemic Neuropathy
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Division of Vascular and Endovascular Surgery
Lower Extremity Embolectomy and stenting Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-9**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2187-4-25**] 10:15
Completed by:[**2187-4-11**]
|
[
"V58.67",
"427.89",
"E942.6",
"401.9",
"250.60",
"311",
"440.22",
"348.30",
"285.1",
"E947.8",
"438.20",
"428.0",
"584.9",
"997.5",
"444.81",
"357.2",
"596.9",
"V44.1",
"455.6",
"272.4",
"414.01",
"438.11",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"00.44",
"38.93",
"00.46",
"00.42",
"38.18",
"39.79",
"39.50",
"39.90",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
14178, 14221
|
7363, 12215
|
330, 603
|
14430, 14437
|
4506, 7340
|
17381, 17555
|
2159, 2195
|
12425, 14155
|
14242, 14409
|
12241, 12402
|
14461, 16954
|
16981, 17358
|
2210, 2625
|
273, 292
|
631, 1083
|
2975, 4487
|
2664, 2959
|
2649, 2649
|
1105, 1874
|
1890, 2143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,026
| 147,849
|
1553
|
Discharge summary
|
report
|
Admission Date: [**2128-4-10**] Discharge Date: [**2128-4-23**]
Date of Birth: [**2068-7-23**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Amoxicillin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Left-sided weakness
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
59yo F h/o allergic rhinitis (without h/o asthma),
hypothyroidism, h/o cholestasis, s/p bioprosthetic mitral valve
thought to be needed after MI and papillary muscle infarction in
[**12-2**], who presented here on [**4-9**] with fatigue, lethargy and
weakness. Her current admission was preceeded by 5 days of
diarrhea and abdominal pain, with no BRBPR or melena. She
presented here on
[**4-7**] and was discharged after abdominal CT and CBC showed no
leukocytosis (eo's of 15). On [**4-8**], she had less of an appetite
and complained to her husband of feeling generalized fatigue,
with no other complaints.
On the day of presentation, she could not stand or walk and
could not figure out how to put on her gloves and she was
brought here. Even at the time of my history, the patient cannot
relate much of what happened that day. But she confirms her
husband's report that she noticed the sudden inability to stand
or walk (she feels due to weakness) and she says that she was
"disoriented,"
although she cannot relate to me what she means by that. At
present, she denies changes in her vision that day. She denies
that she had chest pain or shortness of breath.
Past Medical History:
PMH:
- erythroderma
- hypothyroidism ([**1-30**] Grave's disease s/p RAI ablation)
- history of cholestasis
- overactive bladder
- deep venous thrombosis (arm; when line in place); coumadin
discontinued end of [**3-3**]
- s/p MVR (bio) [**12-2**]; rupture of papillary muscle and MI
(course included chest CT, which showed infiltrates atypical in
distribution for aspiration pneumonia)
- cardiac cath [**12-2**]: normal coronary arteries.
- h/o allergic rhinitis in the spring
- h/o eosinophilia
Social History:
SH: small-business owner, heavy machinery. Married with no kids.
No etoh/smoking
or drugs
Family History:
FH:
- DM in her grandfather.
- bullous pemphigoid
- skin cancer, CAD, multiple strokes in her father
Physical Exam:
98.2 60s 110-140/68-70 18 98% RA
General. Pleasant. Slightly blunted affect. Difficulty giving a
complete history secondary to long term memory impairments.
HEENT. No icterus. MMM. No ulcers.
Chest CTAB
CV S1 S2 no m/r/g
[**Last Name (un) **] Soft NT ND +BS
Ext. WWP. Normal Pulses
Neuro. EOMI. Tongue midline, palate elevates. Hearing intact.
Hyper-reflexive on the left side. She has weakness in the left
deltoid, but only minimal weakness in the right deltoid. She has
good prox lower extremity and ankle strenght. She has a strong
symmetric grip bilaterally.
MSK. She has no synovitis in her hands, with no PIP, MCP, or
wrist swelling. She has normal range of motion in her elbows and
shoulders. She has normal internal and external rotation of her
hips, and flextion of her knees without effusions. No MTP
squeeze, and no Ankle effusion.
R sided hemiparesis - improving, unable to integrate details
into complex picture
Pertinent Results:
CXR - AP UPRIGHT CHEST RADIOGRAPH: Median sternotomy wires are
intact. The cardiomediastinal silhouette is within normal
limits. The pulmonary vasculature is normal. Lungs are clear
without focal consolidation, pneumothorax or pleural effusion.
Contrast is seen within the left upper quadrant, likely
secondary to recent CT examination.
IMPRESSION:
1. No acute cardiopulmonary process.
.
CT - There is no evidence of intracranial hemorrhage. There is a
hypodensity in superior aspect of the left frontal [**Last Name (LF) 3630**], [**First Name3 (LF) **]
represent an area of infarction.
There are calcifications in the basal ganglia bilaterally.
Surrounding osseous structures and soft tissues are
unremarkable. Imaged paranasal sinuses are well aerated.
IMPRESSION: Area of hypodensity in the left frontal [**First Name3 (LF) 3630**] may
represent an acute infarction or partial volume averaging,
correlation with MR [**First Name (Titles) 151**] [**Last Name (Titles) **] sequences is recommended to further
evaluate this finding.
.
MR - CLINICAL INFORMATION: Patient with left-sided weakness,
question of infarct or venous sinus thrombosis.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were acquired. Following
gadolinium, T1 axial and coronal images were obtained. 2D
time-of-flight MRV of the head and 3D time- of-flight MRA of the
circle of [**Location (un) 431**] were obtained.
FINDINGS: BRAIN MRI:
Diffusion images demonstrate multiple foci of slow diffusion in
both cerebral hemispheres distributed in the frontal and
parietal and occipital lobes. Small foci of slow diffusion are
also seen in both cerebellar hemispheres. Findings are
indicative of multiple bilateral supra and infratentorial acute
brain infarcts. Given the disc augmentation of multiple vascular
territories, embolic event is favored. There is no evidence of
acute or chronic hemorrhage identified. There is no mass effect,
midline shift or hydrocephalus seen.
IMPRESSION: Multiple bilateral supra and infratentorial acute
brain infarcts.
MRV OF THE HEAD:
The head MRV demonstrates normal flow signal in the superior
sagittal sinus and deep venous system. The left transverse sinus
is small in size, which could be a normal variation. The right
transverse sinus and jugular vein demonstrate normal flow
signal.
IMPRESSION: Normal MRV of the head. No evidence of sinus
thrombosis.
MRA OF THE HEAD:
Head MRA demonstrates normal flow signal within the arteries of
anterior and posterior circulation. No evidence of vascular
occlusion or stenosis seen.
IMPRESSION: Normal MRA of the head.
.
ECHO - 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. Overall left
ventricular systolic function is normal
(LVEF>55%). Right ventricular systolic function is normal. The
ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The motion of
the mitral valve prosthetic leaflets appears normal. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No evidence of endocarditis. Normally-functioning
bioprosthetic mitral valve with trace regurgitation.
.
LEFT UPPER EXTREMITY ULTRASOUND: Normal compressibility, color
flow, and Doppler waveforms are seen in the left internal
jugular vein, brachial, basilic veins. Though the left axillary
vein is not totally compressible, it shows normal color flow and
Doppler waveforms. Normal color flow and Doppler waveforms are
also demonstrated in the left subclavian vein.
IMPRESSION: No evidence of DVT in the left upper extremity.
.
Skin biopsy - Note: No vasculitis is seen in the sections
examined. No fungal organisms are seen on PAS stain. There is no
increase in dermal mucin on Alcian Blue stain. The findings are
consistent with a hypersensitivity reaction, such as to a drug,
in the appropriate clinical setting. Although less likely, other
considerations also include arthropod bites and an id reaction.
Clinical: 59 y/o white female with complex past medical history
who is admitted with hypertension, fatigue and neuropathy. The
patient also has diffuse morbilliform type rash on the chest,
back, upper extremities, eosinophilia and increased LFT's.
However, eosinophilia, rash and LFTs started prior to
hospitalization, prior to receiving antibiotics. Differential
diagnosis is DRESS/hypersensitivity reaction (due to MVI, NSAID,
or supplement) versus vasculitis Churg-[**Doctor Last Name 3532**] versus viral
exanthem. Location is anterior chest.
.
RUQ U/S: The liver is normal in size and echotexture. No focal
hepatic lesions are identified. No intra or extrahepatic biliary
ductal dilatation. The common bile duct is not dilated,
measuring 5 mm. The visualized portion of the pancreas is seen,
however, the distal body and tail are not well seen. The
gallbladder demonstrates a normal, relaxed, configuration. There
is mild gallbladder wall edema that may be related to third
spacing of fluid. There is a 3 mm echogenic focus in the
dependent portion of the gallbladder, most likely representing a
small polyp. No gallstones are identified.
The hepatic veins are abnormally dilated. The portal vein is
widely patent and demonstrates normal hepatopetal flow.
There is a small amount of perihepatic fluid.
There is a right pleural effusion.
Findings were discussed with neurology resident, Dr. [**First Name (STitle) 9046**]
[**Name (STitle) 7994**], at the time of initial interpretation.
IMPRESSION:
1. Mild gallbladder wall edema without other specific
son[**Name (NI) 493**] signs of cholecystitis.
2. New right pleural effusion.
3. Minimal perihepatic fluid.
.
ECHO - The left atrium is normal in size. The estimated right
atrial pressure is 0-5mmHg. Left ventricular wall thickness,
cavity size, and 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. Trace aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients. No mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The estimated pulmonary artery
systolic
pressure is normal. There is no pericardial effusion.
.
[**2128-4-9**] 07:00PM PT-13.2* PTT-24.7 INR(PT)-1.2*
[**2128-4-9**] 07:00PM PLT SMR-NORMAL PLT COUNT-196
[**2128-4-9**] 07:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2128-4-9**] 07:00PM NEUTS-59.5 BANDS-0 LYMPHS-6.1* MONOS-1.7*
EOS-32.4* BASOS-0.3
[**2128-4-9**] 07:00PM WBC-10.1 RBC-3.61* HGB-10.9* HCT-30.1* MCV-83
MCH-30.2 MCHC-36.1* RDW-14.6
[**2128-4-9**] 07:00PM TSH-1.1
[**2128-4-9**] 07:00PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2128-4-9**] 07:00PM CK-MB-53* MB INDX-14.1* cTropnT-2.02*
[**2128-4-9**] 07:00PM LIPASE-19
[**2128-4-9**] 07:00PM ALT(SGPT)-24 AST(SGOT)-78* LD(LDH)-544*
CK(CPK)-377* ALK PHOS-100 AMYLASE-35 TOT BILI-0.5
[**2128-4-9**] 07:00PM GLUCOSE-98 UREA N-14 CREAT-1.0 SODIUM-135
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
[**2128-4-9**] 07:12PM GLUCOSE-99 K+-3.9
[**2128-4-9**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2128-4-9**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2128-4-9**] 08:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2128-4-9**] 08:45PM URINE HOURS-RANDOM
[**2128-4-9**] 09:55PM D-DIMER-4134*
[**2128-4-9**] 10:05PM LACTATE-1.0
[**2128-4-9**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-392*
POLYS-0 LYMPHS-100 MONOS-0
[**2128-4-9**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-13*
POLYS-0 LYMPHS-0 MONOS-0
[**2128-4-9**] 11:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-21
GLUCOSE-63
[**2128-4-10**] 12:26PM PT-14.0* PTT-28.3 INR(PT)-1.2*
[**2128-4-10**] 12:26PM PLT COUNT-204
[**2128-4-10**] 12:26PM WBC-16.4*# RBC-3.40* HGB-10.3* HCT-28.0*
MCV-82 MCH-30.3 MCHC-36.8* RDW-14.7
[**2128-4-10**] 12:26PM CORTISOL-28.6*
[**2128-4-10**] 12:26PM T4-8.2
[**2128-4-10**] 12:26PM TSH-1.1
[**2128-4-10**] 12:26PM CALCIUM-7.2* PHOSPHATE-3.9 MAGNESIUM-1.8
[**2128-4-10**] 12:26PM CK-MB-96* MB INDX-15.7* cTropnT-2.46*
[**2128-4-10**] 12:26PM LIPASE-19
[**2128-4-10**] 12:26PM ALT(SGPT)-27 AST(SGOT)-85* CK(CPK)-611* ALK
PHOS-85 AMYLASE-29
[**2128-4-10**] 12:26PM GLUCOSE-115* UREA N-14 CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-18* ANION GAP-15
[**2128-4-10**] 02:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2128-4-10**] 02:13PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2128-4-10**] 07:55PM SED RATE-55*
[**2128-4-10**] 07:55PM CRP-78.1*
[**2128-4-10**] 07:55PM ANCA-NEGATIVE B
[**2128-4-10**] 09:18PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2128-4-10**] 09:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2128-4-10**] 11:09PM freeCa-1.04*
[**2128-4-10**] 11:09PM LACTATE-1.1
[**2128-4-10**] 11:09PM TYPE-ART PO2-62* PCO2-24* PH-7.43 TOTAL
CO2-16* BASE XS--5
Brief Hospital Course:
This 59-year old woman was admitted for falls, found to have
mutliple cerebral infarcts, evidence of myocarditis, and
persisent eosinophilia.
.
1. Neurological - The patient was admitted to the neuro-ICU and
required initial support with pressors. She remained afebrile
however, with no source of infection. MRI disclosed bilateral
cerebellar small infarcts inolving frontal and parietal and
occipital lobes, with bilateral cerbral hemisphere infarct in
watershed distributions. Areas were deemed to represent
multiple bilateral supra and infratentorial acute brain
infarcts. Initially on the CT scan she had area of suspicious
involvement in the left frontal [**Month/Day/Year 3630**], bilateral basal ganglia.
It was unsure of these were secondary to periods of hypotension
or embolic phenomenon, although an ECHO was negative for source
of emboli. Due to concern for aspirin sensitivity, the aspirin
was discontinued. Patient may be rechallenged in the future
with aggrenox/aspirin for secondary stroke prevention.
.
2. Cardiac - Patient cardiac enzymes were initially elevated
and remained plateued throughout her stay, thought to be
secondary to myocarditis. Her troponins were elevated but her
CKMB was normal. Patient denies chest pain prior to or during
her stay. Her EKG showed persistent LBBB. Her echocardiogram
was also unremarkable with normal LVEF and no wall motion
abnormalities. Cardiology was curb-sided and recommended
cardiac MRI, which was scheduled but could not be completed for
technical reasons. This issue will need to be addressed as an
outpatient during her cardiology visit. Depending on patient's
symptoms and [**Last Name (LF) 9047**], [**First Name3 (LF) **] echo or an MRI could be entertained at
that point.
.
3. Hematology - Patient noted to have persistent eosinophilia,
prompting multiple consults throughout here stay to investigate
possibile hypereosinophilic syndromes. Hematology considered a
bone marrow biopsy, but deferred this as possible work-up in the
outpatient setting. Review of peripheral smear, makes malignant
process highly unlikely, patient has a CHIC FISH test pending
upon discharge and the result will be followed up in
rheumatology clinic. At that point further workup if necessary
will be determined. Coagulation needs to be addressed as an
outpatient.
.
4. Infectious disease - Cultures remained negative, or no
growth to date at the time of discharge. Steroids were
initiated on on [**4-10**], solumedrol 1g q24, beginning on [**4-10**] for 5
days, then begun on a steroid taper, to decrease by 5mg q week.
Patient is being discharged on 30 mg QD.
.
5. Dermatology - Due to a new red rash on the upper torso,
dermatology was consulted for skin biopsy, with biopsy results
consistent with drug rash, possibly due to vancomycin or
cepahlosporin.
.
6. Gastroenterology - Due to patient's complaints of loose
stools/diarrhea and to aid in a diagnosis via biopsy, a
colonoscopy was considered but was deferred due to resolution of
symptoms.
.
7. Patient had her R SCL pulled on [**4-22**] upon d/c.
.
8. Full Code
.
9. Communication: Husband [**Name (NI) 2174**] [**Name (NI) 9048**], JD Home:
[**Telephone/Fax (1) 9049**]; work [**Telephone/Fax (1) 9050**]
Medications on Admission:
ASA 81 mg qd
[**Doctor First Name **] 60 mg qd
Levothyroxine 100 mcg qd
MVI qd
Oxybutynin 5 mg qd
-pt denies using estradiol (in contrast to OMR info)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for itching.
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergies.
8. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO once a day for
7 days: 25mg qd for 7 days, [**4-23**] to [**4-29**], then dose will
decrease.
9. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
7 days: To begin on [**4-30**] and to end on [**5-6**].
10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: To begin on [**5-7**] and to end on [**5-14**].
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: To begin on [**5-15**], to end on [**5-21**].
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
7 days: To begin on [**5-22**], to end on [**5-28**], to end taper.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left intracranial hemorrhage (basal ganglia/internal capsule)
Hypereosinophilia syndrome
Discharge Condition:
Patient discharged to rehab, walking on her own with deficits in
left shoulder and left leg, tolerating PO feeds and fluids,
vital signs stable, afebrile.
Discharge Instructions:
Patient was admitted for falls, found to have multiple strokes.
She was also found to have abnormal laboratory values and
treated with steroids.
Patient should:
1. Take all medications as prescribed.
2. Keep all follow-up appointments.
3. Seek medical attention if she acquires chest pain, shortness
of breath, nausea, vomiting, fevers greater than 101, or any
other concern that is out of the ordinary for him.
Followup Instructions:
Suture removal from skin biopsy site on [**4-25**]
1. Cardiology:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2128-5-13**]
.
2. Neurology: [**Name8 (MD) 162**], MD [**Last Name (Titles) 23**] 8 [**Hospital1 18**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2128-5-14**] 9:00
.
3. [**Last Name (LF) 1576**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**]-[**Doctor Last Name 1576**] APG (SB)
Date/Time:[**2128-6-16**] 9:50
.
4. Rheumatology - Dr. [**Last Name (STitle) **] - [**Telephone/Fax (1) 2226**] - [**2132-5-5**]:00AM. [**Last Name (NamePattern1) 439**] - [**Location (un) **], 4B, across the street
from emergency room.
.
5. Allergy - Dr. [**Last Name (STitle) 2603**] - [**2128-5-18**], 9:00am.
[**Telephone/Fax (1) 9051**]
.
6. Hematology-Oncology - will be considered by rheumatology or
allergy physicians.
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8,665
| 150,454
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43482+58622
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-6-11**] Discharge Date: [**2115-6-22**]
Date of Birth: [**2041-10-14**] Sex: M
Service: Cardiothoracic
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
gentleman with a history of mitral regurgitation,
hypertension and chronic anemia. He was recently admitted in
[**2115-4-21**], to [**Hospital1 69**] after
ten days of chest pain and shortness of breath. He was found
to be in atrial fibrillation. On chest x-ray he was found to
be in congestive heart failure as well as showing
cardiomegaly. The patient ruled out for an myocardial
infarction at that time.
Cardiac catheterization on that admission revealed a left
ventricular ejection fraction of 48%, three to four plus
mitral regurgitation, 30% left main coronaries without flow
limiting stenosis.
During that admission also, the patient began to have
complaints of visual field disturbances. An MRI was obtained
which showed a left occipital stroke thought to be due to
embolic events from his atrial fibrillation. Mitral valve
surgery was delayed due to the recent onset of stroke. The
patient's symptoms subsequently improved and the patient is
now being admitted for mitral valve repair.
PAST MEDICAL HISTORY:
1. Mitral regurgitation.
2. Chronic fatigue syndrome.
3. Anemia, microcytic.
4. History of gastrointestinal bleed attributed to NSAIDs.
5. Paroxysmal supraventricular tachycardia times five years.
6. History of sleep apnea.
7. Status post back surgery times two.
8. Status post hemorrhoidectomy.
9. Status post ear surgery.
10. Chronic headache times 35 years.
11. Chronic anxiety disorder.
12. Hypertension.
13. Cerebrovascular disease with a facial droop.
14. History of vertigo.
15. Known cerebral small vessel disease.
PREOPERATIVE MEDICATIONS:
1. Potassium chloride.
2. Atenolol 100 mg p.o. q. day.
3. Ativan 0.5 mg p.o. twice a day.
4. Xanax 0.25 mg p.o. twice a day.
5. Klonopin 0.5 mg p.o. q. h.s.
6. Protonix 40 mg p.o. q. day.
7. Aspirin 81 mg p.o. q. day.
8. Lasix 20 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a history of a remote
alcohol abuse, none in 30 years.
PHYSICAL EXAMINATION: On admission, neurologically, the
patient is grossly intact. Pulmonary: Lungs are clear to
auscultation bilaterally. Heart is irregularly irregular
with III/VI murmur. Abdomen is benign. Extremities are
without edema.
LABORATORY: Carotid ultrasound is without stenosis.
Chest x-ray with no acute disease.
White blood cell count 4.4, hematocrit 33.5, platelet count
196. Sodium 140, potassium 4.0, chloride 104, bicarbonate
20, BUN 26, creatinine 1.4, glucose 90.
HOSPITAL COURSE: The patient was taken to the Operating
Room on [**2115-6-11**] for a mitral valve annuloplasty and a left
heart Maze's procedure. The patient tolerated to procedure
well and was transferred to the Intensive Care Unit in stable
condition. The patient was transferred on Milrinone for a
decreased ejection fraction by echocardiogram seen in the
Operating Room.
Immediately postoperatively the patient was noted to have
large amounts of chest tube drainage. The patient's
coagulopathy was corrected and the patient was subsequently
taken back to the Operating Room for re-exploration for
bleeding. No source was found and the patient was returned
to the Intensive Care Unit in stable condition. Please see
Operative Note for further details.
The patient remained on Milrinone and the patient had been
begun on amiodarone for bursts of atrial fibrillation. A
chest x-ray was obtained on postoperative day number one
which showed what appeared to be a bilateral pleural
effusion. Bilateral chest tubes were placed. Chest tubes
put out minimal amounts and the patient had developed large
amounts of secretions being suctioned from his endotracheal
tube.
It was decided to perform a bronchoscopy on the patient. The
bronchoscopy showed mild white secretions bilaterally. The
patient tolerated this procedure well.
On postoperative day number two, the patient remained
intubated. The patient continued to have episodes of atrial
fibrillation and continued on amiodarone and Milrinone. The
patient was weaned and extubated from mechanical intubation
on postoperative day number two. He tolerated this well.
The Milrinone was weaned to off with an adequate cardiac
index.
It was noted that the patient had a rising BUN and
creatinine. The patient was started on diuretics. On
postoperative day number three, the patient was transferred
from the Intensive Care Unit to the regular floor.
The patient was started on a heparin drip for his continued
atrial fibrillation.
The patient had varying amounts of agitation on transfer to
the floor which was thought to be withdrawal of patient's
preoperative benzodiazepine dosing. The patient was
restarted on all of his benzodiazepines. This improved.
The patient continued to diurese and the patient's
oxygenation improved.
The patient continued to be tachycardic and in atrial
fibrillation. Beta blocker was in place. The patient began
working with Physical Therapy.
On postoperative day number eight, it was noted that while
the patient had rate controlled atrial fibrillation at rest,
the patient had rapid atrial fibrillation with ambulation.
The Electrophysiology Service was consulted and the decision
was made to electrically cardiovert the patient.
The patient was taken to the Electrophysiology laboratory on
[**6-20**], and was electrically cardioverted successfully into
sinus rhythm. The patient tolerated this procedure well.
The patient was transferred back to the Regular floor and the
patient quickly went back in to rapid atrial fibrillation.
Per the recommendation of the Arrhythmia Service, the
patient's beta blocker was increased and the patient
subsequently converted into sinus rhythm. The patient has
remained in sinus rhythm, anti-coagulated on Coumadin and the
patient is cleared for discharge on [**2115-6-22**],
postoperative day number ten.
CONDITION ON DISCHARGE: The patient is awake, alert,
oriented times three, performing all of his activities of
daily living independently, ambulating in the halls with his
wife, neurologically non-focal. Temperature maximum 98.9 F.;
pulse 73 in sinus rhythm; blood pressure 136/72; respiratory
rate 18; oxygen saturation 92% on room air. Heart is regular
rate and rhythm without rub or murmur. Lungs are clear to
auscultation bilaterally without wheezes, rhonchi or rales.
Abdomen is flat, soft, nontender, nondistended. Extremities
are warm and well perfused without edema. Sternal incision
is clean and dry. Sutures are intact without erythema or
drainage. Sternum is stable.
LABORATORY: Data is white blood count of 7.2, hematocrit
31.0, platelet count 414. PT is 19.0, INR 2.4. Sodium 136,
potassium 5.2, chloride 100, bicarbonate 30, BUN 27,
creatinine 1.8, glucose 109.
Chest x-ray shows persistent left lower lobe atelectasis and
a small left pleural effusion.
DISCHARGE MEDICATIONS:
1. Percocet 5/325, one to two tablets p.o. q. four hours
p.r.n.
2. Colace 100 mg p.o. twice a day.
3. Combivent MDI one to two puffs q. six hours.
4. Lorazepam 0.5 mg p.o. three times a day.
5. Protonix 40 mg p.o. q. day.
6. Clonazepam 0.5 mg p.o. q. h.s.
7. Alprazolam 0.25 mg p.o. twice a day.
8. Lopressor 150 mg p.o. twice a day.
9. Amiodarone 400 mg p.o. twice a day.
10. Aspirin 81 mg p.o. q. day.
11. Coumadin 3 mg p.o. on [**8-2**] and [**6-24**]; PT INR to
be checked by visiting nurse on [**6-24**] and results are to be
called to Dr. [**First Name4 (NamePattern1) **] [**Month (only) 18082**] office at [**Telephone/Fax (1) 2660**] for
further Coumadin dosing. Coumadin is to be titrated for an
INR of 2.0 to 2.5.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation status post mitral valve repair.
2. Atrial fibrillation status post Maze's procedure and
status post cardioversion.
3. Postoperative renal insufficiency.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is being discharged to home in
stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], N.P.
MEDQUIST36
D: [**2115-6-21**] 16:58
T: [**2115-6-21**] 19:15
JOB#: [**Job Number 93592**]
Name: [**Known lastname 14751**], [**Known firstname 126**] L. Unit No: [**Numeric Identifier 14752**]
Admission Date: [**2115-6-11**] Discharge Date: [**2115-6-24**]
Date of Birth: [**2041-10-14**] Sex: M
Service: Cardiac Surgery
ADDENDUM FOLLOW UP: The patient should follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2115-6-24**] for Coumadin dosing. The
patient should see Dr. [**First Name (STitle) **] in the office in two weeks for
follow up visit. The patient is to follow up with Dr.
[**Last Name (STitle) **] in one month. The patient will be sent home with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] of Hearts Monitor which should have the results sent to
Dr. [**Last Name (STitle) **] as directed.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern1) 5788**]
MEDQUIST36
D: [**2115-6-21**] 17:04
T: [**2115-6-21**] 19:13
JOB#: [**Job Number 14753**]
|
[
"E878.8",
"424.0",
"401.9",
"511.9",
"427.31",
"518.0",
"998.11",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"34.03",
"34.04",
"99.62",
"37.99",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7794, 7976
|
7037, 7773
|
2694, 6031
|
8674, 9454
|
1793, 2087
|
2201, 2675
|
178, 1212
|
1234, 1767
|
2105, 2177
|
8002, 8662
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,719
| 158,561
|
5482
|
Discharge summary
|
report
|
Admission Date: [**2108-3-20**] Discharge Date: [**2108-3-28**]
Date of Birth: [**2074-1-19**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache.
Major Surgical or Invasive Procedure:
[**3-21**] Right Craniectomy.
History of Present Illness:
This is a 34 year old right handed man with ahistory of HTN who
was transferred
from an outside hospital with L MCA stroke.
He initially presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with right sided weakness
and a headache. Initial head CT was normal and LP was performed
which showed elevated protein of >200 he was then admitted to
the floor. He had MRI which was reportedly negative for stroke
and his R sided weakness appeared to have resolved. He later was
found to have a left hemiplegia with right eye deviation and
dysarthria. Repeat head CT showed dense R MCA infarfct with
subsequent MRI showing acute infarct of R MCA territory.
Telephone discussion with a [**Hospital1 18**] stroke fellow (Dr. [**Last Name (STitle) 22158**] to
the decision to give the patient IVtPA around 6:15pm. He was
then then med-flighted to [**Hospital1 18**] for further
evaluation/treatment.
Per patient, he awoke this morning with HA and visual field
defect with R side weakness. He reports that the vision deficit
and weakness has lessened but he still has pressure like
headache over the R temple.
He denies any recent chest pain, racing heart, fever/chills,
cough, N/V/D, abdominal pain and/or injury/falls.
Past Medical History:
1. HTN
2. Fibromyalgia
3. Pseudoseizures
4. Dyslipidemia
- HTN
- HLD
- asthma
- h/o seizures during benzo withdrawal
- idiopathic gastroparesis
- anxiety/depression
- fibromyalgia
Social History:
Lives alone and was working as a auto-mechanic but currently
unemployed. Smokes 1 PPD.
Family History:
Multiple members with stroke including aunt and uncle.
Physical Exam:
On Admission:O: T: BP: 158/112 HR: 62 R: 14 O2Sats: 99% NC
Gen: Mildly sleepy appearing but NAD.
HEENT: Pupils: 3->2mm
Neck: No carotid bruits noted.
Lungs: Clear.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ and no abdominal bruit noted.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Mildly sleepy but eyes open spontaneously.
Orientation: Oriented to person, [**Hospital3 **] Hospital but thinks
its [**2107-4-23**]. Knows [**First Name9 (NamePattern2) 17812**] [**Last Name (un) 2753**] is the president.
Language: Speech fluent with intact repetition. Mildly slow
with
latency and mild/moderate dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. ? L field cut/neglect.
III, IV, VI: Extraocular movements intact bilaterally.
V, VII: L facial droop although does not cooperate when asked to
show me his teeth or smile.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Appears to have near full strength of RUE but R IP [**3-27**].
LUE is plegic with some extensor posturing to noxious stim and
triple flexion of LLE with noxious stim.
Sensation: Appears intact on R but neglects the L. When
touching
both sides, he reports only R and when touching the L side, he
still reports R side.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 0 0 0 1 1
Toes downgoing on R but up on L.
On Discharge:
On the day of discharge he was alert and attentive to events in
the room. He was non-verbal but said his last name once to the
nurse on the morning of discharge. He will show finger on the
right, or a thumb to command. He did not exhibit gaze
preference. Pupils were symmetrically reactive. His eye
movements were conjugate, full. Face shows asymmetry with left
facial droop. Tone in flaccid on the left and there is no
movement. He spontaneous and puposively moves the right, which
is antigravity and likely full strength (poor effort on strength
exam and not always following commands). Relexes were coming up
on the left prior to discharge. his left great toe goes up.
Pertinent Results:
[**3-20**] Brain perfusion - 1. Large right MCA territory infarct with
no evidence of hemorrhage.
2. The mid right M1 segment is occluded with extension to M2
branches.
3. Irregularity along the posteromedial wall of the proximal
right internal carotid artery with surrounding increased
attenuation may represent a focal dissection or, less likely, an
ulcerated plaque. This may have been a source of embolus.
4. Symmetric abnormality on the MTT, CBV and CBF maps.
[**3-20**] CT head/neck - 1. Large right MCA territory infarct with no
evidence of hemorrhage.
2. The mid right M1 segment is occluded with extension to M2
branches.
3. Irregularity along the posteromedial wall of the proximal
right internal carotid artery with surrounding increased
attenuation may represent a focal dissection or, less likely, an
ulcerated plaque. This may have been a source of embolus.
4. Symmetric abnormality on the MTT, CBV and CBF maps.
[**3-21**] Ct head - 1. The previously hypodense right lentiform
nucleus has interval increase in attenuation to now hyperdense,
with the affected area measuring 3.4 x 1.4 cm. Similar increase
of attenuation is also noted in the right periventricular white
matter. While this could represent retained contrast from the
CTA/CTP
study five hours ago, interval hemorrhagic conversion cannot be
excluded.
2. Persistent mass effect with near complete effacement of the
right frontal [**Doctor Last Name 534**], but no gross midline shift. No developing
hydrocephalus.
3. No evidence of subarachnoid hemorrhage or intraventricular
hemorrhagic
extension.
[**3-21**] Brain MRI - Continued maturation of large right MCA
territory infarction with hemorrhagic transformation within the
right putamen. While this examination did not include an MR
angiogram, there is suggestion of interval recanalization of the
right M1 segment which has a probable flow void.
[**3-21**] CT Head - Interval increase in the hemorrhage within the
known large right MCA territory infarct, with increased mass
effect and leftward shift of midline structures and mild uncal
henriation. No evidence of transtentorial herniation.
[**3-21**] CXR - Cardiomediastinal contours are normal. ET tube is in
standard position. The tip is 2.9 cm above the carina. NG tube
tip is in the stomach, the side port is just distal to the GE
junction. Right IJ catheter tip is in the lower SVC. There is no
pneumothorax or pleural effusion. There is mild vascular
congestion.
Right lower lobe atelectasis has improved. Left perihilar and
left lower lobe atelectases are increasing.
[**3-22**] Ct head - 1. Interval right hemicraniectomy. Mildly
decreased leftward shift, from 13 mm to now 10 mm. Unchanged
right frontal [**Doctor Last Name 534**] effacement and mass effect.
3. Similar large ill-defined hemorrhagic focus centered at the
right basal
ganglia, with extensive hypodensity along the right MCA
distribution, may
relate to edema, ischemia or post-surgical changes.
4. Unchanged small intraventricular hemorrhage in the right
occipital [**Doctor Last Name 534**].
[**2108-3-22**]
Cardiomediastinal contours are normal. ET tube is in standard
position. The tip is 2.9 cm above the carina. NG tube tip is in
the stomach, the side port is just distal to the GE junction.
Right IJ catheter tip is in the lower SVC. There is no
pneumothorax or pleural effusion. There is mild vascular
congestion.
Right lower lobe atelectasis has improved. Left perihilar and
left lower lobe atelectases are increasing
CT Head [**2108-3-24**]
FINDINGS: Overall, there is no significant interval change.
There is a large parenchymal hemorrhage in the right frontal
lobe, with surrounding vasogenic edema and mass effect on the
right lateral ventricle. There is a stable 8-mm leftward shift
of midline structures, and similar right transgaleal brain
herniation. There is a stable small amount of intraventricular
hemorrhage seen layering in bilateral posterior horns. There is
persistent air and blood superficial to the dural flap and
similar appearance of the subcutaneous hematoma. There is no
evidence of uncal herniation. The ventricles are stable in size
and configuration. There is air-fluid level in the sphenoid
sinus.
IMPRESSION: Overall, no significant interval change.
1. Stable large right frontal hemorrhage with vasogenic edema.
Stable mass
efect.
2. Stable intraventricular hemorrhage in bilateral occipital
horns.
3. Stable subcutaneous hematoma at the craniectomy site.
CXR [**2108-3-27**]
FINDINGS: As compared to the previous radiograph, there is no
relevant change. No endotracheal tube is seen on today's image.
Normal course of the nasogastric tube. The tip of the tube is
not seen on the image. Right internal jugular vein catheter with
projection of the tip over the mid-to-low SVC. Borderline size
of the cardiac silhouette. No pulmonary edema. No pleural
effusion. No pneumonia.
Brief Hospital Course:
Stroke
[**Known firstname **] [**Known lastname 22159**] was admitted as a OSH transfer after an MRI
demonstrated an acute Right MCA infarct. He was given tPA and
transferred here for further care. He was admitted to the ICU
and was started on mannitol for ICP control. He developed
hypoxia from aspiration and from a failure to protect his
airways and was intubated on a non-emergent basis. Numerous
hypercoagulable labs pending. Homocysteine was elevated and
dyslipidemia and hypertension are present. We will need to
follow pending results. We have continued his statin and
aspirin. He should follow-up in clinic with Dr. [**Last Name (STitle) **] in two
months. Given hemorrhagic conversion, aspirin and heparin were
briefly held until the bleed was stable. He was also started on
Keppra [**Hospital1 **] for seizure rpophylaxis.
Craniectomy
On [**3-21**] Patient developed increasing lethargy and a head Ct
obtained demonstrated interval increase of rigth cerebral edema
with midline shift and right uncas was trending downwards. He
was intubated for airway protection. Neurosurgery called and
patient was taken to the OR for emergent Decompressive right
craniectomy on the evening of [**3-21**]. He tolerated the procedure
well without intraoperative complications. Please review
dictated operative report for details. He remained intubated
and was transferred to SICU for further management. He will need
cranioplasty in one to two months - he will follow-up with
neurosurgery.
Mutism
There is no neurologic reason for this, although it is possible
that edema of the supplementary motor area might contribute. We
think that this is possibly reactive and psychologic in this
setting, particularly given that he was able to utter some words
to his nurse.
Pneumonia
Ceftriaxone was chosen given likely community origin. His chest
x-ray reveals questionable infiltrate without frank pneumonia.
his respiratory status has been excellent without significant
coughing. If his respiratory status worsens, nosocomial coverage
would be indicated. Ceftriaxone should continue until [**2108-4-3**].
Intubation
He was extubated on [**2108-3-27**].
Fever
He was persistently febrile with fever typically lower than 101.
This was attributed as central given surgery, stroke and
persistence despite few other data supporting infection. We
would not recommend broadening antibiotic coverage on the basis
of fever less than 101 alone, but only if there is other
evidence of infection.
Medications on Admission:
- Klonpin 2mg BIS
- Metoprolol 100mg qd
- Simvastatin 80mg qd
- Lisinopril 20mg qd
- Reglan 10mg qd
Discharge Medications:
1. CeftriaXONE 1 gm IV Q24H
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. LeVETiracetam 1000 mg IV BID
5. HydrALAzine 10 mg IV Q6H:PRN SBP > 140
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
8. fluoxetine 20 mg/5 mL Solution Sig: One (1) PO DAILY
(Daily).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for pain.
13. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for to
bm.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Rehabillatation
Discharge Diagnosis:
Right MCA stroke
Itraparenchymal Hemorrhage
Exacerbation of Seizure Disorder
Pneumonia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Not speaking at present. Please see discharge summary for full
description.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to [**Hospital1 22160**] transferred from another hospital, after
having a stroke. You have elevated cholesterol and high blood
pressure, along with elevated homocysteine. Some further
laboratory results are pending. You are now medically safe to go
to rehabilitation.
General Instructions (post operatively)
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after staples have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on as you already have
?????? 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**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
Please call registration on ([**Telephone/Fax (1) 22161**] before your
appointment to update your address and insurance details.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2108-6-5**]
2:30
This will be at [**Hospital1 18**], [**Location (un) 86**], [**Hospital Ward Name 23**] Building, Level 8.
??????Please return to the office in [**7-1**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"V17.1",
"401.9",
"729.1",
"784.3",
"V45.88",
"998.12",
"780.39",
"507.0",
"518.0",
"781.94",
"438.89",
"272.4",
"E878.8",
"787.22",
"431",
"784.59",
"348.5",
"518.82",
"493.90",
"536.3",
"270.4",
"434.11",
"342.90",
"300.4",
"564.00",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"01.25",
"96.72",
"38.93",
"38.91",
"88.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12634, 12699
|
9013, 11498
|
314, 345
|
12830, 13023
|
4110, 8990
|
15248, 16285
|
1941, 1997
|
11648, 12611
|
12720, 12809
|
11524, 11625
|
13047, 15225
|
2012, 2012
|
3418, 4091
|
265, 276
|
373, 1614
|
2651, 3404
|
2025, 2291
|
2306, 2635
|
1636, 1819
|
1835, 1925
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,926
| 128,452
|
22697
|
Discharge summary
|
report
|
Admission Date: [**2189-3-23**] Discharge Date: [**2189-3-29**]
Date of Birth: [**2144-6-13**] Sex: F
Service: PSU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 44-year-old
female with a history of right breast cancer. She is negative
for the BRCA gene, but has a family history of bilateral
breast cancer. She, therefore, presents for bilateral
mastectomies with bilateral [**Last Name (un) 5884**] flap reconstruction.
PAST MEDICAL HISTORY: Significant for right breast cancer
(DCIS). She also has a history of depression.
PAST SURGICAL HISTORY: Significant for breast biopsies x2,
laparoscopies x2, and the bone graft.
ALLERGIES: Penicillin.
MEDICATIONS AT HOME:
1. Prozac 20 mg p.o. daily.
2. Clonazepam 1 mg p.o. at bedtime.
SOCIAL HISTORY: The patient denies alcohol use and no longer
smokes cigarettes, but has a history of tobacco use.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the plastic surgery service on [**2189-3-23**]. She
underwent bilateral mastectomies and bilateral breast
reconstruction using [**Last Name (un) 5884**] flaps. For further information on
these surgeries, please see associated operative notes. The
patient was admitted to the intensive care unit after surgery
for close monitoring and flap checks every half an hour to 1
hour.
She was stable in the postoperative period. She was kept in
the intensive care unit for close monitoring until [**3-27**].
When she was on the floor, she was tolerating a regular diet,
her pain was well-controlled, and her flaps were well-
perfused. The patient initially was on bedrest after the
surgery, but within a few days after surgery was able to get
out of bed to a chair and then ambulate. Each day, her flaps
continued to be well-perfused, and the incisions were clean,
dry and intact. She had 4 JP drains in place, 1 in each flap,
and 1 in each side of the abdomen. These continued to put out
small amounts of serosanguineous discharge throughout her
stay.
On [**3-29**], the patient was tolerating a regular diet, her
pain was well-controlled, she was ambulating well, and she
desired to go home. After discussion with her breast surgeon
and plastic surgeon, the decision was made to send the
patient home. She will go home with the drains in place and
will return to clinic in a week's time for evaluation of the
drains, as well as the incisions.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: To home.
DISCHARGE DIAGNOSES:
1. Right breast cancer.
2. Status post bilateral mastectomies with bilateral deep
inferior epigastric perforator flap reconstruction.
DISCHARGE MEDICATIONS:
1. Colace 100 mg capsule 1 capsule p.o. b.i.d. while taking
pain medications.
2. Fluoxetine 20 mg 1 capsule p.o. daily.
3. Aspirin 81 mg tablet, 1.5 tablets p.o. daily.
4. Clonazepam 1 mg tablet, 1 tablet p.o. at bedtime.
5. Percocet 5/325 mg tablet 1-2 tablets p.o. q 4-6 h. p.r.n.
pain.
6. Clindamycin 300 mg capsules, 1 capsule p.o. t.i.d. for 10
days.
DISCHARGE INSTRUCTIONS: The patient will follow-up with Dr.
[**First Name (STitle) 3228**] in 1 week. She should call for an appointment. She
will also follow-up with Dr. [**Last Name (STitle) 10656**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2189-3-29**] 10:07:44
T: [**2189-3-30**] 13:02:33
Job#: [**Job Number 58787**]
|
[
"998.12",
"174.8",
"E878.6",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.36",
"85.7",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
2446, 2456
|
2415, 2422
|
2477, 2616
|
2639, 3007
|
3032, 3487
|
709, 775
|
588, 688
|
926, 2393
|
165, 458
|
481, 564
|
792, 897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,957
| 156,760
|
35885
|
Discharge summary
|
report
|
Admission Date: [**2163-12-20**] Discharge Date: [**2163-12-30**]
Date of Birth: [**2082-8-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**12-26**] Off Pump Coronary Artery Bypass Graft x 1
[**12-21**] Right groin exploration with femoral thrombectomy,
iliofemoral endarterectomy and patch angioplasty, angiogram with
bilateral catheterization and right external iliac stenting
History of Present Illness:
81 y/o female with new onset shortness of breath. Ruled out for
myocardial infarction but underwent cardiac cath which revealed
three vessel coronary artery disease. Transferred from OSH for
surgical revascularization.
Past Medical History:
Diabetes Mellitus, Chronic kidney disease, Osteoarthritis,
Hyperlipidemia, s/p cholecystectomy, s/p hysterectomy, s/p
partial colectomy, s/p colovesicular fistual repair
Social History:
Quit smoking 5 years ago. Denies ETOH use. Lives alome.
Family History:
Noncontributory.
Physical Exam:
VS:70 14 136/58
Gen: Well-appearing in no acute distress
HEENT: Unremarkable
Neck: Supple, Full range of motion
Chest: Clear to auscultation bilat.
Heart: Regular rate and rhythm, -murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: LLE Warm, well-perfused, but RLE cooler (pt. c/o cramping,
tingling) -edema
Staples in right groin.
Neuro: Grossly intact
Pertinent Results:
[**12-26**] Echo: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. Left ventricular wall thicknesses and
cavity size are normal. Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Post OP
CABG: No change in ventricular or ventricular function during
anf after the off-pump LIMA to LAD anastomosis
[**12-22**] CT: 1. 4-mm right upper lobe irregular opacity could be
atelectasis, scarring adjacent to old impaction or a growing
lesion, should be followed in six months. One followup should be
sufficient to exclude a growing lesion. 2. Severe ascending
aorta calcifications. No aortic valvular calcification. 3.
Displaced descending aortic calcification could be due to old
dissection versus calcified thrombus. 4. Mild volume overload,
bilateral small pleural effusion and dependent atelectasis.
Small pericardial effusion. 5. Moderate emphysema and diffuse
bronchial wall thickening, suggesting chronic bronchitis. 6.
4-mm right upper lobe irregular opacity could be atelectasis,
scarring adjacent to old impaction or a growing lesion, should
be followed in six months. One followup should be sufficient to
exclude a growing lesion. 7. Kidney punctate calcifications, old
scarring and hypodensities, should be evaluated by ultrasound,
incompletely evaluated in this study.
[**12-22**] Carotid U/S: 1. 60-69% stenosis in the right internal
carotid artery. 2. 80-99% stenosis in the left internal carotid
artery.
[**2163-12-26**] 01:08PM BLOOD PT-15.1* PTT-30.9 INR(PT)-1.3*
[**2163-12-30**] 05:30AM BLOOD Glucose-49* UreaN-10 Creat-0.9 Na-139
K-3.7 Cl-100 HCO3-28 AnGap-15
[**Known lastname **],[**Known firstname **] [**Medical Record Number 81540**] F 81 [**2082-8-5**]
Radiology Report CHEST (PA & LAT) Study Date of [**2163-12-29**] 9:55 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2163-12-29**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81541**]
Reason: check ptx
Final Report
HISTORY: Check pneumothorax.
CHEST, TWO VIEWS.
The lungs are hyperinflated and diaphragms flattened, consistent
with COPD.
The patient is status post sternotomy. There is mild
cardiomegaly, with
calcified unfolded aorta. There is a small-to-moderate sized
left
pneumothorax, with a small left effusion, consistent with a
hydropneumothorax.
Compared with [**2163-12-28**] at 13:32 p.m., the left apical
pneumothorax is somewhat
larger. There is mild prominence of interstitial markings, which
may reflect
background parenchymal scarring. There is a tiny right effusion.
There is
minimal patchy increased retrocardiac density, essentially
unchanged, without
frank consolidation. This likely represents some residual
atelectasis.
IMPRESSION:
Slight interval increase in the size of the left pneumothorax,
with small left
effusion (hydropneumothorax).
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: [**Doctor First Name **] [**2163-12-29**] 4:10 PM
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 57323**] was transferred from an
[**Hospital 81542**] hospital for coronary bypass surgery. Upon admission she
was appropriately worked up for surgery. During physical exam
her right lower extremity (right femoral artery used for cath)
appeared to be cooler to touch with no distal pulses and absence
of Doppler signal. Vascular surgery was consulted due to
presumed ischemic right leg. She was emergently taken to the
operating room for right groin exploration with femoral
thrombectomy, iliofemoral endarterectomy and right external
iliac stenting. Please see operative note for surgical details.
Following surgery she was transferred to the CVICU. She was
continued on a Heparin drip and on post-op day one she was
transferred to the telemetry floor for further care. Patient
remained stable while recovering on the floor for several days
with daily input from vascular. Additional tests were performed
(CT and carotid u/s), please see reports for details. On [**12-26**]
she was brought back to the operating room where she underwent a
off pump coronary artery bypass graft. Please see operative note
for surgical details. Following surgery she was transferred to
the CVICU for invasive monitoring.
She was transferred to the step down floor on POD 1. Chest tubes
and pericardial wires were removed per usual protocol. She was
gently diuresed towards her pre-operative weight. Physical
therapy was consulted to work on strength and mobility. She
continued to improve and was discharged to rehab on #4 in stable
condition.
Medications on Admission:
At home (but non-compliant): Aspirin, Glyburide, Enalapril,
Lipitor
At transfer: Aspirin 81mg qd, Colace 100mg [**Hospital1 **], Glyburide 10mg
[**Hospital1 **], Heparin 5000untis SC q8, Novolog SS, Lantus 11units qhs,
Lisinopril 20mg qd, Lopressor 25mg [**Hospital1 **], Zocor 80mg qd
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) PO Q12H (every
12 hours) for 5 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
Coronary Artery Disease s/p Off Pump Coronary Artery Bypass
Graft x 1
Acute ischemia right lower leg s/p Femoral thrombectomy,
iliofemoral endarterectomy and right external iliac stenting
PMH: Diabetes Mellitus, Chronic kidney disease, Osteoarthritis,
Hyperlipidemia, s/p cholecystectomy, s/p hysterectomy, s/p
partial colectomy, s/p colovesicular fistual repair
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 81543**] in [**2-2**] weeks
Dr. [**Last Name (STitle) **] in 2 weeks for coronary artery stenting in 4 weeks.
Dr. [**Last Name (STitle) **] in 1 week for staple removal and carotid stenosis
evaluation.
Completed by:[**2163-12-30**]
|
[
"433.10",
"998.2",
"E879.0",
"429.9",
"433.30",
"250.00",
"715.90",
"440.0",
"997.2",
"585.9",
"272.4",
"440.20",
"443.22",
"444.22",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.18",
"00.45",
"00.41",
"39.90",
"00.44",
"39.50",
"88.47",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7776, 7853
|
4952, 6528
|
342, 585
|
8259, 8265
|
1535, 4929
|
9042, 9343
|
1115, 1133
|
6864, 7753
|
7874, 8238
|
6554, 6841
|
8289, 9019
|
1148, 1516
|
283, 304
|
613, 833
|
855, 1026
|
1042, 1099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,789
| 191,112
|
24698+57430
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-3-15**] Discharge Date: [**2123-3-19**]
Date of Birth: [**2045-5-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
CABG x3/ placement of epicardial leads [**2123-3-15**]
History of Present Illness:
77 yo male admitted to OSH in [**10-7**] for back pain, anemia, and +
troponins. Transferred to [**Hospital1 18**] where cath showed severe 3VD.
Workup also revealed a colon cancer and he underwent right
hemicolectomy . He now presents for CABG with Dr. [**Last Name (STitle) **].
Past Medical History:
1. NIDDM, not on meds
2. Low back pain
3. BPH
4. CHF
5. colon Ca/ colectomy
Social History:
lives alone, has lots of stairs at home, falls often. Drinks at
least [**3-6**] drinks per day. Smoked heavily until 20 years ago. No
illicits.
Family History:
Noncontributory
Physical Exam:
HR 66 right 126/70 left 131/64
70" 135#
elderly, pale -appearing
warm, very thin
PERRL, anicteric sclera, oropharynx benign
no JVD, loud left carotid bruit, ? soft left bruit
RRR grade [**1-4**]/ 6 SEM
lungs CTAB with varicosities traversing thin chest wall
well-healed RLQ scar + BS, soft, NT, ND
extrems warm, well-perfused, 1+ LE edema, no obvious
varicosities
2+ fem/DP pulses; 1+ PT pulses
neuro grossly nonfocal, walks with walker, gait poor, [**4-7**] Bil.
strengths
Pertinent Results:
[**2123-3-18**] 06:10AM BLOOD WBC-9.1 RBC-3.43* Hgb-10.6* Hct-30.8*
MCV-90 MCH-31.0 MCHC-34.5 RDW-15.3 Plt Ct-160
[**2123-3-18**] 06:10AM BLOOD Plt Ct-160
[**2123-3-18**] 06:10AM BLOOD Glucose-143* UreaN-22* Creat-0.9 Na-141
K-4.7 Cl-108 HCO3-25 AnGap-13
[**Known lastname **],[**Known firstname **] J: [**Hospital1 18**] Cath Detail - CCC Record #[**Numeric Identifier 62308**]
[**Numeric Identifier 62309**] - CCC
PROCEDURE DATE: [**2122-11-3**]
INDICATIONS FOR CATHETERIZATION: Coronary artery disease, aortic
stenosis, left ventricular systolic dysfunction, preop for
colectomy.
FINAL DIAGNOSIS:
1. Low normal filling right- and left-sided filling pressures.
COMMENTS:
Right heart catheterization demonstrated reduced filling
pressures
consistent with hypovolemia. The right atrial and PCW filling
pressures
were low normal (4 and 6 mmHg), respectively. There was no
pulmonary
arterial hypertension. Using an assumed oxygen consumption, the
cardiac
index (based on finger oximetry) was slightly depressed at 2.3
L/min/m2.
The PA catheter was secured in place with a protective sleeve.
There
was no evidence of pneumothorax on fluoroscopy.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 30 minutes.
Arterial time = 0 minutes.
Fluoro time = 2 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 0 ml
Premedications:
Versed 0.5 mg IV
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation: none
[**Known lastname **],[**Known firstname **] J:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 62308**]
FINAL REPORT
CAROTID SERIES COMPLETE
REASON: Bruit.
FINDINGS: Duplex evaluation _____ both carotid arteries.
Moderate plaque was
identified on the left. This is homogeneous.
On the right, peak systolic velocities are 86, 58, 103 in the
ICA, CCA, ECA
respectively. The ICA to CCA ratio is 1.5. This is consistent
with less than
40% stenosis.
On the left, peak systolic velocities are 180, 68, 270 in the
ICA, CCA, ECA
respectively. The ICA to CCA ratio is 2.6. This is consistent
with a 60-69%
stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Moderate left-sided plaque with a 60-69% carotid
stenosis. On
the right, there is a less than 40% stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2123-3-13**] 2:00 PM
Procedure Date:[**2123-3-8**]
Brief Hospital Course:
Admitted [**3-15**] and underwent cabg x3 (LIMA to LAD, SVG to OM, SVG
to PDA)/ and LV lead placement with Dr. [**Last Name (STitle) **]. Transferred to
the CSRU in stable condition on epinephrine, nitroglycerin, and
propofol drips. Extubated that evening, and remained on insulin
and neo drips. These were weaned off and he was transferred to
the floor that evening. He began gentle diuresis and beta
blockade. Chest tubes were removed on POD #2. He failed to void
on POD #3 and his foley was reinserted ( leg bag). He was
followed by Dr.[**Name (NI) 10529**] urology service, and will need to see him
when discharged from rehab. The patient must also see Dr. [**Last Name (STitle) **]
from the EP service in a couple of weeks to schedule device
placement. Pacing wires were removed and he continued to make
good progress on the floor. He was cleared for discharge to
rehab on POD #4 in stable condition.
Medications on Admission:
ASA 81 mg daily
lopressor 25 mg [**Hospital1 **]
lipitor 40 mg daily
flomax 0.4 mg daily
metformin 850 mg [**Hospital1 **]
colace 100 mg [**Hospital1 **]
prevacid 20 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
11. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
s/p cabg x3/placement of epicardial leads on [**3-15**]
CHF
colon CA/s/p hemicolectomy
BPH/urinary retention
Discharge Condition:
stable
Discharge Instructions:
may shower over incision and pat dry
no driving for one month
no lotions, creams, or pwders on any incision
no lifting greater than 10 pounds for 10 weeks
call for fever, redness, or drainage
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**1-4**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**2-5**] weeks
follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
follow up with Dr. [**Last Name (STitle) **] ( urology) [**Telephone/Fax (1) 921**] when discharged
from rehab
Completed by:[**2123-3-19**] Name: [**Known lastname 11249**],[**Known firstname **] J Unit No: [**Numeric Identifier 11250**]
Admission Date: [**2123-3-15**] Discharge Date: [**2123-3-19**]
Date of Birth: [**2045-5-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4551**]
Addendum:
PMH also includes :
pacer placement [**10-7**] with hx of type 2 HB/bradycardia
elev. chol.
HTN
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4426**] Rehab & Nursing Center - [**Hospital1 3983**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2123-3-19**]
|
[
"600.01",
"V15.82",
"440.0",
"272.0",
"V10.05",
"V45.01",
"428.0",
"250.00",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"36.15",
"36.12",
"89.60",
"37.74",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7580, 7827
|
3957, 4865
|
334, 391
|
6458, 6467
|
1509, 1958
|
6707, 7557
|
979, 996
|
5090, 6193
|
6326, 6437
|
4891, 5067
|
2110, 2653
|
6491, 6684
|
1011, 1490
|
2672, 3934
|
1991, 2093
|
282, 296
|
419, 701
|
723, 801
|
817, 963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,484
| 192,121
|
4637
|
Discharge summary
|
report
|
Admission Date: [**2110-8-28**] Discharge Date: [**2110-9-7**]
Date of Birth: [**2058-4-16**] Sex: M
Service: MEDICINE
Allergies:
Biaxin / latex
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
DKA, NSTEMI
Major Surgical or Invasive Procedure:
Serial Angiogram of left lower extremity
History of Present Illness:
Mr. [**Known lastname 19650**] is a 52 year old man with a history of CAD s/p 2v-CABG
in [**2100**] (LIMA to LAD, RIMA to PDA at [**Hospital1 2177**]) and recent NSTEMI at
[**Hospital1 112**] in [**5-/2110**], HTN, hyperlipidemia, peripheral vascular disease
c/b R BKA and L fem-pedal bypass, T1DM who was recently started
on HD after an episode of pneumosepsis ([**4-/2108**] transferred from
OSH in DKA and conern for left lower extremity infection.
.
Patient was directly admittd to the MICU where he was alert and
oriented. He was tachycardic to 109, BP 146/77, O2 sat 98% on
room air. He was noted to have black necrotic ulcer on his left
heel without evidence of drainage or sinus tracts to bone.
.
Of note, he was having low grade fevers at home, with BS in
500s. He was admitted with AG MA (24) and hyperglycemia to 500s,
consistent with DKA in setting of possible foot osteomyelitis.
In terms of foot infection, he was seen by podiatry in his MICU
course who felt that based on imaging and clinical picture
patient did not have oseto. He had been on Vanc/Zosyn in the
MICU for presumed infection but given that patient was afebfile,
WBC downtredning, no growth in the blood culture antibiotics
were dced after 2 days. Patient has remained afebrile. Wound
culture from the the left foot ulcer is currently growing coag
positive staph. Being followed by podiatry and vascular
surgery.
.
In terms of his DKA, he was started on insuslin drip in the MICU
and his gap has closed. He is currently dialysis dependent and
does not make urine. Renal is following patient.
.
On admission patient also complained of chest pain and found to
have NSTEMI with elevated troponins. Cath was deffered given
his other active medical issues. He was treated medically with
heparin and started on plavix. Currently patient denies any
further chest pains and his troponins have coniuned to trend
down.
.
Finally patient also complained of diffuse joint pain with
swollen joint. Arthorocensteis was unsuccessful and patient has
been started on prednisone for management of inflammaotry
arthorpathy,
.
Of note, In [**4-/2110**] he was hospitalized for an NSTEMI, pneumonia
and acute kidney injury at [**Hospital1 112**]. He was transferred from an OSH
for hypoxemic respiratory failure and was found to have
bilateral lower lobe consolidations. He was intubated for 1 week
and developed ARDS. Dialysis was initiated for kidney injury. He
had a PEA arrest after his NSTEMI while hospitalized. He spent
one month in rehab after that were he developed the left heel
ulcer. His neck and arm pain started in rehab as well. He says
that he has tried multiple drugs for the pain (gabapentin,
neurontin) but only oxycodone 40 mg q4hr helps the pain.
.
On trasnfere to medicine floor patient denies any chest pain or
SOB. Complains of pain in his foot and his hands which he
reports have improved since being on steriods. Denies
prodcutive cough wheezing, dyrusia, diarrhea.
Past Medical History:
1. CAD s/p 2v-CABG at BCM in [**2100**] (LIMA to LAD, RIMA to PDA)
2. Hypertension
3. Hyperlipidemia
4. Peripheral arterial disease c/b R BKA and L fem-pedal bypass
5. T1DM c/b several episodes of DKA
6. Diabetic nephropathy c/b ESRD now on HD (TRS)
7. s/p L eye resection for retinopathy
8. s/p CVA after CABG, recovered
9. h/o hypoxemic respiratory failure from PNA, ARDS
10. h/o PEA arrest from massive aspiration
11. s/p J-tube, now removed.
Social History:
- Lives at home with fiancee. Unemployed.
- Denies alcohol, tobacco, illicit drug use.
Family History:
DM1 in father, grandfather, grandmother
Physical Exam:
MICU Physical Exam
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, prosthetic left
eye
Neck: supple, JVP not elevated, no LAD. R subclavian tunneled
catheter with dry skin and some erythema around insertion site,
nontender.
CV: tachycardic, regular 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: R BKA. left extremity warm with 1+ DP pulse, PT
dopplerable. No edema. Well perfused. Large black ulcer on left
heel. No drainage or sinus tracts to bone.
Neuro: Grossly intact. Moving all four extremities. Left lower
extremity decreased sensation to ankles.
.
Discharged Physical Exam:
Vitals: 98.8 112/86 100%RA
General: Alert, interactive, appropriate
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA bilaterally w/o crackles or wheezing
Ab: Positive BS??????s, NT/ND,
Ext: No c/c/e on upper extremities, left foot wrapped, s/p right
BKA
MSK: Contratures in the right hand and diffuse muscle atropy.
Neuro: Alert, appropriately oriented, no focal motor deficits
noted on limited exam
Pertinent Results:
Admission/Pertinent Labs:
[**2110-8-28**] 06:15PM BLOOD WBC-13.9*# RBC-2.88*# Hgb-8.5*#
Hct-27.2*# MCV-95# MCH-29.5 MCHC-31.2 RDW-15.9* Plt Ct-505*#
[**2110-8-30**] 11:55AM BLOOD WBC-14.2* RBC-3.36* Hgb-9.9* Hct-30.8*
MCV-92 MCH-29.5 MCHC-32.2 RDW-16.8* Plt Ct-473*
[**2110-9-4**] 07:22AM BLOOD WBC-9.7 RBC-3.47* Hgb-10.2* Hct-32.6*
MCV-94 MCH-29.4 MCHC-31.3 RDW-16.6* Plt Ct-527*
[**2110-8-28**] 06:15PM BLOOD PT-12.4 PTT-29.2 INR(PT)-1.1
[**2110-8-29**] 12:30AM BLOOD ESR-150*
[**2110-9-1**] 03:04AM BLOOD ESR-131*
[**2110-8-28**] 06:15PM BLOOD Glucose-487* UreaN-62* Creat-3.5*#
Na-127* K-4.6 Cl-83* HCO3-21* AnGap-28*
[**2110-8-29**] 06:55AM BLOOD Glucose-149* UreaN-58* Creat-2.9* Na-138
K-4.6 Cl-99 HCO3-25 AnGap-19
[**2110-9-2**] 03:07AM BLOOD Glucose-169* UreaN-58* Creat-2.9* Na-136
K-4.7 Cl-97 HCO3-28 AnGap-16
[**2110-9-5**] 06:25AM BLOOD Glucose-221* UreaN-32* Creat-2.0* Na-132*
K-4.2 Cl-90* HCO3-34* AnGap-12
[**2110-8-28**] 06:15PM BLOOD ALT-13 AST-14 CK(CPK)-32* AlkPhos-239*
TotBili-0.2
[**2110-8-31**] 03:54AM BLOOD ALT-22 AST-22 LD(LDH)-198 CK(CPK)-31*
AlkPhos-337* TotBili-0.2
[**2110-8-28**] 06:15PM BLOOD CK-MB-3 cTropnT-0.22*
[**2110-8-29**] 06:55AM BLOOD CK-MB-39* MB Indx-14.2* cTropnT-1.65*
[**2110-8-29**] 06:00PM BLOOD CK-MB-13* cTropnT-2.58*
[**2110-9-2**] 03:07AM BLOOD CK-MB-3 cTropnT-1.64*
[**2110-9-3**] 07:00AM BLOOD CK-MB-3 cTropnT-1.99*
[**2110-8-29**] 12:30AM BLOOD Calcium-9.2 Phos-5.2* Mg-1.8
[**2110-9-6**] 07:45AM BLOOD Albumin-2.9* Calcium-8.9 Phos-3.3 Mg-1.9
[**2110-8-29**] 02:11AM BLOOD %HbA1c-7.5* eAG-169*
[**2110-9-3**] 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2110-9-1**] 03:04AM BLOOD RheuFac-24* CRP-172.1*
[**2110-9-3**] 07:00AM BLOOD HCV Ab-NEGATIVE
[**2110-9-1**] 03:04AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test
.
Blood Culture, Routine (Final [**2110-9-3**]): NO GROWTH.
.
GRAM STAIN (Final [**2110-9-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2110-9-6**]): Taken from left foot ulcer skin
surface
STAPH AUREUS COAG +. HEAVY GROWTH.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2110-9-5**]): NO ANAEROBES ISOLATED.
.
Blood Culture, Routine (Final [**2110-9-8**]): NO GROWTH.
.
Blood Culture, Routine (Pending): Drawn [**9-4**]: Pending
.
CXR: [**2110-8-28**]
IMPRESSION: Perihilar and bibasilar opacities most suggestive of
pulmonary edema especially given rapid onset since the exam from
earlier the same day.
.
Hand X-ray:
FINDINGS: Extensive vascular changes raise the possibility of
diabetes. On the right, no definite erosive or degenerative
changes. On the left, however, there is suggestion of possible
erosive change involving the ulnar aspect of the base of the
proximal phalanx of the second digit. There also appears to be
some erosive change involving the articular surface of the
radial aspect of the head of the third metacarpal.
.
Venous Duplex Upper Extremity:
IMPRESSION:
1. Heavily calcified brachial and radial arteries bilaterally.
2. Patent right cephalic and left upper arm basilic veins with
diameters as noted.
.
ART Duplex Lower Extremity:
IMPRESSION: Patent left lower extremity bypass with no evidence
of stenosis.
.
Discharged Labs:
[**2110-9-7**] 06:20AM BLOOD WBC-9.6 RBC-3.47* Hgb-10.4* Hct-32.9*
MCV-95 MCH-30.0 MCHC-31.6 RDW-17.7* Plt Ct-469*
[**2110-9-7**] 06:20AM BLOOD Glucose-302* UreaN-31* Creat-1.7* Na-130*
K-4.5 Cl-91* HCO3-31 AnGap-13
[**2110-9-3**] 07:00AM BLOOD ALT-17 AST-24 LD(LDH)-250 CK(CPK)-27*
AlkPhos-248* TotBili-0.2
Brief Hospital Course:
52 year old man with DM1, ESRD on HD, h/o recent NSTEMI
presented with DKA and left chronic heel ulcer; also found to
have NSTEMI on admission.
.
# Type I diabetes complicated by Diabetic Ketoacidosis: Patient
has history of type I diabetes since age 2 complicated by
peripheral neuropathy, retinopathy, nephropathy and PAD with R
BKA. Patient was transferred from OSH with DKA with blood sugars
in the 500, ketonuria and anion gap metabolic acidosis. He was
started on insulin drip in the MICU and received his regular
hemodialysis. His glucose levels normalized and his anion gap
closed and he was transitioned to subq insulin which adequate
glucose control. His home lantus and sliding scale were
increased with help of [**Last Name (un) **] diabetes specialist in the setting
of being started on steroids (see below). Initially there was
concern that his DKA may have been precipitated by infection in
left foot ulcer however ID, podiatry and vascular surgery felt
that patient's ulcer was chronic and not source of infection
(see below). His DKA most likely was triggered by his NSTEMI.
He reports good glucose control at home with HbA1c of 7.5%
during this admission.
.
# NSTEMI: Patient complained of chest pain in the ED. EKG in ED
showed sinus tachycardia with non-specific ST changes. Cardiac
enzymes were elevated with Troponin of 0.22 which peaked to 2.78
and CK-MB of 3 which peaked to 39. He was seen by cardiology who
given patient's other active medical conditions decided to defer
cath and instead treated patient medically with IV heparin,
continued his home plavix, added metoprolol, atorvastatin and
aspirin. His NSTMI was thought to be secondary to demand
ischemia. His cardiac enzymes continued to trend down with
CK-MB trending down to 3 and troponin to 1.64. On [**9-3**] there was
a rise in troponin from 1.64 to 1.99 with normal CK-MB however
patient had no change in his EKG and he was not symptomatic
therefore there was no concern for recurrent ischemia. His TTE
showed mild regional left ventricular systolic dysfunction with
EF 50%; mild to moderate mitral regurgitation and mild pulmonary
hypertension. Cardiology recommended cath in the future once
patient's other medical conditions become stable. He will follow
up with his PCP who will then arrange cardiology follow up for
patient for likely cath.
.
# Dry left foot chronic heel ulcer/pain: On admission patient
reported few days of increasing left foot pain in the area of
his known eschar. Original wound was from a pressure ulcer that
he developed while in rehab last month. He had elevated ESR and
CRP therefore there was concern that he may have osteomyelitis.
However, patient was seen by Podiatry who did not think that his
foot xray from obtained at OSH was concerning for osteomyelitis.
He was initially started on Vanc and Zosyn for presumed
infection [**8-28**] that was stopped on [**8-31**] because there was no
evidence of infection according to ID, vasc, and podiatry.
Vascular surgery was following; patient had ABI which showed
severe PAD; LLE arterial duplex showed patent [**Doctor Last Name **]-tib graft, no
stenoses. He had left leg angiogram which showed small diseased
vessels in his left foot not amenable for any kind of
intervention. Culture from eschar surface of left foot grew MRSA
however since it was not deep from the wound it was not
considered clinically significant. Per vascular and podiatry,
debridement of chronic left heel ulcer was not an appropriate
option given limited blood flow to the foot to support healing
post debridement. He was sent with waffle boot for left heel
ulcer. He will follow up with outpatient podiatrist Dr. [**Last Name (STitle) 1274**]
for further care.
.
# Inflammatory Arthropathy/Rheumatoid Arthritis: On admission
patient endorsed pain in his wrists, shoulder and the joints of
his hands with increased erythema and swelling. Rheumatology
attempted to tap his wrist but was not able to get any fluid. He
was started on prednisone 20 mg PO daily on [**8-30**] for possible
gout and the patient reported improvement of his pain and his
prednisone was slowly [**Doctor Last Name 2949**] to 10mg daily. Patient had positive
rheumatoid factor and found to have erosions on hand-ray which
along with positive CCP suggested rheumatoid arthritis as the
cause for patient's symptoms. Patient will make an appointment
with rheumatologist near cape code for further management and
initiation of any immunomodulator therapy if indicated.
.
# ESRD: Patient was continued on dialysis on TTHSAT schedule.
Patient's vein mapping was completed for fistula placement. He
was seen by transplant surgery for discussion of fistula who
recommended saving right arm for placement of fistula. Patient
will follow up with nephrologist Dr. [**Last Name (STitle) 19651**] and transplant
surgeon Dr. [**Last Name (STitle) **] for further evaluation of fistula placement.
.
# Pulmonary edema: CXR in ED showed "increased perihilar and
bibasilar opacities most suggestive of pulmonary edema
especially because of the rapid change from this morning's CXR
at OSH". [**Month (only) 116**] be more consistent with low lung volumes. Patient's
volume was controlled by HD and he was satting fine on room air
without any difficulty with respiration. He likely had transient
pulmonary edema in the setting of his NSTEMI (see above).
.
# Anemia: On admission patient had HCT of 27.2. Patient received
2 units of transfusion during this hospital. Hematocrit
remained stable during the rest of his hospital course. He did
not have any source of blood loss and his anemia is most likely
secondary to CKD. He was continued on home sevelamer and
Nephrocaps.
.
# Elevated Alk Phos: Alk Phos 239. AST/ALT/tbili normal. No
known history of stones or liver disease. AT [**Hospital1 112**] he had elevated
LFTS (ALT 246 peak, AST 509 peak, Alk phos peak 446). CBD 10 mm.
Resolved on discharge from [**Hospital1 112**]. Remained stable throughout this
admission. Patient will follow up with PCP for further
evaluation.
.
# Access: peripherals (18, 20) HD line (R tunneled catheter,
[**2110-5-23**])
# Communication: Patient, Girlfriend [**Name (NI) **] [**Telephone/Fax (1) 19652**]
# [**Name2 (NI) 7092**]: Full (confirmed)
Transitional Issues:
- One set of blood culture pending at time of discharge
- Patient insulin regimen was increased in the setting of being
started on prednisone. Once he is weaned off of prednisone his
insulin regimen would need further adjustment.
- Patient will follow up with PCP who will monitor patient Alk
phos. PCP will also arrange cardiology appointment for patient
for possible cath.
- Patient will follow up with nephrologist Dr. [**Last Name (STitle) **] for
dialysis and transplant surgeon Dr. [**Last Name (STitle) **] for further
evaluation of fistula placement.
- Per transplant surgeon preserving right arm for fistula.
- Patient will follow up with Rheumatologist for further
evaluation for rheumatoid arthritis and for any immunomodulator
treatment if indicated.
- Patient will follow up with podiatry Dr. [**Last Name (STitle) **] for management
of his left heel ulcer.
Medications on Admission:
- Sevelamer 800
- Diazepam 5 mg tab q4-6hr prn
- ASA 325 mg
- Plavix 75 mg
- simvastatin 80 mg
- Colace 100 mg
- Prilosec 20 mg
- Metoprolol tartrate 50 mg
- Lidoderm 5% patch
- Nephrocaps daily
- Lantus 9 units in AM and PM + carb coverage
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Diazepam 5 mg PO QHS:PRN sleep
8. Renagel *NF* 800 Other daily
9. PredniSONE 10 mg PO DAILY
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
10. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain
11. Metoprolol Tartrate 50 mg PO TID
hold for sbp < 100 or hr < 60
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth Three times a
day Disp #*90 Tablet Refills:*0
12. Glargine 14 Units Breakfast
Glargine 14 Units Bedtime
Insulin SC Sliding Scale using aspart Insulin
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
1. Diabetic Ketoacidosis
2. Non-ST-Elevation Myocardial Infarction
3. Dry Gangrene ulcer of left foot
4. Rheumatoid Arthritis
5. End Stage Renal Disease on dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 19650**], it was a pleasure taking care of you during your
hospitalization at [**Hospital1 18**]. You were transferred from outside
hospital directly to [**Hospital1 18**] ICU for management of your diabetic
ketoacidosis (DKA) and concern about infection in your left foot
ulcer. You were started on insulin drip with subsequent
resolution of your diabetic ketoacidosis and then switched to
subcutaneous insulin with adequate control of your blood sugars.
Initially there was concern that your DKA may have been
precipitated by infection in your left foot ulcer. However you
were evaluated by the podiatry team who felt that your left foot
ulcer appeared dry and did not show any signs of infection. You
also had an angiogram procedure of your left leg by vascular
surgery who found small, diseased vessels in your foot which
were not amenable to intervention. The podiatry team decided
against debridement of your left foot ulcer because of
inadequate blood supply to support proper healing. Please
follow up with your outpatient podiatrist Dr. [**Last Name (STitle) 1274**] to further
management of your left foot ulcer.
Additionally on admission you complained of chest pain and found
to have a heart attack which was managed with medications. You
were evaluated by a cardiology specialist who, based on your
other acute medical problems, decided against doing a cardiac
catheterization (procedure to look at and open narrowed heart
vessels). However they felt strongly that you follow up with a
cardiologist (see below) in order to have cardiac
catheterization once the rest of your medical conditions are
under control.
Finally on admission you also reported having swollen and
painful joints in your hands. Your symptoms, labs tests and
hand-xray suggest a diagnosis of rheumatoid arthritis. You have
been started on prednisone with improvement in your symptoms.
You should follow up with a rheumatologist (see below) who will
try to wean you off of prednisone and start other medications
specific for rheumatoid arthritis.
During this admission you were continued on
Tuesday/Thursday/Saturday dialysis schedule. You also had vein
mapping and discussion with transplant surgery team for possible
placement of a fistula in the near future. Transplant surgery
recommended that you preserve your right arm for possible
fistula graft (meaning avoiding blood draws or blood pressure
checks). You should follow up with your nephrologist Dr. [**Last Name (STitle) 19653**]
and transplant surgeon Dr. [**Last Name (STitle) **] to make sure you have
placement of fistula graft in the near future.
Following changes were made to your medications:
STARTED Prednisone which you should continue until you have seen
your new outaptient rheumatologist
INCREASED Lantus to 14mg twice daily
INCREASED Metoprolol to 50mg three times a day.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Street Address(2) 19654**], [**Location (un) 19655**],[**Numeric Identifier 19656**]
Phone: [**Telephone/Fax (1) 19657**]
Appointment: Monday [**2110-9-8**] 1:45pm
**At this appointment please discuss with your primary care
provider about getting setup with a Cardiologist if you dont
already have one. You need to be seen within 1 month of
discharge with a cardiologist.
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Department: Nephrology
Schedule: Tues, Thurs, Sat
Phone: [**Telephone/Fax (1) 19657**]
*Dr. [**Last Name (STitle) **] will follow up with you at your next diaylsis
schedule for your hospitalization.
Department: TRANSPLANT CENTER
When: MONDAY [**2110-11-17**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19658**], rheumatologist at [**Telephone/Fax (1) 19659**]
near Cape Code to make an appointment for management of your
inflammatory joint disease likely rheumatoid arthritis.
Please call you podiatrist, Dr. [**Last Name (STitle) 1274**] to make an appointment
for management of your left foot ulcer.
Completed by:[**2110-9-8**]
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58,242
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Discharge summary
|
report
|
Admission Date: [**2203-11-19**] Discharge Date: [**2203-12-16**]
Date of Birth: [**2143-10-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Codeine / Streptokinase / Iodine / Bee Pollens / Narcan
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
VP shunt removal [**2203-11-20**]
VP shunt placement [**12-6**]
removal of Kwires R arm [**11-22**]
History of Present Illness:
Mr. [**Known lastname 3989**] is a 60y/o gentleman with HTN, HLD, CAD s/p MI, AFib,
TIA, colon cancer s/p resection, s/p abdominal trauma with
splenectomy and left hand digit amputations, right forearm
fracture with plan for hardware removal [**11-22**], as well as
complicated hospital course last month for spontaneous SAH and
pneumonia now s/p trach/PEG/VP shunt who was sent from rehab to
an OSH for altered mental status and was transferred to [**Hospital1 18**]
due to concern for VP shunt complication vs infection.
He was admitted to Neurosurgery [**Date range (1) 4216**] after presenting to an
OSH with the "worst headache of his life" and being found to
have a spontaneous SAH in the setting of Coumadin use (no trauma
and no known cerebral artery malformations). He was intubated
in the ED, and was treated by an external ventricular drain.
His course was complicated by AFlutter requiring Dilt drip, VAP
(treated with Vanc/Cefepime, d/c'd to rehab on Vanc), brief
hypotension and pressors, and DVT (was restarted on Warfarin).
He underwent trach, PEG, and V-P shunt placement and was
discharged to rehab at [**Hospital1 700**]. His recent
baseline is that he is normally alert and responsive, able to
sit at edge of bed but not walking yet, and has no focal neuro
deficit.
Per transfer records, at rehab this morning at 1:30AM he was
confused, only A+O x1, slow to respond, and only verbalizing the
word "yes." Per report he had some new right-sided weakness.
Had temp 102.9 and was noted to have cloudy foul-smelling urine
in condom cath. EMS was called and he received 800cc NS en
route to the OSH.
At the OSH, his VS were T 101.5, BP 167/118, HR 90, RR 16. He
had WBC 13.3. CXR with question of consolidation, and CT head
w/o contrast with no acute process. Received Acetaminophen,
Ceftriaxone 1g IV, Azithromycin 250mg IV as well as Cefepime 2g
IV and was transferred to [**Hospital1 18**].
In the [**Hospital1 18**] ED, initial VS were T 97.6, HR 75, BP 110/70, RR
18, POx 98% 3L TM. Labs were notable for WBC 15.8 (74% PMNs, no
bands), UA with 0 epis, 35 WBC, few bacteria, moderate leuks,
>182 RBCs (foley had been placed). CXR showed R>L bibasilar
opacities. He was evaluated by Neurosurgery and underwent VP
shunt study which was normal. VP shunt was tapped and CSF
revealed WBC 425 (87% polys), protein 57, glucose 63. Gram
stain showed 4+ PMN, 4+ GPCs in pairs/clusters. He received 1L
NS and Vancomycin 1g IV and was admitted to Medicine for further
management. VS prior to transfer were 97.6, 67, 10, 170/83,
100%.
On arrival to the floor, patient was A&O x3, he denied fever,
chills, chest pain, SOB, abdominal pain, N/V, dysuria or
diarrhea. He reports headache with hip and knee pain that is
chronic. He wants to eat, but his daughter emphasize that he is
chronically NPO because he aspirated.
Past Medical History:
Type II Diabetes on oral agents
Systemic Lupus Erythematosus
Coronary Artery Disease s/p MI in [**2186**]
Hepatitis C
COPD with emphysema and asthmatic component (FEV1 60% predicted
[**1-7**])
Diastolic Congestive Heart Failure EF 55% in [**3-/2198**]
Seizure disorder
TIA 199
Colon Cancer s/p resection in [**2194**] without chemotherapy
s/p abdominal trauma with subsequent splenectomy and amputation
of digits of his left hand
Hyperlipidemia
Hypertension
h/o cocaine abuse
Neuropathy and chronic pain on methadone
Chronic Atrial Fibrillation on Coumadin
Obstructive Sleep Apnea on home CPAP
Left Total Knee Replacement [**2201**]
Social History:
On disability, former mechanic. Quit smoking [**2181**]. Denies EtOH,
h/o cocain abuse, none since [**2181**].
Family History:
Adopted - Unknown birth family hx
Physical Exam:
Admission:
VS 98.4, 150/100, 69, 18, 98 on 2L NC, FS 98, 144.2 lbs
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear, PERRL
NECK supple, no JVD, no LAD, trach in place
PULM Scattered crackles at right lung base, no wheezes
CV irregularly irregular, normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g, g-tube in place
EXT Right forearm splinted, WWP 2+ pulses palpable bilaterally,
no c/c/e
GU Foley draining clear yellow urine
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Exam on Discharge:
Alert, pleasant, occasionally confused
Discongigate gaze
Oriented to location and self, PERRL 3-2mm, left nasolabial
droop
Moves all extremities to command, antigravity
Gait - not tested
incision is c/d/i and well approximated, sutures have been
removed
abd: soft, steris in place, g-tube in place and intact
extr: no c/c/e
Pertinent Results:
Admission:
[**2203-11-19**] 11:40AM BLOOD WBC-15.8* RBC-3.74* Hgb-10.9* Hct-34.8*
MCV-93 MCH-29.1 MCHC-31.3 RDW-17.4* Plt Ct-399#
[**2203-11-19**] 11:40AM BLOOD Neuts-74.0* Lymphs-18.3 Monos-7.2 Eos-0.1
Baso-0.5
[**2203-11-19**] 11:40AM BLOOD PT-12.0 PTT-31.0 INR(PT)-1.1
[**2203-11-19**] 11:40AM BLOOD Glucose-93 UreaN-21* Creat-0.6 Na-140
K-3.6 Cl-99 HCO3-34* AnGap-11
[**2203-11-19**] 11:40AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
Microbiology:
[**2203-11-19**] 1:12 pm CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final [**2203-11-19**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other Oxacillin RESISTANT Staphylococci
MUST be
reported as also RESISTANT to other.
Rifampin should not be used alone for therapy.
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2203-11-20**] 5:45 pm CATHETER TIP-IV Site: CATHETER
RIGHT SHUNT CATH TIP.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. >15 colonies.
Imaging:
[**11-20**] CXR:
IMPRESSION: Slight worsening of dependent bibasilar opacities,
which may
reflect an evolving aspiration pneumonia in the setting of
fever.
[**2203-11-21**] Wrist XR - In comparison with study of [**11-14**], there is
little overall change in the extensive fixation device about
previous fracture of the distal radius. Widening of the
scapholunate interval is not definitely appreciated on this
study. Overlying cast greatly obscures bony detail.
[**2203-11-21**] CT head - Stable appearance of ventricular catheter and
ventricular size
[**11-22**] CXR - stable b/l lower base opacities suspicious for
pneumonia
[**2203-11-23**] CSF culture, source shunt. GRAM STAIN: no
polymorphonuclear leukocytes seen, no microorganism seen;
preliminary fluid culture is no growth. WBC: 240(lymph 14%,
Mono 23%, Polys 63%, RBS 0), Tprot: 28, Glucose: 76.
[**12-1**] ECHO:
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45%). There is
no ventricular septal defect. The right ventricular cavity is
mildly dilated 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. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. 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 ([**1-31**]+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild symmetric LVH with mild to moderate global
hypokinesis. Dilated and hypokinetic right ventricle. Mild to
moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2203-10-5**],
overall systolic function is slightly worse and hypokinesis
appears global. Severity of mitral regurgitation has increased.
Estimated pulmonary pressures are lower.
[**12-2**] Chest x-ray
FINDINGS:
Right lung opacities have slightly worsened since previous
exam and are
slightly more confluent, suspicious for an infectious process or
aspiration. There is no pleural effusion or pneumothorax. Stable
cardiac contour is moderately enlarged.
CHEST 4:35 A.M., [**12-12**]
IMPRESSION: AP chest compared to [**12-2**] through [**12-11**].
Right lower lobe consolidation and small accompanying pleural
effusion have improved since [**12-11**]. Mild-to-moderate
enlargement of the cardiac silhouette has improved since
[**12-2**], whether due to decreased
cardiomegaly and/or pericardial effusion. Left lung grossly
clear. ET tube and right internal jugular line are in standard
placements and an upper enteric tube passes into the stomach and
out of view. No pneumothorax.
[**2203-12-12**] 8:22 AM
PORTABLE HEAD CT
COMPARISON: Prior head CTs without contrast from [**2203-12-10**], [**2203-12-6**] and dating back to [**2203-10-5**].
FINDINGS: Study is limited due to the presence of artifact
produced by EEG electrodes and wires. Again seen is a right
frontal approach ventricular shunt terminating in the right
lateral ventricle. There is persistent enlargement of the
visualized lateral ventricles which are significantly unchanged
when compared to prior examination. There is opacification of
mastoid air cells, likely related to patient's supine position.
Many of the previously described findings are obscured due to
the artifact generated by the EEG electrodes, limiting an
adequate comparison.
RESPIRATORY CULTURE (Final [**2203-12-14**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +.
CXR [**12-13**]
FINDINGS: As compared to the previous radiograph, the
pre-existing right
opacity is minimally more extensive than on the previous image.
Otherwise,
there is no relevant change. Moderate cardiomegaly,
normal-appearing left
lung, the monitoring and support devices are constant.
Video Swallow [**12-16**] - pending
Brief Hospital Course:
Brief Course:
Mr. [**Known lastname 3989**] is a 60y/o gentleman with HTN, HLD, CAD s/p MI, AFib,
TIA, colon cancer s/p resection, s/p splenectomy, right forearm
fracture s/p ORIF with pins, and recent SAH and pneumonia now
s/p trach/PEG/VP shunt who presented with delirium that is
likely due to shunt infection. CSF cultures grew coag positive
staph aureus. Patient underwent VP shunt removal and received IV
antibiotics.
#. Altered mental status: Likely [**3-3**] infection (UTI vs PNA vs
shunt infxn).
He is currently back at his reported neurologic baseline but the
morning of presentation he had transient change in speech and
level of interactiveness. He had fever and leukocytosis.
Post-splenectomy status puts him at risk of serious infection
with encapsulated organisms. UA suggestive of UTI. CXR also
suggests possible PNA. More concerning is CSF with coag
positive staph. Patient underwent VP shunt removal and received
IV vancomycin and ceftazidime. Note that he does have hardware
in his arm but with no arm pain, not concerning for infection.
He is mentating fine, with good urine output and no elevation in
lactate so suspicion for shock is low but he certainly is
septic.
#. SAH in [**10/2203**] s/p trach, PEG, VP shunt.
His recent baseline is that he is normally alert and responsive,
able to sit at edge of bed but not walking yet, has some
left-sided weakness. He is continued on Tizanidine, Gabapentin.
#. h/o AFib: currently in AFib by exam.
Normally on Warfarin but has been off in anticipation of
returning to OR for Ortho surgery and has been bridged with
Dalteparin. Continued on metoprolol.
#. CAD s/p MI in the past: stable.
TTE with LVEF= 45-50% secondary to hypokinesis of the basal-mid
inferior wall, and inferior/anterior septum. He is on a statin
and BB.
#. HTN: BP currently elevated.
BP elevated but will permit in the setting of infection.
Lisinopril was recently uptitrated at rehab. Continue
Lisinopril, Metoprolol.
#. s/p MVA with Rt forearm fracture: s/p ORIF with hardware in
place.
Plans for removal of hardware soon but this will likely be put
off in the setting of infection. Dr. [**Last Name (STitle) **] is his Orthopedic
surgeon.
#. Neuropathy and chronic pain: stable. Continue Methadone,
Gabapentin and Dilaudid, Fluoxetine
#. h/o DM2 in the past: not on insulin currently.
FEN: NPO with tube feeds (NPO after MN), replete electrolytes
PRN
PPX: Heparin gtt, colace/senna, Methadone/Dilaudid
ACCESS: PIV
CODE: Full Code (confirmed)
COMMUNICATION: Patient
EMERGENCY CONTACT: [**Name (NI) 1453**] [**Name (NI) 4217**] (wife) [**Telephone/Fax (1) 4218**]
DISPO: Medicine floor for now
[**11-19**] transferred from [**Hospital3 417**] for fevers, transient
neuro symptoms
[**11-20**] VP shunt removed, EVD placed, ICP 7 post-op with drain
clamped as of 1820oriented, moves all 4 to command readily
[**11-21**]: EVD- open at 20, exam he is awake, alert pupils [**5-3**]
sluggish bilaterally, gave thumbs up on LUE, right arm casted
and moved fingers slightly to command, wiggles toes to command.
Started on sub q Heparin, as ICP was high, EVD unclamped, head
CT performed which showed
Ortho consult was done regarding his R arm fx : On schedule for
OR with Dr. [**Last Name (STitle) **] [**11-22**] for removal fo Kwires
On [**11-23**], pt remained stable in the ICU and was transferred to
Step Down Unit. ID was consulted and they recommended CSF
cultures, Legionella test, blood cultures and treatment with
Vancomycin and Ceftriaxone. His vanco trough was 25.5 and thus
his dose was held. Video swallow evaluated him and recommended
he be NPO for a repeat study. On [**11-24**], patient's repeat trough
was 15.5 at target goal. Video swallow was rescheduled for
[**11-25**]. Urine analysis and for legionellar was negative. CSF was
sent for analysis and culture. The CSF WBC was 75 and RBC 125.
ID recommended continuing the current antiobiotic regimen. His
neurologic status remained stable on [**11-26**]. On [**11-27**], CSF was
sent for analysis and culture: WBC 19; RBC 5. He remained
neurologically stable.
[**11-28**] the patient remained afebrile and neurologicly stable.
[**11-29**] neurologic exam he became more lethargic and CT showed a
slight increase in ventricles size. EVD was set on 15, his trach
was decannulated.
[**11-30**]: his mental status improved , CSF study showed pr:15,
glu:74 and no organism in smear.
[**12-1**]: Patient diaphoretic and got an ECG. Cardiology was
consulted at the request of Dr [**First Name (STitle) **] regarding the evaluation
and management of altered mental status, diaphoresis, abnormal
ECG and positive cardiac troponin T. Cardiology recommended:
-start unfractionated heparin IV infusion without a bolus, with
a goal PTT 50-60 sec. Check PTT prior to infusion and adjust
percardiac sliding scale.
-Continue ASA 81mg daily after initial dose of 325mg tonight.
-Switch dosing schedule of metoprolol from 75mg [**Hospital1 **] to
50mg q8h (daily dose of 150mg). Adjust dose and intervals (q8h,
q6h) to achieve a target HR 55-65 bpm. Maintain SBP<140 mmHg if
OK from a neurosurgical perspective. Therapeutic options include
conversion of lisinopril to captopril with oral titration to
achieve goal BP vs. initiation of NTG IV
infusion with eventual transition to long-acting nitrates.
-Switch simvastatin to atorvastatin 80mg daily starting tonight
- Continue to cycle cardiac biomarkers (cTnT, CPK, MB q6h until
peak) as well as serial ECGs.
- Keep patient NPO in anticipation of possible cardiac
catheterization. Please check coags (PTT, INR in AM).
- Pt has a reported allergy to iodine. This needs to be further
clarified by the primary team, as contrast for cardiac
catheterization contains iodine and may cross-react. He has had
prior catheterizations and CT with contrast with no
documentation
of pre-treatment.
- He may require stenting which will mean at least 1 month of
ASA and
clopidogrel. He also has a recent DVT and chronic AF with a
CHADS2 score of 4 that requires, ideally, warfarin indefinitely.
[**12-6**]: Patient went to the OR for a VP shunt placement. Aspirin
was held and 1 unit of platelets were given prior to the
procedure.
[**12-7**] : last night his o2 sat went down to 70s and after
suctioning came back to 99. CXR which did not show any
infiltration. Respiratory therapist got involved and found tube
feeding fluid in the lung. He remained afebrile.
[**12-8**]: exam stable. vomited x1 s/p pills. Med rec increasing
Metoprolol to 10mg IV Q4 hours until taking PO.
[**12-9**]: HR 60-70 overnight. 2 doses of Lopressor held overnight.
Re-started tube feeds. Changed IV Lopressor to PO. Continued
Captopril 25mg TID. Vanc discontinued per ID recs.
[**12-10**]: Increased lethargy, hand tremors noted, desaturation,
thick sputum. Sputum was sent for analysis. He also underwent a
CXR and non-contrast head CT. He became diaphoretic-UA sent-
foley d/ced and replaced. Blood cultures and electrolytes were
sent.
[**12-11**]: EEG, CSF sent, desat overnight. He was intubated and tx
to ICU- likley PNA.
[**12-12**]: The Sputum culture showed staph aureus coag +
[**12-13**]: Mr. [**Known lastname 3989**] was extubated. Tube feedings were re-started
and his neurologic status remained stable.
[**12-14**]: He remained neurologically stable. Hypertensive in PM.
Required Hydralazine and additional doses of Metoprolol.
[**12-15**]: Patient had some questionable seizure activity
charecterized by a hand tremor as visulized by his daughter. On
[**12-16**] we started the patient on Keppra and restarted the patient
on his Coumadin for his Atrial Fib.
Now DOD, patient is afebrile, vital signs stable and
neurologically stable. He received his first dose of coumadin
(5mg) today for a goal of 2.0-3.0 for AFIb. His incision is
clean, dry, intact without evidence of infection. He is
tolerating tubefeeds. He is currently non-ambulatory but is
working with PT/OT. He is set for discharge to rehab in stable
condition and will follow-up with Dr. [**First Name (STitle) **] accordingly.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR DAILY
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
3. Docusate Sodium (Liquid) 100 mg PO BID
4. esomeprazole magnesium *NF* 40 mg PO/TUBE daily
5. Fluoxetine 60 mg PO/NG DAILY
6. Gabapentin 600 mg PO/NG TID
7. Petroleum Jelly, White *NF* (white petrolatum) instill under
eyelid as directed Topical QID
8. Senna 1 TAB PO/NG HS
9. Simvastatin 20 mg PO/NG DAILY
10. Tizanidine 4 mg PO/NG HS
11. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
12. Metoprolol Tartrate 75 mg PO BID
13. Methadone 10 mg PO/NG TID
14. Lisinopril 30 mg PO DAILY
15. dalteparin (porcine) *NF* 12,500 unit/0.5 mL Subcutaneous
daily
16. Acetaminophen 650 mg PO/NG Q6H:PRN pain/fever
17. Albuterol Inhaler 4 PUFF IH Q4H:PRN SOB/wheezing
18. Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
19. HYDROmorphone (Dilaudid) 2 mg PO/NG Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Bisacodyl 10 mg PO/PR DAILY
3. Fluoxetine 60 mg PO DAILY
4. Gabapentin 600 mg PO Q8H
5. Methadone 10 mg PO TID
6. Metoprolol Tartrate 50 mg PO TID
7. Senna 1 TAB PO HS
8. Tizanidine 4 mg PO HS
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
10. Famotidine 20 mg PO Q12H
11. LeVETiracetam 500 mg IV BID
12. Atorvastatin 80 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Vancomycin 750 mg IV Q 12H
15. Warfarin 5 mg PO QMOWEFR
16. Warfarin 7.5 mg PO QTUTHSASUN
17. Docusate Sodium (Liquid) 100 mg PO BID
18. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
VP shunt infection
VP shunt replacement
dysphagia
pneumonia
confusion
NSTEMI
Atrial fibrillation
lethargy
seizures
hypertension
R arm radial fracture revision
Discharge Condition:
??????
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may shower, please keep wound clean and dry
- steri strips will fall off on their own
??????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.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone [**Telephone/Fax (1) 1228**]
[**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 1950**] 10
Date/Time [**2204-1-2**] 12:20
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2204-1-9**] 1:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2204-1-9**] 1:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2204-1-9**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]: please call [**Telephone/Fax (1) 1669**] to schedule a
follow up within 4-6 weeks with a repeat head CT scan.
Completed by:[**2203-12-16**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"02.21",
"38.91",
"38.97",
"02.34",
"96.71",
"02.43",
"33.24",
"96.04",
"78.63"
] |
icd9pcs
|
[
[
[]
]
] |
20496, 20568
|
10810, 11246
|
343, 445
|
20780, 20787
|
5093, 5828
|
21584, 22484
|
4118, 4153
|
19852, 20473
|
20589, 20759
|
18888, 19829
|
20965, 21561
|
4168, 4730
|
281, 305
|
6566, 10787
|
473, 3316
|
4749, 5074
|
20802, 20941
|
3338, 3973
|
3989, 4102
|
5863, 6531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,764
| 138,929
|
17071
|
Discharge summary
|
report
|
Admission Date: [**2182-3-25**] Discharge Date: [**2182-3-29**]
Service: NEUROSURGERY
Allergies:
Penicillins / Phenytoin / Nitrofurantoin / Carbamazepine /
Naproxen
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
S/P Fall with SAH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 y/of female with was celebrating her birthday yesterday at a
restaurant with her daughter and fell while stepping out of the
booth. The patient was on coumadin and became more lethargic
over the next 24 hours, not recognizing her daughters. Pt lives
with daughter, [**Name (NI) 6480**] since [**2182-1-4**] when family noticed pt
losing some short term
memory and confusing her pills.
Past Medical History:
Hypertension
Autonomic Failure
Recent Memory Loss
A-Fib
Dementia
Glaucoma
Hypothyroidism
Social History:
Widower lives with daughter
Family History:
Non contributory
Physical Exam:
On admission
Pupils: [**1-4**]
Head: left temple abrasion/laceration, no hemotypanum
Neck: C-Collar in place
Abd: soft nontender
Cardiac: Regular no murmers
Neuro: Prefers eyes closed pupils [**1-4**], did not follow commands,
localizes bilaterally
Pertinent Results:
[**2182-3-29**] 06:40AM BLOOD WBC-7.7 RBC-3.43* Hgb-10.6* Hct-30.7*
MCV-89 MCH-30.9 MCHC-34.5 RDW-14.2 Plt Ct-170
[**2182-3-29**] 06:40AM BLOOD Plt Ct-170
[**2182-3-25**] 09:20PM BLOOD Fibrino-424*
[**2182-3-29**] 06:40AM BLOOD Glucose-89 UreaN-24* Creat-0.7 Na-141
K-4.1 Cl-112* HCO3-20* AnGap-13
[**2182-3-25**] 09:20PM BLOOD Amylase-116*
[**2182-3-29**] 06:40AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.3
[**2182-3-25**] 09:21PM BLOOD Glucose-150* Lactate-1.6 Na-141 K-4.1
Cl-102 calHCO3-21
Brief Hospital Course:
Mrs. [**Known lastname 43113**] was admitted to the ICU for two day was montored with
close neurological checks and follow up head CTs showed decrease
bilateral subarachnoid hemorrhage layering along the sulci,1.5
cm focus of right frontal intraparenchymal hemorrhage and mild
surrounding edema is also unchanged. She had an MRI due to
unusual right frontal bleed, which was negative for any tumor.
On [**3-27**] she was transferred the the floor each day he became
more awake though disorientated she would follow commands and
move all extremeties. She was diagnosed with a right wrist
fracture and was placed in a splint. On [**3-28**] she was noted to
have WBC increased fro 7.9-> 11.4 but was afebrile a UA showed a
UTI an she was started on a Bactrim. Her Exelon patch was dc'd
as family reported that her fall occurred shortly after starting
on that medication. On discharge she remained confused but would
follow commands, moving all extremities strongly.
Medications on Admission:
Exelon patch, Rythmolol, Sectrol, Captopril, Norvasc,
midrodrine, levoxyl, xalatan, alphagan, senna, mvi and e-mycin
eye drops
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
SAH s/p fall
Left wrist fracture
Discharge Condition:
Neurologically stable
Discharge Instructions:
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Please follow up with Orthopaedics, Dr. [**Last Name (STitle) **] on [**2182-4-11**], call
[**Telephone/Fax (1) 2007**] for an appointment
Follow up with Dr [**Last Name (STitle) 548**] in 4 weeks with a head CT call
[**Telephone/Fax (1) 2992**] for an appointment
|
[
"814.00",
"599.0",
"427.31",
"294.8",
"244.9",
"V58.61",
"851.82",
"E884.2",
"401.9",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
2851, 2948
|
1709, 2674
|
297, 304
|
3025, 3049
|
1198, 1686
|
3546, 3814
|
895, 913
|
2969, 3004
|
2700, 2828
|
3073, 3523
|
928, 1179
|
240, 259
|
332, 722
|
744, 834
|
850, 879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,310
| 121,631
|
31990
|
Discharge summary
|
report
|
Admission Date: [**2108-11-12**] Discharge Date: [**2108-11-20**]
Date of Birth: [**2042-12-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Diovan / Opioid Analgesics
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2108-11-12**]
Coronary Artery Bypass Graft x4 (left internal mammary artery >
left anterior descending, saphenous vein graft > diagonal,
saphenous vein graft > obtuse marginal, saphenous vein graft >
posterior descending artery) [**2108-11-16**]
History of Present Illness:
Ms. [**Known lastname **] is a 65 F with HTN, + FH of early CAD, + smoker and
little recent medical care transferred from CMI service
following cath yesterday. Up until last month, she had had no
medical followup. She recently decided to have cataract surgery
and the following events occurred as a result of preop workup.
She has had at least a two year history of gradually worsening
exertional angina and dyspnea on exertion but never sought
medical attention. Symptoms also occured with times of emotional
stress. She initially attributed her symptoms to stress and
anxiety. Over the last couple months, her exertional chest pain
sometimes took hours before going away (initially responded
quickly to rest). Symptoms (CP and dyspnea) also occurring at
rest with minor emotional stressors.
.
She had persantine MIBI on [**2108-10-18**] which showed possible mild
lateral wall ischemia. She also developed hypertension to
210/120 during stress and required presentation to OSH ED. She
was started on an antihypertensive regimen with prn SLNTG. In
the two weeks PTA she has taken at least 5 per day.
.
She was admitted for cath yesterday. Found to have 99% LCx
lesion that could not be stented. Also had disease of RCA, LAD
(see below). Got Plavix 600 x 1 pre cath. Cardiac [**Doctor First Name **]
consulted; plan for CABG after Plavix washout.
.
Following cath started on heparin gtt (since continued mild CP
and ST depressions/TWI in lateral leads). Also has been on nitro
gtt for CP. Reports CP during cardiac cath; following this has
had intermittent 0.5-1/10 CP with one increase to [**8-7**] last
night, responsive to increase in nitro gtt. Reports severe
anxiety, relieved by benzos.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, black stools or
red stools. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
-HTN
-Anxiety with panic attacks
-Depression
-Discoid lupus (diagnosed by biopsy of nonhealing ulcers 15 yrs
ago), no treatment or other known manifestations of SLE
-TMJ
-Cataracts
-s/p ovarian cyst removal
-s/p tonsillectomy
.
Cardiac Risk Factors: (-)Diabetes,(-)Dyslipidemia,
(+)Hypertension
.
Cardiac History: None previously known
Social History:
Social history is significant for the current tobacco use (1 to
1-1/2 PPD x 50 yrs). There is no history of alcohol abuse.
Family History:
There is significant family history of premature coronary artery
disease. Sister with MI at 32 and CABG at 34; other sister with
MI at 48 and cardiac arrest; other sister with hypertension and
died at 59 during stress test. Father with fatal MI at 56.
Physical Exam:
VS - T 98.6; BP 99/63(range 99-133); P 82(range 66-82); R22;
95-97%RA
Gen: WDWN middle aged female in NAD. Oriented x3. Appears
slightly anxious.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with no noted JVP elevation. No carotid bruits.
CV: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. R groin with moderate ecchymoses, slightly firm
over pubis. No active ooze or obvious hematoma.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Initial EKG ([**11-12**] AM) demonstrated NSR at 97, normal
axis/intervals, ST depressions V4-V6, I; TWI aVL. ECG [**11-13**] AM
(during CP) also with NSR at 76, lateral ST depressions and TWI
(V5, V6, I, aVL).
.
2D-ECHOCARDIOGRAM performed on [**2108-11-13**] demonstrated: Mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
an abnormal systolic flow contour at rest (likely due to a
hyperdynamic LV function).
.
ETT performed on [**2108-10-18**] demonstrated: + chest and jaw pain with
hypertension to 210/120; imaging showing ?mild lateral wall
ischemia vs. artifact.
.
CARDIAC CATH performed on [**2108-11-12**] demonstrated: 99% mid LCx
lesion (failed attempt to stent), 100% OM1 and 90% OM2; 50% mid
LAD and 80% D1 (also aneurysmal); 60% mid RCA. Patent renals. 3
cm infrarenal AAA.
.
[**2108-11-19**] 11:05AM BLOOD WBC-9.1 RBC-2.93* Hgb-9.4* Hct-27.3*
MCV-93 MCH-32.1* MCHC-34.5 RDW-14.3 Plt Ct-311
[**2108-11-18**] 05:30AM BLOOD WBC-11.3* RBC-2.69* Hgb-8.9* Hct-25.2*
MCV-94 MCH-33.1* MCHC-35.4* RDW-14.0 Plt Ct-234
[**2108-11-12**] 12:13PM BLOOD WBC-7.4 RBC-3.77* Hgb-11.7* Hct-34.1*
MCV-91 MCH-31.1 MCHC-34.4 RDW-13.7 Plt Ct-342
[**2108-11-19**] 11:05AM BLOOD Plt Ct-311
[**2108-11-12**] 12:13PM BLOOD Plt Ct-342
[**2108-11-12**] 12:13PM BLOOD PT-14.1* PTT-150* INR(PT)-1.2*
[**2108-11-19**] 11:05AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-140
K-4.2 Cl-105 HCO3-28 AnGap-11
[**2108-11-12**] 12:13PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-135
K-2.8* Cl-99 HCO3-25 AnGap-14
[**2108-11-12**] 12:13PM BLOOD ALT-19 AST-18 AlkPhos-80 TotBili-0.4
CHEST (PA & LAT) [**2108-11-20**] 12:21 PM
FINDINGS: In comparison with study of [**11-18**], the small apical
pneumothorax appears to be even less than on the previous study.
Brief Hospital Course:
She was taken to the operating room on [**11-16**] where she underwent
a CABG x4. She was transferred to the ICU in critical but stable
condition. She was extuabted later that same day. She was
transferred to the floor on POD #1. She developed a small left
apical pneumothorax after her chest tubes were pulled that
remained stable on subsequent chest xray. She also developed a
pruritic generalized rash for which her lasix was discontinued
and she was treated with sarna lotion. She otherwise did well
postoperatively and was ready for discharge home on POD #4.
Medications on Admission:
Meds at home:
hydralazine 25 [**Hospital1 **]
HCTZ 25 mg daily
Norvasc 10 mg daily
Oxazepam 10 mg TID
ASA 325 mg (or ?650 mg) daily
Chantix (prescribed, not started)
SLNTG prn
.
Currents meds here:
Metoprolol 25 [**Hospital1 **]
ASA 325 mg daily
heparin gtt
NTG gtt (current at 0.3 mcg/kg/min)
Amlodipine 10 mg daily
HCTZ 25 mg daily
Hydralazine 25 mg [**Hospital1 **]
Diazepam 10 mg Q6h
Lorazepam 0.5-1 prn
Nicotine patch
Simethicone, maalox
Zolpidem prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
every four (4) hours as needed for itching.
Disp:*qs qs* Refills:*2*
4. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
Anxiety
Depression
Hypertension
TMJ
Discoid lupus
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**]
Continue to use sarna lotion for rash - if the itching increases
or the rash does not continue to improve please call
[**Telephone/Fax (1) 170**]
Smoking cessation - please continue to refrain from smoking if
you are having difficulty please follow up with PCP
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) 10543**] in [**1-31**] weeks ([**Telephone/Fax (1) 4475**])
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2108-11-20**]
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41,945
| 136,696
|
640
|
Discharge summary
|
report
|
Admission Date: [**2129-3-9**] Discharge Date: [**2129-3-17**]
Date of Birth: [**2082-11-14**] Sex: F
Service: MEDICINE
Allergies:
Bactrim DS
Attending:[**Doctor First Name 3298**]
Chief Complaint:
pain crisis
Major Surgical or Invasive Procedure:
right internal jugular central venous catheter placement
History of Present Illness:
46 yo F with sickle cell anemia, multiple admission for pain
crises who presented with an acute onset bilateral knee,
shoulder, hip, and chest pain, consistent with prior pain
crises.
The patient experienced the acute onset of knee pain the morning
of her admission, while brushing her teeth, about 20 minutes
after getting up. This was followed by chest, shouler, and hip
pain bilaterally. Given the severe pain, the patient presented
to the emergency room.
In the ED, initial vital signs were 98.2 95 133/81 20 100%
4L/NC. The patient was given normal saline 1 liter and dilaudid
1 mg IV x 3.
There was concern that she was developing acute chest and she
was admitted to the MICU. She complained of significant pain
when she arrived the the ICU.
Past Medical History:
1) Sickle Cell Disease- Hgb SS: diagnosed at age 3 with
complications including avascular necrosis of R hip, acute chest
syndrome, and pulmonary infarction. Spleen autoinfarction.
-Pneumococcal vaccine [**2126**]
-Influenza vaccine [**2126**]
-H Flu & Meningococcal vaccine [**1-/2114**]
2) Hepatitis C- Genotype 1B. Dx in [**2106**]'s, believed to be due to
frequent transfusions. Liver biopsy [**3-24**], stage III fibrosis. In
[**2120**], was on peg interferon & ribavarin, but d/c'd due to
neutropenia.
3) S/P cholecystectomy for gallstones in [**2096**]'s
4) S/P appendectomy in [**2096**]'s
5. Proteinurea- Started lisinopril 2.5 mg 1 po daily [**4-/2127**]
Social History:
Married, works as executive assistant for housing development.
Social smoking in high school, none currently. Rare ETOH use,
only on holidays. Denies drug use.
Family History:
Multiple family members on mother's side of family with sickle
cell disease.
Physical Exam:
Admission Physical Exam
Vital signs: 99.2 114/70 100 18 100%/2L
Gen: Appears uncomfortable, complain in diffuse arthalgia.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. CTAB.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric.
Palate elevates symmetrically. Tongue protrudes in midline.
Strength 5/5 throughout upper and lower extremities.
Discharge Physical Exam
Vital signs: Tc: 98.7 BP 100/60 (98/58-108/70) HR 83 (78-90) O2
98% RA
Gen: appears more comfortable and in NAD,
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. CTAB.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric.
Palate elevates symmetrically. Tongue protrudes in midline.
Moving all extremities.
Pertinent Results:
ADMISSION LABS:
.
[**2129-3-9**] 09:35AM BLOOD WBC-11.8* RBC-2.67* Hgb-9.4* Hct-28.7*#
MCV-107*# MCH-35.2* MCHC-32.7# RDW-16.0* Plt Ct-425
[**2129-3-9**] 09:35AM BLOOD Neuts-62.3 Lymphs-29.2 Monos-6.4 Eos-1.4
Baso-0.8
[**2129-3-9**] 09:35AM BLOOD Glucose-99 UreaN-8 Creat-0.5 Na-138 K-4.9
Cl-105 HCO3-24 AnGap-14
[**2129-3-9**] 03:45PM BLOOD CK(CPK)-84
[**2129-3-11**] 03:56AM BLOOD ALT-25 AST-53* LD(LDH)-615* AlkPhos-58
TotBili-6.4* DirBili-1.7* IndBili-4.7
[**2129-3-9**] 09:35AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9.
Micro Labs
Urine Culture [**3-10**]:
10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
Urine [**3-15**]: No growth
Blood Culture [**3-10**], [**3-11**], [**3-13**], [**3-14**]: No Growth Final
Throat Strep [**3-11**]: Negative
CXR [**3-10**]:
1. Since the recen radiograph one day prior, there has been
development of
new bilateral diffuse pulmonary infiltrates, likely pulmonary
edema, however infection and infarction cannot be excluded.
2. Development of marked cardiomegaly and findings consistent
with heart
failure.
3. Multiple loops of distended large bowel incompletely imaged
on this
radiograph.
CXR [**3-12**]:
A right IJ central line is present, tip over right atrium,
relatively low. Clinical correlation regarding possible
retraction is requested. There are low inspiratory volumes.
There is probable enlargement of the cardiomediastinal
silhouette, even allowing for this. There are diffuse patchy
opacities throughout both lungs, increased retrocardiac density
consistent with left lower lobe collapse and/or consolidation,
and equivocal small effusions. Again seen is diffuse increased
density of the bones, likely related to the patient's sickle
cell. Increased density at the right humeral head could be due
to osteonecrosis.Compared with [**2129-3-11**] at 2:04 a.m. and allowing
for technical differences, no definite interval change.
Tib/Fib X-Ray [**3-14**]:
FINDINGS: In comparison with the study of [**2129-1-29**], there is
little overall
change. Again there are areas of sclerosis involving the distal
femur,
proximal and much of the shaft of the tibia, and the talar dome.
Findings areall consistent with bone infarcts consistent with
the patient's known
diagnosis of sickle cell anemia.
ECHO [**3-17**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2127-1-9**], the left ventricular ejection fraction is
somewhat lower.
DISCHARGE LABS
[**2129-3-16**] 05:35AM BLOOD Glucose-140* UreaN-7 Creat-0.4 Na-133
K-3.9 Cl-99 HCO3-26 AnGap-12
[**2129-3-16**] 05:35AM BLOOD ALT-16 AST-40 LD(LDH)-450* AlkPhos-54
TotBili-1.7*
[**2129-3-16**] 05:35AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.8
Brief Hospital Course:
46 yo F with sickle cell anemia, multiple admission for pain
crises, who presented with the acute onset bilateral knee,
shoulder, hip, and chest pain. She developed hypoxia and
bilateral pulmonary infiltrates, requiring MICU transfer for
exchange transfusion.
#Sickle cell disease/Acute Chest Syndrome: The patient presented
with severe pain. Her initial chest x-ray was normal. EKG was
normal, and MI was ruled out with serial cardiac enzymes. The
patient was treated with oxygen, IV fluids, and IV Dilaudid for
presumed vaso-occlusive pain crisis. The day after admission,
she developed fever to 101.8 and a progressive oxygen
requirement, with CXR showed bilateral infiltrates and a
massively dilated heart. Due to concern for acute chest
syndrome, she was transferred to the MICU. She was started on
CTX/azithro for coverage of community-acquired pneumonia.
In the MICU, given the patient's high-grade hemolysis and acute
chest syndrome she underwent exchange transfusion on [**2129-3-10**]
with a total of 6 units of PRBC's infused, with a goal of
getting her hemoglobin S concentration under 30%. A right
internal jugular central venous catheter was placed for access.
Her post exchange transfusion hematocrit was 24.5, and initially
remained stable until the morning of [**3-12**] when it dropped to
21.1, she was given 1 unit of PRBC's with improvement only to
22, with a goal hemoglobin of over 8. She was given another
unit of PRBC's and her Hct stabilized around 28.
The patient had a lot of difficulty with pain-control, requiring
an IV Dilaudid PCA and bolus doses of IV dilaudid for
breakthrough pain. The pain service was consulted, and assited
with management. After exchange transfusion the patient was
significantly better controlled on the hydromorphone PCA and prn
IV hydromorphone. She was transferred back to the floor on [**3-13**].
She was was subsequently placed on a PO dialudid regimen. She
was discharge with 24 extra tabe of dilaudid.
# Fever: She spiked fever to 101 shortly after leaving ICU and
had another low grade temp however fever curve improved. CXR
improved and she was asymptomatic. Urine and blood cultures were
negative. She noted that she typically has low grade temps
during her crises. She was started on a 7 day course of
levofloxacin. She will complete her course on [**3-19**].
# Constipation: She had not had a bowel movement since [**3-9**]. She
noted that she has gone 2 weeks previously without a bowel
movement. She was on colace and senna but was resistent to
trying any other [**Doctor Last Name 360**]. She did have a bowel movement prior to
discharge and never had notable pain, distension, or nausea.
# Proteinuria: Patient with a history of proteinuria and was
started on lisinopril 2.5mg as an outpatient. Initially held but
was restarted prior to discharge.
# Left Lower Extremity Growth: This was noted during her
previous hospitatlization which was closely monitored. X-ray was
done to check for possible osteo which was negative. X-ray did
show findings consistent with bone infarction.
# Hepatitis C- Genotype 1B. Chronic, stable. Diagnosed in early
[**2106**]'s, likely [**12-23**] chronic transfusions. Liver biopsy [**3-24**] with
stage III fibrosis. In [**2120**], was on peg interferon & ribavarin,
but d/c'd due to neutropenia.
Transitional Issues:
1. Hemoglobin electophersis was pending upon discharge and will
need to be followed up
Medications on Admission:
lisinopril 2.5 mg daily
hydroxyurea 1000 mg [**Hospital1 **]
folic acid 5 mg daily
hydromorphone 2 mg PO Q2H PRN pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg twice a day Disp #*60 Capsule
Refills:*0 (Zero)
2. FoLIC Acid 1 mg PO DAILY
3. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN Pain
Hold for sedation, RR<12
RX *hydromorphone 2 mg q3h Disp #*24 Tablet Refills:*0 (Zero)
4. Hydroxyurea 1000 mg PO BID
5. Levofloxacin 750 mg PO DAILY Start: In am
RX *levofloxacin 750 mg daily Disp #*2 Tablet Refills:*0 (Zero)
6. Lisinopril 2.5 mg PO DAILY Start: In am
Hold if SBP<90
7. Senna 1 TAB PO BID:PRN constipation
RX *sennosides 8.6 mg twice a day Disp #*60 Tablet Refills:*0
(Zero)
8. Amoxicillin-Clavulanic Acid 875 mg PO Q12H temp higher than
100.4
Then, go to emergency room right away
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Sickle cell vasoocclusive pain crisis
- Sickle cell acute chest syndrome
- Pneumonia
Secondary Diagnoses
- Proteinuria
- HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with a sickle cell pain crisis. You
developed acute chest syndrome, and were transferred to the
intensive care unit. A central line was placed, and you treated
with exchange transfusion. Following exchanged transfusion, your
condition improved significantly.
You developed a fever and were treated with antibiotics for
pneumonia. You will continue taking antibiotics (Levofloxacin
750mg) until [**3-19**].
Your pain was managed with a PCA pump temporarily and you were
successfully transitioned to oral medications. You will be
discharged on Dilaudid 2-4mg every 3 hours as needed until your
appointment with Dr. [**Last Name (STitle) **] on [**2129-3-24**]. Please call your PCP if
your pain is not adequately managed on this regimen.
You heart was noted to be enlarged on a chest x-ray. You had an
echocardiogram to assess the function of your heart which was
normal.
Medication Changes
Continue Levofloxacin 750mg daily
You can take your dialudid 2-4mg every 3 hours as needed until
you meet with Dr. [**Last Name (STitle) **] on [**2129-3-24**].
Start Docusate 100mg [**Hospital1 **]
Start Senna 8.6mg [**Hospital1 **] as needed
You came to the hospital with a sickle cell pain crisis. You
developed acute chest syndrome, and were transferred to the
intensive care unit. A central line was placed, and you treated
with exchange transfusion. Following exchanged transfusion, your
condition improved significantly.
You developed a fever and were treated with antibiotics for
pneumonia. You will continue taking antibiotics (Levofloxacin
750mg) until [**3-19**].
Your pain was managed with a PCA pump temporarily and you were
successfully transitioned to oral medications. You will be
discharged on Dilaudid 2-4mg every 3 hours as needed until your
appointment with Dr. [**Last Name (STitle) **] on [**2129-3-24**]. Please call your PCP if
your pain is not adequately managed on this regimen.
You heart was noted to be enlarged on a chest x-ray. You had an
echocardiogram to assess the function of your heart which was
normal.
Medication Changes
Continue Levofloxacin 750mg daily
You can take your dialudid 2-4mg every 3 hours as needed until
you meet with Dr. [**Last Name (STitle) **] on [**2129-3-24**].
Start Docusate 100mg [**Hospital1 **]
Start Senna 8.6mg [**Hospital1 **] as needed
Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
When: THURSDAY [**2129-3-24**] at 4:30 PM
With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2129-3-29**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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icd9pcs
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|
1826, 1987
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82,562
| 150,704
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50002
|
Discharge summary
|
report
|
Admission Date: [**2198-8-23**] Discharge Date: [**2198-9-11**]
Date of Birth: [**2114-7-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Vicodin Es / Ciprofloxacin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Hypertension, chest pressure, fever, altered mental status.
Major Surgical or Invasive Procedure:
Nasogastric tube placement.
History of Present Illness:
The patient is an 84 y.o. female with h/o Parkinsons disease,
breast CA s/p resection, spinal stenosis, and multiple UTIs
referred from [**Hospital1 599**] [**Hospital1 1501**] for hypertension.
.
Referral to the ED was made for concern of HTN. On review of the
records it appears the pt had noted some pressure starting [**8-22**]
180/90 with a P58 for which received her usual Propanolol and an
additional Inderal 10mg, after which her BPs decreased to 150/78
with a HR of 48. Then last night pt was noted to have a BP of
251/158 which she was given another dose of Inderal 10mg PO.
Given the concern for increasing HTN she was referred to [**Hospital1 18**].
Prior to leaving she was noted to have a BP of 180/90. Per ED
signout pt reportedly endorsed chest pressure at nursing home.
Pt though denies any chest pain or pressure history. According
to the pt's sister who is present she called the nursing home
directly to find out more information and it appears that there
was some miscommunication between the staff there and the worker
present with her during the HTN episodes noted no complaint of
pain.
.
In the ED her initial vitals were noted to be BP 125/61, HR 75,
RR 14, Sat 95% on RA. She was noted to have very cloudy urine on
urine collection as well as a leukocytosis of 15.5. In the ED
her U/A was also suspicous for an infection, in the ED she
recieved Sinemet for her Parkinson's disease and was admitted
for a rule out.
.
On the floor, the patient appears well, she is much improved,
according to her daily health aid, [**Doctor First Name **]. She denies CP, SOB at
this time. Does endorse abdominal pain, likely secondary to
constipation. She has not had a BM in about one week [**First Name8 (NamePattern2) **] [**Doctor First Name **].
The patient has had decreased po intake and has seemed lethargic
since Wednesday [**First Name8 (NamePattern2) **] [**Doctor First Name 102108**] report. The patient endorses
dysuria since that time as well, and feels that her symptoms are
similar to other UTIs she has had in the past. Her CP has
largely resolved since admission.
Past Medical History:
- Breast cancer, s/p resection, chemo and XRT
- Bipolar disorder
- Parkinsons disease
- Osteoarthritis
- Hypothyroidism
- Depression
- Spinal stenosis
Social History:
Lived alone in [**Location (un) 55**] with 24 hour health care aid up
until 6 months ago. Had walked with a walker up until 6 months
ago, prior to a depressive episode after which she refused to
get out of bed. Never smoked, denies alcohol use.
Family History:
Non-contributory.
Physical Exam:
Physical Exam on admission [**2198-8-23**]:
Vitals - Tm:98.7 (afebrile since admission) HR 72 BP 149/71
(149-166/71-113) RR 20 O2: 95% RA
GENERAL: Elderly Caucasian Female with parkinson tremor in NAD,
appears comfortable.
HEENT: No scleral icterus, EOMI, MMM.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI SEM
noted in the right upper sternal border.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: hypoactive BS, Soft, slight ttp in RLQ, mildly
distended. No HSM. No rebound, rigidity or guarding.
EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3, but has trouble with verbal communication [**1-15**]
dementia, and requires a lot of prompting/repeating of
questions. CN 2-12 grossly intact. Parkinsonism tremors noted.
Pertinent Results:
OSH LABS from [**2198-8-23**]:
WBC 13.8, Hgb/Hct 14.4/44.7, Plt 314
Na 141, K 3.7, Cl 104, CO2 27, BUN 10, Cr 0.6
.
Labs on admission
WBC-15.5*# RBC-4.90 Hgb-14.6# Hct-44.9# MCV-92 MCH-29.8
MCHC-32.5 RDW-13.7 Plt Ct-330
Neuts-79.3* Lymphs-14.3* Monos-4.1 Eos-2.0 Baso-0.3
PT-12.1 PTT-26.4 INR(PT)-1.0
Glucose-155* UreaN-14 Creat-0.8 Na-141 K-4.0 Cl-101 HCO3-29
AnGap-15
Calcium-10.6* Phos-3.2 Mg-2.2
Lactate-1.7
.
Cardiac enzymes negative x3
.
LFTs WNL
.
Micro:
[**8-24**], [**8-25**], [**8-26**], [**8-27**], [**8-31**], [**9-3**], [**9-6**] BCx - NGTD
[**9-2**], [**9-3**], [**9-4**] - Urine culture positive with vancomycin
resistent enterococcus (felt by infectious disease to be
contaminent)
[**2198-8-28**] - CSF fluid culture negative
[**9-3**], [**9-4**] - clostridium difficle negative
.
Imaging:
[**8-23**] CXR PA and lateral: No acute pulmonary process.
.
[**8-24**] AXR including lateral decubitus: No free intraperitoneal
air. There is a mild amount of stool seen within the colon.
Visualized loops of small bowel and colon are within normal
limits in caliber with no evidence of obstruction. Lung bases
show no abnormalities. There is a mild degree of degenerative
changes in the lumbar spine and hip joints bilaterally.
.
[**8-26**] CT Head: No acute intracranial process.
.
[**8-26**] CXR Portable: Evaluation of the patient with NG tube
placement and
clinically suspected aspiration. Compared to [**2198-8-25**]. The NG
tube tip is in the distal stomach. Cardiomediastinal silhouette
is stable. The lungs are clear and there is no evidence of
consolidation that might be suspicious for aspiration process.
CT Torso w/contrast [**2198-8-28**]:
1. No pulmonary embolism, aneurysm, or dissection.
2. Sub-2-mm left lower lobe nodule, does not require followup in
the absence of a prior smoking history.
3. Diffuse low attenuation of the liver suggests fatty
infiltration; stable right adrenal nodule, probably an adenoma.
CT Sinus [**2198-9-5**]:
IMPRESSION:
1. No evidence of sinus disease.
2. No evidence of abscess formation or soft tissue stranding.
Brief Hospital Course:
The patient is an 84 year old female with Parkinson's disease,
bipolar disorder, h/o breast cancer, who presented with
hypertension and ?UTI on [**2198-8-23**], and progressed to have
delerium, tachycardia, and fever with previous Tmax 104 that
started on [**2198-8-26**]. Pt was noted to have a waxing/[**Doctor Last Name 688**] course.
The DDx of her fevers included c.difficile colitis, aseptic
meningitis s/p cipro, viral meningitis, bacterial meningitis,
neuroleptic-like malignant syndrome from withdrawal of Sinemet
secondary to patient's refusing meds on admission, or serotonin
syndrome. Her course was complicated by new Afib v Aflutter
since [**2198-8-27**] and intermittent episodes of HTN with systolic BPs
in the 200s as well as severe aspiration requiring Dobhoff
placement.
.
# Fever/leukocytosis: Tmax this admission: 104F ([**2198-8-26**]). Max
leukocytosis 20K on [**2198-8-26**]. Multiple blood cultures:
[**Date range (1) 104402**] NGTD. PICC tip [**2198-9-5**]: no significant growth.
Urine cultures: NGTD, except Uculture from [**2198-9-2**] with VRE,
final culture [**2198-9-4**] showed >100K VRE. Pt initially started on
ciprofloxacin, and upon transfer to MICU her medications were
ceftriaxone, metronidazole, and vancomycin. ID felt that the VRE
in the urine was most consistent with colonization as opposed to
true pathogen. Cipro was discontinued for concern of aseptic
drug induced meningitis. There was some initial concern
regarding intraabdominal source given tenderness on exam;
however abdominal CT was performed which showed no acute
process. Pt was transferred to the ICU for delerium with fever
up to 104. Upon admission to the ICU, pt had LP to r/o
meningitis which showed WBC8, RBC2 (diff 41 L and 59 M) from
tube 4, total protein was 51 and glucose was 113. This was felt
to be consistent with a partially treated bacterial or viral
meningitis and thus empiric antibiotics and antivirals were
continued including ceftriaxone and acyclovir. Vancomycin was
DC'd on [**8-28**]. Noninfectious causes were strongly considered as
well, given overall hemodynamic stability with such significant
fevers ?????? med effect (ciprofloxacin causing aseptic meningitis),
NMS given withdrawal of antiparkinsonian meds and tachycardia
with hypertension. A CK was checked and was relatively low.
Lexapro and TCA's were held out of concern for serotonin
syndrome. Sinemet was restarted out of concern for withdrawal of
antiparkinsonian meds. Patient was noted to have persistent low
grade fevers despite empiric treatment with po Vanco for
cdifficile colitis in setting of persistent diarrhea. C diff was
negative x 3. On discharge, it was felt that her fevers were
most likely non-infectious in origin. Goals of care were
discussed, and it was felt that the majority of non-invasive
testing for her fevers was unrevealing, and that invasive
testing was not in the patient's best interest, given her
advanced Parkinson's disease. Patient's leukocytosis was
resolving on discharge.
.
# Tachycardia. The patient was noted to be intermittently in
Afib vs. flutter vs. MAT (difficult to appreciate given baseline
tremor). TSH was checked and was normal. CTA of chest was
negative for pulmonary embolism. Home dose of propanolol was
changed to metoprolol 25mg TID for more selective and improved
rate control. The cause for the new onset tachycardia was
thought to be secondary to the patient's undderlying fevers or
autonomic dysfunction. The patient was not placed on
anticoagulation besides ASA since her tachycardia was
paroxysmal.
.
# Delerium. Multiple possible causes including electrolyte
abnormalities (hypernatremia in particular), infection (CNS
infection or effects of UTI or other infection), med effect or
med withdrawal (has been difficult to maintain PO access) were
all considered. LP was thought to be consistent with partially
treated meningitis and antibiotics were continued for a 10 day
course. IV Acyclovir was continued until HSV returned negative,
then was stopped. The patient's mental status was noted to
improve after her transfer back to the wards, however, this had
a waxing/[**Doctor Last Name 688**] course with periods of delirium associated with
Sinemet dosing.
.
# Hypertension. On admission, the patient was noted to have
consistent blood pressure measurements in the 200s systolic.
This was thought to be largely due to artifact given upper
extremity rigidity, however elevated BP was documented on lower
extremity readings as well. In general her blood pressure was
very labile ranging from 100's-230's. Initially propanolol and
lisinopril were continued. Patient was then transitioned to
metoprolol for improved HR and BP control and Hydralazine was
added PRN. Her blood pressures were noted to improve on this
regimen, although they would occasionally increase to the
170s-180s systolic. Plasma metanepherines were ordered to rule
out pheochoromocytosis and were found to be within normal range.
Lisinopril has been titrated upward to 20 mg daily.
.
# Hyperglycemia. Patient was reported to have
hyperglycemia/borderline DM at baseline per her caregiver,
[**Name (NI) **]. This was not listed on patient's PMH from [**Hospital1 1501**].
Fingersticks were noted to be quite high, especially on tube
feeds initially. Thought to be due to glucose concentration in
tube feeds. Fingersticks were noted to improve on 10u Lantus
[**Hospital1 **] started [**2198-9-4**] and with changing tube feeds to Nutrim
Pulmonary which had a lower glucose concentration. On discharge,
it was elected to defer insulin therapy, given goals of care.
.
# Rash on back and vagina. Also new rash noted on anterior chest
and UEs bilaterally on [**2198-9-7**]. Patient was evaluated by
dermatology and diagnosed with vaginal yeast infection and
miliaria rubra/profundus and superimposed fungal infection on
back. Chest/UE rash thought to be a drug rash, and was noted to
resolve off IV antibiotics. Patient remained asymptomatic
without pruritus. Back and vaginal rash improved on nystatin
ointment and powder.
.
# FEN: Feeds were given through NGT. Patient was kept NPO as she
was noted to be unsafe for swallowing. She was evaluated by
speech and swallow on [**2198-9-6**] and patient was noted to have
significant residue and aspiration. Discussed goals of care with
brother and daughter. On discharge, she will continue the
Dobhoff tube for tube feeds.
.
# Parkinsons. On simemet, this was continued per Neurology
recommendations for concern of withdrawal effect from
anti-parkinsonian medications.
.
# Bipolar disorder. Lithium was held per neurology
recommendations.
.
# Dispo: DNR/DNI. Discharge to home with hospice care. Ordered
for standing tylenol to suppress fever on dishcarge, and with SL
morphine/ativan prn. Will use dobhoff tube for feedings, given
dysphagia.
Medications on Admission:
Levothyroxine 112mcg daily
Propanolol 10mg daily
Trazadone 25mg [**Date Range 5910**]
Rozerem 8mg 4hrs prior to sleep
Sonata 10mg [**Name2 (NI) 5910**]
Lexapro 10mg daily
Pyridium 100mg TID
Acidophilus
Zofran
colace
MVI w/ minerals
Carbidopa-Levodopa 25/100 2 tabs QID
Percocet PRN
Surmontil 100mg daily
Ipratropium nebs PRN
ASA 81mg daily
Lithium 600mg [**Name2 (NI) 5910**]
Maalox 1 tab q4PRN
Calcium Carbonate 1gm daily
Vit D 50,000unit qmonthly
Senna PRN
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
QID (4 times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
Disp:*90 grams* Refills:*2*
5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for rash.
Disp:*30 grams* Refills:*2*
6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for fever, pain.
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H
(every hour) as needed for pain, shortness of breath.
Disp:*20 mL* Refills:*0*
9. Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO Q 8H
(Every 8 Hours) as needed for pain, fever.
10. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.5-2 mg PO Q2
hours as needed for anxiety, agitation.
Disp:*20 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 417**] Hospice
Discharge Diagnosis:
PRIMARY:
Advanced Parkinson's disease
Hypertensive urgency
Persistent fevers of unknown origin
Discharge Condition:
Stable, blood pressure measurements within normal limits,
temperature/fevers controlled with standing tylenol
Discharge Instructions:
You were admitted to the hospital because of high blood pressure
and fevers. You were treated with blood pressure medications and
antibiotics. No infectious source was found for your fevers. As
discussed, the Parkinson's disease has become much more advanced
over the past several months. Given the fact that you were
unable to swallow effectively, a dobhoff tube was placed to
provide you with your medications and your nutrition.
.
You are being discharged to home with hospice care. You should
follow-up with your primary care doctor within 1-2 weeks of
discharge from the hospital. He will call you to arrange a home
visit, but if you do not hear from his office, please call
[**Telephone/Fax (1) 8324**].
Followup Instructions:
Please make an appointment with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name (STitle) **] within 1-2 weeks of discharge from the hospital. His
office phone is: [**Telephone/Fax (1) 8324**]. He is aware of your discharge to
home with hospice care. He will plan to make a home visit in the
next 1-2 weeks. Please call his office number if you do not hear
from him in the next few days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2198-9-11**]
|
[
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"E930.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
14338, 14396
|
5886, 12704
|
360, 390
|
14534, 14646
|
3792, 5040
|
15404, 15976
|
2968, 2987
|
13213, 14315
|
14417, 14513
|
12730, 13190
|
14670, 15381
|
3002, 3773
|
261, 322
|
418, 2516
|
5049, 5863
|
2538, 2690
|
2706, 2952
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,207
| 183,478
|
26652
|
Discharge summary
|
report
|
Admission Date: [**2175-2-23**] Discharge Date: [**2175-3-23**]
Date of Birth: [**2109-6-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine Containing Agents Classifier / Iodine; Iodine Containing
/ Iodine / Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary ARtery Bypass Grafting x 4 [**2175-2-24**]
Sternal Re-wiring [**2175-2-28**]
Bronchoscopy [**2175-2-28**]
Hemodialysis
Sternal Debridement [**2175-3-14**]
Rectus Myocutaneous Flap to wound [**2175-3-14**]
Chest wound exploration [**2175-3-17**]
Transesophageal Echo [**2175-3-22**]
Chest tube placement [**2175-3-23**]
History of Present Illness:
This is a 65 year old gentleman who was transferred from
[**Hospital6 3105**] where he was admitted 3 days prior to
this admission with chest pain and dizziness. He had a
catheterization done at the outside hospital that showed
3-vessel disease. He has a history of hypertension and diabetes
melitus, and a positive family history for coronary artery
disease. He has mild dyspnea on exertion and has been stable
since arrival to the outside hospital. He has no fever, weight
change, syncope, claudication. He has mild lower extremity
edema.
Past Medical History:
Hypertension
Hyperlipidemia
Chronic Renal Insufficiency
Hyperplastic polyps of the colon
Obstructive Sleep Apnea
Diabetes Mellitus
Social History:
The patient quit smoking 30 years ago. He lives with his wife
and does not drink alcohol.
Family History:
THe patien'ts father had coronary artery disease
Physical Exam:
ON admission:
v/s 98.9, pulse 71, BP 126/64, RR 22, 96% on room air
Gen: pleasant, overweight gentleman in no acute distress
HEENT: moist mucous membranes
CV: regular rate and rhythm, no murmur
Neck: no masses
Pulm: trace bibasilar rales
Extr: trace lower extremity edema
Abd: obese, nontender/nondistended
Pertinent Results:
SEROLOGIES:
[**2175-2-23**] 08:00PM BLOOD WBC-10.5 RBC-4.97 Hgb-15.8 Hct-43.7
MCV-88 MCH-31.8 MCHC-36.2* RDW-13.5 Plt Ct-248
[**2175-2-24**] 12:53PM BLOOD WBC-12.6* RBC-3.13*# Hgb-9.9*# Hct-27.8*#
MCV-89 MCH-31.7 MCHC-35.7* RDW-13.5 Plt Ct-169
[**2175-2-24**] 02:31PM BLOOD WBC-15.8* RBC-3.69* Hgb-11.7* Hct-32.8*
MCV-89 MCH-31.7 MCHC-35.6* RDW-13.7 Plt Ct-204
[**2175-2-25**] 02:38AM BLOOD WBC-11.1* RBC-3.86* Hgb-12.2* Hct-33.7*
MCV-87 MCH-31.5 MCHC-36.0* RDW-14.0 Plt Ct-223
[**2175-2-26**] 02:00AM BLOOD WBC-13.4* RBC-3.41* Hgb-10.9* Hct-29.9*
MCV-88 MCH-31.9 MCHC-36.3* RDW-14.2 Plt Ct-168
[**2175-3-1**] 04:11AM BLOOD WBC-18.2* RBC-2.92* Hgb-9.3* Hct-25.8*
MCV-88 MCH-32.0 MCHC-36.2* RDW-14.6 Plt Ct-209
[**2175-3-3**] 04:34AM BLOOD WBC-17.6* RBC-3.58* Hgb-11.1* Hct-32.0*
MCV-89 MCH-31.0 MCHC-34.7 RDW-14.7 Plt Ct-281
[**2175-3-22**] 09:20AM BLOOD WBC-3.7* RBC-3.46* Hgb-10.8* Hct-30.9*
MCV-89 MCH-31.2 MCHC-34.9 RDW-19.4* Plt Ct-223
[**2175-3-23**] 02:25AM BLOOD WBC-4.9 RBC-3.45* Hgb-10.6* Hct-31.5*
MCV-91 MCH-30.6 MCHC-33.5 RDW-20.0* Plt Ct-258
[**2175-3-23**] 01:25PM BLOOD Hct-19.2*# Plt Ct-195
[**2175-3-23**] 04:12PM BLOOD Hct-21.9*
[**2175-2-23**] 08:00PM BLOOD PT-13.0 PTT-26.0 INR(PT)-1.1
[**2175-2-24**] 09:06PM BLOOD PT-14.7* PTT-36.2* INR(PT)-1.3*
[**2175-3-2**] 01:12AM BLOOD PT-14.3* PTT-32.7 INR(PT)-1.3*
[**2175-3-10**] 02:54AM BLOOD PT-13.8* PTT-31.6 INR(PT)-1.2*
[**2175-3-11**] 02:00AM BLOOD PT-27.8* PTT-141.8* INR(PT)-2.9*
[**2175-3-14**] 04:44PM BLOOD PT-19.4* PTT-36.4* INR(PT)-1.8*
[**2175-3-23**] 02:25AM BLOOD PT-39.0* PTT-124.5* INR(PT)-4.4*
[**2175-3-23**] 09:12AM BLOOD PT-50.5* PTT-150* INR(PT)-6.0*
[**2175-3-23**] 01:25PM BLOOD PT-41.6* PTT-119.0* INR(PT)-4.7*
[**2175-2-23**] 08:00PM BLOOD Glucose-116* UreaN-15 Creat-1.2 Na-141
K-4.2 Cl-104 HCO3-26 AnGap-15
[**2175-2-24**] 09:06PM BLOOD UreaN-11 Creat-1.0 Na-138 Cl-109*
HCO3-21*
[**2175-3-18**] 03:23AM BLOOD Glucose-87 UreaN-57* Creat-5.2*# Na-130*
K-4.1 Cl-92* HCO3-16* AnGap-26*
[**2175-3-20**] 03:36AM BLOOD Glucose-88 UreaN-42* Creat-4.0* Na-134
K-4.0 Cl-98 HCO3-18* AnGap-22*
[**2175-3-23**] 02:25AM BLOOD UreaN-49* Creat-3.9* Na-138 Cl-101
HCO3-12*
[**2175-2-23**] 08:00PM BLOOD ALT-58* AST-30 AlkPhos-66 Amylase-94
TotBili-0.6
[**2175-2-26**] 02:00AM BLOOD ALT-38 AST-76* LD(LDH)-300* AlkPhos-39
Amylase-39 TotBili-0.4
[**2175-3-8**] 05:09PM BLOOD ALT-65* AST-71* LD(LDH)-505* AlkPhos-98
Amylase-142* TotBili-3.3*
[**2175-3-11**] 02:00AM BLOOD ALT-1862* AST-3330* LD(LDH)-4810*
AlkPhos-83 Amylase-61 TotBili-2.7*
[**2175-3-12**] 04:17PM BLOOD ALT-4363* AST-7923* AlkPhos-144*
TotBili-5.9*
[**2175-3-14**] 11:56AM BLOOD ALT-2550* AST-1546* AlkPhos-169*
Amylase-56 TotBili-6.3*
[**2175-3-15**] 08:20AM BLOOD Amylase-53
[**2175-3-16**] 03:13AM BLOOD ALT-923* AST-285* LD(LDH)-421*
AlkPhos-128* Amylase-54 TotBili-8.0* DirBili-6.7* IndBili-1.3
[**2175-3-21**] 03:22AM BLOOD ALT-170* AST-119* LD(LDH)-425*
AlkPhos-124* TotBili-12.6*
[**2175-3-22**] 03:18AM BLOOD ALT-149* AST-129* LD(LDH)-397*
AlkPhos-134* Amylase-138* TotBili-13.0*
[**2175-3-23**] 02:25AM BLOOD ALT-143* AST-160* LD(LDH)-426*
AlkPhos-123* Amylase-209* TotBili-14.3* DirBili-12.6*
IndBili-1.7
[**2175-3-23**] 11:00AM BLOOD CK(CPK)-297*
[**2175-3-23**] 02:42PM BLOOD ALT-240* AST-661* LD(LDH)-792* AlkPhos-91
TotBili-15.7*
[**2175-2-23**] 08:00PM BLOOD Lipase-297*
[**2175-2-25**] 09:50AM BLOOD Lipase-18
[**2175-3-17**] 03:02AM BLOOD Lipase-89*
[**2175-3-19**] 02:10AM BLOOD Lipase-211*
[**2175-3-19**] 02:10AM BLOOD Lipase-211*
[**2175-3-19**] 02:10AM BLOOD Lipase-211*
[**2175-3-19**] 02:10AM BLOOD Lipase-211*
[**2175-3-20**] 03:36AM BLOOD Lipase-190*
[**2175-3-23**] 02:25AM BLOOD Lipase-454*
[**2175-2-23**] 08:00PM BLOOD Albumin-4.0
[**2175-3-2**] 09:40AM BLOOD Albumin-2.2* Mg-2.2
[**2175-3-20**] 03:36AM BLOOD Albumin-2.0* Calcium-7.2* Phos-4.1 Mg-2.3
[**2175-3-22**] 03:18AM BLOOD Albumin-1.9* Calcium-8.9 Phos-2.9 Mg-2.2
[**2175-3-23**] 02:25AM BLOOD Albumin-2.0* Calcium-7.4* Phos-5.1*#
Mg-2.2
[**2175-2-28**] 08:12AM BLOOD Vanco-10.3*
[**2175-3-20**] 03:36AM BLOOD Vanco-21.2*
[**2175-3-21**] 03:22AM BLOOD Vanco-15.1*
[**2175-3-22**] 07:11AM BLOOD Vanco-17.0*
[**2175-3-22**] 08:18PM BLOOD Vanco-21.1*
[**2175-2-25**] 09:26PM BLOOD Glucose-106* Lactate-1.4 K-3.8
[**2175-3-10**] 07:40PM BLOOD Glucose-151* Lactate-4.5* K-4.1
[**2175-3-15**] 02:30PM BLOOD Glucose-111* Lactate-6.3* K-3.4*
[**2175-3-17**] 03:23AM BLOOD Glucose-108* Lactate-3.0* K-3.8
[**2175-3-23**] 07:53AM BLOOD Glucose-37* Lactate-16.4* K-4.5
[**2175-3-23**] 08:46AM BLOOD Glucose-69* Lactate-16.8* Na-143 K-4.0
Cl-98*
[**2175-3-23**] 11:04AM BLOOD Glucose-105 Lactate-20.2* K-4.0
[**2175-3-23**] 02:43PM BLOOD Glucose-123* Lactate-18.2*
[**2175-3-23**] 03:46PM BLOOD Glucose-121* Lactate-19.0*
[**2175-3-23**] 04:38PM BLOOD Glucose-140* Lactate-22.3* Na-147 K-4.8
RADIOLOGY:
[**2175-2-24**] CXR: The heart size is normal. The mediastinal contour
demonstrates an ectatic aorta. The hilar is unremarkable. The
lungs are
clear. There are no pleural effusions.
[**2175-2-24**] CXR: Prominent volume loss and associated alveolar
process
(which could be secondary to mucus or hemorrhage) resulting with
partial right upper lobe collapse. There is associated
rightward tracheal deviation and hyperlucency of the remainder
of the right lobe.
Widened mediastinum and enlarged cardiac silhouette could be
related to post- operative changes, (enlarged cardiac
silhouette could also be secondary to pericardial effusion).
These findings as well as the interval CABG are new since one
day prior & were discussed by telephone with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Swan-Ganz catheter via the right internal jugular vein sheath
tip is in the right main pulmonary artery. The endotracheal
tube tip is slightly low lying but in satisfactory position. The
NG tube tip is in the stomach.
[**2175-2-26**] KUB: There are multiple tubes overlying the abdomen
(likely the chest tubes). There are dilated loops of small bowel
in the right upper quadrant which is a nonspecific finding.
There is also a single dilated loop in the left flank which is
also nonspecific. There is no obvious evidence of free air in
this supine radiograph. No abnormal calcifications are noted.
Upright chest radiograph perform in the same day did not
demonstrate free air.
[**2175-3-1**] CT: . ETT located at the level of the carina.
2. Dehiscence of the median sternotomy with extensive
subcutaneous emphysema and a small fluid collection. No
evidence of intrathoracic abscess, pneumothorax or pericardial
effusion.
3. Fatty infiltration of the liver.
4. No evidence of intraperitoneal free air.
These findings were discussed with the surgical PA caring for
the patient at the time of dictation.
[**2175-3-18**] Abdominal Ultrasound: No evidence for intracranial
hemorrhage or mass effect. Two hypodensities in the cortex could
represent acute/subacute ischemia. In addition, CT may not
adequately visualize hypoxic brain injury. For these reasons, MR
is advised.
[**2175-3-23**] CT TOrso: . Multiple large bilateral acute pulmonary
emboli.
2. Interval development of right upper lobe consolidation,
which may
represent pneumonia Vs. aspiration. Multiple other foci of
air-space
consolidation could represent multi-focal pneumonia.
3. Focal low density 2.5 cm lesion in the superior spleen which
could
represent an infarct.
4. Large right pleural effusion with associated subsegmental
atelectasis.
5. Status post myocutaneous graft placement in the previous
site of sternal
dehiscence containing drainage catheter. Status post abdominal
wall
reconstruction. No evidence of gas or surrounding inflammatory
changes to
suggest infection of this graft.
6. No evidence of intra-abdominal abscess or acute abdominal
process to
explain the patient's recurrent fever.
7. Multiple filling defects (thrombi) in the right femoral and
internal and external iliac veins.
MICROBIOLOGY:
[**3-20**] Blood Culture: C. Albicans
[**3-21**] SPutum Culture: Yeast
CARDIOLOGY:
[**2175-2-24**] TEE: Pre Bypass: The left atrium is moderately dilated.
The interatrial septum is aneurysmal. A left-to-right shunt
across the interatrial septum is seen at rest. A small secundum
atrial septal defect is present. There is mild symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction. Resting regional wall motion abnormalities
include mild inferior hypokinesis. LV EF 50%. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. Unable to visualize distal ascending
aorta. There are complex (>4mm) atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
Post bypass: Some improvement in infeior wall motion. LVEF 50 -
55%. RV function unchanged. MR remains trace, TR remains mild.
Aortic contours intact without visible dissection. Remaining
exam unchanged. Results discussed with surgeons.
[**2175-3-22**] TTE: A left-to-right shunt across the interatrial septum
is seen at rest via a patent foramen ovale. Left ventricular
wall thickness, cavity size, and systolic function are normal.
Right ventricular free wall motion is normal. There are complex
(>4mm) nonmobile atheroma in the aortic arch. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is a
trivial/physiologic pericardial effusion.
NEUROLOGY:
[**2175-3-22**] EEG: This is an abnormal EEG due to the presence of
diffuse
background slowing along with focal slowing observed over the
right
frontal and parietal and temporal regions as well as focal left
frontal
slowing. At times, the left frontal slowing became more rhythmic
and
sharp in nature and could potentially represent seizure. This
EEG is
demonstrative of an encephalopathy in that background rhythms
are
slowed. Common causes of encephalopathy include medications,
metabolic
causes, and infectious processes as well as anoxia. The focal
slowing
and rhythmic slowing represent areas of focal irritability in
the brain
that serve as potential regions of epileptogenesis.
Brief Hospital Course:
This is a 65 year old gentleman who unforunately expired from
respiratory failure secondary to complications that occured
status-post coronary artery bypass grafting. Below is a brief
summary of his hospital course, denoted by organ systems:
From a cardiology standpoint, the patient was admitted as a
transfer from an outside hospital with 3-vessel coronary artery
disease. He was taken to the operating room on hospital day 2
for coronary artery bypass grafting (please see the operative
report of Dr. [**First Name (STitle) **] [**Name (STitle) **] for full details). His
post-operative course was remarkable for aggitation with
disruption of his sternal wires requiring emergent evacuation of
hematoma and sternal rewiring [**2175-2-28**] (please see the operative
report for full details). Subsequently, plastics surgery was
consulted and rectus myocutaneous flap was used for eventual
reconstruction (please see the operative report of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] for full details). He had subsquent echocardiography
revealing normal cardiac function, however he required pressors
for a week prior t
From a pulmonary standpoint the patient failed 2 trials of
extubation in the post-operative period requiring emergent
intubation. He was subsequently found to have mild pulmonary
edema. A chest tube was placed in the right hemithorax for
evacuation of hematoma on [**2175-3-23**]. He was found to have
bilateral pulmonary emboli on CTA of [**2175-3-23**] despite being on
anticoagulation for heparin-induced thrombocytopenia with
extremity DVTs. Due to his multi-organ dysfunction and overall
morbid state his respiratory function worsened on maximum
ventilatory support and this was the primary cause of death.
From an infectious disease standpoint the patient proved to have
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23729**]. Due to his presumed septic picture with
hypotension on pressors for 2 weeks prior to his expiration, he
had been empirically placed on Vancomycin and Zosyn, however
Caspofungin was added for candidal [**Last Name (NamePattern1) 23729**]. Infectious Disease
consultation assisted with his antibiotics coverage.
From a renal standpoint, the patient had baseline chronic renal
failure with decompensation due to multi-organ failure requiring
hemodialysis.
From a hematologic standpoint, the patient developed
heparin-induced thrombocytopenia with the unfortunate
development of multiple lower and upper extremity deep venous
thrombosis. Argatroban drip was used to provide anticoagulation.
Due to hypotension he also was found to have shock liver with
markedly worsening LFTs in the last week of his hospital course.
The patient expired on 5:20 pm on [**2175-3-23**] due to respiratory
compromise secondary to multisystem organ failure. A short ACLS
code was initiated when the patient was asystolic but was
discontinued after approximately 20 minutes. The patient's
family was present at the bedside and consoled. An autopsy was
declined.
Medications on Admission:
Lasix 40 mg po qdaily
Atenolol 100 mg po qdaily
Lipitor 10 mg po qdaily
Vitamin B12 100 mcg qdaily
Flonase
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Coronary ARtery Disease
Secondary: liver failure, renal failure, heparin-induced
thrombocytopenia, respiratory distress, sepsis, encephalopathy,
diabetes mellitus
Discharge Condition:
Expired
Followup Instructions:
-
Completed by:[**2175-3-23**]
|
[
"584.5",
"414.01",
"518.5",
"745.5",
"423.0",
"401.9",
"250.00",
"117.9",
"995.92",
"415.11",
"411.1",
"453.41",
"038.8",
"428.0",
"278.01",
"327.23",
"E934.2",
"349.82",
"434.91",
"287.4",
"998.31",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.74",
"36.15",
"33.22",
"39.95",
"96.6",
"34.79",
"38.95",
"77.61",
"36.13",
"34.04",
"88.72",
"34.01",
"54.72",
"00.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
15923, 15932
|
12724, 15766
|
366, 695
|
16148, 16158
|
1936, 12701
|
16181, 16214
|
1542, 1592
|
15953, 16127
|
15792, 15900
|
1607, 1607
|
316, 328
|
723, 1265
|
1622, 1917
|
1287, 1419
|
1435, 1526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,384
| 167,755
|
11188+11189
|
Discharge summary
|
report+report
|
Admission Date: [**2170-10-5**] Discharge Date: [**2170-10-20**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
male with a past medical history of coronary artery disease
with angina, severe chronic obstructive pulmonary disease,
who was initially admitted to [**Hospital3 1280**] Hospital in
[**Location (un) 47**] for shortness of breath, substernal chest pain,
and diaphoresis. Cardiac catheterization there showed
3-vessel disease with left main 70% occlusion, right coronary
artery 100% occlusion, left circumflex 90% occlusion, left
anterior descending artery 80% to 90% occlusion, with an
ejection fraction of 65%.
The patient was subsequently transferred to the [**Hospital1 346**] for possible coronary artery bypass
graft. On admission, he was noted to have ecchymosis in his
left groin site which was where the initial catheterization
was attempted at [**Hospital3 1280**] Hospital and his left upper
extremity site where catheterization was finally performed at
the outside hospital.
On [**10-6**], the patient had an episode of syncope while on
the commode with accompanying hypotension and was transferred
to the Medical Intensive Care Unit for further care. The
episode was thought to be secondary to vasovagal syncope.
While on the Medical Intensive Care Unit Service he had
another episode of syncope. Additionally, he has had several
episodes of anginal-type chest pain relieved by
nitroglycerin. The expanding hematoma in the left arm was
complicated by superimposed cellulitis, and he was started on
oxacillin and eventually switched to p.o. Levaquin. The left
groin hematoma also continued to expand. He has required
several blood transfusions due to his hematocrit drop.
Cardiothoracic Surgery felt that the patient was not a good
surgical candidate given his severe chronic obstructive
pulmonary disease.
Subsequently, the patient underwent high-risk angioplasty.
His cardiac catheterization showed left main stenosis of 50%,
left circumflex was stented. His course was complicated by
hypotension secondary to cardiac tamponade. A pericardial
drain was placed which drained 700 cc of frank blood. His
hypotension resolved with dopamine and pericardial drainage.
He also sustained a right iliac dissection which was stented
at the end of the procedure.
Following his cardiac catheterization, the patient was
transfused 2 units of packed red blood cells and 2 units of
fresh frozen plasma and transferred to the Coronary Care
Unit.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease.
3. Peripheral vascular disease with claudication.
4. Status post bilateral carotid endarterectomy.
5. Peptic ulcer disease.
6. Arthritis.
MEDICATIONS ON TRANSFER: Protonix, Atrovent, Levaquin,
Beconase, Lipitor, nitroglycerin drip, Colace, aspirin,
Lopressor, and Atrovent nebulizers.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 97,
pulse 94, blood pressure 133/51, respiratory rate 20,
saturation 93% on 2 liters of oxygen through nasal cannula.
Drips with dopamine and intravenous fluids. In general,
somnolent but arousable. HEENT revealed pupils were equal,
round, and reactive to light and accommodation, but enlarged
to 6 mm, dry mucous membranes, sclerae were anicteric, no
jugular venous distention. Bilateral scars at carotids.
Cardiovascular had distant heart sounds. Pulmonary was clear
anteriorly. Abdominal examination was nontender and
nondistended, positive bowel sounds. Extremities had severe
ecchymoses of the left upper extremity, right upper
extremity, bilateral flanks. Skin breakdown on right arm,
draining serosanguineous fluid.
LABORATORY DATA ON PRESENTATION: White blood cell count
15.1, hematocrit 31.2, platelets 186. Sodium 137, potassium
4, chloride 100, bicarbonate 31, BUN 25, creatinine 0.9,
glucose of 108. INR 1.2, PTT 26.8, PT 13.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: The patient has had a tenuous course
from a cardiovascular standpoint. After the catheterization
the patient continued to drain frank blood from the
pericardial drain requiring several units of packed red blood
cells, fresh frozen plasma, and platelets. His aspirin and
Plavix were held during this episode. The bleeding
eventually stopped as documented by serial echocardiograms,
and the pericardial catheter was removed without any
complications. He was eventually weaned off the dopamine.
He was gradually started on Lopressor and Captopril. The
Lopressor dosage titration was limited by worsening shortness
of breath. He continued to have paroxysmal atrial
fibrillation, controlled by Lopressor and diltiazem. He also
continued to have intermittent chest pain with no
electrocardiogram changes and some relief with sublingual
nitroglycerin. Additionally, he has had episodes of
hypotension which have been responsive to fluid boluses. It
is likely the result of multiple medications and fluid
depletion.
In light of his recurrent hypotension, the captopril was
discontinued. He continued to be on aspirin and Plavix. His
last echocardiogram showed an ejection fraction of greater
than 55%, and no signs of tamponade.
2. PULMONARY: He continued to be on 2 liters of
supplemental oxygen with saturations of 92% to 93%. He
continued his Atrovent nebulizers, Atrovent MDI, and Medrol.
3. DERMATOLOGY: On the Medical Intensive Care Unit Service
he was treated with Levaquin for possible cellulitis.
However, it was discontinued in light of no source of
infection. He continued to have severe ecchymoses of his
extremities and groin. The effected areas had gotten
slightly better over the course of his stay. He has had skin
breakdown in his right arm. The wound cultures have been
negative. The friable skin is likely secondary to long-term
steroid use.
4. GENITOURINARY: The patient's flank hematoma tracked down
to his testicular and penile area. The ecchymosis is
currently stable and not expanding. The testicular edema was
unchanged. He has had a urinary tract infection and being
treated with a 10-day course of ciprofloxacin.
5. HEMATOLOGY: His hematocrit has been stable since removal
of his pericardial catheter.
6. CODE STATUS: The patient is do not resuscitate/do not
intubate.
DISCHARGE DIAGNOSES:
1. Coronary artery disease with 3-vessel disease, status
post stent times two to his left circumflex artery.
2. Urinary tract infection.
3. Chronic obstructive pulmonary disease.
4. Peripheral vascular disease.
5. Arthritis.
6. Status post carotid endarterectomy.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. b.i.d.
2. Cardizem 30 mg p.o. b.i.d.
3. Medrol 5 mg p.o. q.d.
4. Atrovent MDI 3 puffs b.i.d. with spacer.
5. Protonix 40 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d. times 30 days.
7. Neutra-Phos 1 packet t.i.d. with meals.
8. Aspirin 325 mg p.o. q.d.
9. Atrovent nebulizers q.4h.
10. Lipitor 80 mg p.o. q.d.
11. Sublingual nitroglycerin 0.4 mg q.5min. times three
p.r.n. for chest pain.
12. Ciprofloxacin 255 mg p.o. b.i.d. times 10 days.
13. Heparin 5000 units subcutaneous b.i.d.
14. Multivitamin 1 tablet p.o. q.d.
15. Tylenol p.r.n.
CONDITION AT DISCHARGE: Condition on discharge was guarded.
DISCHARGE STATUS: To [**Hospital3 1280**] Hospital.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2170-10-23**] 18:25
T: [**2170-10-25**] 07:40
JOB#: [**Job Number 35994**]
(cclist)
Admission Date: [**2170-10-5**] Discharge Date: [**2170-10-20**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
male with a past medical history of coronary artery disease
with angina, severe chronic obstructive pulmonary disease,
who was initially admitted to [**Hospital3 1280**] Hospital in
[**Location (un) 47**] for shortness of breath, substernal crushing chest
pain, and diaphoresis. Cardiac catheterization there showed
3-vessel disease (left main 70% occlusion, right coronary
artery 100%, left circumflex 90%, left anterior descending
artery 80% to 90%), with an ejection fraction of 65%.
The patient was subsequently transferred to [**Hospital1 346**] for possible coronary artery bypass
graft. On admission he was noted to have ecchymoses in his
left groin area (site of initial catheterization attempt at
[**Hospital3 1280**] Hospital) and left upper extremity (site where
catheterization was finally performed at [**Hospital3 1280**]
Hospital).
On [**10-6**], the patient had an episode of syncope while on
the commode with accompanying hypotension and was transferred
to the Medical Intensive Care Unit for further care. The
episode was thought to be secondary to vasovagal syncope.
While in the Medical Intensive Care Unit Service he had
another episode of syncope. Additionally, he had several
episodes of anginal type chest pain relieved by
nitroglycerin. An expanding hematoma in the left arm was
complicated by superimposed cellulitis, and he was started on
oxacillin and then switched to Levaquin. The left groin
hematoma also continued to expand. He has required several
blood transfusions due to a hematocrit drop. Cardiothoracic
Surgery felt the patient was not a good surgical candidate
given his severe chronic obstructive pulmonary disease.
Subsequently, the patient underwent high-risk angioplasty.
Catheterization showed left main 40% to 50% stenosis, and the
left circumflex was stented. His course was complicated by
hypotension secondary to cardiac tamponade. A pericardial
drain was placed which drained 700 cc of frank blood. His
hypotension resolved with dopamine and pericardial drainage.
He also sustained a right iliac dissection which was stented
at the end of the procedure.
Following catheterization, the patient was transfused 2 units
of packed red blood cells and 2 units of fresh frozen plasma
and transferred to the Coronary Care Unit.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease.
3. Peripheral vascular disease with claudication.
4. Status post bilateral carotid endarterectomy.
5. Peptic ulcer disease.
6. Arthritis.
MEDICATIONS ON TRANSFER: Protonix, Atrovent, Levaquin,
Beconase, Lipitor, nitroglycerin drip, Colace, aspirin,
Lopressor, and Atrovent nebulizers.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 97,
pulse 94, blood pressure 133/50, respiratory rate 20,
saturation 93% on 2 liters of oxygen via nasal cannula.
Drips with dopamine and intravenous fluids. In general,
somnolent but arousable. HEENT revealed pupils were equal,
round, and reactive to light and accommodation, but enlarged
to 6 mm, dry mucous membranes, sclerae were anicteric, no
jugular venous distention. Bilateral scars at carotids.
Cardiovascular had distant heart sounds. Pulmonary was clear
anteriorly. Abdominal examination was nontender and
nondistended, positive bowel sounds. Extremities had severe
ecchymoses of the left upper extremity, right upper
extremity, bilateral flanks. Skin breakdown on right arm,
draining serosanguineous fluid.
LABORATORY DATA ON PRESENTATION: White blood cell count
15.1, hematocrit 31.2, platelets 186. Sodium 137,
potassium 4, chloride 100, bicarbonate 31, BUN 25,
creatinine 0.9, glucose of 108. INR 1.2, PTT 26.8, PT 13.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: The patient has had a tenuous course
from a cardiovascular standpoint. After the catheterization,
the patient continued to drain frank blood from the
pericardial drain requiring several units of packed red blood
cells, fresh frozen plasma, and platelets. His aspirin and
Plavix were held during this episode. The bleeding
eventually stopped as documented by serial echocardiograms,
and the pericardial catheter was removed without any
complications. He was eventually weaned off the dopamine.
He was gradually started on Lopressor and diltiazem. He
continued to have intermittent chest pain with no
electrocardiogram changes and some relief with sublingual
nitroglycerin. Additionally, he has had episodes of
hypotension which have been responsive to fluid boluses. It
is likely the result of multiple medications and fluid
depletion.
In light of his recurrent hypotension, the captopril was
discontinued. He continued to be on aspirin and Plavix. His
last echocardiogram showed an ejection fraction of greater
than 55%, and no signs of tamponade.
2. PULMONARY: He continued to be on 2 liters of
supplemental oxygen with saturations of 92% to 93%. He
continued his Atrovent nebulizers, Atrovent MDI, and Medrol.
3. DERMATOLOGY: On the Medical Intensive Care Unit Service
he was treated with Levaquin for possible cellulitis.
However, it was discontinued in light of no source of
infection. He continued to have severe ecchymoses of his
extremities and groin. The effected areas had gotten
slightly better over the course of his stay. He has had skin
breakdown in his right arm. The wound cultures have been
negative. The friable skin is likely secondary to long-term
steroid use.
4. GENITOURINARY: The patient's flank hematoma tracked down
to his testicular and penile area. The ecchymoses is
currently stable and not expanding. The testicular edema was
unchanged. He has had a urinary tract infection and being
treated with a 10-day course of ciprofloxacin.
5. HEMATOLOGY: His hematocrit has been stable since removal
of the pericardial catheter.
6. CODE STATUS: Do not resuscitate/do not intubate.
DISCHARGE DIAGNOSES:
1. Coronary artery disease with 3-vessel disease, status
post stent times two to left circumflex artery.
2. Urinary tract infection.
3. Chronic obstructive pulmonary disease.
4. Peripheral vascular disease.
5. Arthritis.
6. Status post carotid endarterectomy.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. b.i.d.
2. Cardizem 30 mg p.o. b.i.d.
3. Medrol 4 mg p.o. q.d.
4. Atrovent MDI 3 puffs b.i.d. with spacer.
5. Protonix 40 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d. times 30 days.
7. Neutra-Phos 1 packet t.i.d. with meals.
8. Aspirin 325 mg p.o. q.d.
9. Atrovent nebulizers q.4h.
10. Lipitor 80 mg p.o. q.d.
11. Sublingual nitroglycerin 0.4 mg q.5min. times three for
chest pain.
12. Ciprofloxacin 250 mg p.o. b.i.d..
13. Heparin 5000 units subcutaneous b.i.d.
14. Multivitamin 1 tablet p.o. q.d.
15. Tylenol p.r.n.
CONDITION AT DISCHARGE: Condition on discharge was guarded.
??????DISCHARGE STATUS: To [**Hospital3 1280**] Hospital.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2170-10-31**] 20:38
T: [**2170-11-3**] 09:28
JOB#: [**Job Number 35995**]
(cclist)
|
[
"780.2",
"998.2",
"423.0",
"414.01",
"492.8",
"411.1",
"785.51",
"998.12",
"682.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.64",
"39.90",
"88.53",
"39.50",
"37.0",
"36.01",
"36.06",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
13648, 13915
|
13942, 14511
|
11471, 13627
|
14526, 14895
|
7708, 10022
|
10285, 11443
|
10044, 10259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,571
| 151,371
|
44900
|
Discharge summary
|
report
|
Admission Date: [**2107-7-25**] Discharge Date: [**2107-8-2**]
Date of Birth: [**2043-6-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Progressive DOE and fatigue
Major Surgical or Invasive Procedure:
[**7-25**] CABGx4 (LIMA->LAD, SVG->PDA, SVG->OM, SVG->D1)
History of Present Illness:
Mr [**Known lastname 28678**] is a 64 year old man who reported activity intolerance
over the past year. A cardiac catheterization prior to admission
showed 3VD and normal hemodynamics.He was therefore admitted on
[**2107-7-25**] for an elective CABG.
Past Medical History:
DM2
dyslipidemia
PVD with LE claudication
GERD
depression
diabetic neuropathy
CRI(1.9)
Social History:
divorced, estranged from immediate family
former etoh
-tob
on disability
Family History:
non contributory
Physical Exam:
NAD
140/70, 84 SR
HEENT -
Chest CTAB
CV: RRR -M/R/G, no edema, +pp
Neuro: MAE
Pertinent Results:
[**2107-8-2**] 05:50AM BLOOD Hct-29.2*
[**2107-8-2**] 05:50AM BLOOD UreaN-58* Creat-2.0* K-4.8
[**2107-8-1**] 06:00AM BLOOD UreaN-61* Creat-2.0*
[**2107-7-31**] 05:20AM BLOOD Glucose-80 UreaN-62* Creat-2.2* Na-138
K-4.1 Cl-101 HCO3-24 AnGap-17
Brief Hospital Course:
Ms. [**Known lastname 28678**] was trasferred to the SICU in critical but stable
condition on phenylephrine at 0.1. He was extubated by POD # 1.
His drips were weaned by POD#3, however he was started on
natrecor for several days. He was transferred to the staerp down
unit by post op day 5.His creatinine rose from baseline to 2.2
however returned to baseline within 2 days. He failed a voiding
trial and was started on flomax...
Medications on Admission:
avandia 8 QD, glipizide ER 10 QD,
zoloft 150 [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 QD, avapro 150 QD, crestor 10 QD, insulin
70/30 20 units QHS
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Tablet(s)
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: Two (2)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Rosiglitazone Maleate 2 mg Tablet Sig: Four (4) Tablet PO
DAILY (Daily).
12. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
13. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 4444**]
Discharge Diagnosis:
CAD
DM2
PVD
GERD
Depression
Neuropathy
CRI(1.9)
Discharge Condition:
Good.
Discharge Instructions:
Shower daily, washi incision with mild soap and water and pat
dry. No lotions, creams or powders, no baths.
No lifting more than 10 pounds or driving until after follow up
appointment with surgeon.
Call with temperature more than 101.5, redness or drainage from
incision, or weight gain more than 2 pounds in one day or five
in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 5686**] 2 weeks
Dr. [**Last Name (STitle) 3390**] 2 weeks
Completed by:[**2107-8-2**]
|
[
"414.01",
"272.4",
"411.1",
"250.60",
"440.21",
"424.0",
"530.81",
"788.20",
"357.2",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"39.61",
"99.04",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
3367, 3441
|
1304, 1735
|
347, 407
|
3533, 3541
|
1036, 1281
|
3927, 4079
|
905, 923
|
1944, 3344
|
3462, 3512
|
1761, 1921
|
3565, 3904
|
938, 1017
|
280, 309
|
435, 688
|
710, 799
|
815, 889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,021
| 152,568
|
21668
|
Discharge summary
|
report
|
Admission Date: [**2193-9-21**] Discharge Date: [**2193-9-27**]
Date of Birth: [**2138-4-26**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
mental status changes, alcohol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 56 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) **] w/ longstanding alcohol dependence who
presented to [**Hospital 56991**] Hospital seeking detox. By report, he
admitted to drinking one pint of liquor per day over the past 5
years. His last drink was on [**9-17**] when he tried to detox
himself, but then got sick. He presented to [**Hospital3 **] on [**2193-9-18**]. He has had 2 prior detoxes over the last 5
years. Longest period of sobriety was 3 months, which was
approximately one year ago. On [**2193-9-20**], pt began to see "ants"
and was given haldol 5 mg x 1. Later that day, he was found to
be not oriented to place or time. He was given depakote for
seizure prevention as well as ativan. He became more confused
during the day and received a total of 6 mg of ativan, 1500
depakote, 0.2 mg clonidine, and 15 mg of Haldol. He was then
brought to the emergency room, where he was noted to be alert
and oriented x 1, with confused speech, and tremulousness. He
was given a total of 90 mg valium, 2 mg ativan and was admitted
to the [**Hospital Unit Name 153**] for treatment of impending DT's and alcohol
withdrawal.
Past Medical History:
Etoh abuse as above (one pint of liquor x 5 years)
No history of DT's, seizures, blackouts
No other PMH
Social History:
works as restaurant manager for Papa [**Male First Name (un) 45193**] in [**Location (un) 5344**],
divorced with 3 children, lives in [**Hospital1 **]. Denies drug use or
tobacco, 2 prior detoxes, longest sobriety 3 mos long
Family History:
uncle with alcohol dependence
Physical Exam:
PE upon presentation: T 97 P 79 BP 140/82 R 18 sat 100% Room
air
Gen: obtunded, middle-aged man
HEENT: pupils 4 mm bilaterally, reactive to light, EOMI, OP
clear w/ white plaques on tongue; dry MM
Neck: supple, no LAD
skin: minor bruising, no spiders
Chest: anteriorly clear, exam limited [**2-18**] patient's
restraints/posey
CV: RRR, [**Last Name (un) 55863**] pulses, no m/r/g
ABD: thin, exam limited by posey, no tenderness, NABS, no caput
or spider angioma, liver edge 2-3 cm below costal margin
EXTRM: mild bruising throughout, good cap refill, no edema or
clubbing
NEURO: Initially obtunded, moving all extremities, unable to
cooperate with exam
NERUO exam upon [**Hospital Unit Name 153**] tranfer:
thought he was in [**Hospital1 392**], said date was [**2193-9-26**]. Knew president
was "[**Doctor Last Name **] W" but thought his running mate was [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) 1806**],
could not spell "world" backwards. Thought labor day was next
week. CN exam intact. Moving all extremities, limited by
restraints. Could not assess asterixis, finger to nose, given
posey/restraints.
Pertinent Results:
ADMIT LABS:
[**2193-9-21**] 06:18AM GLUCOSE-107* UREA N-3* CREAT-0.4* SODIUM-141
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2193-9-21**] 06:18AM ALT(SGPT)-65* AST(SGOT)-79* ALK PHOS-75 TOT
BILI-1.6*
[**2193-9-21**] 06:18AM CALCIUM-8.6 PHOSPHATE-1.2* MAGNESIUM-1.2*
[**2193-9-21**] 06:18AM WBC-3.3* RBC-3.66* HGB-13.3* HCT-36.4*
MCV-99* MCH-36.2* MCHC-36.4* RDW-11.1
[**2193-9-21**] 06:18AM PLT SMR-LOW PLT COUNT-90*
[**2193-9-21**] 06:18AM PT-12.1 PTT-25.1 INR(PT)-0.9
[**2193-9-20**] 10:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2193-9-20**] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2193-9-20**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2193-9-20**] 09:00PM GLUCOSE-128* UREA N-7 CREAT-0.6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
[**2193-9-20**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2193-9-20**] 09:00PM WBC-2.8* RBC-3.71* HGB-13.1* HCT-36.1* MCV-97
MCH-35.4* MCHC-36.4* RDW-11.3
[**2193-9-20**] 09:00PM NEUTS-50.1 LYMPHS-36.3 MONOS-10.8 EOS-1.5
BASOS-1.4
[**2193-9-20**] 09:00PM PLT COUNT-103*
Brief Hospital Course:
Patient was admitted to the [**Hospital Unit Name 153**]. He was protecting his airway
with no signs of impending seizures. He was continued on valium
per a CIWA scale. He was switched to an ativan drip on [**2193-9-21**]
for persistent CIWA scale from [**11-1**] and high valium
requirements. The drip was at 1.5 mg/hr with titration to CIVA
<8. Patient was sedated on this drip and he was transitioned to
oral valium over the next few days. The drip was turned off on
[**2193-9-24**]. On [**2193-9-24**], he was noted to have increasing secretions
with elevated temp to 102.8 and a ?RLL infiltrate on xray. He
was cultured and thought to have a possible aspiration
pneumonia. He was started on empiric treatment with levofloxacin
and flagyl. Blood cultures have been negative to date, but his
sputum grew pansensitive Strep pneumo. Patient has been afebrile
since this initial spike. He was noted to remain drowsy and
confused during his [**Hospital Unit Name 153**] course, but w/o hallucinations.
Initially, pt was NPO, given his change in mental status and
risk for aspiration. He was given IVF, banana bag for
supplementation, as well as thiamine, folate, and a
multivitamin.
Of note, he had a transaminitis on admission, which has slowly
improved during [**Hospital Unit Name 153**] course. Social work consultation was made
for addictions assistance. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] course continued
[**Date range (1) 56992**]/04, and then he was called out to the general medical
floor for the remainder of his hospital course. Please see below
for floor course.
1. Alcohol withdrawal: No valium requirement for over 48 hours
per CIWA scale monitoring. He initially had a 1:1 sitter and was
in restraints [**2-18**] agitation and pulling lines, confusion. All
of this agitation resolved within 24 hours of his stay on the
general medical floor. He was seen by the addictions consult and
given information on alcohol detox programs. He clearly stated
he was interested in remaining sober.
2.?aspiration: Pt thought to have ?RLL infiltrate on xray and
had temp x 1 in [**Hospital Unit Name 153**]. His sputum culture grew pan sensitive
strep pneumo. He is on levo/flagyl for coverage of aspiration as
well as community acquired pneumonia. He will be discharged with
a prescription to complete a 7 day course of levo.
3. tranaminitis: trended down to normal during admission. Likely
[**2-18**] alcohol intoxication.
4. FEN: continued thiamine, folate, regular diet (once mental
status improved).
5. ppx: bowel regimen
6. thrush: nystatin s/s during admission with improvement
7. anemia: slow trend downward during ICU stay to 30, then 32 at
discharge. Likely was [**2-18**] alcohol abuse vs blood draws vs
dilutional (received IVF upon admission) Borderline
macrocytosis, which likely points to alcohol as etiology. B12,
folate, fe studies all normal. No evidence of GI bleed. Should
f/u as outpatient to make sure count continue to normalize.
8. dispo: discharged to home to f/u in [**Company 191**] with new PCP (he did
not have one). To also follow up with social work (per
Addictions consult).
FULL CODE
Medications on Admission:
none at home
(received haldol, klonipin, depakote just before admission)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Alcohol dependence
Discharge Condition:
stable
Discharge Instructions:
**Please follow up with your new primary care physician, [**Name10 (NameIs) 3**]
below.
**Please follow up with social work, as below.
**You have 3 more days of antibiotic to complete treatment for
your mild pneumonia.
**It is also recommended that you take some nutritional
supplements, such as thiamine, a multivitamin, and folate, which
can be purchased over the counter.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1037**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2193-12-31**] 3:00
If you need to be seen sooner, please call the clinic for an
appointment.
Completed by:[**2193-9-27**]
|
[
"482.49",
"303.91",
"790.4",
"112.0",
"507.0",
"285.9",
"291.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7986, 7992
|
4421, 7584
|
352, 358
|
8074, 8082
|
3131, 4398
|
8506, 8807
|
1931, 1962
|
7707, 7963
|
8013, 8053
|
7610, 7684
|
8106, 8483
|
1977, 3112
|
271, 314
|
386, 1546
|
1568, 1673
|
1689, 1915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,119
| 111,916
|
10019
|
Discharge summary
|
report
|
Admission Date: [**2108-12-15**] Discharge Date: [**2108-12-19**]
Service: NEUROSURG
FINAL DIAGNOSIS: Cardiorespiratory arrest following
cerebrovascular accident.
HISTORY OF PRESENT ILLNESS: This is a 77 year old lady who
was transferred to [**Hospital1 69**]
status post fall with change in mental status. CT scan
showed evidence of subdural hemorrhage.
PHYSICAL EXAMINATION: On exam she was initially arousable to
name. Pupils were reactive. Air entry was bilaterally
equal. She had a pacemaker in situ with regular rate and
rhythm. There was no murmur. Abdomen was soft and
nontender, bowel sounds heard. Left hand showed evidence of
an old stroke with contracture and clonus and the same with
the left lower extremity. Neuro exam was not possible
because she was uncooperative. There was residual left
hemiparesis. She was moving the right arm and leg well.
LABORATORY DATA: CT scan was repeated on admission which
showed extension of the subdural hematoma involving the
sagittal, falx tentorium as well as the left convexity.
There was also parenchymal hemorrhage involving the occipital
and parietal lobes. There was substantial left to right
subtentorial herniation. Admission labs were hematocrit of
37.1, white cell count 12.4, platelets 219. INR was 3.2, PT
21.3, PTT 40.7. Sodium was 143, potassium 3.9, chloride 107,
bicarb 23, urea 28, creatinine 1. Blood sugar was 132. CK
was elevated to 1365, troponin less than 0.3.
HOSPITAL COURSE: The coagulopathy was corrected, but despite
there was an extension of the subdural bleed. The
neurosurgery team evaluated the possibility of evacuation of
the subdural hematoma to relieve the pressure. The patient's
general condition and very low ejection fraction put her at a
very high anesthesia risk. The risk was discussed with the
family and the family decided against any surgical
intervention and opted for comfort measures only.
The rest of the [**Hospital 228**] medical treatment was discontinued
and she was given morphine and comfort measures were given.
The patient eventually passed away on [**2108-12-19**], at
10:42 a.m.
CONDITION ON DISCHARGE: The patient expired at 10:42 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 33505**], M.D. [**MD Number(1) 33506**]
Dictated By:[**Doctor Last Name 22706**]
MEDQUIST36
D: [**2108-12-19**] 14:19
T: [**2108-12-23**] 09:53
JOB#: [**Job Number 33507**]
|
[
"427.31",
"V45.01",
"530.81",
"401.9",
"438.20",
"852.20",
"272.0",
"428.0",
"E884.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1485, 2128
|
113, 175
|
393, 1467
|
204, 370
|
2153, 2465
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,874
| 148,105
|
39838
|
Discharge summary
|
report
|
Admission Date: [**2168-1-20**] Discharge Date: [**2168-1-24**]
Date of Birth: [**2116-8-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Niacin / Heparin Agents / Vistaril / Propofol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain and shortness of breath with exertion
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x2
History of Present Illness:
51 year old female with history of coronary artery disease
admitted to OSH with DOE for a couple of months and chest pain
for 3 days. She began taking naprosyn for shoulder pain during
these 3 days of increase chest pain. She reports ride sided
chest pain and shortness of breath as well as new PND. She took
additional lasix with improvement in PND. She was transferred to
[**Hospital1 18**] for cardiac catheterization.
[**2168-1-6**] Cardiac Cath:
1. Coronary angiography in this right dominant system revealed
two
vessel coronary artery disease. The LMCA had no
angiographically
apparent disease. The LAD had a totally occluded ostium, with
faint
right-to-right and left-to-right collaterals noted. The LCX had
mild
disease and a widely patent stent. The RCA had patent stents
with an
ostial PDA lesion.
2. Resting hemodynamics revealed elevated right- and left-sided
filling
pressures, with mean RA pressure of 11 mmHg and mean PCW
pressure of 18
mmHg. There was moderate pulmonary hypertension, with mean PA
pressure
of 34 mmHg and peak PA pressure over greater than [**2-15**] systemic
pressure.
There was mild systemic hypertension, with SBP of 150 mmHg.
Past Medical History:
Heparin induced thrombocytopenia
Congestive heart failure EF=38%
Diabetes Mellitus
Hypertension
hyperlipidemia
CAD with PCI in [**2161**]- total of 3 stents
Chronic renal insufficiency
obesity
previous thigh abcess and breast wound swab +MRSA
cardiac arrest during anesthia induction
Past Surgical History
cataract surgery
right femur surgery
Social History:
-Tobacco history: 29 year smoking history, quit 7 years ago
-ETOH: Occasional
-Illicit drugs: None
Married. Lives in [**Location **], MA. 9 year old son.
Family History:
CAD.
Physical Exam:
Pulse:91 Resp:20 O2 sat:97/RA
B/P Right:135/50 Left:146/70
Height:5'2" Weight:245 lbs
General:NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right:+1 Left:+1
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2168-1-24**] 08:59AM BLOOD Hct-23.8* Plt Ct-218
[**2168-1-24**] 04:23AM BLOOD WBC-10.4 RBC-2.78* Hgb-7.3* Hct-22.6*
MCV-81* MCH-26.3* MCHC-32.4 RDW-14.8 Plt Ct-202
[**2168-1-23**] 03:41AM BLOOD WBC-9.7 RBC-2.90* Hgb-7.8* Hct-23.2*
MCV-80* MCH-26.9* MCHC-33.7 RDW-14.9 Plt Ct-155
[**2168-1-22**] 05:42AM BLOOD WBC-10.7 RBC-3.06* Hgb-8.1* Hct-24.4*
MCV-80* MCH-26.6* MCHC-33.4 RDW-14.9 Plt Ct-127*
[**2168-1-24**] 04:23AM BLOOD Glucose-131* UreaN-53* Creat-1.3* Na-131*
K-4.3 Cl-96 HCO3-28 AnGap-11
[**2168-1-23**] 03:41AM BLOOD Glucose-172* UreaN-43* Creat-1.1 Na-133
K-4.4 Cl-98 HCO3-29 AnGap-10
[**2168-1-22**] 05:42AM BLOOD Glucose-111* UreaN-38* Creat-1.1 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2168-1-20**]
Echo:
PRE BYPASS The left atrium is mildly dilated. The left atrium is
elongated. Mild spontaneous echo contrast is seen in the body of
the left atrium. The left atrial appendage emptying velocity is
depressed (<0.2m/s). Mild spontaneous echo contrast is seen in
the body of the right atrium. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is moderate regional left ventricular systolic dysfunction with
apical akinesis and at least the suggestion of a small apical
aneurysm. The mid-distal septal segments, and distal anterior
walls are severely hypokinetic. The rest of the walls display
mild global hypokinesis. There is no ventricular septal defect
seen. The right ventricle displays borderline normal free wall
function. The right ventricular apex is not well seen. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS Normal right ventricular systolic function. Left
ventricle displays same focal deficits noted in pre-bypass but
other wall segments show improved function. Overall ejection
fraction now about 40%. Mitral and tricuspid regurgitation
improved from pre-bypass - now mild. The thoracic aorta is
intact after decannulation.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2168-1-20**] where the patient underwent coronary
bypass grafting x2 with left internal mammary artery to left
anterior descending coronary and reverse saphenous vein single
graft from aorta to posterior descending coronary artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. She was started
on iron supplements for a hematocrit of 23.8, for which she was
asymptomatic. Home dose regimen of insulin was reinstituted and
blood sugars were improved at the time of discharge. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with VNA services and home physical
therapy in good condition with appropriate follow up
instructions.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - one Tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - one Tablet(s) by mouth daily
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - one
Tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet -
one
Tablet(s) by mouth twice a day
GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule -
one Capsule(s) by mouth twice a day
GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet -
one Tablet(s) by mouth twice a day
HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - one Tablet(s) by mouth every 6
hours as needed
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 35 units every morning and 70 units every
evening
INSULIN LISPRO [HUMALOG PEN] - (Prescribed by Other Provider) -
100 unit/mL Insulin Pen - sliding scale before meals and at
bedtime
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - one Tablet(s) by mouth twice a
day
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - one
Tablet(s) by mouth daily
METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet -
one Tablet(s) by mouth twice a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - one Tablet(s) by mouth twice a day
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg
Capsule
- one Capsule(s) by mouth twice a day
TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - one
Tablet(s) by mouth twice a day as needed
ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily at bedtime as needed
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one
Tablet(s) by mouth daily
CALCIUM CARBONATE [CALCIUM 600] - (Prescribed by Other
Provider)
- 600 mg (1,500 mg) Tablet - one Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - one Capsule(s) by mouth daily
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,200 mg-144 mg Capsule - one Capsule(s) by mouth twice a day
Plavix - last dose:[**2168-1-6**] 75mg
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
10. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
17. potassium chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO twice a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
18. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
19. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Lantus 100 unit/mL Solution Sig: 35 units qam and 70 units
qpm units Subcutaneous as directed.
Disp:*1 vial* Refills:*2*
21. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: Based on fingerstick sliding
scale.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
HIT(recent neg),h/o CHF,IDDM,HTN,hyperlipidemia,PCI x3 ([**2161**]),
morbid obesity,previous thigh abcess and breast wound swab +MRSA
cardiac arrest during anesthia induction,cataract surgery,right
femur surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema 1+
bilateral LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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**
Recommended Follow-up:
Followup Instructions:
You have a follow up appointment with your surgeon Dr.[**First Name8 (NamePattern2) 177**]
[**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2168-2-16**] 1:00.
Dr.[**Name (NI) 9379**] office will call you to schedule an appointment
with your cardiologist.
Please contact your primary care doctor Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 67560**]
to be seen in 4 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:[**2168-1-24**]
|
[
"278.01",
"250.00",
"585.9",
"V85.41",
"412",
"272.4",
"403.90",
"V12.53",
"V12.04",
"V45.82",
"V15.82",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
11343, 11426
|
5223, 6693
|
361, 395
|
11683, 11913
|
2835, 5200
|
12860, 13468
|
2150, 2156
|
9093, 11320
|
11447, 11662
|
6719, 9070
|
11937, 12837
|
2171, 2816
|
272, 323
|
423, 1595
|
1617, 1962
|
1978, 2134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,883
| 172,093
|
41080
|
Discharge summary
|
report
|
Admission Date: [**2188-2-13**] Discharge Date: [**2188-2-18**]
Date of Birth: [**2129-11-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / lisinopril / Losartan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Old anterior myocardial infarction with Left ventricular
thrombus. Surgical consultation to examine benefits of
revascularization. No symptoms of heart failure at this time.
Major Surgical or Invasive Procedure:
[**2188-2-13**] Coronary artery bypass grafting x2 with the left
internal mammary artery graft to left anterior descending,
reverse saphenous vein graft to diagonal branch
[**2188-2-14**] Right popliteal/tibial artery embolectomy
History of Present Illness:
58 year old male with history of ischemic cardiomyopathy.
Calculated EF by MRI is 44%. Regional wall motion abnormalities
and late gadolinium enhancement consistent with prior anterior,
anteroseptal, and anteroapical myocardial infarction. No
evidence of LV thrombus by MRI on [**2187-10-22**].
Past Medical History:
Ischemic cardiomyopathy. s/p AMI [**2184**], EF 44%
LV apical thrombus by echo [**2187-10-15**]-now on Pradaxa
Left anterior fasicular block
Hyperlipidemia
Perforated sigmoid diverticulitis
Post-operative ileus
Hx DVT/PE
Abdominal surgery x4 for perforated
sigmoid diverticulitis-prior [**Doctor Last Name **] colostomy.
Ventral hernia repair-anterior abdominal wall
Skin cancer resection
Social History:
Lives with: alone
Occupation: Musician/Teacher
Tobacco: none
ETOH: [**1-18**]/week
Family History:
Father-prostate CA(64yo), Mother-uterine CA(68yo),
Grandfather-MI(50yo)
Physical Exam:
Pulse: 68 Resp: 18 O2 Sat: 100% RA
B/P Right: Left: 122/82
Height: 5'[**87**]" Weight: 189 lbs
General: NAD,
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Softly Distended [x] Bowel sounds
+ [x] well healed mid-line incision, two horizontal scars at
previous stoma sites, mild TTP at previous stoma sites
Extremities: Warm [x], well-perfused [x]
Edema trace
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 none
Pertinent Results:
[**2188-2-13**] Echo: PRE-CPB: The left atrium is mildly dilated. No
thrombus is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. The left ventricular
cavity is mildly dilated. The apical anterior and anteroseptal
wall segments are thinned and akinetic. The apex is also
akinetic. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %). A large globular thrombus
is seen in the apex of the left ventricle, measuring 1.5cm x
1.7cm. The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. No thoracic aortic dissection is seen. There are three
aortic valve leaflets. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
POST-CPB: The LV thrombus is no longer seen. The LV continues to
have regional wall motion abnormalities as described pre-bypass.
The estimated EF is 40-45%. The RV systolic function is normal.
There is no evidence of aortic dissection.
[**2188-2-13**] Carotid U/S: Limited study particularly of the right
carotid due to the central line but no evidence of stenosis seen
bilaterally.
[**2188-2-14**] CTA: 1. Thrombus in mid-to-distal right below-knee
popliteal artery extending into the proximal right anterior
tibial artery and filling the entire right common
tibial-peroneal trunk. Multiple filling defects in right
posterior tibial and peroneal arteries. Multiple filling defects
in left anterior tibial artery and diminutive flow in the left
distal peroneal artery. 2. Bilateral small pleural effusions and
adjacent opacities at the lung bases, likely atelectasis.
Patient is status post CABG with air within the mediastinum
post-surgical. 3. Ventral abdominal wall hernia with loops of
bowel; however, no stranding and no evidence of bowel
obstruction. 4. Colonic diverticulosis.
[**2188-2-18**] 06:00AM BLOOD WBC-5.8 RBC-3.60* Hgb-11.5* Hct-34.0*
MCV-95 MCH-31.8 MCHC-33.7 RDW-12.7 Plt Ct-235#
[**2188-2-13**] 01:19PM BLOOD WBC-10.8# RBC-3.17*# Hgb-10.5*#
Hct-30.4*# MCV-96 MCH-33.1* MCHC-34.6 RDW-12.9 Plt Ct-129*
[**2188-2-18**] 06:00AM BLOOD Plt Ct-235#
[**2188-2-18**] 06:00AM BLOOD PT-30.9* PTT-28.2 INR(PT)-3.0*
[**2188-2-13**] 01:19PM BLOOD PT-14.7* PTT-27.6 INR(PT)-1.3*
[**2188-2-13**] 01:19PM BLOOD Fibrino-181
[**2188-2-18**] 06:00AM BLOOD Glucose-143* UreaN-18 Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-28 AnGap-10
[**2188-2-13**] 02:35PM BLOOD UreaN-20 Creat-0.8 Na-138 K-4.0 Cl-108
HCO3-26 AnGap-8
[**2188-2-13**] 02:35PM BLOOD UreaN-20 Creat-0.8 Na-138 K-4.0 Cl-108
HCO3-26 AnGap-8
[**2188-2-18**] 06:00AM BLOOD Glucose-143* UreaN-18 Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-28 AnGap-10
Brief Hospital Course:
Was admitted to same day surgery and was brought to the
operating room where he underwent a coronary artery bypass graft
x 2. Please see operative report for surgical details, of note
there was LV thrombus noted on TEE seen at start of case, not
present after bypass. He had dopplerable pulses in both groins
and both extremities in the OR and following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. He underwent an urgent carotid duplex to further
examine for thrombus which was negative. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
Shortly after extubation there was a loss of Doppler signals in
his right lower extremity both DP and PT. Vascular surgery was
immediately consulted and he underwent a CTA which showed a
thrombus in mid-to-distal right below-knee popliteal artery
extending into the proximal right anterior tibial artery and
filling the entire right common tibial-peroneal trunk. He was
then brought to the operating room where he underwent a right
popliteal/tibial artery embolectomy. Following surgery he was
again transferred back to the CVICU. Heparin was started and
later that day he was weaned from sedation and extubated without
incident. Beta blockers and diuretics were started and he was
gently diuresed towards his pre-op weight. On post-op day two he
was transferred to the step-down floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol. He
continued to make good progress while working with physical
therapy for strength and mobility. He was initiated on coumadin
for LV thrombus and right leg thrombosis. He was ready for
discharge home with services on [**2188-2-18**]. He was unable to be
started on ace inhibitor due to blood pressure and needs to be
considered as an outpatient.
Medications on Admission:
Celexa daily (? dose) x past month
Metoprolol 25'
Simvastatin 80'
Fish oil 1000'
ASA 81'
Pradaxa 150"
Temazepam 15 PRN insomnia
CoQ10 50'
Calcium
Melatonin 3 HS
Vit D
Saw [**Location (un) **]
Grape Seed
Garlic
Advil 200-400 daily PRN abdominal pain
ES Tylenol 6-8 tabs/day - stopped
Hydrocodone cough syrup - pt unable to identify name PRN - ?
dosage - takes "swigs" occassionally
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. warfarin 1 mg Tablet Sig: inr goal 2-3 Tablets PO once a day:
please take [**11-18**] tablet (0.5 mg) on [**2-19**] then have INR drawn [**2-20**]
for further dosing .
Disp:*100 Tablet(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
10. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
11. ACE inhibitor
Please consider starting ace inhibitor as outpatient as he does
not have enough blood pressure to start as inpatient
12. coumadin/INR
Labs: PT/INR for Coumadin ?????? indication:LV clot/s/p right
popliteal embolectomy
Goal INR: [**12-20**]
First draw [**2-20**] wednesday
Results to [**Hospital1 **] heart center phone [**Telephone/Fax (1) 6256**]
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Coronary artery disease s/p CABG
Ischemic right foot with popliteal artery embolus s/p
embolectomy
Ischemic cardiomyopathy
Chronic systolic heart failure
LV apical thrombus
Left anterior fasicular block
Hyperlipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage
Right medial calf - incision from embolectomy - leave open to
air
Edema +1 bilateral
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) **] at MWMC on [**3-6**] at 9:30AM
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] in [**Location (un) 1110**] on [**3-10**] at 11AM
Vascular surgery: Dr. [**Last Name (STitle) **] [**2188-3-11**] 4:00 pm
Wound check in [**Hospital Unit Name **], [**Hospital Unit Name **] on Tues [**2188-2-26**] at
10:15am
Please call to schedule appointments with your
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27772**] in [**2-19**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication:LV clot/s/p right
popliteal embolectomy
Goal INR: [**12-20**]
First draw [**2-20**] wednesday
Results to [**Hospital1 **] heart center phone [**Telephone/Fax (1) 6256**]
Completed by:[**2188-2-18**]
|
[
"414.8",
"412",
"272.4",
"997.2",
"414.01",
"426.2",
"428.0",
"E878.2",
"428.22",
"444.22",
"429.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11",
"38.08"
] |
icd9pcs
|
[
[
[]
]
] |
9231, 9269
|
5208, 7048
|
476, 707
|
9531, 9824
|
2372, 5185
|
10664, 11661
|
1559, 1632
|
7479, 9208
|
9290, 9510
|
7074, 7456
|
9848, 10641
|
1647, 2353
|
263, 438
|
735, 1031
|
1053, 1443
|
1459, 1543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,068
| 190,829
|
42990+42991
|
Discharge summary
|
report+report
|
Admission Date: [**2190-11-25**] Discharge Date: [**2190-11-29**]
Date of Birth: [**2154-6-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Epilepsy
Major Surgical or Invasive Procedure:
[**2190-11-25**]: s/p left temporal lobectomy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
History of Present Illness:
This is a 36 yo RH man with refractory complex partial and
simple partial epilepsy who had Bilateral hippocampal depth
electrodes, bilateral fronto-orbital depth electrodes, bilateral
temple strip electrodes x3, right frontolateral reference
electrodes" on [**10-13**] by Dr. [**Last Name (STitle) **]. The electrodes were removed
after localization of seizure focus and a temporal lobectomy was
planned.
Past Medical History:
Epilepsy - seizures typicall consist of <5 minutes difficulty
producing speech, body rigidity, no LOC
Hepatitis B
HSV
Depression
Social History:
This patient is married with a 22 month old son. [**Name (NI) **] works for
TSA at an airport. He is a 8 py smoker but has not smoked since
high school. He occasionally uses EtOH. He denies drug use.
Family History:
He was adopted from Vietnamese Orphanage at age 18 months. He
has no knowledge of parents/relatives.
Physical Exam:
On admission:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2-1.5 EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift
Upon Discharge:
Oriented x 3. PERRL, EOMs intact.
Face symmetric, tongue midline.
No drift.
Full strength and sensation throughout.
Ambulating without assistance.
Incision clean, dry, and intact - sutures in place.
Pertinent Results:
Head CT [**2190-11-25**] - post-op scan:
IMPRESSION:
1. Patient is status post temporal-frontal craniectomy with post
surgical
changes including bifrontal pneumocephalus, left temporal fossa
pneumocephalus, subcutaneous emphysema within the surgical area
and swelling of soft tissue. In comparison to prior CTs, there
is diffuse cervical effacement underlying areas of
pneumocephalus.
2. Residual blood is noted in the surgical bed extending to the
left temporal fossa. There is no other foci of intracranial
bleed or acute infarction.
Followup CT is recommended with attention to this area.
3. Fluid collection is noted within the surgical bed in the left
temporal
region.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 39193**] was electively admitted on [**2190-11-25**] for a left
temporal lobectomy with Dr. [**Last Name (STitle) **] for seizure control.
Post-operatively he was extubated and transitioned to the ICU.
He had headache and mild nausea controlled with medications. His
post-op CT showed post-surgical changes as well as
pneumocephalus. O2 treatment was recommended. He was
neuologically intact.
On POD#1 his headache has improved somewhat. He was without
seizure activity. His foley was discontinued. His diet was
advanced. He was neurologically intact and was transfered to the
SDU. He continued to be medically stable and was evaluated by PT
who felt that he was safe to be discharged to home without
services. He was discharged to home on [**2190-11-29**].
Medications on Admission:
Lamictal 100 mg b.i.d., Zonegran 200 mg b.i.d., Valtrex,
gabapentin 400 mg t.i.d., Celexa, and Strattera.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp/Ha.
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
7. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO Q 12H
(Every 12 Hours).
8. Atomoxetine 40 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-18**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) for 1 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) for 1 days: on [**11-29**].
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Neurologically stable. Oriented x 3. Ambulating without
assistance.
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.
??????You may wash your hair only after sutures have been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????No Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin for
4 weeks post-operatively
??????Please continue to take your home seizure medications as
prescribed by your neurologist
??????Clearance to return to work will be addressed at your
post-operative office visit. No driving.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
Followup Instructions:
-Please return to clinic on [**2190-12-8**] at 10am for suture removal
with the nurse practitioner. Please call [**Telephone/Fax (1) 3231**] to make
any changes to your appointments.
-Please follow-up with your Neurosurgeon 4 weeks
post-operatively with a Head CT w/o contrast. You will also need
to be seen 3 months post-operatively with a MRI Brain with and
without contrast. Please call [**Location (un) 3230**] at [**Telephone/Fax (1) 3231**] to make
this appointment.
Completed by:[**2190-11-29**] Admission Date: [**2190-12-3**] Discharge Date: [**2190-12-9**]
Date of Birth: [**2154-6-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Headache and Back Pain
Major Surgical or Invasive Procedure:
Lumbar Puncture x2
History of Present Illness:
This is a 36 y/o with intractable epilepsy who had depth
electrode and subdural grid monitory from [**2190-10-13**] to [**2190-10-22**].
He underwent a left temporal lobectomy with Dr. [**Last Name (STitle) **] on
[**11-16**]/0/09. He reports that he has had pain at his incision site
since being discharged, which has improved. Starting yesterday
he noted low
back pain and neck pain. This this has progressively worsened
over the
last 24 hours to where he now has excrutiating pain with even to
slightest movements of his limbs. He notably denies any fevers.
His appetite has been poor and he has been forcing himself to
eat
only small quantities. His headache is overall improved since
the
surgery. No abdominal pain. No constipation or diarrhea.
Past Medical History:
Epilepsy - seizures typicall consist of <5 minutes difficulty
producing speech, body rigidity, no LOC
Hepatitis B
HSV
Depression
Social History:
This patient is married. He has 2 children. He works for TSA at
an airport. He is a 8 py smoker but has not smoked since high
school. He occasionally uses EtOH. He denies drug use.
Family History:
He was adopted from Vietnamese Orphanage at age 18 months. He
has no knowledge of parents/relatives.
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 96.5 BP: 123/79 HR:84 R:20 O2Sats: 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-16**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 3
Left 2 2 2 3 3
Toes downgoing on R, upgoing on L.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge: The patient was oriented x 3. PERRL, EOMs intact.
Face symmetric, tongue midline. No drift.
Full strenght throughout.
All incisions are healed and all sutures have been
removed.
Ambulating independently.
Pertinent Results:
[**2190-12-3**]
GLUCOSE-137* UREA N-8 CREAT-1.1 SODIUM-139 POTASSIUM-4.3
CHLORIDE-106 TOTAL CO2-27 ANION GAP-10
CALCIUM-8.4 PHOSPHATE-2.7 MAGNESIUM-1.8
WBC-13.9* RBC-3.79* HGB-12.4* HCT-34.6* MCV-91 MCH-32.8*
MCHC-36.0* RDW-12.8
PLT COUNT-227
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
LACTATE-1.7
PT-10.9 PTT-25.4 INR(PT)-0.9
GLUCOSE-129* UREA N-7 CREAT-1.2 SODIUM-139 POTASSIUM-3.8
CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
estGFR-Using this
WBC-11.3*# RBC-4.31* HGB-13.9* HCT-39.7* MCV-92 MCH-32.2*
MCHC-34.9 RDW-12.9
NEUTS-64.5 LYMPHS-27.1 MONOS-6.0 EOS-1.2 BASOS-1.2
NEUTS-64.5 LYMPHS-27.1 MONOS-6.0 EOS-1.2 BASOS-1.2
PLT COUNT-248
[**2190-12-2**] Head CT:
Postoperative change from left temporal lobectomy, with slight
increase in the degree of blood products in the left temporal
lobectomy site.
Brief Hospital Course:
Mr. [**Known lastname 39193**] was admitted to the Neurosurgery service. He was
started on Vancomycin and Ceftazidime for presumed meningitis.
Bedside LP was attempted without success. INR LP was ordered. He
was receiving Morphine and Valium for pain control.
He had significant nausea and emesis. His craniotomy site was
clean and dry without erythema but their was an increasing tense
collection. He was transfered to the step down unit for Q2 hr
neuro checks in the pm of [**2190-12-3**] after the LP.
He had an MRI +/-gad which showed expected post-operative
changes. A repeat LP was done on [**12-5**] and cultures were sent.
On [**12-7**] a PICC line was placed for home antibiotics. [**12-8**]
final antibiotic recommendations were made. The patient's
girlfriend will be helping to administer the IV antibiotics. She
was taught how to do this on [**2190-12-9**] and then the pt was
discharged home with services.
As of [**12-9**] preliminary cultures have shown no microorganisms.
HSV negative.
Medications on Admission:
Medications prior to admission:
Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID
Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID
Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H
Zonisamide 200 mg Capsule Sig: One (1) Capsule PO Q 12H
Atomoxetine 40 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-18**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO Q 12H
(Every 12 Hours).
6. Atomoxetine 40 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain/spasm.
Disp:*20 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain: Take with food.
Disp:*40 Tablet(s)* Refills:*0*
11. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for Pain: No driving while on this medication.
Disp:*40 Tablet(s)* Refills:*0*
12. CefTAZidime 2 g IV Q8H
13. Vancomycin 1000 mg IV Q 8H
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Sodium Chloride 0.9 % 0.9 % Syringe Sig: 5-20 MLs Injection
SASH and PRN as needed for line flush.
17. Alteplase 2 mg Recon Soln Sig: Two (2) mg Injection PRN as
needed for occlusion or sluggishness.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Life care
Discharge Diagnosis:
Meningitis
Epilepsy
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
General Instructions
??????Take your pain medicine as prescribed.
??????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.
Followup Instructions:
Follow-Up Appointment Instructions
-Please follow-up with your Neurosurgeon 4 weeks
post-operatively with a Head CT w/o contrast. You will also need
to be seen 3 months post-operatively with a MRI Brain with and
without contrast. Please call [**Location (un) 3230**] at [**Telephone/Fax (1) 3231**] to make
this appointment.
Please follow-up with Infectious Disease on [**2190-12-27**] 9:30am
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2190-12-27**] 9:30am
[**Hospital **] Medical Building, G level.
Completed by:[**2190-12-9**]
|
[
"322.9",
"V12.09",
"345.91",
"054.9",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31",
"01.53"
] |
icd9pcs
|
[
[
[]
]
] |
14693, 14757
|
11521, 12528
|
7606, 7627
|
14821, 14821
|
10577, 11346
|
15289, 15901
|
8774, 8876
|
13064, 14670
|
14778, 14800
|
12554, 12554
|
14966, 15266
|
8920, 9127
|
12586, 13041
|
10297, 10558
|
7544, 7568
|
2390, 2590
|
7655, 8407
|
9420, 10283
|
11355, 11498
|
8905, 8905
|
14835, 14942
|
8429, 8559
|
8575, 8758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,667
| 195,432
|
12623
|
Discharge summary
|
report
|
Admission Date: [**2125-5-2**] Discharge Date: [**2125-5-29**]
Date of Birth: [**2069-7-5**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Symptomatic ascending and descending aortic
aneurysm.
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old
Ethiopian gentleman who presented with back pain. CAT scan
at the time and transthoracic echocardiogram revealed a 7.0
centimeter descending aortic aneurysm with a dilated aortic
root and severe aortic insufficiency. This was confirmed by
cardiac catheterization which showed that he had normal
coronary arteries.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS ON ADMISSION:
1. Labetalol 200 mg b.i.d.
2. Zestril.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient underwent replacement of his
aortic valve with a #25 St Jude valve and replacement of the
ascending and descending aorta in a one stage procedure on
[**2125-5-2**]. He was subsequently transported to the CSRU in
stable and intubated condition. He was on a Nitroglycerin
and Nipride drip initially in the CSRU. Slow weaning of his
ventilator support was started on postoperative day zero.
On postoperative day one, it was noted that he had no
movement in his bilateral lower extremities. A cerebrospinal
fluid drain was placed at this point to reduce spinal cord
edema. Neurology consultation was obtained at this time.
The findings were consistent with paraplegia likely to be the
result of anterior spinal artery syndrome probably due to
spinal cord ischemia during the surgery. He was started on
intravenous steroids to decrease the potential edema around
the cord and cerebrospinal fluid drainage was continued. He
remained hemodynamically stable over the next few days. He
needed BiPAP on postoperative day two for slight respiratory
difficulty due to pleural effusion. During this time, he did
not recover motor function in the lower extremities.
His examination findings at this time were cranial nerves II
through XII intact. The tone was normal in upper
extremities, flaccid in lower extremities equally. Light
touch sensation was preserved throughout the lower
extremities. Vibration was normal in the upper extremities.
It was decreased but preserved in the lower extremities. Pin
prick was dull instead of sharp distal to T3 bilaterally.
Strength was [**5-27**] upper extremities throughout with no
movement in either leg. Reflexes upper extremities positive.
Diminished but equal patella, Achilles. Cerebellar
examination was slow but equivocal rapid alternating
movements.
Renal consultation was obtained on [**2125-5-6**], due to rising
creatinine. This was felt to be prerenal azotemia. Per
renal recommendations, his Captopril was discontinued. He
continued to steadily improve apart from his paraplegia. His
renal failure resolved. His chest tubes and pacing wires
were discontinued on [**2125-5-7**]. He was transferred from the
CSRU to regular floor on [**2125-5-9**].
A sacral decubitus ulcer was noted prior to transfer. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consultation was obtained on [**2125-5-10**], for rising
blood sugar. Per recommendation, he was started on Glipizide
and sliding scale. He was also continued on Coumadin and
Heparin drip. On [**2125-5-13**], he had a high fever up to 101.5.
His Foley was changed. He was started on Diflucan apart from
the Vancomycin and Levaquin that he was already on. Skin
care consultation was obtained for the coccygeal decubitus
ulcer and recommendations followed.
Rehabilitation screening was started. His Foley catheter was
discontinued on [**2125-5-14**], and he was started on a bladder and
bowel regimen including intermittent straight
catheterization. He continued to be stable over the rest of
his stay in the hospital while awaiting a rehabilitation bed.
He was started on Baclofen for leg cramps per neurology
recommendation.
A plastic surgery consultation was obtained on [**2125-5-28**], for
the sacral decubitus ulcer and per recommendations Duoderm
patch is currently being used. A urology consultation was
also obtained on [**2125-5-25**], as the patient expressed concern
regarding his future sexual activity. Recommendation from
the urologist was that Viagra could work well. They also
mentioned erection could stimulate autonomic dysreflexia if
he was risk. If Viagra was not successful, other medical
modalities like , etc., could be explored. The
patient was not interested at the current time but was aware
of the options.
The patient is currently ready for discharge awaiting a
rehabilitation bed.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding scale.
2. Dulcolax 10 mg PR q.d.
3. Vitamin C 500 mg b.i.d.
4. Colace 100 mg b.i.d.
5. Enteric Coated Aspirin 325 mg q.d.
6. Glipizide 5 mg b.i.d.
7. Clonidine TTS 0.3 mg per day, change q.week.
8. Labetalol 400 mg p.o. b.i.d.
9. Duoderm patch to coccyx, change every two days.
10. Norvasc 10 mg q.d.
11. Protonix 40 mg q.d.
12. Zinc Sulfate 220 mg q.d.
13. Baclofen 20 mg t.i.d.
14. TUMS two t.i.d.
15. Magnesium Oxide 200 mg b.i.d.
16. Multivitamins one q.d.
17. Benadryl 25 mg q.h.s. p.r.n.
18. Tylenol 650 mg q4hours p.r.n.
19. Percocet one to two tablets q4-6hours p.r.n.
20. Serax 15 to 30 mg q.h.s. p.r.n.
21. Coumadin 5 mg q.d.
FO[**Last Name (STitle) **]P: Dr. [**Last Name (Prefixes) **] in four weeks. Follow-up with
neurology in four to six weeks. Urology follow-up with Dr.
[**Last Name (STitle) 9345**] in four to six weeks.
CONDITION ON DISCHARGE: Stable.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2125-5-29**] 17:26
T: [**2125-5-29**] 17:38
JOB#: [**Job Number 39011**]
|
[
"344.1",
"707.0",
"336.1",
"997.09",
"276.1",
"E878.1",
"441.2",
"584.9",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.44",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
4660, 5540
|
658, 738
|
756, 4634
|
163, 218
|
247, 593
|
617, 632
|
5565, 5838
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,134
| 141,412
|
35792
|
Discharge summary
|
report
|
Admission Date: [**2122-3-16**] Discharge Date: [**2122-3-23**]
Date of Birth: [**2058-4-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation [**3-16**]; Extubation [**3-17**]
PICC placement
History of Present Illness:
63M BIBEMS from Asst'd living for unresposniveness, intubated in
the field by EMS for aiwray protection. By report pt was in his
USOH last night (last seen when 8 pm meds were administered),
but was found by the personal care assistant at his [**Hospital **] Facility at 7:35 this morning in his bed. He as "foaming
at mouth," and he had evidence of significant bladder
incontinence. He was lying across the bed with his feet on the
floor and his head touching the wall. His eyes were closed and
he was completely unresponsive. There was no observed movement.
EMS was called. When they put a mask on his face, the PCA saw
him move his hand a little; it appeared volitional to her.
Nonetheless, because he was unresponsive, he was intubated. He
received 120 succ and 10 Versed at approx 8 AM.
Initial evaluation in the ED revealed "unresponsiveness with
non-reactive pupils, absent corneal reflexes, and decorticate
posturing." (At this point, an emergent CTA to evaluate
vertebrobasilar system was recommended.) He underwent imaging:
CTA head, which revealed .... Neuro was consulted and found his
exam to be improving. In the ED he received 750mg Levaquin for ?
atelectastsis vs infiltrate on CXR, 1500cc NS, and K repletion.
He has an 18g EJ and an 18g AC for access and has been HD
stable. An ABG on the vent was: 7.49/30/500/23 on 500 x 14 x 5 x
100%. He was sedated with Versed on the vent.
He has no known history of seizures, and the [**Doctor Last Name **] staff know of no
recent evidence of CNS trauma or infection. ROS is not
possible.
Past Medical History:
DM, type 2
HTN
CAD s/p MI
PVD
Diverticulosis
Achalasia
Depression
Panic disorder
Cyclic vomiting
Agoraphobia
"slow movements" per [**Doctor Last Name **] chart
Social History:
He has been a resident of [**Location 4367**] [**Hospital3 400**] ([**Telephone/Fax (1) 80657**])
since [**2121-12-4**]. PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**] [**Telephone/Fax (1) 608**]. Brother
is next of [**Doctor First Name **]: [**Name (NI) **] [**Name (NI) 4597**] [**Telephone/Fax (1) 81405**] or [**Telephone/Fax (1) 81406**]. He
has a history of alcohol abuse but has not had any since moving
into the [**Doctor Last Name **] facility over 3 months ago. He has a long smoking
history but quit in the last couple of weeks, now using the
nicotine patch. Other substance abuse is not known. He is
generally independently mobile but with "slow movements" and
requires assistance with medications and with personal care. The
underlying reason for these needs is unclear at this time.
Family History:
Unknown
Physical Exam:
VS: afebrile (temp < 100), satting well on room air,
normotensive.
Gen: NAD
HEENT: PERRL
CV: s1s2 irregular no m/r/g
PULM: CTAB
Abd: +BS, soft, NT/ND
Ext: MAE, increased tone in upper ext, follows commands
inconsistently
Neuro: Alert, follows commands inconsistently
Pertinent Results:
[**2122-3-16**] 04:59PM BLOOD WBC-10.0 RBC-4.31* Hgb-12.6* Hct-35.1*
MCV-82 MCH-29.1 MCHC-35.8* RDW-13.6 Plt Ct-207
[**2122-3-20**] 05:29AM BLOOD WBC-6.1 RBC-3.61* Hgb-10.9* Hct-30.9*
MCV-86 MCH-30.1 MCHC-35.2* RDW-13.9 Plt Ct-168
[**2122-3-17**] 04:18AM BLOOD PT-13.6* PTT-26.5 INR(PT)-1.2*
[**2122-3-16**] 10:00AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-121*
K-2.8* Cl-83* HCO3-27 AnGap-14
[**2122-3-20**] 05:29AM BLOOD Glucose-93 UreaN-9 Creat-0.7 Na-140 K-4.2
Cl-109* HCO3-28 AnGap-7*
[**2122-3-16**] 04:59PM BLOOD ALT-27 AST-51* CK(CPK)-2934* AlkPhos-92
TotBili-0.6
[**2122-3-18**] 12:32AM BLOOD CK(CPK)-[**Numeric Identifier 81407**]*
[**2122-3-18**] 08:04AM BLOOD CK(CPK)-[**Numeric Identifier 81408**]*
[**2122-3-20**] 05:29AM BLOOD CK(CPK)-[**Numeric Identifier **]*
[**2122-3-16**] 04:59PM BLOOD CK-MB-10 MB Indx-0.3 cTropnT-<0.01
[**2122-3-16**] 11:47PM BLOOD cTropnT-<0.01
[**2122-3-16**] 11:47PM BLOOD CK-MB-8
[**2122-3-17**] 04:18AM BLOOD CK-MB-8 cTropnT-<0.01
[**2122-3-16**] 04:59PM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8
[**2122-3-18**] 04:45AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.9
[**2122-3-20**] 11:24AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.0
[**2122-3-16**] 04:59PM BLOOD Osmolal-248*
[**2122-3-16**] 04:59PM BLOOD TSH-0.35
[**2122-3-16**] 10:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2122-3-16**] 05:40PM BLOOD Lactate-2.3*
[**2122-3-17**] 09:00AM BLOOD freeCa-1.02*
EEG: IMPRESSION: Abnormal EEG due to a slowed and disorganized
posterior
waking background suggestive of a mild diffuse early
encephalopathy. No
discharging features were, however, noted.
CT HEAD:IMPRESSION: Prominent periventricular white matter
disease, likely related to small vessel ischemia. Otherwise, no
acute intracranial abnormality, vascular abnormality or abnormal
focus of contrast enhancement.
MRI: IMPRESSION:
1. Prominent periventricular white matter disease and
ventriculomegaly, both of which appear unchanged from the
comparison CT exam.
Brief Hospital Course:
63M intubated in the setting of altered mental status, with ? of
seizure activity, and found to be hyponatremic.
# Mental status: Initial differential included seizure,
toxic-metabolic (hyponatremia), stroke unlikely given CTA
imaging, CNS infection (initially afebrile but then developed
fever on arrival). Started empirically on Ceftriazone and
Vancomycin. LP was performed and did not reveal any infectious
etiology. Neurology was consulted and recommended EEG and MRI.
EEG was without any evidence of seizure. Prominent
periventricular white matter disease and ventriculomegaly, both
of which appear unchanged from the comparison CT exam. Neuro
followed initially. Per brother who visited his second day,
patient was essentially at baseline.
# Hyponatremia: Na 121 could have caused seziure and post-ictal
state if this was a rapid decline in the serum sodium.
Hyponatremia was attributed to decreased oral intake and effect
of HCTZ. HCTZ was stopped and it is recommended that it not be
started again. Hyponatremia resolved with normal saline
administration.
# Elevated CK: This was thought initially to be an effect of a
seizure. The large increase however may have been related to
succinylcholine given in intubation. It peaked at 100,000 and
trended down. Myoglobin was present in the urine. Fluids were
given at a generous rate and the patient did not develop any
evidence of renal failure. Fluids were held when CK was less
than 20,000.
# Respiratory Failure: Intubated in the setting of obtundation
and possible seizure. No problems with oxygenation. Chest x-ray
with aspiration vs atelectasis on left side. He was continued
on Levofloxacin for this and was extubated the morning after
admission. He completed a course of levofloxacin. He did not
have an oxygen requirement.
# HTN: Pt has hx of significant HTN, on several meds. All
medications were restarted except HCTZ. Labetolol was
increased for improved blood pressure control. HCTZ held per
above.
# DM2: Not on any agents at this time. Fingersticks were
followed and he was on an ISS PRN.
# CAD: History of MI in the past. Cardiac enzymes were cycled
and negative. Medications were continued. Patient was noted to
not be on an ASA as an outpatient. Will defer this issue to
outpatient managment.
# Achalasia: Hx severe achalsia by report. Speech and Swallow
was obtained and provided appropriate dietery modifications.
Initially with decreased mental status was on dysphasia diet and
later cleared by speech and swallow for regular diet.
# Psych hx: History of depression, agoraphobia. On ativan at
baseline. Remeron and Zyprexa were initially held given concern
for Seratonin syndrome. These were restarted the second day of
hospitalization.
# Ppx: pneumoboots / IV PPI / VAP Bundle
# Code: PRESUMED FULL
# Contact: PCP [**Name Initial (PRE) 5351**] [**Telephone/Fax (1) 81409**] (Urban Med)
Medications on Admission:
Amlodipine 10 mg po daily
Ammonium lactate lotion 12% [**Hospital1 **]
Catapres patch 3 weekly on saturdays
HCTZ 25 mg po daily (increased on [**2122-2-25**] from 12.5 QD)
Labetalol 400 mg po tid
Lisinopril 40 mg po daily
Metoclopramide 5 mg po QACHS
Mirtazapine 30 mg po qhs
MVI
Nicotine 21mg patch daily
Omeprazole 20 mg po bid
Sucralfate 1 gram qid
Zyprexa 15 mg po qhs
Acetaminoprhn prn
Almacone oral susp 30 ml q6h prn
Lorazepam 0.5 mg po qhs prn
MoM prn [**Name2 (NI) 81410**]
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for fever.
8. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
12. Olanzapine 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Hyponatremia
Elevated creatinine kinase
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because you were found
unconscious. You were found to have a very low sodium level.
This was likely an effect of you not eating enough as well as a
medication (HCTZ). We stopped your HCTZ. You initially had to
be intubated. In the intensive care unit your sodium improved
with fluids and you woke up and were able to be extubated.
Medication changes:
Stop taking HCTZ
Your lopressor was increased to 600mg twice a day
Please continue to take your other medications as previosuly
directed.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
You should see your PCP [**Last Name (NamePattern4) **] [**12-26**] weeks and have your labs (CK,
electrolytes, renal function) checked. You should talk with
your PCP about the need for further neurology follow up, and the
possibility of starting a statin to protect your cerebral
vasculature.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 608**] in [**12-26**] weeks
Completed by:[**2122-3-24**]
|
[
"728.88",
"414.01",
"250.00",
"276.1",
"518.0",
"412",
"276.8",
"507.0",
"780.39",
"443.9",
"311",
"530.0",
"401.9",
"300.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10073, 10159
|
5362, 5478
|
325, 387
|
10243, 10252
|
3357, 4967
|
11366, 11527
|
3045, 3054
|
8798, 10050
|
10180, 10222
|
8291, 8775
|
10276, 10646
|
3069, 3338
|
10666, 11343
|
275, 287
|
415, 1966
|
4975, 5339
|
5493, 8265
|
1988, 2149
|
2165, 3029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,057
| 125,406
|
13590
|
Discharge summary
|
report
|
Admission Date: [**2133-3-19**] Discharge Date: [**2133-4-14**]
Service: GENERAL [**Doctor First Name **]
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname **] is an 82 year old
female who lives alone and has a very supportive family. Her
past medical history is significant only for smoking 15
cigarettes per day and otherwise her health is usually good.
She recently developed obstructive jaundice which was
followed by placement of an endoprosthesis by Dr. [**Last Name (STitle) **]
during endoscopic retrogram cholangiopancreatography. At
that time, she also had a peri-ampullar cancer identified by
a fine needle aspirate biopsy and CT angiography here at the
[**Hospital1 69**]. Now that her
obstructive jaundice has resolved, she has presented for the
Whipple procedure on [**2133-3-19**].
PAST MEDICAL HISTORY:
1. Status post appendectomy as a child.
2. Right knee arthroplasty.
MEDICATIONS:
None.
ALLERGIES:
Bactrim and Ceclor.
SOCIAL HISTORY: The patient lives alone and has a very
supportive family. She smokes approximately 15 cigarettes
per day.
HOSPITAL COURSE: The patient was brought in to the hospital
on [**2133-3-19**], to undergo the Whipple procedure. She
tolerated the procedure well. There were no complications.
The patient was stable immediately postoperatively. Her pain
was controlled with epidural anesthesia. Given her smoking
history, also, she was having some aggravation of her chronic
obstructive pulmonary disease. In the Intensive Care Unit,
the patient underwent diuresis for her mild congestive heart
failure and she also received aggressive chest physical
therapy and was encouraged to do incentive spirometry. The
patient remained stable. She had a low urine output and low
blood pressure both of which responded to boluses of
intravenous fluid and on postoperative day three, the patient
was transferred from the Intensive Care Unit to the Floor in
stable condition.
Her anesthesia was changed to Dilaudid PCA and her
respiratory status was still in need of aggressive chest
Physical Therapy and incentive spirometry. On postoperative
day five, she began to pass flatus but she was kept NPO for a
bout of emesis. That night, she also had an episode of
confusion.
On postoperative day six, the patient was started on
Lopressor for high blood pressure and tachycardia. She also
was noticed to have bilious drainage from her [**Location (un) 1661**]-[**Location (un) 1662**]
drain. At this point, the patient although was tolerating
sips, was started on TPN for nutritional support. She was
advanced to clears and continued to receive aggressive chest
Physical Therapy. The patient underwent a CT scan on
postoperative day seven which revealed no undrained
collection, but the incision was noted to be draining copious
amounts of bilious fluid from the lateral edges. Her abdomen
remained soft and nontender, nondistended. Her drains were
in place. When the patient was noted to have bilious
drainage from her wound, she was started once again on
antibiotics; this time, she was started on Levofloxacin and
Flagyl.
Her wound continued to drain bilious fluid and both her [**Doctor Last Name 406**]
and [**Location (un) 1661**]-[**Location (un) 1662**] were draining bilious drainage. On
postoperative day nine, the patient was noted on physical
examination to have possible fascial dehiscence of her wound
at the right lateral edge. Upon exploration of the wound by
the chief medical resident, Dr. [**Last Name (STitle) 9779**], it was felt that the
patient did have a fascial dehiscence of her wound and at
that point, it was felt that the patient should be taken back
to the Operating Room for a wound exploration and closure.
This was postoperative day nine from her Whipple, [**2133-3-28**].
The patient underwent an abdominal wound exploration and
closure. She tolerated the procedure well and there were no
complications. Postoperatively, the patient was continued on
Levofloxacin and Flagyl. She had a decrease in her urine
output postoperatively from her wound closure which responded
to an intravenous fluid bolus. She was cardiovascularly
stable throughout. Her pain was controlled with morphine
p.r.n.
She continued to receive aggressive chest Physical Therapy
and incentive spirometry. The patient was kept NPO on
intravenous fluids and continued to receive TPN.
Postoperatively, the patient was also placed on Ampicillin.
Her wound was noted to have retention sutures in place but
she continued to have bilious drainage from all portions of
her wound, mostly from the right lateral edge of the wound
which was in a dependent position. Her abdomen was nontender
and nondistended, soft to palpation. She only had areas of
tenderness surrounding her wound.
Postoperatively, the patient was requiring dressing changes
approximately every one to two hours and a stoma care
consultation was obtained, and at this point it was
recommended that the patient have Miconazole Powder applied
around the wound edges, followed by Double-Guard, which would
protect the skin from necrosis effects of the bilious
drainage. At this point, the patient was also started on
Somatostatin in hopes of decreasing the wound drainage.
On postoperative day 13 from her Whipple and postoperative
day four from her wound exploration, the patient underwent a
CT scan of the abdomen which only revealed a small fluid
collection over the medial segment of the left lobe of the
liver. She also had small bilateral pleural effusions. The
CT scan was reviewed with the attending radiologist, and at
this point, the small amount of collection was felt to be too
small for drainage.
On postoperative day 17 status post Whipple and postoperative
day eight status post wound exploration and closure, the
patient was noted to have marked decrease of her wound
drainage. At this point, it was felt that a trial of
stopping the Somatostatin was attempted. The patient, at
this point although, continued on Levofloxacin, Flagyl and
Ampicillin. The following day, the patient's wound drainage
was noticed to be increased once again and was bilious in
character. At this point, it was felt that her Somatostatin
should be restarted and the patient kept on sips for comfort
and on TPN to decrease the amount of drainage to her wound.
Eventually, by postoperative day 25 status post Whipple and
postoperative day 16 status post her wound closure, at this
point her antibiotics had been discontinued. Her wound
drainage had greatly decreased from immediately
postoperatively, requiring every one to two hour dressing
changes. The patient was now only requiring dressings
changes every six to eight hours. At this point, it was
noted that her wound dressing was no longer saturated with
bilious material.
At this point, the nature of the wound drainage was mostly
serous, occasional bilious, but markedly decreased in amount.
The patient was out of bed, ambulating with assistance three
times a day. She continued on her TPN. At this point, the
patient also was noted to have loose diarrheal stools which
were sent off for Clostridium difficile and noted to be
negative. At this point, her Flagyl was discontinued.
The patient was felt stable to be discharged to
rehabilitation to continue her dressing changes and to
receive nutritional support.
The patient's pathology from her Whipple procedure revealed
an adenocarcinoma of the ampulla of the duodenum, poorly
differentiated, and mucin producing. She had trans-renal
invasion, duodenal wall, with direct extension into the
pancreas. There was focal vascular invasion. Five lymph
nodes were identified without malignancy.
DISCHARGE MEDICATIONS:
1. Sandostatin 100 micrograms subcutaneously three times a
day.
2. Lopressor 25 mg p.o. twice a day.
3. Regular insulin sliding scale.
4. Total parenteral nutrition as written.
DISCHARGE INSTRUCTIONS:
1. Her dressing change involves removing the old dressing
and cleaning the skin adjacent to the wound with normal
saline moist gauze, followed by a foam cleanser to the distal
end of the wound and patted dry. Then, following this,
Miconazole Powder is applied to the reddened areas and the
excess dusted away. The stoma adhesive surrounding her wound
can be replaced p.r.n. Indications for it to be changed are
lightening of the stoma adhesive edges. Using No-Sting
barrier wipes, the wound edges are cleaned and not covered by
stoma adhesive. Then over the Miconazole Powder,
Double-Guard Ointment is applied to the reddened skin. The
dressing under the straps is a normal saline 4 by 4 gauze.
Then, the entire wound is covered with gauze, ABDs and an
Exudry.
Please change this dressing every four to eight hours as
necessary and if the dressing remains dry overnight it does
not need to be changed until the morning.
2. Her diet is sips for comfort.
3. She should receive TPN for nutritional support.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to [**Hospital 38**] Rehabilitation.
FOLLOW-UP INSTRUCTIONS:
1. The patient should follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] on
[**4-27**], at 10:15 a.m. in the [**Last Name (un) 469**] Seven Center.
DISCHARGE DIAGNOSES:
1. Periampullar cancer status post Whipple procedure.
2. Status post wound exploration and closure.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 9704**]
MEDQUIST36
D: [**2133-4-14**] 11:22
T: [**2133-4-14**] 11:39
JOB#: [**Job Number 41027**]
|
[
"197.8",
"575.12",
"998.3",
"152.0",
"496",
"E878.2",
"997.4",
"428.0",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"86.22",
"99.15",
"52.7",
"54.21",
"54.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9257, 9621
|
7711, 7893
|
1132, 7688
|
7917, 8943
|
8959, 9036
|
147, 844
|
9060, 9236
|
866, 989
|
1006, 1114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,871
| 190,823
|
42210
|
Discharge summary
|
report
|
Admission Date: [**2195-9-12**] Discharge Date: [**2195-9-17**]
Date of Birth: [**2114-8-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Altered mental status, need for IVFs and diuresis concomitantly
(for hypercalcemia)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 yo male with history of hypertension, coronary artery
disease, and hypercalcemia that has not been worked up in the
past, presents with altered mental status. At baseline, patient
is alert and oriented x [**1-25**]. Today, the patient's daughter
found the patient to be altered, and more agitated and agressive
than usual. She noted that he was generally weak as well, and
had trouble picking up his coffee cup. The family reports that
the patient had been somewhat weak for weeks and has recently
had some problems with falling. They deny any history of
fevers, abdominal pain, nausea or vomiting, or diarrhea.
Patient does have a history of chronic cough, which has not
worsened or changed in character over the past few days. There
was report of difficulty swallowing, as well as auditory
hallucinations as well, though these could not be classified
further. The patient denies any urinary symptoms. He initially
presented to the OSH where they performed CT head which
demonstrated no intracranial hemorrhage, and small age
indeterminate lacunar infarct in the basal ganglia. Labs at the
OSH were notable for elevated BNP for which patient received 60
mg of IV Lasix. Troponin at the outside hospital <0.01. BNP
was noted to be 9207. Head CT was performed and reportedly
negative.
In the ED, initial vitals were T 97.4, P 52, BP 200/100, R 20,
Sat 92%RA. Patient's neurological exam was non-focal, and
patient followed commands. Patient was reported to be
O2-dependent, but refusing to wear oxygen. ECG showed no
evidence of STEMI, with normal intervals. Lab testing revealed
calcium of 11.9, free calcium 1.52, and creatinine of 2.0 from
baseline of 1.5. BNP was 7984. Hematocrit was noted to be
46.5. Chest X-ray revealed diffuse reticular opacities with
bibasilar opacities that likely represent fibrosis but may
represent pneumonia, with no effusions and no congestion.
Patient was given levofloxacin 750 mg IV x 1 for this finding.
Patient developed erythema and pruritus around the infusion
site, and was administered diphenhydramine 50 mg IV x 1, which
helped symptomatically. Urinalysis was negative. ABG showed
7.43/34/53/23. Patient was initially admitted to medical floor,
but team thought that since patient would require fluids and
diuresis that it would require closer monitoring in an ICU.
On the floor, the patient reports being tired at the current
time. He reports no chest pain or dyspnea, no abdominal pain.
Past Medical History:
Hypertension
Coronary artery disease s/p CABG 8 years ago, also had MI in
[**1-/2195**], no intervention undertaken
COPD
Hypercalcemia, unknown etiology
Hyperlipidemia
s/p Cholecystectomy
Social History:
Lives alone, daughter visits twice a day. Was born in the US, of
Portuguese descent.
- Tobacco: current smoker, 1-2 packs per day, 70-140 pack year
history
- Alcohol: None
- Illicits: None
Family History:
He is one of 11: one sister has parathyroid adenoma.
Son has PUD (stomach) and [**Doctor Last Name **].
Physical Exam:
Admission:
Vitals: T: 95.6 BP: 62 P: 189/99 R: 12 O2: 93%RA
General: Alert, oriented x 2 to person and time, no acute
distress, intermittently agitated
HEENT: Sclera anicteric, MM dry, oropharynx otherwise clear
Neck: supple, JVP elevated to 3 cm above clavicle at 60 degrees
bed elevation, no cervical or supraclavicular LAD
Lungs: Rhonchorous sounds bilaterally, with rales at bases, no
wheezes present, not using accessory muscles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx2, CNs grossly intact, strength equal bilaterally in
all extremities, sensation intact to light touch in all
extremities, reflexes equal and normal in all extremities
Discharge:
Vitals: 96.2-97.6, 149-180/76-102 (144/84), 53-67, 18, 97-100%
on RA
General: Alert, calm and hard of hearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD appreciated, no cervical or supraclavicular
LAD
Lungs: scattered wheezes anteriorly, some upper airway sounds
again, clearing with cough, no frank crackles.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left hand swelling is resolved.
Neuro: AAOx1, CNs grossly intact, strength equal bilaterally in
all extremities, sensation intact to light touch in all
extremities, reflexes equal and normal in all extremities
Pertinent Results:
Chemistry
[**2195-9-12**] 02:30AM BLOOD WBC-10.9 RBC-5.04 Hgb-16.5 Hct-46.5
MCV-92 MCH-32.7* MCHC-35.5* RDW-14.7 Plt Ct-223
[**2195-9-16**] 05:45AM BLOOD WBC-9.9 RBC-4.21* Hgb-13.7* Hct-39.4*
MCV-94 MCH-32.5* MCHC-34.7 RDW-14.6 Plt Ct-196
[**2195-9-12**] 02:30AM BLOOD Neuts-65.1 Lymphs-27.6 Monos-4.5 Eos-1.4
Baso-1.4
[**2195-9-12**] 02:30AM BLOOD PT-13.3 PTT-32.3 INR(PT)-1.1
[**2195-9-12**] 02:30AM BLOOD Glucose-106* UreaN-31* Creat-2.0* Na-142
K-3.8 Cl-106 HCO3-25 AnGap-15
[**2195-9-17**] 06:00AM BLOOD Glucose-79 UreaN-34* Creat-1.4* Na-138
K-3.5 Cl-109* HCO3-21* AnGap-12
[**2195-9-15**] 07:05AM BLOOD ALT-22 AST-50* AlkPhos-64 TotBili-0.7
[**2195-9-12**] 02:30AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-7984*
[**2195-9-12**] 07:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2195-9-12**] 02:30AM BLOOD Albumin-4.3 Calcium-11.9* Phos-2.7 Mg-2.0
[**2195-9-16**] 05:45AM BLOOD Calcium-10.4* Phos-2.4* Mg-1.7
[**2195-9-17**] 06:00AM BLOOD Calcium-10.0 Phos-2.3* Mg-1.6
[**2195-9-14**] 05:10AM BLOOD TSH-1.1
[**2195-9-12**] 07:55AM BLOOD PTH-389*
[**2195-9-14**] 05:10AM BLOOD PEP-NO SPECIFI IgG-848 IgA-157 IgM-469*
IFE-NO MONOCLO
[**2195-9-12**] 04:14AM BLOOD freeCa-1.52*
[**2195-9-13**] 07:21AM BLOOD freeCa-1.37*
[**2195-9-15**] 02:20PM BLOOD freeCa-1.40*
[**2195-9-17**] 06:29AM BLOOD freeCa-1.30
Urine
[**2195-9-17**] 09:21AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2195-9-12**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2195-9-12**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2195-9-17**] 09:21AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
[**2195-9-17**] 09:21AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-FEW Epi-1
[**2195-9-17**] 09:21AM URINE Hours-RANDOM TotProt-58
[**2195-9-17**] 09:21AM URINE U-PEP-PND
Urine Culture
URINE CULTURE (Final [**2195-9-13**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
10,000-100,000 ORGANISMS/ML.
Blood Culture x2 Pending.
CXR on admission: diffuse reticular opacities with bibasilar
opacities that likely represent fibrosis but may represent
pneumonia, with no effusions and no congestion
CT head at OSH: no intracranial hemorrhage, and small age
indeterminate lacunar infarct in the basal ganglia
EKG: sinus bradycardia at 55 bpm, NANI, diffuse [**Last Name (LF) **], [**First Name3 (LF) **]
depressions in V2-V5 c/w prior
ECHO [**2195-9-12**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed with
regional variation (LVEF= 25-30 %). The right ventricular free
wall thickness is normal. Right ventricular chamber size is
normal. with depressed free wall contractility. 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. The left ventricular inflow pattern suggests
impaired relaxation. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT Head [**2195-9-13**]:
FINDINGS: There is mild-to-moderate brain atrophy seen. Diffuse
hypodensities in the white matter indicate small vessel disease.
There is no definite acute hemorrhage, mass effect or midline
shift seen. There is
prominence of extra-axial spaces in the frontal region as seen
on the previous study, which appears to be secondary to atrophy
and widening of the subarachnoid space. Bone images are
unremarkable.
IMPRESSION: No significant change since [**2195-9-11**]. No definite
acute
hemorrhage is identified.
Urine Culture
URINE CULTURE (Final [**2195-9-13**]):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
10,000-100,000 ORGANISMS/ML.
Blood Culture x2 Pending.
CXR on admission: diffuse reticular opacities with bibasilar
opacities that likely represent fibrosis but may represent
pneumonia, with no effusions and no congestion
CT head at OSH: no intracranial hemorrhage, and small age
indeterminate lacunar infarct in the basal ganglia
EKG: sinus bradycardia at 55 bpm, NANI, diffuse [**Last Name (LF) **], [**First Name3 (LF) **]
depressions in V2-V5 c/w prior
ECHO [**2195-9-12**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed with
regional variation (LVEF= 25-30 %). The right ventricular free
wall thickness is normal. Right ventricular chamber size is
normal. with depressed free wall contractility. 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. The left ventricular inflow pattern suggests
impaired relaxation. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
CT Head [**2195-9-13**]:
FINDINGS: There is mild-to-moderate brain atrophy seen. Diffuse
hypodensities in the white matter indicate small vessel disease.
There is no definite acute hemorrhage, mass effect or midline
shift seen. There is
prominence of extra-axial spaces in the frontal region as seen
on the previous study, which appears to be secondary to atrophy
and widening of the subarachnoid space. Bone images are
unremarkable.
IMPRESSION: No significant change since [**2195-9-11**]. No definite
acute
hemorrhage is identified.
Brief Hospital Course:
81 yo male with h/o CAD, hypertension, and hypercalcemia of
unknown etiology presents with altered mental status,
hypercalcemia, and acute on chronic kidney injury.
# Hypercalcemia: Patient reportedly has long-standing
hypercalcemia due to primary hyperparathyroidism. On further
discussions with daughter in law, the patient had been referred
by his primary care physician to [**Name Initial (PRE) **] surgeon who recommended
parathyroidectomy. Per family report, the patient reportedly
became so agitated with this news that he had a myocardial
infarction and therefore never underwent surgery. He also never
took the medication prescribed by his PCP for this condition.
The patient's PTH returned elevated at 387. His TSH was 1.1. He
was treated with intravenous fluids and calcitonin and started
on cinacalcet for management of his calcium level while
in-house. External records were unable to be obtained from his
primary care provider. [**Name10 (NameIs) **] was then transitioned to
cinacalcet per endocrinology consult. He will require ongoing
endocrinology management. Would revisit idea of surgical
removal as outpatient.
# Toxic-metabolic encephalopathy: The patient was confused on
admission. WOrkup positive for hypercalcemia only which as
likely source of altered mental status. His mental status
normalized with treatment of hypercalcemia. The patient's CXR
showed fibrosis but was felt not consistent with pneumonia. CT
head at the OSH showed a lacunar infarct in the basal ganglia of
unknown acuity but given his non-focal neurological exam, was
not felt to be the underlying etiology for his acute altered
mental status. The patient's EKG was stable and troponins
negative. The patient required small doses of zyprexa for
agitation and delirium precautions were initiated with good
effect (limit tethers, optimize sensory environment, sleep-wake
cycle preservation). The patient was also continued on his home
sertraline. He was at baseline upon discharge.
# Chronic systolic heart failure: TTE revealed EF of 25-30% in
context of known coronary artery disease. Patient was started
on Lisinopril and spironolactone while in house. He will follow
up with the heart failure clinic / cardiology as an outpatient.
# Acute on chronic kidney injury: The patient presented with
creatinine 2.0 from baseline 1.5 due to hypercalcemia, amd
dehydration, as well as NSAID use at home. Renal function
returned to baseline with hydration.
# ?? COPD: Patient is apparently not on any COPD medications at
home, but is on an unidentified amount of home O2. He may
benefit from outpatient PFTs as well as optimization of his home
pulmonary regimen as an outpatient. (we were onable to obtain
records from PCP to determine if this workup was previously
done). He was stable on room air in the hospital.
# Hypertension: The patient was continued on metoprolol tartrate
(home medication). He remained hypertensive SBPs160s, therefore
was started on lisinopril and spironolactone as above.
# Coronary artery disease: The patient was continued on home
aspirin, metoprolol in-house. His cardiac enzymes were cycled
and remained stable, in the setting of
renal failure.
# Transitional issues:
- Please assess compliance to cinacalcet. Would reconsider
surgery as outpatient.
- Pt should drink 1.5-2 L daily.
- Monitor Calcium closely
- Can uptitrate cinacalcet as needed
- Heart failure follow up clinic for medical optimization of
systolic CHF.
- Consider further pulm evaluation for ? history of COPD
- Urine Protein Electrophoresis pending at time of discharge.
- 2 blood cultures also pending.
Medications on Admission:
Atorvastatin 10 mg PO QHS
Lorazepam 0.5 mg PO TID PRN
Aspirin 325 mg PO daily
Metoprolol tartrate 50 mg PO BID
Meclizine 25 mg PO TID
Omeprazole 20 mg PO BID
Naproxen 220 mg PO q6-8h
Nitroglycerin 0.4 mg SL PRn
Setraline 150 mg PO QHS
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: If chest pain
doesn't resolve, call 911.
7. sertraline 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablets* Refills:*0*
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please have lab work done in one week on [**2195-9-24**] including free
calcium, calcium, sodium, potassium, bicarbonate, chloride, BUN,
creatinine, magnesium, and phosphate. Please have labs faxed to
Dr. [**Last Name (STitle) 15170**] at [**Telephone/Fax (1) 49757**].
11. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
1. Hypercalcemia, primary hyperparathyroidism, hypertension,
Coronary artery disease, chronic obstructive pulmonary disease
2. Hyperlipidemia, tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 35085**],
It was our pleasure caring for you at [**Hospital1 18**].
You were admitted for hypercalcimia causing confusion.
We found on exam an elevated level of parathyroid hormone, a
hormone which is central in controlling the calcium in your
blood.
We made the following changes in your medications
START cinacalcet for your high calcium levels
START spironolactone for your heart failure and blood pressure
START lisinopril for your heart failure and blood pressure
START colace as needed for constipation - over the counter
STOP meclizine
HOLD naproxen
Please keep the following appointments below.
Please stop smoking. It is important to for you to stop smoking
for your cardiac and respiratory health.
Please check daily weights. Call your cardiologist if your
weight goes up by more than 3lbs in one day.
Followup Instructions:
Please attend the following appointments:
Cardiology:
Name: [**Last Name (LF) 831**], [**First Name3 (LF) 488**]
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
Appt: [**9-21**] at 11:15am
Primary Care:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
Appt: [**9-29**] at 1:45pm
Endoscopy:
Name: [**Last Name (LF) 91511**], [**First Name3 (LF) **]
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 9674**]
Appt: [**10-12**] at 1:15pm
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
[]
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] |
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,369
| 122,658
|
25152
|
Discharge summary
|
report
|
Admission Date: [**2104-10-4**] Discharge Date: [**2104-10-11**]
Date of Birth: [**2035-6-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
S/P fall.
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
The pt. is a 69 year-old left-handed male with a history of
previous strokes, hypertension, diabetes mellitus, colon cancer
who presented after a fall. The pt stated that he was in his
usual state of health today. He was at work, walking down steps
and stated that he "missed the last few steps and fell down."
He did state that he felt the sensation as if he were going to
fall just before he tumbled down the stairs. He missed about
three stairs and
landed on his right side, injuring his right knee. He denied
lower extremity weakness, numbness at the time. He denied a
sensation as if his legs buckled. He denied tripping over any
obstructions. Again, he did state that he transiently felt
lightheaded, but denied vertigo or dysequilibrium. He denied
head injury, loss of consciousness as a result of the fall. A
physician witnessed the event and came right to the patient's
aid. EMS was called and the patient was taken to an OSH. He
noted that on the way to the OSH, he was very diaphoretic and
nauseous, but this later resolved. This sort of event has never
happened to the patient in the past.
At the OSH, an abnormality was noted on an imaging study and he
was brought to the [**Hospital1 18**] for further evaluation.
The pt. denied headache, loss of vision, diplopia, dysphagia.
Denied Denied difficulties producing or comprehending speech.
Denied focal weakness, numbness. He does occasionally experience
parasthesiae in his toes. He denied gait abnormalities.
On review of systems, the pt. denied recent fever or chills. No
night sweats or recent weight loss or gain. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denied arthralgias or myalgias.
.
Patient was transferred to the medicine service as Neurology
work-up complete and patient developed melena.
Past Medical History:
-hypertension
-type 2 diabetes mellitus
-prior history of stroke; the pt stated that 3 years ago, he
developed the acute onset of diplopia and left hand weakness.
These deficits gradually improved over a four day course.
Thirteen days after the original event, the pt experienced
another stroke, again presenting with diplopia and left arm
weakness. He was uncertain of facial weakness during these
episodes. He stated that he was told that he had a stroke "near
the sixth nerve in the pons." His deficits gradually improved
over six months' time and he stated that he is currently without
residua.
-h/o colon cancer, s/p right hemicolectomy
Social History:
The pt is a retired food scientist. He lives at home with his
wife. [**Name (NI) **] denied use of tobacco, alcohol, or illicit drugs.
Family History:
Remarkable for a number of family members with type 2 diabetes
mellitus. No history of Alzheimer's, ICH, ischemic stroke.
Physical Exam:
Vitals: T: 97.9 P: 73 R: 16 BP: 221/102 SaO2: 97% 2L NC
General: Awake, alert, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no JVD or carotid bruits appreciated. No nuchal
rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: small ecchymosis over right knee.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty. Able to name [**Doctor Last Name 1841**] forward and backward
without difficulty. Language is fluent with intact repitition
and comprehension. There were no paraphasic errors. Pt. was
able to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall [**2-28**] at 5 minutes. The pt. had good
knowledge of current events. There was no apraxia or neglect.
-cranial nerves: Olfaction not tested. PERRL 3 to 2mm and
brisk.
VFF to confrontation. There is no ptosis bilaterally.
Fundoscopic exam revealed no papilledema, exudates, or
hemorrhages; venous pulsations present. EOMI without nystagmus.
Sensation intact to light touch over face. No facial droop,
facial musculature symmetric. Hearing intact to finger-rub
bilaterally. Palate elevates symmetrically in midline. 5/5
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
-motor: Normal bulk throughout. Tone slightly increased in the
lower extremities. No adventitious movements noted.
No pronator drift bilaterally.
Delt Bic Tri WrF WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5 5 5 4+ 4+ 4 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-sensory: No deficits to light touch, vibratory sense,
proprioception throughout. There was diminished pinprick
sensation up to the level of the ankle bilaterally. No
extinction
to DSS.
-coordination: No intention tremor, dysdiadochokinesia noted.
FNF
and HKS WNL bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-gait: Good initiation. Narrow-based, normal arm swing.
Pertinent Results:
Radiologic Data:
CT head (performed at OSH): roughly 3 cm in diameter right
parietooccipital hemorrhage, which appears acute (reviewed with
radiologist on call).
.
[**10-4**] Brain MRI:
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion
axial images of the brain were obtained.
FINDINGS: There is a well-defined area of hyperintense T1 and T2
signal in
the right occipitoparietal lobe with some mild surrounding
edema. Following
gadolinium, enhancement is seen at the anterior portion of the
hemorrhage.
Findings are suggestive of a mass, most likely metastasis, with
associated
small area of hemorrhage and mild surrounding edema. No other
discrete areas
of enhancement or signal abnormalities are seen. There is no
mass effect,
midline shift or hydrocephalus. The abnormality in the right
parietooccipital
region demonstrates slow diffusion secondary to blood products.
IMPRESSION: Small 15 x 12 mm area of hemorrhage in the right
parietooccipital
region with surrounding enhancement indicative of an underlying
mass with mild
surrounding edema. No other areas of enhancement seen. Given the
peripheral
location of the lesion, metastasis is considered to be the most
likely
diagnosis.
.
[**2104-10-4**];
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler
ultrasound of the right and left common femoral, superficial
femoral, and popliteal veins was performed. There is normal
flow, augmentation, compressibility, and waveforms. No
intraluminal thrombus was identified.
IMPRESSION: No left or right lower extremity DVT.
.
CT EXAMINATION OF THE CHEST, ABDOMEN AND PELVIS WITH AND WITHOUT
THE
ADMINISTRATION OF INTRAVENOUS CONTRAST, AND WITH ORAL CONTRAST:
INDICATION: 69-year-old male with right parietal lobe bleed.
Assess for
primary lesion.
TECHNIQUE: Contiguous 5 mm axial images were obtained from the
lung bases to the pubic symphysis with the administration of
oral contrast only. Following, contiguous 5 mm axial images were
obtained from the lung apex through the abdomen with the
administration of intravenous contrast bolus, as well as
three-minute delayed imaging through the abdomen and pelvis.
FINDINGS: No prior CT examination for comparison.
Evaluation of the lungs reveals a 6 mm calcified nodule within
the right upper lobe (series 3, image 21). No other focal
nodules are seen. There is
atelectasis within both lung bases, left side greater than
right. No focal
consolidation.
Evaluation of the mediastinum reveals calcified lymph nodes,
likely from prior granulomatous disease. There is calcification
of the proximal aspect of the LAD. There is a small pericardial
effusion. The heart is not enlarged.
There is calcification of the thoracic aorta.
There is a moderate-sized hiatal hernia, and gas within the mid
and distal
esophagus. The mid esophageal wall is somewhat thickened, which
could be
related to reflex esophagitis, however, this would be better
evaluated with endoscopy. The liver, spleen, pancreas, adrenal
glands, and kidneys are grossly normal without solid mass.
Simple cysts are seen within the right kidney. There is no
evidence of hydronephrosis. Calcified gallstones are seen
dependently within the gallbladder. There are no dilated loops
of large or small bowel. There is no free intraperitoneal gas or
free fluid.
There is marked enlargement of the prostate, which measures 7.0
x 3.9 cm in maximum dimension. Chunky calcifications are
identified within the prostate. There is marked distention of
the urinary bladder, likely related to bladder outlet
obstruction from the enlarged prostate. No evidence of
dilatation of the distal ureters. There are loops of small bowel
within a right-sided inguinal hernia, however, there is no
evidence of incarceration or inflammation. No suspicious lytic
or osseous lesions are seen.
IMPRESSION:
1. No evidence of solid mass within the chest, abdomen or
pelvis.
2. Findings in the lungs compatible with prior granulomatous
disease.
3. Gallstones.
4. Enlarged prostate, with probable bladder outlet obstruction.
Correlation
with PSA value recommended.
5. Thickened esophageal wall, better evaluated with endoscopy.
.
TECHNIQUE: 3D time-of-flight MRA of the circle of [**Location (un) 431**]
acquired.
FINDINGS: The maximum intensity and source images of the MRA
demonstrate
normal flow signal in the arteries of anterior and posterior
circulation. In the region of right parietooccipital hemorrhage,
no abnormal vascular
structures are seen.
.
HISTORY: 69-year-old man with previous MRI revealing a
hemorrhage in the right parietooccipital lobe and mass
concerning for metastases. MRA did not reveal any abnormal
vasculature in this area and a body CT was unrevealing as far as
a primary neoplastic process.
INTERPRETATION: Whole body images of the skeleton were obtained
in anterior and posterior projections and no focal abnormal
uptake or penia was noted. The kidneys and urinary bladder are
visualized, the normal route of tracer excretion.
IMPRESSION: No evidence of bony metastases.
.
[**2104-10-7**]:
INDICATION: 69-year-old man with right parietooccipital
hemorrhage, likely
metastatic. Assess for thyroid primary.
COMPARISON: None.
FINDINGS: Targeted ultrasound examination of the thyroid
demonstrates normal thyroid parenchyma, without evidence of
nodule or mass. The left lobe measures 1.9 x 1.7 x 4.0 cm. The
right lobe measures 1.6 x 1.7 x 3.7 cm.
IMPRESSION: Unremarkable thyroid.
.
Brief Hospital Course:
1. Right parietooccipital hemorrhage: Not clear whether this
lead to presenting symptoms, but unlikely. He was initially
admitted to ICU for BP management, but was called-out to floor
on HD two after BP came down on labetalol gtt. On admission, he
had evidence of distal LUE weakness which quickly improved. He
also had a left inferior temporal quadrantanopsia which
persisted. MRI revealed enhancement underneath the bleed
concerning for mass. Therefore, metastatic work-up performed
which included CT torso (normal except for thickened esophagus,
enlarged prostate), thyroid scan (normal). In addition, LP
performed and CSF cytology negative for malignant cells. He was
evaluated by both neurooncology and neurosurgery who recommended
repeat CT scan and follow-up in one month.
.
2. Blood loss anemia: The pt had progressively declining Hct
over the hospital stay. Stool was guaiac positive. He also
reported one episode of melena. GI was consulted and
recommended EGD and colonoscopy. He was transferred to the
medicine service. He received a Golytely prep overnight prior
to EGD/Colonoscopy. Colonoscopy was deferred given negative
colonoscopy several months prior and non-bleeding duodenal ulcer
found of EGD. Hematocrits remained stable prior to discharge
and patient wothout any more bleeding after EGD.
.
3. Renal failure: On admission, the pt had a creatinine of 1.1.
This subsequently rose to 1.4-1.5 range despite aggressive IV
hydration and good p.o. intake. He did receive a dye load for
CT torso, but was medicated with mucormyst. Attempts were made
to obtain outside records to determine baseline creatinine
(given h/o diabetes and HTN, likely preexisting nephropathy).
Patient declined straiht cath to determine a post-void residual.
This should be followed-up as an outpatient, however, patient
without urination difficulties or symptoms prior to discharge.
.
4. HTN: BP was elevated on admission. He was originally
admitted to ICU for BP control with labetalol gtt. This was
eventually transitioned to p.o. metoprolol. He required
titration of metoprolol and lisinopril for persistently elevated
BP into the 160s.
.
5. DM2: The pt's fingersticks were acceptable. He was
maintained on glyburide and a sliding scale of regular insulin.
Metformin was held due to low creatinine clearance.
.
Dispo: Patient hemodynamically stable prior to discharge with no
further evidence of GI Bleeding and non-bleeding duadenal ulcer
found. Patient to follow-up with PCP and Neurology as
outpatient.
Medications on Admission:
-lisinopril 10mg po daily
-metformin 500mg po bid
-glyburide 20mg po daily
-lovastatin 20mg po daily
Discharge Medications:
1. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
2. 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*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
4. Glyburide 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Insulin Regular Human Subcutaneous
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
Diabetes Mellitus
Parietal hemorrhage
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience chest pain, shortness of breath,
numbness or weakness, blood in your stools or black stools.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**12-30**] weeks
after discharge from the hospital.
.
Please follow-up with your neurologist as instructed by
Neurology.
Completed by:[**2104-10-13**]
|
[
"431",
"V10.05",
"401.9",
"250.00",
"532.40",
"584.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
14677, 14683
|
11203, 13726
|
326, 330
|
14774, 14781
|
5762, 11180
|
15006, 15242
|
3139, 3264
|
13878, 14654
|
14704, 14753
|
13752, 13855
|
14805, 14983
|
4404, 5743
|
3279, 3799
|
277, 288
|
358, 2300
|
3814, 4387
|
2322, 2968
|
2984, 3123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,123
| 198,031
|
8042
|
Discharge summary
|
report
|
Admission Date: [**2124-8-22**] Discharge Date: [**2124-9-1**]
Date of Birth: [**2051-4-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
weakness, black stool
Major Surgical or Invasive Procedure:
EGD, Capsule endoscopy
History of Present Illness:
73yo M with CAD s/p CABG and PCI, diastolic HF, AF, mechanical
AVR, who is transferred from [**Hospital1 1474**] for low Hct from GIB.
Patient had been feeling week for about 2 weeks and woke up
feeling unsteady on the day of admission. He called his PCP and
was prompted to go to [**Hospital1 1474**]. VItal signs were stable. His
labs there were: Hct 14.1, guiac pos, PT42.8 INR 4.7, nml CE,
BNP 285.
He was given protonix and 2 u of PRBC and 5mg Vit K and 2uFFP.
On arrival to [**Hospital1 18**] ED, his vital signs were T98 P71 BP113/74
R20 100% on RA. He again received 5mg Vit K and 4u FFP. Patient
refused NG lavage. GI evaluated the patient. On review of
system, patient noted dark brown stool for the past 2 weeks but
no BRBPR/hemetemesis. Patien denies NSAID use. Patient claims
that he had INR checked 2 weeks ago and it was 4. He had
shingles 6 weeks ago, had been on ABX for several days and also
had been using propoxyfene. No change in dietary habits. Had not
had abdominal pain, nausea or diarrhea. He currently denies CP,
palpitation, dizziness, urinary problems, [**Name (NI) **]. [**Name2 (NI) **] reports
DOE today.
Past Medical History:
# CAD s/p CABG (LIMA>>>LAD, SVG>>>/OM/D1/RCA) ; recently stented
3DES
# Diastolic heart failure with hypertension and hyperlipidemia
# GIB -1/06EGD / colonoscopy:erosive gastritis, while
colonoscopy
showed diverticulosis, ectasias in rectum, mild radiation
proctitis, and grade one hemorrhoids. 2nd [**3-20**] episode: EGD
showed gastritis and ulcers with unremarkable biopsy. 3rd
episode: EGD show gastritis. Patient suppose to get capsule
study but never followed up.
# St. [**Male First Name (un) 923**] Mechanical AVR in [**2106**]
# Atrial Fibrillation noted 1 month ago, cardioverted
# Prostate ca s/p lupron tx
# Gout
# 4.4 cm AAA, last imaged [**7-19**]
# Prior ETOH abuse (a case of beer a day). He stopped drinking
heavily about 8-9 years ago [**2116**] GIB after drinking an excess
amount of alcohol, endoscopy revealing several stomach ulcers,
s/p 6 units PRBC.
# Cataracts, s/p surgery bilaterally
# Borderline glaucoma
# Hematuria approximately 6-7 months ago (currently consulting
with a urologist and oncologist). Patient reports having a
cystoscopy that was unremarkable.)
# Hx of Cellulitis of right leg
# Hx of mild hepatitis
# recent shingles
Social History:
Retired worker at [**Company 2676**] where he was exposed to microwaves
and various heavy metals. Smoked 3 packs/day x 10-12 years, quit
approximately 35 years ago. EtOH (as above). No drug use.
Family History:
Father died of CAD at age 65.
Physical Exam:
T97.6 P72 BP142/72 R18 100% on 2L
Gen- NAD, pleasant
HEENT- anicteric, PERRLA, EOMI, mmm, neck supple, JVD up to
angle of mandible
CV- rrr, SEM [**2-21**] at LUSB, mechanical valve click, no rubs
RESP- crackles L>R, no accessory muscle use
[**Last Name (un) **]- soft, nontender, nondistended
EXT- no edema
Pertinent Results:
[**2124-8-30**] 06:45AM BLOOD WBC-7.0 RBC-3.93* Hgb-9.7* Hct-31.3*
MCV-80* MCH-24.7* MCHC-31.1 RDW-18.2* Plt Ct-265
[**2124-8-26**] 06:10AM BLOOD WBC-7.9 RBC-3.80* Hgb-10.0* Hct-31.4*
MCV-83 MCH-26.4* MCHC-31.9 RDW-18.5* Plt Ct-226
[**2124-8-22**] 04:30PM BLOOD WBC-7.1 RBC-2.40*# Hgb-5.8*# Hct-17.9*#
MCV-75* MCH-24.2* MCHC-32.4 RDW-18.3* Plt Ct-244
[**2124-9-1**] 08:00AM BLOOD PT-25.3* PTT-72.0* INR(PT)-2.6*
[**2124-8-30**] 10:31PM BLOOD PT-21.3* PTT-100.0* INR(PT)-2.1*
[**2124-8-28**] 04:00PM BLOOD PT-18.2* PTT-117.6* INR(PT)-1.7*
[**2124-8-22**] 08:44PM BLOOD PT-25.1* PTT-32.0 INR(PT)-2.5*
[**2124-8-28**] 07:00AM BLOOD Glucose-126* UreaN-12 Na-137 K-3.3 Cl-98
HCO3-29 AnGap-13
[**2124-8-22**] 08:44PM BLOOD Glucose-114* UreaN-30* Creat-0.9 Na-144
K-3.8 Cl-108 HCO3-27 AnGap-13
[**2124-8-25**] 07:50AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9
Cardiology Report ECG Study Date of [**2124-8-22**] 3:48:26 PM
Sinus rhythm with first degree atrio-ventricular conduction
delay and flat
P waves. Non-diagnostic repolarization abnormalities. Compared
to the previous
tracing of [**2124-5-2**] no major change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 240 88 444/466.14 59 31 16
AP CHEST XR: Heart size is at upper limits of normal. Median
sternotomy wires and surgical clips are again noted. Pulmonary
vasculature is unremarkable. There is elevation of the left
hemidiaphragm with associated left basilar atelectasis. No
definite pleural effusions are identified. Osseous and soft
tissue structures are unremarkable.
IMPRESSION: No overt CHF.
Capsule Endoscopy Report
Patient Name: [**Name (NI) **] [**Known lastname 28747**]
ID: [**Numeric Identifier 28748**]
Birth Date: [**2057-4-17**]
Gender: Male
Referred By: [**Last Name (NamePattern4) 28749**]
Test Date: [**2124-8-24**]
Reason for referral:
This patient is referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] and Dr. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) **] for evaluation of gi bleeding
Procedure Data:
Height: 68.0 Inches. Weight: 150 Lbs. Waist: 34.0 Inches. Build:
Normal. Gastric Passage Time: 0h 10m. Small Bowel Passage Time:
6h 7m.
Procedure Info & Findings:
1. Poor preparation in the majority of the small bowel
Summary & Recommendations:
Summary: 1. Poor preparation in the small bowel precluded a
complete evaluation of the small bowel 2. otherwise Normal small
bowel capsule endoscopy
Recommendations: 1. Follow HCT/HGB. 2. Follow Up with referring
physician
Small Bowel Enteroscopy:
Findings: Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Mucosa: Normal mucosa was noted.
Duodenum:
Mucosa: Normal mucosa was noted.
jejunum:
Mucosa: Normal mucosa was noted.
ileum: Not examined.
Impression: Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
Normal mucosa in the jejunum
Additional notes: No source of bleeding found in upper GI tract
to mid jejunum. All sites well visualized. Will procede with
inpatient capsule study at this point. Continue PPI.
Brief Hospital Course:
1) Acute blood loss anemia / GI bleed: Admission hct 16. He was
admitted to the ICU and transfused PRBC and FFP. EGD done in ICU
identified no source of bleeding. Colonoscopy done in [**1-21**]
showed diverticulosis, rectal angioectasia, and grade I hemorr.
Capsule endoscopy was the performed. Though the prep was fair,
no bleeding lesions were identified. The Hemoglobin remained
stable and at that time anti-coagulation was restarted with IV
heparin drip and warfarin. (for mechanical valve). The bleed was
presumed to be precipitated by ASA, Plavix, and a
supra-therapeutic INR.
After discussion between Dr [**Last Name (STitle) **], hospitalist attending and
the patient's cardiologist, plavix was stopped as the stents
were placed in [**1-21**]. ASA and warfarin continued.
.
2) AVR/St. Jude's valve:
- Careful anticoagulation was started and INR goal of 2.5-3.5
was achieved. IV heparin coverage was maintained during this
time. No signs of bleeding noticed and hematocrit remained
stable.
3) CAD s/p stent:
After, initially holding the meds, all meds were restarted
slowly and titrated to the hoem dose. On ASA. Plavix stopped
(refer above) Dr. [**Last Name (STitle) **] agreed that Plavix should be d/c'd for
now given s/p 6 mos stenting (cypher, drug-eluting) and
life-threatening GI bleed.
.
4) Diastolic CHF (EF 60% 1/06): Remained stable, medications
continued.
.
5) H/o Afib: currently in sinus rhythm; continue beta-blocker
and amiodarone. On Anticoagulation.
.
6) Postherpetic neuralgia: Left neck; oxycodone prn, lidocaine
patch
.
7) h/o AAA: stable AAA without any evidence of rupture /
compromise on CTA [**4-20**]. No abdmonial pain or any other symptoms.
Bp well controlled.
.
8) GOUT: No active issues; continued allopurinol.
Medications on Admission:
Atorvastatin 40 mg
Furosemide 40 mg [**Hospital1 **]
Toprol XL 50 mg
Amiodarone 200 mg QD
Ferrous Sulfate 325
Clopidogrel 75 mg
Protonix 40 mg
Quinapril 20 mg
Zolpidem 5 mg
Sucralfate 1 g QID
Allopurinol 200 mg
Aspirin 81 mg
Warfarin 4 mg
gabapentin stopped last night
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*30 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).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
Coronary artery disease s/p stenting
Congestive heart failure
Atrial fibrillation
Post-herpetic neuralgia
Gout
h/o abdominal aortic aneurysm
Discharge Condition:
Stable
Discharge Instructions:
1. Take all your medications that you were taking before coming
to the hospital , except plavix. Plavix has been stopped after
discussion with your cardiologist because of the risk of
bleeding.
2. The dose of warfarin had been increased and you should take 5
mg once daily. The INR goal is 2.5-3.5.
3. Please get blood tests for INR and CBC done on Monday
[**2124-9-4**]. (Instructions provided). Please contact your doctor to
get the results checked.
4. Return to the emergency room or call your doctor if you
notice any bleeding, black stool, chest pain, shortness of
breath.
5. Make an appointment with your primary doctor in the next 1
week.
6. Also make an appointment with your cardiologist in the next
2-4 weeks. The appointment with your gastroentrologist has been
made for you.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2125-3-26**] 1:00
Gastroentrology: Dr [**Last Name (STitle) **], L ([**Telephone/Fax (1) 1954**]) [**2124-10-2**] at 1pm
Primary care - Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] - Your doctor is on vacation
but will return on [**2124-9-4**]. Please make an appointmet to see him
next week for follow up of your blood tests.
Cardiology - Make an appointment with your cardiologist in the
next 2 weeks.
|
[
"053.19",
"428.0",
"428.30",
"V43.3",
"285.1",
"790.92",
"V45.81",
"578.9",
"414.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10056, 10062
|
6499, 8251
|
336, 360
|
10271, 10280
|
3317, 6476
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11120, 11749
|
2943, 2974
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8571, 10033
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8277, 8548
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|
2989, 3298
|
275, 298
|
388, 1526
|
1548, 2713
|
2729, 2927
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,611
| 184,550
|
50194
|
Discharge summary
|
report
|
Admission Date: [**2135-4-6**] Discharge Date: [**2135-4-15**]
Date of Birth: [**2085-10-21**] Sex: F
Service: SURGERY
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
This 49-year-old lady with severe peripheral
vascular disease and diabetes, as well as renal
insufficiency, has previously had a right below-the-knee
amputation. She has developed gangrene and rest pain of her
left forefoot.
Major Surgical or Invasive Procedure:
L TMA
History of Present Illness:
This 49-year-old lady with severe peripheral vascular disease
and diabetes, as well as renal insufficiency, has previously had
a right below-the-knee
amputation. She has developed gangrene and rest pain of her left
forefoot.
Past Medical History:
1. Raynauds
2. DM type 1 complicated by peripheral neuropathy
3. htn
4. CRI
5. CVA
6. UC
7. R partial hallux amputation
8. Laparoscopic distal pancreatectomy for neuroendocrine tumor
9. R 2nd toe amputation
Social History:
occasional alcohol
former tobacco (15 pack years)
Family History:
non contributory
Physical Exam:
a/o x3
nad
cta
rrr
abd - benign
RLE amp site bk C/D/I
LLE TMA positve erythema / sutures intact / negative drainage
palp fem b/l
LLE slight dop pt and dp
Pertinent Results:
[**2135-4-12**] 04:51AM BLOOD
WBC-8.2 RBC-2.53* Hgb-8.8* Hct-26.2* MCV-104* MCH-34.7*
MCHC-33.5 RDW-14.2 Plt Ct-245
[**2135-4-12**] 04:51AM BLOOD
Plt Ct-245
[**2135-4-8**] 02:10AM BLOOD
PT-14.6* PTT-35.5* INR(PT)-1.3*
[**2135-4-12**] 04:51AM BLOOD
Glucose-135* UreaN-14 Creat-1.0 Na-143 K-4.1 Cl-108 HCO3-31
AnGap-8
[**2135-4-12**] 04:51AM BLOOD
Calcium-9.0 Phos-2.8 Mg-1.8
Brief Hospital Course:
This 49-year-old lady with severe peripheral vascular disease
and diabetes, as well as renal insufficiency, has previously had
a right below-the-knee amputation. She has developed gangrene
and rest pain of her left forefoot. An arteriogram showed no
options in terms of bypass or endovascular interventions. She is
now undergoing a TMA in hopes of salvaging part of her foot.
Pt underwent TMA with out difficulties. Transfered to the VICU
in stable condition.
POD # 1 pt had acute respiratary failure secondary to sepsis. Pt
intubated on the floor and sent to the SICU.
She spent 4 days in the SICU. She was weaned from vent and
pressors.
After her stay in the SICU. She was transfered to the floor in
stable condition.
She remained on AB [**Hospital 33589**] hospital stay.
On DC she is stable
NWB LLE TMA site
Medications on Admission:
ASA 81 qd, Lantus 20 qhs, HISS, Asacol 400 qd, Lisinopril 40 qd,
Neurontin 800 tid, Nicotine Patch 21 qd, MS Contin 30 po qid,
Dilaudid 4 prn, Prednisone 10 qd, HCTZ 50 qd, Calcium c Vit. D
600 [**Hospital1 **] Folic Acid qd, Lopressor 25 qd, Simvastatin 20 qd,
Nifedical 30 qd Celexa 10 qd
Discharge Medications:
1. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**6-10**]
hours as needed: prn.
17. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q6H (every 6 hours).
18. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
19. Hexavitamin Tablet Sig: One (1) Cap PO once a day.
20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
21. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
22. Insulin
Lunch Dinner Bedtime
Humalog 3 Units Humalog 3 Units Humalog 3 Units
bedtime
Glargine 20 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-60 mg/dL [**1-4**] amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 2 Units 2 Units 0 Units 0 Units
141-160 mg/dL 4 Units 4 Units 2 Units 2 Units
161-180 mg/dL 6 Units 6 Units 4 Units 3 Units
181-200 mg/dL 8 Units 8 Units 6 Units 4 Units
201-220 mg/dL 10 Units 10 Units 8 Units 5 Units
221-240 mg/dL 12 Units 12 Units 10 Units 6 Units
>240 mg/dL 14 Units 14 Units 12 Units 7 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] [**Hospital **] Hospital @ MentroWest
Discharge Diagnosis:
Ischemic left foot
acute sepsis / needing intubation / bp resusitation for
hypotension
DM
CRI
Discharge Condition:
stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
transmetatarsal amputation you are non weight bearing for [**4-8**]
weeks. You should keep this amputation site elevated when ever
possible.
You are Non weight beariing on your left lower extremity
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 14 days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
Call Dr [**Last Name (STitle) **] and schedule an apoointment for tweo weeks.
He can be reached at [**Telephone/Fax (1) 3121**].
Call [**Hospital 20424**] clinic and make an appointment in one to two weeks to
see your [**Last Name (un) 387**] diabetic doctor
Completed by:[**2135-4-15**]
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72,439
| 144,809
|
29369
|
Discharge summary
|
report
|
Admission Date: [**2194-11-14**] Discharge Date: [**2194-11-19**]
Date of Birth: [**2131-11-19**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Percodan / Codeine
Attending:[**Doctor First Name 3290**]
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
Central Line placement, arterial line placement
History of Present Illness:
Ms. [**Known lastname **] is a 62 year old woman with a PMHx s/f metastatic
[**Known lastname 499**] cancer, local thyroid carcinoma, afib on coumadin, and
recent pyelonephritis who presents with bilateral flank pain and
fevers chills x 1 day. Ms. [**Known lastname **] was in her usual state of
health until two weeks ago when she was diagnosed with a kidney
infection at [**Hospital **] hospital which was presumed to be
secondary to kidney stones. She was started on 10 days of
augmentin and was instructed to follow up with Dr. [**Last Name (STitle) 770**] in
urology for further management. Urine culture demonstrated
pan-negative E coli > 100,000 cfu. She completed her antibiotic
course approximately 5-6 days ago. Last night, Ms. [**Known lastname **] noted
severe bilateral flank pain which improved with a hot bath and
worsened with lying supine. She also noted chills, orthostatic
dizziness, and chills.
.
She presented to the [**Hospital1 **] ED with the above complaints and
was found to have bilateral hydronephrosis.
In the ED, initial VS: 98.0 110 106/66 18 100%. Labs notable for
leukocytosis to 20. Patient given vanc/ctx. CTU demonstrated b/l
hydro with no clear stone. Urology consulted and recommended
admission to medicine for IR drainage.
.
On arrival to the floor she was still in considerable pain (CVA
tenderness) and was febrile to 101. IR has consented her for b/l
nephrostomy tubes, and she has been consented for FFP to rectify
her INR of 2.1 (on coumadin).
Past Medical History:
Thyroid Cancer- s/p thyroidectomy 5 years ago at [**Hospital1 2025**] with Dr.
[**Last Name (STitle) **]
[**Name (STitle) **] Cancer - s/p 2 subtotal colectomies last 3 years ago. On
Chemotherapy, oncologist is Dr. [**Last Name (STitle) 15759**] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Medical Center. Known mets to gallbladder s/p cholecystectomy 9
months ago.
Paroxysmal Afib
Depression
GERD
DMII
PAH
?Celiac Disease
Sleep Apnea-not on CPAP
Hysterectomy
Torn Right Rotator Cuff
Social History:
Pt is separated from husband, but he still provides emotional
support during chemotherapy. Lives by herself but sisters visit
quite often. House burned down in [**Month (only) 404**] of last year, but son
rebuilt it himself--he is a contractor. Ms. [**Known lastname **] used to work
as a cook in one of her husband's restaurants. Denies tobacco
use ever, alcohol use ever, and other drug use ever.
Family History:
Mother died of lung cancer 54, father died of lung cancer age
60, 7 siblings with thyroid cancer.
Physical Exam:
On Admission
VS - Temp 101F, 105/55BP , 87HR , 16R , 96 O2-sat % RA
GENERAL - well-appearing woman in moderate distress secondary to
flank pain.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, diffuse TTP in abdomen, no masses or
HSM, no rebound/guarding, laparotomy/cholecystectomy scar
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), + CVA tenderness
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-27**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
On Admission:
[**2194-11-13**] 08:50PM [**Month/Day/Year 3143**] WBC-20.0* RBC-3.71* Hgb-11.5* Hct-36.4
MCV-98 MCH-30.9 MCHC-31.6 RDW-16.0* Plt Ct-299
[**2194-11-13**] 08:50PM [**Month/Day/Year 3143**] Glucose-167* UreaN-11 Creat-1.3* Na-137
K-3.0* Cl-102 HCO3-21* AnGap-17
[**2194-11-13**] 08:50PM [**Month/Day/Year 3143**] ALT-14 AST-22 AlkPhos-153* TotBili-0.4
[**2194-11-13**] 08:50PM [**Month/Day/Year 3143**] Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-1.3*
[**2194-11-13**] 09:00PM [**Month/Day/Year 3143**] Glucose-158* Lactate-1.7 K-3.0*
Septic Shock Labs:
[**2194-11-15**] 01:43AM [**Month/Day/Year 3143**] WBC-69.7*# RBC-2.99* Hgb-9.4* Hct-29.2*
MCV-98 MCH-31.5 MCHC-32.2 RDW-16.0* Plt Ct-236
[**2194-11-15**] 02:01PM [**Month/Day/Year 3143**] Glucose-253* UreaN-23* Creat-2.6* Na-133
K-4.4 Cl-106 HCO3-17* AnGap-14
[**2194-11-15**] 02:01PM [**Month/Day/Year 3143**] ALT-74* AST-100* AlkPhos-182* TotBili-0.3
[**2194-11-15**] 07:05AM [**Month/Day/Year 3143**] Lactate-4.1*
Discharge labs:
[**2194-11-19**] 05:50AM [**Month/Day/Year 3143**] WBC-15.9* RBC-3.04* Hgb-9.2* Hct-28.9*
MCV-95 MCH-30.4 MCHC-32.0 RDW-16.2* Plt Ct-186
[**2194-11-19**] 05:50AM [**Month/Day/Year 3143**] Glucose-109* UreaN-18 Creat-0.9 Na-141
K-3.7 Cl-107 HCO3-28 AnGap-10
INR Trend:
[**2194-11-19**] 05:50AM [**Month/Day/Year 3143**] PT-22.6* PTT-33.7 INR(PT)-2.2*
[**2194-11-18**] 05:36AM [**Month/Day/Year 3143**] PT-21.3* PTT-33.3 INR(PT)-2.0*
[**2194-11-17**] 03:18AM [**Month/Day/Year 3143**] PT-21.5* INR(PT)-2.0*
[**2194-11-16**] 03:25PM [**Month/Day/Year 3143**] PT-25.7* INR(PT)-2.5*
MICRO:
[**2194-11-13**] 10:45 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2194-11-18**]**
URINE CULTURE (Final [**2194-11-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROBACTER CLOACAE COMPLEX. 10,000-100,000
ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROBACTER CLOACAE
COMPLEX
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
RADIOLOGY:
- CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Study Date of
[**2194-11-13**] 9:10 PM -
IMPRESSION:
1. Severe left and moderate right hydronephrosis with bilateral
hydroureter, left greater than right. Both ureters taper
abruptly within a region of stranding and small bowel tethering
in the pelvis, indicating that the ureteral obstruction could
secondary to adhesions from prior surgery. If this patient has
had prior radiation to the pelvis, post-radiation fibrosis
should be considered as well. No stones are definitely seen in
the collecting system.
2. Multiple dilated loops of small bowel without a definite
transition point and air/stool throughout the [**Date Range 499**] that could
relate to an early or low-grade small-bowel obstruction,
possibly secondary to adhesions. There are no secondary signs of
ischemia.
3. Small pulmonary nodules measuring up to 6 mm should be
followed up with a chest CT in 12 months if the patient is a
nonsmoker and has no risk of
malignancy. Otherwise, followup CT at 6 months is recommended.
4. Small hepatic hypodensity is too small to characterize, but
is
statistically a simple cyst.
5. Tiny hiatal hernia.
Brief Hospital Course:
Ms. [**Known lastname **] is a 62 year old woman with a past medical history of
thyroid and metastatic [**Known lastname 499**] cancer currently undergoing current
chemotherapy with FOLFIRI who presented with bilateral
hydronephrosis and pyleonephritis, requiring brief MICU stay for
septic shock.
# Septic Shock secondary to Pyelonephritis.
Ms. [**Known lastname **] previously had pyelonephritis secondary to
pan-sensitive E. coli in early [**Month (only) 1096**] and was treated with 10
days of augmentin. Following initial therapy, she presented to
[**Hospital1 18**] with 2 days of bilateral flank pain and chills. E coli
grew only from left nephrostomy tube during this admission, not
right, though no definite stones seen on final read of CT
abdomen/pelvis. Positive UA on admission, hydronephrosis,
fevers, leukocytosis and borderline hypotension to SBPs
100s-110s. Ms. [**Known lastname **] was initially started on Vancomycin and
Ceftriaxone, but was transitioned to Vancomycin and Cefepime
(for greater GU coverage). Ms. [**Known lastname **] was hypotensive to SBPs in
the 60s soon after placement of bilateral percutaneous
nephrostomy tubes (intraoperatively frank pus was noted from
left kidney). Ms. [**Known lastname 48642**] hypotension did not respond to 3L IV
NS, and was transferred to the MICU where she was started on
norepinephrine and vasopressin for [**Known lastname **] pressure support.
Pressors were weaned off the morning of [**11-16**]. Her urine culture
grew pan-sensitive e. coli, so antibiotics were narrowed to oral
ciprofloxacin on transfer to floor, and she will continue on
ciprofloxacin for a total course of antibiotics of 2 weeks, last
dose [**2194-11-26**]. [**Month/Day/Year **] cultures drawn after starting antibiotics
remained negative. Nephrostomy tubes will remain in place
likely for at least 2-3 months; urology will determine whether
or not she would benefit from internal ureteral stents as an
outpatient. She will follow up with urology in the next week,
then with IR in [**2-26**] weeks. Nephrostomy care instructions were
given to patient.
# Bilateral hydronephrosis:
Likely secondary to obstructing adhesions from prior surgery.
There was question of non-obstructive stones seen on CT in left
renal pelvis, but final report shows no definite stones.
Bilateral percutaneous nephrostomy tubes were placed under IR on
[**2194-11-14**]. Urology will follow her as an outpatient to determine
whether to internalize her stents.
# Metastatic [**Date Range **] cancer s/p resection
Currently undergoing chemotherapy with FOLFIRI. Dr. [**Name (NI) 15759**]
(pt's outpatient oncologist) aware of admission.
# Paroxysmal Afib:
Coumadin held on admission prior to percutaneous nephrostomy
tube placement, then restarted at lower dose in setting of
antibiotics. Metoprolol home dose was continued as well. She
did have afib with RVR sustained in 130s, hemodynamically
stable, the day prior to discharge. Once diuresed effectively,
heart rates improved, and she returned to [**Location 213**] sinus rhythm.
She will be discharged on warfarin 3mg daily, next INR to be
checked at PCP office [**Name9 (PRE) 2974**] [**11-21**].
# DMII:
Oral hypoglycemics were held in house. SSI was maintained.
Restarted on glipizide and metformin on discharge.
# Prior history of Thyroid cancer:
Synthroid was continued. TSH on admission was 0.29, which is
difficult to interpret in acute illness but should be rechecked
as outpatient to ensure proper suppression.
# Full Code during this hospitalization
Transitional Issues:
- INR to be checked Friday [**11-21**]
- Electrolytes to be checked next week [**2194-11-27**] at PCP visit
[**Name Initial (PRE) **] Urology and Interventional Radiology followup regarding
nephrostomy tubes
- CT abdomen-pelvis showed Small pulmonary nodules meausuring up
to 6- mm should be followed-up with CT 6 months
Medications on Admission:
Vicodin 5 mg-500 mg q4-6 hrs as needed for pain
Lasix 20 mg Tab Oral 1 Tablet(s)
citalopram 40 mg daily
glipizide 10 mg [**Hospital1 **]
metformin 500 mg [**Hospital1 **]
Synthroid 137 mcg daily
Toprol XL 50 mg daily
omeprazole 20 mg [**Hospital1 **]
Coumadin 5 mg daily
Discharge Medications:
1. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every [**2-26**]
hours as needed for pain.
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Synthroid 137 mcg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
please take 3mg daily until you hear back from your primary care
doctor's office about whether you need to change the dose;
please have your INR checked on Friday, [**11-21**] at your primary
care doctor's office.
10. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*36 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Care Network
Discharge Diagnosis:
Primary Diagnosis:
Septic Shock secondary to Pyelonephritis
Secondary Diagnoses:
Atrial Fibrillation
Metastatic [**Month/Year (2) **] Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you were having flank
pain and chills, which turned out to be from a very severe
kidney infection. You were also found to have obstruction in
the ureters, which run from your kidneys to your bladder. You
were started on antibiotics, and nephrostomy tubes were placed
in each of your kidneys to relieve obstruction in the ureters.
Your [**Known lastname **] pressures became very low after the procedure, so you
were transfered to the intensive care unit, where you required
medications to support your [**Known lastname **] pressure for 1-2 days, after
which the antibiotics kicked in, and you improved.
The following changes have been made to your medications:
- Please START ciprofloxacin 500mg every 12 hours for 9 more
days (to treat your urinary and kidney infection)
- Please DECREASE your warfarin dose to 3mg daily or as
otherwise directed by your primary care doctor
(the antibiotic can interact with your warfarin and increase the
coumadin level in your [**Last Name (LF) **], [**First Name3 (LF) **] we have to monitor your
coumadin levels closely while you are on the antibiotic)
PLEASE have your INR (coumadin level) drawn on Friday [**11-21**] at
your primary care doctor's office, and they will instruct you
with how to proceed with your coumadin dosing.
You will follow up with your primary care doctor [**First Name (Titles) **] [**11-27**]-- please have your electrolytes checked at that time.
You have been provided with instructions on how to care for your
nephrostomy tubes until your followup appointment. If you have
any questions, please call Interventional Radiology at
([**Telephone/Fax (1) 45313**].
If you have any questions regarding the plan for your
nephrostomy tubes, please contact the urology office at the
number listed below ([**Telephone/Fax (1) 164**].
Followup Instructions:
Please be sure to keep all of your followup appointments as
listed below:
Please have your INR (coumadin level) drawn at your primary care
physician's office on Friday, [**11-21**].
Name:[**Doctor First Name **] [**Last Name (NamePattern4) 70549**],MD
Specialty: Primary Care
Address: [**Location (un) 8056**], [**Location (un) **],[**Numeric Identifier 45328**]
Phone: [**Telephone/Fax (1) 8058**]
When: Thursday,[**11-27**] at 11:30am
--> Please have your electrolytes checked at this visit.
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2194-12-3**] at 9:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name:[**Doctor Last Name **] [**Last Name (NamePattern4) 70550**], MD
Specialty: Hematology/Oncology
Location: [**Doctor Last Name **] RIVER MEDICAL ASSOCIATES
Address: [**Hospital1 25492**], 2ND FL, [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 70551**]
When: A message was left with the nursing staff that you were
being discharged from the hospital and need a follow up
appointment. If you do not hear in the next two days, please
call above number for status of an appointment.
The Interventional Radiologists will also call you to set up an
appointment with them in [**2-26**] weeks.
|
[
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"038.42",
"584.5",
"785.52",
"599.0",
"427.31",
"311",
"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"55.03",
"38.93",
"38.91"
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icd9pcs
|
[
[
[]
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13591, 13634
|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,586
| 166,165
|
756
|
Discharge summary
|
report
|
Admission Date: [**2132-9-17**] Discharge Date: [**2132-9-26**]
Service: MEDICINE
Allergies:
Histamine H2 Inhibitors / Codeine / Sulfa (Sulfonamide
Antibiotics) / Proton Pump Inhibitors / Penicillins / Demerol
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 5501**] is a [**Age over 90 **] year-old woman with a history of
Parkinson's, CAD, dilated CM (EF 30%), chronic mesenteric
ischemic s/p stents, recent fall complicated by humeral
fracture, aspiration pneumonia. Please see admission note for
full details of history. Briefly, she was admitted to OSH [**9-9**]
with aspiration pneumonia. She was treated with broad spectrum
antibiotics but decomepensated, with [**Last Name (un) **], demand ischemia,
concern for new mesenteric ischemia. She was transferred from
OSH ICU to [**Hospital1 18**] ICU on [**9-17**].
.
In the ICU, she was hemodynamically stable, without oxygen
requirement. Vancomycin and levofloxacin (needs 6 more days to
complete 10 day course) were started. PICC was placed.
Aspiration was thought to be in part secondary to compromised
mental status from polypharmacy. Zyprexa was given because
patient was moaning, resulting in BP drop to the 80s. EKG showed
lateral TW changes, thought to be secondary to demand. Plavix
was held.
Past Medical History:
* Cardiac Risk Factors: (-)Diabetes, (+)Dyslipidemia, (+)
* Hypertension
* Cardiac History: NSTEMI [**3-/2132**]
* Percutaneous coronary intervention today showed anatomy as
follows:
LMCA ostial 60-70%, distal 40-50%
LAD origin 60-70%
LCx mild diffuse
RCA 95% proximal, mid diffuse 70%, distal 70%
Left main and severe two vessel CAD, RCA felt to be culprit.
Successful PTCA and BMS X2 to RCA. Recommending aspirin 325mg
daily X1 month then 162mg daily. Plavix 75mg daily X1-12 months.
Gentle hydration of 1.5 L after contrast load.
* No Pacemaker/ICD.
.
Other Past History:
- Coronary artery disease
- Non Q-Wave MI in [**2132-3-20**]
- Chronic Angina
- Peripheral vascular disease
- Mesenteric Ischemia s/p multiple PCIs of mesenteric
vasculature (SMA, celiac artery etc.)
- Hypertension
- Gout
- Parkinson's: Lower half
- Chronic anemia: Pernicious
- Hyperlipidemia
- Osteopenia: Formerly treated with calcium and Fosamax
- Cataracts
- Hemorrhoids
- Colonic polyps s/p polypectomies
- Cholecystectomy
- Direct brachial artery repair
- Retinal surgery
Social History:
Widowed, lives alone; is retired school principal. Has a driver
and paid visiting nurse/housekeeper who comes to patient's home
three hours a day. Has two children in the area. Patient does
not smoke (remote tobacco use history), drink alcohol and denies
illicit drug use. She has 24 hour help at home.
Family History:
Hypertension, Alzheimer's disease. No family history of sudden
cardiac death.
Physical Exam:
Vitals: T:96.7 BP: 112/50, HR:88 20 97%RA
General: lays in bed vocalizing sound, delirious
HEENT: edentulous, NGT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Unable to fully assess lungs due to pt constant
vocalizing
CV: regular, no murmurs
Abdomen: mildly distended, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: LE edema L>R especially on knee, skin tears on lower arm
SKIN: Stage 2-3 Decub ulcer on coccyx, deep tissue injury to
heels bilaterally
Pertinent Results:
[**2132-9-24**] 06:14AM BLOOD WBC-9.1 RBC-3.62* Hgb-10.6* Hct-32.7*
MCV-90 MCH-29.4 MCHC-32.5 RDW-17.3* Plt Ct-382
[**2132-9-23**] 06:18AM BLOOD WBC-7.5 RBC-3.21* Hgb-9.6* Hct-28.9*
MCV-90 MCH-29.8 MCHC-33.1 RDW-17.3* Plt Ct-286
[**2132-9-21**] 05:35AM BLOOD WBC-9.9# RBC-3.57* Hgb-10.3* Hct-32.6*
MCV-91 MCH-28.9 MCHC-31.7 RDW-17.3* Plt Ct-385
[**2132-9-20**] 06:30AM BLOOD WBC-6.5 RBC-3.15* Hgb-9.3* Hct-29.1*
MCV-92 MCH-29.5 MCHC-32.0 RDW-17.3* Plt Ct-343
[**2132-9-19**] 07:40AM BLOOD WBC-8.1 RBC-3.25* Hgb-9.7* Hct-30.3*
MCV-93 MCH-29.9 MCHC-32.0 RDW-17.2* Plt Ct-345
[**2132-9-18**] 08:21AM BLOOD WBC-8.8# RBC-3.35* Hgb-10.0* Hct-29.6*
MCV-88# MCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-360#
[**2132-9-24**] 06:14AM BLOOD Plt Ct-382
[**2132-9-24**] 06:14AM BLOOD PT-12.1 PTT-27.9 INR(PT)-1.0
[**2132-9-24**] 06:14AM BLOOD Glucose-97 UreaN-44* Creat-1.4* Na-138
K-4.7 Cl-108 HCO3-19* AnGap-16
[**2132-9-18**] 08:21AM BLOOD CK(CPK)-42
[**2132-9-24**] 06:14AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 5501**] was transferred here from OSH with concerns of
suspected aspiration PNA, OSH CXR reports look like recurrent
aspiration PNA w/ new infiltrates every day and possible sepsis
on [**9-11**], would be c/w known delerium and PD and high doses of
dilaudid/ativan/oxazepam/haldol. She had sputum Cx at OSH which
was + for yeast only on [**9-16**] so was continued on levofloxacin
and vanc. In the MICU she was found to be afebrile, hd stable
and not 02 dependent so she was transferred to the floor. On the
floor she continued to be delirious with waxing and [**Doctor Last Name 688**]
alertness, as well as agitation.
# Goals of care: On admission the patient was very agitated and
delirious. The family at the time agreed to make the patient DNR
but continued potential for intubation. Goals during the first
week of admission were to support the patient and continue
medication with the hopes of allowing the patient to improve her
mental status and clarity. While the patient did improve to some
degree, demonstrating the ability to speak a few words and
respond to questions, her status waxed and waned significantly.
At baseline the patient would lay in bed screaming or vocalizing
sound without a clear source of pain or agitation. She continued
tube feeds with an NG tube and medications for underlying
conditions. After a week of admission, a family meeting was held
where it was felt that care should be transitioned to comfort
measures only. The ng-tube was pulled and PO meds were dced. The
patient was continued on IV morphine for pain, sublingual
zyprexa for agitation. Palliative care was consulting.
.
#PNA: Suspected to be secondary to aspiration, with possible
contribution from AMS secondary to polypharmacy. S&S evaluation
done, and the patient failed, so she was NPO, no meds, no ice
chips. She did a course of vancomycin and levofloxacin (last day
[**9-23**]); PICC placed. Patient remained stable on room air.
.
# Altered mental status: likely secondary to delirium from
multiple infections and pain from recent humerus fracture.
Baseline dementia, Parkinson's are also contributing. Per family
& primary neurologist, her mental status was significantly
better than this prior to this hospitalization. Over the course
of admission the patient had some increased alertness but waxing
and [**Doctor Last Name 688**]. No haldol was given bc of interaction with sinemet.
Prior to beind made CMO, no zyprexa was given bc of past
hypotensive event. Hydromorphone for pain.
.
#CAD: Known 3VD, recent DES. Plavix held in ICU while
stabilizing patient. Troponin elevations were likely secondary
to demand in the setting of sepsis rather than secondary to
plaque rupture. Currently downtrending from OSH (0.63-->0.52).
Restarted plavix, then dced as inconsistent with goals of care.
Metoprolol given until ng tube pulled.
.
# CKI: creatinine currently at baseline 1.3. Pt given small
fluid boluses to maintain urine output while keeping low EF in
consideration.
.
#Hx of mesenteric ischemia: no evidence of active ischemia
during this admission.
.
#Shoulder Fx: pt given PRN dilaudid, standing tylenol.
.
#PD: Likely contributing to swallowing difficulties. patient was
on home sinemet until po meds dced. If pt seems to be suffering
from pd related problems at the nursing home, can be given
sublingial sinemet.
.
#Gout. home Allopurinol was continued during the admission but
could not be administered without ng tube. Can restart if
patient able to tolerate crushed in applesauce or pureed PO
feeds.
.
#Anemia: Baseline Hct around 31, Hx of pernicious anemia. B12
Qmonth.
.
# FEN: TF initially per ngtube, did not tolerate full feeds.
Ultimately held given goals of care. replete electrolytes,
regular diet
# Prophylaxis: Subcutaneous heparin
# Access: picc
Medications on Admission:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop
Ophthalmic QID (4 times a day) as needed for itchy eyes.
7. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): To legs.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
15. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
18. Isosorbide Mononitrate 20 mg Tablet Sig: 1.5 Tablets PO
twice a day.
19. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO ONCE (Once).
Vancomycin 500mg IV Q24 [**9-10**]->
.
Discharge Medications:
1. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) puffs Inhalation Q4H (every 4 hours)
as needed for SOB.
3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for pain.
7. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane PRN (as needed) as needed for sore throat.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO TID (3 times a day) as needed for agitation.
9. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours).
10. morphine concentrate 20 mg/mL Solution Sig: 3-6 mg PO q3h as
needed for pain: 0.15-0.3ml .
11. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day:
Can give crushed in applesauce or pudding if patient is
tolerating po feeds.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 5502**]Nursing & Rehabilitation Center - [**Location (un) 5503**]
Discharge Diagnosis:
aspiration pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from another hospital ICU after
aspiration event. Over the course of your admission you became
stable on room air but continued to be delirious and
deconditioned. In discussion with your family it was decided to
make you comfort measures only. You will continue to receive
medications to treat pain and agitation but will not receive
unnecessary measures to prolong life.
Followup Instructions:
none
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11244, 11354
|
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|
332, 338
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,775
| 172,084
|
5369
|
Discharge summary
|
report
|
Admission Date: [**2200-11-18**] Discharge Date: [**2200-11-28**]
Date of Birth: [**2168-1-8**] Sex: M
Service: SURGERY
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
fever, diffuse abdominal pain x 4 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 32-year-old male with a complicated recent
past medical history, well-known to Dr. [**Last Name (STitle) 1924**], who is
transferred from his rehabilitation facility with the above
complaints. According to the patient, his temperature was 103F
at
its maximum. His pain began 4 days prior and worsened to the
point that he was motivated to ask for transfer to [**Hospital1 18**] for
further evaluation.
He denies nausea/emesis, and was doing relatively well until
this
recent illness. His 2 office visits with Dr. [**Last Name (STitle) 1924**] were quite
reassuring.
Past Medical History:
PMH:
-Seronegative arthritis, possibly ankylosing spondylitis, of
hips, knees, wrist, on steroids/immunosuppressants since
[**2190**](methotrexate, sulfasalazine, Enbrel, Humira, Remicade,
prednisone)
-anemia of chronic disease
-MRSA infection
-PUD
-anabolic steroid abuse (16 months in early 20s)
.
PSH:
-L TKR [**3-1**] c/b wound dehiscence & septic arthritis in
[**3-2**]
-R THR [**10-30**]
-L THR [**1-26**]
-R THR [**4-28**]
-L tibial osteotomy
-L4-L5 laminectomy [**2193**] (s/p MVA with traumatic disc herniation)
Social History:
Disabled, lives with mother in [**Name (NI) **], MA. Was a
semiprofessional body builder in early 20s with h/o anabolic
steroid abuse x 16 months. Tobacco 1 pack/day x 10 years.
Denies alcohol use.
Family History:
noncontributory
Physical Exam:
v/s 99.6 114 100/50 17 96% 3 liters
Gen: obese male in severe distress
HEENT: NC/AT, EOMI, PERRL bilat., dry MM, soft neck, midline
trach, no LAD
Cor: sinus tachycardia, no m/g/r
Pulm: CTA bilat.
[**Last Name (un) **]: hypoactive BS, soft, diffusely tender with voluntary
guarding at hypogastrium, obese and mildly tympanitic. Ostomy
pink with diarrhea and flatus in bag
PVasc: palp. pulses, no edema
Musc/Skel: full ROM
Neuro: grossly intact, non-focal
Pertinent Results:
[**2200-11-18**] 04:00PM BLOOD WBC-24.0*# RBC-4.34*# Hgb-11.8*#
Hct-37.6*# MCV-87 MCH-27.2 MCHC-31.4 RDW-16.0* Plt Ct-555*
[**2200-11-19**] 01:17AM BLOOD WBC-18.2* RBC-3.48* Hgb-9.8* Hct-30.5*
MCV-88 MCH-28.0 MCHC-32.0 RDW-15.8* Plt Ct-472*
[**2200-11-18**] 04:00PM BLOOD Neuts-93* Bands-2 Lymphs-1* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2200-11-18**] 04:00PM BLOOD PT-47.5* PTT-49.2* INR(PT)-5.4*
[**2200-11-19**] 01:17AM BLOOD PT-41.1* PTT-50.2* INR(PT)-4.5*
[**2200-11-19**] 09:10AM BLOOD PT-23.9* PTT-32.3 INR(PT)-2.3*
[**2200-11-19**] 01:17AM BLOOD ALT-7 AST-6 AlkPhos-92 Amylase-8
TotBili-0.1
[**2200-11-19**] 01:17AM BLOOD Lipase-14
[**2200-11-19**] 01:17AM BLOOD Albumin-2.0* Calcium-7.2* Phos-4.0 Mg-1.6
[**2200-11-18**] 04:04PM BLOOD Lactate-1.9
[**2200-11-19**] 03:19AM BLOOD Lactate-0.6
[**11-19**]: CT-
1. Diffuse thickening of the large bowel compatible with
pancolitis, likely related to C. Difficile or other infectious
cause. No evidence of acute complication.
2. Interval removal of previously noted pigtail catheters. Two
small residual fluid collections in the upper abdomen.
Post-operative changes related to cecostomy and extensive
debridement of the anterior abdominal wall.
3. Small bilateral para-aortic lymph nodes.
4. Bibasilar atelectasis.
5. Non-obstructing bilateral renal calculi again noted. No
hydronephrosis.
6. Old inferior wall fracture of the right orbit.
Brief Hospital Course:
The patient was admitted to the ICU for serial exams and close
monitoring.
Neuro: The patient was routinely monitored, adn was continued on
most home pain medications. He was put on a PCA for further
relief.
CV: no issues
Pulm: no issues
GI/ID: Serial exams were performed, and the patient was made
NPO. The patient had a CT in the ED; please see results section
for report. Serial lactates were also performed, which
decreased to 0.6 after 24 hours (from 1.9). The patient was put
on oral vancomycin, vancomycin enemas and IV metronidazole,
Linezolid, Meropenem, and fluconazole (given his past cultures
and antibiotic resistance), and ID was consulted. Meropenem and
Fluconazole were stopped and he continued on PO Vanco, Vanco
enemas, IV Flagyl (C diff colitis), and Linezolid (peri-orbital
cellulitis). FOllowing a CT of the orbit to evaluate possible
peri-orbital cellulitis, the linezolid was also subsequently
stopped. When the patient had less abdominal pain, his diet was
advanced; the patient tolerated this well. His intake and
output was closely monitored. By the end of his discharge, the
patient's diarrhea had significantly decreased, and only had
loose bowel movements cooinciding with enema administration.
GU: A Foley was placed for close monitoring of urine output.
ENdo: The patient was put on a sliding scale on insulin
ID: As previously mentioned, the patient was put on oral
vancomycin, vancomycin enemas and IV metronidazole, Linezolid,
Meropenem, and fluconazole (given his past cultures and
antibiotic resistance), and ID was consulted (see above).
Cultures were monitored.Linezolid, meropenem and fluconazole
were subsequently stopped. The patient was negative for c.diff
three times, as well as toxin B once. A second toxin B is
pending. The patient should continue on the vanc and flagyl for
a total of 14 days.
Heme: no issues
Other: opthalmology was consulted, as the patient developed some
erythema and edema of the left upper eyelid; a CT of the orbit
was also performed. As there was no orbital involvement, and
the erythema and edema quickly resolved, linezolid was stopped.
Proph: The patient was put on lovenox (and later coumadin)
during his stay and had pneumoboots
Medications on Admission:
metoprolol 25mg [**Hospital1 **]
vit D qd
prednisone 20mg po qd
lansoprazole 30mg qd
MVI qd
FeSO4 300mg qd
pregabalin 150mg tid
clonidine 0.1mg patch tp qTues
MS Contin 120mg qam and qom, 60mg at lunch
MSIR 30mg po five times daily
Florastor i [**Hospital1 **]
Nystatin 5mg po qid
Discharge Medications:
1. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
Disp:*40 Capsule(s)* Refills:*0*
2. Vancomycin 500 mg Recon Soln Sig: One Hundred (100) mg.
Recon Soln Intravenous QID (4 times a day) for 4 days: Please
administer via ostomy.
Disp:*4000 mg. Recon Soln(s)* Refills:*0*
3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q6H (every 6 hours) for 4 days.
Disp:*[**Numeric Identifier 389**] mg* Refills:*0*
4. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for anxiety, agitation.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 10 days: Swish and Swallow.
6. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO once a
day.
11. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
12. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a week: every tuesday.
13. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet
Sustained Release PO Q12H (every 12 hours).
14. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q 24H (Every 24 Hours): Noon Daily.
15. Morphine 30 mg Tablet Sig: One (1) Tablet PO 5X DAILY ():
6/10/14/18/22:00.
16. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every Tuesday).
17. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO 5X DAILY ():
6/10/14/18/22:00.
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<120, HR<60.
19. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
20. Klonopin 2 mg Tablet Sig: One (1) Tablet PO three times a
day: Hold for sedation.
21. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
22. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Continue until INR therapeutic with
coumadin.
Disp:*20 20* Refills:*0*
23. Coumadin 5 mg Tablet Sig: Two (2) Tablet PO once a day:
Monitor daily INR, adjust until therapeutic.
24. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
25. Morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
26. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/headache.
27. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
28. Ondansetron 4 mg IV Q6H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Clostridium difficile colitis
Discharge Condition:
Good
Discharge Instructions:
Continue taking lovenox and coumadin until your INR is
therapeutic. Please have your doctor at the rehabilitation
facility follow up on your clostridium difficil toxin B, which
is still pending.
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 see blood or dark/black material when you vomit or have a
bowel movement.
* 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 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.
* Continue to ambulate several times per day.
* No heavy ([**9-9**] lbs) until your follow up appointment.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**]
Date/Time:[**2200-12-9**] 12:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2200-12-9**] 11:15
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7508**] Call to schedule
appointment if you are unable to make the appointment above
Completed by:[**2200-12-1**]
|
[
"790.99",
"008.45",
"V43.64",
"V55.3",
"682.0",
"V85.4",
"720.0",
"V43.65",
"533.90",
"716.99"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.14",
"99.15",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9064, 9119
|
3653, 5878
|
312, 318
|
9193, 9200
|
2218, 3630
|
10871, 11408
|
1711, 1728
|
6277, 9041
|
9140, 9172
|
5905, 6254
|
9224, 10848
|
1743, 2199
|
233, 274
|
346, 932
|
954, 1478
|
1494, 1695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,489
| 105,911
|
2588+2589
|
Discharge summary
|
report+report
|
Admission Date: [**2128-11-1**] Discharge Date: [**2128-11-19**]
Date of Birth: [**2084-7-24**] Sex: F
Service: SURGERY
Allergies:
Flagyl / Bactrim / Reglan
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain with nausea, vomiting
Major Surgical or Invasive Procedure:
[**2128-11-2**]:
1. Exploratory laparotomy with lysis of adhesions (4
hours).
2. Small bowel resection with primary anastomosis.
3. Small bowel repairs (2).
History of Present Illness:
43 F with ulcerative colitis s/p proctocolectomy and ileostomy
and history of multiple episodes of small bowel obstruction
(last episode a couple of years ago) presents with abdominal
pain since 9AM the day prior to admission. Pain was intermittent
initially upper abdomen and then now mainly lower abdomen, no
radiation of pain, intensity 8 at the worst, relieved with pain
meds in the OR, no other definite relieving or aggravating
factors. Associated nausea vomiting. Vomited at least 10 times
on the day prior to admission, initially clear then bilious. No
blood. Is still passing gas from ileostomy and has noticed any
decrease in [**Street Address(1) 13068**] zosyn in the ED.
Past Medical History:
1. Ulcerative colitis - diagnosed age 11, [**Last Name (un) 13069**] pouch [**2107**],
revision with ileostomy [**2109**]
2. GERD - diagnosed [**2123**], partially controlled on pantoprazole,
gastroscopy [**10-21**] showed mild GE junction inflammation but no
Barrett's
3. Multiple episodes of partial small bowel obstruction due to
adhesions - last in [**2124**], usually relieved by rehydration in the
ED, have not required hospitalization
4. Depression
5. Seasonal allergies
6. Frequent UTIs - on nitrofurantoin prophylactically
7. Lateral epicondylitis
8. Unclear history of thyroid disease
9. RLQ reducible incisional hernia
Social History:
Lives with husband and six month old infant. Works as
psychologist. No tobacco, social alcohol.
Family History:
Father with SLE. Mother with Ulcerative colitis. Grandmother
with Rheumatoid arthritis. Multiple other family members with
ulcerative colitis or [**Name (NI) 4522**] disease, including uncle, great
aunt, and [**Name2 (NI) 12232**].
Physical Exam:
On Admission:
VS: 98.7 92 101/72 20 98
General: moderately uncomfortable appearing
HEENT: Looks dry
Cardiovascular: regular rate and rhythm, normal S1 and S2, no
m/c/r
Lungs: clear to auscultation bilaterally
Abdomen: Minimal distension, soft tenderness lower abdomen more
suprapubic and LLQ. No guarding or rebound. Ileostomy present
with some output in bag with no gas. Bag was just emptied.
Digital exam of ileostomy showed no narrowing suggestive of
stenosis.
Extremities: warm and well perfused, 2+ pulses
Neurological: alert and oriented x3
Pertinent Results:
On Admission:
[**2128-11-1**] 04:15PM LACTATE-1.4
[**2128-11-1**] 03:50PM GLUCOSE-145* UREA N-11 CREAT-0.6 SODIUM-147*
POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-25 ANION GAP-13
[**2128-11-1**] 03:50PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2128-11-1**] 03:50PM WBC-10.1# RBC-4.63 HGB-13.2 HCT-38.8 MCV-84
MCH-28.6 MCHC-34.1 RDW-14.2
[**2128-11-1**] 03:50PM PLT COUNT-254
[**2128-11-1**] 03:50PM PT-13.2 PTT-23.6 INR(PT)-1.1
[**2128-11-1**] 08:56AM LACTATE-1.6
[**2128-11-1**] 08:45AM GLUCOSE-152* UREA N-10 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-24 ANION GAP-13
[**2128-11-1**] 12:00AM PLT COUNT-319
[**2128-11-1**] 12:00AM NEUTS-90.9* LYMPHS-4.7* MONOS-3.8 EOS-0.2
BASOS-0.3
[**2128-11-1**] 12:00AM WBC-17.5*# RBC-5.59* HGB-16.0 HCT-46.7 MCV-84
MCH-28.6 MCHC-34.1 RDW-14.1
[**2128-11-1**] 12:00AM GLUCOSE-147* UREA N-14 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-21* ANION GAP-27*
.
IMAGING:
[**2128-11-1**] ABD/PELVIC CT W/CONTRAST:
1. Findings concerning for a closed loop small bowel
obstruction, likely secondary to adhesions. No free air.
2. Cholelithiasis.
3. Left ovarian cyst.
.
[**2128-11-1**] KUB/upright:
ABDOMEN, SUPINE AND UPRIGHT: An ileostomy is noted within the
right lower quadrant. There is a paucity of bowel gas throughout
the abdomen, with suggestion of fecalized small bowel loops in
the pelvis. No free air or pneumatosis is identified. No
abnormal intra-abdominal calcifications are seen. A prominent
[**Last Name (un) 13070**] lobe is noted, making determination of hepatomegaly
uncertain.
IMPRESSION: Paucity of bowel gas, with suggestion of fecalized
small bowel loops in the pelvis. Correlation with CT is
recommended.
.
[**2128-11-3**] ECG:
Sinus tachycardia. Tracing is normal except for rate. Compared
to the previous tracing of [**2120-5-24**] there is no change.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
107 120 72 320/402 68 70 60
.
[**2128-11-7**] ABD COMPL INCLUDING LAT:
Markedly dilated loops of apparently both small and large bowel
as well as of the stomach. Paucity of gas within the stomach.
This raises the possibility of an obstruction. CT would be
superior to plain radiographs for evaluating this possibility.
Brief Hospital Course:
Pt was seen and evaluated in the ED and determined to have a
small bowel obstruction. She was admitted to the floor for
conservative management of a small bowel obstruction. An NG tube
was placed and the patient was made NPO and started on mIVF. Her
symptoms initially improved, with resolution of her nausea and
vomiting. On HD 2, the patient had return of her symptoms and
exploratory laparotomy was discussed and agreed to proceed with
the procedure. She was taken to the OR, where she underwent
exploratory laparotomy with lysis of adhesions (4 hours), small
bowel resection with primary anastomosis, and small bowel
repairs (2). Intraoperatively she required neosynephrine to
maintain pressures and was admitted to the SICU intubated. She
was weaned off of neosynephrine in the unit, and was maintained
on propofol and intubated secondary to tenuous respiratory
status. On POD4 (HD6), the patient was extubated without
complication. On POD5, she had increasing ostomy output. The
patient was transferred to the floor for further recovery. The
patient was seen and evaluated by physical therapy, nutrition
and the ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 13071**] planning during this
admission. Once her ostomy output was stable, her NG tube was
discontinued without complication. She was started on TPN for
prolonged NPO status and increased metabolic needs on POD#7. The
patient was unable to tolerate sips or clears during two
attempts early on post-operatively. Ultimately, she was able to
tolerate sips on POD#10, and her diet was prodressively advanced
to a low residue regular by POD#13 with good intake. TPN was
discontinued on POD#12. The patient required multiple IV fluid
boluses for increased ostomy output. Loperamide was used to
control and stabilize her ostomy output, and the patient
eventually was able to tolerate her fluid intake goal of greater
than 1.5 liters daily, which enablabled discharge as she no
longer required IV fluids. A small area of erythema was noticed
around her surgical wound, and she was started on Ciprofloxacin
for a wound infection. Her wound was opened in two locations and
packed with AMD moist-to-dry dressings twice daily with
improvement.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge on [**2128-11-19**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
low residual regular diet and daily fluid requirement of 1.5
liters, ambulating, voiding without assistance, and pain was
well controlled. She received ostomy teaching and supplies. She
was discharged home with VNA services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
FEXOFENADINE [[**Doctor First Name **]] - (Prescribed by Other Provider) -
Dosage
uncertain
FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - Dosage
uncertain
LEVOTHYROXINE - (Prescribed by Other Provider; 50 mcg) - 75 mcg
Tablet - 1 Tablet(s) by mouth daily
NITROFURANTOIN MACROCRYSTAL [MACRODANTIN] - 50 mg Capsule - one
Capsule(s) by mouth as directed
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth twice a
day
SERTRALINE - (Prescribed by Other Provider; 125 mg daily) - 25
mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day
TRIMETHOBENZAMIDE - 300 mg Capsule - 1 Capsule(s) by mouth tid
prn vomiting
.
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - 500 mg (1,250 mg)-200 unit Tablet - 1 (One)
Tablet(s) by mouth once a day
LOPERAMIDE - 2 mg Tablet - 1 Tablet(s) by mouth daily in am prn
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(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) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea: Titrate as described.
Disp:*60 Capsule(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for shortness of breath
or wheezing.
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
7. Sertraline 50 mg Tablet Sig: 0.25 Tablet PO QHS (once a day
(at bedtime)).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-19**]
hours as needed for fever or pain.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Trimethobenzamide 300 mg Capsule Sig: One (1) Capsule PO
three times a day as needed for nausea.
11. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-16**] each
nostril Nasal once a day as needed for allergy symptoms.
13. [**Doctor First Name **] Oral
14. Calcium Oral
15. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO As directed by PCP for prophylaxis [**Name9 (PRE) **] symptoms.
16. Ostomy Supplies:
Convatec Surfit Natura Wafer # [**Numeric Identifier 13072**] as directed.
.
Disp: #10/box, 1 box with 11 Refills
17. Ostomy Supplies:
Convatec Surfit Natura Pouch # [**Numeric Identifier 13073**] as directed.
.
Disp: #10/box, 1 box with 11 Refills
Discharge [**Numeric Identifier **]:
Home With Service
Facility:
CareGroup VNA
Discharge Diagnosis:
1. Small intestinal obstruction.
2. Multiply operated abdomen.
3. Status post total proctocolectomy - ulcerative colitis.
Discharge Condition:
Good.
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 is 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 [**5-23**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at 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.
.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2128-12-6**]
8:00. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 13074**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 13075**] (PCP) in [**2-17**] weeks.
Completed by:[**2128-11-19**] Admission Date: [**2128-11-20**] Discharge Date: [**2128-11-28**]
Date of Birth: [**2084-7-24**] Sex: F
Service: SURGERY
Allergies:
Flagyl / Bactrim / Reglan
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Increased ostomy output.
Major Surgical or Invasive Procedure:
PICC placement.
History of Present Illness:
44-y.o. female was discharged from our service one day prior to
admission. She had been in the hospital 19 days recovering from
surgery. She had an ex-lap with lysis of adhesions and SB
resection on [**11-2**]. She had continued intermittent sbo symptoms
post-operatively. When discharged to home with services she had
been tolerating a regular diet with 1 to 2 liters ostomy output.
She comes back in because she had been having mashed potatoes
consistency output. However yesterday afternoon the consistency
changed to liquid and she had to change her full bag at least
ten times. She also had some associated nausea with one emesis.
Past Medical History:
1. Ulcerative colitis - diagnosed age 11, [**Last Name (un) 13069**] pouch [**2107**],
revision with ileostomy [**2109**]
2. GERD - diagnosed [**2123**], partially controlled on pantoprazole,
gastroscopy [**10-21**] showed mild GE junction inflammation but no
Barrett's
3. Multiple episodes of partial small bowel obstruction due to
adhesions - last in [**2124**], usually relieved by rehydration in the
ED, have not required hospitalization
4. Depression
5. Seasonal allergies
6. Frequent UTIs - on nitrofurantoin prophylactically
7. Lateral epicondylitis
8. Hypothyroidism
9. RLQ reducible incisional hernia
Social History:
Lives with husband and six month old infant. Works as
psychologist. No tobacco, social alcohol.
Family History:
Father with SLE. Mother with Ulcerative colitis. Grandmother
with Rheumatoid arthritis. Multiple other family members with
ulcerative colitis or [**Name (NI) 4522**] disease, including uncle, great
aunt, and [**Name2 (NI) 12232**].
Physical Exam:
On admission:
T 96.6 P 104 BP 116/80 RR 16 O2sat 99 on RA
A&Ox4, NAD
Tachy, regular
Clear lungs
Abd soft, non-tender, ostomy bag with liquid contents, incision
healing well, no hernias
Ext - no edema
Pertinent Results:
[**2128-11-19**] 05:14AM CK-MB-2 cTropnT-<0.01
[**2128-11-20**] 05:43AM PLT COUNT-576*
[**2128-11-20**] 05:43AM WBC-13.2*# RBC-4.01* HGB-11.4* HCT-34.9*
MCV-87 MCH-28.3 MCHC-32.6 RDW-14.7
[**2128-11-20**] 05:43AM GLUCOSE-130* UREA N-10 CREAT-0.6 SODIUM-135
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-25 ANION GAP-18
[**2128-11-20**] 05:48AM LACTATE-2.4*
[**2128-11-20**]: KUB showed nonspecific bowel gas pattern. Few small
air fluid levels. No free air under the diaphragm.
Brief Hospital Course:
On [**2128-11-20**], the patient was admitted to the general surgery
service. She was continued on a regular diet with loperamide
while ostomy output was monitored. CT abdomen with contrast
showed markedly-dilated proximal small bowel loops and more
distal collapsed small bowel loops. Contrast was seen entering
the ileostomy. These findings were concerning for partial small
bowel obstruction. Stool cultures were repeatedly negative for
salmonella, shigella, campylobacter, E. coli O157:H7, yersinia,
vibrio, and C. difficile toxin. Fluid losses from the high
ostomy output were replaced mL for mL with LR IV. Loperamide
was stopped as it showed limited benefit. GI was consulted and
agreed with partial small bowel obstruction, with infectious
colitis and enteroenteric fistula on the differential as well.
Ostomy output varied from 1 to 2 L per day, and KUB on
[**2128-11-24**] showed single dilated air-filled small bowel loop in
the left lower quadrant consistent with partial small bowel
obstruction, with unchanged bowel gas pattern. TPN was started
for nutrition. With overall symptomatic improvement by
[**2128-11-28**], the patient was discharged home in stable condition,
NPO with TPN and IVF replacement, to follow up with Dr. [**Last Name (STitle) 468**]
in 1 week.
Medications on Admission:
Discharge Medications: [**2128-11-19**]
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea: Titrate as described.
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for shortness of breath
or wheezing.
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 10 days.
7. Sertraline 50 mg Tablet Sig: 0.25 Tablet PO QHS (once a day
(at bedtime)).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-19**]
hours as needed for fever or pain.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Trimethobenzamide 300 mg Capsule Sig: One (1) Capsule PO
three times a day as needed for nausea.
11. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-16**] each
nostril Nasal once a day as needed for allergy symptoms.
13. [**Doctor First Name **] Oral
14. Calcium Oral
15. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO As directed by PCP for prophylaxis [**Name9 (PRE) **] symptoms.
16. Ostomy Supplies:
Convatec Surfit Natura Wafer # [**Numeric Identifier 13072**] as directed.
Discharge Medications:
1. Lactated Ringers Parenteral Solution Sig: One (1) mL per
1 mL ostomy output as fluid replacement Intravenous once a day.
Disp:*15 liters* Refills:*0*
2. [**Doctor First Name **] 60 mg Tablet Sig: as directed Tablet PO as directed.
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO as directed.
5. 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*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Trimethobenzamide 300 mg Capsule Sig: One (1) Capsule PO
three times a day as needed for nausea.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Basic chem-10 serum electrolytes on Tuesday [**11-30**] and Friday
[**12-3**].
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. TPN Electrolytes Intravenous
Discharge [**Month/Year (2) **]:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Partial small bowel obstruction.
Discharge Condition:
Stable
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Continue to take cycled TPN at home for nutrition.
Please continue all medications as prescribed. Continue 1mL for
1mL fluid replacement with LR.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2128-12-6**]
8:00
Completed by:[**2128-11-28**]
|
[
"V45.72",
"560.81",
"477.8",
"244.9",
"E870.0",
"V44.2",
"998.59",
"V13.02",
"530.81",
"041.04",
"311",
"493.90",
"998.2",
"E878.2",
"998.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.71",
"45.62",
"54.59",
"38.93",
"46.73"
] |
icd9pcs
|
[
[
[]
]
] |
16945, 18237
|
14517, 14535
|
21608, 21615
|
16441, 16922
|
21932, 22104
|
15970, 16203
|
19797, 21531
|
21552, 21587
|
18263, 18263
|
21760, 21909
|
12902, 13791
|
16218, 16218
|
14453, 14479
|
14563, 15207
|
16232, 16422
|
21629, 21736
|
15229, 15840
|
15856, 15954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,521
| 144,541
|
16720
|
Discharge summary
|
report
|
Admission Date: [**2107-2-16**] Discharge Date: [**2107-3-6**]
Service: TRAUMA SURGERY
HISTORY OF THE PRESENT ILLNESS: This is an 86-year-old
gentleman who was found at the bottom of his stairs by EMTs.
He had been noted by his family to not have been able to be
located for three to four days. Therefore, the police were
sent to his house. He was living alone at the time. He was
found down. He had been down approximately three days at
least.
PAST MEDICAL HISTORY: Unknown.
ADMISSION MEDICATIONS: Unknown.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile. His vital signs were stable. He was
noncommunicative with a GCS of approximately 12. In the
Emergency Bay, he was intubated.
LABORATORY DATA/STUDIES: A chest x-ray and pelvic x-ray were
normal.
A head CT showed a chronic left subdural hematoma, right
parietal interparenchymal bleed, a left frontotemporal
interparenchymal bleed.
His neck CT was negative.
The abdominal CT showed mild ductal dilatation of his
intrahepatic ducts and dilated CBD.
HOSPITAL COURSE: He was admitted to the Trauma Service to
the Trauma ICU at that time, intubated, and was started the
next day on Zosyn for the question of ductal dilatation as
well as for prophylaxis. The patient was hydrated and was
able to be weaned off the ventilator and extubated.
He was transferred to the floor. He is doing well on the
floor. His decubitus ulcers which were on his right side,
right hip, right abdomen, right shoulder, and right face,
were debrided in the CCU and he was continued on wet-to-dry
dressing changes as well as silver nitrate. The silver
nitrate was discontinued during his hospital course. The
patient was also started on vancomycin for an elevated white
count. A chest x-ray was done. Blood cultures were done.
The patient was noted to have a retrocardiac infiltrate.
The patient had an ERCP during his hospital course which
showed a tremendous amount of sludge and a choledochoduodenal
fistula. Those were all cleaned out. The sludge was cleaned
out and ballooned during the ERCP and the patient did well.
The family refused surgical intervention for his gallbladder
and any surgical intervention for treatment of his biliary
sludge.
Therefore, the patient went to the Operating Room on [**2107-3-1**]
for a percutaneous endoscopic gastrostomy tube. The patient
tolerated the procedure well and was started on tube feeds at
that time. He was started on ProMod with fiber and was
quickly taking the goal of 65 cc per hour which he tolerated.
The patient continued to do well. Speech and swallow was
consulted for evaluation of his ability to swallow. It was
found that he was grossly aspirating. Therefore, the patient
was continued n.p.o. The patient continued to do well post G
tube placement and was brought up to goal quickly. His white
count which had been elevated slowly improved post PEG
placement and he continued to improve and gain strength.
The patient had all of his medications switched to per G tube
at that time and his IV fluids were Hep-Locked. The patient
did well from that standpoint. On hospital day number 18,
his white count and LFTs were close to being normal. The
patient was discharged in stable condition to a
rehabilitation facility.
The patient was discharged to rehabilitation in stable
condition.
DISCHARGE DIAGNOSIS:
1. Status post fall, being found down for three days.
2. Decubitus ulcer, status post debridement and wet-to-dry
dressing changes.
3. Status post endoscopic retrograde
cholangiopancreatography and sludge removal.
4. Status post percutaneous endoscopic gastrostomy tube.
DISPOSITION: The patient was discharged to rehabilitation in
stable condition.
DISCHARGE MEDICATIONS:
1. Iron 325 per G tube q.d.
2. Lopressor 25 per G tube b.i.d.
3. Flagyl 500 mg per G tube t.i.d. times 14 days for
treatment of retrocardiac infiltrate.
4. Levofloxacin 500 mg per G tube q.d. times 14 days.
5. Albuterol inhaler q. four hours p.r.n.
6. Risperdal per G tube 0.5 mg q.h.s.
7. Heparin subcutaneously 5,000 units b.i.d.
8. Famotidine 20 mg per G tube q.d.
9. Reglan 10 mg per G tube b.i.d.
10. Multivitamin liquid 5 cc per G tube q.d.
11. Zinc sulfate 220 mg per G tube q.d.
12. Vitamin C liquid 500 mg per G tube b.i.d.
13. .................... 5 mg per G tube q.d.
14. Levobunolol 0.5% one drop O.U. q.d.
15. .................... 0.15% one drop O.S. q.d.
The patient also had wet-to-dry dressing changes, normal
saline, b.i.d. to decubitus ulcers and was on aspiration
precautions with the head of the bed elevated at all times
above 30 degrees and was also given ProMod with fiber at 65
cc an hour which is his goal rate.
The patient was discharged to rehabilitation in stable
condition and instructed to follow-up with Dr. [**Last Name (STitle) **] in two
weeks in the Trauma Clinic for postoperative check and
instructed to continue his antibiotics for 14 days for
treatment of pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2107-3-6**] 08:10
T: [**2107-3-6**] 08:26
JOB#: [**Job Number 47306**]
|
[
"682.6",
"574.91",
"276.5",
"852.20",
"853.00",
"707.0",
"575.5",
"228.09",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.6",
"86.28",
"43.11",
"96.04",
"51.88",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
3755, 5242
|
3376, 3732
|
1079, 3355
|
520, 551
|
566, 1061
|
486, 496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,228
| 125,558
|
22088
|
Discharge summary
|
report
|
Admission Date: [**2179-9-5**] Discharge Date: [**2179-9-30**]
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p fall down stairs
Major Surgical or Invasive Procedure:
s/p Trach and PEG
History of Present Illness:
[**Age over 90 **] F who lived independently who was found at the bottom of
stairs. Pt presented to referring hospital and was found to have
subderal hematoma. GCS was 15 at OSH but when transfered here
found to have GCS of 8.
Past Medical History:
COPD
CVA 2 months prior
HTN
Social History:
Lives with family
Family History:
None
Physical Exam:
99.8 HR 96 SBP 86/60 RR 16 95% on NRB
Open scalp laceration on posterior scalp.
R pupil pinpoint non reactive
L pupil 3-2mm
CTA b
RRR
Soft NT/ND
Rectal normal tone G-
Pelvis stable
Moving all ext
Pertinent Results:
[**2179-9-5**] 04:06AM GLUCOSE-247* LACTATE-4.8* NA+-132* K+-4.4
CL--104
[**2179-9-5**] 04:06AM PO2-254* PCO2-22* PH-7.55* TOTAL CO2-20* BASE
XS-0
[**2179-9-5**] 04:15AM PT-15.2* PTT-29.6 INR(PT)-1.5
[**2179-9-5**] 04:15AM PLT SMR-NORMAL PLT COUNT-178
[**2179-9-5**] 04:15AM WBC-18.0* RBC-3.36* HGB-9.8* HCT-29.3* MCV-87
MCH-29.1 MCHC-33.4 RDW-12.9
[**2179-9-5**] 04:15AM cTropnT-<0.01
[**2179-9-5**] 04:15AM ALT(SGPT)-17 CK(CPK)-128 ALK PHOS-57
AMYLASE-42
[**2179-9-5**] 04:21AM LACTATE-5.9*
[**2179-9-5**] 09:10AM LACTATE-6.0*
[**2179-9-5**] 06:45PM LACTATE-2.4* K+-4.2
Brief Hospital Course:
Pt was admitted on [**9-5**] and transferred to the TSICU. She was
intubated for her declining mental status. Neurosurgery was
consulted and it was felt that non-operative management of her
Subdural hematoma was indicated. Her scalp laceration was packed
and hemostasis was achieved. She required significant fluid and
blood resusitation. MRI of her C spine revealed no injury of the
C spine. Repeat head Ct showed worsening of her subdural and a
new R parietotemporal CVA as well as a L parietotemporal
infarct. Neurology was consulted and suggested Increasing her
cerebral perfusion with pressors. She was given a complete
course of Kefzol for her open scalp laceration. She was started
on TF through an NGT and was quickly advanced to goal. Dilantin
was started for seizure prophylaxsis however it was felt that
this could be stopped due to her injury and no seizure activity
during her hospitalization. PT was consulted and continued to
work with her throughout her hospital stay. Attempts at
extubation failed and a discussion was caried out with her
health care proxy. It was decided that she would undergo a
Tracheostomy and PEG at the bedside, which she tolerated well.
Repeat CXR showed worsening pulmonary edema associated with her
significant fluid resusitation and she was started on Lasix for
diuresis. Also, sputum cultures grew G-R and she completed a 14
day course of abx. Repeat CXR continued to show RUL
consolidation. She underwent a bronchoscopy that showed minimal
secretions. Pt continued to improve from a neurological
standpoint and was moving all ext and tracking with her eyes at
time of discharge. Prior to D/C speech and swallow was consulted
for Passy Muir valve placement. They felt a smaller sized trach
would be neccessary for valve placement. After that she could
undergo a swallow evaluation to assess her ability. She is
currently been off antibiotics and tolerating Trach Mask for
extended periods of time.
Medications on Admission:
Asa 81 QD
Avapro
Atenolol 50 QD
Ativan PRN
Discharge Medications:
1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
Disp:*45 * Refills:*2*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: 0.5 Tablet PO twice a day for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Roxicet 5-325 mg/5 mL Solution Sig: Five (5) cc PO every [**5-11**]
hours as needed for pain.
Disp:*600 cc* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subderal hematoma
R stroke
Pneumonia
Blood loss anemia
Respiratory failure
Scalp laceration s/p closure
Discharge Condition:
Stable
Discharge Instructions:
Continue vent support. TM as tolerated. Continue TF at goal. OOB
with assistance.
Followup Instructions:
F/U with Dr. [**Last Name (STitle) **] in [**4-8**] wks.
Completed by:[**0-0-0**]
|
[
"873.0",
"518.5",
"852.22",
"434.11",
"496",
"285.1",
"707.0",
"482.83",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04",
"96.6",
"99.07",
"99.05",
"86.59",
"31.1",
"96.72",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
4647, 4726
|
1526, 3470
|
294, 314
|
4874, 4882
|
910, 1503
|
5012, 5096
|
672, 678
|
3563, 4624
|
4747, 4853
|
3496, 3540
|
4906, 4989
|
693, 891
|
234, 256
|
342, 570
|
592, 621
|
637, 656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,333
| 123,313
|
851
|
Discharge summary
|
report
|
Admission Date: [**2196-4-27**] Discharge Date: [**2196-5-3**]
Service: CARDIOTHORACIC
Allergies:
Atenolol
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe mass
Major Surgical or Invasive Procedure:
[**2196-4-27**]: Right thoracotomy; right upper lobe/right middle
lobe bilobectomy with chest wall resection of ribs 3 through
5 and pulmonary arterioplasty; mediastinal lymph node
dissection;
intercostal muscle and pericardial fat pad buttresses; flexible
bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
Mr. [**Known lastname 5900**] was seen as an outpatient for URI and found to have a
7cm RUL mass which was largely FDG avid. He had FDG avidity in
the anterior abdomen, with recent negative colonoscopy, and no
CT coorelate of abnormality. He had negative mediastinoscopy and
was admitted to undergo RULobecotomy by Dr. [**Last Name (STitle) **].
Past Medical History:
Hypertension
Chronic renal insufficiency (baseline creatinine 1.3)
Elevated PSA
BPH requiring foley insertion several times
Colon polyps
Hypothyroidism
Porphyruria cutanea tarda
Social History:
Married to [**Doctor First Name **], five children. Works as an active lawyer. Quit
smoking 40 years ago. Prior: 2 PPD x 20 years. 2 glasses of
wine/daily. No known chemical exposures.
Family History:
noncontributory
Physical Exam:
T: 97.7 HR: 89 SR BP: 114/62 Sats: 96% RA
General: 85 year-old man doing well
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds right > left
GI: bowel sounds positive abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: Right thoracotomy site clean dry intact no erythema,
margins well approximated
Neuro: non-focal.
Pertinent Results:
[**2196-5-2**] WBC-7.9 RBC-3.23* Hgb-9.5* Hct-28.3 Plt Ct-469*
[**2196-5-1**] WBC-8.3 RBC-3.10* Hgb-9.1* Hct-27.1 Plt Ct-384
[**2196-4-27**] WBC-19.0*# RBC-3.65* Hgb-10.6* Hct-30.8 Plt Ct-389
[**2196-5-1**] Glucose-94 UreaN-17 Creat-0.9 Na-132* K-4.1 Cl-101
HCO3-25
[**2196-4-28**] Glucose-174* UreaN-27* Creat-1.1 Na-133 K-4.6 Cl-104
HCO3-21
[**2196-4-27**] Glucose-182* UreaN-23* Creat-1.0 Na-135 K-4.6 Cl-105
HCO3-21
[**2196-5-2**] Calcium-8.2* Phos-4.0 Mg-1.7
CXR:
[**2196-5-3**] Stable overall volume to moderate to large air and
fluid
collections in the persistent right pleural space, despite
increase in
relative volume of fluid.
[**2196-5-2**]: Grossly stable to slightly larger right apical ptx,
s/p ct removal. increased right pleural effusion. Stable left
pleural effusion. Large subq emphysema. right pleural
thickening. post-op changes. no other change.
[**2196-5-1**]: The right lower chest tube has been removed. The
upper chest tube is still in place. There continues to be a
moderate amount of right-sided subcutaneous emphysema.
Otherwise, no significant change in appearance of the lungs.
[**2196-4-27**]: Right chest tubes overlie right lung apex and right
lower lung, with extensive subcutaneous emphysema in the right
chest wall and extending up right neck. Increased lucency of the
right lower lung may reflect compensatory hyperinflation of the
RLL rather than a basal pneumothorax. ET tube lies 7 cm from
carina. Gaseous distension of stomach.
Brief Hospital Course:
Mr. [**Known lastname 5900**] was admitted following Right thoracotomy; right upper
lobe/right middle
lobe bilobectomy with chest wall resection of ribs 3 through 5
and pulmonary arterioplasty; mediastinal lymph node dissection;
intercostal muscle and pericardial fat pad buttresses; flexible
bronchoscopy with bronchoalveolar lavage. He was transferred to
the TSICU intubated and was extubated later that evening. He
transfered to the floor POD 1.
Respiratory: Extubated in POD1. Aggressive pulmonary toilet,
nebs and incentive spirometer were administered. He weaned from
the oxygen with room air oxygen saturations 93-97%.
Chest tube: posterior apical & basilar chest tube were to
suction initially and placed to water-seal with serosanguious
drainage. Airleak remained on suction POD 2, therefore
chest-tubes remained. On [**2196-5-1**] the postieror apical CT was
removed.
Residual small apical pneumothorax was seen. On [**2196-5-2**] the
anterior apical chest tube was clamped. Chest film revealed
stable right pneumothorax therefore the chest tube was removed.
Chest films: he was followed by serial chest films which showed
stable right apical pneumothorax, right lower lobe effusions.
Card: Immediately postoperatively he was hypotensive and
responded to a fluid challenge and minimal pressors. On
[**2196-5-2**] he had a brief episode of atrial fibrillation 120's
which responded to 2.5 mg IV lopressor and 12.5 PO he converted
to SR 70.s He remained hemodynamically stable with blood
pressures 100-120.
GI: Prophylaxis bowel regime & PPI were continued. He was
placed on a strict bowel regime with good results, large BM
[**2196-5-2**].
Nutrition: On POD1 he was found to have a hoarse vocal quality.
Speech was consulted and recommended to continue baseline diet
of thin liquids and
regular solids as tolerated. His electrolytes were repleted as
needed.
Renal: The patient was placed on flomax given history of urinary
retention.
Foley was removed he voided 50 cc with a residual of 600cc. The
foley was replaced with plan of foley trials at rehab. The
flomax was switched to Uroxatral 10 mg daily which he was taken
at home.
Heme: Intraoperatively he was transfused with 4 Units of PRBC,
postoperative he did well requiring no further transfusion with
a stable HCT of 26-30 range.
Incision: Right thoracotomy site clean, margins well
approximated, without erythema
Pain: Epidural Bupvacaine/Dilaudid was managed by the acute pain
service. Once removed on POD he was converted to PO pain
medications with good control.
Disposition: He was followed by physical therapy who
[**Hospital 5901**] rehab. He will follow-up with Dr. [**Last Name (STitle) **] as
an outpatient.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth day
FLUOCINONIDE - (Prescribed by Other Provider) - 0.05 % Cream -
apply [**Hospital1 **] prn
LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet
-
1 Tablet(s) by mouth day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth day
PNV W/O CALCIUM-IRON FUM-FA [M-VIT] - (Prescribed by Other
Provider) - Dosage uncertain
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once 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. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on 12
hrs off 12 hrs. cut in [**12-12**] on either side of right
thoracotomy site (DO NOT PLACE ON INCISION).
8. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constiparion.
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day:
hold SBP < 100.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Right upper lobe mass
Hypertension
Chronic renal insufficiency (baseline creatinine 1.3)
Elevated PSA
BPH requiring foley insertion several times
Colon polyps
Hypothyroidism
Porphyruria cutanea tarda
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Right thoracotomy incision develops drainage or redness
-Chest tube sites: cover with a bandaid until healed
-You may shower. No tub bathing or swimming for 6 weeks
-Foley replaced for urinary retention of 600cc. Foley trial at
rehab
-No driving while taking narcotics.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**0-0-**] on [**2196-5-17**] 1:30pm
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Chest X-Ray [**Location (un) **] Radiology 30 minutes before your
appoitment.
Follow-up with your urologist Dr. [**Last Name (STitle) **] as an outpatient.
Completed by:[**2196-5-3**]
|
[
"198.89",
"530.81",
"427.31",
"788.20",
"585.9",
"277.1",
"403.90",
"244.9",
"162.8",
"338.18",
"512.1",
"V15.82",
"V12.72",
"600.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"40.3",
"34.79",
"32.49"
] |
icd9pcs
|
[
[
[]
]
] |
8042, 8136
|
3317, 6028
|
244, 545
|
8382, 8382
|
1820, 3294
|
9007, 9381
|
1343, 1360
|
6642, 8019
|
8157, 8361
|
6054, 6619
|
8533, 8984
|
1375, 1801
|
182, 206
|
573, 920
|
8397, 8509
|
942, 1122
|
1138, 1327
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,451
| 143,371
|
13789
|
Discharge summary
|
report
|
Admission Date: [**2162-8-15**] Discharge Date: [**2162-8-16**]
Date of Birth: [**2084-2-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2962**]
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
[**2162-8-16**]-Pacemaker generator changed. Tolerated procedure well
with no complications.
History of Present Illness:
78 W with pmhx of CAD s/p CABG, HTN, afib s/p pacer in [**2158**],
hyperlipidemia, DM, hypothyroidism, CVA presents with
asymptomatic bradycardia. She was taking her blood pressure with
a home monitor and noted a low heart rate. She noted an episode
of lightheadness, which resolved spontaneously. She otherwise
was asymptomatic, denied SOB, cp, n/v, diarrhea, constipation.
.
Pacer followed at OSH, and denies malfunction, checked in [**Month (only) **]
by phone, and was without malfunction.
.
In ED VS 97.8 164/44 39 222 100% 3L. She was evaluated by EP and
found to have a nonfunctioning pacemaker, was given 2.5 mg Vit K
PO. Temp wire was held as not indicated, patient being
asymptomatic.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CABG x4: LIMA to the LAD, saphenous vein graft to left
circ, saphenous vein graft to PDA, and question saphenous
vein graft to RCA.
2. Diabetes.
3. Hypercholesterolemia.
4. Hypertension.
5. Hypothyroid.
6. Atrial fibrillation.
7. History of cerebrovascular accident.
8. S/p Dual Chamber [**Company 1543**]
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: CABG, anatomy as follows: LIMA to the LAD,
saphenous vein graft to left circ, saphenous vein graft to PDA,
and question saphenous vein graft to RCA
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
n/c
Physical Exam:
VS: T97.9 , BP 151/52 , HR 39 , RR 16, 99 O2 % on 2L
Gen: WDWN female, NAD, AAOx3, pleasant,
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm 10 cm
CV: Bradycardic, regular normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild crackles at bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
EKG demonstrated
brady, 35bpm, LAD, QT prolonged .6 (unchanged from prior [**6-20**]
before pacer), II, III, AVF, V2-V6 TWI, *** with no significant
change compared with prior dated ***.
Brief Hospital Course:
78 year old female with past medical history of HTN, DM, CAD,
sick sinus s/p pacer in [**2158**], presents with bradycardia and
pacemaker failure.
.
#) RHYTHM - Pt was bradycardic on admission with HRs in the
30s-40s. An EKG showed a prolonged QT-interval, bradycardia,
and II, III, AVF, V2-V6 T-wave inversions which showed no change
from previous EKGs in [**2158**]. Her pacemaker was interrogated in
the ER, relieving that it was not functioning and would need to
be replaced. The patient reported mild lightheadedness which
resolved. She was placed on bedrest overnight, and all nodal
agents and anticoagulants held in anticipation for permanent
pacemaker replacement. Vit K was given in the ER for an INR of
2.5. INR decreased to 2 and pacemaker generator was replaced on
[**2162-8-16**]. She tolerated the procedure well and was able to be
discharged later that day on all of her normal home medications.
Give prescription for augmentin for UTI which will also cover
her for prophylaxis for infection following pacemaker generator
change.
.
#) CAD- s/p CABG,no ischemic events during admission.
.
#) PUMP- Remained euvolemic during admission, EF last documented
>55. Did well following pacemaker generator change and
discharged on home medications.
.
#)Urinary Tract Infection-she reported dysuria during admission
and urinalysis was positive for blood and leukocytes. Urine
culture with 10,000-100,000 colonies E.coli. She was given
ceftriaxone for one dose in hospital and discharged on Augmentin
for 7 days to cover for UTI and for infection prophylaxis
following pacemaker generator change.
#) HTN - Hypertensive on admission, blood pressure stable on
disharge. Restarted on home medications.
.
#) Hyperlipidemia - statin was continued, no interventions.
.
#) DM - started on insulin sliding scale while hospitalized.
Discharged on normal antidiabetic regimen.
.
#) Hypothyroidism- TSH 3.2, FT4 2.2, home dose of synthroid
continued
.
#) ARF- at baseline, no interventions
.
#) CVA- aspirin and coumadin held prior to procedure. Restarted
prior to discharge. She is already scheduled for INR check 2
days after discharge.
.
#) CODE: presumed FC
Medications on Admission:
Lasix 80mg Daily
Cartia 240mg Daily
Glipizide 2+[**2-27**]
HCTZ 12mg Daily
Metoprolol 50mg [**Hospital1 **]
Lipitor 20mg Daily
Levothyroxine 75mcg
Warfarin 3mg Daily
Aspirin 81mg Daily
Metoformin 500mg Daily
Amiodarone 200mg Daily
NTG
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Cartia XT 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
4. Glipizide Oral
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: take
as directed according to your blood levels which you should have
checked regularly. .
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every 5 minutes, may repeat 3 times as needed for
chest pain for as directed doses: place one tab under your
tongue if you develop chest pain. You may repeat every five
minutes for a total of 3 pills.
10. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia secondary to pacemaker failure.
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because of slow heart rate.
We checked your pacemaker and found that the battery was not
working. You were given some Vitamin K to reverse the Coumadin
that you take and then the generator of your pacemaker was
replaced.
None of your medications were changed. You can take your usual
dose of coumadin tonight.
In addition you also have a urinary tract infection. You should
take the antibiotic Augmentin 500mg two times per day for a
total of 7 days.
You should call your doctor if you continue to have pain with
urination or notice blood in your urine despite taking this
antibiotic. In addition you should be evaluated if you develop
fever. You should return to the hospital if you notice that
your heart rate is slow again or if you develop pain in your
chest, shortness of breath, light headededness, fainting, or any
concerning bleeding.
Followup Instructions:
You should follow up in one week in device clinic. Please call
tomorrow to schedule that appointment. The phone number is
[**Telephone/Fax (1) 59**]
You should follow with your primary care physician within two
weeks of discharge from the hospital. Please call the office to
schedule that appointment tomorrow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]
|
[
"427.89",
"250.00",
"996.01",
"427.31",
"244.9",
"E878.4",
"V45.81",
"414.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.87"
] |
icd9pcs
|
[
[
[]
]
] |
7020, 7026
|
3354, 5526
|
327, 422
|
7113, 7119
|
3142, 3331
|
8052, 8499
|
2386, 2391
|
5812, 6997
|
7047, 7092
|
5552, 5789
|
7143, 8029
|
2406, 3123
|
276, 289
|
450, 1679
|
1701, 2245
|
2261, 2370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,435
| 172,078
|
12969
|
Discharge summary
|
report
|
Admission Date: [**2134-10-15**] Discharge Date: [**2134-10-27**]
Date of Birth: [**2058-8-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
Craniotomy and evacuation of subdural hematoma
History of Present Illness:
76M H/O AAA Repair ([**2134-8-29**]), CAD/CABG ([**2131**]), HTN W/ frequent
urination, polyuria, dysuria, and DOE. The patient had a recent
[**Hospital1 18**] admission ([**Date range (1) 39772**]) for R Groin Hematoma and
Anemia. At that time, his Cr was 1.6 on admission (with a
baseline of 1.2-1.3) which was presumed secondary to his recent
contrast dye exposure for AAA Repair. His Cr has peaked at 1.9
and his [**Last Name (un) **] was held - he was then DCed with PCP [**Last Name (NamePattern4) 702**].
Patient then presented to [**Hospital6 33**] today with
several weeks of the frequent urination, polyuria, dysuria, and
DOE. All of the symptoms aforementioned began after his AAA
repair. His most disturbing symptom has been his frequent
urination - up to 12 times per night, causing him to lose much
sleep over the past couple weeks.
ROS: He's had no urgency, incontinence, hesitation, polyphagia,
CP, orthopnea, LE swelling, PND, fevers, pruritis, rash, abd
pain, diarrhea, or chills. He reports constipation, mild
fatigue, weight loss (indetermine amount, but clothes fitting
more loosely), anorexia and B/L hip, lower back, and anterior
thigh and leg pain that begins after 1-2 minutes of walking,
worsens with increased walking, and remits when he stops
walking.
At the OSH, his Cr was 6.3 and SBP 220. He was transferred to
[**Hospital1 18**] ED: T97.8 HR83 BP151/80 RR15 OS96%2L. STARTED ON NITRO
GTT.
Past Medical History:
Endovascular AAA Repair ([**Hospital6 33**]; [**2134-8-29**])
CAD/CABG (4V CABG; [**2127**])
Hypertension
Hyperlipidemia
Social History:
Lives alone on his ranch in Hully ,MA. No children. Retired
maintenence worker for [**Location (un) 86**] [**Male First Name (un) 17703**] Electric Co. He quit
smoking in [**2124**] and has 30 p-y. He previously (many years ago)
drank ETOH heavily, but has not drank for "many years". He could
not quantify the amount. He has never used illegal drugs. His
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital1 34**] at [**0-0-**].
Family History:
His brother died of an MI at 51 and his parents may have died
from MI's. There is no known history of renal or autoimmune
disease (SLE, Rh).
Physical Exam:
VS T97.6 P83 BP160/80 RR20 O2Sat95%RA FS116 (82-396) 1260/1575
GENERAL: No acute distress
HEENT: OMMM, head wound clean, dry and intact. No erythema or
fluctuance.
NECK: Supple, no JVD
CARDIOVASCULAR: Normal S1, S2, RRR, no MRG
LUNGS: Clear
ABDOMEN: Active bowel sounds, NT, ND, no rebound, no guarding.
Palpable pulsation, but non-tender.
EXTREMITIES: No LE edema, pulses intact.
NEURO: Alert and oriented X 3. No pronator drift.
CNII-XII
Strength 5/5 all extremities, symmetric
Sensation grossly intact
Reflexes 2+ throughout, downgoing babinski bilaterally
Finger to nose, rapid alternating movements smooth and intact.
SKIN: erythematous pruritic papules on back only, no vesicles or
pustules.
Pertinent Results:
[**2134-10-15**] 05:17PM HCT-29.7*
[**2134-10-15**] 03:15PM GLUCOSE-120* UREA N-99* CREAT-6.5* SODIUM-143
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-26 ANION GAP-18
[**2134-10-15**] 03:15PM CK(CPK)-58
[**2134-10-15**] 03:15PM CK-MB-NotDone cTropnT-0.02*
[**2134-10-15**] 03:15PM CALCIUM-9.3 PHOSPHATE-5.8* MAGNESIUM-2.3
[**2134-10-15**] 06:55AM GLUCOSE-199* UREA N-100* CREAT-6.6*
SODIUM-142 POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
[**2134-10-15**] 06:55AM CK(CPK)-52
[**2134-10-15**] 06:55AM CK-MB-NotDone cTropnT-0.02*
[**2134-10-15**] 06:55AM TOT PROT-6.0* CALCIUM-9.3 PHOSPHATE-6.0*
MAGNESIUM-2.2
[**2134-10-15**] 06:55AM %HbA1c-5.7
[**2134-10-15**] 06:55AM WBC-7.2 RBC-3.03* HGB-9.2* HCT-26.8* MCV-88
MCH-30.3 MCHC-34.2 RDW-14.1
[**2134-10-15**] 06:55AM PLT COUNT-135*
[**2134-10-15**] 06:55AM EOS CT-430
[**2134-10-14**] 10:52PM URINE HOURS-RANDOM UREA N-575 CREAT-76
SODIUM-47 POTASSIUM-51
[**2134-10-14**] 10:52PM URINE OSMOLAL-408
[**2134-10-14**] 09:55PM GLUCOSE-152* UREA N-106* CREAT-6.7*#
SODIUM-140 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
[**2134-10-14**] 09:55PM CK(CPK)-62
[**2134-10-14**] 09:55PM CK-MB-NotDone cTropnT-0.01
[**2134-10-14**] 09:55PM CALCIUM-9.4 PHOSPHATE-5.1*# MAGNESIUM-2.4
[**2134-10-14**] 09:55PM WBC-7.2 RBC-3.12* HGB-9.4* HCT-27.2* MCV-87
MCH-30.2 MCHC-34.6 RDW-14.0
[**2134-10-14**] 09:55PM NEUTS-80.6* LYMPHS-12.3* MONOS-3.7 EOS-3.1
BASOS-0.2
[**2134-10-14**] 09:55PM PLT COUNT-145*#
[**2134-10-14**] 09:55PM PT-13.5 PTT-27.5 INR(PT)-1.2
[**2134-10-14**] 09:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2134-10-14**] 09:55PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2134-10-14**] 09:55PM URINE RBC-[**5-13**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0
CT HEAD W/O CONTRAST [**2134-10-16**] 3:51 AM
Left hemispheric subdural hematoma with midline shift and
suggestion of uncal herniation.
CT HEAD W/O CONTRAST [**2134-10-25**] 3:00 PM
There is a large subdural hematoma along the left convexity,
primarily in the frontal region. It is unchanged in size since
the postoperative study performed at 12:39 p.m. on [**10-16**].
It is smaller in size compared to the preoperative study
performed at 3:40 a.m. on [**10-16**].
There is no evidence of acute hemorrhage within the subdural
hematoma. However, there are new acute blood products in the
extracranial soft tissue hematoma overlying the left
frontoparietal craniotomy. Craniectomy defect. The ventricles
appear patent and symmetric, without hydrocephalus. The basal
cisterns are patent and symmetric. The visualized paranasal
sinuses and mastoid air cells are normally aerated.
Brief Hospital Course:
76M H/O AAA Repair ([**2134-8-29**]), CAD/CABG ([**2131**]) to [**Hospital1 18**] with HTN
and ARF of unknown etiology then to SICU after acute massive SDH
- now stable and neurologically intact S/P SDH evacuation, but
continued renal insufficiency - possibly secondary to
cholesterol emboli.
.
SICU course: Patient developed acute HA and then obtundation
early in his course. Acute Fronto-Parietal SDH w/ mass effect
discovered. Now S/P craniectomy and successful hematoma
evacutation. Started on phenytoin (then DCed) and steroid taper.
Pt improved neurologically (to near baseline) in the SICU, but
renal status has remained poor.
.
MICU course: After continuous hydration late in his course, in
the face of renal failure, developed acute pulmonary edema.
Aggressive diuresis commenced - with dramatic clinical
improvement. BP was still elevated, but stable for transfer to
medical floor.
FLOOR course:
* Acute renal failure: As above acute issues began to resolve,
patient's creatinine remained high (max to 6.8). Patient had
access prepared for imminent dialysis, however, given brisk
diuresis near the end of [**Hospital 228**] hospital course, renal
consultants felt that dialysis could be deferred. Indeed it was
felt that patient had post-ATN diuresis with possible full
recovery of function. [**Month (only) 116**] not require hemodialysis. At the time
of discharge, patient's creatinine remained at ~5, however,
patient continued to have excellent urinary output.
* RASH: Late in hospital course, patient developed a pruritic,
erythematous papular rash on trunk which improved somewhat with
hydrocortisone cream.
* HTN: As noted above, blood pressure initially in urgency
range, however, was titrated to SBP130s-190s, generally 160s
with goal 140-160. Multiple regimen combinations attempted, and
ultimately stabilized to Labetalol HCl 800 mg PO TID, Isosorbide
Dinitrate 40 mg PO TID, Hydralazine HCl 50 mg PO Q8H. Primary
care physician [**Name (NI) 653**] with notice to followup on regimen.
* SDH: Unchanged by CT from prior post-craniotomy film. Stable
per discussion with neurosurgery. To followup with neurosurgery
in 2 weeks following discharge. No residual neurological
symptoms. Neuro exam at baseline.
* CAD/CABG/AAA: Stable. Aggressively controlled blood pressure
within parameters as noted above. Aspirin was held given
subdural hematoma. Statin was continued.
* Anemia: This was thought in part due to EPO deficiency [**1-4**]
chronic renal disease. Stools guaiac negative.
* Hyperglycemia: Likely secondary to steroids during acute
increase in intracranial pressure. Sliding scale insulin
administered, and requirement decreased with taper of steroids.
At the time of discharge, patient had normal neuro exam, was
able to ambulate independently, and had excellent blood pressure
control. Patient was to followup with neurosurgery consultants
as noted above.
Medications on Admission:
Diovan 160 mg PO DAILY
Lopressor 50 mg PO BID
Lipitor 40 mg DAILY
ASA 325 mg PO DAILY
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. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*90 Tablet(s)* Refills:*2*
6. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical
DAILY (Daily).
Disp:*1 tube* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Acute Renal Failure
Subdural hematoma
Hypertension
Abdominal Aortic Aneurysm Repair
Coronary artery disease
Discharge Condition:
Good: Ambulating independently, no supplemental oxygen
requirement, back to baseline mental status
Discharge Instructions:
Continue to take your medications as directed.
- Hydralazine 50mg three times a day
- Isosorbide dinitrate 40mg three times a day
- Labetalol 800mg three times a day
- Lipitor 10mg daily
- Colace 100mg twice a day
- Protonix 40mg daily
- Albuterol inhaler 1-2 puffs every 4-6 hours as needed for
shortness of breath
Please call 911 if you begin to have a severe headache or
weakness on one side.
Please followup with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13175**].
His office will call you with a follow-up appointment. Please
call them [**0-0-**] if you do not hear from them by Tuesday
[**2134-11-2**].
Dr.[**Name (NI) 14510**] office (Neurosurgery) will call you to make an
appointment for follow up one month from discharge. If you do
not receive a call by one week following discharge, please call
[**Telephone/Fax (1) 2731**] ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39773**]) to make appointment.
Followup Instructions:
Please have visiting nurse service draw chemistries and CBC, and
send to Dr. [**Last Name (STitle) 13175**] ([**0-0-**]) primary care physician and Dr
[**Last Name (STitle) 4090**] [**Telephone/Fax (1) 3637**].
Patient should maintain a blood pressure within the range of
systolic 140-160.
Please follow blood sugar as it was moderately elevated
following dexamethasone treatments (discontinued).
Kidney: [**Name6 (MD) 4102**] [**Name8 (MD) 4090**], MD, [**Hospital **] Clinic One [**Last Name (un) **] Place,
[**Location (un) 86**], [**Telephone/Fax (1) 39774**], Thursday [**11-4**], 1PM.
Patient will be called by [**Hospital1 18**] Neurosurgery for followup CT and
appointment [**Telephone/Fax (1) 2731**] ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39773**]).
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2134-12-9**] 3:00
Test for consideration post-discharge: Complement CH50
|
[
"432.1",
"414.00",
"428.0",
"403.91",
"584.9",
"445.89",
"285.9",
"496",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"01.31",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10155, 10226
|
6099, 9002
|
329, 378
|
10378, 10478
|
3342, 6076
|
11502, 12553
|
2466, 2608
|
9138, 10132
|
10247, 10357
|
9028, 9115
|
10502, 11479
|
2623, 3323
|
277, 291
|
406, 1830
|
1852, 1974
|
1990, 2450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
249
| 149,546
|
48759
|
Discharge summary
|
report
|
Admission Date: [**2155-2-3**] Discharge Date: [**2155-2-14**]
Date of Birth: [**2075-3-13**] Sex: F
Service: NEUROLOGY
Allergies:
Altace / Bactrim
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
chest pain, hematochezia
Major Surgical or Invasive Procedure:
IA TPA, MERCI clot retrieval
History of Present Illness:
79 yo female with CAD s/p CABG in [**2129**], recent cath with only
LIMA-LAD patent, HTN, HLP, COPD, and afib who presents with 5
day history of red/maroon stools. Patient was at her PCP's
office earlier last week and was found to be anemic (HCT not in
system) and was planned for a colonscopy this week. She was at
home, and earlier today developed substernal chest pressure that
was persistent. She describes this pressure as a squeezing
sensation, different and worse than her usual anginal symptoms
for which she takes nitro. Usually her pain occurs with exertion
or at night when she's not wearing her oxygen and is limited to
her arm, but today it was also in her chest as well. She
described the pain as [**2155-9-26**] initially, and nitro at home did
not help, nor did increasing her O2 from 2-> 3L.
.
In the ED, initial VS: 97.8, 99, 116/, 24, 100%RA. Initially,
the patient was noted to have bright red blood on rectal exam.
She was tachycardic to the low 100s, but BP remained stable. She
received nitro SL and morphine which improved her CP to [**2155-3-20**].
Cardiology was consulted for the STD seen in the lateral leads,
but they felt this was likely c/w demand ischemia given her
significant anemia and severe coronary disease. She was given 2
units of PRBCs and 2 units of FFP prior to transfer. GI was
called, and felt the patient should have reversal of her INR
(4.5). She was given 5 mg IV vitamin K as well. Her BP remained
stable, and her HR improved to the 80s. She had a 20 and 16G PIV
placed. Her vitals prior to transfer to the MICu were 110/65,
89, 20, 98% 3L. She did complain of some dyspnea/tachypnea prior
to transfer, but her O2 sats remained 98% with 3L of O2.
Past Medical History:
- Coronary artery disease, s/p 3V CABG EF 50%
- Left subclavian stent [**51**]/[**2146**].
- Atrial fibrillation.
- Hypertension.
- Hyperlipidemia.
- COPD (FEV1/FVC 53, FEV1 0.63)
- GERD
- Anemia.
- Hypothyroidism
Social History:
denies tobacco, ETOH, or drugs.
Family History:
Mother with myocardial infarction in her 60s. No diabetes
mellitus. Grandfather with chronic obstructive pulmonary
disease.
Physical Exam:
VS - Temp 99.0F, BP 102/56, HR 72, R 28, O2-sat 96 2L% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD up to ears, no carotid bruits
LUNGS - bibasilar crackles, good air movement, resp unlabored,
no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-21**] throughout, sensation grossly intact throughout,
Pertinent Results:
[**2155-2-3**] 06:20PM BLOOD WBC-9.9# RBC-2.45*# Hgb-7.0*# Hct-22.5*#
MCV-92 MCH-28.8 MCHC-31.2 RDW-15.1 Plt Ct-251
[**2155-2-3**] 11:26PM BLOOD Hct-26.6*
[**2155-2-4**] 11:35AM BLOOD Hct-31.6*
[**2155-2-5**] 04:54AM BLOOD WBC-13.0* RBC-3.47* Hgb-10.1* Hct-31.0*
MCV-90 MCH-29.2 MCHC-32.6 RDW-16.4* Plt Ct-201
[**2155-2-6**] 06:55AM BLOOD WBC-11.4* RBC-3.58* Hgb-10.6* Hct-32.1*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.4 Plt Ct-187
[**2155-2-7**] 06:58AM BLOOD WBC-10.4 RBC-3.28* Hgb-10.0* Hct-28.7*
MCV-88 MCH-30.4 MCHC-34.8 RDW-15.2 Plt Ct-173
[**2155-2-7**] 12:25PM BLOOD Hct-31.7*
.
Echo:The left atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 20-30 %) with regional variation. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with severe global free wall hypokinesis. 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. Mild to moderate ([**1-18**]+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2153-12-5**], the left
ventricular ejection fraction is markedly reduced.
.
CXR [**2-3**]:Findings suggesting mild congestive heart failure.
CT head, CTA head/neck, CTP [**2155-2-7**]
NON-CONTRAST CT: There is no evidence of acute intracranial or
parenchymal
hemorrhage. There is mild bihemispheric hypoattenuation of the
periventricular
and subcortical white matter consistent with sequelae of small
vessel ischemic
disease. The bilateral basal ganglia show small hypoattenuations
consistent
with old lacunar infarcts. There is calcification of the
intracranial carotid
artery. Also noted is a left maxillary sinus mucosal thickening.
The other
paranasal sinuses and mastoid air cells are well aerated.
CTA OF THE NECK AND HEAD: There is abrupt cutoff of the right
MCA at the
junction of the M1 and M2 segments. This represents a thrombus
within the
right MCA . Also noted is calcification of the bilateral carotid
bulbs. The
remaining intracranial and cervical vessels are unremarkable.
The vertebral
and carotid ostia are unremarkable. A stent is noted in the left
subclavian
artery which is patent.
Also noted are sternotomy wires, bibasilar atelectatic changes
in the
visualized lung apices and a hypoplastic or absent thyroid
gland. Clinical
correlation is recommended.
There are several enlarged mediastinal lymph nodes, the largest
of which is
precarinal and measures 14.3 mm.
CT PERFUSION: There is increased mean transit time in a large
right MCA
territory distribution in the right frontoparietal region. This
is associated
with decreased cerebral blood flow but normal cerebral blood
volume. This
likely represents an acute large infarct with some mismatch
possibly
representing an area of penumbra.
Rotation of the C1 over C2 vertebra is likely positional in
nature.
IMPRESSION: Acute right MCA vascular territory infarct as
described above.
CT head [**2155-2-8**]
IMPRESSION: No intracranial hemorrhage or edema.
HbA1c 5.5
LDL 33
Brief Hospital Course:
79 yo female with CAD s/p CABG with only patent LIMA-LAD, COPD,
HTN, afib who presents with hematochezia, anemia, and angina,
sent to MICU initally where she was transfused with HCT back up
to 31, c/b NSTEMI with CHF.
.
# Stroke: has h/o Afib but her anticoagulation was held in the
setting of acute GIB complicated by NSTEMI. It was felt she
would restart ASA 325mg upon discharge. The pt was intact
neurologically throughout admission until [**2-7**] when she was
found to have acute onset dysarthria, L facial droop, L
hemiparesis. Code stroke was called and pt was found to have R
MCA embolic infarct on CT head. She was sent emergently to neuro
IR for IA TPA and MERCI clot retrieval. She was initially
transferred to the neuro ICU and has been continuing to improve
clinically. Her coumadin has been re-started and her hematocrit
has remained stable. Her LDL was 33 and HbA1c was 5.5. Her INR
on day of transfer ([**2-14**]) was 3.1 and today's dose will be held.
Please monitor daily for goal [**2-19**].
.
# Hematochezia: likely due to angiodysplasia vs diverticulosis
as pt had colonoscopy in [**2152**] with only polyps. on transfer out
of the MICU her HCT was up to 31 (was initially 22.5 on
admission) after 3U pRBC. While on the floor she was transfused
1 more unit of blood and her HCT was maintained around 30
without any evidence of GI bleeding (stools were without blood).
She was continued on [**Hospital1 **] po pantoprazole. Her hematocrit has
remained stable in the low 30s. Gastroenterology plans to
perform a colonoscopy as an outpatient in [**6-24**] weeks. Given her
other comorbidities and stable hematocrit it was decided to
defer this procedure at this immediate time.
.
# NSTEMI: Patient has known bad coronary disease with diseased
grafts as well taking up to 3 NTG daily for anginal pain.
patient's initial ECG with afib with RVR and lateral STD and
TWI; most likely due to demand ischemia. Pt had CP and 1st set
CE was neg, but then subsequent had Trp peak up to 1.8 (CK 556,
CKMB 10.4) c/w NSTEMI in setting of acute lower GI bleed.
Cardiology was consulted and recommended holding anticoagulation
until she was stable from her GIB. Her chest pain improved with
transfusions, nitro, and morphine, and now pt has been CP free
while on the floor. she was started on metoprolol 25 tid,
atorvastatin 80mg. her lisinopril and imdur were held to avoid
hypotension in the setting of GIB. Her lisinopril has been
resumed and her blood pressure has been well-controlled.
.
# Dyspnea/tachypnea: Patient has COPD at baseline, and uses O2
(2L) at night for comfort and angina with exertion. During the
day, she should be using her O2 but she has not been using it
due to difficulty with portability. Now with EF 20-30% severely
dropped form 50% in [**2153**], likely due to NSTEMI. Also likely
worsened initially in MICU in the setting of volume (blood, FFP,
and IVFs). Diuresed well with IV lasix in the MICU and on the
floor. She was started on po 20mg lasix daily and maintained on
her fluticasone and ipratropium nebs. She is currently doing
well on her home requirements of 2L O2 via nasal cannula.
.
# Afib: patient on metoprolol and coumadin as an outpatient.
Given her above h/o GIB complicated by NSTEMI, cardiology/GI
consults recommended that due to her CHADS2 score of 3 she
should be restarted on ASA 325mg once her GIB was stabilized. It
was felt that the pt would have this started upon d/c. Despite
these efforts the pt suffered from an embolic stroke entailed
above and therefore will be continued on coumadin with goal INR
[**2-19**].
.
# Hypothyroidism: cont levothyroxine
.
# DM2: RISS. Glipizide may be resumed at the time of transfer.
.
# CKD: creat 1.3-1.5 at the time of presentation, now trending
down to 0.9-1.
.
Medications on Admission:
Albuterol
Coumadin 1 mg daily
Fluticasone 220 mcg 1 puff [**Hospital1 **]
Glipizide 5 mg daily
Imiquimond 5% packet apply twice a week
Imdur 90 mg daily
Lisinopril 2.5 mg daily
Levothyroxine 75 mcg daily (150 mcg on sunday)
Atorvastatin 40 mg daily
Macrobid 50 mg QHS
Pantoprazole 40 mg daily
HCTZ 50 mg daily
Spiriva 1 puff daily
Metoprolol succinate 100 mg daily
Aspirin 81 mg daily
Ferrous gluconate 325 mg daily
Coenzyme Q10 100 mg daily
Calcium/Vitamin D daily
MVI daily
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
4. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Warfarin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM: Adjust as needed for goal INR [**2-19**].
7. Levothyroxine 75 mcg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily): Q Mon, Tues, Wed, Thurs, Fri, Sat.
8. Levothyroxine 75 mcg Tablet [**Month/Day (3) **]: Two (2) Tablet PO DAILY
(Daily): on Sunday only.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Glipizide 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
NSTEMI
Right MCA stroke
Lower GI bleed
Discharge Condition:
A&Ox3, dysarthric. R gaze preference, surgical pupil (left
eye). L facial droop. Extinction to L on DSS. Antigravity
strength in all extremities.
Discharge Instructions:
You were initially admitted with a gastrointestinal bleed and
chest pain. During your hospital course you had a stroke which
was treated with intraarterial TPA and MERCI clot retrieval.
Your hematocrit has remained stable and you will be transferred
to a rehabilitation facility for further care.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2155-2-14**] 8:40
Provider: [**Name10 (NameIs) 9977**] IN [**Location (un) 2788**] Phone:[**0-0-**]
Date/Time:[**2155-2-14**] 1:15
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2155-2-18**]
1:00
Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (neurology) to schedule a follow up
appointment in two months. His office can be reached at ([**Telephone/Fax (1) 76682**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
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"250.00",
"414.02",
"285.1",
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"784.51",
"342.80",
"428.0"
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icd9cm
|
[
[
[]
]
] |
[
"88.41",
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icd9pcs
|
[
[
[]
]
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12423, 12520
|
6631, 10405
|
302, 333
|
12603, 12755
|
3213, 6608
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|
2361, 2486
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10931, 12400
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12541, 12582
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10431, 10908
|
12779, 13168
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2501, 3194
|
238, 264
|
361, 2059
|
2081, 2296
|
2312, 2345
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,858
| 185,726
|
2025
|
Discharge summary
|
report
|
Admission Date: [**2134-5-20**] Discharge Date: [**2134-5-29**]
Date of Birth: [**2071-4-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
Abdominal Pain.
Major Surgical or Invasive Procedure:
paracentesis x 3
PICC line placement
History of Present Illness:
Mr. [**Known lastname 916**] is a 63 yo, M, with hx of IgA deficiency, Crohn's
disease, liver disease w/ nodular regenerative hyperplasia, COPD
and hx of heavy smoking and ETOH consumption who was admitted to
[**Hospital1 18**] on [**2134-5-20**] w/ complaints of Severe Abdominal Pain, the
patient describes that he felt a sudden onset severe abdominal
pain, described as sharp and "like someone was twisting my
intestine", [**11-9**] on pain scale, he describes it as generalized
abdominal pain w/ no radiation to the back or any other areas,
denies precipating factors and the pain was exacerbated by
movement. The pain was accompanied by nausea, SOB and mild
fever, he denies diarrhea or constipation, denies melena, bloody
stools, denies change in urinary habits, denies other associated
sxs. The pain was constant and he refers he never had this pain
in the past. He called 911 and was brought to the ED were he was
found to have Ascities and an abdominal tap was performed.
.
The patient has had multiple admissions in the past 6 months, he
reports that he noticed his ascities in [**Month (only) **]/[**2133-12-1**] and that he
has been feeling SOB. His last admission was about 2 weeks ago
when he came to the hospital complaining of Fever, Abdominal
distention and what seems to be an episode of Hematequeczia.
He underwent #2 Abdominal taps in the past month, the first one
was perfomed on [**2134-5-10**] and was reported positive for
Malignancy.
.
He was admitted to the floor transiently and then became
hypotensive and transfered to the SICU for ?strangulated hernia,
subsequently found to be reductible w/out obstruction on CT/US.
Past Medical History:
bowel resection [**2123**], esophageal stricture dilated [**2125**].
- IgA deficiency, gets monthly IVIG
- Iron deficiency anemia- monthly IV Fe
- Liver Disease- HCV (-) [**4-2**], HBsAb (+) HBsAg,cAb,IgMHBc (-)
[**4-2**]
-Nodular regenerative hyperplasia on biopsy is associated with
other clinical conditions such as Felty's syndrome or other
immunologically mediated disease such as SLE, sarcoidosis,
polymyalgia rheumatica, primary biliary cirrhosis, primary
sclerosing cholangitis
-C/b development of ascites, splenomegaly
- S/p mitral valve repair for MVP in '[**31**]
- COPD
- Hypothyroidism
- H/o prostate cancer in-situ
- H/o chronic prostatitis
- H/o empyema
- Bronchiectasis
- PCP [**Name Initial (PRE) 11091**] [**4-5**] (HIV test negative at that time)
- GERD
- HTN
- h/o duodenitis
Social History:
Works as accountant, currently downsizing business. Quit smoking
one year ago, previously 2ppd. Has about 3 drinks per night. No
IVDA. In a monogamous relationship with a woman. Stopped
drinking 1 week ago.
Family History:
Father died of MI at age 79. Mother with HTN.
Physical Exam:
VS: Afebrile 95 111/58 29 O2 sat 98% RA
Gen: cachectic, NAD
HEENT: PERRL, EOMI, clear OP, dry, anicteric
Neck: supple, JVD to lower ear lobe
Lungs: dull at bases b/l, crackles [**2-1**] way up back
Heart: RRR +S1/S2 no m/r/g
Abd: Distended, + surgical mid abd scar, + ventral
hernia(reducible) w/slight erythema/warmth, + fluid wave, tender
to light palpation diffusely however no rebound/guarding, + BS,
+ splenomegaly
Ext: 3+ pitting edema from ankle
Neuro: A&O, No focal deficits
Pertinent Results:
[**2134-5-20**] 06:57PM BLOOD WBC-13.7*# RBC-5.81# Hgb-16.7# Hct-49.1
MCV-85 MCH-28.8 MCHC-34.1 RDW-17.9* Plt Ct-263
[**2134-5-29**] 05:23AM BLOOD WBC-11.0 RBC-4.87 Hgb-13.9* Hct-41.6
MCV-85 MCH-28.6 MCHC-33.5 RDW-17.9* Plt Ct-269#
[**2134-5-20**] 06:57PM BLOOD Neuts-77* Bands-12* Lymphs-8* Monos-1*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2134-5-23**] 04:10AM BLOOD Neuts-82* Bands-13* Lymphs-2* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2134-5-20**] 06:57PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2134-5-23**] 04:10AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Burr-2+
Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
[**2134-5-20**] 06:57PM BLOOD PT-12.6 PTT-22.9 INR(PT)-1.1
[**2134-5-21**] 09:10AM BLOOD PT-17.1* PTT-34.7 INR(PT)-1.6*
[**2134-5-28**] 05:41AM BLOOD PT-14.7* PTT-24.4 INR(PT)-1.3*
[**2134-5-29**] 05:23AM BLOOD Plt Ct-269#
[**2134-5-23**] 04:10AM BLOOD Ret Aut-1.6
[**2134-5-22**] 03:47AM BLOOD Fibrino-443*
[**2134-5-20**] 06:57PM BLOOD Glucose-90 UreaN-23* Creat-1.3* Na-136
K-4.7 Cl-97 HCO3-23 AnGap-21
[**2134-5-29**] 05:23AM BLOOD Glucose-101 UreaN-15 Creat-0.6 Na-140
K-4.2 Cl-107
[**2134-5-20**] 06:57PM BLOOD ALT-38 AST-54* LD(LDH)-207 AlkPhos-427*
Amylase-36 TotBili-1.0
[**2134-5-28**] 05:41AM BLOOD ALT-9 AST-12 AlkPhos-183* TotBili-0.8
[**2134-5-20**] 06:57PM BLOOD Lipase-12
[**2134-5-22**] 03:47AM BLOOD Lipase-7
[**2134-5-24**] 06:15AM BLOOD Lipase-21
[**2134-5-21**] 09:10AM BLOOD cTropnT-<0.01
[**2134-5-20**] 06:57PM BLOOD Albumin-3.1* Calcium-7.8* Phos-5.7*#
Mg-1.5*
[**2134-5-24**] 06:15AM BLOOD Albumin-4.0 Calcium-8.9 Phos-2.0* Mg-2.0
[**2134-5-27**] 05:15AM BLOOD Mg-1.6
[**2134-5-23**] 07:50AM BLOOD PSA-0.8
[**2134-5-23**] 04:10AM BLOOD Hapto-232*
[**2134-5-20**] 07:00PM BLOOD Lactate-3.7*
[**2134-5-20**] 09:28PM BLOOD Lactate-2.5*
.
Micro:
Peritoneal Fluid [**2134-5-21**]
WBC [**Numeric Identifier 11093**] RBC 7425 Poly 81 Band 0 Lymph 0 Mono 0 Macro 12 Other
7 ATYPICAL CELLS
TP 1.9 gluc 5 Cr 0.9 LDH 208 [**Doctor First Name **] 56 t.bili 0.4 alb 2.1
.
Peritoneal Fluid [**2134-5-23**]
WBC [**Numeric Identifier **] RBC 8000 Poly 89 Band 0 Lymph 4 Mono 7 Macro 0 Other 0
TP 1.9 gluc 174 LDH 733 alb 1.3
.
Peritoneal Fluid [**2134-5-24**]
WBC [**Numeric Identifier 11094**] RBC 7425 Poly 97 Band 1 Lymph 1 Mono 1 Macro 0 Other 0
TP 2.1 gluc 115 alb 1.4
.
Bl Cx [**5-20**] no growth
[**2134-5-20**] 8:02 pm BLOOD CULTURE SET 2 R HAND.
**FINAL REPORT [**2134-5-26**]**
AEROBIC BOTTLE (Final [**2134-5-26**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2134-5-24**]):
REPORTED BY PHONE TO [**Doctor First Name **],JAUDETTE -CC6B- @ 14:15
[**2134-5-22**].
PRESUMPTIVE VEILLONELLA SPECIES. ISOLATED FROM ONE SET
ONLY.
.
[**2134-5-20**] 8:45 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2134-5-22**]**
URINE CULTURE (Final [**2134-5-22**]): <10,000 organisms/ml.
.
[**2134-5-21**] 1:35 am PERITONEAL FLUID
**FINAL REPORT [**2134-7-19**]**
GRAM STAIN (Final [**2134-5-21**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-5-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2134-5-25**]):
PRESUMPTIVE VEILLONELLA SPECIES. RARE GROWTH.
FUNGAL CULTURE (Final [**2134-6-4**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2134-5-21**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Final [**2134-7-19**]): NO MYCOBACTERIA
ISOLATED.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2134-5-23**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2134-5-23**] 1:15 pm PERITONEAL FLUID
**FINAL REPORT [**2134-5-27**]**
GRAM STAIN (Final [**2134-5-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-5-26**]):
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2134-5-27**]): NO ANAEROBES ISOLATED.
.
[**2134-5-24**] 6:15 am BLOOD CULTURE
**FINAL REPORT [**2134-5-30**]**
AEROBIC BOTTLE (Final [**2134-5-27**]):
REPORTED BY PHONE TO [**Female First Name (un) 11095**] VIEL AT 1235 AM ON [**5-25**]..
ENTEROCOCCUS FAECIUM. 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: 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
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC BOTTLE (Final [**2134-5-30**]): NO GROWTH.
.
[**2134-5-24**] 4:00 pm PERITONEAL FLUID
**FINAL REPORT [**2134-5-30**]**
GRAM STAIN (Final [**2134-5-24**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2134-5-27**]):
ENTEROCOCCUS SP..
Isolated from broth culture only, indicating very low
numbers of
organisms.
SENSITIVITIES PERFORMED ON CULTURE # 207-1052R
([**2134-5-23**]).
ANAEROBIC CULTURE (Final [**2134-5-30**]): NO ANAEROBES ISOLATED.
.
[**5-26**], [**5-27**] - Bl Cx no growth.
.
Imaging:
CHEST (PORTABLE AP) [**2134-5-20**] 8:46 PM
.
SINGLE AP UPRIGHT PORTABLE CHEST: Compared to [**2134-5-9**] and chest
CT of [**2134-5-5**]. Low lung volumes. Large retrocardiac hiatal
hernia, better demonstrated on the prior CT. Heart size is upper
limits of normal, allowing for technique. There is left basilar
atelectasis. Again demonstrated is an ill-defined peripheral
opacity in the right peripheral lower lung zone, with a small
amount of lung herniating between the ribs better demonstrated
on the prior CT. This is unchanged from the prior chest x-ray.
However, there is a new focal area of consolidation in the right
lower lobe medially, which is concerning for new pneumonia.
IMPRESSION:
1) New consolidation in the medial aspect of the right lower
lung zone, concerning for pneumonia.
2) Stable appearance of opacity in the right lower lung zone,
with a small amount of herniating lung, better demonstrated on
the prior chest CT.
3) Large retrocardiac opacity, likely relating to the large
hernia seen on the prior CT.
.
CT ABDOMEN W/O CONTRAST [**2134-5-21**] 2:52 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
TECHNIQUE: MDCT axial images from the lung bases through the
pubic symphysis were obtained with oral but not intravenous
contrast.
There are small bilateral pleural effusions, left greater than
right. Note is made of extensive coronary calcifications. There
is ground glass opacity in the right middle lobe with
consolidation and bronchograms concerning for focal pneumonia.
Bibasilar atelectasis is present at the lung bases.
Optimal evaluation of the visceral organs is limited secondary
to lack of intravenous contrast. Allowing for this factor, the
liver is nodular without focal mass, consistent with cirrhosis.
There is splenomegaly with the spleen measuring up to 15 cm.
Multiple paraesophageal varices are identified. There is a small
hiatal hernia. The gallbladder is distended and contains a small
stone. There is no definitive gallbladder wall thickening. The
adrenals and pancreas appear normal. No stones or hydronephrosis
are identified within the kidneys. There are extensive
calcifications throughout the abdominal aorta and its branches.
There is moderate ascites with pockets of low-density fluid
intercalating throughout the mesentery. Small bubbles of free
air are identified along the anterior abdominal wall, likely
secondary to recent paracentesis. There are small ventral
hernias containing nonobstructed loops of colon. Contrast is
seen extending throughout the bowel to the level of the distal
sigmoid colon. There is no evidence of obstruction or large
intraperitoneal abscess. The small bowel is relatively unchanged
in appearance with multiple areas of bowel wall thickening.
There are numerous mesenteric and retroperitoneal lymph nodes
which do not meet CT criteria for pathologic enlargement.
CT PELVIS WITH WITHOUT CONTRAST: Foley catheter is seen in a
partially distended bladder. Moderate ascites is again
identified with a layering density in the cul-de-sac with a few
air bubbles, perhaps reflecting a small hematoma. The rectum,
sigmoid colon, and large bowel are grossly unremarkable.
Calcifications are seen within the prostate.
BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are
identified.
IMPRESSION:
1. No evidence of bowel obstruction as contrast and air are seen
extending throughout the colon to the level of the distal
sigmoid.
2. Nodular liver varices and splenomegaly consistent with
cirrhosis. Moderate ascites is present.
3. Focal ground glass opacity in the right mid to lower lobe
concerning for pneumonia.
4. Small pockets of free intraperitoneal air, likely secondary
to recent paracentesis. No evidence of pneumatosis or
pneumobilia.
5. Multiple areas of small bowel wall thickening, relatively
unchanged compared to prior study without evidence of abscess.
These findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 3:00
a.m. on [**2134-5-21**].
.
US ABD LIMIT, SINGLE ORGAN [**2134-5-21**] 12:15 AM
UPPER QUADRANT ULTRASOUND: Liver echotexture is coarsened, not
appreciably changed from the prior examination. The liver
surface is nodular consistent with cirrhosis. There is no
evidence of focal hepatic mass or intrahepatic ductal
dilatation. There is significant lower quadrant ascites. A spot
was marked in the left lower quadrant for paracentesis. The
gallbladder wall is thickened and the gallbladder is slightly
distended. No pericholecystic fluid or definite stones are
identified.
IMPRESSION:
1. Moderate to large amount of ascites. Spot marked in the left
lower quadrant for paracentesis.
2. Findings consistent with hepatic cirrhosis.
.
[**2134-5-21**] 06-[**Numeric Identifier 11096**] PERITONEAL FLUID
SPECIMEN DESCRIPTION: Received 1000ml tan color fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: Ascites, now with SBP, heterogenous liver, prior
Cytology with malignant cells.
NEGATIVE FOR MALIGNANT CELLS.
Predominantly neutrophils with rare reactive mesothelial
cells and monocytes.
.
EKG [**2134-5-21**]
Normal sinus rhythm. Low limb lead voltage. Q waves in leads
V1-V2 suggest
prior anteroseptal myocardial infarction. Left atrial
abnormality. Q waves in leads III and aVF suggest prior inferior
myocardial infarction. Left axis deviation suggestive of
possible left anterior fascicular block. Compared to the
previous tracing of [**2134-5-9**] there has been no diagnostic interval
change.
.
PARACENTESIS DIAG. OR THERAPEUTIC [**2134-5-24**] 3:05 PM
PROCEDURE: The risks and benefits of the procedure were
explained to the patient and written informed consent was
obtained. Initial ultrasonographic imaging was performed
demonstrating a large amount of ascites throughout the abdomen.
Under son[**Name (NI) 493**] guidance, a spot was marked in the left lower
quadrant for paracentesis. The patient was prepped and draped in
standard sterile fashion. Local anesthesia was achieved via
injection of 5 cc of 1% lidocaine with bicarbonate. An 18-gauge
[**Last Name (un) 11097**] needle was advanced into the ascitic pocket. Diagnostic
samples were obtained for microbiology, cell count and
differential, and chemistry. Following this, three liters of
serosanguinous ascitic fluid were aspirated. The patient
tolerated the procedure well, with no complications evident at
the time of the procedure.
IMPRESSION: Successful ultrasound-guided diagnostic and
therapeutic paracentesis.
.
[**2134-5-25**] 06-[**Numeric Identifier 11098**] PERITONEAL FLUID
ATYPICAL.
Rare atypical cells present in a background of reactive
mesothelial cells and inflammatory cells, can not exclude
malignancy.
.
CT ABD&PELVIS W/O C COLON TECHNIQUE [**2134-5-25**] 5:24 PM
ABDOMEN CT WITHOUT AND WITH INTRAVENOUS CONTRAST:
The hazy opacity with septal thickening and interstitial disease
in the right middle lobe has decreased since [**2134-5-21**], likely
reflecting resolving pneumonia and atelectasis. Bilateral
subsegmental atelectasis in the lower lobes persist. Bilateral
small pleural effusions persist. As before, there is a hiatal
hernia. As before, there are esophageal varices.
The liver remains a nodular in contour and has volume
redistribution consistent with cirrhosis. There are no masses
within the liver. Portal and hepatic veins are patent. As
before, there is splenomegaly. There is extensive ascites. There
is minimal enhancement of the peritoneal lining, not unexpected
in someone with recent paracentesis.
There is a normal appearance of the pancreas and main pancreatic
duct. Biliary ducts are not dilated. The gallbladder is mildly
distended but has a thin wall. Bilateral kidneys are normal in
appearance, as are the adrenal glands. There is retroperitoneal
fat stranding, particularly about the celiac axis with some
small lymph nodes, which is a nonspecific finding. This is
unchanged in appearance from the [**2134-4-3**] CT. There are multiple
mesenteric lymph nodes, which is slightly increased since [**4-5**],
also nonspecific. There is extensive central small bowel wall
thickening and extensive enhancement of segment of proximal
small bowel, similar in appearance to recent CTs, likely
reflecting patient's ongoing active Crohn's disease. No bowel
obstruction.
CT PELVIS WITHOUT AND WITH CONTRAST: There is small amount of
gas within patient's ascites within the pelvis, likely
reflecting recent paracentesis. Prostate and seminal vesicles
are normal in appearance. Urinary bladder is normal in
appearance. Rectal tube is in place. There is no lymphadenopathy
within the pelvis. There is extensive pelvic ascites. There is
soft tissue stranding and edema within the buttocks and proximal
bilateral lower extremities. Scrotal calcifications bilaterally
are of uncertain etiology. Ultrasound could be performed as
clinically indicated.
CT COLONOGRAPHY:
There is slightly limited evaluation of the rectum because of
fluid, however, no definite rectal lesions are seen on either
pre-contrast or post-contrast images. Sigmoid colon is well
evaluated, as is the descending colon and splenic flexure, the
latter particularly on the post-contrast images and there are no
lesions to suggest colon cancer. The transverse colon is well
distended on the supine images and is without polyp or evidence
of cancer. The hepatic flexure is slightly suboptimally seen
over a short segment, however, it is distended on the prone
imaging and there are no findings to suggest cancer. The
ascending colon and cecum are well distended, particularly on
the prone images and are without findings to suggest
adenocarcinoma or polyps.
BONE WINDOWS: No suspicious lytic or sclerotic lesions within
the bones.
Multiplanar reformats were essential in evaluating the colon,
small bowel, and remainder of the abdomen.
IMPRESSION:
1. No findings to suggest adenocarcinoma within the colon. No
evidence for adenocarcinoma elsewhere. Extensive small bowel
enhancement and wall thickening, particularly in the central
abdomen and left upper quadrant is not significantly changed
from [**2134-4-3**].
2. Slightly increased lymphadenopathy within the mesentery and
within the retroperitoneum about the celiac and SMA are slightly
increased, likely related to patient's Crohn's disease, however,
this is uncertain.
3. Extensive ascites, however, there is no concerning peritoneal
enhancement or evidence of peritoneal nodularity to suggest
carcinomatosis. Small amount of gas is likely related to
paracentesis.
4. Resolving right middle lobe disease likely reflects clearing
pneumonia.
5. Cirrhosis with ascites, varices, and splenomegaly.
.
GUIDANCE FOR [**Female First Name (un) **]/ABD/PARA CENTESIS US [**2134-5-27**] 2:18 PM
PROCEDURE: The risks and benefits of the procedure were
explained to the patient, and written informed consent was
obtained. Initial son[**Name (NI) 493**] imaging demonstrated a large
volume of ascites throughout the abdomen. Under son[**Name (NI) 493**]
guidance, a site was selected for paracentesis in the left lower
quadrant. The patient was prepped and draped in standard sterile
fashion. Local anesthesia was achieved via injection of 4 cc of
1% lidocaine with bicarbonate. An 18 gauge [**Last Name (un) 11097**] needle was then
advanced into the ascitic pocket and 5 liters of ascitic fluid
were aspirated. The patient tolerated the procedure well,
without complications evident at the time of the procedure.
IMPRESSION: Successful ultrasound-guided therapeutic
paracentesis.
.
Gastrointestinal mucosal biopsies, two: [**2134-5-27**]
A. Jejunum:
1. Poorly-differentiated adenocarcinoma with ulceration.
2. Immunostains of the tumor are positive for cytokeratin CK-20
and negative for CK-7, with satisfactory controls.
B. Antrum:
1. Mild chronic inactive inflammation, with tiny
focus of intestinal metaplasia.
2. No tumor.
Note: The features of the tumor are consistent with a primary
intestinal origin.
.
EGD [**2134-5-27**]
Erythema and friability in the antrum compatible with gastritis
(biopsy)
Mass in the mid jejunum at 50cms (biopsy)
Otherwise normal small bowel enteroscopy to mid jejunum.
Brief Hospital Course:
Mr. [**Known lastname 916**] is a 63 yo male with Crohn's disease, IgA deficiency,
admitted with abdominal pain and ascites, lower extremity edema
found to have SBP/bacteremia and malignant ascites. His
hospital course is summarized below by problem.
.
# SBP/Malignant Ascites/Liver disease - Patient has a h/o
nodular regenerative hyperplasia with new ascites x several
months. Patient had three large volume paracentesis (see results
section) during this admission. Fluid cytology c/w adeno CA of
unclear primary and SBP growing [**Name (NI) **] and Veillonella species.
Based on the reports of Pathology, Cytology and Flow Cytometry,
it was unclear as to the origin of the malignancy ddx:
Adenocarcinoma vs Lymphoma. The tumor Cells are CEA positive,
CDK20 positive and CDK 7 negative which is consistent w/ an
Adenocarcinoma most likely originated from the GI tract, based
on the patient's hx of Crohn's Disease, Adenocarcinoma of the
Colon is a possibility that we need to r/o, his last Colonoscopy
was [**4-3**] ys ago, and there's a hx of Malignant Polyp many years
ago according to the patient. He had a virtual colonoscopy
showing evidence of multiple areas of small bowel wall
thickening (have worsened since [**2131**]). No other increased
lymphadenopathy noted. His ascitic fluid from [**5-10**] was read as
large atypical cells with scant cytoplasm. The cell block showed
CK20 positive, CK7 negative, CEA positive. Cells express CD138
and MIB fraction is 100%. HHV-8 negative. His flow cytometry
from this fluid shows that 70% of cells are T-cells that express
mature T-lineage antigens (CD3,5,2,7) and have a
helper-to-cytotoxic ratio of 0.78. B-cells are nearly absent.
This is a non-specific marker profile. Oncology evaluated the
patient and after reviewing the pathology, cytology and
immunohistochemistry findings determined that the most likely
diagnosis was a poorly differentiated GI Carcinoma. It was
determined that tissue would be obtained from an EGD which was
performed and biopsies taken pending at the time of discharged
but included in results section of this report. He was
discharged with close follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**] for
ongoing management. He likely needs ongoing therapeutic
paracentesis on an ongoing basis. He was discharged on
Cefepime, Linezolid and Flagyl after PICC was placed for home
access. He was also treated with Ursodiol, Aldactone and lasix
to manage his ascites.
.
# Bacteremia/Bacterial Peritonitis: Patient grew both [**Last Name (NamePattern1) **] and
Veillonella in both the peritoneal fluid and blood. Veillonella
can be a mouth flora often confused with meningococcus, of
questionable virulence. Patient was followed by infectious
diseases. He as treated with broad coverage including Linezolid
for [**Last Name (NamePattern1) **], Cefepime and Flagyl. No further cultures were positive.
He was discharged with a PICC for ongoing antibiotic treatment
with scheduled follow up with ID.
.
# Anemia. Likely multifactorial given chronic illness, GI
malignancy likely. Patient's Hct at baseline is in mid 30's.
Dropped to 27 on [**2134-5-27**]. No evidence of active bleeding. He was
transfused one unit pRBCs. Hemolysis labs were negative. He wad
discharged with stable Hct and scheduled follow up.
.
# COPD. Patient is on chronic steroids and PCP [**Name Initial (PRE) **]. Patient was
treated with high dose steroids given his acute infection with
Hydrocortisone 100 mg q 8 hrs x 3 doses. He was then continued
on Prednisone. He was no longer hypotensive after his initial
episode. He was continued on Albuterol/Atrovent nebs.
.
# IgA deficiency. Monthly IVIG infusions, no active issues.
.
# HTN - BP meds held in setting of hypotension initially.
.
# Hypothyroidism. Continued Synthroid.
.
Patient was discharged in stable condition with outpatient
follow up with GI and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2148**].
Medications on Admission:
1. Prednisone 10 mg Tablet Tablet PO DAILY
2. Ursodiol 300 mg PO BID
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Levothyroxine 25 mcg po QD
5. Lorazepam 0.5 mg PO QHS PRN
6. Trimethoprim-Sulfamethoxazole 160-800 mg PO QD
7. Spironolactone 50 mg po QD
8. Furosemide 40 mg po QD
9. Prilosec 20 mg Po QD
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
11. Pantoprazole 40 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*
12. Cefepime 2 g Piggyback Sig: Two (2) g Intravenous every
eight (8) hours for 2 weeks.
Disp:*84 g* Refills:*0*
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
14. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*100 mg* Refills:*0*
15. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day: start after taking Cefepime for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
18. PICC care per protocol
19. PICC care per protocol
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY:
- Crohn's
- malignant ascites
.
SECONDARY:
- IgA deficiency, gets monthly IVIG
- Iron deficiency anemia- monthly IV Fe
- Liver Disease- HCV(-)[**4-2**],HBsAb (+),HBsAg,cAb,IgMHBc(-)[**4-2**]
- mitral valve repair for MVP in '[**31**]
- Hypothyroidism
- GERD
- HTN
- COPD
Discharge Condition:
stable
Discharge Instructions:
--seek immediate medical attention if experiencing fever,
chills, or any concerning symptoms
--return to [**Hospital Ward Name **] 8 for paracentesis if ascites becomes
uncomfortable
--take all medications as prescribed
Followup Instructions:
Provider: [**Name10 (NameIs) 5085**] [**Name11 (NameIs) **],BEC [**Hospital **] [**Hospital 11099**] CLINIC
Date/Time:[**2134-7-1**] 9:00
.
make an appointment to see [**Last Name (LF) **], [**First Name3 (LF) **] (hepatologist) Liver
Center, [**Last Name (NamePattern1) 11100**] [**Location (un) 86**], [**Numeric Identifier 718**], Phone:
[**Telephone/Fax (1) 2422**] within two weeks of discharge
.
make an appointment to see [**Last Name (LF) 903**],[**First Name3 (LF) 251**] (primary care doctor)
[**Telephone/Fax (1) 904**] within two weeks of discharge
.
make an appointment to see [**Last Name (LF) 11101**], [**First Name3 (LF) **] (infectious disease)
Division of Infectious Disease, [**First Name9 (NamePattern2) 11102**]
[**Location (un) 86**], [**Numeric Identifier 718**], Phone: [**Telephone/Fax (1) 457**] within one week of
discharge.
Completed by:[**2135-2-23**]
|
[
"530.81",
"555.9",
"279.01",
"401.9",
"280.9",
"197.6",
"567.23",
"496",
"244.9",
"152.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.93",
"99.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
28473, 28522
|
22015, 25987
|
288, 327
|
28846, 28855
|
3633, 21992
|
29124, 30008
|
3065, 3114
|
26394, 28450
|
28543, 28825
|
26013, 26371
|
28879, 29101
|
3129, 3614
|
232, 250
|
355, 2003
|
2025, 2823
|
2839, 3049
|
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