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Discharge summary
|
report
|
Admission Date: [**2101-12-10**] Discharge Date: [**2101-12-31**]
Date of Birth: [**2042-9-16**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Levofloxacin/Dextrose 5%-Water
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
ARF and question of multiple myeloma
Major Surgical or Invasive Procedure:
[**2101-12-20**]:
1. Anterior T3 corpectomy.
2. Anterior spinal fusion T2-T4.
3. Application of inner body cage T2-T4.
4. Posterior spinal fusion T1-T5.
5. Segmental posterior instrumentation T2-T5.
6. Thoracic decompression laminectomy T1-T2,T2-T3, T3-4 and
T4-
T5 .
[**2101-12-27**]: Thoracentesis
History of Present Illness:
59 y/o man with PMH significant for hypercholesterolemia, HTN,
and [**Hospital 22982**] transferred from [**Hospital3 **] for further care for
ARF and question of multiple myeloma. Pt was in his usual state
of health until mid [**7-/2101**] when he noted that he was feeling
poorly with fatigue, low grade fevers of 99, and nausea. The pt
was seen in his PCP's office where he reports numerous labs were
drawn that did not show any abnormality. However, the pt
continued to have the above symptoms. Then, in late [**9-/2101**] he
"strained" his back lifting some heavy items while doing a home
remodeling project. The discomfort improved slowly with
ibuprofen until [**10/2101**] when he fell while fishing and struck
his back. He has experienced increasing back pain since that
time. Two weeks after the accident, he presented to his PCP for
further evaluation. At that time, films revealed compression
fractures of L1 and L3. The pt was prescribed percocet and also
continued on ibuprofen for the pain. However, it continued to
worsen to the point where he was bed bound and needing a cane
for ambulation. He also experienced severe nausea and
constipation. On [**2101-12-5**], the pt presented to [**Hospital3 **]
for further care. At that time, he rated his back pain [**11-1**].
The pt was found to have lumbar and rib fractures in addition to
hypercalcemia, ARF, and anemia. A body scan was then obtained on
[**2101-12-6**] for further evaluation showing bilateral renal
enlargement without evidence of excretion (nonspecific but
compatible with infiltrative disease or acute
glomerulonephritis), increased uptake in left ribs, increased
uptake in multiple joints suggesting polyarthirits, and
increased uptake in the epigastrium. The pt also had multiple
other radiology studies--- please see below for the individual
results. Of note, at the time he entered the OSH, the pt had
been taking 1200 mg of ibuprofen daily for approximately six
weeks.
.
Tonight, the pt reports that he continues to have severe back
pain with any movement. It does not radiate but is localized to
his lumbar back. He reports that he has had several stools with
resolution of his constipation. His nausea is also much better
but his appetite remains poor. Of note, the pt had noted
decreased urine output at home but had attributed this to
deydration secondary to his poor PO intake. At this time, he
reports that he is making large amounts of urine.
Past Medical History:
PMH:
1. Hypercholesterolemia
2. HTN
3. DJD
4. Episodic vertigo
5. Sleep apnea on nasal CPAP
6. Occular migraines
.
PSH:
1. S/P scopes of the knees bilaterally
2. S/P hernia repair at age 2
Social History:
The pt is married. He worked for Inspiron Corporation in [**Location (un) 2624**]
but retired in 04/[**2101**]. No tobacco (quit smoking 30 years ago)
or drugs. Rare ETOH. The pt's PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] in [**Hospital1 **]
Family History:
The pt's mother has osteoporosis and lupus. His father has heart
disease. Several other family members have DM and
hypercholesterolemia.
Physical Exam:
98.7 164/96 83 18 95% 3L NC
Gen- Tired, slightly anxious appearing gentleman resting in bed.
Alert and oriented. NAD. Pleasant.
HEENT- NC AT. EOMI. Anicteric sclera. MMM. No lesions in the
oropharynx.
Cardiac- RRR. S1 S2. No m,r,g.
Pulm- CTA anteriorly and laterally. No wheezes, rales, or
rhonchi.
Abdomen- Soft. Diffuse, minimal tenderness. No rebound or
gaurding. ND. Positive bowel sounds.
Extremities- No c/c/e. 2+ DP pulses bilaterally.
Neuro- CN II-[**Doctor First Name 81**] intact. 5/5 strength in upper and lower
extermities bilaterally.
Pertinent Results:
Labs from [**Hospital3 **]:
([**12-6**]) C-ANCA- <1:20 P-ANCA- <1:20 C3 complement- 144
C4 complement- 39
([**12-10**]) WBC- 9.4, Hct- 25.7, platelets- 252, Na- 142, K- 3.8,
chloride- 117, bicarb- 14, BUN- 75, creatinine- 6.6, glucose- 83
.
CXR ([**12-7**])- Heat size is within normal limits. No acute
infiltrate seen. Pleural thickening laterally on the left.
Question healing left fifth rib fracture. Costophrenic angle is
minimally blunted.
.
AP and lateral thoracic spine ([**12-7**])- Bones are osteoporotic.
There are significant blastic and lytic changes in the T3
vertebral body with loss of height suspicious for metastatic
disease. On the AP film, the spinous processes are aligned.
Pedicles are intact.
.
Lumbar spine ([**12-7**])- Moderate loss of vertebral body height of
L1 and L2. No destructive porcess seen. However, metastatic
disease involving the bone cannot be excluded. Bones overall are
osteoporotic. On the AP film, spinous processes are aligned and
pedicles are intact.
.
Lateral film cervical spine ([**12-7**])- C1 through C6 is
identified. C7 is not seen. Vertebral bodies are aligned. No
significant loss of height. Minimal disc space narrowing at
C5-C6.
.
Lateral film skull ([**12-7**])- Small lucencies seen throughout the
skull questionable for metastatic disease.
.
AP pelvis ([**12-7**])- Both hips are internally rotated. No obvious
fracture on the single view. Limited images of the iliac bones
show no fracture. There is overlying stool and feces.
.
Single view right femur ([**12-7**])- No blastic or lytic lesions
seen.
.
Single view left femur ([**12-7**])- No blastic of lytic lesions
seen.
.
Single view right humerous ([**12-7**])- No blastic or lytic lesions
seen.
.
Single view left humerous ([**12-7**])- No blastic or lytic lesions
seen.
.
Bone scan total body ([**12-6**])- Bilateral renal enlargement
without evidence of excretion. The appearance is nonspecific but
compatible with infiltrative disease or acute
glomerulonephritis. Increased uptake in the left ribs is likely
posttraumatic despite the recent nondiagonstic left rib x-rays.
Increased uptake in multiple joints suggest polyarthritis.
Increased uptake in the epigastrium is a nondiagnostic finding
and is not explained on the basis of either this exam or the
recent abdomen CT scan.
.
Renal US ([**12-5**])- Kidneys are normal without evidence of renal
mass, stone, or obstruction. The right kidney measures 13.0 cm
in length and the left measures 12.5 cm. Small amount of urine
in the bladder.
.
Noncontrast CT scan of abdomen and pelvis ([**12-5**])- Moderate
compression of the L2 vertebral body and mild compression of the
superior endplate of L1. No other definite abnormality is seen.
Sigmoid diverticulosis.
.
Noncontrast CT of T spine ([**12-11**])- Lytic destruction of the T4
verterbal body with extension into the perivertebral tissues
bilaterally. Posteriorly this extends into and slightly narrows
the spinal canal. Lytic soft tissue lesion within the left T3
transverse process. L1 insufficiency fracture of indeterminate
age. Diffuse bony demineralization. Large bilateral pleural
effusions.
.
Noncontrast CT of L spine ([**12-11**])- Moderate/severe L2 and mild
L1 insufficiency compression fractures. Diffuse bony
demineralization.
.
MRI L-T spine ([**12-12**])- Pathologic compression fracture of T3,
with a soft tissue lesion involving the vertebral body, pedicle
and transverse process. Epidural soft tissue is also present,
displacing, but not compressing, the spinal cord. Mild chronic
L1 compression fracture. Edema within the L2 vertebral body,
suspicious for a multiple myeloma lesion.
Possible subtle compression fracture as there is mild loss of
vertebral body height.
.
T-spine plain film ([**12-22**])- Patient is status post posterior
thoracic spinal fusion, spanning T2-T6 with [**Location (un) 931**] rods and
pedicle screws. The patient is also status post L4 corpectomy,
new when compared to [**2101-12-11**]. The remaining thoracic
vertebral bodies maintain normal height. Multilevel
degenerative endplate changes noted. No listhesis.
Cardiomediastinal contours are unremarkable. Visualized lung is
clear. Surgical staples are seen to overlie the posterior
midline of the thorax.
.
L-spine plain failm ([**12-22**])- Again seen are compression
fractures involving the L1 and L2 vertebral bodies. Loss of
height is similar in degree when compared to the CT exam of
[**2101-12-11**]. No listhesis. Intervertebral body disc spaces are
maintained. Surgical staples project over the right lower
quadrant. There is mild degenerative change involving the
bilateral sacroiliac joints.
.
Bone Marrow biopsy ([**12-13**])- DIAGNOSIS: CELLULAR BONE MARROW,
EXTENSIVELY INFILTRATED BY A PLASMA CELL MYELOMA. The bone
marrow aspirate shows a predominance of plasma cells, enumerated
at 76% of marrow cellularity. Some plasma cells show atypical
features. The concurrent bone marrow biopsy was sub-optimal for
morphological evaluation and light chain immunoprofiling.
However small marrow spicules are present and show at least 50%
plasma cells. Overall the findings are consistent with
involvement by plasma cell myeloma.
.
Bone Marrow cytogenetics ([**12-13**])- FISH was performed with a
panel of Abbot Molecular Inc./ Vysis, Inc. probes for MM and is
interpreted as ABNORMAL for the CCND1-XT probe. FISH evaluation
for an IGH-CCND1 rearrangement was performed on nuclei with the
Vysis LSI IGH/CCND1 Dual Color, Dual Fusion Translocation Probe
for IGH at 14q32 and CCND1 at 11q13 and is interpreted
as ABNORMAL, although an IGH-CCND1 rearrangement was not
detected. An abnormal hybridization pattern was observed in
24/100 nuclei, indicative of tetrasomy for the corresponding
region on chromosome 11. A single hybridization was detected
with the LSI D13S319 Probe at 13q14.3 in 5/100 nuclei, which is
within the normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 5% of cells in normal
samples
can show apparent 13q deletion using this probe set. No
rearrangement was detected with the LSI IGH/FGFR3 Dual Color,
Dual Fusion Translocation
Probe for IGH at 14q32 and FGFR3 at 4p16 in 100/100 nuclei,
which is within the normal range established for these probes in
the Cytogenetics
Laboratory at [**Hospital1 18**]. Up to 1% of cells in normal samples can
show apparent IGH-FGFR3 rearrangement using this probe set. One
hybridization signal with the LSI p53 Probe at 17p13.1 was
observed in 3/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory at
[**Hospital1 18**]. Up to 3% of cells in the normal samples can show apparent
17p deletion using this probe set.
.
Surgical pathology ([**12-20**])- T3 lesion: Fibrous tissue with
plasma cell infiltrate, consistent with plasmacytoma. T3 bone:
Plasmacytoma. Fragments of bone, cartilage and fibroadipose
tissue with focal areas of necrosis, consistent with fracture.
.
ECG ([**12-27**])- Sinus rhythm. Probable left ventricular hypertrophy.
Prominent U waves could be due to left ventricular hypertrophy
or possible drug/electrolyte/metabolic effect. Since the
previous tracing of [**2101-12-11**] ST-T wave changes have decreased.
.
TTE ([**12-23**])- The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. The aortic valve leaflets (3) are mildly thickened.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild to moderate ([**1-24**]+) mitral
regurgitation is seen.
.
Bilateral Lower Extremity ultrasound ([**12-26**])- No evidence of
bilateral lower extremity DVT.
.
AP and lateral CXR ([**12-27**])- Moderate-sized left-sided pleural
effusion with associated atelectasis versus consolidation.
Unchanged appearance of cervical/thoracic hardware.
.
Portable CXR ([**12-27**])- No pneumothorax. Near complete interval
resolution left- sided pleural effusion.
.
Microbiology:
-Stool cultures negative for C. Difficile [**12-11**] & [**12-12**]
-T3 wound swab negative for microorganisms [**12-12**]
-Urine cultures no growth [**12-23**]
-Blood cultures no growth x2 [**12-23**]
-Pleural fluid no growth, cytology pending [**12-27**]
-Blood cultures x2 pending [**12-28**]
Brief Hospital Course:
59 y/o man with PMH significant for hypercholesterolemia, HTN,
and [**Hospital 22982**] transferred from [**Hospital3 **] for further care for
ARF and question of multiple myeloma.
.
1. Multiple myeloma- was the initial concern compression
fractures, ARF, anemia, hypercalcemia, and blastic and lytic
lesions seen on plain imaging (not on bone scan). However,
review of the OSH records do not reveal a U-PEP or S-PEP. The pt
had also not had a bone marrow biopsy. SPEP and UPEP done at
[**Hospital1 18**] was consistant with myeloma. Here, imaging showed mass at
T3, SPEP had + monoclonal spike and bone marrow bx. confirmed
myeloma (M spike in plasma and urine, 76% plasma cells in
marrow, renal failure). His calcium was slightly elevated on
admission (10), but has normalized. Baseline crt 0.9. He has
been anemic, with low retic and elevated ferritin, and was
transfused 2uPRBC's [**12-13**], 2 uPRBC's [**12-23**], 2 uPRBC's [**12-24**], with
2 uFFP [**12-20**]. He was given vitamin K 10mg x3 for
anticoagulation. As treatment he received dexamethasone for 40mg
po for 4 days (day 1 [**Date range (3) 70400**]). He is scheduled for
outpatient follow-up with Dr. [**Last Name (STitle) **] [**2102-1-5**].
.
2. [**Name (NI) 10271**] Pt with severe ARF on presentation to the OSH,
creatinine initially 12.6 ([**12-5**]) ---> 11.4 ([**12-7**]) ---> 6.6
([**12-10**]) with a BUN of 145 ([**12-5**]) ---> 133 ([**12-7**]) ---> 75
([**12-10**]). Urine protein was in the nephrotic range by a spot
protein/creatinine ratio. Renal US did not show obstruction,
stones, or any other clear abnormality. ARF thought to be
multifactorial - hypercalcemia, NSAID use - 1200mg motrin daily
for 6 weeks for back pain) and myeloma kidney. This improved
here and by discharge creatinine was 0.8. He was advised to
discontinue NSAID use.
.
3. T3 vertebral lesion - Seen by ortho spine - Dr [**Last Name (STitle) **] - he
was taken to surgery [**12-20**] for T3 corpectomy and T1-T5 fusion
which was uncomplicated. After which he was placed in TLSO brace
whenever head >45 degrees and worked with PT prior to discharge.
Post operative pain control with dilaudid PO. He additionally
experienced chest wall muscle spasm controlled with flexeril
10mg po tid. He has follow-up for staple removal w/ortho
[**2102-1-4**]. Additionally he had a DEXA to look for osteoporosis -
has a T score -3.5, likely from his lactose intolerance.
.
4 Post-operative fevers - Started post op day 1 and continued
for the remainder of his hospitalization, max 102. He had no
specific localizing signs or symptoms except a left sided
pleural effusion which was tapped by thoracentesis [**12-27**] and
found to be transudative and sterile. It did not recur after
throcentesis. Blood cultures pending NG [**12-23**] x4, urine neg [**12-23**],
pleural fluid cx [**12-27**] NGTD, blood cx NGTD x4 [**12-28**]. Given
immunocompromised state from MM (hypogammaglobulinemia)
pneumonia possible (at risk for infection with incapsulated
organsims), no apparent response to abx (vanco x5d,
flagyl/ciprox4d, azithro/ctx x1 day). TB potential was
considered, but ppd negative, and with regard to pulmonary TB,
no intrapulmonary findings on imaging and no cough. MM induced
or drug fevers were also entertained. Antibiotics were stopped
48 hours prior to discharge per recomendation of ID and he
continued to have low-grade fevers (<100.5) but continued to
have no localizing signs or symptoms and was decided stable for
discharge.
.
5. Anemia - Normocytic, likely [**2-24**] infiltration of marrow by
myeloma cells, inappropriately low retic on admission, with
elevated feritin, could be a component of chronic disease,
vitamin B12 and folate WNl, iron studies c/w anemia of chronic
dx. Last tx [**12-24**], hct relatively stable since. Tranfussion goal
hct>21 unless brisk bleeding present or active end-organ
damage/angina, active type and cross.
.
6. Diarrhea - had some diarrhea - for 2 days initially. C diff
was neg, but he was given empiric metronidazole with resolution
of diarrhea.
.
7. OSA- on home CPAP, had his machine in house and was able to
initiate use prior to discharge, which worked well for him.
.
8. HTN- He was continued on his home dose of norvasc. Metoprolol
was added peri-operatively and he was discharged on this
medication.
.
9. h/o hyperlipidemia: on fenofibrate as outpatient, held on
admission [**2-24**] renal failure, now that renal failure improved
consider restarting (though potentially nephrotoxic so held on
discharge, recommend discussing with PCP for alternative
medication with consideration for MM treatment.
.
10. OSteoporosis - should be considered for bisphosphinates
after this acute phase, after discussion with heme onc re
calcium levels etc.
.
11. FEN- Lactose free diet. Agressive IV hydration.
.
12. Proph- Bowel regimen; Pneumoboots, lovenox.
.
13. Advanced [**Name (NI) 70401**] Pt's wife is his Healthcare Proxy, full
code.
Medications on Admission:
Medications at Home:
1. Tricor 145 mg daily
2. ASA 81 mg daily
3. Norvasc 10 mg daily
4. Ibuprofen PRN
5. Glucosamine daily
.
Medications at [**Hospital3 **]:
1. Epoetin alfa [**Numeric Identifier 961**] units SC Mon-Wed-Fri
2. Calcitonin nasal spray 1 spray daily
3. Odensetron 4 mg IV Q8H PRN
4. Amlodipine 10 mg daily
5. Tylenol 650 mg Q6H PRN
6. Morphine 2 mg SC Q4H PRN
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*3*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 tabs* Refills:*3*
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
8. HYDROmorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
Disp:*QS bottle* Refills:*0*
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 14 days: apply to affected groin area.
Disp:*QS tube* Refills:*0*
11. Flexeril 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Vital Care of [**Doctor Last Name **]
Discharge Diagnosis:
Multiple Myeloma
Acute renal failure
L1/L2 compression fracture
L3 vertebral body tumor
Discharge Condition:
Stable
Discharge Instructions:
Please refer to instruction sheet.
Please keep incision clean and dry. If you notice any increased
redness, swelling, drainage, temperature >101.4, or shortness of
Please take all medications as prescribed. You may resume any
normal home medications.
Please follow up as below. Call with any questions.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] (Orthopedics) on
Wednesday, [**2102-1-4**] at 10:30am, located in the [**Hospital Ward Name 23**]
clinical center [**Location (un) **]. You will have your staples removed at
this visit. Please call ([**Telephone/Fax (1) 2007**] if questions.
.
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Thursday,
[**2102-1-5**] at 1:30pm. This is located in the [**Hospital Ward Name 23**]
clinical center [**Location (un) 436**]. Please call [**Telephone/Fax (1) 3237**] if
questions.
.
You have an appointment with a new primary care doctor (Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on Thursday [**3-9**] at 11:10am. If you need to
change this appointment, or make a sooner appointment please
call [**Telephone/Fax (1) 250**]. Your appointment will be on the [**Location (un) **] of
the [**Hospital Ward Name 23**] Building at [**Location (un) 830**]. Please go to the
Central Suite on the [**Location (un) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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19487, 19555
|
12824, 17753
|
339, 648
|
19687, 19696
|
4395, 12801
|
20053, 21270
|
3669, 3808
|
18178, 19464
|
19576, 19666
|
17779, 17779
|
19720, 20030
|
17800, 18155
|
3823, 4376
|
263, 301
|
676, 3113
|
3135, 3325
|
3341, 3653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,659
| 179,021
|
9077
|
Discharge summary
|
report
|
Admission Date: [**2144-3-2**] Discharge Date: [**2144-3-5**]
Date of Birth: [**2108-2-5**] Sex: F
Service: [**Hospital 11212**] [**Hospital6 733**] Firm
HISTORY OF PRESENT ILLNESS: (Per admitting Intensive Care
Unit intern) Ms. [**Known lastname 9449**] is a 36-year-old woman with
metastatic breast cancer to subcutaneous tissue, lung, liver,
bone, and brain who presented from [**Hospital3 417**] Hospital
for endoscopic retrograde cholangiopancreatography for bile
leak, status post cholecystectomy for a perforated
gallbladder.
On the evening of [**2144-2-25**], the patient developed the
acute onset of epigastric pain and presented to [**Hospital3 418**] Hospital on [**2144-2-26**]; where she was found to
have an acute abdomen. She was tachycardic to 140 and had a
white blood cell count reportedly to 22. The patient was
taken to the operating room for exploratory laparotomy. She
underwent a cholecystectomy. Intraoperatively, the patient
was found to have free bilious fluid in the abdomen as well
as adhesions of omentum to the posterior surface of the
gallbladder, through which the bile was leaking. There was
no obvious gallbladder metastases. However, there was a
large palpable mass in the retroperitoneum (felt to be either
pancreatic mass versus retroperitoneal lymphadenopathy). At
that time, the decision was made to pursue internal stenting
via endoscopic retrograde cholangiopancreatography at a later
date. Thus, a biopsy of a liver metastases was obtained.
There were no intraoperative cholangiogram. There was no
obvious indication of biliary obstruction; though, a right
upper quadrant ultrasound on [**2-27**] revealed 3.6-cm
dilatation of the common bile duct, as well as dilatation of
the intrahepatic bile ducts.
Postoperatively, the patient complained of shortness of
breath. A chest x-ray revealed total opacification of her
left lung and was felt to represent infiltrates plus
effusion. The patient's oxygen saturation dropped to less
than 90%, and the patient was given intravenous Lasix. The
patient's left-sided pleural effusion was drained by
thoracentesis; the fluid from which was found to be
exudative.
Postoperatively, the patient was put on levofloxacin and
metronidazole. She was still on levofloxacin on transfer to
[**Hospital1 69**], where she was meant to
undergo an endoscopic retrograde cholangiopancreatography.
REVIEW OF SYSTEMS: On review of systems, the patient denied
a history of lower extremity edema, chest pain, shortness of
breath, nausea and vomiting, diarrhea, fever, and chills.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer; diagnosed approximately two
years ago. Metastatic to the liver, bone, lung, brain, small
bowel, and other areas. Status post two cycles of Navelbine,
status post two cycles of Taxol and carboplatin (last cycle
ended on [**2144-2-24**]). Status post radiation therapy for
brain metastases.
2. Echocardiogram on [**2144-2-29**] revealed an ejection
fraction of 65%. No wall motion abnormalities were found.
Normal right ventricular function was noted. There was some
mild pulmonary hypertension.
MEDICATIONS ON ADMISSION: Outpatient medications included
Percocet, Decadron, Ativan, Zofran, Duragesic patch.
MEDICATIONS ON TRANSFER: (Medications on transfer from [**Hospital3 418**] Hospital included)
1. Ascorbic acid 500 mg intramuscularly q.d.
2. Pepcid 20 mg intravenously q.12h.
3. Duragesic patch 100 mcg q.48h.
4. Neupogen 300 mcg q.d.
5. Heparin subcutaneously.
6. Solu-Cortef 100 mg p.o. t.i.d.
7. Dilaudid patient-controlled analgesia.
8. Levofloxacin 500 mg p.o. q.d.
9. Ativan 0.5 mg p.o. b.i.d.
10. Metoprolol 5 mg intravenously q.6h. p.r.n.
11. Vitamin A 5000 IU intramuscularly q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home with her husband.
They have pets. The patient worked for [**Doctor Last Name **] Elevator
Company. The patient has a positive smoking history. She
denies alcohol abuse.
PHYSICAL EXAMINATION ON PRESENTATION: (Per admitting
Intensive Care Unit intern) Vital signs revealed a
temperature of 99.2, heart rate of 130, blood pressure
of 114/71, satting 97% on 2 liters. In general, awake,
alert, comfortable, in no acute distress. Head, eyes, ears,
nose, and throat revealed pupils were equal, round, and
reactive to light. Extraocular movements were intact. Mild
scleral icterus. Moist mucous membranes. Positive pasty
white film on tongue. No oral lesions. Cardiovascular
examination revealed tachycardic. Normal first heart sound
and second heart sound. Lungs revealed decreased breath
sounds one third of the way up the left lung base with
dullness to percussion. No wheezes or crackles. Abdomen was
soft, mildly tenderness to palpation along the incision site.
No rebound or guarding. Hypoactive bowel sounds. Positive
vertical incision, no erythema. [**Location (un) 1661**]-[**Location (un) 1662**] drain in
place. Extremities revealed no edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
with complete blood count at [**Hospital1 188**] revealed a white blood cell count of 10.5, hematocrit
of 32.9, platelets of 133. INR of 1.9. Chem-7 revealed a
sodium of 144, potassium of 3.6, chloride of 101, bicarbonate
of 31, blood urea nitrogen of 19, creatinine of 0.3, glucose
of 157. Calcium was 7, magnesium was 2.1, and phosphorous
was 2.1. Liver function tests revealed an ALT of 100, AST
of 133, alkaline phosphatase of 675, amylase of 11, lipase
of 15. Total bilirubin at the outside hospital was 2.6.
Pleural fluid analysis from the outside hospital reportedly
revealed Gram stain negative. White blood cell count of 267
(with 21% polys and 49% lymphocytes). Red blood cells
were [**Pager number **]. Total protein of 2.8, albumin of 1.6, LDH of 750,
glucose of 233, and pH of 7.59.
RADIOLOGY/IMAGING: Chest x-ray at the outside hospital
reportedly revealed (on [**2144-2-27**]) almost complete
opacity of the left hemithorax with some right opacification.
Ultrasound performed on [**2144-2-27**] (at the outside
hospital) reportedly revealed massive dilatation of the
common bile duct (3.5 cm), with dilatation of the
intrahepatic bile duct. The pancreatic head and structures
were not well visualized.
HOSPITAL COURSE: The patient was admitted on transfer from
[**Hospital3 417**] Hospital to the [**Hospital1 188**] Intensive Care Unit.
The patient's Intensive Care Unit course was notable for
decreased urine output which responded to intravenous
boluses. Also, the patient was mildly tachycardic with
oxygen saturations to 88% on room air. These difficulties
resolved over [**2144-3-3**]; and, later that day, the
patient was called out to the Medicine floor, where she was
transferred to the [**Hospital6 733**] Medicine Firm.
On [**2144-3-4**], the patient underwent endoscopic
retrograde cholangiopancreatography. This revealed massive
common bile duct dilatation with distal common bile duct
obstruction. Previous cholecystectomy with a leak through
the cystic stump was noted. At that time, the patient
underwent successful sphincterotomy with successful
metal-covered Wallstent placed in the common bile duct. Also
noted on the endoscopic retrograde cholangiopancreatography
was antral gastritis.
The patient was maintained on intravenous antibiotics for
approximately 24 hours post endoscopic retrograde
cholangiopancreatography. Thereafter, she was switched to
levofloxacin and metronidazole.
The patient's diet was successfully advanced, and she was
tolerating food well by approximately 36 hours post
endoscopic retrograde cholangiopancreatography.
In terms of the patient's pulmonary status, the patient's
left pleural effusion was noted to have recurred. Due to its
exudative nature, and the patient's diagnosis, it was felt
that the patient's pleural effusions would continue to
recurrent despite any efforts at repeated thoracenteses.
Thus, the Pleural Disease Service was consulted. They
discussed various options with the patient including the
possibility of pleurodesis. However, at that time the
patient wished to defer that option, as she was breathing
well and without difficulty. The patient was given a contact
number for Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31343**] should she desire
pleurodesis or other intervention in the future.
The patient's surgical sites and [**Location (un) 1661**]-[**Location (un) 1662**] drain site
remained clean, dry, and intact, and without erythema or
tenderness. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain collected
approximately 300 cc of serosanguineous fluid on the day
before discharge. The patient's pain was well controlled on
her intravenous patient-controlled analgesia. This was
subsequently switched to her outpatient regimen of
analgesics.
CONDITION AT DISCHARGE: Vital signs were stable, afebrile;
very anxious for discharge.
DISCHARGE DIAGNOSES:
1. Bile leak, status post ruptured gallbladder.
2. Status post endoscopic retrograde
cholangiopancreatography; stent placement to the common bile
duct (on [**2144-3-4**]).
3. Metastatic breast cancer.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. q.d. times 13 more days.
2. Metronidazole 500 mg p.o. t.i.d. times 13 more days.
3. Decadron 5 mg p.o. b.i.d.
4. Duragesic patch 100 mcg topically (to be changed every 48
hours).
5. Zantac 150 mg p.o. b.i.d.
6. Percocet (5/325) one to two tablets p.o. q.6h. p.r.n.
7. Zofran 8 mg p.o. b.i.d. p.r.n.
8. Heparin 5000 units subcutaneous b.i.d.
DISCHARGE STATUS: The patient was discharged to home with
[**Hospital6 407**] to see her at her house. [**Hospital6 3429**] will facilitate dressing changes and will
notify an medical doctor of any change in the [**Initials (NamePattern4) 228**]
[**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain output. The patient was to have a
physical therapy and home safety evaluation to help her with
strengthening, conditioning, and ambulation.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with her oncologist,
Dr. [**Last Name (STitle) 31344**], on the week following discharge. The patient
was to discontinued use of subcutaneous heparin once she is
able to ambulate reliably. In the meantime, the patient
should have her platelets checked periodically while on
subcutaneous heparin.
2. The patient was also to follow up with the surgeon who
performed her cholecystectomy (Dr. [**Last Name (STitle) **]. He will evaluate the
patient for her postoperative course, remove her staples, and
remove her [**Location (un) 1661**]-[**Location (un) 1662**] drain when it is necessary.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2144-3-9**] 18:64
T: [**2144-3-12**] 09:14
JOB#: [**Job Number 31345**]
|
[
"998.89",
"E878.6",
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"174.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
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"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
9033, 9238
|
9264, 10099
|
3162, 3248
|
6319, 8933
|
8948, 9012
|
2421, 2582
|
10119, 11007
|
200, 2400
|
3274, 3798
|
2604, 3135
|
3815, 6301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,394
| 130,929
|
51563
|
Discharge summary
|
report
|
Admission Date: [**2166-11-4**] Discharge Date: [**2166-11-9**]
Date of Birth: [**2113-10-15**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Toprol Xl / Lipitor / Levofloxacin / Compazine /
Vancomycin / Zocor
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
mental status changes, hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
53F with ESRD on HD, CAD s/p CABG, HTN, DM type 2, PVD, presents
from [**Location (un) **] dialysis with decreased responsiveness. She is
reportedly drowsy at baseline and slept throughout her session.
At the end of dialysis, the ambulance personnel who arrived to
take her home were concerned for her increased lethargy and
brought her instead to [**Hospital1 18**] ED. VS stable in the field, 117/70,
HR 95, RR 20, glucose 189.
.
In the ED she was reportedly drowsy but somewhat combative. Her
ABG was consistent with hypercarbic respiratory failure
(7.27/77/31) and she was started on CPAP as she became more
somnolent. CXR showed moderate CHF. She received a head CT on
the way to the unit that was normal. On arrival to the MICU, her
ABG was 7.26/76/89 and she continued to be very somnolent,
almost unresponsive to voice or touch. She was then electively
intubated.
.
She was hospitalized in [**2166-8-24**] with a similar presentation
and her hypercapnea was thought to be secondary to COPD and
obesity hypoventilation. During her hospitalization she suffered
PEA arrest likely trigerred by worsening hypoxia of unclear
etiology. She was resuscitated after one round of epi and
atropine and intubated for a short period. She was extubated
without complication. CPAP was unsuccessful due to
claustrophobia.
Past Medical History:
1. PVD: prior work-up at the [**Hospital1 112**]
2. CAD s/p CABG in [**2160**] at [**Hospital1 112**]
3. DM 2
4. h/o CVA - c/b residual numbness/weakness of left arm and leg
5. HTN
6. Hyperlipidemia
7. Elevated LFTs, unknown etiology (?NASH)
8. CKD (type 4 RTA) on HD (TuThSa)
9. COPD
Social History:
She works for the Department of Mental Retardation. She lives
alone. Her son lives in the same building. She smokes [**11-25**] ppd
(used to be more) for ~15 years. She denies a history of
alcohol/drug use.
.
Family History:
(+)HTN, DM; no FH cancer
Physical Exam:
VS: 96.7, 113/56, 107, 99% BiPAP FiO2 30%
Gen: somnolent obese woman, minimally arousable to voice and
touch
HEENT: anicteric, MMM
Neck: supple, difficult to assess JVP
Lungs: Coarse breath sounds anteriorly bilaterally
CV: RRR, nl S1S2, no m/r/g
Abd: +BS, obese, soft, nontender
Ext: warm, dry skin over lower extremities, 2cm-diameter crusted
ulceration on LLE, 1+ pedal edema b/l
Neuro: somnolent, minimally responsive to voice, painful stimuli
Pertinent Results:
[**2166-11-4**] 09:30PM WBC-9.8 HCT-39#
[**2166-11-4**] 09:30PM NEUTS-80* BANDS-0 LYMPHS-11* MONOS-5 EOS-0
BASOS-0 ATYPS-4* METAS-0 MYELOS-0
[**2166-11-4**] 09:30PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-1+
[**2166-11-4**] 09:30PM PLT SMR-NORMAL PLT COUNT-343
[**2166-11-4**] 09:30PM GLUCOSE-188* UREA N-15 CREAT-3.9*# SODIUM-134
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-31 ANION GAP-15
[**2166-11-4**] 09:30PM estGFR-Using this
[**2166-11-4**] 09:30PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-1.9
Brief Hospital Course:
A/P: 53F w/ CAD s/p CABG, DM2, HTN, morbid obesity, CKD on HD
presents with hypercarbic respiratory failure
.
## hypercarbic respiratory failure: likely multifactorial
including contributions from COPD, obesity hypoventilation, OSA.
CXR showed moderate pulmonary edema although pt reportedly
completed HD session without incident. She was intubated for
hypercarbic respiratory failure and improved quickly. She was
extubated the following day without incident. She maintained
good oxygen saturation and was more interactive post extubation.
She was transferred to the floor but was noted to be lethargic
and was transferred to the MICU second time, by arrival to micu
she was back to her baseline. She was encouraged to use bipap,
however patient refused. Around 1 AM [**2166-11-9**] patient demanded
to leave, she was told of the risk of leaving against medical
advise. She expressed understanding of risks and potential
consequences of discharge and desired to be discharged anyway.
Patient signed a discharge AMA form.
.
## somnolence: likely from hypercarbic respiratory failure, had
extensive workup during last hospitalization that did not find
evidence of drug intoxication, sepsis, thyroid dysfunction. Head
CT negative. Sepsis less likely given afebrile, WBC not
elevated. Urine tox was positive for methadone and otherwise
negative. Mental status improved post extubation and patient
more interactive.
.
# UTI - enterococus in urine sample, given ampicillin in the
hosptial and given a prescription for amoxicillin at time of
discharge.
.
## CKD: completed dialysis session on day of admission. Whe was
dialysed on her usual cycle.
## CAD: continued ASA
## DM: Insulin SS and glargine
Medications on Admission:
Meds (from last visit w/ PCP [**2166-10-6**]):
- ASA 325mg daily
- pletal 100mg [**Hospital1 **]
- protonix 40mg daily
- tramadol 50-100mg [**Hospital1 **] prn
- insulin glargine 38 units qhs
- insulin humalog sliding scale
- Zetia 10mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypercarbic respiratory distress
Sleep Apnea
ESRD on dialysis
CAD
DM 2
HTN
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
YOU ARE LEAVING AGAINST MEDICAL ADVISE. We recommend that you
stay in the hosptial for further work up however you are
refusing further care. If you have any shortness of breath,
lethargy, fevers or chills or any other concerning symptoms
please return to the emergency room ASAP.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**11-25**] weeks.
Please continue to [**Last Name (un) 5511**] your scheduled dialysis sessions.
Completed by:[**2166-11-9**]
|
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icd9cm
|
[
[
[]
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[
"93.90",
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icd9pcs
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[
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|
6071, 6078
|
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302, 358
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437, 1752
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1774, 2060
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2076, 2286
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69,172
| 104,464
|
37781
|
Discharge summary
|
report
|
Admission Date: [**2141-1-2**] Discharge Date: [**2141-1-8**]
Date of Birth: [**2073-3-25**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: Ms. Ms. [**Known lastname 84593**] is a 67-year-old
female with metastatic renal cell carcinoma, admitted today
to begin cycle 1, week 1, high-dose IL-2 therapy.
Her oncologic history began in [**2134**], after she underwent an
MRI to evaluate back pain was incidentally found to have a
left kidney mass. She underwent left nephrectomy at that
time. A small liver lesion was noted during her yearly
followup CT scans for which she underwent an ultrasound which
did not reveal metastatic disease. During an annual mammogram
on [**2140-7-8**], she was discovered to have a new density in
her right breast. An ultrasound guided biopsy of this mass
was performed on [**2140-8-11**], and pathology revealed the
presence of an invasive carcinoma with clear cell features
concerning for metastatic renal cell carcinoma. PET CT
performed on [**2140-8-26**], showed the presence of a lesion in
the medial right hepatic lobe, worrisome for a growing
neoplasm. An additional low attenuation lesion on the lateral
right hepatic lobe was also seen. No liver lesion was
biopsied on [**2140-9-12**], with pathology consistent with renal
cell carcinoma. She was referred here to discuss treatment
options. She was planned for liver and breast resection on
[**2140-10-28**], but her liver lesion was more extensive than
thought prior to surgery and could not be resected. She
underwent right partial mastectomy with pathology from the
breast and a repeat liver biopsy confirming metastatic kidney
cancer. Systemic options were discussed and she wanted to
consider high-dose IL-2 therapy. She passed eligibility
testing and presents today to begin cycle 1, week 1, high-
dose IL-2 therapy.
PAST MEDICAL HISTORY: Thyroid cancer [**2131**], status post
thyroidectomy and radioiodine treatment; renal cell cancer as
above; status post tonsillectomy in [**2091**]; bladder surgery in
[**2099**]; status post hysterectomy and bladder repair in [**2101**];
cholecystectomy in [**2118**]; multiple bladder repairs including a
sling in [**2136**], and multiple rectocele repairs from [**2137**]-[**2139**];
arthroscopic left knee surgery in [**2127**].
ALLERGIES: Levofloxacin, morphine, and tape.
MEDICATIONS: Evista 60 mg p.o. daily, Effexor 37.5 mg p.o.
daily, Toprol XL 75 mg daily on hold, Synthroid 150 mcg daily
with additional 75 mcg on Wednesdays, temazepam 30 mg p.o. at
bedtime, Estrace cream every other day, vitamin D 1000 units
daily, calcium 600 mg p.o. b.i.d.
PHYSICAL EXAMINATION: GENERAL: Well-appearing female, no
acute distress. Performance status 1. VITAL SIGNS: 96 9, 78,
20, 142/70, O2 sat 96% on room air. HEENT: Normocephalic,
atraumatic. Sclerae anicteric. Moist oral mucosa with areas
of erythema on her bilateral lower mandible. NECK: Supple.
Lymph nodes. No cervical, supraclavicular or bilateral
axillary lymphadenopathy. HEART: Regular rate and rhythm,
S1, S2. CHEST: Clear bilaterally. ABDOMEN: Rounded, soft,
nontender, no HSM or masses. EXTREMITIES: No edema.
NEUROLOGIC: Exam nonfocal. SKIN: Right upper quadrant right
breast scars are well-healed.
LAB RESULTS: White blood count 6.4, hemoglobin 12.8,
hematocrit 37.1, platelet count 274,000, INR 1, BUN 16,
creatinine 1, sodium 140, potassium 4.3, chloride 105, CO2
26, glucose 111, ALT 64, AST 54, LDH 209, CK 119, total bili
0.3, albumin 4.0.
HOSPITAL COURSE: Ms. [**Known lastname 84593**] was admitted and underwent
central line placement to begin therapy. Her admission weight
was 91 kg and she received interleukin-2, 600,000 units per
kg based on adjusted ideal body weight, equaling 40.1
milliunits IV every 8 hours x14 potential doses. During this
week she received of [**11-9**] doses, with 2 doses held due to
development of shock on day 5, and 2 doses held due to
fatigue on days 4 and 5. Side effects during this week
included diarrhea improved with antiemetic therapy; mild
nausea improved with Ativan; an erythematous pruritic skin
rash; mucositis and fatigue.
On treatment day #5, after her 10th dose of IL-2, she became
hypotensive and was placed on dopamine to a max of 6 mcg per
kilogram per minute. At that time her blood pressure was in
the high 50s. She was placed in Trendelenburg with Neo-
Synephrine added and titrated up to 3.5 mcg of Neo with
continued hypotension. She was given a liter of normal
saline. She initially stabilized with blood pressure in the
high 90 to low 100s, and then again developed hypotension to
the 70-80 range with additional IV fluids given. She was
hypoxic to the 80s requiring non-rebreather, and there was
concern for pulmonary edema given recent IL-2 dosing,
capillary leak and fluid boluses. She was also noted to be
lethargic with difficulty staying awake. Decision was made to
transfer her to the ICU, given maximum Neo and dopamine
dosing currently on the floor, with associated hypoxia and
lethargy concerning for CO2 retention. She was transferred to
the unit where she improved from a mental status perspective.
She was slowly weaned off vasopressor therapy and was
transferred out of the unit the following day doing well. Her
hypoxia improved and she was treated with Lasix on treatment
day #6 once her systolic blood pressure stabilized. She had
no further hypotension throughout her hospitalization.
During this week she developed acute renal failure with a
peak creatinine of 3.3 improved to 2.9 at the time of
discharge. She had associated oliguria and metabolic acidosis
with a minimum bicarb of 18 improved with bicarbonate
replacement intravenously. Electrolytes were monitored and
repleted per protocol. Strict I's and O's, serum chemistries
were maintained. Intravenous fluids were initially continued
at maintenance and increased when she developed hypotension.
During this week she developed transaminitis with a peak ALT
of 55 and a peak AST of 71, both improved at the time of
discharge. She developed hyperbilirubinemia with a peak
bilirubin of 3.2, improved to 1.9 at the time of discharge.
She was anemic without need for packed red blood cell
transfusion. She developed thrombocytopenia with a platelet
count low of 103,000 without evidence of bleeding. She had no
coagulopathy or myocarditis noted. By [**2141-1-8**], she had
recovered from side effects to allow for discharge to home.
CONDITION ON DISCHARGE: Alert, oriented and ambulatory.
DISCHARGE STATUS: To home with her husband.
DISCHARGE DIAGNOSIS: Metastatic renal cell carcinoma -
status post cycle 1, week 1, high-dose IL-2 complicated by
shock, pulmonary edema and acute renal failure.
DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily x5 days or
until you reach pretreatment weight, Tylenol 1-2 tablets
q.i.d. p.r.n. fever or pain, Zantac 150 mg p.o. b.i.d. p.r.n.
indigestion, lorazepam 0.5 mg t.i.d. p.r.n. nausea/vomiting,
Benadryl 25-50 mg q.i.d. p.r.n. pruritus, Compazine 10 mg
t.i.d. p.r.n. nausea/vomiting, Keflex 500 mg p.o. b.i.d. x5
days, Lomotil 1-2 tabs q.i.d. p.r.n. diarrhea, Eucerin cream
topically, Sarna lotion topically, levothyroxine 750 mcg p.o.
daily, venlafaxine 37.5 mg p.o. daily, Gelclair 15 ml t.i.d.
p.r.n. mucositis, Nystatin 5 ml p.o. q.i.d. p.r.n. thrush,
Percocet 1-2 tablets t.i.d. p.r.n. pain.
FOLLOWUP PLANS: Ms. [**Known lastname 84593**] will return in 1 week for week
number 2 of therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 7782**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2141-2-22**] 16:20:11
T: [**2141-2-23**] 15:05:46
Job#: [**Job Number 84594**]
|
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icd9cm
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[
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[
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icd9pcs
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6712, 7701
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57,911
| 143,222
|
30188
|
Discharge summary
|
report
|
Admission Date: [**2140-6-3**] Discharge Date: [**2140-6-9**]
Date of Birth: [**2067-7-29**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
fever, AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 72 yo M history of CHF (EF 20%), DMII, CAD s/p PTCA,
PVD s/p graft and protein S deficiency with multiple PE's s/p
IVC filter on Coumadin now here for fever and AMS. Pt's family
noticed that he was "acting weird" and "talking nonsense" at
home and he had fever to 103. Pt has history of recurrent UTIs,
was recently in hospital in [**3-/2140**] for MRSA bacteremia and E
coli UTI. Pt appearently has AMS when he has UTIs in past.
In the ED, initial VS were T 101 HR 70 BP 130/88 RR 20 O2 sat
98%. On exam, pt was noted to have new onset RLE warmth, edema,
appears cellulitic. There was low suspicion for necrotizing
fascitis. AMS resolved on arrival here, pt was noted to be
AAOx3. Dopplers showed good bilat pulses. Labs were remarkable
for WBC 11.3, 92% neutrophils. Cr was at baseline at 2.0. ALT
and AST slightly elevated at 41 and 53, respectively. Lactate
was 1.8. CXR, urine were neg. Pt was given Vanc/Ceftaz for
broad coverage for cellulitis. BPs were in mid 90s to low 80s
but never tachycardic. Pt reports hypoTN to 80s is normal for
him [**2-18**] home regimen. Pt was also given Tylenol 1000mg PO for
fever. Pt was given IVF 500cc x2, as well as another 500cc with
antibiotics. On transfer, VS were T 100.4, HR 87, BP 92/57, RR
14, O2 sat 96 on 3L.
.
On arrival to the MICU, pt is lying comfortably in bed, has no
complaints excepts chills. Not in any pain. Denies cough,
shortness of breath, chest pain, abdominal pain, diarrhea,
dysuria. Endorses vomiting x1 earlier today before coming to
the ED. Denies bloody stools. Did fall few days ago and
bruised left side of body. Did not hit his head. Denies
dizziness, fainting. Endorses normal appetite and good PO
intake.
Past Medical History:
1. Hypercoagulable syndrome. He is status post IVC filter.
2. Protein S deficiency.
3. Multiple pulmonary emboli.
4. Type 2 diabetes.
5. Hypertension.
6. Two-vessel coronary artery disease with PTCA to the left
circumflex on [**2138-5-17**].
7. Severe peripheral artery disease with diabetic ulcer and
revascularization of rt leg in [**2135**]
8. Cardiomyopathy with LVEF of 20%. His most recent echo on
[**2138-10-13**].
9. History of upper GI bleeding, no reports in our system.
10. He is status post ICD placement in [**2138-12-17**].
11. [**3-28**] MRSA bacterimia s/p vancomycin x1 month
12. CKD with baseline 2.0
Social History:
Former mechanic. Lives with his wife and daughter in [**Name (NI) 392**].
Independent of basic ADL's and ambulates with cane/ walker.
Denies tobacco. Former heavy EtOH, quit 25 yrs ago. Denies
illicits.
Family History:
No known family history of recurrent UTI. Mother with DM. Father
died of Alzheimer's disease.
Physical Exam:
Physical Exam
Alert, oriented, no acute distress, shivering
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: R leg with redness, induration and warmth up to knee,
posterior are of left thigh with ecchymosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
admission labs:
[**2140-6-3**] 09:10PM BLOOD WBC-11.3*# RBC-3.50* Hgb-11.2* Hct-35.1*
MCV-101* MCH-32.1* MCHC-32.0 RDW-18.0* Plt Ct-168
[**2140-6-3**] 09:10PM BLOOD Neuts-92.4* Lymphs-4.6* Monos-2.3 Eos-0.5
Baso-0.2
[**2140-6-4**] 04:33AM BLOOD PT-17.5* PTT-34.4 INR(PT)-1.6*
[**2140-6-3**] 09:10PM BLOOD Glucose-231* UreaN-33* Creat-2.0* Na-134
K-5.0 Cl-102 HCO3-18* AnGap-19
[**2140-6-3**] 09:10PM BLOOD ALT-41* AST-53* AlkPhos-126 TotBili-0.5
[**2140-6-3**] 09:10PM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.5* Mg-1.8
[**2140-6-3**] 09:27PM BLOOD Lactate-1.8
.
urine
[**2140-6-3**] 10:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2140-6-3**] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
micro
URINE CULTURE (Final [**2140-6-4**]): <10,000 organisms/ml
Blood Culture, Routine (Final [**2140-6-9**]): NO GROWTH
Blood Culture, Routine (Final [**2140-6-9**]): NO GROWTH.
imaging
CXR
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The patient is
status post left-sided dual-chamber pacemaker with leads
terminating in the right atrium and right ventricle, in
unchanged positions. There is moderate cardiomegaly which is
stable. The aorta is tortuous. The pulmonary vascularity is
normal without edema. Calcified bilateral pleural plaques are
redemonstrated. Lungs are clear without focal consolidation.
No pleural effusion or pneumothorax is present. Degenerative
changes of the right glenohumeral and acromioclavicular joint
are noted, with narrowing of the right subacromial space
compatible with underlying rotator cuff disease.
IMPRESSION: No acute cardiopulmonary abnormality. Bilateral
calcified
pleural plaques.
Brief Hospital Course:
This is a 72 yo M history of CHF (EF 20%), DM, CAD s/p PTCA, and
protein S deficiency with multiple PE's s/p IVC filter on
Coumadin now admitted for fever, likely [**2-18**] cellulitis.
.
# Hypotension: Patient found to be hypotensive with systolics
in the 80s-90s in the emergency department however not
tachycardic. Differential included sepsis in setting of active
infection vs cardiac etiology, given h/o CHF. On review of
prior outpatient records, patient does appear to have lowish BPs
so this could be his baseline. Patient had no signs of bleed. On
arrival to the MICU, his were in normal range. He was continued
on the vanc/ceftaz started in the ED for cellulitis. His home
antihypertensives were held. Blood pressures fell into the 70s
for a period of time which improved without intervention into
the 80s-90s and then 100s overnight. His baseline SBPs range in
the mid 90s. He remained asymptomatic and otherwise
hemodynamically stable. Metoprolol was restarted prior to
discharge.
# Fever/RLE cellulitis: Patient was started on vancomycin and
ceftaz in the ED which were continued during his MICU stay. He
completed a 7 day course of antibiotics on the floor and his
erythema and warmth in the RLE resolved.
# Gout: continued Allopurinol
# Hypothyroidism: continued Levothyroxine
# HTN/CAD: continued Simvastatin, ASA. His metoprolol and
lisinopril were initially held in the setting of hypotension and
concern for possible sepsis.
# Chronic systolic CHF (EF 20%): The pt arrived to the hospital
significantly above his dry wt after going a significant period
of time as an out patient without diuretic meds. We initially
diuresed this pt with 40mg of IV lasix daily to which his UOP
responded appropriately. He was then transitioned to 20mg of PO
torsemide as an outpt and a follow up appointment was arranged
with the heart failure clinic. His creating was mildly elevated
from his baseline on discharge and we held his lisinopril until
his kidney function was rechecked at follow up appointments.
# DMII: HbA1C 8.0 on [**2140-5-21**]. He was continued on his home lantus
and insulin sliding scale while in house.
# h/o VT: continued home Amiodarone
# Insomnia: continued home Amitriptyline, Diazepam
# Protein S deficiency: On arrival to the ED his INR was sub
therapeutic. He was started on heparin gtt for anticoagulation
while his warfarin dose was up titrated. On discharge his INR
was 1.7. He was started on Enoxaparin [**Hospital1 **] until his INR reached
a therapeutic range. Pt was also instructed to continue to
overlap enoxaparin with warfarin for 24 hrs after reaching a
therapeutic INR.
#Transitional:
1. Lisinopril was held at discharge to be restarted once kidney
function is back to baseline
2. repeat INR should be followed up and LMWH should be
discontinued 24 hrs after achieving therapeutic INR
3. F/u appointments arranged with pcp and cardiology
Medications on Admission:
1. Allopurinol 100 mg PO daily
2. Amiodarone 200 mg PO daily
3. Amitriptyline 200 mg PO QHS
4. Diazepam 10 mg PO QHS PRN insomnia
5. Levothyroxine 50 mcg PO daily
6. Lisinopril 2.5 mg PO daily
7. Simvastatin 10 mg PO daily
8. Aspirin 81 mg PO daily
9. Docusate sodium 100 mg PO BID PRN constipation
10. Lactobacilli acidophilus (bulk)
11. Warfarin 5 mg 5x/week, 2.5mg on Mon and Thurs
12. Lantus 20 units SC QHS
13. Metoprolol succinate 25 mg PO daily
14. Insulin Regular Human 10 units SC QAM and 6 units SC QPM
15. Percocet 5-325 mg PO Q6H PRN pain
16. Lasix 20mg daily
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please continue this dose until you follow up with with Dr. [**Name (NI) 10875**] office.
Disp:*60 Tablet(s)* Refills:*0*
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred-Ten (110)
mg Subcutaneous Q12H (every 12 hours): You should continue
taking this until isntructed not to do so by your
[**Hospital3 **].
Disp:*30 mL* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Please monitor your INR and discuss further dose
adjustments with your [**Hospital3 **].
Disp:*90 Tablet(s)* Refills:*0*
12. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
13. insulin regular human 100 unit/mL Solution Sig: Ten (10)
units Injection qAM.
14. insulin regular human 100 unit/mL Solution Sig: Six (6)
units Injection qPM.
15. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
16. lactobacillus acidophilus Oral
17. diazepam 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
18. Outpatient Lab Work
Please draw labs on [**2140-6-13**] for electrolytes, BUN, creatinine.
Please fax results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 71936**]
Diagnosis: Acute on chronic systolic congestive heart failure
428.23
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
Cellulitis
Congestive Heart Failure Exacerbation
Secondary diagnosis:
Diabetes mellitus
Hypertension
Protein S deficiency
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with fevers,
confusion and weight gain. We discovered you had an infection in
your right leg that we treated with antibiotics. We also
increased your dose of diurectic medication as well to remove
the excess fluid from your body. It is important that you Weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
Please call your [**Hospital3 **] in [**Location (un) 38**] to arrange
for follow up and your next INR check. You should continue your
enoxparin injections for 24 hours AFTER your INR is in the
therapeutic range, then discontinue the enoxaparin.
The following changes have been made to your medications:
-Please START enoxaparin injections, 110 mg subcutaneous
injections, twice a day
-Please STOP furosemide
-Please START torsemide 20 mg daily for fluid removal. If you
feel lightheaded or dizzy, please call Dr.[**Name (NI) 3536**] office to
discuss dose adjustments.
-Please STOP your lisinopril until you follow up with Dr. [**Name (NI) 10875**] office
-Please INCREASE your warfarin dose to 6 mg daily, every day.
You should discuss further dose adjustments with your
[**Hospital3 **]
Please see below for follow up appointments that have been made
on your behalf
Followup Instructions:
Name: [**Name6 (MD) **] [**Name8 (MD) 36023**], MD
Location: [**Location (un) 2274**]-[**Location (un) **]
When: Tuesday [**6-14**] at 1:30
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 36024**]
Department: CARDIAC SERVICES
When: MONDAY [**2140-6-20**] at 10:30 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2140-8-24**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"682.7",
"403.90",
"780.61",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10908, 10965
|
5382, 8280
|
301, 308
|
11174, 11174
|
3636, 3636
|
12721, 13596
|
2936, 3033
|
8903, 10885
|
10986, 10986
|
8306, 8880
|
11357, 12698
|
3048, 3617
|
251, 263
|
336, 2046
|
11076, 11153
|
3652, 5359
|
11005, 11055
|
11189, 11333
|
2068, 2700
|
2716, 2920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,884
| 176,925
|
15791
|
Discharge summary
|
report
|
Admission Date: [**2108-10-16**] Discharge Date: [**2108-11-26**]
Date of Birth: [**2035-8-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: On presentatio the patient is an
80 year-old woman found to be in an motor vehicle accident.
She is a restrained driver versus a brick wall. She is awake
and confused at the scene and became obtunded, intubated by
EMS, arrived to [**Hospital1 69**] in
collar, intubated. GCS of 3. Initial systolic blood
pressure of 74, decreased breath sounds on left, left chest
tube was placed. Initial attempt went to the abdomen.
Repeat systolic blood pressure 110, heart rate 78. Chest
x-ray of pelvis. X-ray done, access was obtained,
laboratories sent, Foley and G tube placed, to the Operating
Room for emergent laparotomy. In the Operating Room
difficult to ventilate with decreased systolic blood
pressures. Right chest tube was placed with initial return
of 200 cc of blood.
PHYSICAL EXAMINATION: Intubated, C collar, GCS of 3,
temperature 35.5, heart rate 78, blood pressure 70/palp.
HEENT trachea midline. No JVD. Chest stable. Clear to
auscultation bilaterally. Decreased breath sounds on the
left. Heart regular rate and rhythm. Abdomen soft,
nondistended, positive bowel sounds. FAST examination
negative. Pelvis stable. Extremities no obvious
deformities. Good capillary refill. Back had no step offs.
LABORATORY: White blood cell count 12.2, hematocrit 36.0,
platelets 305, PT 13.9, PTT 33.4, INR 1.3, amylase 69, sodium
138, potassium 4.0, chloride 104, glucose 269. Initial
arterial blood gas 7.08, 91, 72, 29, lactate 4.4, tox screen
was negative. Pelvis x-ray negative for fracture. Chest
x-ray was rotated.
HOSPITAL COURSE: The patient was taken to the Operating Room
for emergent exploratory laparotomy. At the laparotomy the
patient was found to have decreased blood pressure and O2
saturations and increased difficulty of ventilation. A right
chest tube was placed at 200 cc of return of blood. No
obvious abdominal injury on laparotomy. Pericardial window
was performed with drainage of blood. Sternotomy performed.
Cardiothoracic surgery scrubbed for emergent intraop consult
and was found a right atrial tear times three and multiple
right lung lacerations. The laparotomy was performed
initially with suspected left diaphragmatic injury following
low left chest tube placement and hemodynamic instability.
There was no hemoperitoneum found and the patient remained
hypotensive despite volume resuscitation. Right chest tube
was inserted with only 200 cc output. A pericardial window
resulted in diagnosis of tamponade and ongoing pericardial
bleeding. Sternotomy was performed and found massive right
hemothorax, multiple perforations of right atrium. The
incision was extended into the right chest. Dr. [**Last Name (STitle) 70**]
and Dr. [**Last Name (STitle) 519**] then placed her on cardiopulmonary bypass and
primary repair of the atrium and multiple staplings and
oversewing of the right lung parenchyma were performed.
Unable to close any of her wounds primarily. Estimated blood
loss was 5000 cc. The patient received 20 units of red blood
cells, 11 units of fresh frozen platelets, 7 units of
platelets, 2 units of cryoprecipitate, 13,000 cc of
crystalloid with a urine output of 600 cc during the case.
The patient was taken intubated to the Intensive Care Unit in
critical condition. The patient on postoperative day one
required multiple blood products including the Operating [**Apartment Address(1) 45455**] units of blood as well as fresh frozen plasma. She was
maintained on pressors including epi and Levophed as well as
neo. She was covered empirically with Cefuroxime for
potential abdominal and chest infection. Over the next few
days the patient was slowly weaned off of her pressors. She
remained intubated with chest tubes in place. She had an
ophthalmology consult for diffuse orbital swelling. They
recommended eye drops, which were started with no evidence of
ocular trauma found. The patient continued to slowly wean
off of her pressors. By postoperative day number three she
was on smaller amounts of pressors and she was not requiring
any further transfusions. She continued to slowly progress
and on postoperative day number four she went back to the
Operating Room for closure. On the [**12-21**] she
underwent exploratory laparotomy, wash out, partial facial
closure of her abdomen and skin closure of her abdomen. The
thorax was explored and her sternotomy wound was also closed.
She tolerated this relatively well and she continued to wean
off of her pressors over the next few days.
She went back to the Operating Room two days later for
complete closure of her abdomen on the 18th, which she
tolerated well. She was recultured and antibiotics were
again continued. She remained on Cefuroxime. She continued
to slowly wean off her pressors and improved slowly. She had
a negative CT of her head and her C spine. She was started
on Vancomycin for sputum cultures with staph coag positive
from a bronch, which she underwent for worsening chest x-rays
as well as sputum on the 20th. It showed mild secretions
nonpurulent. She continued to slowly improve. Neurosurgery
followed her and there were no acute changes with her
neurological status. She also underwent CT scan with
reconstruction of her TLS, which was done. Plain films
showed a question of a T12 anterior wedge compression
fracture. The patient continued to slowly improve. CT of
her C spine showed compression fractures of T8 through 11.
Her head showed right subdural hematoma, parietal
subarachnoid and a pansinusitis. ENT was consulted for this.
ORL or ENT saw her and recommended maxillary of facial CT for
facial fractures and for nasal spray, which she was started
on. The patient continued to improve and neurosurgery
followed her for her head bleeds. She was treated for
sinusitis. Lines were changed. Chest x-rays were followed.
The patient continued to decrease her pressor requirements.
She slowly improved over the next few weeks.
Other events, neurosurgery noted that her thoracic
compression fractures were probably old and there was no
brace needed. In terms of her neurological examination she
had follow up head CTs with no worsening and they did not
require any further treatment. The patient continued to
improve and infectious disease saw the patient and they
started Vancomycin and continued some Zosyn and she was pan
cultured intermittently for fevers. OMSF saw the patient on
the 24th for a left subcondylar fracture. She had a repeat
CT including all of the mandible and they did not recommend
treatment of the let subcondylar fracture and that was their
recommendation. Furthermore she slowly improved and she was
weaning slowly each day off the Levophed drip and was also at
this point in her course. By CICU day 15 she continued to
improve and was noted to be completely off of all pressors.
Her cultures were growing staph aureus and hip cultures were
negative. She was continued on Zosyn and Vancomycin for a
full course. The patient continued to improve and by the end
of [**Month (only) **] she ended up continuing to do well, but slowly
weaning from the vent. It was clear that she did well on
pressor support, but was not ready to be extubated and she
would require full pressor support wean. On [**11-14**] she
underwent a percutaneous tracheostomy without complications.
She was tolerating tube feeds with a nasogastric feeding
tube. She remained with that. By postoperative day thirty,
twenty six and thirteen the patient continued to do well.
She was intermittently diuresed over the prior two weeks
slowly with bouts of hypotension when the diuresis was too
aggressive. Therefore she was started on po Lasix down her
nasogastric tube and it was decided that she would undergo a
percutaneous placement of a J tube or a PEG, which was done
in interventional radiology in mid [**Month (only) 1096**], which she
tolerated well. She is continuing to wean her pressor
support down to 10, PEEP of 7.5 and does well with this with
only occasional episodes of desaturation, very sporadically
if she has a plug has to be placed on a rate for a short time
and then return to her pressor support wean. Her central
lines were removed. A PICC was placed in interventional
radiology, which is her main access and she continues to do
well on pressor support wean and a slow diuresis with 60 po
Lasix b.i.d.
Now she is currently postop day forty one, thirty seven and
twenty four from her original thoracotomy, laparotomy and
closures, status post her motor vehicle accident with right
atrial tear, pneumothoraces, subarachnoid and subdural
hemorrhages and adult respiratory distress syndrome and is
doing well on the following setting, 50% FIO2, PEEP of 7.5,
pressure support of 10. Her current medications are
Amiodarone, Neutrophos, heparin subQ, NPH, sliding scale
insulin, Lasix 60 mg b.i.d., Fluconazole and Fentanyl prn.
She is on Promote tube feeds at 85 cc an hour. Her current
doses of her medications are Fluconazole 200 mg per PEG q 24
hours times four days, she is currently day two of four.
Furosemide 60 mg per PEG b.i.d., potassium chloride 4
milliequivalents in 100 milliliters per K of less then 4.0,
Fentanyl 10 to 25 mg intravenous q 4 hours prn,
_______________ 2 to 4 mg intravenous q 6 hours prn,
Simethicone 40 to 80 mg po q.i.d. prn, Amiodarone 200 mg po q
day, morphine 2 to 8 mg intravenous q one hour prn,
Neutrophos one packet po t.i.d. hold for phosphorus greater
then 3.5, Albuterol 6 to 10 puffs inhaler q 2 hours prn. NPH
10 units q 12 hours. She gets regular sliding scale insulin,
which is given for 120 to 160 2 units, 160 to 200 4 units,
200 to 240 6 units, 240 to 280 8 units, 280 to 320 10 units,
greater then 300 12 units. Heparin 5000 units subQ q 12
hours, Miconazole powder 2% applied q.i.d. prn to effected
areas, calcium gluconate 2 grams intravenous for calcium less
then 1.1 ionized, magnesium sulfate 2 grams per intravenous
prn magnesium less then 1.5, Lacrilube ointment applied each
eye prn. Promote at 85 cc an hour per her PEG tube.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (STitle) 45456**]
MEDQUIST36
D: [**2108-11-26**] 12:14
T: [**2108-11-26**] 12:28
JOB#: [**Job Number 19685**]
|
[
"518.82",
"276.6",
"852.00",
"861.00",
"852.20",
"E815.0",
"427.31",
"423.9",
"860.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"34.09",
"39.61",
"99.15",
"54.62",
"88.72",
"34.72",
"37.4",
"96.72",
"31.1",
"42.23",
"78.41",
"77.31"
] |
icd9pcs
|
[
[
[]
]
] |
1720, 10452
|
964, 1702
|
162, 941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,514
| 142,207
|
2003
|
Discharge summary
|
report
|
Admission Date: [**2108-10-18**] Discharge Date: [**2108-11-6**]
Date of Birth: [**2047-9-9**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
1.Cardiac catheterization with Bare Metal Stent placement to LAD
2.Intubation for respiratory distress associated with acute
pulmonary edema
3.Right IJ line placement for central venous access
History of Present Illness:
Mr. [**Known lastname 10983**] is a 61 year-old man with a PMH significant for HTN
who presented to the ED on [**2108-10-18**] at 3AM complaining of
progressively worse chest and abdominal pain for >1 day. He was
unable to give a complete history as he was in extreme pain and
discomfort. He described having increased sensation of pressure
on his sternum and he also had shortness of breath which was
worse when sitting vs. standing.
.
In the ED Mr. [**Known lastname 11013**] initial vital signs were BP of
150-190/100-136, HR ranged 120-140, and RR=19-25. IV
nitroglycerin was started and the patient was ruled out for an
aortic dissection with a CT torso. The patient was in
respiratory distress for presumed acute pulmonary edema as
evidenced on CT. He was intubated for airway protection. An EKG
showed rate 109, NSR, with a left axis deviation and ST
elevations in V3 and V5. CK cardiac enzymes were flat. He
received ASA, eptifibitide drip, clopidogrel load of 600 mg, a
heparin bolus and a code STEMI was called.
.
He was transferred emergently to the cardiac catheterization lab
where he was found to have an occluded LAD distal to D1, into
which a BMS was placed. He recieved 40mg of IV furosemide and
started bicarbonate IVF at 125cc/hr.
On CCU admission the team was unable to take a full ROS as the
patient was intubated and sedated, however, the patient's last
discharge summary indicated recent complaints of nausea,
vomiting, diarrhea and chronic lower back pain.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, history of smoking
2. CARDIAC HISTORY: None
3. OTHER PAST MEDICAL HISTORY:
# Malignant Hypertension: thought to be secondary to medication
non-compliance
# Pulmonary Embolus: Recurrent [**Known lastname 11011**] s/p IVC filter, recent admit
for PE 11/[**2107**]. Not anticoagulated due to poor compliance and
followup.
# Heroin abuse: methadone maintenance clinic Habit Management;
per pt, quit 20 yrs ago
# Hepatitis B previous infection, now sAg negative
# Hepatitis C, undetectable HCV RNA [**3-29**]
# Chronic obstructive pulmonary disease
# Gastroesophageal reflux disease
# PTSD ([**Country 3992**] veteran)
# Anxiety / Depression
# Antisocial personality disorder
# Microcytic anemia
# Vitamin B12 deficiency
# Chronic kidney disease baseline Cr 1.5
Social History:
Intermittently lives with friends in [**Name (NI) 4288**] MA, but currently
homeless. He smokes one pack of cigarettes per week, with a 10
year smoking history. Former heroin user but states he quit 20
years ago and is now maintained with methadone. The patient is
on disability and he has Mass Health for insurance. No recent
illicits per patient. He states that his girlfriend of 17 years
died last month after an acute heart attack and he has been very
upset and grieving since this event.
Family History:
Father died of an MI, unknown age; mother died of pancreatic
cancer. Patient unable to elaborate on details of father's
cardiac history.
Physical Exam:
Admission Physical Exam:
VS: T=97.6F, BP=143/102, HR=95, Ventilator: AC mode 600/18,
tidal volumes of 800, with a PEEP of 5 and an FiO2 of 100%
GENERAL: Intubated, sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: Regular rhythm, normal rate, no audible murmurs
LUNGS: diffuse bilateral inspiratory and expiratory wheezes.
Prominent bibasilar inspiratory crackles.
ABDOMEN: Soft, wincing with deep palpation.
EXTREMITIES: No cyanosis or edema. 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:
LABS AT ADMISSION:
.
[**2108-10-18**] 12:20PM HCT-23.6*
[**2108-10-18**] 11:42AM TYPE-ART PO2-78* PCO2-38 PH-7.45 TOTAL CO2-27
BASE XS-2
[**2108-10-18**] 11:13AM CK(CPK)-66
[**2108-10-18**] 11:13AM CK-MB-NotDone cTropnT-0.58*
[**2108-10-18**] 11:11AM GLUCOSE-73 UREA N-21* CREAT-1.3* SODIUM-142
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
[**2108-10-18**] 11:11AM ALT(SGPT)-9 AST(SGOT)-13 LD(LDH)-245 ALK
PHOS-85 AMYLASE-103* TOT BILI-0.2
[**2108-10-18**] 11:11AM LIPASE-12
[**2108-10-18**] 11:11AM ALBUMIN-3.2* CALCIUM-8.1* PHOSPHATE-3.4
MAGNESIUM-1.5* URIC ACID-6.6
[**2108-10-18**] 11:11AM TSH-3.6
[**2108-10-18**] 11:11AM WBC-4.7 RBC-2.95* HGB-8.0* HCT-24.4* MCV-83
MCH-27.1 MCHC-32.7 RDW-14.8
[**2108-10-18**] 11:11AM PLT COUNT-214
[**2108-10-18**] 11:11AM PT-15.1* PTT-31.1 INR(PT)-1.3*
[**2108-10-18**] 06:55AM GLUCOSE-175* LACTATE-1.2
[**2108-10-18**] 06:55AM O2 SAT-98
[**2108-10-18**] 06:55AM freeCa-1.14
[**2108-10-18**] 04:51AM GLUCOSE-253* K+-4.4
[**2108-10-18**] 04:51AM HGB-9.6* calcHCT-29 O2 SAT-96
[**2108-10-18**] 03:10AM GLUCOSE-111* UREA N-24* CREAT-1.3* SODIUM-140
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
[**2108-10-18**] 03:10AM estGFR-Using this
[**2108-10-18**] 03:10AM CK(CPK)-76
[**2108-10-18**] 03:10AM cTropnT-0.66*
[**2108-10-18**] 03:10AM CALCIUM-9.4 PHOSPHATE-3.6
[**2108-10-18**] 03:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-10-18**] 03:10AM WBC-9.2# RBC-3.47* HGB-9.3* HCT-29.2* MCV-84
MCH-26.9* MCHC-32.0 RDW-14.9
[**2108-10-18**] 03:10AM NEUTS-84.5* LYMPHS-12.4* MONOS-2.1 EOS-0.7
BASOS-0.3
[**2108-10-18**] 03:10AM PT-14.7* PTT-32.2 INR(PT)-1.3*
[**2108-10-18**] 03:10AM PLT COUNT-286
[**2108-10-18**] 03:10AM FIBRINOGE-465*
[**2108-10-18**]:ABG 7.28/51/152/25
[**2108-10-19**] 04:20AM BLOOD %HbA1c-5.4
[**2108-10-19**] 04:20AM BLOOD Triglyc-113 HDL-35 CHOL/HD-4.5 LDLcalc-99
LDLmeas-97
ADDITIONAL STUDIES AND LABS:
[**2108-10-18**] troponin .66 and later [**2108-10-27**] troponin was 0.24
[**2108-10-18**] and [**2108-10-19**] Sputum Cultures - negative for any
microorganisms
.
CARDIAC CATHETERIZATION ([**2108-10-18**]):
Selective coronary angiography of this right dominant system
revealed single vessel coronary artery disease. The LMCA was
normal. The LAD was occluded after D1 with collaterals from the
RCA. The LCX and RCA had minimal disease. Successful PTCA,
thrombectomy and stenting of the proximal LAD (distal to the
first diagonal) with a Driver (3x30mm) bare metal stent
postdilated with a 3.0mm balloon. Final angiography
demonstrated no angiographically apparent dissection, no
residual stenosis and TIMI III flow throughout the vessel (See
PTCA comments).
Successful closure of the right femoral arteriotomy site with a
6F Mynx closure device. Limited resting hemodynamics revealed
systemic arterial hypertension with BP 152/106. Primary PCI was
delayed due to the patient requiring emergent intubation in the
emergency department for acute pulmonary edema. FINAL DIAGNOSIS:
One vessel coronary artery disease.
Acute anterior myocardial infarction managed by acute PTCA,
thrombectomy and stenting of the proximal left anterior
descending artery with a bare metal stent. Primary PCI delayed
due to emergent intubation for acute pulmonary edema. Successful
closure of the right femoral arteritomy site with a 6F Mynx
closure device.
CTA CHEST/ABD/PELVIS ([**2108-10-18**]):
CTA OF THE CHEST: No acute aortic pathology including no
dissection. No filling defect in the main pulmonary arteries to
suggest embolism. Nonenhancing region in the anteroapical
portion of the left ventricle is compatible with infarction.
Small bilateral pleural effusions and mild pericardial effusion.
Both lungs demonstrate diffuse thickening of interstitial
marking and consolidative changes compatible with moderate
pulmonary edema, which in some region also has nodular
appearance.
CTA OF THE ABDOMEN: The liver, spleen, gallbladder, adrenal
glands, kidneys, stomach, duodenum and loops of small bowel and
large bowel appear
unremarkable. The aorta is normal in diameter throughout its
course with no acute pathology. The common iliac artery and
their branches are also well opacified. The administered
contrast refluxes back into the IVC and hepatic veins,
compatible with the patient's diagnosis of heart failure. The
IVC filter is in place. No pathologically enlarged nodes in the
abdomen. No free air or fluid in the abdomen.
BONE WINDOWS: Severe compression deformity of the L1 vertebral
body with
retropulsion of bony fragments into the canal and acute kyphotic
angulation is unchanged in comparison to [**2107-8-22**]. Also
noted is loss of height of the superior endplates of the T9 and
L3 vertebral bodies, nchanged. There are degenerative changes of
the lumbar facet joints.
IMPRESSION: No acute aortic pathology and no pulmonary embolism.
Acute myocardial infarction involving antero-apical heart area.
Moderate heart failure and small bilateral pleural effusions.
Unchanged compression fractures of the thoracic and lumbar
spine.
..
TRANSTHORACIC ECHOCARDIOGRAM ([**2108-10-19**]):
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. A large apical
thrombus is seen in the left ventricle. The clot is mural and
not mobile. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary of severe
hypokinesis of the anterior septum and anterior free wall. There
is extensive apical hypokinesis with dyskinesis of the true
apex. Tissue doppler imaging suggests a normal left ventricular
filling pressure(PCWP<12mmHg). There is no ventricular septal
defect. Right ventricular chamber size is normal. with focal
hypokinesis of the apical free wall. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the findings of
the prior study (images reviewed) of [**2108-9-26**], extensive
anteroapical infarct now evident, with apical thrombus.
IMPRESSION: extensive anteroapical myocardial infarct with a
large apical mural thrombus.
[**2108-10-24**] CXR : Preliminary report indicates resolution of prior
parenchymal opacities, no pleural effusions or infiltrates. No
cardiomegaly. Mild basilar bronchial thickening as noted in
prior CXR studies still present.
[**2108-10-26**] CT HEAD: No evidence of acute intracranial hemorrhage
or major territorial infarction. MRI is more sensitive for
evaluation of acute infarction.
[**2108-10-26**] CT ABD/PELVIS :
1. No evidence of retroperitoneal bleeding/hematoma.
2. IVC filter at the infrarenal vein position with evidence of
collateral
venous varice formation.
3. Unchanged deformity in L1 and L3 vertebral bodies.
4. Unchanged marked underlying degenerative diseases.
[**2108-10-28**] Right Femoral Vascular Ultrasound:
1. Complete thrombosis of the right common femoral vein
extending into the
right popliteal and upper calf veins.
2. No pseudoaneurysm and no arteriovenous fistula.
[**2108-10-28**] EKG: Normal sinus rhythm with prominent T wave
inversions in the precordial leads with Q waves in leads V1-V2
suggestive of anterior ischemia/infarction. Q-T interval
prolongation with intraventricular conduction delay. Compared to
the previous tracing of [**2108-10-26**] the T wave abnormalities are
more prominent in the precordial leads.
[**2108-11-1**] EKG : Normal sinus rhythm with intraventricular
conduction defect of the left bundle-branch block variety.
Prominent T waves in the anterior
leads consistent with probable evolving anterior myocardial
infarction.
T wave inversions are also noted in the inferior leads.
[**2108-11-1**] 06:10AM BLOOD Mg-2.4 Iron-33*
[**2108-11-1**] 06:10AM BLOOD calTIBC-270 Hapto-110 Ferritn-192 TRF-208
[**2108-11-1**] : WBC 5.1, Hgb 8.9, Hct 26.6, Plts 245
PT 27.3, INR 2.7 , Na 139, K 3.9, Cl 101, HCO3 31,BUN
20,
Cr 1.2, Glucose 81, Ca 8.8, Mg 2.4, Phos 3.9
[**2108-11-3**] 05:12AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.1* Hct-26.5*
MCV-82 MCH-28.2 MCHC-34.5 RDW-15.8* Plt Ct-242
[**2108-11-4**] 05:35AM BLOOD PT-25.5* INR(PT)-2.5*
[**2108-11-5**] 05:20AM BLOOD WBC-5.2 RBC-3.06* Hgb-8.3* Hct-25.7*
MCV-84 MCH-27.1 MCHC-32.3 RDW-15.2 Plt Ct-241
Brief Hospital Course:
In summary, this is a 61 year-old man with a past medical
history of HTN and polysubstance abuse who presented to the ED
with chest and abdominal pain and was found to have an anterior
STEMI. He is now status post BMS to the mid-LAD. Post cardiac
catheterization he presented to the CCU with acute onset
pulmonary edema and respiratory failure and was intubated on
assist control ventilation. He was diuresed with IV Lasix
initially and he was successfully extubated without
complications on hospital day 2. Post-extubation, there were no
further respiratory issues and Lasix was eventually
discontinued. Serial CXRs showed resolution of the pulmonary
edema and the patient's oxygen saturation levels have been
consistently >97% on room air. As the patient was being screened
for possible placement in a rehabilitation facility or a shelter
it was decided to check his PPD. PPD testing done with a
negative PPD confirmed on [**2108-10-27**].
CORONARY ARTERY DISEASE: In terms of Mr.[**Known lastname 11013**] coronary
artery disease, he underwent catheterization at admission with
BMS placed to LAD. His CK peaked at 76 and his TropT peaked at
0.66. He was continued on Plavix 75mg PO daily, 325mg daily
aspirin and started on high dose 80mg of atorvastatin daily. He
was kept on Integrillin drip for 18 hours. After the
catheterization, there were no further episodes of chest pain
with the exception of some mild [**2110-2-26**] intermittent chest pain
on [**2108-11-1**] which was reproducible on exam and felt to be
musculoskeletal in origin at the left sterno-costal junction.
EKG showed t-wave inversions in V2-V5 which had been present in
multiple prior EKGs, otherwise NSR, rate mid-70s and oxygen
saturation 98% RA. Warm compresses helped to alleviate this
costo-sternal discomfort. Mr. [**Known lastname 10983**] was advised that he would
need to continue Clopidogrel for at least one month and aspirin
for life. He is aware of the risks of repeat cardiac events
and/or stroke if he fails to adhere to this regimen and he was
advised to be compliant with his medications after discharge.
PUMP FUNCTION:Regarding pump function, the patient presented to
the CCU with acute pulmonary edema on imaging in the setting of
a recent MI. He was intubated in the cardiac cath lab. Recent
TTEs had shown no baseline systolic heart failure, although
likely there was a component of diastolic dysfunction in the
setting of severe HTN. A TTE after the cath showed LVEF of 30%
and apical hypokinesis with LV mural thrombus. Thus, he likely
developed this systolic heart failure after suffering his recent
MI. He was started on ACEI and BB to limit further remodeling
and control his HR. To manage his mural thrombus, he was
started on a heparin drip and then bridged to Coumadin 2.5 mg
qhs and his INR was 2.7 on [**2108-11-1**]. He has failed
anticoagulation in the past due to medication non-compliance.
Mr. [**Known lastname 10983**] has a history of pulmonary embolisms and DVTs per
records and he had an IVC filter placed in [**2105**]. The patient was
warned of the increased risk of embolic stroke and blood clots
in the acute setting of apical thrombus and hypokinesis as well
as large DVTs. He was initially started on heparin drip and
later bridged to Warfarin 2.5mg qhs which he continued for the
rest of his hospitalization. He had his daily INR/PT checked.
.
RHYTHM: The patient had occasional sinus tachycardia bouts with
exertion but he was in normal sinus rhythm on telemetry for the
majority of his hospital stay.
..
RESPIRATORY FAILURE: As above, he presented to the CCU
intubated presumably due to acute pulmonary edema in the setting
of poor cardiac output and recent ACS/ STEMI. He was extubated
without complications and was gradually weaned back to room air
and had oxygen saturations of 97-99% on room air at time of
discharge.
ABDOMINAL PAIN / CONSTIPATION: Mr. [**Known lastname 10983**] had some mild lower
quadrant abdominal distention and pain with deep palpation. He
had severe constipation which was probably exacerbated by his
methadone regimen and multiple psychiatric medications. He was
started on a bowel regimen with Dulcolax, Senna, Colace and then
lactulose was added and patient began to have regular daily
bowel movements and his mild abdominal distension and nausea
improved thereafter for the remainder of his hospital stay.
COFFEE-GROUND EMESIS: At time of presentation, it appeared he
was having abdominal discomfort because he grimaced on deep
palpation of his abdomen. Pancreatic and liver enzymes were
sent and all returned normal. The abdominal pain later resolved
post-extubation with the exception of some mild lower quadrant
distension and tenderness in the setting of severe constipation.
CT chest/[**Last Name (un) 103**]/pelvis was negative for pulmonary or intra-aortic
process. Abdominal imaging was unremarkable. He was also noted
to have coffee ground aspirate from his OG tube, which cleared
after gastric lavage. However, on hospital day 1 his hematocrit
dropped rather precipitously from 29 to 24. A central line was
placed and 2U PRBCs transfused to which he responded
appropriately with a hematocrit bump to 30. GI was consulted
and did not believe there was any urgent indication for scope,
as his bleeding had resolved.
.
He was started on [**Hospital1 **] PPI and tapered to daily 40mg PO dose.
His hematocrit increased to baseline mid 30s and remained stable
for the rest of the hospitalization. GI service would like to
perform upper endoscopy, but as he is no longer actively
bleeding there is no indication for an urgent inpatient
procedure and GI felt that patient could follow up at a later
date as an outpatient for an elective EGD.
# HYPERTENSION: He has a history of malignant hypertension
managed with clonidine, amlodipine, and unclear whether he takes
HCTZ as his discharge summaries reflect different regimens. We
attempted to work with an ACEI and BB given comorbidity of CAD
keeping in mind that he has very difficult to control HTN at
baseline and may require additional medications. Ultimately,
blood pressure was well controlled with a triple regimen of 5mg
daily Lisinopril, Clonidine patch and 25mg PO BID Metoprolol.
..
# COPD: We continued the patient' home ipratropium and
albuterol nebs as needed while he was hospitalized.
..
# Right LE DVT: Identified on [**2108-10-27**] after patient complained
of right groin pain and right leg became swollen. Vascular
surgery consult done and thrombectomy or other procedure was
deemed not needed as circulation appears intact, there is no
evidence for compartment syndrome and swelling is slowly
resolved. Pt has an IVC filter that was placed after an episode
of PE in the past. Coumadin has been continued and pt will need
to continue this indefinitely. Pt will also need a hematology
consult in the future to assess for clotting derangements once
DVT is resolved. Pt will need a repeat LE ultrasound in [**1-25**]
months to assess for interval change. The patient's compliance
with his INR checks at [**Company 191**] and the importance of taking his
daily Warfarin to prevent strokes and additional clots or
complications was stressed and reinforced on multiple occasions.
# METHADONE MAINTENANCE: We continued his home methadone dose
of 135 mg daily.
..
# DEPRESSION / ANXIETY: Stable; we continued his home
duloxetine, clonazepam, and quetiapine initially and Psychiatry
was consulted for additional input during the [**Hospital 228**] hospital
stay and the patient's Seroquel was increased to 200mg qhs
dosing alongside 50mg [**Hospital1 **] prn Seroquel regimen as well. The
patient continued to have some hypotension and Seroquel was
discontinued. He had his duloxetine gradually uptitrated and his
symptoms were well controlled at time of discharge.
# SOCIAL : Social work consult was arranged to explore the best
approach for the patient to be able to more easily afford his
medications. A search was initiated to help place Mr. [**Known lastname 10983**]
in a short term housing/rehabilitation/partial shelter setting
given his multiple medical comorbidities and his social
situation which is complicated by his polysubstance abuse
history and intermittent homelessness. Physical therapy also
evaluated Mr. [**Known lastname 10983**] and felt that he was stable for discharge
and felt he was physically capable to resume his
pre-hospitalization activity.
#PROPHYLAXIS:
DVT prophylaxis was with heparin SQ, then switched to heparin
drip after the finding of apical thrombus on TTE and patient
ultimately bridged to Coumadin. GI prophylaxis with PPI [**Hospital1 **]
initially given concern over potential GI bleed. PPI later
switched to 40mg daily Protonix. He was kept on a cardiac,
heart-healthy diet. His code status remained full code
throughout his hospital stay.
Medications on Admission:
Methadone 135mg daily
Acetaminophen prn
Duloxetine 20 mg daily
Quetiapine 100 mg daily
Clonazepam 1 mg TID
Albuterol prn
Clonidine 0.3 mg/24 hr Patch Weekly
Amlodipine 10 mg daily
HCTZ 12.5mg daily
Tiotropium 18mcg daily
ASA -uncertain dose
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. Methadone 10 mg/mL Concentrate Sig: 13.5 cc PO DAILY (Daily).
3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
7. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Outpatient Lab Work
Please check INR on Wednesday [**11-8**] and call results to
[**Company 191**] coumadin clinic at [**Telephone/Fax (1) 2173**]
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please check INR on [**11-8**].
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] house
Discharge Diagnosis:
Anterior ST elevation Myocardial Infarction
Systolic dysfunction with Ejection Fraction 30%
Malignant Hypertension
History of Heroin use, now on Methadone
Right lower extremity Deep Vein Thrombosis
and Left Ventricle thrombus
Discharge Condition:
Stable. Physical therapy clearance obtained.
[**2108-11-5**]: INR 2.2, Hct 25.7
Stable. Physical therapy clearance obtained.
Labs [**2108-10-31**] : Hct 26.6, INR 2.7
[**2108-10-31**] : BUN 20, Cr 1.2
Discharge Instructions:
You had a heart attack and a bare metal stent was placed in your
left coronary artery to keep it open. You need to take
Clopodigrel (Plavix) every day for one month so this stent does
not clot off and cause another heart attack. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s. You also have a weakened heart and the tendency to retain
fluid. WE have started you on Toprol (metoprolol succinate) and
Lisinopril to help your heart work better. Taking aspirin every
day helps prevent blood clots. You should go to cardiac
rehabilitation after your cardiologist says it is OK. This will
help your heart recover and prevent another heart attack.
You have a large clot in your right leg vein. We started you on
Warfarin (coumadin) to slowly dissolve the blood clots. You need
to get your coumadin level checked frequently to make sure it is
high enough. You may have bleeding from the coumadin, bruising
or nose bleeds are common. Please call Dr. [**Last Name (STitle) 5717**] if you have
dark stools, severe bruising or any serious bleeding.As
discussed, be sure to follow-up at [**Hospital 191**] [**Hospital 197**] Clinic for your
INR level checks to monitor your Coumadin therapy.
Please stop smoking. Information was given to you on admission
regarding smoking cessation. This is the single most important
thing you can do for your health.
.
Please weigh your self every day in the morning and call Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) 5717**] if your weight increases more than 3 pounds in
1 day or 6 pounds in 3 days.
Please eat a low sodium diet, information was given to you about
avoiding high sodium foods.
Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time:
[**11-12**] at 3:20pm.
.
Primary care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Date/time:
Thursday [**11-8**] at 3:30pm.
Completed by:[**2108-11-6**]
|
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"428.0",
"585.9",
"403.00",
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"453.41",
"428.21",
"578.9",
"410.11",
"304.01",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"37.22",
"38.93",
"00.45",
"00.66",
"88.55",
"36.06",
"96.71",
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icd9pcs
|
[
[
[]
]
] |
24127, 24229
|
12972, 21821
|
308, 503
|
24499, 24703
|
4271, 7312
|
26414, 26842
|
3368, 3506
|
22112, 24104
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24250, 24478
|
21847, 22089
|
7330, 11067
|
24728, 26391
|
3547, 4252
|
2119, 2124
|
252, 270
|
531, 2019
|
11077, 12949
|
2155, 2839
|
2041, 2099
|
2855, 3352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,493
| 151,094
|
29757+57658
|
Discharge summary
|
report+addendum
|
Admission Date: [**2148-10-25**] Discharge Date: [**2148-10-29**]
Date of Birth: [**2102-9-25**] Sex: M
Service: DENTAL
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 51674**]
Chief Complaint:
left jaw pain
Major Surgical or Invasive Procedure:
[**2148-10-25**] I&D of left masticator abscess
History of Present Illness:
46yo M, h/o recent dental extraction, significant pyschiatry
history, on methadone, who presented to the [**Hospital1 112**] ED with mental
status changes while on his way to his psychiatrist appointment.
This was originally thought to be due to methadone dosing, but
subsequently he became hypotensive and picture was c/w sepsis.
He reports left mandibular molar tooth partial extraction, then
complete extraction 1 week ago. He has been taking penicillin
since extraction, but left mandibular pain has gotten worse and
his developed swelling over his left jaw. Denies fevers at home.
No difficulty breathing. Tolerating secretions and was eating
without difficulty. He received Vanco, Levaquin, Flagyl in the
ED, as well as IVF resuscitation.
Past Medical History:
HTN
Chronic neck pain
Bipolar
Dental extraction as above
Social History:
+ cig, denies etoh/IVDA
Family History:
Noncontributory
Physical Exam:
Upon admission:
102.8 95.1 98 140/88 18 97%RA
NAD, awake, no respiratory distress, no stridor, no drooling,
appears comfortable
Ears - TM intact with no erythema bil, AS anterior EAC w/ mild
edema ([**3-8**] edema tracking upward from mandible)
Nose - septal deviation, no drainage middle meatus
NP - nomass
OC - trismus to 3 cm, tongue - no edema, FOM - soft bilaterally
and nontender, left posterior mandibular alveolar ridge w/ pus
coming from partially intact tooth, edema and sig tenderness of
left posterior mandibular alveolar ridge, clear saliva from left
parotid duct
OP - 3 + cryptic tonsils bil with no exudate or erythema, uvula
midline
Neck - approx 4 x 3 cm area of induration without overlying skin
erythema centered over left mandibular body and angle, soft
medial portion of left submandibular triangle, submental, and
right submandibular area
Pertinent Results:
[**2148-10-25**] 04:15PM UREA N-26* CREAT-1.1
[**2148-10-25**] 04:15PM ALT(SGPT)-15 AST(SGOT)-14 ALK PHOS-98
AMYLASE-94 TOT BILI-0.3
[**2148-10-25**] 02:48PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2148-10-25**] 11:00AM GLUCOSE-105 UREA N-33* CREAT-1.8* SODIUM-139
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17
[**2148-10-25**] 11:00AM CALCIUM-9.3 PHOSPHATE-5.1* MAGNESIUM-2.1
[**2148-10-25**] 11:00AM WBC-18.5* RBC-3.85* HGB-12.6* HCT-37.5*
MCV-98 MCH-32.7* MCHC-33.5 RDW-13.8
[**2148-10-25**] 11:00AM PLT COUNT-354
[**2148-10-25**] 11:00AM NEUTS-81.5* LYMPHS-13.8* MONOS-4.2 EOS-0.4
BASOS-0.1
TEETH (PANOREX FOR DENTAL)
Reason: preop, eval for bony changes
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with sepsis likely [**3-8**] deep space L lower molar
peridontal abscess
REASON FOR THIS EXAMINATION:
preop, eval for bony changes
INDICATION: 46-year-old male with sepsis and questionable left
lower molar periodontal abscess.
COMPARISON: None.
PANOREX: Absence of nearly all the molars is noted apart from a
single right lower molar. There is marked bone loss in the area
of concern provided in the given history about the left lower
premolars and molars (likely teeth [**Doctor First Name **] #17 through 20). No
periapical abscesses are noted. Several dental fillings are
seen.
IMPRESSION: Marked bone loss involving the left lower jaw,
likely related to known periodontal disease. No definite
periapical abscess is seen elsewere. A CT of the neck will be
performed.
CT NECK W/CONTRAST (EG:PAROTID
Reason: eval for peri-mandibular abscess, lateral pharyngeal
space a
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with sepsis [**3-8**] deep space left lower molar
peridontal abscess; masticator space infection
REASON FOR THIS EXAMINATION:
eval for peri-mandibular abscess, lateral pharyngeal space
abscess
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 46-year-old man with sepsis secondary to deep space
left lower molar periodontal abscess and masticator space
infection. Evaluate for perimandibular abscess and lateral
pharyngeal space abscess.
COMPARISON: Panorex radiograph of the teeth from the same day.
TECHNIQUE: Multidetector CT scanning of the neck was performed
after intravenous contrast and displayed in axial and coronal 5
mm sections.
FINDINGS: There is a multilocular fluid collection with
enhancing walls centered around the left mandibular body and
ramus. The largest rim-enhancing locule measures 3.7 cm AP x 2.8
cm TV x 2.5 cm CC. The collection is seen on both sides of the
mandible. There is no frank osteomyelitis or erosion of the
bone. Again noted is the bone loss in the region of the left
molars and premolars, described on the Panorex study, with no
dominant defect.
The inflammation infiltrates the muscles of mastication
including the left medial and lateral pterygoids which are
expanded and demonstrates rim enhancement, with effacement of
fat planes between them. The masseter muscle on the left is also
similarly markedly expanded with peripheral enhancement. The
abnormalities involve the masticator space, extend into the
infratemporal fossa where there is soft tissue density and
effacement of fat, and also extend into the parapharyngeal
prestyloid spaces. The left tonsillar pillar is displaced
medially, although it shows normal density and enhancement, and
does not appear to be directly involved by the process. There is
passive left lateral narrowing of the oropharynx at this level.
The left parotid as well as the left submandibular gland are
indurated and enlarged. There is thickening of the left platysma
muscle, as well as enlarged level 1 lymph nodes on the left.
There are also several asymmetric left level 2, 3, and 4 lymph
nodes, without frank necrosis.
The left external carotid artery is somewhat narrowed just
distal to the common carotid bifurcation, but remains patent by
enhancement. The left internal jugular vein is well seen up
until roughly the level of the atlas where it appears effaced
and slit-like (2:49). Immediately more caudally it is of normal
caliber, similar to the opposite side. There is no definite
evidence of venous sinus thrombosis. Note is made of a right-
sided catheter extending into the right jugular vein and
extending down into the superior vena cava.
The thyroid gland appears normal.
The lung apices are clear.
IMPRESSION:
1. Transspatial multilocular rim-enhancing expansile fluid
collections centered along the left mandible, with inflammatory
infiltration of the muscles of mastication which are expanded
and rim-enhancing. This appearance is concerning not only for
confluent abscesses, likely of odontogenic origin, but also for
pyomyositis, although the extensive changes in the muscles of
mastication may be "reactive."
2. No frank osteomyelitis is appreciated at this time, although
the process is centered at the left mandibular body and ramus,
at the site of demonstrable bone loss, due to known periodontal
disease.
3. Poor visualization of the left internal jugular vein at the
level of the skull base where it becomes quite slit-like and
effaced, and partial thrombosis cannot be excluded.
4. Extensive surrounding inflammation in the left facial soft
tissues, including induration of the parotid and submandibular
glands, thickening of the platysma, and distortion of the
oropharynx due to displacement of the left tonsillar pillar.
ECHO [**10-28**]
Conclusions:
The left atrium is normal in size. 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 aortic root is mildly dilated at the sinus level.
The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be
determined. There is no pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow identified.
Mild
symmetric left ventricular hypertrophy with preserved global
biventricular
systolic function.
These findings are c/w hypertensive heart.
Brief Hospital Course:
He was admitted to the Surgical Service; ENT and OMFS were
consulted. He was taken to the operating room for I & D of his
left masticator abscess. There were no introperative
complications; postoperatively he has done well. He is
tolerating a regular soft diet; his pain is being controlled
with Percocet. He will continue with a 7 day course of Augmentin
after discharge and follow up with Dr. [**First Name (STitle) **] in clinic this
week.
Medications on Admission:
Methadone
Seroquel
Topamax
Ultram PRN
Discharge Medications:
1. 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*
2. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 7 days.
Disp:*qs Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
12. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Left masticator space abscess/Cellulitis
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
increased facial swelling/pain, increased shortness of breath,
chest pain and/or any other symptoms that are concerning to you.
Continue with the antibiotics until they are all gone.
It is recommended that you eat foods which are soft in texture
to avoid excess chewing because of your recent surgery.
You will need to follow up with your outpatient providers
regarding your pain medication prescriptions.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in Clinic this Friday, call
[**Telephone/Fax (1) 274**] for an appointment.
Follow up with your primary care providers in [**Location (un) 86**] and [**Location (un) 9084**] after discharge. You will need to call for an appointment.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 925**] DMD [**MD Number(1) 51675**]
Completed by:[**2148-10-29**] Name: [**Known lastname 11986**],[**Known firstname **] ([**Doctor First Name **]) Unit No: [**Numeric Identifier 11987**]
Admission Date: [**2148-10-25**] Discharge Date: [**2148-10-29**]
Date of Birth: [**2102-9-25**] Sex: M
Service: DENTAL
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11988**]
Addendum:
He is being discharged on Fentanyl 75 mcg patch q 72 hours and
not Percocet.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5160**] DMD [**MD Number(1) 11989**]
Completed by:[**2148-10-29**]
|
[
"296.80",
"998.59",
"523.30",
"305.53",
"038.9",
"314.01",
"478.24",
"682.0",
"723.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"38.93",
"28.0"
] |
icd9pcs
|
[
[
[]
]
] |
11886, 12082
|
8616, 9060
|
330, 380
|
10377, 10384
|
2218, 2946
|
10906, 11863
|
1298, 1315
|
9148, 10263
|
3930, 4043
|
10313, 10356
|
9086, 9125
|
10408, 10883
|
1330, 1332
|
277, 292
|
4072, 8593
|
409, 1159
|
1346, 2199
|
1181, 1240
|
1256, 1282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,150
| 130,027
|
36707
|
Discharge summary
|
report
|
Admission Date: [**2101-5-10**] Discharge Date: [**2101-5-18**]
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2101-5-10**] 1. Redo sternotomy.
2. Redo coronary artery bypass surgery x2, with a left
internal mammary artery graft to the left anterior
descending and reversed saphenous vein graft to the
right coronary artery.
3. Aortic valve replacement with a 21-mm St. [**Hospital 923**] Medical
Biocor Epic tissue valve.
History of Present Illness:
88 yo F s/p CABGx3 in [**2101**] Medical Center with complaints of occasional
dizziness and progressive dyspnea on exertion. Recent
echocardiogram revealed critical aortic stenosis. She underwent
a
cardiac catheterization which revealed native three vessel
disease with two occluded vein grafts out of three. Given the
severity of her disease, she has been referred for consideration
of a redo CABG/AVR.
Past Medical History:
acute systolic heart failure
Hyperlipidemia
paroxysmal atrial fibrillation
complete heart block
coronary artery disesae
aortic stenosis
hypertension
Colon Cancer
Arthritis
Social History:
Lives with:alone in [**Location (un) 3307**]; has 4 grown children
Occupation:Retired
Tobacco:1ppd x 10 years, quit 50+years ago
ETOH:denies
Family History:
3 sons with CAD, s/p MIs and stents in their 50s
Physical Exam:
General:
Skin: Dry [x] intact [x] well healed median sternotomy incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic- loudest at
left sternal border, radiates to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema Varicosities: trace edema bilateral ankles, superficial
varicosities, well healed scars of open GSV harvest bilaterally
ankle to knee
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left: not palpable [**3-8**] edema
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: radiation of murmur
Pertinent Results:
Pre Bypass: Patient is AV paced at baseline. The left atrium is
moderately dilated. The left atrium is elongated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate regional left ventricular systolic dysfunction with
Septal hypo/dyskinesis (difficult to interepret in the setting
of pacing), anterior and anteroseptal severe hypokiensis.
Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %). Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
aortic root. There are simple atheroma in the ascending aorta.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation with some redundnacy of leaflets is
seen.
Post Bypass: Patient is AV paced on epinepherine and
phenylepherine. There is a tissue valve in the aortic position
with a small perivalvular leak which does not change after
protamine. No AI, peak gradients 10-18mm hg. No change in
biventricular function. Aortic contours intact. Remaining exam
is unchanged. All findings discussed with surgeons at the time
of the exam.
[**2101-5-17**] 06:20AM BLOOD WBC-8.1 RBC-3.18* Hgb-9.5* Hct-29.1*
MCV-91 MCH-29.7 MCHC-32.5 RDW-15.4 Plt Ct-216
[**2101-5-17**] 04:09AM BLOOD WBC-8.1 RBC-3.17* Hgb-9.9* Hct-30.7*
MCV-97 MCH-31.1 MCHC-32.2 RDW-14.6 Plt Ct-228#
[**2101-5-18**] 04:02AM BLOOD PT-29.8* INR(PT)-3.0*
[**2101-5-17**] 06:20AM BLOOD PT-15.2* INR(PT)-1.3*
[**2101-5-17**] 05:50AM BLOOD PT-15.0* INR(PT)-1.3*
[**2101-5-14**] 04:00AM BLOOD PT-12.3 PTT-28.0 INR(PT)-1.0
[**2101-5-18**] 04:02AM BLOOD UreaN-28* Creat-1.3* K-4.0
[**2101-5-17**] 06:20AM BLOOD Glucose-113* UreaN-25* Creat-1.0 Na-140
K-4.3 Cl-102 HCO3-29 AnGap-13
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2101-5-10**] where the patient underwent redo
sternotomy, CABG x 2 and aortic valve replacement. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Cefazolin was used for surgical antibiotic
prophylaxis. Within 24 hours the patient was extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact. Vasopressor support was weaned by POD 2,
beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient's permanent pacer was interrogated by the
electrophysiology service. Coumadin and amiodarone were started
for atrial fibrillation. Simvastatin dose was decreased on
initiation of amiodarone. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 8 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to rehab on IV
lasix and telemetry, in good condition with appropriate follow
up instructions.
Medications on Admission:
Amlodipine 10mg po daily
Fosinopril 20mg po daily
Nadolol 60mg po daily
Klor-Con 10mEq po BID
Simvastatin 80mg po qHS
ASA 81mg po daily
Naproxen Sodium 220 PRN: back pain
Dipyridamole 50mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg twice a day for 1 week, decrease to 400 mg once a
day on [**5-24**], then after 1 week decrease to 200 mg daily on [**5-31**]
and follow up with Dr [**Last Name (STitle) 31925**].
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
6. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 40 mg IV Q12H
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO Q12H (every 12 hours).
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change daily for goal INR [**3-9**] for atrial fibrillation.
12. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
(dose decreased when amio started).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
acute systolic heart failure
Coronary artery disesae s/p CABG
Aortic stenosis s/p AVR
Acute systolic heart failure
Hyperlipidemia
paroxysmal atrial fibrillation
complete heart block
hypertension
Colon Cancer
Arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2101-6-2**] 1:15
Please call to schedule appointments
Primary Care Dr [**First Name8 (NamePattern2) 31092**] [**Last Name (NamePattern1) 83018**] in [**2-5**] weeks [**Telephone/Fax (1) 27929**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-5**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2101-5-18**]
|
[
"427.31",
"424.1",
"272.4",
"401.9",
"428.0",
"428.21",
"285.9",
"V45.01",
"V10.05",
"287.5",
"414.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.11",
"36.15",
"39.63",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7327, 7399
|
4489, 5863
|
242, 575
|
7661, 7763
|
2250, 4466
|
8388, 8937
|
1380, 1431
|
6109, 7304
|
7420, 7640
|
5889, 6086
|
7787, 8365
|
1446, 2231
|
183, 204
|
603, 1009
|
1031, 1205
|
1221, 1364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,111
| 178,622
|
25816
|
Discharge summary
|
report
|
Admission Date: [**2141-6-30**] Discharge Date: [**2141-7-5**]
Date of Birth: [**2069-3-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Left Arm Discomfort
Major Surgical or Invasive Procedure:
CABGx2(SVG->LAD, OM) [**2137-6-30**]
History of Present Illness:
72 y/o female with left arm pain and no other symptoms who had
an ETT which showed ST depression. Stress Echo showed inferior
and posterior hypokenesis. Cardiac Cath performed on [**6-23**]
revealed severe 3 vessel disease. And pt was then referred for
bypass surgery.
Past Medical History:
Hypertension
Hypercholesterolemia
Hypothyroidism
Colon Cancer s/p colon resection 86
Breast Cancer s/p Left radical mastectomy with radiation 70
s/p Appendectomy
Social History:
Reitred, Lives with Husband,
Quit smoking in [**2122**] after 35 pack year history. Denies ETOH.
Family History:
Mother died at afe of 60 of CHF.
Physical Exam:
VS: 68 142/78 Ht 5'5" Wt 148lbs
General: WD/WN female in NAD
Skin: R upper chest petechiae and L chest scarring
HEENT: Oropharynx benign, EOMI, PERRLA
Neck: Supple, -JVD
Heart: RRR, +S1S2, with sodt systolic murmur at apex
Lungs: CTAB
Abd: Soft, NT/ND, +BS
Ext: Warm, trace [**Last Name (un) **], varicosity of right GSV
Neuro: A&Ox3, nonfocal
Pertinent Results:
Pre-op CXR [**6-28**]: 1. No evidence of congestive heart failure or
pneumonia.
2. Area of increased density overlying the left first rib at the
lung apex
could possibly represent a superimposition of structures,
although left apical lung nodule or sclerotic lesion within the
first rib cannot be excluded.
Post-op [**2141-7-1**] CXR: No PTX with good lung expansion following
removal of multiple lines and tubes. No new infiltrates and no
CHF.
Pre-op EKG [**6-28**]: Sinus rhythm 68. Non-specific ST-T wave
abnormalities.
[**2141-6-30**] 10:23AM BLOOD WBC-7.3 RBC-3.20*# Hgb-9.7*# Hct-27.6*#
MCV-86 MCH-30.2 MCHC-35.0 RDW-12.9
[**2141-7-1**] 03:24AM BLOOD WBC-11.4*# RBC-3.21* Hgb-9.7* Hct-28.7*
MCV-89 MCH-30.1 MCHC-33.7 RDW-13.7 Plt Ct-243
[**2141-7-5**] 06:40AM BLOOD WBC-11.5* RBC-3.10* Hgb-9.2* Hct-27.8*
MCV-90 MCH-29.7 MCHC-33.2 RDW-13.9 Plt Ct-345#
[**2141-6-30**] 11:20AM BLOOD PT-15.5* PTT-39.0* INR(PT)-1.6
[**2141-7-2**] 05:10AM BLOOD PT-12.5 PTT-25.9 INR(PT)-1.0
[**2141-6-30**] 11:20AM BLOOD UreaN-12 Creat-0.8 Cl-103 HCO3-24
[**2141-7-4**] 05:50AM BLOOD Glucose-123* UreaN-14 Creat-1.0 Na-131*
K-4.4 Cl-96 HCO3-28 AnGap-11
[**2141-7-4**] 05:50AM BLOOD Mg-1.9
[**2141-7-1**] 12:43PM BLOOD freeCa-1.11*
Brief Hospital Course:
As mentioned in the HPI, pt is a 72 y/o female with severe 3vd
on cath. She was initially seen in outpatient clinic and then
scheduled for surgery. On [**2141-6-30**] she was a same day admit and
was brought to the operating room and underwent CABG surgery.
Please see op note for full details. Pt. tolerated the procedure
well with a total bypass time of 57 minutes and cross clamp time
of 46 minutes. She was transferred to the CSRU in stable
condition with a MAP of 85, CVP 10, PAD 16, [**Doctor First Name 1052**] 24, HR 92
A-paced being titrated on Nitro and Neo. Later on op day, pt was
weaned from mechanical ventilation and propofol and was
successfully extubated. Pt. was awake, alert, MAE, and following
commands. On POD #1 pt appeared to be doing well. Chest tubes
and swan-Ganz catheter were removed. Nitro was already weaned
and pt was started on diuretic and b-blockade per protocol. He
was transferred to the telemetry floor. POD #3 pt had rapid
A.Fib w/ vent. response of 180 in the AM. Pt. converted with
Amio/Lopressor/Mg. Po Amio started and pt. was stable. Lungs had
some scattered rhonchi, 1+ edema. Pt. was slowly improving but
need to get OOB and ambulate more. POD #[**4-18**] pt. appeared to be
doing well. She had no new events the past two days nor no
episodes of A.Fib. She was at level 5 and was discharged home
with services. Physical Exam at d/c:
VS: 98.1 71 108/59 18
Neuro: A&Ox3, nonfocal
Chest: Sternum stable, -clicks or drainage
Lungs: Bibasilar crackles
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND,+BS
Ext: 1+ edema
Medications on Admission:
1. Vasoctec 15mg [**Hospital1 **]
2. Lopressor 50mg [**Hospital1 **]
3. Norvasc 5mg qd
4. Zocor 40mg qd
5. Tricor 145mg qd
6. Synthroid 50mcg qd
7. HCTZ 25mg qd
8. ASA 81mg qd
9. Ativan 0.5mg qhs
10. Calcium 500mg [**Hospital1 **]
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Then decrease to 400 mg PO daily for 1 week,
then 200 mg PO daily.
Disp:*50 Tablet(s)* Refills:*0*
6. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Doctor Last Name **]
Discharge Diagnosis:
Coronary artery disease s/p Coronray Artery Bypass Graft x 2
Hypertension
Hypercholesterolemia
Hypothyroidism
Colon Cancer s/p colon resection 86
Breast Cancer s/p Left radical mastectomy with radiation 70
s/p Appendectomy
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Do not use powders, lotions, creams on wounds.
Call our office for sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 64290**] for 1-2 weeks.
Dr. [**Last Name (STitle) 36812**] in [**1-15**] weeks
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Call [**Doctor First Name **] @
[**Telephone/Fax (1) **] to schedule.
Completed by:[**2141-7-5**]
|
[
"244.9",
"997.1",
"427.31",
"V10.3",
"414.01",
"V10.05",
"401.9",
"413.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5787, 5848
|
2646, 4194
|
340, 378
|
6114, 6121
|
1404, 2623
|
6460, 6758
|
991, 1025
|
4475, 5764
|
5869, 6093
|
4220, 4452
|
6145, 6437
|
1040, 1385
|
281, 302
|
406, 676
|
698, 861
|
877, 975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,278
| 161,226
|
33482
|
Discharge summary
|
report
|
Admission Date: [**2142-11-13**] Discharge Date: [**2142-11-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Foreign body swallowed
Major Surgical or Invasive Procedure:
Laryngoscopy
Esophagealgastroduodenoscopy (EGD)
History of Present Illness:
87M with history of atrial fibrillation not currently on
coumadin, chronic renal insufficiency (baseline Cr mid 2s),
hypertension, hyperlipidemia, gout, mild dementia, bilateral
sensorineural hearing loss who ingested a drill bit at a dentist
appointment on the morning of AM of [**11-13**].
.
In the ED, initial VS were: 97.1 109 140/95 16 100% RA. CXR
demonstrated foreign body in cervical region. Foreign body was
not directly visualized by nasopharyngoscope per ENT. Seen by
surgery for possible open retrieval, transferred to MICU for EGD
by GI instead.
.
In MICU, VS were: 98.9 98 103/65 15 100% on RA. Foreign body
could not be visualized by EGD. Progression followed with
serial XRays. Serial abdominal exams benign. VS and hematocrit
remained stable. EKG with 2nd degree heart block with 4:1 and
3:1 conduction and the patient remained in Atrial fibrillation
vs. atrial flutter. ACEi and BB held and patient was kept NPO on
IVF in the interim as the foreign body is waiting to pass.
.
Vitals on the floor were T98.4 BP134/80 P84 RR18 O2 98RA.
Denied pain or discomfort.
.
Review of systems: Difficult historian given mild dementia
(+) Per HPI
(-) Denies fever/chills, cough, shortness of breath. Denies
pain, nausea, vomiting.
Past Medical History:
Chronic renal failure (baseline creatinine ~2.5)
Hypertension
Hyperlipidemia
Atrial fibrillation off coumadin for dental work (CHADS2 is 2,
no h/o stroke or TIA)
Gout
Benign prostatic hyperplasia
Social History:
Retired pediatric endocrinologist, former Chief of division at
[**Hospital 4415**]. Originally from South [**Country 480**].
Married, lives with wife. Denies tobacco, illicit drug use. One
glass wine/night. Has three sons, one who lives in the area and
owns restaurants.
Family History:
No history of coronary artery disease or MIs.
Physical Exam:
VS: 98.9 98 103/65 15 100% on RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op with some dried blood on
teeth and evidence of recent dental work
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/
NEURO: oriented to self and date
.
On transfer to the floor:
Vitals: T:98.4 BP:134/80 P:84 R:18 O2:98RA
General: alert, comfortable, no acute distress, hearing impaired
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular. No m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
Admission Labs:
[**2142-11-13**] 05:40PM WBC-8.2 RBC-4.34* HGB-12.4* HCT-36.7* MCV-85#
MCH-28.6 MCHC-33.8 RDW-14.8
[**2142-11-13**] 05:40PM NEUTS-57.6 LYMPHS-29.2 MONOS-6.4 EOS-6.4*
BASOS-0.4
[**2142-11-13**] 05:40PM PLT COUNT-259
[**2142-11-13**] 05:40PM PT-16.7* PTT-29.3 INR(PT)-1.5*
[**2142-11-13**] 05:40PM GLUCOSE-101* UREA N-36* CREAT-2.4* SODIUM-141
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
[**2142-11-13**] 05:49PM GLUCOSE-97 NA+-142 K+-4.7 CL--105 TCO2-24
.
Imaging:
[**11-14**] CXR: Small rod-like radiopaque foreign body seen within the
lower
cervical region. This finding was reported to patient's primary
care doctor, Dr. [**Last Name (STitle) 77644**] and suggestion was made that the
patient undergo bronchoscopy or video guided removal of the
foreign radiopaque object.
.
[**11-13**] CT Neck: 1. Previously noted retained foreign body within
the right aspect of the neck seen on chest radiograph is no
longer visualized on the current study. Recommend further
evaluation with plain radiographs of the chest and abdomen to
evaluate for passage of the radiopaque structure.
2. Multinodular goiter with coarse calcifications in the right
lobe of the
thyroid gland. Clinical correlation is recommended, and if there
is continued clinical concern, an ultrasound can be obtained.
3. Cervical spondylosis with mild-to-moderate central canal
narrowing at
multiple levels.
.
[**11-13**] KUB: Linear radiopaque foreign body projecting over the
right upper
quadrant of the abdomen, likely within a bowel loop, but it
cannot be
discerned whether it lies within large or small bowel. No free
intraperitoneal air or evidence of bowel obstruction.
.
[**11-16**] CT abdomen/pelvis:
ABDOMEN: The visualized portion of the chest demonstrates
calcified
atherosclerotic disease of the coronary arteries as well as the
intrathoracic
aorta. The intrathoracic aorta is also noted to take a tortuous
course.
Within the limits of a non-contrast study, the liver shows no
focal lesion or
intrahepatic biliary dilatation. The gall bladder shows no
stones or wall
edema. The spleen is normal in size and appearance. The pancreas
shows no
evidence of masses. The adrenal glands are normal appearing
bilaterally. The
right kidney is more atrophic-appearing than the left. The left
kidney
demonstrates a cyst in the upper pole which measures 23 x 16 mm
(2; 23).
The small and large bowel show no evidence of obstruction. In a
loop of small
bowel is seen a linear density, and there does not appear to be
evidence of
perforation or fat stranding in this region. Compared to the KUB
performed on
the same day, there has been no appreciable movement. Compared
to multiple
KUBs from [**11-13**] to the present, there has been gradual
movement of this
object. It does not appear to be within the colon. There is no
free air or
free fluid.
Calcified atherosclerotic disease is seen throughout the
abdominal aorta and
into the iliac branches. There is an infrarenal abdominal aortic
aneurysm
that measures 39 x 37 mm in the axial plane and spans
approximately 4.5 cm
longitudinally. There is no intimal calcification displacement
or periaortic
stranding to suggest rupture.
BONES: Severe degenerative changes are seen in the thoracolumbar
spine
primarily in the form of marginal osteophytes and facet joint
hypertrophy.
IMPRESSION:
1. Metallic density likely representing swallowed drill bit
within the loop
of small bowel without evidence of perforation - finding
discussed with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5144**] at 14:49 on [**2142-11-16**].
2. Infrarenal aortic aneurysm without evidence of rupture.
3. Severe spinal degenerative changes.
4. Atrophic kidneys, right worse than left.
.
[**11-19**] KUB
Radiodense foreign body attributed to a drill bit continues to
project over the L3 vertebral body level, but now has a change
in its
orientation, with a more diagonal position compared to the
vertical position
on the prior study of one day earlier. A non-obstructive bowel
gas pattern is
again visualized, and there is no evidence of free
intraperitoneal air.
Within the imaged portion of the lung bases, nonspecific
bibasilar fibrosis is
evident.
Brief Hospital Course:
7M with history of atrial fibrillation not currently on
coumadin, chronic renal insufficiency (baseline Cr mid 2s),
hypertension, hyperlipidemia, gout, mild dementia, bilateral
sensorineural hearing loss with 2.5cm long foreign body (drill
bit) ingestion, awaiting passage per rectum/stools
.
# Foreign body ingestion:
ENT could not get the drill bit out by laryngoscopy and GI did
EGD in MICU without success either. The patient was initially
NPO but his diet advanced to fulls and then regular to encourage
natural/gentle peristasis. Serial abdominal exams remained
benign and KUBs were ordered 2-3 times daily; all stool was
collected and monitored for passage of the drill bit. It was
progressing but then stopped. CT abdomen confirmed it is in the
small bowel and may be sticking to the side of the lumen. No
perforations although Gen [**Doctor First Name **] and GI both continued to follow.
On the day of discharge the drill bit was noted to have passed
into the ileum (and perhaps the cecum). Given that the patient
was asymptomatic the decision was to discharge with follow up in
[**Hospital **] clinic the day after discharge.
.
# Atrial fibrillation: Patient's CHADS2 score ~2 and his
coumadin was held for any possibility of surgical interventions
on the foreign body. His INR drifted down to 1.2. He was
initially also off rate control with his Toprol XL, which was
resumed as his heart rates crept up and his diet was advanced.
.
# Dental procedure: Recently and the setting in which the
patient ingested the drill bit. He was on amoxicillin PO for a
two week course, which was continued in house. The patient was
initially on ampicillin IV when he was strictly NPO. He will
need to complete his amoxicillin course (7 more days) as
outpatient.
.
#Chronic renal insufficiency: Creatinine near baseline of 2.5.
His lisinopril was initially held but then resumed.
.
#Benign Prostatic Hyperplasia: No urinalysis this admission.
Patient denied symptoms. He was resumed on his home flomax when
diet was advanced.
.
#Hyperlipidemia: Statin held in MICU. LFTs in [**2140**] were WNL. He
was resumed on his home simvastatin when diet was advanced.
.
#Hypertension: The patient's lisinopril and metoprolol were held
while NPO and resumed when his diet was advanced, with general
stability of his blood pressures.
.
#Gout: Stable, without flares while in-house. The patient's
colchicine was held while NPO and then resumed when his diet was
advanced.
.
#Hpylori positive - Lab drawn inadvertently in MICU. The patient
and wife are aware and were encouraged to follow this up with
his primary care doctor, particularly ?triple therapy.
.
#Multinodular goiter: Asymptomatic during this hospitalization.
This was incidental finding on CT with no evidence of thyroid
dysfunction. Patient and wife are aware and were encouraged to
follow this up as an outpatient with his primary care doctor.
.
# Code: Full code, confirmed in MICU
Medications on Admission:
Lisinopril 2.5mg daily
Simvastatin 40mg daily (? dose)
Coumadin 2.5mg 5x/week and 1.25mg 2x/week (T/Th)
Metoprolol SR 25 mg daily
Colchicine 0.6mg M/W/F
Flomax 0.4mg qhs
Aspirin 81 mg QD
Vitamin D 50,000 U 1x/week
Tums Ultra 1000 QD
Prednisone 10 mg QD:PRN evening gout flares
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 7 days: Complete the total 14 day course of
antibiotics for your dental work.
6. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO DAILY (Daily).
8. rivastigmine 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal DAILY (Daily).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Foreign body ingestion
Multinodular goiter
Helicobacter pylori
Infrarenal abdominal aortic aneurysm that measures 39 x 37 mm
.
Secondary:
Hypertension/hyperlipidemia
Atrial fibrillation
Chronic renal insufficiency
Mild dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You were admitted after swallowing a drill bit at your
dentist's office. The Ears, Nose and Throat doctors attempted to
remove the drill bit by laryngoscopy but were unsuccessful. The
gastroenterologists attempted to remove it by EGD but were also
unable to. You were closely monitored, initially in the ICU, as
the passage of this sharp object was potentially dangerous as it
can cut through your gastrointestinal tract. Your diet was
gradually advanced and the drill bit safely passed into your
small bowel where it remains. In discussions with the
gastroenterologists, it was felt that further attempts to remove
the drill bit via more invasive techniques may be more harmful
than beneficial. The plan is to discharge you home where you
will be watched closely until the drill bit passes through your
system and into your stool.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> STOP Coumadin until the drill bit passes and you follow up
with your primary care physician.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **]
[**Name (STitle) 77645**]. You should discuss, in particular, management of your
goiter and H.pylori infection (whether to treat these). You can
reach his office at: [**Telephone/Fax (1) 77646**].
Name: [**Telephone/Fax (1) **],[**Telephone/Fax (1) **] A. MD
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) **] [**Apartment Address(1) 77647**], [**University/College **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 77646**]
Appointment: Wednesday [**2142-11-21**] 10:15am
.
Please follow up with gastroenterology tomorrow, [**11-21**] for an
appointment to have another x-ray performed. They will call you
this afternoon with the time and place of the appointment
Completed by:[**2142-11-20**]
|
[
"272.4",
"441.4",
"241.1",
"041.86",
"427.32",
"600.00",
"427.31",
"290.0",
"E915",
"936",
"274.9",
"403.90",
"585.9",
"389.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
11437, 11443
|
7277, 10211
|
287, 337
|
11724, 11724
|
3054, 3054
|
13194, 14007
|
2130, 2177
|
10538, 11414
|
11464, 11703
|
10237, 10515
|
11877, 13171
|
2192, 3035
|
1470, 1607
|
225, 249
|
365, 1450
|
3070, 7254
|
11739, 11853
|
1629, 1826
|
1842, 2114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,388
| 101,052
|
28400
|
Discharge summary
|
report
|
Admission Date: [**2191-1-22**] Discharge Date: [**2191-1-23**]
Date of Birth: [**2118-11-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 72-year-old female with a history of non-small cell
lung cancer (diagnosed in [**2178**]), non-massive hemoptysis (s/p
right fifth posterior intercostal artery embolization on
[**2191-1-12**]), and recent admission for weakness ([**2191-1-14**] to
[**2191-1-18**]). She presents from home today following dyspnea at
home. Patient reportedly had been found to be confused at home
with with O2Sat 50% on room air, which then came up to 99% on
NRB. In the field, intial BP was 80/palp, so patient received
200 mL NS enroute to the ED. [**Name (NI) **] son is concerned that
patient's new medication, levothyroxine, is the reason for
presentation since the patient became acutely ill 2 hours
following the first time she took the medicine the morning prior
to presentation. Patient was reportedly doing well and had
breakfast without difficulty, though after taking her medication
with Ensure was found to have white frothy secretions.
.
Vitals upon presentation to the ED were: T 99.8, HR 84, BP
109/60, RR 16, O2Sat 75% RA. Patient was given levofloxacin and
Zosyn. Family refusing translator in the ED. Patient is DNI,
though family was not ready to have CMO discussion according to
ED resident. Prior to transfer to the unit, vitals were: T 99.9,
HR 73, BP 77/47, RR 12, O2Sat 100% NRB.
Past Medical History:
1) Stage IV NSCLC
- thoracotomy with biopsy and partial resection ([**2178**])
- XRT to right chest wall + mediastinum ([**2178**])
- 6 cycles of carboplatin/gemcitabine or cisplatin/paclitaxel
(between [**2184**] and [**2185**])
- 2 cycles of possible vinorelbine ([**2187**])
- 6 cycles of pemetrexed 500 mg/m2 ([**2188**])
- erlotinib 150 mg/day ([**Month (only) 404**] to [**2189-4-28**])
- 2 cycles of docetaxel 35 mg/m2 and cetuximab 250 mg/m2 weekly
between [**2189-10-28**] and [**2190-11-28**]
- 1 cycle of carboplatin 5 AUC D1 and gemcitabine 1000 mg/m2 D1
of 21 day cycle in [**2190-3-28**] ([**2190-4-21**])
- palliative chest radiotherapy to [**2181**] cGy completed ([**2190-6-2**])
2) Hypertension
3) GERD
4) Anxiety
5) Palpitations
6) Hypothyroidism
7) Hypercholesterolemia
8) s/p resection of colonic polyps
Social History:
The patient is originally from [**Location (un) 6847**]. She has been in the
United States since [**84**]/[**2187**]. She denies exposure to heavy
chemicals of asbestos. Tobacco: Denies, though was exposed to
fumes during her work as a cook back in [**Location (un) 6847**].
EtOH: Denies. Illicits: Denies. Patient has 4 children.
Family History:
Non-contributory.
Physical Exam:
VS: T 97.1, HR 81, BP 112/57, RR 21, O2Sat 94% on 95% facemask
with 5L NC
GEN: Somnolent
HEENT: PERRL, EOMI, oral mucosa slightly dry
NECK: Supple, no [**Doctor First Name **]
PULM: Minimal breath sound on right, left side with coarse
breath sounds and basilar crackles
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND, non-tympanitic
EXT: no peripheral edema, significant clubbing of bilateral
fingernails
SKIN: no rashes
NEURO: Oriented x 3, somnolent, difficult to perform full neuro
exam in setting of language barrier and somnolence
Pertinent Results:
Lab results on admission:
[**2191-1-21**] 11:25PM WBC-8.9 RBC-3.91* HGB-10.4* HCT-33.2* MCV-85
MCH-26.5* MCHC-31.2 RDW-17.9*
[**2191-1-21**] 11:25PM NEUTS-84.8* LYMPHS-10.8* MONOS-3.7 EOS-0.4
BASOS-0.3
[**2191-1-21**] 11:25PM PLT COUNT-358
[**2191-1-21**] 11:25PM GLUCOSE-108* UREA N-40* CREAT-1.0 SODIUM-135
POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
[**2191-1-21**] 11:29PM TYPE-ART PO2-215* PCO2-59* PH-7.30* TOTAL
CO2-30 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2191-1-21**] 11:25PM PT-13.4 PTT-27.7 INR(PT)-1.1
[**2191-1-21**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-MOD
[**2191-1-21**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2191-1-21**] CXR:
IMPRESSION: Increased airspace consolidation overlying the left
lower lung
zone. Likely pneumonia or aspiration. Otherwise stable
appearance with stents overlying the right mid lung zone and
near entire collapse of the right hemithorax from known squamous
cell malignancy.
Brief Hospital Course:
This is a 72-year-old female with a history of non-small cell
lung cancer (diagnosed in [**2178**]), non-massive hemoptysis (s/p
right fifth posterior intercostal artery embolization on
[**2191-1-12**]), and recent admission for weakness ([**2191-1-14**] to
[**2191-1-18**]).
.
#. Hypoxia: Most likely related to new LLL infiltrate on chest
xray, though other possibilities include aspiration event or
health-care associated/community acquired PNA. As such, Ms.
[**Known lastname **] was covered broadly with vancomycin/zosyn/levofloxacin.
She was also treated for influenza with oseltamivir given her
poor pulmonary reserve. A DFA for flu and urine legionella
antigen were sent. However, despite the antibiotics and IVF,
Ms. [**Known lastname **] continued to be hypoxic. She was given maximal 02 with
venti mask, but still had increased work of breathing. After
long discussions with family, it was decided to make patient
DNR/DNI and not place invasive central venous catheters for
pressure support. Throughout the night on [**1-23**] patient had
increasingly labored breathing and the family was called to the
bedside. Ms. [**Known lastname **] eventually passed surrounded by family.
.
#. Hypotension: This was concerning for sepsis, even though Ms.
[**Known lastname **] was initially fluid responsive. She was continued on
fluids (as her 02 sats tolerated) and antibiotics. Moreover,
she developed a pronounced cardiac arrhythmia toward the end of
her life, which also contributed to her poor cardiac output.
.
#. Urinary tract infection: UTI on admission might also be
contributing to septic picture and altered mental status.
Again, antibiotic coverage with Vancomycin, Zosyn, Levofloxacin.
.
#. Somnolence: Multifactorial, with etiologies including
sepsis, hypotension, hypoxia, and hypercarbia. An ABG in ED
showed respiratory acidosis at 7.30/59/215. Patient was
ventilated maximally with venti mask, though no invasive
ventilation pursued as above.
.
#. NSCLC: Patient has survived well beyond the documented
expectations of her physicians. Most recently has had course
complicated by non-massive hemoptysis s/p embolization. She has
been on home hospice for approximately a year. Family
understood gravity of the situation and Ms. [**Known lastname 68912**] strength thus
far, but still hoped for a miracle.
Medications on Admission:
*per discharge on [**2191-1-19**]*
1) Acetaminophen 325-650 mg PO Q6H:PRN pain
2) Amiodarone 200 mg PO DAILY
3) Prednisone 5 mg PO DAILY
4) Metoprolol Succinate 25 mg PO DAILY
5) Pantoprazole 40 mg PO Q24H
6) Pravastatin 40 mg PO DAILY
7) Ranitidine HCl 150 mg PO HS
8) Morphine SR 15 mg PO Q12H
9) Docusate Sodium 100 mg PO BID
10) Multivitamin PO DAILY
11) Aspirin 81 mg PO DAILY
12) Ibuprofen 400 mg PO Q8H:PRN pain
13) Fentanyl 50 mcg/hr Patch Transdermal Q72H
14) Lasix 20 mg PO DAILY
15) Levothyroxine 100 mcg PO DAILY
17) Potassium Chloride PO
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
|
[
"799.02",
"780.09",
"486",
"530.81",
"427.89",
"162.3",
"V12.72",
"300.00",
"038.9",
"276.2",
"V45.89",
"244.9",
"599.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7547, 7556
|
4566, 6904
|
324, 330
|
7616, 7634
|
3474, 3486
|
2875, 2894
|
7506, 7524
|
7577, 7595
|
6930, 7483
|
7658, 7677
|
2909, 3455
|
277, 286
|
358, 1658
|
3500, 4543
|
1680, 2506
|
2522, 2859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,133
| 178,351
|
13808
|
Discharge summary
|
report
|
Admission Date: [**2188-10-15**] Discharge Date: [**2188-11-1**]
Date of Birth: [**2122-3-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Cortisone / Flovent
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR/MVR/LVAD placement
Past Medical History:
1. Aortic Valve Replacement [**2181**] (St. Jude's Valve)
2. HTN
3. DM (dx 1 year ago)
4. Hypercholesterolemia
5. Hypothyroidism
6. COPD
7. Atrial Fibrillation, on Coumadin, s/p multiple cardioversions
without success
8. Cardiac cath [**8-12**] showed NORMAL coronary arteries,
moderate/severe AR:
Cath Report:
1. Coronary arteries are normal.
2. Severe aortic regurgitation.
3. Moderate diastolic ventricular dysfunction.
Social History:
SOCIAL HISTORY: Patient lives with husband in [**Name (NI) 1411**], supportive
family. Reports 40-year smoking history, smoked 1 pack/week. No
ETOH, no IVDA.
Family History:
FAMILY HISTORY: Patient did not grow up with her family, so
family history is unknown. Brother did have CEA.
Brief Hospital Course:
1. CV: Pt was admitted with stable hemodynamics on [**2188-10-15**]. She
has been in atrial fibrillation since that time. Exam has shown
a stable III/VI SEM. Lungs have been clear to auscultation and
she has had no lower extremity edema or increased JVP. Pt was
taken off of Coumadin and started on heparin gtt upon admission
and was taken to CT surgery on [**2188-10-22**] to replace her prosthetic
aortic valve.
2. ID: Pt had originally had her surgery delayed due to molar
abscess and a elevated WBC which remained high for weeks as she
was treated with antibiotics. Upon admission, she had no signs
of molar abscess and between admission and surgery she was
afebrile without focal signs of infection. Her WBC was elevated
on [**10-21**] to 11.7 and then 14.8, but was WNL at 10.8 on the day of
surgery.
3. Renal: Patient's creatinine was consistently in the 1.0-1.3
range from admission until day of surgery.
4. Pulm: Patient has a hx of COPD but experienced no SOB from
admission until day of surgery.
5. DM: Patient's blood glucose on CMP ranged from 121 to 227
from admission until day of surgery. Her Metformin was
discontinued on [**2188-10-20**] and she was started on ISS in
preparation for her surgery.
Taken to the operating room on [**2188-10-22**] for an aortic valve
replacement and mitral valve replacement. After the valves were
placed, she suffered a catastrophic separation of her LA from
her LV after weaning from cardiopulmonary bypass. Please see
the operative note for detail of surgical events. She went back
on bypass, and had an LVAD placed. She was admitted to the CSRU
from the OR late that evening in critical condition. She had
significant bleeding problems, and was re-explored at the
bedside a number of times during her course. She remained on
inotropes and pressors, received multiple units of blood
products, and her condition ultimately began to stabilize. On
[**10-30**], she was noted to have increasing acidosis, and became
aneuric. CVVH was initiated, and her abdomen was explored at
the bedside by Dr. [**First Name (STitle) **]. Her bowel was ischemic, and her
abdomen was left open. The following day, her acidosis remained
profound, and she was taken for angiography of her SMA. This
showed no acute clot, but rather diffuse spasm. Papaverine
intra-arterial infusion was begun. By the following morning,
[**11-1**], she'd continued to deteriorate. Her acidosis had
worsened. Her LVAD flows began to decrease. She ultimately
became bradycardic, which progressed to asystole. She was
pronounced dead at 1115 on [**2188-11-1**].
Discharge Disposition:
Expired
Discharge Diagnosis:
aortic stenosis
mitral regurgitation
atrial fibrillation
cardiac failure
Discharge Condition:
EXPIRED
Completed by:[**2188-11-2**]
|
[
"785.51",
"276.2",
"998.59",
"428.0",
"995.92",
"396.2",
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"996.02",
"038.9",
"570",
"557.9",
"427.31",
"785.52",
"584.9",
"496",
"998.11",
"272.0",
"250.00",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.65",
"35.22",
"39.61",
"54.12",
"96.72",
"00.13",
"99.15",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
3701, 3710
|
1087, 3678
|
291, 315
|
3826, 3864
|
970, 1064
|
3731, 3805
|
248, 253
|
337, 762
|
794, 938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,372
| 176,291
|
48143
|
Discharge summary
|
report
|
Admission Date: [**2110-10-24**] Discharge Date: [**2110-10-31**]
Service: Medicine
CHIEF COMPLAINT:
Bright red blood per rectum and lightheadedness.
HISTORY OF PRESENT ILLNESS: The patient is an 87 year old
man in a rehabilitation facility, who was observed to have
bright red blood per rectum. He was seen to have a large
bowel movement with bright red blood as well as blood clots.
The patient felt dizzy and his blood pressure was taken as
90/40. He was given 250 cc of normal saline and transferred
to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], where his hematocrit
was found to be 19.9. His baseline hematocrit is around 29.
PAST MEDICAL HISTORY: 1. Dementia. 2. Frequent falls. 3.
Coronary artery disease, status post coronary artery bypass
grafting in [**2105**] and myocardial infarction in [**2093**]. 4.
Congestive heart failure with a left ventricular ejection
fraction of 25% in [**2104**]. 5. Intermittent atrial
fibrillation, not anticoagulated because of fall risk. 6.
Anemia. 7. Type 2 diabetes mellitus. 8. Hypertension. 9.
Hyperlipidemia. 10. Hypothyroidism. 11. Most recently
admitted from [**10-16**] for diuresis for
congestive heart failure exacerbation.
MEDICATIONS ON ADMISSION: Digoxin 0.125 mg p.o.q. Monday,
0.25 mg p.o.q. Wednesday, Lasix 80 mg p.o.b.i.d.,
spironolactone 25 mg p.o.q.d., Cozaar 50 mg p.o.b.i.d.,
glyburide 5 mg p.o.b.i.d., aspirin 81 mg p.o.t.i.d., Isordil
40 mg p.o.t.i.d., Colace, metformin 1,000 mg p.o.b.i.d., iron
sulfate 160 mg p.o.q.d., Lipitor 10 mg p.o.q.d., Casodex
(bicalutamide) 50 mg p.o.q.d., Synthroid 0.15 mg p.o.q.d.,
ranitidine 150 mg p.o.q.d., Toprol XL 50 mg p.o.q.d.,
hydralazine [**2119-11-22**] mg p.o.q. a.m./afternoon/p.m.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient was afebrile with a pulse of 72 to 80, blood
pressure 116/34, respiratory rate 15 and oxygen saturation
100%. General: Pale elderly gentleman in no acute distress.
Head, eyes, ears, nose and throat: Pupils equal, round, and
reactive to light and accommodation, fundi with sharp disks,
no hemorrhage, oropharynx without discharge, mucous membranes
dry. Neck: Supple, no bruits. Chest: Clear to
auscultation bilaterally, no wheezes, rales or rhonchi.
Cardiovascular: Regular rate and rhythm, normal S1 and S2,
no murmur. Abdomen: Soft, nontender, nondistended, positive
bowel sounds. Rectal: Normal tone, dark stool, guaiac
positive. Musculoskeletal: 5/5 strength in upper and lower
extremities. Neurologic examination: Alert and oriented
times three, poor short term memory.
Physical examination on discharge showed crackles to one-half
way up lungs, left greater than right, and 1+ edema to
mid-calves. Cardiovascular: Regular rate and rhythm.
Nasogastric lavage: Negative for blood.
LABORATORY DATA: Admission white blood cell count was 11.5
with 79.8 neutrophils, 0 bands, 12.6 lymphocytes, 5.9
monocytes, 1.1 eosinophils and 0.6 basophils, hemoglobin 6.7,
hematocrit 19.9, platelet count 329,000, sodium 132,
potassium 5, chloride 96, bicarbonate 29, BUN 63, creatinine
1.1, prothrombin time 12.9 and INR 1.1. Serial CK were 60,
45 and 24. [**2110-10-31**]: White blood cell count 14.2,
hemoglobin 11.8, hematocrit 33.4. [**2110-10-30**]: White
blood cell count 13, hemoglobin 11.3, hematocrit 33.9.
[**2110-10-29**]: White blood cell count 12.4, hemoglobin
12.1, hematocrit 36.4. [**2110-10-28**]: White blood cell
count 11.7, hemoglobin 12.1, hematocrit 35.4. [**2110-10-27**]: White blood cell count 14, hemoglobin 12.1, hematocrit
34.8. [**2110-10-26**]: White blood cell count 12.2,
hemoglobin 9.8, hematocrit 28.3. [**2110-10-31**]: Sodium
138, potassium 3.9, chloride 103, bicarbonate 25, BUN 23,
creatinine 1.1 and glucose 129. [**2110-10-29**]:
Helicobacter pylori antibody positive. [**2110-11-1**]:
Urinalysis (straight catheterization), greater than 50 red
blood cells, greater than 50 white blood cells, few bacteria,
no epithelial cells.
RADIOLOGIC DATA: Tagged red blood cell scan, [**2110-10-24**]: Blood flow images show increased diffuse activity in
the left side of the abdomen, delayed blood pool images
obtained over one hour show no increased activity in the
region of the gastrointestinal tract, delayed blood pool
images obtained over a third half-hour show a brief focus of
increased activity in the left mid-abdomen, the activity
moves up into the left and diffuses out over one-half hour;
impression, (1) increased diffuse activity over the left side
of the abdomen could represent a region of hyperemia which
can be seen with diverticulitis, (2) brief focus of activity
over the left mid-upper quadrant of the abdomen could
represent a small bleed which disperses in the bowel, its
location is difficult to identify but could represent
bleeding in the transverse colon.
[**2110-10-26**] chest x-ray: Increased pulmonary
vascularity with associated perihilar haziness in a bilateral
lower lobe interstitial pattern; there are probably small
pleural effusions bilaterally; impression, congestive heart
failure with interstitial edema and probable small bilateral
pleural effusions. [**2110-10-31**], chest x-ray
(unofficial read): Left lower lobe infiltrate, small nodular
opacity in the right lung at level between fifth and sixth
ribs.
[**2110-10-28**], small bowel follow-through: Several air
filled loops with small and large bowel throughout the
abdomen; the patient was given barium to drink and this
reached the cecum over three to four hours; no intrinsic mass
effect or filling defects are seen over 1 cm in size; the
terminal ileum was normal in appearance; impression, no
obvious mass or mass effect is identified. [**2110-10-27**], upper gastrointestinal endoscopy: Reducible small
sized hiatal hernia in the esophagus, stomach with diffuse
continuous erythema of the mucosa with no bleeding noted in
the antrum; these findings are compatible with gastritis;
duodenum, multiple cratered nonbleeding ulcers ranging in
size from 2 to 5 mm were found in the duodenal bulb.
HOSPITAL COURSE: The patient felt asymptomatic during his
hospital stay. He himself did not complain of shortness of
breath, weakness or dizziness, although he is a poor
historian. He was admitted to the Medical Intensive Care
Unit initially, where two large bore intravenous lines were
placed. He received three times daily hematocrit checks and
was transfused with four units of packed red blood cells,
with appropriate hematocrit bump to 29.
The patient was then transferred to the floor and given two
more units. His hematocrit was 31.5 afterwards. He had no
further transfusions and his hematocrit was 34.4 on
discharge. His stool was guaiac negative on discharge. His
antihypertensive medications, besides losartan, were held for
most of the hospitalization because of the concern of risk
for hypotension, especially given his likely recent bleed.
He was restarted on Toprol XL 50 mg daily and Lasix 80 mg
twice a day on [**2110-10-30**]. He had a systolic blood
pressure of approximately 130 and pulse approximately 75 on
these medications. He will be discharged with his baseline
antihypertensive regimen, which includes Isordil 40 mg three
times a day and hydralazine [**2119-11-22**] mg in the morning, noon
and evening, with hold parameters applied. He usually had a
regular rate and rhythm but occasionally was in atrial
fibrillation. As evaluated on previous admission, the
patient is a poor candidate for anticoagulation given that he
has a history of frequent falls.
On [**2110-10-27**], the patient underwent an upper
gastrointestinal endoscopy which showed multiple, 2 to 5 mm,
nonbleeding duodenal ulcers. Colonoscopy was attempted on
[**2110-10-27**], but failed because the patient had too
much residual stool despite having consumed one gallon of
GoLYTELY. A colonoscopy was successfully performed after he
drank another gallon. The colonoscopy revealed nonbleeding,
grade II, internal hemorrhoids and diffuse continuous
melanosis. Otherwise, he had a normal colonoscopy with no
evidence of bleeding. A small bowel follow-through,
performed on [**2110-10-28**], also was normal and did not
yield a source of bleeding.
The source of the patient's gastrointestinal bleed,
therefore, was most likely his duodenal ulcers. He was found
to be Helicobacter pylori positive and was started on triple
therapy as well as a proton pump inhibitor twice a day for
life. He had been receiving 81 mg of aspirin three times a
day prior to admission. Because of his ulcers, yet his
multiple cardiac risk factors, it was decided to continue him
on aspirin but only on 81 mg per day.
A chest x-ray on [**2110-10-30**] revealed a possible small
nodule in the left lung at the level between the fifth and
six ribs. This could potentially be followed up with an
outpatient CT scan. However, given the patient's age and his
co-morbidities, as well as his being an extremely poor
candidate for chemotherapy or surgery, this workup may not be
necessary. The chest x-ray also revealed a left lower lobe
infiltrate. The patient had been afebrile and without cough
during his hospitalization. He will be started on
levofloxacin 250 mg per day for ten days. His urinalysis on
[**2110-10-30**] showed a possible urinary tract infection,
which levofloxacin would cover. He did have red blood cells
in his urine and it is unclear whether this is due to trauma
from catheter insertion. He should have a repeat urinalysis
as an outpatient.
CONDITION AT DISCHARGE: Guarded, owing to the patient's
baseline health with multiple co-morbidities.
DISCHARGE STATUS: Full code.
DISCHARGE DIAGNOSES:
Gastrointestinal bleed, likely from duodenal ulcers.
Positive for Helicobacter pylori.
DISCHARGE MEDICATIONS:
Digoxin 0.125 mg p.o.q. Monday, 0.25 mg p.o.q. Wednesday.
Lasix 80 mg p.o.b.i.d.
Spironolactone 25 mg p.o.q.d.
Cozaar 50 mg p.o.b.i.d.
Glyburide 5 mg p.o.b.i.d.
Aspirin 81 mg p.o.q.d.
Isordil 40 mg p.o.t.i.d.
Colace one to two tablets p.o.b.i.d.p.r.n. constipation.
Metformin 1,000 mg p.o.b.i.d.
Iron sulfate 160 mg p.o.q.d.
Lipitor 10 mg p.o.q.d.
Casodex (bicalutamide) 50 mg p.o.q.d.
Synthroid 0.15 mg p.o.q.d.
Omeprazole 30 mg p.o.b.i.d.
Toprol XL 50 mg p.o.q.d.
Hydralazine [**2119-11-22**] mg p.o.q. a.m./afternoon/p.m., hold for
systolic blood pressure less than 100.
Levofloxacin 250 mg p.o.q.d., last day [**2110-11-9**].
Clarithromycin 500 mg p.o.b.i.d., last day [**2110-11-11**].
Amoxicillin 1 gm p.o.b.i.d., last day [**2110-11-11**].
DISPOSITION: The patient was discharged to a rehabilitation
facility for work on his ambulation. His wife should contact
Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 101490**] to schedule a follow-up appointment in
about three weeks. Dr. [**Last Name (STitle) 101490**] is at [**Telephone/Fax (1) 101491**]. Mrs.
[**Known lastname 62041**] is at [**Telephone/Fax (1) 101492**].
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2110-10-31**] 15:25
T: [**2110-11-3**] 08:40
JOB#: [**Job Number **]
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|
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|
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|
6163, 9615
|
1835, 2594
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9630, 9740
|
111, 161
|
190, 728
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2619, 6145
|
751, 1294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,743
| 136,583
|
50438
|
Discharge summary
|
report
|
Admission Date: [**2176-12-20**] Discharge Date: [**2177-1-8**]
Date of Birth: [**2108-4-1**] Sex: M
Service: MEDICINE
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Cough, shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 68 year old gentleman with h/o CAD, DM2, HTN, hep C
who presents with 4 days of productive cough and shortness of
breath. He reports that beginning 4 days ago, he developed
cough productive of yellow/brown sputum which has worsened over
this time period. He notes shortness of breath worsening in
this setting. He endorses chills, but denies subjective fevers.
He also reports anterior chest pain with coughing and worse
with deep inspiration.
.
In addition, over the past several days he has had profuse
watery diarrhea which has slowed yesterday and no episodes
today. He reports he noted "specks of blood" in his stool when
the diarrhea was heavy. He reports stool was dark in color, not
black; he has not been taking his iron. He also reports N/V and
throwing up "black specks", no bright red blood, but this too
has resolved. He denies abdominal pain.
.
In the ED, initial vs were: T 100.7 P 108 BP 100/60 RR 20 O2 sat
85%RA-->100%NRB. CXR demonstrated a diffuse patchy opacity in
the right lower lobe consistent with pneumonia with a possible
second focus of pneumonia at the left lung base versus
atelectasis. There was also question of accompanying right
parapneumonic effusion. On exam he had guaic negative brown
stool. He received 2L NS and 1L with 40meq KCL. Additionally,
he received 750mg IV levofloxacin. He was written for 40meq PO
KCL x2, but he did not tolerate the doses.
.
On arrival to the ICU, he says he still feels SOB, but improved.
He c/o CP with cough and deep inspiration. He reports his
neuropathy is "awful" and requests his pain medications.
.
Review of sytems:
(+) Per HPI
Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. No palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Chronic
arthritic pain, no myalgias. + neuropathic pain. He does
report intermittent symmetric LE swelling that is chronic.
Denies orthopnea/PND.
Past Medical History:
- Diabetes Mellitus (dx in [**2156**]) complicated by neuropathy and
retinopathy, but currently not on insulin
- Low Back Pain s/p "many" spine surgeries
- Sleep Apnea
- Depression
- Hepatitis C
- Hypertension
- Asthma
- Hypercholesterolemia
- Coronary Artery Disease s/p MI in [**2148**] and [**2153**], says he had
angioplasties in the past
- Squamous Cell Carcinoma of the oropharynx
- Varicose Vein Surgery in [**2153**] and [**2156**]
- Stroke in [**2157**] and [**2159**] without residual deficits
- Iron Deficiency Anemia
- Lung nodule
- h/o asbestos exposure
Social History:
Occupation: previously employed with IRS, but not working since
first MI in 80s
Home: lives alone but with supportive friends
[**Name (NI) 1139**]: quit 30 years ago; 40 PPY
EtOH: denies
Non-prescription Drugs: denies
Family History:
CAD
Type 2 DM
Physical Exam:
General: Alert, oriented, no acute distress, able to speak in
full sentences. Coughs intermittently during exam productive of
yellow sputum.
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased BS right base, but o/w without significant
wheezes, rales, rhonchi.
CV: Borderline sinus tachy, no mrg appreciated.
Abdomen: +BS, mildly TTP diffusely, without rebound/guarding.
Ext: Tender to even light touch b/l LEs. No edema.
Pertinent Results:
[**2176-12-20**] CXR: A diffuse patchy opacity in the right lower lobe
consistent with pneumonia. There may be a second focus of
pneumonia at the left lung base versus atelectasis. Question
likely accompanying right parapneumonic effusion.
.
EKG: Sinus tachycardia at a rate of 103. Wavy baseline, but
has TW flattening in III, aVF. TWI in V1 (old), TW flattening
in V2.
Brief Hospital Course:
68 y/o M with DM, sleep apnea, admitted with nausea and CA
pneumonia, developed aspiration pneumonia and then ventilator
associated pneumonia.
.
MICU COURSE
Mr. [**Known lastname **] returned to the micu after initially being treated for
a MSSA CAP and MSSA bacteremia, for which he was receiving a
planned course of nafcillin until [**2177-1-2**]. the reason for
re-admission to the ICU was an aspiration event. He required
intubation due to hypoxemia and developed ARDS. Has was
supported with mechanical ventilation and slowly recovered,
getting extubated on [**2175-12-31**]. He did have some hypotension while
intubated, presumed due to sedating medications. He was
pancultured to rule out sepsis. One blood culture out of two
from [**12-31**] returned with GPCs, presumed contaminant. Nonetheless,
given that he was low grade febrile and had a slight WBC count,
his nafcillin was braodened to vanco and zosyn. This was
narrowed back to just vancomycin on [**2177-1-2**], with a plan to d/c
all antibiotics in 48-72 hours if surveillence cultures were
negative. during his MICU course he was noted to occasionally
have some loose guaiac positive diarrhea but never required
transfusion.
.
RESPIRATORY FAILURE: Patient was admitted to the ICU with
community-acuqired pneumonia and aspiration pneumonitis. There
was some concern that he might be developing a
ventilator-acquired pneumonia, however pulmonary function has
been improving. Legionella and flu studies negative. Sputum
culture showed MSSA and he completed 12 days of gram positive
coverage. He completed 11 days of GP/GN coverage following
aspiration event. Positive blood cultures were likely a
contaminant. He did have a spike in WBC on [**12-31**] that has been
trending down. He has had chest discomfort with deep inspiration
and with coughing. He continues to have LLL and RUL
opacifications on CXR, with developing RLL consolidation. He was
evaluated by speach and swallow on [**2176-1-1**] who found him to be
unsafe to take PO. Since then, he was reevaluated. Diet was
advance and he tolerated a ground consistency, thin liquid diet
without further aspiration. He was treated with Vanc/Zosyn for 8
day course from [**12-31**] to [**1-7**] for VAP. After starting this
antibiotic course, he was afebrile with normal WBC. He was
weaned to 3 L/min O2.
.
NAUSEA: Patient had nausea, vomiting, and diarrhea on admission
that resolved initially. He was treated with zofran PRN with
good effect. He was on Prilosec as an outpatient, now on
lansoprazole. Stool was C. diff negative. He was continued on
a [**Hospital1 **] PPI. He did not have any [**Doctor First Name **] or bloody stools.
.
TYPE 2 DIABETES: Diet controlled per patient at home. He was
continued on ISS and Lantus while in house. His insulin was
discontinued on discharge per request of his PCP.
.
CORONARY ARTERY DISEASE: Ischemia ruled out by CE and ECG. He
was continued on ASA, and statin.
.
CHRONIC PAIN: Mainly in the setting of neuropathy, although it
is unclear if this could be related to his diabetes. He was
continued on his outpatient pain regimen with duragesic patch,
neurontin, oxycodone prn. He was not discharged with narcotics
as he already has perscriptions for this from his PCP.
.
LUNG NODULE: He had a lung nodule noted on [**10-2**] CT abd and
appeared more prominent than [**1-/2176**] study measuring 8mm. 6 month
f/u imaging was recommended. Does have possible left lung base
infiltrate as well but mass not visualized on CXR and seems less
likely to represent postobstructive pneumonia.
.
ANEMIA: Baseline hct fluctuates somewhat, but appears most
consistently mid 30s. Low MCV with h/o iron deficiency, but
patient reports he is not taking iron any longer. Iron studies
from [**2174**] c/w Fe deficiency. B12 and folate normal in [**10-2**].
Guaiac negative on exam in the ED. No c-scope in our system
since [**2167**] at which time poor prep, but did not show significant
pathology. Hct has been trending down in ICU. No bloody or
melinotic stools.
- Follow Hct as outpatient, consider for Iron therapy
- Outpatient colonoscopy
- Continue PPI
.
REMOTE HCV INFECTION: stable. pt reported history of Hep C
infection, but no active RUQ pain or abnormal LFTs. Confirmed
anti-HCV Ab positivity, no viral load in our system. HepB
serologies negative for past/prior infection.
.
HYPERLIPIDEMIA: Continue pravastatin
.
HYPERTENSION: Patient on diltiazem at home, but pressures have
been stable here. He has not required antihypetensives.
.
ASTHMA: PFTs in our system last from [**2168**] at which time they
were normal.
- continue home ipratropium prn; add albuterol prn
.
BENIGN PROSTATIC HYPERTROPHY: Cont home finasteride.
.
FEN: Continue tube feeds. Replete electrolytes.
.
PROPHYLAXIS: Subcutaneous heparin. On PPI as outpatient.
.
ACCESS: PIVs.
.
CODE: FULL.
.
COMMUNICATION: Health care proxy is his friend [**Name (NI) **] [**Name (NI) 105097**],
phone number: [**Telephone/Fax (1) 105098**]
Medications on Admission:
Neurontin 1600 mg tid
Celebrex daily
Diltiazem 90 mg daily
Pravastatin 20mg daily
Baby Aspirin 81 mg daily
Nitroglycerin 0.3 mg Sublingual prn
??Lasix 40 mg daily (not sure if he's taking)
Prilosec
MVI
Oxycodone 20mg tid prn
Clonazepam 2mg hs prn
Diazepam 5mg [**Hospital1 **] prn
Zoloft 150 mg hs
Trazodone 150 mg hs
Colace 100 mg [**Hospital1 **]
Vitamin D 800 units daily
Salsalate 1500 mg [**Hospital1 **]
Celecoxib 200 mg [**Hospital1 **]
Ipratropium MDI
Trazodone 150 mg daily
Sertraline 150 mg daily
Aspirin 81 mg daily
Nitroglycerin 0.3 mg SL prn
Duragesic 600 mcg/hr Patch 72 hr (verified by old d/c summary
and with patient)
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
3. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Fentanyl 100 mcg/hr Patch 72 hr Sig: Six (6) Patch 72 hr
Transdermal Q72H (every 72 hours).
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed as needed for chest pain: Seek medical
attention if CP does not resolve.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
11. Oxycodone 20 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
12. Neurontin 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Salsalate 500 mg Tablet Sig: Three (3) Tablet PO three times
a day.
15. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. Diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
17. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Outpatient Lab Work
CBC
19. Home oxygen
4L/min nasal canula oxygen, to be worn continuously. To be
weaned as tolerated per ongoing VNA assessment to maintain O2
saturation 92-95 %.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
COMMUNITY-ACUQIRED PNEUMONIA
VENTILATOR-ACQUIRED PNEUMONIA
ASPIRATION PNEUMONIA
ACID REFLUX
TYPE 2 DIABETES
CORONARY ARTERY DISEASE
CHRONIC PAIN
LUNG NODULE
ANEMIA
REMOTE HCV INFECTION
HYPERLIPIDEMIA
HYPERTENSION
ASTHMA
BENIGN PROSTATIC HYPERTROPHY
Discharge Condition:
Stable, on 3L oxygen
Discharge Instructions:
You were admitted for an infection in your lungs. While you
were being treated for this infection, you choked on some of
your food. You were taken to the intensive care unit and
intubated. You may also have developed an infection in your
lungs while intubated. We gave you antibiotics to treat all
three infections.
Please keep all scheduled appointments.
Please seek medical attention if you have new trouble breathing,
choke on your food, have dark stools, bloody stools,
lightheadedness, or any other concenring symptoms.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name (STitle) 4702**] at
[**2-13**] at 2:00 PM.
You can call [**Telephone/Fax (1) 105099**] if you need to change this.
Completed by:[**2177-1-9**]
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"V45.82",
"362.01",
"311",
"458.29",
"V12.54",
"412",
"724.5",
"276.0",
"792.1",
"997.31",
"276.52",
"414.01",
"787.22",
"518.89",
"041.11",
"600.00",
"482.41",
"518.5",
"V15.84",
"070.54",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11460, 11517
|
4120, 9084
|
295, 302
|
11810, 11833
|
3720, 4097
|
12412, 12623
|
3192, 3207
|
9770, 11437
|
11538, 11789
|
9110, 9747
|
11857, 12389
|
3222, 3701
|
229, 257
|
1950, 2349
|
330, 1932
|
2371, 2940
|
2956, 3176
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,341
| 121,351
|
30890
|
Discharge summary
|
report
|
Admission Date: [**2145-7-23**] Discharge Date: [**2145-7-31**]
Date of Birth: [**2084-3-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
SVC syndrome
Major Surgical or Invasive Procedure:
possible TPA clot lysis and SVC venogram and angioplasty???
History of Present Illness:
61 year old man with metastatic esophageal cancer to liver and
lung presents with 2-3 days of vague facial swelling. Yesterday
morning, patient began to complian of mild positional dyspnea
with standing. Yesterday afternoon, patient developed acute
facial swelling and plethora and bilateral UE edema. He had
stopped his lovenox 5 days prior after completed a shorted
course as determined given the emphasis on quality of life and
goals of care. Lovenox was for a sponatenous R upper extremity
DVT on [**6-8**].
.
He began on epirubicin, cisplatin, and Xeloda on [**2145-5-20**].
However, he developed severe dehydration, mouth sores, and
overall failure to
thrive on this and was admitted to the hospital on [**5-28**], eight
days after his treatment. He ended up having a prolonged
admission for several weeks during which time he developed
febrile neutropenia, numerous infections, and pneumococcal
bacteremia as well as acute renal failure and thrombocytopenia.
He also was found to have right and was started on Lovenox for
that. Patient has TPN/lab dual port, esophageal stent placed,
was admitted with facial swelling and found to have SVC syndrome
likely due to a clot in the SVC around his port.
.
In the ED, VSS, CT chest with no evidence of PE but evidence of
acute on chronic SVC syndrome. Patient was started on heparin
drip.
.
ROS: otherwise negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
He initially presented in [**11/2142**] due to dysphagia and weight
loss. At that time, he had a barium swallow, which showed a
pinpoint narrowing of his distal esophagus. He had endoscopy
and underwent dilatation of this stricture. He did not have
much improvement with the dilatation and in [**Month (only) 116**] of this year
underwent a second dilatation once again with no improvement.
He had motility tests, which were most consistent with
achalasia. In [**Month (only) **], he underwent a Botox injection to the
narrowing in order to help to release it. He had a CT scan
after this which showed a 1.5 cm gastrohepatic lymph node. On
[**2143-8-28**] he underwent an upper endoscopy on which they saw
distal esophageal narrowing. They also performed multiple
biopsies of the area of narrowing. Of note, they saw some
ulceration in the GE junction and a thick abnormal fold
concerning for esophageal or gastric cardia cancer. The biopsy
showed moderate to poorly differentiated adenocarcinoma. After
this he underwent endoscopic ultrasound, however, they were
unable to pass the ultrasound probe beyond the stricture. He
has had a port, g-tube, and esophageal stent
placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**]
with concurrent radiation therapy. Radiation was completed on
[**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**]
with febrile neutropenia and dehydration. He underwent an
esophagectomy on [**2144-1-20**]. Pathology from this showed a
metastatic adenocarcinoma with 4/6 perigastric lymph nodes
positive, and a separate foci of tumor in the adjacent adipose
tissue. He completed treatment in [**2144-1-4**]. He had liver
lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on
[**2145-1-27**] and the pathology came back as consistent with
metastasis from esophageal cancer.
.
PAST MEDICAL HISTORY:
====================
- Esophageal cancer- moderate to poorly differentiated
adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in
[**10-11**], now s/p minimally invasive esophagectomy [**1-10**].
- h/o atrial fibrillation
- h/o S. viridans bacteremia
- Sinusitis, status post surgery
- Hypertension
- Vocal cord paralysis
Social History:
He originally moved from [**Country 6171**] 17 years ago. Married, 2
children. Teaches French and Spanish. He used to smoke a pack a
day, but quit 15 years ago. He used to drink a couple of glasses
of wine with dinner each night, but not since diagnosis.
Family History:
He has a father with pancreatic cancer who died at the age of
70.
Physical Exam:
Vitals - 96.3, 126/70, 111, 22, 93% 2L
GENERAL: NAD, very pelasant gentleman, hoarse
SKIN: warm and well perfused, UE plethora, superficial veins
over abdomen serving as collaterals
HEENT: AT/NC, EOMI, PERRLA, facial plethora, endemotous cheeks,
anicteric sclera, patent nares, MMM, good dentition, no LAD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, bilateral upper ext plethora
and hand swelling, 1+ pitting,
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower
extremities, DTRs [**6-8**]
Pertinent Results:
[**2145-7-23**] 03:30AM PT-12.9 PTT-22.3 INR(PT)-1.1
[**2145-7-23**] 03:30AM WBC-9.4 RBC-4.40* HGB-13.7* HCT-41.1 MCV-93
MCH-31.1 MCHC-33.3 RDW-16.1*
[**2145-7-23**] 03:30AM CK-MB-NotDone cTropnT-<0.01 proBNP-110
[**2145-7-23**] 03:30AM ALT(SGPT)-70* AST(SGOT)-32 CK(CPK)-20* ALK
PHOS-224* TOT BILI-0.6
[**2145-7-23**] 03:30AM GLUCOSE-114* UREA N-29* CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
CTA Chest [**2145-7-23**]:
1. Narrowed lumen of the distal SVC is chronic. However,
thrombosis of the
SVC along the MediPort catheter is new. Together with diffuse
stranding of
the upper chest wall and opacification of multiple collateral
vessels,
findings are consistent with SVC syndrome.
2. Status post esophagectomy with gastric pull-up. The gastric
pull-up is
filled with fluid. Tree-in-[**Male First Name (un) 239**] opacities in the right lung are
improved. Mild
consolidation in the left lower lung was previously present and
may represent
aspiration with atelectasis.
3. Left pleural effusion is improved.
4. Liver metastases.
5. Likely evolving splenic infarct.
6. Left diaphragmatic hernia containing a loop of transverse
colon.
Venogram:
Brief Hospital Course:
Patient is a 61 year old Male with metstatic esophageal cancer
presenting with SVC syndrome secondary port clot on hep gtt.
.
# SVC syndrome - Secondary to visible port clot on dual lumen
port placed in 7/[**2143**]. Patient had completed course of lovenox
for R UE dvt spontanous 5 days prior. Patient will now need
lifelong anticoagulation. No indication for steroids or
diruetics. Endovascular stent placement not needed and no
evidence of airway obstruction. Pt was started on heparin gtt
with improvement of sxs. Subsequent venogram continued to show
extensive clot burden. Pt had a TPA infusion for 1 day without
complete resolution of the clot; pt was monitored in the ICU
during this time and there were no complications. Discussion
among oncology, surgery, and IR resulted in the decision NOT to
remove the port. Pt was transitioned from heparin gtt to
lovenox on the floor
.
# Esophageal cancer - known liver and lung mets. Causing
external compression of SVC. Patient was not able to tolerate
chemo. given progression of disease, goal is quality of life.
Family meeting was done as outpatient and no further chemo to be
administered.
.
# Nutrition - patient was started on TPN one month in setting of
progression of esophageal ca and colitis. Patient is Eating 3
meals per day with 1-2 nutritional supplements. Megace had been
stopped on previous admission but resuming now.
- regular diet with ensure supplementation
- nutrition c/s for TPN taper, not done now, since no TPN
- patient successfully tolerated PO, eating croissants, ensure
and a regular diet prior to d/c
.
# FULL CODE
Medications on Admission:
Lovenox 80mg SC BID
Lorazepam 0.5-1mg q4-6h prn
Megestrol 400 mg PO daily
Metoclopramide 5mg TID
Metoprolol 100mg [**Hospital1 **]
Oxycodone 5-10mg q4-6h prn
Prochlorperazine 10mg q6-8h prn
omeprazole 20mg PO daily
Zolpidem 10mg hs prn
zofran 8mg PO Q8h prn
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous every twelve (12) hours.
Disp:*100 syringes* Refills:*2*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for nausea.
3. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
DAILY (Daily).
Disp:*QS QS* Refills:*2*
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
9. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Tablet(s)
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
16. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for nausea.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Primary:
SVC symdrome secondary to clot around mediport
s/p lysis of clot
s/p venogram and ballon angioplasty and rotorooter
metastatic esophageal cancer
s/p Upper DVT
Discharge Condition:
stable, afebrile, tolerating diet
Discharge Instructions:
You were admitted for facial swelling which was found to be
caused by a clot around your port site causing "superior vena
cava" syndrome. You required clot lysis with a heparin drip. You
are to continue lovenox for lifelong anticoagulation. You
underwent a venogram and a vessel angioplasty balloon dialation
procedure. Please take all medications as prescribed. Go to all
scheduled follow up appointments.
.
Contact your physician if you develop repeated swelling of your
face or upper extremity edema as this may reflect another clot
around your port. Development of unilateral leg swelling or
sudden shortness of breath and chest pain may also reflect a
blood clot.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 3731**] Date/Time:[**2145-8-10**]
10:30
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2145-8-10**] 1:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2145-8-12**] 10:00
Completed by:[**2145-7-31**]
|
[
"401.9",
"459.2",
"996.74",
"197.0",
"E878.8",
"197.7",
"427.31",
"V10.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"00.41",
"39.50",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
10194, 10285
|
6307, 7910
|
284, 345
|
10499, 10535
|
5090, 6284
|
11252, 11707
|
4326, 4393
|
8218, 10171
|
10306, 10478
|
7936, 8195
|
10559, 11229
|
4408, 5071
|
232, 246
|
373, 1741
|
3708, 4037
|
4053, 4310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,916
| 139,456
|
30135
|
Discharge summary
|
report
|
Admission Date: [**2162-5-17**] Discharge Date: [**2162-5-22**]
Service: CARDIOTHORACIC
Allergies:
Naproxen / Erythromycin Base
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2162-5-17**] - AVR(21mm [**Company 1543**] Mosaic Pericardial Valve)
History of Present Illness:
This is an 83-year-old woman who was diagnosed with severe
aortic stenosis and was followed through the years until the
recent echocardiogram showed [**First Name8 (NamePattern2) **]
[**Location (un) 109**] of 0.6 with a normal LV function.
Past Medical History:
HTN
AS/AI
Social History:
Retired. Never smoked and rarely drinks.
Family History:
None
Physical Exam:
84 SR 140/80 140/80 63" 185
GEN: NAD
HEENT: Unremarkable
LUNGS: Clear
HEART: RRR, III/VI SEM
ABD: Benign
EXT: Warm, well perfused, 2+ pulses.
NEURO: Nonfocal
Pertinent Results:
[**2162-5-17**] ECHO
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thicknesses and cavity size are
normal. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Moderate to severe (3+) aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB: There is an aortic valve prosthesis with no peri-valve
leaks and no AI. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) 50255**] systolic
fxn. Aorta intact. Other parameters as pre-bypass.
[**2162-5-20**] CXR
AP single view of the chest is analyzed in direct comparison
with a similar preceding study of [**2162-5-17**]. During the
interval, the patient has been extubated, the Swan-Ganz catheter
and the right jugular sheath have been removed and the same
holds for the bilateral chest tubes and mediastinal tubes
including the NG tube. There is no evidence of a pneumothorax
nor are there any significant pulmonary parenchymal
abnormalities or evidence of pulmonary vascular congestion. The
lateral pleural sinuses remain free. On previous examination
demonstrated left lower lobe atelectasis has cleared up.
Brief Hospital Course:
Ms. [**Known lastname 10116**] was admitted to the [**Hospital1 18**] on [**2162-5-17**] for surgical
management of her aortic valve stenosis. She was taken directly
to the operating room where she underwent an aortic valve
replacement using a 21mm [**Company 1543**] Mosaic Pericardial Valve.
Postoperatively she was taken to the intensive care unit for
monitoring. She later awoke neurologically intact and was
extubated. On postoperative day one, she was transferred to the
step down unit for further recovery. Later that day, she
developed rapid atrial fibrillation which was treated with IV
lopressor. She developed long pauses with loss of consciousness
and was temporarily paced. She was thus returned to the
intensive care unit for further monitoring. She was gently
diuresed towards her preoperative weight. The physical therapy
service was consulted for assistance with her postoperative
strength and mobility. She ultimately converted back into a
normal sinus rhythm and was transferred back to the step down
unit for further recovery. She continued to make steady progress
and was discharged home on [**2162-5-22**]. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Toprol xl 25'
Lisinopril 10'
Terazosin 5'
Aspirin 81'
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
AS/AI s/p AVR
HTN
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain 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. 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.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**] (Cardiologist) in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 71814**] (PCP) in [**2-14**] weeks.
Call with all questions or concerns.
Completed by:[**2162-5-26**]
|
[
"424.1",
"427.32",
"780.2",
"401.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
4500, 4549
|
2354, 3609
|
262, 336
|
4611, 4618
|
919, 2331
|
5129, 5480
|
714, 720
|
3713, 4477
|
4570, 4590
|
3635, 3690
|
4642, 5106
|
735, 900
|
203, 224
|
364, 606
|
628, 640
|
656, 698
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,069
| 134,335
|
35082
|
Discharge summary
|
report
|
Admission Date: [**2106-10-17**] Discharge Date: [**2106-10-22**]
Date of Birth: [**2053-8-28**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right sided weakness and slurred speech, CODE STROKE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 yo RH [**Male First Name (un) 4746**] with PMH of HTN, ETOH abuse until recently,
long-standing tobacco abuse, positive family history for stroke,
no regular health care, who was noticed to have an acute onset
of difficulty speaking this afternoon around 1:10PM. It was
also noticed that he was slurring his words somewhat. His
presented to [**Hospital3 417**] in [**Hospital1 1474**]. ED physicians mainly
noticed the expressive aphasia, but not loss of strength. He was
given iv tPA around 2 hours after onset. A hCT showed a
pronounced hypodensity in the right frontal area. Althought his
was interpreted as a sign of acute stroke, retrospectively, this
appears to be an old stroke. There were no clear hypodensity on
the left and no clear loss of [**Doctor Last Name 352**]-white matter
differentiation. He tolerated the bolus and the infusion well.
His EKG was normal and his baseline INR was 1.1. He was on one
BP med, but he does not know which one. He was transferred to
[**Hospital1 18**] for further care. At arrival at [**Hospital1 18**], his expressive
aphasia had largely resolved.
Past Medical History:
Previous cerebral vascular surgery, at [**Hospital3 **] (circa [**2102**])
Hypertension
EtOH abuse
Tobacco Abuse
Right shoulder surgery
Chronic right knee injury
Social History:
History of EtOH and tobacoo abuse. Lives in an apartment with
his cat. His brother is his health care proxy (and the above HPI
was verified with his brother) [**Name (NI) **] cell: [**Telephone/Fax (1) 80134**].
PCP is Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Street Address(2) **], [**Hospital1 1474**].
Family History:
Mother has HTN and has had strokes.
Physical Exam:
Vitals: T 97.1, HR 88, BP 156/92, RR 18, SpO2 98%
General: unkempt, nicotine stained and filthy nails
CVS: S1+2 no added sounds
Lungs: fine [**Last Name (un) 38142**] at the bases
Abd: soft, non-tender, normal bowel sounds
Neurological examination
NIHSS = 0
Expressive aphasia had largely resolved, slight dysarthria (very
softly spoken). He is fluent, comprehends well, can name all
high
frequency items and can repeat. He is oriented x 3 and grossly
attentive, can register 3 objects and repeat them in 5 minutes.
No right/left confusion, no apraxia. He has no facial asymmetry.
All cranial nerves are intact. He has a very mild left UE
pronation, no clear drift. Formal strength testing is normal.
Reflexes are symmetric. Sensation is grossly intact.
Coordination: he has symmetric FFM and [**Doctor First Name **]. Gait not assessed.
Pertinent Results:
LABS:
[**2106-10-17**] 08:50PM BLOOD WBC-6.7 RBC-4.06* Hgb-13.1* Hct-34.8*
MCV-86 MCH-32.3* MCHC-37.7* RDW-12.5 Plt Ct-396
[**2106-10-22**] 06:00AM BLOOD WBC-6.4 RBC-4.06* Hgb-13.2* Hct-35.1*
MCV-87 MCH-32.4* MCHC-37.4* RDW-12.6 Plt Ct-398
[**2106-10-17**] 08:50PM BLOOD PT-13.7* PTT-29.5 INR(PT)-1.2*
[**2106-10-17**] 08:50PM BLOOD Glucose-92 UreaN-17 Creat-1.1 Na-132*
K-3.8 Cl-96 HCO3-24 AnGap-16
[**2106-10-22**] 06:00AM BLOOD Glucose-97 UreaN-12 Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
[**2106-10-18**] 03:24PM BLOOD ALT-19 AST-7 AlkPhos-19* TotBili-0.4
[**2106-10-17**] 08:50PM BLOOD Calcium-9.9 Phos-4.5 Mg-1.9
[**2106-10-18**] 03:24PM BLOOD TotProt-6.5 Albumin-2.1* Globuln-4.4*
Cholest-146
[**2106-10-18**] 03:24PM BLOOD Triglyc-98 HDL-25 CHOL/HD-5.8 LDLcalc-101
[**2106-10-18**] 03:24PM BLOOD %HbA1c-5.9
[**2106-10-18**] 03:24PM BLOOD Ammonia-20
IMAGING:
CTA Head/Neck, CTP ([**10-17**]): IMPRESSION:
1 Area of reversible ischemia in the distribution of the left
middle cerebral artery. No evidence of conversion to acute
infarction.
2. Stenosis at the origin of the left vertebral artery from the
left
subclavian.
TTE ([**10-18**]): The left atrium is normal in size. A patent foramen
ovale is present. The estimated right atrial pressure is 0-5
mmHg. There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>65%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Transmitral Doppler and tissue velocity imaging
are consistent with Grade I (mild) LV diastolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal systolic function. PFO is present. Moderately dilated
ascending aorta.
CT Head ([**10-18**]): IMPRESSION:
1. Right MCA territory hypodensity, consistent with edema from
acute infarction/ischemia. This may extend slightly more
anteriorly than in the preceding study.
2. No evidence of hemorrhage.
3. Chronic small vessel ischemic disease.
NOTE ADDED AT ATTENDING REVIEW: There is no evidence of acute
infarction in the right MCA territory. This area demonstrates
atrophy, apparently related to old infarction. The region of
slow flow seen in the left MCA distribution on the CT perfusion
study has not evolved to infarction on this examination.
Bilateral LENIs ([**10-19**]):
IMPRESSION: No evidence of deep vein thrombosis in either leg.
TEE ([**10-21**]): The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. A patent
foramen ovale is present. The width of the PFO is <10 mm with a
tunnel length of >25 mm. Overall left ventricular systolic
function is normal. Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is mildly dilated. There are
simple atheroma in the ascending aorta. 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. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
IMPRESSION: Patent foramen ovale as described above. Complex
atheroma in the descending aorta.
Brief Hospital Course:
The patient is a 53 year old right handed man with a history of
old right frontal stroke, hypertension, and EtOH abuse, who
presented with acute onset of right sided weakness and slurred
speech. At the OSH, he was found to have an expressive aphasia,
and he was given IV tPA at approximately 2 hours after onset. A
head CT showed a pronounced hypodensity in the right frontal
area which was interpreted as acute stroke, but retrospectively,
this appears to be an old stroke. He was transferred to [**Hospital1 18**]
for further care, and upon arrival to [**Hospital1 18**], his expressive
aphasia had largely ressolved.
He was initially admitted to the NeuroICU, and while there had
fluctuating aphasia and dysarthria which improved with lying
flat and giving IVF to keep his SBP 140-180. CTA head/neck and
CTP showed an area of reversible ischemia in the distribution of
the left middle cerebral artery, no evidence of conversion to
acute infarction, and stenosis at the origin of the left
vertebral artery from the left
subclavian. Repeat Head CT showed no evidence of acute
infarction in the right MCA territory, this area demonstrates
atrophy apparently related to old infarction. He was unable to
have an MRI given a history of metal in his eye.
TTE showed LVEF >65%, and a patent foramen ovale. He also had
moderate symmetric left ventricular hypertrophy, grade I (mild)
LV diastolic dysfunction, the aortic root is moderately dilated
at the sinus level, the ascending aorta is moderately dilated.
He then had a TEE to rule out atrial septal aneurysm which
showed the PFO is <10 mm with a complex (>4mm) atheroma in the
descending thoracic aorta. Based on the TTE/TEE results and his
risk for falls with alcoholism, the decision was made not to
start Coumadin.
He was started on ASA 325 mg daily. FLP showed Chol 146, TG 98,
HDL 25, LDL 101, and he was started on Lipitor 40 daily. He was
continued on his home HCTZ and Lisinopril. He was maintained on
a CIWA scale, and was started on MVI, thiamine, and folate. He
was started on Nicotine patch. He will follow up with Dr. [**Last Name (STitle) **]
in Neurology as an outpatient.
Medications on Admission:
Lisinopril
HCTZ
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 2 weeks.
Disp:*14 Patch 24 hr(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. Lisinopril Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Ischemic Stroke, Left frontoparietal
Discharge Condition:
Stable, slurred speech resolved, walking steadily without
assistance
Discharge Instructions:
You were admitted to the hospital with slurred speech and right
sided weakness. You were given IV tPA, a clot busting medicine
for stroke, prior to transfer here. Your Head CT showed a
stroke in the left frontal area. An ultrasound of your heart
showed a small hole (called a PFO) which might be a source of
blood clots that could cause a stroke.
The following changes were made to your medications:
We started you on a full strength aspirin (325 mg) which you
should continue to take once a day to prevent stroke in the
future. We found that your cholesterol was high, so we started
you on a cholesterol lowering medication, Lipitor (40 mg), which
you should take once a day.
Please continue your Lisinopril and Hydrochlorothiazide (HCTZ)
at your normal home doses.
Please call your doctor or go to the ER if you develop any new
neurologic symptoms, such as slurred speech, headache, nausea,
vomiting, dizziness, trouble finding words, or weakness or
numbness in your arms or legs.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2105-12-9**] at 1:00 pm in the [**Hospital Ward Name 23**]
Center, [**Location (un) 858**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"305.01",
"305.1",
"784.3",
"434.91",
"401.9",
"V17.1",
"V45.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9960, 10015
|
7024, 9162
|
370, 377
|
10096, 10167
|
2976, 7001
|
11205, 11550
|
2063, 2101
|
9229, 9937
|
10036, 10075
|
9188, 9206
|
10191, 11182
|
2116, 2957
|
278, 332
|
405, 1506
|
1528, 1692
|
1708, 2047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,244
| 102,338
|
29736
|
Discharge summary
|
report
|
Admission Date: [**2130-3-5**] Discharge Date: [**2130-3-6**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
stab wounds to R chest neck and face s/p assult
Major Surgical or Invasive Procedure:
OR with plastic surgery for repair of R facial nerve and closure
of multiple stab wounds
History of Present Illness:
85M stabbed multiple times by intruder. Lacerations include R
neck, R chestx2, L chest and R lower face. +moderate pain, but
controlled with meds. No difficulty opening or closing mouth.
No changes in vision/hearing. No nausea, vomiting, headache.
Initial trauma workup including CTA of neck and chest had ruled
out need for emergent OR. He received ancef and tetanus. NO
difficulty swallowing.
Past Medical History:
hypertension, peptic ulcer disease
Physical Exam:
PE: T-98.2 BP-129/39 HR-96 RR-18 O2sat-100%2L
gen: thin, elderly man, with large bulky dressing to face.
face: R mandibular laceration, 8 cm, gaping with large flap.
+exposed bone. bleeding controlled. sensation to chin intact.
dog eared lac just inferior to nose. bleeding controlled
mouth: no teeth (wears dentures at baseline) No intraoral
lesions.
R neck: 2cm superficial laceration
R clavicular area: 2cm superficial lac, 3cm superficial lac,
abrasion over sternal notch
Left upper chest: 3cm wound
neuro: alert and oriented x 3
Brief Hospital Course:
Plastic Reconstructive surgery was consulted to manage patients
facial lacerations. Was found to have a severed R facial nerve.
Patient taken to OR for repair of nerve and closure of stab
wounds. Postoperative course was uncomplicated. Observed in the
TICU overnight for neuro checks. On day of discharge, physical
therapy worked with patient and deemed him safe for discharge to
home without any need for additional services.
Medications on Admission:
atenolol
HCTZ
protonix
MVI
Discharge Medications:
atenolol
HCTZ
protonix
MVI
Discharge Disposition:
Home
Discharge Diagnosis:
stabbing victim
Discharge Condition:
stable
Discharge Instructions:
1)Return to Plastic Surgery clinic on Friday for suture removal;
call [**Telephone/Fax (1) 4652**] to make an appt
2)If you have increased pain, swelling, bleeding or expanding
pulsatile mass in your neck, go to nearest ED immediately
Followup Instructions:
Plastic Surgery clinic on Friday [**2130-3-10**] Call [**Telephone/Fax (1) 4652**] to
schedule appointment
|
[
"401.9",
"958.4",
"874.8",
"873.50",
"285.1",
"951.4",
"E966",
"875.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.79",
"86.59",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
2026, 2032
|
1470, 1898
|
306, 397
|
2092, 2101
|
2384, 2494
|
1975, 2003
|
2053, 2071
|
1924, 1952
|
2125, 2361
|
899, 1447
|
219, 268
|
425, 825
|
847, 884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,780
| 105,500
|
48411
|
Discharge summary
|
report
|
Admission Date: [**2182-4-12**] Discharge Date: [**2182-4-19**]
Date of Birth: [**2100-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
ARF/ Unsteady gait
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 82 year old patient of Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who presented
to [**Company 191**] episodically with 3 days of unsteady gait per his wife.
She provides the majority of the history today as she states his
dementia is quite severe. She reports that for the last 3 days,
he has been shaking on his feet and has actually fallen twice.
Once, it appeared that his knees gave out and another time he
fell to the left side. She denies any head injury or LOC. She
states that he had almost fallen multiple other times but was
either steadied by his wife or fell into a wall which prevented
his fall.
She reports multiple problems with his legs in the past. He
reports he had rickets as a child and had surgery to bilateral
knees. Additionally, his statin was stopped in the past due to
myalgias. She states he had an episode like this three years ago
that improved with physical therapy, but she is not sure if it
was quite this bad. Both patient and wife deny dizziness, leg
pain, urinary symptoms, though frequency of urination is old,
decreased urine output,
urinary odor, constipation, diarrhea, headaches, chest pain,
shortness of breath, fevers, cough or other symptoms. He has not
had any blood in his urine or his stool She does report he has
seemed "groggier" than usual over the last few days but is not
able to further characterize. Given his CKD, she ensures that he
drinks 1 quart of water daily to stay hydrated and does not feel
that he has had decreased or increased PO intake recently. He
did have a prostate biopsy for surveillance of his prostate ca
on [**4-4**] which came back negative on pathology. Both deny any
symptoms after the biopsy.
In the ED, initial vs were: T97.8 P74 BP 156/74 RR 16 O2 sat
100%. Patient was given amp of calcium, insulin 10u IV, amp of
dextrose and kayexelate for hyperkalemia. CT head was negative
for acute intracranial process, and CXR was unremarkable. Labs
were remarkable for hyperkalemia and acute renal failure.
On the floor, vitals are 141/72, HR 75, RR 16 O2 sat 100% RA. He
is comfortable and has no complaints, he is accompanied by his
wife who provides most of the history.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Per OMR:
* hypertension
* dementia
* mild chronic renal insufficiency: Cr 1.4-1.6 at baseline
* MGUS with detailed evaluation in [**2178**]
* remote history of testicular cancer
* prostate cancer, more recently evaluation is negative for
prostate cancer
* chronic leg pain, EMG suggesting radiculopathy, degenerative
lumbar changes seen on skeletal survey
* regular debridement of toenails/foot lesions by podiatry
* psoriasis
Social History:
Former smoker, quit 15 years ago; EtOH: drinks one drink a night
most nights, sometimes two drinks when out with friends
(1x/2weeks). [**Name2 (NI) **]d; wife accompanying him here.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97 BP: 141/72 P: 75 R: 18 O2: 100 RA
General: Alert, oriented to [**Hospital **] Hospital, not oriented to year or
month, no acute distress, comfortable.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur heard throughout the precordium, no rubs, gallops
Abdomen: soft, non-tender, moderately distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. No
CVA or flank tenderness
GU: penile prosthesis. 0.25 mm well circumscribed superficial
erosion on glans. Prostate exam non-tender, without nodules,
within normal limits. Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact. Strength 5/5 in all extremities. Gait
not assessed. + Dysmetria on finger to nose test. Slow and
somewhat uncoordinated movements for RAMS (hand turning).
Pertinent Results:
LABS ON ADMISSION:
[**2182-4-12**] 06:20PM BLOOD WBC-7.0 RBC-3.71* Hgb-10.6* Hct-32.2*
MCV-87 MCH-28.7 MCHC-33.0 RDW-15.2 Plt Ct-294
[**2182-4-12**] 06:20PM BLOOD Neuts-75.8* Lymphs-16.9* Monos-5.1
Eos-1.9 Baso-0.3
[**2182-4-12**] 06:20PM BLOOD PT-11.2 PTT-24.1 INR(PT)-0.9
[**2182-4-12**] 06:20PM BLOOD Glucose-78 UreaN-116* Creat-11.8*#
Na-131* K-6.1* Cl-101 HCO3-16* AnGap-20
[**2182-4-13**] 01:44PM BLOOD ALT-19 AST-37 LD(LDH)-344* AlkPhos-36*
TotBili-0.2
[**2182-4-12**] 06:20PM BLOOD TotProt-6.3* Albumin-4.0 Globuln-2.3
Calcium-9.5 Phos-5.9*# Mg-3.1*
[**2182-4-13**] 01:44PM BLOOD calTIBC-263 Ferritn-210 TRF-202
[**2182-4-12**] 06:20PM BLOOD Osmolal-328*
[**2182-4-12**] 06:20PM BLOOD PEP-PND
[**2182-4-13**] 07:23AM BLOOD Type-ART pO2-89 pCO2-33* pH-7.36
calTCO2-19* Base XS--5
[**2182-4-12**] 06:40PM BLOOD Glucose-67* K-6.3*
[**2182-4-12**] 06:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2182-4-12**] 06:20PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-4-12**] 06:20PM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2182-4-12**] 06:20PM URINE Eos-NEGATIVE
[**2182-4-12**] 10:04PM URINE Hours-RANDOM Creat-43 Na-69 K-11
TotProt-73 Prot/Cr-1.7*
[**2182-4-12**] 10:04PM URINE U-PEP-PND Osmolal-284
Labs on discharge:
[**2182-4-19**] 08:20AM BLOOD WBC-5.8 RBC-3.42* Hgb-9.2* Hct-29.2*
MCV-85 MCH-26.8* MCHC-31.4 RDW-14.9 Plt Ct-343
[**2182-4-19**] 08:20AM BLOOD Plt Ct-343
[**2182-4-19**] 08:20AM BLOOD Glucose-78 UreaN-54* Creat-2.8* Na-147*
K-4.0 Cl-112* HCO3-24 AnGap-15
[**2182-4-13**] 01:44PM BLOOD calTIBC-263 Ferritn-210 TRF-202
[**2182-4-12**] 06:20PM BLOOD Osmolal-328*
[**2182-4-12**] 06:20PM BLOOD PEP-TWO TRACE IgG-580* IgA-198 IgM-53
IFE-MULTIPLE T
[**2182-4-13**] 01:44PM BLOOD C3-106 C4-19
IMAGING:
Renal U/S: No hydronephrosis.
CXR: No acute cardiopulmonary abnormality.
CT Head: 1. No acute intracranial abnormality. 2.
Age-appropriate cortical and cerebellar atrophy, with chronic
small vessel ischemic change.
TEE: The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal for the patient's body size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is a mild resting left ventricular outflow tract obstruction. A
mid-cavitary gradient is identified. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is no
systolic anterior motion of the mitral valve leaflets. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Skeletal Survey: No focal lytic bony lesion is seen.
Brief Hospital Course:
82 yo M with h/o prostate, testicular cancer, MGUS, and dementia
presents with worsening ataxia, found to have renal failure and
hyperkalemia.
.
# Acute kidney injury: Pt's creatinine was increased ten-fold on
admission (baseline 1.5 to 11). Did not appear volume overloaded
and urine lytes revealed FeNa of 13%. Urine eosinophils
negative. There was concern for AIN or possible cast nephropathy
given MGUS. His complement levels were normal, but SPEP and UPEP
were positive and remaining clinical picture was suggestive of
multiple myeloma. His creatinine improved to 2.8 on discharge,
and he required IV fluid hydration while hospitalized, though
his creatinine continued to trend down even while drinking PO
fluids alone. He did develop hypernatremia to 147 on the day of
discharge (at which point he was hydrating with only PO fluids),
but renal was comfortable discharging as long as patient had
close follow-up. His wife was instructed several times to be
sure to encourage PO fluids at home, and he will have his
chemistries recheck as an outpatient on Monday, [**2182-4-22**]. He has
renal follow up and close PCP [**Name9 (PRE) 702**] as well. Lisinopril,
gabapentin, and citalopram were all held on discharge, given the
fact that his renal function had not completely normalized.
Lisinopril should likely not be restarted given his higher risk
of volume depletion and cast nephropathy.
# Multiple Myeloma: Given patient's history of MGUS, acute renal
failure, and increase in light chains, heme-onc was consulted
for evaluation of progression to multiple myeloma. Bone marrow
biopsy was performed, and showed >20% plasma cells
(preliminarily, close to 60% plasma cells). He had a negative
skeletal survey. He will follow-up with oncology as an
outpatient for possible initiation of chemotherapy. Before any
chemotherapy is started, the positive PPD found on this
admission should be addressed. It is unclear if he has ever had
treatment for his positive PPD in the past.
.
# Bradycardia: In the MICU, patient was noted to be unresponsive
for 90 seconds. Monitoring showed bradycardia to 30s. Was
eventually aroused, with blood sugar of 100, EKG within normal
limits (rate of 60), and unremarkable ABG. Telemetry strip
showed possible junctional escape rhythm, and cardiology was
consulted for possible pacer placement. Cardiology felt likely
junctional escape with sick sinus syndrome, deferred pacing and
recommended avoiding AV nodal agents. He was monitored on
telemetry throughout his stay and had no other arrhythmias.
.
# Ataxia: Patient's initial complaint. [**Month (only) 116**] have been due to
weakness and electrolyte abnormalities (hyperkalemia known to
cause lower extremity weakness). Head CT negative for acute
intracranial process and has had a negative RPR in past. There
were no acute changes in his neurological status, and he was
cleared by PT to go home with services.
.
# Agitation/Sundowning: Patient was noted to have episodes of
sundowning while on the general medical floors. While inhouse,
he was maintained on zyprexa 5mg, which was very effective for
him.
.
# Murmur: Systolic murmur on exam had not been documented in
recent outpatient notes. He had an echocardiogram to evaluate
for structural heart disease, but the echo showed only mild
LVOT, which likely accounts for the murmur..
.
# Anemia: Pt had stable hemoglobin of 9. Unclear baseline,
likely acute on chronic secondary to his multiple myeloma. Guiac
positive in ED which is consistent w/ recent prostate biopsy.
Denied melena, hematemesis. Anemia studies consistent with
anemia of chronic disease, likely secondary to multiple myeloma.
.
# Hypertension: Home lisinopril held in setting of renal failure
as documented above. SBPs in 130s, 140s, sometimes to 160s/170s.
Continued on home amlodipine 10mg QD. Hydralazine could be
started in the short term as an outpatient. AV nodal blocking
agents and ACE inhibitors should be avoided.
OUTPATIENT TO DO'S:
1. Follow-up BMP drawn on [**2182-4-22**] (with particular attention to
sodium and BUN/Cr)
2. Ensure that heme-onc is aware of positive PPD before
initiating chemotherapy
3. Blood pressure check, consider starting hydralazine if not
well controlled (avoid AV nodal blocking agents and ACE-i)
4. Assess the need to restart citalopram, gabapentin as an
outpatient after renal function has normalized.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
CITALOPRAM - 20 mg Tablet - 0.5 Tablet(s) by mouth once a day
for
1 week; then increase to 1 qd
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day.
Increased from 5 mg 1 month ago.
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply daily as needed
for for 7 to 10 days only
.
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - (OTC) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
6. Outpatient Lab Work
Please check Basic Metabolic Panel on Monday, [**2182-4-22**]
before your appointment at [**Company 191**]. Also fax results to DR. [**First Name (STitle) **]
[**Name (STitle) **]. Fax #: [**Telephone/Fax (1) 9420**] (Ph# [**Telephone/Fax (1) 721**]).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
* Acute on chronic renal insufficiency
* Symptomatic bradycardia due to junctional escape rhythm
* Multiple Myeloma
SECONDARY DIAGNOSES:
* vascular dementia
* MGUS
* remote history of testicular cancer
* prostate cancer
* hypertension
* carotid aneurysm
* obstructive sleep apnea
* chronic leg pain, possibly secondary to radiculopathy
* psoriasis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2182-4-12**] after you were having
falls. We found that you were in kidney failure and you went to
the ICU temporarily. This may have been due to the antibiotics
you took earlier this month. Your kidney function was improving
nicely at the time of discharge. You will need to follow up as
an outpatient with the kidney doctors when [**Name5 (PTitle) **] leave the
hospital.
During your work up for kidney failure, there was a concern that
your MGUS may be progressing further. A bone marrow biopsy was
performed and suggest you have multiple myeloma. You are to
follow up with Dr. [**Last Name (STitle) **], your hematologist/oncologist, for
further management of this.
While you were in the ICU, you also had an episode where your
heart was beating very slowly and you were unresponsive. This
did not occur again while you were in the hospital. You will
need to follow up with the heart doctors as [**Name5 (PTitle) **] outpatient.
The following changes were made to your medications:
1. STOP taking lisinopril (broken down by kidney)
2. STOP taking citalopram (broken down by kidney)
3. STOP taking gabapentin (broken down by kidney)
PLEASE ENSURE YOU HAVE BLOODWORK CHECKED ON [**2182-4-22**]. AS WE
DISCUSSED WITH YOUR WIFE, YOU SHOULD BE DRINKING AT LEAST [**1-26**]
LITERS PER DAY!!!
Followup Instructions:
The following appointments are already scheduled for you:
Department: [**Hospital3 249**]
When: MONDAY [**2182-4-22**] at 9:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
YOU WILL HAVE LABWORK DRAWN ON THIS DAY AND MAKE SURE YOUR
DOCTOR FOLLOWS IT UP WITH YOU. RESULTS SHOULD ALSO BE FAXED TO
DR. [**Last Name (STitle) **] (YOUR KIDNEY DOCTOR)
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2182-4-25**] at 3:30 PM
With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2182-5-2**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2182-5-6**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2182-5-6**] at 10:20 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 **] [**Location (un) 2352**] SUITE B
When: MONDAY [**2182-6-3**] at 10:30 AM
With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2182-6-11**] at 10:45 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,828
| 107,706
|
49386
|
Discharge summary
|
report
|
Admission Date: [**2157-3-22**] Discharge Date: [**2157-4-4**]
Date of Birth: [**2096-5-22**] Sex: F
Service: MEDICINE
Allergies:
Meperidine
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Fever, cough urinary frequency
Major Surgical or Invasive Procedure:
PICC placement
R nephrostomy replacement
History of Present Illness:
60 yo woman with endometrial/cervical cancer s/p chemo/XRT c/b
severe radiation cystitis/colitis s/p colectomy resulting in
short gut syndrome), enterocutaneous fistula, vesiculopelvic
fistula s/p bilat nephrostomy tubes, chronic rectal bleeding,
here w/ fever and malaise and abdominal pain. Admitted to MICU
for closer monitoring. Most recently admitted for hydronephrosis
and line bacteremia (CN staph), noted at that time to have high
alk phos (3000s) and elevated Bili (as high as 5) thought to be
[**1-14**] TPN induced cholestasis. Completed Vanco [**2157-3-15**].
.
USOH since discharge until 4 days prior to admission. Developed
fever, chills, then developed non-productive cough 2 days prior
to admission. One day prior to admission, noted chest pain
across lower chest, but predomininantly on L under breast, worse
with deep inspiration. Also noted increasing urinary frequency.
Denies nausea, vomiting, increased abdominal pain (has "surface
abdominal pain" chronically - "it's the muscles").
.
In ED, noted to be mildly hypotensive to 80s. Given two liters
of fluid with good response. Received Vancomycin/Zosyn. CXR
revealed no pneumonia, but some degree of atelectasis. She also
spiked temp t o101. KUB revealed dilated loops of bowel, but no
overt evidence of obstruction. CTA chest, abdomen/pelvis was
pending at the time of this note.
Past Medical History:
1. Endometrial/cervical cancer
2. S/p TAH in [**2153**] (due to uterine cancer)
3. Chylous ascites
4. Colectomy, cholecystectomy, and ileostomy ([**11-16**], likely
related to radiation bowel damage.)
5. Small bowel removal and ileostomy ([**6-17**])
6. S/p ventral hernia w/ repair
7. PE s/p IVC filter
8. Anxiety
9. Bronchitis ([**2099**])
10. Pneumonia ([**2109**])
11. Nephrostomy tube replacements, multiple (last [**2-16**] on L)
12. Hyperbilirubinemia and hyper alkaline phosphatemia thought
to be [**1-14**] TPN induced chronic cholestasis.
13. Anemia of chronic disease
14. VRE
Social History:
Lives with her husband and has 2. Denies current alcohol use.
Had been banking executive prior to development of health
issues. Smokes + [**12-14**] PPD for 19 years.
Family History:
Father 83 (deceased, CVA, MI); Mother (deceased, 92, CVA);
Brother (79, esophageal cancer); Sister (60s, colon cancer, lung
mass, afib)
Physical Exam:
VS T 98.1 BP 105/52 (105-116/54-66) HR 112 (112-139) RR25 O298%
GENERAL: NAD, mild diaphoretic, tachypneic
HEENT: Icteric sclerae, EOMI, Dry MM
NECK: JVP ~6cm, supple, no LAD
CARDIOVASCULAR: RRR, tachy, S1, S2, reg, no murmurs
LUNGS: mild tachypenia, CTAB
ABDOMEN: Soft, tender diffusely, no rebound, no guarding,
suprapubic fistula with dressings dry and intact
BACK: Nephrostomy tube and sites intact, no erythema or
tenderness, clear urine.
EXTREMITIES: Warm, 2+ pitting edema in bilat lower extremities
R>L
NEURO: A/OX3.
Pertinent Results:
[**2157-3-22**] 10:30AM BLOOD WBC-4.5 RBC-3.10*# Hgb-10.6*# Hct-32.1*#
MCV-104* MCH-34.2* MCHC-33.0 RDW-19.3* Plt Ct-171
[**2157-3-22**] 10:30AM BLOOD Neuts-71.7* Lymphs-12.5* Monos-14.6*
Eos-0.8 Baso-0.5
[**2157-3-22**] 10:30AM BLOOD Glucose-106* UreaN-33* Creat-0.6 Na-146*
K-3.4 Cl-108 HCO3-32 AnGap-9
[**2157-3-22**] 10:30AM BLOOD ALT-44* AST-58* CK(CPK)-8* AlkPhos-[**2056**]*
Amylase-6 TotBili-5.2* DirBili-3.3* IndBili-1.9
[**2157-3-22**] 10:30AM BLOOD Lipase-7
[**2157-3-27**] 04:45AM BLOOD GGT-312*
[**2157-3-22**] 10:30AM BLOOD TotProt-6.0* Albumin-2.6* Globuln-3.4
Calcium-9.0 Phos-2.0* Mg-2.1
[**2157-3-22**] 03:07PM BLOOD Lactate-2.3*
[**2157-4-1**] 05:22AM BLOOD WBC-6.2 RBC-2.35* Hgb-7.8* Hct-24.3*
MCV-103* MCH-33.3* MCHC-32.2 RDW-18.4* Plt Ct-205
[**2157-4-1**] 05:22AM BLOOD Glucose-124* UreaN-39* Creat-1.0 Na-133
K-5.3* Cl-103 HCO3-26 AnGap-9
[**2157-4-1**] 05:22AM BLOOD ALT-48* AST-52* LD(LDH)-85* AlkPhos-2129*
TotBili-3.6*
[**2157-3-27**] 04:45AM BLOOD GGT-312*
[**2157-4-1**] 05:22AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
.
.
CXR [**2157-3-25**]:
The left upper extremity approach PICC line has been removed.
There are stable bilateral pleural effusions, left greater than
right. There is marked stability of the retrocardiac opacity
previously noted consistent with left lower lobe collapse.
IMPRESSION: Aside from the removal of the left upper extremity
PICC line, there is little interval change again demonstrating
left lower lobe collapse and bilateral pleural effusions, left
greater than right.
.
[**3-22**] SINGLE UPRIGHT AP ABDOMINAL RADIOGRAPH: In the right lower
quadrant, there are two loops of dilated small bowel measuring
up to 3.8 cm. No other loops of dilated bowel are seen. There is
evidence of numerous prior procedures including bilateral
nephrostomy tubes, IVC filter, and clips in the pelvis and
scattered throughout the abdomen. No free air is seen under the
hemidiaphragms. Colostomy bag is noted in the right lower
abdomen.
.
[**3-22**] CT chest, abd/pelivs:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with compressive atelectasis,
unchanged.
3. Unchanged appearance of extensive radiation changes in the
pelvis.
4. Bilateral nephrostomy tubes.
5. No intrahepatic biliary dilatation.
6. Generalized soft tissue edema.
7. No evidence of small bowel obstruction.
.
[**3-23**] Fistulogram:
Enterocutaneous fistula with no evidence of abscess.
.
UNILAT LOWER EXT VEINS Study Date of [**2157-3-27**] 11:21 AM
1. No evidence of DVT within the visualized portion of the left
common
femoral, superficial femoral, and popliteal veins.
2. Monophasic waveform within the left common femoral,
superficial femoral, and popliteal veins, indicating limited
transmission of both respiratory variation and change in
pressures from Valsalva. These findings are most consistent
with an occlusion within the left common or external left iliac
vein. There is normal waveform demonstrated within the right
common femoral vein indicating that the lesion is unlikely to be
within the IVC. Review of a prior CT Torso from [**3-22**] shows
compression upon the left external iliac vein by an overlying
fluid filled presumed loop of bowel, This finding may account
for such a monophasic waveform.
.
FOOT AP,LAT & OBL RIGHT Study Date of [**2157-3-28**] 6:01 PM
No evidence of fracture or dislocation.
Brief Hospital Course:
60 YO F h/o endometrial/cervical CA s/p XRT c/b bowel
obstruction leading to colectomy and short gut syndrome on TPN,
who was admitted to the MICU for klebsiella urosepsis, abdominal
wound infection with [**Date Range 8974**].
.
* Fever: Patient continue to spike temperature while on cipro
for UTI and vanco for wound infection. Potential sources of
infection included UTI, wound infection, c.diff.
-PICC was pulled and cultured, but without growth.
-wound culture from abd grew [**Date Range 8974**] and streptococcus
-blood cultures with no growth
-initial urine culture grew Klebsiella. Subsequent urine
culture grew yeast.
-initially on ciprofloxacin and vancomycin, but cipro broadened
to zosyn given persistent fevers. Also started on fluconazole
given persistant fevers with funguria. After afebrile x 48
hours therapy was narrowed on [**3-29**] narrowed therapy to
levofloxacin (to cover Klebsiella, [**Month/Year (2) 8974**]) and fluconazole.
Remained afebrile for subsequent hospitalization. Will complete
2 weeks course of IV levofloxacin and fluconazole.
.
* HYPERBILIRUBINEMIA: Patient has history of hyperbilirubinemia
and elevated alkaline phosphatase felt secondary to cholestasis
in setting of TPN. High GGT and minimally elevated AST and ALT
consistent with this diagnosis.
-Treated w/ ursodiol.
-Abd CT did not demonstrate acute hepatic pathology.
.
* NUTRITION: Short gut syndrome. Clears. Initially held on TPN
while awaited blood culture results and resolution of fever, on
PPN instead.
-PICC line placed [**3-29**] after afebrile x 48 hours
* Tachycardia: HR elevated throughout hospital stay even after
fever defervesed. EKG demonstrated sinus tach w/ ectopy. Given
risk for DVT/PE, U/S lower extremities were obtained and were
negative for DVT. Likely secondary to dehydration, especially
given high ostomy output.
.
* ANEMIA: Likely multifactoral. Macrocytic, although B12 and
folate levels wnl. Iron studies indicate ACD. Was maintained on
epogen; received 1 U PRBCs on day of discharge, and TPN
contained folate.
.
-RENAL/GU: Initially Klebsiella urosepsis. Subsequent urine
cultures from nephrostomy tubes grew yeast. Will continue
antibiotics and antifungal agents as above. R nephrostomy tube
replaced [**4-1**] for poor output and subsequently drained well.
.
*Orthostatic Hypotension: Patient was to be discharged [**4-1**] but
became orthostatic. In conjuction w/ increase in BUN and Cr
over prior days, felt secondary to dehydration. Patient
received additionsl fluid boluses and 1 L PRBCs.
.
*Prophylaxis: Given high risk for DVT, prescribed heparin and
pneumoboots, but patient repeatedly decline these treatments.
.
*Goals of Care: Given Ms. [**Known lastname 103420**] susceptibility to
infections, discussion was initiated in conjunction with [**First Name8 (NamePattern2) 2270**]
[**Last Name (NamePattern1) 1764**] regarding goals of care. These discussions will be
continued as an outpatient. Ms. [**Known lastname 3694**] did confirm that she
is DNR/DNI.
Medications on Admission:
1. Ativan p.r.n.
2. Mirtazapine 15 mg
3. Epogen five times per week
4. TPN
5. Vancomycin (completed [**2157-3-15**])
6. Ursodiol TID
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
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. Levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous once a day for 12 days.
Disp:*QS QS* Refills:*0*
4. TPN Electrolytes Solution Sig: One (1) TPN Solution
Intravenous once a day: 2.2 liters; 300g dextrose; 96g amino
acids; 175 NaCl; 100 NaAcetate; 20 NaPo4; 45 KCl; 5 KAc; 15
MgSO4; 8 CaGluc.
**50 g fats twice weekly ONLY**
Cycle over 12 hours.
Disp:*QS QS* Refills:*2*
5. PICC Sig: line care per protocol once a day.
Disp:*qs * Refills:*2*
6. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig:
One (1) Intravenous once a day for 12 days.
Disp:*qs qs* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Octreotide Acetate 100 mcg IV Q8H
10. IV Fluids
Please administer 1 L NS after each TPN order.
Thanks
11. Outpatient Lab Work
Thursday [**2157-4-7**]: Please draw CBC, Chem10, Total Bilirubin,
Alkaline Phosphatase, AST, ALT.
12. Outpatient Lab Work
qMonday blood draws: CBC, Chem10. Please release to nutritionist
for tailoring TPN order.
13. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] units
Injection 5 times per week.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Klebsiella urosepsis
- Cellulitis
- Candidal pyelonephritis
- Hyperbilirubinemia, elevated alkaline phosphatase (likely
secondary to cholestatis related to chronic TPN)
.
Secondary Diagnoses:
-Endometrial/cervical cancer s/p TAH in [**2153**] (due to uterine
cancer)
-Chylous ascites
-Colectomy, cholecystectomy, and ileostomy ([**11-16**], likely
related to radiation bowel damage.)
-Small bowel removal and ileostomy ([**6-17**])
-PE s/p IVC filter
-Nephrostomy tube replacements, multiple (last [**2-16**] on L)
-Anemia of chronic disease
Discharge Condition:
Stable
Discharge Instructions:
You were hospitalized and treated for a serious infection, and
found to have a urinary tract infection and skin infection. The
urinary tract infection was serious and caused a dangerously low
blood pressure that required admission to the intensive care
unit.
.
You were also found to have elevations in some liver tests; but
imaging of your liver was normal.
Take all medications as directed. You will need to receive
antibiotics by vein for several weeks.
Attend all follow up appointments.
If you develop fever, chills, shortness of breath, chest pain,
worsening or severe abdominal pain, persistant nausea/vomiting,
or any other symptom that concerns, contact your primary doctor
or if unavailable, go to the emergency room.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2157-4-11**] at
12:20 PM.
.
You will need to have blood tests to help your doctor follow
your liver function and to help determine your TPN prescription
.
Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**] Date/Time:[**2157-6-1**] 7:00
Provider: [**Name10 (NameIs) 6122**] WEST Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2157-6-1**] 8:30
Completed by:[**2157-4-4**]
|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,582
| 176,559
|
35096
|
Discharge summary
|
report
|
Admission Date: [**2179-9-10**] Discharge Date: [**2179-9-19**]
Date of Birth: [**2113-9-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina and shortness of breath.
Major Surgical or Invasive Procedure:
[**2179-9-14**] - Coronary Artery Bypass Graft x 3 (Left internal
mammary->Left anterior descending artery, Saphenous vein
graft->Diagonal artery, Saphenous vein graft->Obtuse marginal
artery)
History of Present Illness:
65yo male with known CAD, s/p MI [**2164**] and PCI w/ stent [**2171**], who
presented to [**Hospital 487**] Hospital with intermittent angina relieved
with rest on [**9-8**]. In the ED pain resolved with sl
NTG/Lopressor and IV NTG. He was also given Plavix. Cardiac
catheterization revealed LVEF 30%. Coronaries included occluded
RCA w/LT to RT collaterals,90% cx, 70% LAD. He was transferred
here for surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction, s/p PCI and
stent [**2171**], Hypertension, Hyperlipidemia
Social History:
Denies ETOH use, Nonsmoker, Retired saleman who lives with his
wife
Family History:
No remarkable family history noted
Physical Exam:
Admission
VS 98.0 128/80 66 20 96% RA
HEENT: PERRL
NECK: Supple, No JVD, No bruits
LUNGS: Clear
HEART: RRR, left apical, nlS1-S2, +S4 at apex.
ABDOMEN: Soft, nor organomegally
EXT: No edema, pulses 2+
Discharge
VS 99.9 123/70 93 20 98% 2L
Gen NAD
Neuro A&Ox3 nonfocal exam
Pulm CTA bilat
CV RRR, no M/R/G. Sternum stable, incision CDI
Abdm soft, NT/+BS
Ext warm 1+ pedal edema
Pertinent Results:
ECHO [**2179-9-14**] - PRE CPB 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. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis with thinning and akinesis of the lateral wall.
Overall left ventricular EF is about 30%. At one point during
the pre bypass period, worsening global function was noted with
an EF of about 20%. This improved with nitroglycerine infusion.
The right ventricle displays normal free wall contractility.
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 structurally normal. Mild (1+) mitral regurgitation
is seen. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the procedure.
POST CPB The patient is receiving epinephrine by infusion. The
patient is being AV paced. There is normal right ventricular
systolic function. The left ventricle displays continued
akinesis of the lateral wall with improved function of the
remaining segments. The EF is around 40%. The mitral
regurgitation may be slightly worse. The thoracic aorta appears
intact.
[**2179-9-11**] 07:50AM BLOOD WBC-12.8* RBC-4.55* Hgb-13.2* Hct-37.1*
MCV-82 MCH-29.1 MCHC-35.6* RDW-13.7 Plt Ct-296
[**2179-9-17**] 05:10AM BLOOD WBC-14.4* RBC-3.92* Hgb-11.3* Hct-32.8*
MCV-84 MCH-28.8 MCHC-34.3 RDW-13.4 Plt Ct-247
[**2179-9-11**] 07:50AM BLOOD PT-12.7 PTT-26.6 INR(PT)-1.1
[**2179-9-11**] 07:50AM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-138
K-4.8 Cl-105 HCO3-28 AnGap-10
[**2179-9-17**] 05:10AM BLOOD Glucose-154* UreaN-12 Creat-1.0 Na-136
K-4.2 Cl-100 HCO3-31 AnGap-9
[**2179-9-11**] 07:50AM BLOOD ALT-33 AST-30 LD(LDH)-207 CK(CPK)-51
AlkPhos-91 Amylase-30
[**2179-9-11**] 07:50AM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.2 Mg-2.0
UricAcd-3.9
Brief Hospital Course:
Mr. [**Known lastname 80153**] was admitted to the [**Hospital1 18**] on [**2179-9-10**] via transfer
from [**Hospital6 3105**] for surgical management of his
coronary artery disease. He was worked-up by the cardiac
surgical service in the usual preoperative manner. Heparin and
nitroglycerin were continued. Troponins were cycled which peaked
at 0.58 and began trending downward. On [**2179-9-14**], Mr. [**Known lastname 80153**] was
taken to the operating room where he underwent coronary artery
bypass grafting to three vessels. Postoperatively he was taken
to the cardiac surgical intensive care unit for monitoring.
Within 24 hours, Mr. [**Known lastname 80153**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. Beta blockade, aspirin and a Statin were resumed. He
was then transferred to the step down unit for further recovery.
He was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. The patient did have two
episodes of NSVT. EP service was consulted and recommendations
to increase beta-blocker were implemented. His hospital stay
was otherwise uneventful. On POD 5 he was discharged home with
visiting nurses.
Medications on Admission:
ASA 325mg/D
Famotidine 20mg [**Hospital1 **]
Lisinopril 40mg/D
Magoxide 400mg [**Hospital1 **]
Simvistatin 80mg/D
Metoprolol 50mg/D
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Myocardial Infarction
PMH: s/p Myocardial Infarction [**2164**], s/p PCI and stent [**2171**],
Hypertension, Hyperlipidemia
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) 23261**]
surgery office 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) Keep wounds clean and dry, OK to shower and wash incision.
Gently pat the wound dry. Please shower daily. No bathing or
swimming for 1 month. No lotions, creams or powders to incision
until it has healed. Use sunscreen on incision if exposed to
sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 6 weeks.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr.[**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 80154**] in [**1-31**] weeks
Completed by:[**2179-9-19**]
|
[
"414.01",
"427.1",
"V45.82",
"429.9",
"276.7",
"401.9",
"410.71",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"39.64",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
6489, 6572
|
3933, 5184
|
353, 547
|
6800, 6806
|
1700, 3910
|
7549, 7741
|
1243, 1279
|
5366, 6466
|
6593, 6779
|
5210, 5343
|
6830, 7526
|
1294, 1681
|
282, 315
|
575, 1009
|
1031, 1142
|
1158, 1227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,994
| 115,444
|
48539+48540
|
Discharge summary
|
report+report
|
Admission Date: [**2111-6-9**] Discharge Date: [**2111-6-18**]
Date of Birth: [**2046-6-27**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
African American female with HIV, last CD4 count 240 and
viral load of undetectable in [**2111-4-19**], and a history of
Factor VIII deficiency, chronic obstructive pulmonary
disease, asthma, hypertension, diabetes mellitus, who
presents to [**Hospital1 69**] for
shortness of breath.
The patient was in her usual state of health until the
evening prior to presentation on [**2111-6-9**], when she began
having chief complaint of shortness of breath. This shortness
of breath subsequently progressed and became very acute on
the morning of presentation approximately 6:00 a.m. She took
her usual MDIs but had no relief. She called the EMTs who
subsequently brought the patient to the Emergency Department
of [**Hospital1 69**].
Upon arrival, the patient was noted to be tachypneic and
wheezing. On review of systems, the patient's granddaughter
had an upper respiratory infection. The patient denied any
fever, chills, nausea, vomiting, chest pain or headache. She
denied any rhinorrhea but did have mild pharyngitis, sinus
congestion. She still smokes one half pack to one pack per
day. She has a chronic nonproductive cough which is
unchanged. The patient also reported that she had been
relatively noncompliant with all her medications.
While in the Emergency Department, the patient was given
nebulizers times two with no improvement. She was given a
trial of Heliox with a little improvement. Chest x-ray
revealed bilateral infiltrates. She was given intravenous
Solu-Medrol and intravenous Levofloxacin and Bactrim.
PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2104**], last CD4 approximately 230 in
[**2111-4-19**], with a viral load undetectable.
2. Hypertension.
3. Diabetes mellitus times twenty-five years.
4. Chronic obstructive pulmonary disease.
5. Chronic bronchitis.
6. Asthma since childhood, no history of intubation
required.
7. Factor VIII deficiency, status post steroids followed by
hematology/oncology periodically.
8. History of alcohol abuse in the past.
9. Spinal stenosis, L4-L5.
10. History of renal failure secondary to volume depletion.
MEDICATIONS ON ADMISSION:
1. AZT 200 mg p.o. b.i.d.
2. 3TC 150 mg p.o. b.i.d.
3. Nevirapine 200 mg p.o. b.i.d.
4. Glyburide 5 mg p.o. b.i.d.
5. Megace 400 mg p.o. q.d.
6. Timoptic 0.5% O.U. b.i.d.
7. Multivitamins one tablet p.o. q.d.
8. Bactrim one DS tablet p.o. q.d.
9. Mycelex troches p.r.n.
10. Albuterol two puffs inhaled q6hours p.r.n.
11. Atrovent two puffs b.i.d.
12. Accubid two puffs b.i.d.
13. Prilosec 20 mg p.o. q.d.
14. Lopressor 50 mg p.o. b.i.d.
15. Reglan 10 mg p.o. t.i.d.
16. Epogen 5000 units subcutaneous Monday, Wednesday and
Friday.
ALLERGIES: Motrin causes bleeding.
PHYSICAL EXAMINATION: Upon presentation, temperature is
95.9, pulse 133, blood pressure 180/71, respiratory rate 32,
saturating 95% in room air. In general, the patient was an
ill appearing black female sitting upright, tachypneic and
short of breath with short sentences. Head, eyes, ears, nose
and throat examination is normocephalic and atraumatic.
Extraocular movements are intact. The pupils are equal,
round, and reactive to light and accommodation. The
oropharynx was clear. No lymphadenopathy was appreciated.
The neck was supple. Chest examination - expiratory wheezes
noted, decreased breath sounds throughout, no stridor, no
crackles. Cardiovascular examination - tachycardia, II/VI
systolic murmur heard best at the right upper sternal border.
Abdominal examination is soft, normoactive bowel sounds,
nontender, nondistended, no guarding, no rebound.
Extremities no cyanosis, clubbing or edema. Neurologically,
the patient is [**Year (4 digits) 3584**] and oriented, responds to commands,
speaks in short sentences. Deep tendon reflexes are 2+
throughout. Cranial nerves II through XII are intact.
Sensation intact.
LABORATORY DATA: Upon presentation, white count was 10.1,
hematocrit 24.9, platelet count 343,000, 42% neutrophils, 52%
bands, 4% monocytes, 0.7% eosinophils. Sodium 136, potassium
5.0, chloride 106, bicarbonate 15, blood urea nitrogen 53,
creatinine 3.6, glucose 325. CK enzymes 130. Arterial blood
gases on 100% nonrebreather was pH 7.21, pCO2 46, paO2 296.
Electrocardiogram revealed sinus tachycardia at 140, left
ventricular hypertrophy, T wave inversion and ST depression
in lead V5 through V6. T wave inversions noted in lead III.
Chest x-ray revealed the heart size normal, diffuse bilateral
interstitial process with septal lines, pulmonary edema
versus interstitial pneumonitis.
HOSPITAL COURSE: This is a 64 year old female with HIV,
diabetes mellitus, asthma and chronic obstructive pulmonary
disease presenting with acute shortness of breath.
1. Cardiac - The patient was admitted originally to the
Medicine Service and placed on telemetry for rule out
myocardial infarction protocol. The patient subsequently
ruled in for myocardial infarction with shortness of breath.
Her troponins were positive at 9.0. CK enzymes were 130 and
upward trending. At that time, cardiology consultation was
called and evaluated the patient. Echocardiogram was
obtained which revealed ejection fraction of less than 40%
with wall motion abnormality consistent with ischemia.
That evening after cardiology consultation, the patient
subsequently became hypotensive and CK enzymes subsequently
increased to 1600 with positive MB index and positive
troponin greater than 50. The patient was found with agonal
respirations. The patient was emergently intubated and was
brought to the Medical Intensive Care Unit and subsequently
brought to the Cardiac Catheterization Suite where a cardiac
catheterization was performed.
A tight mid left circumflex lesion was seen. Percutaneous
transluminal coronary angioplasty was performed and a stent
was placed. The patient subsequently did well post cardiac
catheterization. The patient was continued on Aspirin and
started on Plavix. The patient's Lopressor was subsequently
titrated up. Given the fact that the patient had acute renal
failure post cardiac catheterization and unable to tolerate
ace inhibitor, the patient was started on Hydralazine and
Isordil in order to decrease morbidity and mortality.
Congestive heart failure - The patient during hospital course
had an episode of flash pulmonary edema, congestive heart
failure from a blood transfusion. Upon initial admission,
cardiac echocardiogram revealed ejection fraction of less
than 40% and wall motion abnormalities consistent with
ischemia. During hospital course, the patient was
subsequently diuresed well. Repeat echocardiogram revealed
ejection fraction of 40% with 3+ mitral regurgitation and
akinesis of the basal inferior and lateral walls with mild
regional left ventricular systolic dysfunction. The patient
was subsequently diuresed further and I&Os were followed.
2. Neurology - The patient upon admission was relatively
[**Name2 (NI) 3584**] and oriented times three, however, during hospital
course status post cardiac catheterization and intubation and
acute renal failure, the patient's mental status subsequently
waxed and waned and the patient was subsequently confused
most of the time. Neurology service was consulted and the
patient's mental status was thought secondary to toxic
metabolic encephalopathy and related to her uremia and other
medical conditions. The patient's mental status was
subsequently improved with resolution of her uremia.
3. Pulmonary - The patient was originally admitted to the
Medicine service, however, when the patient became
hypotensive and was emergently intubated, the patient was
subsequently transferred to the Medical Intensive Care Unit.
Status post cardiac catheterization, the patient was
subsequently Dopamine pressors for blood pressure support for
a brief period of time. The patient was subsequently rapidly
extubated and subsequently did well after extubation. The
patient was able to be weaned down from face mask to nasal
cannula as well as maintaining her oxygen saturation
relatively well. The patient has a history of chronic
obstructive pulmonary disease and asthma and was continued on
nebulizer treatment and continued her MDIs with good effect.
4. Infectious disease - The patient has a history of HIV
positivity since [**2104**], on highly active antiretroviral
therapy with her last CD4 count of 230 and a viral load which
was undetectable. Upon admission to [**Hospital1 190**], the patient was subsequently continued on her
highly active antiretroviral therapy. However, when the
patient's acute renal failure subsequently began, the
patient's medication therapy was renally adjusted.
5. Renal - The patient had an episode of acute renal
failure, status post cardiac catheterization. The patient's
renal failure was thought secondary to possibly contrast
nephropathy, cardiac catheterization versus emboli from
cardiac catheterization to the renal glomerulus. The
patient's creatinine subsequently began increasing and
subsequently plateaued at 6.1 to 6.2 and remained stable at
that time level. However, approximately a week into the
[**Hospital 228**] hospital course, the patient subsequently began
making some urine and responded well with Lasix and the
patient was subsequently diuresed with Lasix and renal
function was observed very carefully. The patient's renal
function at the time of this dictation remains stable at 6.1
and was expected to subsequently trend downward. However, if
renal function does not improve, the patient will
subsequently require temporary dialysis.
6. Diabetes mellitus - The patient had a history of diabetes
mellitus and was continued on fingerstick glucoses and
sliding scale insulin with good effect.
7. Hematology - The patient had a history of acquired Factor
VIII deficiency. During her last hospitalization, the
patient required multiple transfusions of Factor VIII.
However, during this hospital course, hematology/oncology
service was consulted in regards to the patient's care. As
per hematology/oncology, the patient's Factor VIII deficiency
seemed to have resolved and did not require any transfusions
during this hospital course. However, the patient required
transfusion of packed red blood cells secondary to her
anemia. However, during transfusion, the patient had
subsequently flash pulmonary edema requiring Lasix therapy
and intubation. As per hematology/oncology, transfusion of
packed red blood cells will be held off until absolutely
necessary due to the fact that the patient has a
predisposition for congestive heart failure.
8. Fluids, electrolytes and nutrition - During her stay in
the Medical Intensive Care Unit, the patient was intubated
and did not have good nutrition and subsequently after the
patient was successfully extubated, the patient was able to
tolerate sips and moderate p.o. Nutrition consultation was
consulted in regards to help with the patient's nutritional
status and the patient was encouraged to take p.o. liquids
and solids.
9. Lines, access - The patient has a poor peripheral access.
During her stay in the Medial Intensive Care Unit, the
patient had a right internal jugular triple lumen as a
central line for venous access. On [**2111-6-17**], the triple
lumen central line was changed over a wire.
10. The patient is full code, full care.
DISCHARGE DIAGNOSES:
1. Myocardial infarction, status post percutaneous
transluminal coronary angioplasty with stent placement to
the mid left circumflex.
2. Acute renal failure.
3. HIV.
4. Hypertension.
5. Diabetes mellitus.
6. Chronic obstructive pulmonary disease.
7. Congestive heart failure.
An addendum to this discharge summary will be performed at a
later date for the patient's multiple medical problems.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Last Name (NamePattern1) 5588**]
MEDQUIST36
D: [**2111-6-17**] 17:15
T: [**2111-6-17**] 19:27
JOB#: [**Job Number 102138**]
Admission Date: [**2111-6-9**] Discharge Date:
Date of Birth: [**2046-6-27**] Sex: F
Service:
NOTE: Admitted before with discharge summary up until
[**2111-6-18**]. This is a continuation of this discharge summary.
HOSPITAL COURSE:
1. NEUROLOGIC: The patient's neurological status after the
31st had improved fully. She is [**Month/Day/Year 3584**] and oriented x3 with
slight changes in her memory, but this issue was resolved by
[**Month (only) **].
2. CARDIAC: The patient was watched on cardiac medications.
Blood pressure was monitored. She did have an episode on
[**2111-6-20**] at night of acute shortness of breath, diaphoresis and
she looked very sick, very tachypneic. Her saturations were
89% on room air, 94% on 6 liters. Blood pressure 120/80,
heart rate 70. Electrocardiogram showed a question of mild
J-point elevation in V2-V3 of 2 mm. Lung exam revealed poor
air movement, wheezes, decreased breath sounds throughout.
Arterial blood gases: pH 7.11, PCO2 71, PO2 62. Aggressive
nebulizers were given. Gas improved slowly throughout the
course of the night, 40 mg intravenous Lasix and then 120 mg
intravenous Lasix were given. Chest x-ray showed congestive
heart failure, pulmonary edema and by 3:20 a.m. gas was 7.21,
60, 71 and then by 4:50 a.m. it was improved to 7.23, 56,
119. The patient was also ruled out for myocardial
infarction. Troponin was 8; it had been 50 in the past, so
this was actually followed and was found to be trending down
8 to 7 to 6 and her CKs ended up being negative. The actual
cause of this acute decompensation was not fully known,
probably a combination between congestive heart failure and
chronic obstructive pulmonary disease flare since it improved
with nebulizers and Lasix, not clear which one, but we do not
think she had another cardiac event.
3. PULMONARY: For chronic obstructive pulmonary disease, we
continued her metered dose inhalers and after this one night,
she continued to do well.
4. INFECTIOUS DISEASE: She is on antiretrovirals for human
immunodeficiency virus, Bactrim prophylaxis.
5. RENAL: Creatinine continued to trend down. It went from
5 to 4.6 and remained stable between 4.5 to 4.6 by discharge.
6. ENDOCRINE: We continued to check her fingersticks and
regular insulin. She was on glyburide. Her sugars were high
and we are continuing to watch and will ask nutrition for
help on a good nutrition supplement for a diabetic.
7. HEME: Acquired factor VIII deficiency, now stable. No
issues.
DISCHARGE PLAN: The changes we made to her medications, she
did well on a stable dose of Lasix 80 mg po qd. It was an
adequate dose to keep her negative. She was started on
captopril on [**2111-6-24**], 25 [**Hospital1 **] for renal protection because of
her renal failure and probable diabetic etiology for this
renal failure. She also is on Procrit and Tums and she is
resisting rehabilitation, but we will try to convince her and
her family that this is the best option for her. Physical
therapy saw her and agrees that she is not safe to go home by
herself. She will be discharged to a short term
rehabilitation if her family will agree and if she will agree
pending bed availability.
DISCHARGE MEDICATIONS:
1. Captopril 25 mg po bid
2. Glyburide 5 mg po bid
3. Atrovent/Albuterol metered dose inhaler 2 puffs qid
4. Nystatin swish and swallow 4 to 6 cc po qid
5. AZT zidovudine 100 mg po bid
6. 3TC lamivudine 50 mg po qd
7. Flovent 110 mcg 2 puffs inhaled [**Hospital1 **]
8. Colace 100 mg po bid
9. Lipitor 80 mg po qd
10. Multivitamin 1 po qd
11. Megace 400 mg po qd
12. Timoptic 0.5
13. Optic 1 GGT both eyes [**Hospital1 **]
14. Bactrim double strength 1 po qd
15. Reglan 10 mg po tid with meals
16. Nevirapine 200 mg po bid
17. Prilosec 20 mg po qd
18. Enteric coated aspirin 325 mg po qd
19. Plavix 75 mg po qd until [**7-18**] to complete a 30 day course
20. Toprol XL 150 mg po qd
21. Lasix 80 mg po qd
22. Imdur 30 mg po qd
23. Tums 500 mg po bid with meals
24. Procrit 4000 units subcutaneous twice a week
DISCHARGE DIAGNOSES:
1. Coronary artery disease
2. Congestive heart failure
3. Status post myocardial infarction
4. Status post stent
5. Chronic obstructive pulmonary disease
6. Chronic renal failure
7. Acute renal failure
8. Hypertension
9. Human immunodeficiency virus
DISCHARGE CONDITION: Stable
FOLLOW UP: Dr. [**Last Name (STitle) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Name8 (MD) 6340**]
MEDQUIST36
D: [**2111-6-24**] 09:57
T: [**2111-6-24**] 11:28
JOB#: [**Job Number 33849**]
|
[
"493.20",
"410.11",
"401.9",
"584.9",
"250.00",
"585",
"424.0",
"414.01",
"V08"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"36.06",
"96.71",
"88.56",
"36.01",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
16622, 16630
|
16340, 16600
|
15499, 16319
|
2347, 2929
|
12508, 14780
|
16642, 16938
|
2952, 4765
|
188, 1754
|
14797, 15476
|
1776, 2321
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,371
| 114,810
|
45692
|
Discharge summary
|
report
|
Admission Date: [**2190-9-1**] Discharge Date: [**2190-9-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Cough and sob
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year old female with from nursing facility, non-productive
cough for 2 weeks. Nursing home found her more short of breath
today using accessory muscles to breathe with RR 22-24 and
82%RA, Temp 98.9F, HR 106, BP 170/82. She was placed on 2L
nasal canula and sent to ED for further evaluation. Patient
denies shortness of breath, chest pain, leg swelling, PND,
orthopnea. Main complaint is cough. Was started on keflex at
NH on [**8-18**], unclear reasons although per pt for cough.
Past Medical History:
Hyperthyroidism (toxic multinodular goiter)
Hypertension
h/o fainting/falls with transient syncope
- Admission [**4-28**] initially sinus bradyarrhytmia, resolved when
HR>60; Admit [**6-26**] r/o MI; no evidence of arrhytmia on tele
- Last echo [**10-26**]: EF > 55%, Normal wall motion, mildly dilated
left atrium, trivial MR, E/A 0.50
GERD
Recurrent UTIs (last [**4-28**])
CRI: baseline Creatinine 1.2-2.0
ORIF femoral fracture
h/o B12 deficiency
dementia
Social History:
Lives in nursing home. Some distant tobacco use, denies etoh.
Previously worked as a receptionist. Son, [**Name (NI) 3924**] [**Name (NI) 97379**]
(HCP/POA: [**Telephone/Fax (1) 97380**]) lives in [**Location 7349**].
Family History:
No history of CAD, sudden death
Physical Exam:
V: 97.0F HR 80 BP 155/64 RR 26 94/6L n.c.
Gen: awake, alert and oriented x 2+ (not oriented to month/day
but oriented to year), tachypneic, frequent rattling cough but
able to speak in short sentences
HEENT: PERRL, EOMI, OP clear, MM sl dry
Neck: supple, JVP 7cm
CV: RRR, S1, S2, no murmurs appreciated
Pulm: bilateral coarse breath sounds, crackles left base, right
with scattered rhonchi and prolonged exp wheeze
Abd: Normoactive BS, soft, ND/NT
Ext: WWP, no edema, dry skin
skin: seborrheic keratosis and multiple bruises but no rash
Pertinent Results:
WBC 11.0 Hct 34.4 Plt 214
N:83 Band:10 L:4 M:3 E:0 Bas:0
.
136.|.100.|.31 258
---------------
4.2.|.21.|.1.4
.
8:00 p.m. CK: 108 MB: 3 Trop-T: <0.01
.
proBNP: 1461
.
UA: large leuks, neg nitrites, small blood, [**5-2**] WBC, 0-2 RBC,
few bacteria
.
lactate:2.7
.
CXR: New right middle and right lower lung zone opacities and
bilateral peribronchial cuffing representing either multifocal
pneumonia, asymmetric pulmonary edema, or bronchitis.
.
EKG: Sinus tachy 108, normal axisand intervals. TWIS III old.
Only change from prior is tachycardia.
Brief Hospital Course:
In the ED upon first arrival Temp 102.4F and given tylenol.
Given Vancomycin 1g x 1 and Levofloxacin 750mg x 1. Given
Albuterol and Ipratropium Nebs and solumedrol 125mg x 1. UA was
negative. Blood and urine cultures done. EKG done without
evidence of acute ischemia. Oxygen increased from 2L to 6L
(Oxygen sat 94%/6L). And she was admitted to ICU for further
monitoring. After 1 day in the ICU she was deemed stable, and
though direct discharge from ICU was considered, decision was
made to monitor one more day on the general medical floor.
Course as outlined below:
# Pneumonia - Given fever, elevated white count with bands,
hypoxia and RML, RLL opacities consistent with pneumonia. Most
c/w with CAP, no history of aspiration. No h/o COPD. Urine
legionella negative. Did well the night of admit with minimal
O2 requirements, cough remained unproductive so no sputum
culture was obtained. Throughout stay continued to deny SOB or
increased WOB, was afebrile throughout hospital stay.
Originally started on Levo/vanc for HAP and flagyl for possible
aspiration PNA. Antiobiotics narrowed the morning of admission
at recommendation of pulmonary ICU attending to Levofloxacin,
renally dosed, with projected duration of 10 days for CAP, last
dose to be [**2190-9-10**]. On day of discharge o2 sat 93% RA.
# Elevated BNP - Did have some crackles in bases on lung exam
consistent with atelectasis, does not appear volume overloaded,
no peripheral edema. Was monitored for signs of volume overload
but did not develop overt heart failure during hospitalization.
# CRI - Creatinine on admit at baseline. CRI felt to be due to
HTN. Throughout stay was monitored for worsening renal function
but none was observed. All medications renally dosed during
stay. At discharge creatinine was 1.3 down from 1.4 on
admission.
# HTN - Well controlled at baseline. Not an issue since admit.
Was continued on home norvasc dosing.
All other chronic medical issues did not necessitate medical
intervention or medication adjustments during her
hospitalization.
Any necessary communication was with her son: [**Name (NI) 3924**] [**Name (NI) 97379**],
HCP/POA: [**Telephone/Fax (1) 97380**]
FULL CODE reconfirmed by son and pt.
Medications on Admission:
amlodipine 5mg daily
donepezil 10mg po qhs
raloxifene 60mg daily
methimazole 5mg daily
ASA 325mg daily
cholecalciferol 400unit daily
Calcium Carbonate 500 mg po q12hours
colace/senna/dulcolax/MOM prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for Pain or Fever.
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO Daily ().
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for Constipation.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for Constipation.
11. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 7 days: last dose [**2190-9-10**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care doctor or return to the ER with
any increased shortness of breath or other concerning symptoms.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2190-9-3**]
|
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icd9cm
|
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2722, 4953
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68,929
| 174,034
|
55090
|
Discharge summary
|
report
|
Admission Date: [**2146-4-1**] Discharge Date: [**2146-4-8**]
Date of Birth: [**2090-8-14**] Sex: F
Service: MEDICINE
Allergies:
Albay Honey Bee Venom
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Left leg cellulitis
Major Surgical or Invasive Procedure:
Biopsy of the left lateral thigh on [**4-4**]
History of Present Illness:
A 55 Year old female with PMH RA, fibromylagia, hypothyroidism
is transferred from [**Hospital3 **] for evaluation of
cellulitis of the left lower extremity due to concern for
necroizing faciitis.
She reports that she had a flu like illness 1 week ago with
associated malaise, nausea and vomiting, she was unable to
tolerate oral intake and did not take spironolactone. She noted
tightness in her left leg beginning 5 days ago and redness
begining 4 days ago distally and spreading proximally to the
hip. She had subjective fevers and chills and presented to the
[**Hospital3 **] ED for evaluation where labs showed WBC 27.6
and Cr 1.36, she was treated with ceftriaxone, vancomycin and
evaluated by surgery who expressed concern for necrotizing
faciitis and recommended transfer to [**Hospital1 18**] for further
evaluation.
In the ED, initial vitals were: 100.0 100 120/90 20 99% 2L Nasal
Cannula, Labs showed Cr 1.5 (baseline unknown) Na132 WBC 25.6
89%PMN She was seen by general surgery who recommended CT to
rule out necrotizing faciitis. CT showed diffuse swelling but no
air to suggest necrotizing fasiitis, no abcess. She was given
morphine 5mg IV x3 and admitted to medicine. Vitals: 98 NSR, RR
24, 112/67, 98% 2L NC, temp 98.2
On the floor, she repoted anxiety but denied pain. She denies
recent car trips or plane flights, denies history of DVT.
Past Medical History:
TN
Asthma
Rheumatoid arthritis
Fibromyalgia
Hypothyroidism
Anxiety/depression
Alcoholism sober x 20 years
Morbid obesity
Restless Leg Syndrome
Past Surgical History:
Hysterectomy ([**2128**])
Removal of ganglion on wrist
Social History:
Lives alone but is in close contact with two sisters who reside
nearby. Works as a tutor and office manager at family business.
History of alcoholism x 20 years. Smoker, >20Pack year history
Denies illicits/IVDU.
Family History:
Rheumatoid arthritis, endometrial and other GYN cancers
Physical Exam:
Physical Exam on Admission:
VS: t98.0 bp131/73 p96 rr14 SaO2 94% 2LNC
GENERAL: Middle aged overweight female appearing anxious but in
NAD, comfortable, appropriate.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM
NECK: Supple, no elevated JVP
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes
ABDOMEN: Overweight Soft/NT/ND, no rebound/guarding.
EXTREMITIES:
Left lower extremity: Blanching Erythemia extending from the
ankle to the upper thigh extending medially near the vaginal
area. Dry, crusted skin with underlyuing edema. DP/PT pulse 1+
Right lower extremity: no erythemia, tace edema DP/PT pulse 1+
NEURO: Awake, A&Ox3, CNs II-XII grossly intact
Physical Exam on Discharge:
Vitals: T 98.3 BP 140/77 HR 91 RR 20 O2sat 97% RA
GENERAL: Obese female who looks comfortable and in no acute
distress.
HEENT: PERRLA, EOMI, sclerae anicteric, conjunctiva pink, dry
mucous membranes, oropharynx clear.
NECK: Supple, no JVD, thyroid barely palpable bilaterally.
Carotids 2+ bilaterally w/o bruits.
HEART: RRR, nl S1-S2, no MRG.
LUNGS: Wheezes bilaterally. No rhonchi or rales.
ABDOMEN: Obese. Soft/ND. Diffuse tenderness to palpation. No
rebound/guarding. Multiple pinpoint purple nonblanching macules
over the lower two quadrants.
EXTREMITIES: LLE has a much improved blanching erythematous rash
from hip to dorsum of foot. Induration is now absent and much of
the erythema has dissipated. Erythema over lateral hip has
advanced a bit beyond the borders but unchanged from 2 days ago.
Bullae on posterior and lateral aspect of thigh have opened up
and finished weeping. Bullae have begun to scab over. Bullae on
posterior ankle is open and weeping w/ skin sloughing off. No
crepitus. PT and DP pulse 2+.
RLE: no erythemia, trace edema. PT and DP 2+.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Pertinent Results:
Admission labs:
[**2146-3-31**] 10:45PM BLOOD WBC-25.6* RBC-4.71 Hgb-13.5 Hct-42.7
MCV-91 MCH-28.7 MCHC-31.6 RDW-13.8 Plt Ct-166
[**2146-3-31**] 10:45PM BLOOD Neuts-89.3* Lymphs-7.1* Monos-2.8 Eos-0.5
Baso-0.3
[**2146-3-31**] 10:45PM BLOOD Glucose-110* UreaN-21* Creat-1.5* Na-132*
K-3.4 Cl-93* HCO3-23 AnGap-19
[**2146-4-1**] 07:15AM BLOOD ALT-20 AST-27 AlkPhos-141* TotBili-0.2
[**2146-4-2**] 06:30AM BLOOD Albumin-2.9* Calcium-7.8* Phos-4.4 Mg-2.2
[**2146-4-2**] 06:30AM BLOOD CRP-GREATER TH
[**2146-4-1**] 07:15AM BLOOD Vanco-4.8*
[**2146-3-31**] 11:12PM BLOOD Lactate-1.8
Pertinent Labs:
Sodium and Renal Function Trend:
[**2146-4-1**] 07:15AM BLOOD Glucose-105* UreaN-20 Creat-1.3* Na-132*
K-3.4 Cl-94* HCO3-24 AnGap-17
[**2146-4-2**] 06:30AM BLOOD Glucose-103* UreaN-13 Creat-1.3* Na-133
K-3.5 Cl-95* HCO3-25 AnGap-17
[**2146-4-3**] 06:40AM BLOOD Glucose-102* UreaN-14 Creat-1.6* Na-127*
K-3.6 Cl-90* HCO3-23 AnGap-18
[**2146-4-3**] 03:30PM BLOOD Glucose-110* UreaN-17 Creat-2.0* Na-125*
K-3.9 Cl-89* HCO3-22 AnGap-18
[**2146-4-4**] 02:00PM BLOOD Glucose-94 UreaN-21* Creat-2.4* Na-120*
K-4.0 Cl-83* HCO3-19* AnGap-22*
[**2146-4-4**] 05:00PM BLOOD Glucose-89 UreaN-22* Creat-2.4* Na-120*
K-3.6 Cl-84* HCO3-22 AnGap-18
[**2146-4-4**] 07:39PM BLOOD Glucose-93 UreaN-23* Creat-2.4* Na-122*
K-3.4 Cl-85* HCO3-21* AnGap-19
[**2146-4-5**] 12:14AM BLOOD Na-119* K-3.8 Cl-84*
[**2146-4-5**] 05:50AM BLOOD Glucose-100 UreaN-25* Creat-2.6* Na-125*
K-4.3 Cl-90* HCO3-22 AnGap-17
[**2146-4-5**] 04:21PM BLOOD Glucose-134* UreaN-26* Creat-2.5* Na-130*
K-4.1 Cl-95* HCO3-23 AnGap-16
[**2146-4-6**] 05:48AM BLOOD Glucose-99 UreaN-28* Creat-2.6* Na-133
K-3.9 Cl-98 HCO3-28 AnGap-11
ABGs
[**2146-4-4**] 12:31PM BLOOD Type-ART pO2-73* pCO2-53* pH-7.23*
calTCO2-23 Base XS--5
[**2146-4-4**] 05:50PM BLOOD Type-ART pO2-72* pCO2-62* pH-7.20*
calTCO2-25 Base XS--4 Intubat-NOT INTUBA
[**2146-4-4**] 08:13PM BLOOD Type-ART pO2-76* pCO2-72* pH-7.15*
calTCO2-26 Base XS--5
[**2146-4-5**] 09:47PM BLOOD Type-[**Last Name (un) **] Temp-36.5 pO2-39* pCO2-56*
pH-7.25* calTCO2-26 Base XS--3
Imaging:
CT Lower leg [**2146-3-31**]: Diffuse subcutaneous soft tissue edema and
fluid along the superficial fascial planes in the left lower
extremity, predominantly in the left leg, consistent with known
history of cellulitis. No evidence of subcutaneous air to
suggest necrotizing fasciitis.
LENI Left [**2146-4-1**]: IMPRESSION: No evidence of deep vein
thrombosis in the left leg.
CXR [**2146-4-6**]: Cardiac size is top normal. Right PICC tip is in
the lower SVC. There is no pneumothorax or pleural effusion.
Aside from improving atelectasis in the right lower lobe, the
lungs are clear. There are no new lung abnormalities.
Brief Hospital Course:
55 yo F w/ PMH of morbid obesity, COPD, Rheumatoid Arthritis and
hypothyroidism was treated for Left leg bullous cellulitis and
hospital course complicated by hyponatremia, acute kidney injury
and transient respiratory acidosis.
#Left leg Bullous cellulitis- the patient had extensive bright
red, indurated, hot, entire left leg with edema and concern for
possible necrotizing fascitis so was sent here from Lawrenece
General. CT scan showed no evidence of subcu air, and there was
no evidence on exam of necrotizing fasciitis. She was followed
by surgery who felt no surgical interventions were necessary.
She was originally on vancomycin and when she developed bullae
she was broadened to Vanc/Cefepime and Clinda for a few days.
Dermatology was consulted because of the extensive bullae and
areas of sloughing for concern of something like scaleded skin
syndrome or SJS due to new antibiotics. They felt that her rash
was consistent with a bullous cellulitis, and took a biopsy on
[**4-4**] to r/o linear IGA reaction to vancomycin. She was afebrile
and her WBC was downtrending throughout her hospital course and
she was never hypotensive or with signs of sepsis. She was
transitioned to oral antibiotics on [**4-7**] to complete a total of
14 days of antibiotics. At the time of discharge she still has
extensive skin changes on her left leg, with darkening of the
skin compared to the right, with multiple coalescing bullae
especially over the left lateral hip, and crusting over and
scabing on the inner thigh with some sloughing on the posterior
leg.
-Started Doxycycline 100mg po BID
-Started Keflex 500mg TID (will need to be uptitrated to QID
when patient's renal function normalizes)
#Hyponatremia- the patient came in with a low sodium. She was
given a few liters of fluid and it was stable. Her sodium then
decreased. Her volume status was difficult to assess. She was
briefly fluid restricted with worsening in her hyponatremia.
Ultimately, it was felt that she was hypovolemic and she was
aggressively given IV fluids wiht improvement in her sodium.
Her sodium was noraml at the time of discharge.
#Acute renal failure- patients renal function was elevated on
admission at 1.4 (up from her baseline of 0.7). She developed
worsening renal function 48 hours into her hospitalization. Her
creatinine peaked at 2.6 and was downtrending at the time of
discharge. The etiology of her renal failure was likely a
combination of contrast nephropathy and hypovolemia. Her
medications were renally dosed at this creatinine clearance, and
this will need to be followed up on by her PCP. [**Name10 (NameIs) **] was
discharged off of her atenolol and spirinolactone.
#Asthma Exacerbation- patient takes spiriva at home for her
asthma. She had extensive wheezes on admission and required
multiple nebulizer treatments and her lungs were clear at the
time of discharge.
#Respiratory Acidosis- Around the time of the patient's acute
renal failure, she was noted to be very drozy with an oxygen
requirement. An ABG was performed which revealed a severe
respiratory acidosis. She was briefly transferred to the ICU
where it was believed that her acidosis was in part due to
hypoventilation from narcotics (exacerbated by her decreased
renal clearance of morphine). She received narcan and was
treated with BiPAP with improvement. At the time of discharge,
she no longer needed oxygen and had a normal respiratory and
mental status. She may, however, benefit from an outpatient
sleep study as she likely has a component of OSA
#Tobacco Abuse- patient was counseled on quiting smoking given
her COPD.
-She reported that she has quit smoking and is currently on
wellbutrin which will likely help with this
#Depression/Fibromyalgia- she was stable
-NSAIDS were held during this admission and at the time of
discharge as her renal function is not back to baseline
Transitional Issues:
Pending labs/studies: None
Medications started:
1. Doxycycline 100mg by mouth twice a day (antibiotic) through
[**4-13**]
2. Keflex 500mg by mouth three times a day (antibiotic) through
[**4-13**]
Medications changed: None
Medications stopped:
1. Ibuprofen (important not to take until your kidney's are back
to normal)
2. Spironolacone (hold until you are told to by your PCP)
3. Ropinerole (hold until you are told by your PCP)
4. Atenolol (hold until your PCP tells you to restart)
Follow-up needed for:
1. You will need to get your labs drawn on [**4-11**] and your doctor
will discuss these with you at your follow-up appointment
2. You will follow-up with Dermatology (per below)
3. You will need to have your blood pressure monitored since you
are off of your blood pressure medication due to the kidney
function
4. Improvement of the cellulitis
5. You will need to have your stitches removed from your skin
biopsy on [**4-18**] (your primary care physician can do this)
Medications on Admission:
Atenolol 100 mg daily
Fluoxetine 40 mg daily
Buproprion 150 mg TID
Ropinirole 1 mg [**11-22**] PRN
Spironolactone (50 mg daily
Pravastatin 10 mg daily
Hydroxychloroquine 200 mg [**Hospital1 **]
Lyrica 75 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Levothyroid 100mcg
Spiriva Daily
Multivitamin
Discharge Medications:
1. Device
Patient requires a bariatic small base quad cane.
2. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
3. Wellbutrin 75 mg Tablet Sig: Two (2) Tablet PO three times a
day.
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): on area under left breast.
Disp:*1 tube* Refills:*2*
11. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): take through [**2146-4-13**].
Disp:*11 Capsule(s)* Refills:*0*
12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours): take through [**2146-4-13**].
Disp:*17 Capsule(s)* Refills:*0*
13. Outpatient Lab Work
CBC and Chem-7 to be drawn on [**2146-4-11**]
ICD9 584.9
Please fax to Dr.[**Name (NI) 37061**] office at Fax #: [**Telephone/Fax (1) 88047**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cellulitis, Acute kidney injury, respiratory acidosis
Secondary: COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].
You were transferred to [**Hospital1 18**] because of concern over your left
leg infection. The doctors at the [**Name5 (PTitle) **] hospital were concerned
that this is something that would require surgery so they sent
you here to [**Hospital1 18**]. You were evaluated by the surgeons who felt
that you did not require surgery based on the imaging and your
exam. You were treated with IV antibiotics and then as it
improved we switched you over to oral antibiotics and you were
tolerating those well at the time of discharge. Because your
skin was blistering on top, we had the dermatologists see you
and they performed a biopsy and felt that this blistering was
due to the excess fluid that was in your leg. Your leg had
dramatically improved while you were here and will continue to
heal after you go home. It will be important to keep your leg
elevated whenever you are not on your feet.
While you were here you had a lot of wheezing and were not
exhaling out as much as you needed too, so we briefly had you in
the ICU to give you a special kind of breathing treatment called
BIPAP, and then you were back on the regular medical floor. It
will be important to keep up with your inhalers as an
outpatient. You were breathing well without wheezing at the
time you were discharged.
-We recommend that you get a sleep study as an outpatient to
determine if you would benefit from sleeping with CPAP
Your kidneys were not working 100% on admission and this was
worsened by having the IV contrast that you needed for the CT
scan of your leg. This was improving but not back to normal at
the time of your discharge, so it will be important to have your
labs drawn on MOnday [**4-11**] and your PCP will [**Name9 (PRE) 702**] on this
and decide if you need to see a kidney specialist or not.
Transitional Issues:
Pending labs/studies: None
MEdications started:
1. Doxycycline 100mg by mouth twice a day (antibiotic) through
[**4-13**]
2. Keflex 500mg by mouth three times a day (antibiotic) through
[**4-13**]
Medications changed: None
Medications stopped:
1. Ibuprofen (important not to take until your kidney's are back
to normal)
2. Spironolacone (hold until you are told to by your PCP)
3. Ropinerole (hold until you are told by your PCP)
4. Atenolol (hold until your PCP tells you to restart)
Follow-up needed for:
1. You will need to get your labs drawn on [**4-11**] and your doctor
will discuss these with you at your follow-up appointment
2. You will follow-up with Dermatology (per below)
3. You will need to have your blood pressure monitored since you
are off of your blood pressure medication due to the kidney
function
4. Improvement of the cellulitis
5. You will need to have your stitches removed from your skin
biopsy on [**4-18**] (your primary care physician can do this)
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) 4768**] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 79357**] office is working on a follow up appointment
for 4-8 days after your hospital discharge. Please call the
office number listed below on Monday [**4-11**] to discuss this
appointment. Thank you,
Location: [**Location (un) **] FAMILY PRACTICE
Address: [**Location (un) 4769**], [**Location (un) **],[**Numeric Identifier 4770**]
Phone: [**Telephone/Fax (1) 4771**]
If your leg is not improving or you have more questions about
the rash. You call to schedule a follow-up with [**Hospital 2652**]
clinic at [**Telephone/Fax (1) 1971**] to make an appointment.
|
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icd9cm
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|
1994, 2208
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,377
| 164,349
|
9546
|
Discharge summary
|
report
|
Admission Date: [**2178-8-29**] Discharge Date: [**2178-9-7**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea/Fatigue/Decreased Exercise Tolerance
Major Surgical or Invasive Procedure:
[**2178-9-1**] MV Repair with 28mm CE annuloplasty band; MAZE
procedure; Pericardectomy
History of Present Illness:
This 86 year old male with worsening symptoms of shortness of
breath was investigated and was found to have a severe mitral
regurgitation, plus
mild to moderate tricuspid regurgitation with an enlarged right
and left atria. His angiogram showed normal coronary arteries
and he was electively admitted for mitral valve repair or
replacement.
Past Medical History:
Chronic AF
HTN
BPH
Raynaud's Syndrome
Pulmonary HTN
Social History:
Lives with wife in [**Name (NI) **]. Retired. Never smoked. 1 glass of
wine daily.
Family History:
Both sons with AF
Sister with PPM/AF
Physical Exam:
GEN: WDWN in NAD
HEART: Irregular rate and rhythm, III/VI systolic murmur with
quiet diastolic murmur
LUNGS: Clear
ABD: Benign
EXT: Warm, dry, pulses intact
NEURO: Nonfocal
Pertinent Results:
[**2178-9-4**] 07:35AM BLOOD WBC-5.8# RBC-3.02* Hgb-9.8* Hct-29.8*
MCV-99* MCH-32.5* MCHC-32.9 RDW-14.4 Plt Ct-184
[**2178-9-4**] 07:35AM BLOOD Glucose-124* UreaN-38* Creat-1.0 Na-132*
K-4.7 Cl-95* HCO3-26 AnGap-16
[**2178-9-3**] Bedside Swallowing [**Name (NI) **]
Pt is not demonstrating any s&s of aspiration or dysphagia at
this time. Coughing episode this am at breakfast may have been
related to pt's current confusion. However, it appears that pt
can tolerate a PO diet consistency that he is currently ordered
for.
[**2178-9-3**] CXR
1. No evidence of pneumothorax after removal of a right internal
jugular central venous line and removal of left-sided chest
tube.
2. Unchanged mild congestive heart failure.
[**2178-9-1**] EKG
Atrial fibrillation
Q-Tc interval appears prolonged but is difficult to measure
Probable left bundle branch block
Poor R wave progression - could be in part lead placement but
clinical
correlation is suggested
Since previous tracing of [**2178-8-30**], poor R wave progression
present
[**2178-9-7**] 06:30AM BLOOD PT-16.1* INR(PT)-1.8
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 32416**] was admitted to the [**Hospital1 18**] on [**2178-8-29**] for surgical
management of his mitral valve disease. His coumadin was stopped
and heparin was continued. As his INR was slow to drift towards
normal, vitamin K was given with good effect. On [**2178-9-1**], Mr.
[**Known lastname 32416**] was taken to the operating room where he underwent a
mitral valve repair with a 28mm [**Last Name (un) **] [**Doctor Last Name **] annuloplasty
band, a MAZE procedure and a pericardectomy. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. Amiodarone was started ofr his atrial fibrillation.
On postoperative day one, Mr. [**Known lastname 32416**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Coumadin was resumed. His pacing wires and
drains were removed when protocol was met. Mr. [**Known lastname 32416**]
experienced some confusion and aggitation at night which slowly
resolved over his postoperative course. On postoperative day
two, he was transferred to the cardiac surgical step down unit
for further recovery. Mr. [**Known lastname 32416**] was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. Mr.
[**Known lastname 32416**] was noted to have some coughing with a meal and a speech
and swallow consult was obtained. A bedside swallowing
evaluation was performed which showed no evidence of aspiration
and a regular diet was continued without issue. Mr. [**Known lastname 32416**]
continued to make steady progress and was discharged to rehab on
postoperative day #6. He will follow-up with Dr. [**Last Name (Prefixes) **],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Atenolol 25mg [**Hospital1 **]
Coumadin
Lasix 40mg QD
Lisinopril 5mg QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
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 BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 7 days: Then decrease dose to 200 mg PO daily.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Mitral regurgitation
Chronic AF
BPH
Pulmonary hypertension
Raynaud's syndrome
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
You should shower daily, let water flow over wounds, pat dry
with a towel.
Call our office for sternal drainage, temp.>101.5
Do not use creams, lotions, or powders on wounds.
[**Last Name (NamePattern4) 2138**]p Instructions:
Please follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Please follow-up with your cardiologist Dr. [**Last Name (STitle) **] in 2
weeks.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in
[**1-9**] weeks.
Call for appointments.
Completed by:[**2178-9-7**]
|
[
"V58.61",
"443.0",
"424.0",
"416.8",
"786.8",
"429.9",
"790.92",
"600.00",
"V58.83",
"427.31",
"423.1",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31",
"37.33",
"99.04",
"88.72",
"35.33",
"39.61",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5136, 5214
|
312, 402
|
5335, 5342
|
1211, 2287
|
965, 1003
|
4257, 5113
|
5235, 5314
|
4160, 4234
|
5366, 5659
|
5710, 6040
|
1018, 1192
|
2338, 4134
|
228, 274
|
430, 773
|
795, 849
|
865, 949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,342
| 165,519
|
49012
|
Discharge summary
|
report
|
Admission Date: [**2176-6-17**] Discharge Date: [**2176-6-20**]
Date of Birth: [**2130-4-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
tarry black stools
Major Surgical or Invasive Procedure:
EGD
TIPS
History of Present Illness:
46 year old woman with EtOH/HCV cirrhosis who was recently
admitted on [**2176-6-4**] with coffee ground emesis and black colored
stools.
.
Today the patient called her PCP and reported 3 episodes of jet
black diarrhea, which was similar to her prior episode of UGIB.
She denied hematemesis, but reported diffuse abdominal pain and
poor po intake all weekend. The patient denies the use of
NSAIDs, anti-coagulants, iron supplementation or pepto bismol.
She has no known history of bleeding disorders.
Of note since her last discharge [**2176-6-7**] she was having loose,
brown watery stools. Due to her chronic diarrhea, she is always
orthostatic.
.
In the ED the patient's vitals were as follows T 98.3 HR 86, BP
92/66 (BP tends to run chronically low) RR 20 O2sat 96% RA. Her
stool was grossly guaiac positive. She received 4l of IVF. Her
Hct was 41 (thought to be hemoconcentrated as her entire cell
line was up from baseline). She was seen by GI and transferred
to the unit for an EGD and overnight monitoring.
.
During her last admission, she required 9U PRBCs and aggressive
IVF resuscitation. An EGD was performed on [**2176-6-4**] which showed
grade I varices at the lower third of the esophagus, grade 1
esophagitis in the gastroesophageal junction, portal
gastropathy, duodenitis in the proximal bulb and large duodenal
varix.
Past Medical History:
-Heavy ETOH abuse
-HCV
-Elevated portal pressures with varices and portal gastropathy
-Chronic LE neuropathy
-Diastolic CHF
-Asthma
-Depression
-Osteopenia
.
PSH:
-CCY
-TAH for endometrial hyperplasia
Social History:
Lives with husband and 29 y.o son from a previous marriage.
Heavy etoh abuse in the past, last drink 3 months ago. Had "DTs"
in during years of EtOH abuse never admitted for withdrawal
symptoms. Tobacco 1 ppd x 30 years. No IVDU.
Family History:
Father died of MI in 80's. Many alcoholics in family. One
cousin with celiac sprue.
Physical Exam:
Vitals: T97.7 HR 77 BP 100/36 R16 O2 99RA
Gen: Caucasian female in NAD lying on stretcher
HEENT: MMM dry, poor dentition, oropharynx
Chest: CTA b/l, no gmr
CV: nl rate, S1S2, no gmr
Abd: soft, round, slightly protuberant, +BS, liver 2 finger
breadth below costal margin
Extr: warm, no cce
Neuro: A & O X 3, strength 5/5 in upper and lower extremity
Skin: spider angiomata on upper torso
Pertinent Results:
Labs on admission
[**2176-6-17**] 11:30AM BLOOD WBC-8.3# RBC-4.69 Hgb-14.0 Hct-41.3
MCV-88 MCH-29.7 MCHC-33.8 RDW-15.6* Plt Ct-119*#
[**2176-6-17**] 11:30AM BLOOD Neuts-72.5* Lymphs-19.9 Monos-4.5 Eos-2.3
Baso-0.9
[**2176-6-17**] 11:30AM BLOOD Plt Ct-119*#
[**2176-6-17**] 11:30AM BLOOD PT-19.1* PTT-39.6* INR(PT)-1.8*
[**2176-6-17**] 11:30AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-132*
K-4.6 Cl-96 HCO3-24 AnGap-17
[**2176-6-17**] 11:30AM BLOOD ALT-19 AST-48* AlkPhos-93 Amylase-23
TotBili-4.1*
[**2176-6-17**] 11:30AM BLOOD cTropnT-<0.01
[**2176-6-17**] 04:18PM BLOOD Hgb-12.8 calcHCT-38
.
[**2176-6-18**]
TIPS
IMPRESSION:
1. Successful placement of a transjugular intrahepatic
portosystemic shunt using three 10-mm bare metallic Wallstents
extending from a right portal vein to the right hepatic vein.
2. Slightly unusual hepatic venous anatomy identified with two
separate right hepatic veins which were small in caliber.
3. Gradient between the portal vein and IVC pre-TIPS placement
was 13 mmHg. Post- TIPS placement the gradient was 9 mmHg.
.
.
.
[**2176-6-20**] 05:30AM BLOOD WBC-4.6 RBC-3.24* Hgb-10.2* Hct-28.7*
MCV-89 MCH-31.5 MCHC-35.6* RDW-15.7* Plt Ct-59*
[**2176-6-20**] 12:01AM BLOOD Hct-27.6*
[**2176-6-19**] 06:22PM BLOOD Hct-29.6*
[**2176-6-19**] 03:03AM BLOOD WBC-7.3 RBC-3.37* Hgb-10.2* Hct-30.2*
MCV-90 MCH-30.3 MCHC-33.9 RDW-15.6* Plt Ct-77*
[**2176-6-18**] 11:39PM BLOOD Hct-31.5*
Brief Hospital Course:
46 F with history of alcohol/hep C cirrhosis, portal
hypertension who was recently admitted with an UGIB found to
have a grade I varices, represents today with black tarry stools
similar to her prior presentation.
.
DDX includes from most likely to least likely bleeding varices
(given prior EGD), PUD, AVMs, Dieulafoy lesion, M-W tears
(unlikely given no hx of retching)
.
1) Upper GI bleed:
An EGD was performed on HD#1 but was aborted due to the fact
that the patient had consumed a [**Location (un) 6002**] while in the ED and was
vomiting during the procedure. The patient was aggressively
suctioned, but there is a possibility that she may have
aspirated. Serial hcts were done and remained >30. The patient
remained HD stable. She was kept on levo, octreotide and IV PPI.
She had a 16 and 18 gauge IV.
.
An EGD was performed the following day with showed a duodenal
varix. Due to the patient's hx of UGIB and the nature of the
varix, TIPs was performed on the same day. There were no
complications. Doppler U/S was performed the following day
which showed the following:
.
Patent TIPS with flow rates ranging from 84 to 151 cm/sec.
Patent and appropriate directional flow in the portal vein,
hepatic vein, hepatic artery.
.
She was transferred to the general medical wards following her
procedure on [**2176-6-20**], with hct (31->29-27->28). On the morning
of discharge, pt was frustrated, and stated that she wanted to
leave AMA. She was ultimately seen by interventional radiology,
who inspected the site of her TIPs procedure, and by the GI
service. She was discharged home with instructions to check her
hct and follow-up with her PCP and the GI service within [**1-13**]
weeks.
.
.
2) Transient episode of hypoxia
- During the EGD, she vomited up gastric contents and had a
transient episode of hypoxia. Her O2sats fell to the high 80s.
She was placed temporarily on 2L NC and her sats improved to the
high 90s. Throughout her course the patient had transient desats
to high 80s. She reported being asymptomatic. Repeat CXR
showed moderate right pleural effusion and a small left pleural
effusion. Consolidation was also present at the bases c/w
atelectasis or aspiration. Repeat CXR on [**6-20**] showed "Moderate
bilateral pleural effusions and pulmonary vascular congestion,
which developed between [**6-18**] and [**6-19**] have decreased
substantially, there is
no interstitial edema, and consolidation in the left lower lobe,
probably
atelectasis has improved." She was discharged home without
further treatment, as she declined to go home with oxygen.
.
.
3) Thrombocytopenia:
On admission patient's plts were 119. This is around baseline.
Of note on last admission plts fell to 48K. This was attributed
to octreotide and chronic hypersplenism. Low platelets may also
be a reflection of liver disease and low thrombopoietin.
.
4) Cirrhotic liver disease
Patient reports that she drank for over 30 years. She also has a
history of hep C (VL 600-700,000 copies/mL detected.) Her
coagulopathy (INR 1.8) [**1-11**] liver disease.
.
She is on nadolol, furosemide and spironolactone at home but
this has been held in the setting of her GIB. Elevated LFTS [**1-11**]
to chronic liver disease. Will monitor. She has no localizing
abd pain on exam.
.
6) Neuropathy
Continue neurontin.
.
7) Hypothyroidism
Continue Levoxyl.
.
9.) FEN: NPO for EGD, following procedure gluten free diet given
celiac disease. Hyponatremia prob [**1-11**] to poor PO intake.
.
10.) Prophy: on PPI, pneumoboots, no SC heparin given GIB and
INR>1.8
.
11.) Code Status: full code
.
Pt was discharged home on [**2176-6-17**], with stable hct (28's). She
continued to require O2 to maintain O2 sats in the 90s, however
she refused to take home O2, and denied any symptoms of SOB with
O2 sats in the 80s on RA. She was instructed to follow-up with
the GI service and her primary care physician [**Name Initial (PRE) 176**] 2-4 weeks,
and specifically to have her hematocrit checked before following
up with her PCP.
Medications on Admission:
levothyroxine 50 mcg
neurontin 900 [**Hospital1 **]
protonix 40
nadolol 20
lasix 40
albuterol
atrovent
niacin 250 [**Hospital1 **]
trental 400 tid
kcl 80 meq
pyridoxine
spirinolactone 25
thiamine
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once)
for 1 doses.
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Niacin 250 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day:
for SBP prophylaxis. .
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Trental 400 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day.
10. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO qd prn: take
as needed for nausea. .
Discharge Disposition:
Home
Discharge Diagnosis:
gi bleeding from duodenal varices secondary to portal
hypertension.
Discharge Condition:
stable.
Discharge Instructions:
Please continue to take all of your medications as prescribed.
If you experience any worsening symptoms such as vomitting
blood, dark tarry stools, light-headedness, chest pain,
shortness of breath, abdominal pain or distension, please
contact your primary care provider or the emergency department.
Followup Instructions:
Please follow-up with your primary care provider [**Name Initial (PRE) 176**] [**1-13**]
weeks. Please also follow-up with your Dr. [**Last Name (STitle) 497**], please have
your CBC drawn prior to seeing Dr. [**Last Name (STitle) 497**].
|
[
"287.5",
"518.0",
"493.90",
"244.9",
"V64.1",
"070.70",
"537.89",
"303.90",
"311",
"456.8",
"579.0",
"733.90",
"571.5",
"355.8",
"456.1",
"578.1",
"571.2",
"997.3",
"572.3",
"428.0",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9390, 9396
|
4106, 8126
|
300, 310
|
9508, 9518
|
2675, 4083
|
9866, 10109
|
2166, 2252
|
8372, 9367
|
9417, 9487
|
8152, 8349
|
9542, 9843
|
2267, 2656
|
242, 262
|
338, 1679
|
1701, 1903
|
1919, 2150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,536
| 183,487
|
33584+57860
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-9-17**] Discharge Date: [**2108-10-1**]
Date of Birth: [**2041-6-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalosporins /
Erythromycin Base
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Questionable insulinoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 50390**] is a 67 yo female with history of morbid obesity,
atrial fibrillation on chronic coumadin, questionable DVT,
depression, history of OSA, asthma, hyopothyroidism presenting
from [**Hospital3 417**] Medical Center for workup of possible
insulinoma.
Per reports, the patient is a resident at at [**Hospital1 **] [**Last Name (un) **]
Rehabiliation facility. She was found to have a fingerstick
glucose of 30 there and was transferred to [**Hospital3 417**] Mecial
Center for further evaluation. She was transferred to the ICU
for recurrent hypoglycemia and Cpeptide/insulin levels were
found to be elevated. Of note, the patient has no history of
diabetes. A cosyntropin stimulation test was performed which was
interpreted as "mild suppression of HPA axis", as cortisol went
from 10 - 19 with stim. The patient was started on 10 mg
prednisone, with glucose levels in the 100's afterwords.
Endocrinology was consulted, who was concerned for a possible
insulinoma. As patient is morbidly obese, she did not fit in the
CT scanner at the OSH, and was transferred to [**Hospital1 18**] for imaging.
Regarding her low blood sugars, the patient had been
expericening episodes of diaphresis and confusion assocaited
with sweats and visual changes since [**2108-9-9**]. Her BG was checked
and found to be hypoglycemic per above. She was given juice and
sugar cubes, but her sugars would temporally respond then dip to
the 30's-40's after an hours or so. She denies any recent
insulin use or oral hypoglcyemic use. Of note, she has been
trying to lose weight through diet and exercise, losing a total
of 50 lbs in the last year with 10 lbs in the last month.
Regarding the endocrionlogy consult, she had a cosyntropin test
per above which suggested adrenal suppression possibly from
chronic inhaled steroid use, and increased levothyroxine dosing
leading to HPA suppression. This led to a recommendation of
lifelong prednisone use which started at 10 mg daily. She was
further evaluated on [**9-15**] where insulin concentration was 114,
proinsulin was 53, and C-peptide was 14.6 all c/w insulin
hypersecrtion from insulinoma or receiving a secreatgogue such
as a sulfonylurea. Given that the patient did not have any
further episodes of hypoglycemia, endocrinology was under the
impression that hypoglycemic episode related to sulfonylurea
ingestion. Suggested CT abdomen as well as tapering of
prednisone 1mg per week to goal of [**4-7**] mg daily.
At the OSH, a left sided PICC was placed given poor access. A
portable CXR performed that showed "complete opacity of the left
hemithorax with increasing infiltrate at the right lung base and
gastric congestion in the right lung". Regarding placement, the
left PICC line position was difficult to ascertain due to
distorted anatomy from "left lung collapse" with concern for
placement in the left innominate vein. INR around that time was
5.0, and the patient claism to continue to have oozing from the
site since placement on [**2108-9-16**].
At time of transfer, the patient's T was 97.8, pulse 88, RR 20
saturating 95% on no documented O2 supplemnetation with BP of
137/62.
.
ROS: Endorsed visual changes involving central clouding and
peripheral acuity. Resolved after the hospital "gave her some
meds". Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Bronchtis, questionable asthma
History of pna
morbid obesity
hypothyroidsism
atrial fibrillation on coumadin
depression
questionable history of venous thrmoboembolism
OSA (per report)
Social History:
Former tax accountant. Nondrinker/never smoker. Lives at rehab.
Has an adopted daughter.
Family History:
Unknown per patient. Father died when she was 30. Mother died of
complications related to obesity. No siblings.
Physical Exam:
Admission:
VS:97.9 137/67 66 20 94% on 6L
GENERAL: NAD obese.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple. Could not appreciate JVD or thyroid
HEART: Distant HS. Normal S1/S2
LUNGS: Distant BS. Otherwise CTABL ausculated anteriorly
ABDOMEN: Obese. NBS. NTTP. No organomegaly apprecaited
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. Left power
PICC in place
GU: foley in place with cloudy urine
NEURO: Awake, A&Ox3, CNs II-XII grossly intact
Brief Hospital Course:
67 yo female with history of morbid obesity, atrial fibrillation
on chronic coumadin, questionable DVT, depression, history of
OSA, asthma, hyopothyroidism presenting from OSH for evaluation
of possible insulinoma.
.
# HYPOXIA/LOBAR LUNG COLLAPSE: Patient is in chronic respiratory
acidosis due to small airways collapse and air trapping. She
was found to have complete left upper lobe and partial lower
lobe collapse on CT scan after admission. Echo performed to
evaluate for pulmonary hypertension was suboptimal given
patient's habitus. Most likely cause for O2 requirement is a mix
of obstructive airway disease with Pickwickian physiology. She
experienced respiratory decompensation with hypercarbia and was
transferred to the MICU where she was intubated for respiratory
failure. Bronchoscopy showed collapse of left large airways due
to extrinsic compression by right atrium and secretions in right
lung. Serial CXRs showed an evolving right sided pneumonia.
She completed an 8 day course of vancomycin and aztreonam for
pneumonia. Due to the patient's body habitus and obstruction,
she required a large amount of PEEP on the ventilator. She
underwent a bronchoalveolar lavage which was unrevealing. Due
to poor ability to wean from the ventilator, the patient
underwent tracheostomy. She was weaned to intermittent trach
mask with periods of rest on MMV, and required CPAP/PSV
overnight for transient episodes of desaturation at night.
.
# SUPRATHERAPEUTIC INR: Persistently elevated INR (5.0) after
admission despite holding Coumadin. Likely related to
malnutrition/malabsorption as opposed to liver dysfunction or
medication effect in this patient. She received a dose of PO
vitamin K prior to MICU transfer. In the MICU, INR improved.
It remained stable for the remained of admission.
.
# HYPOGLYCEMIC EPISODES AT OSH: OSH endocrine workup concerning
for insulinoma vs. adrenal insufficiency vs. medication effect
due to inappropriate insulin/secretagogue. Other potential
causes ruled out here. She was followed by endocrine here and
had no further episodes of hypoglycemia. Endocrine was not
concerned for insulinoma. The patient would benefit from
endocrine follow-up, and was instructed to do so on discharge.
.
# ?ADRENAL INSUFFICIENCY: Abnormal cosyntropin stim test at OSH
although sub-optimal study. ABD CT shows ?1.5cm adrenal nodule,
left. Her repeat cortisol stimulation testing here off of
steroids was normal suggesting that she does not actually have
adrenal insufficiency.
.
# PROTEUS UTI: She had a positive UA with urine culture growing
Proteus. Given her allergies, she was started on aztreonam for
treatment. UTI proven aztreonam sensitive. She completed an 8
day course of antibiotics. UTI resolved.
.
# ASTHMA: The patient was continued on nebs and inhalers
throughout admission.
.
# ATRIAL FIBRILLATION: Chronic. Patient's coumadin was held on
admission for supratherapeutic INR. Coumadin was restarted and
she remained therapeutic for the remained for admission.
.
# HYPOTHYROIDISM: Patient was continued on home dose
levothyroxine 200 mcg qday.
.
# OBESITY: Morbidly obese. Has had pannus resection in past.
She was followed by wound care for pannus [**Female First Name (un) **]. She was
treated with nystatin and cream.
.
# DEPRESSION: She was continued on Celexa 20 mg qday.
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing, shortness
of breath
Miconazole Powder 2% 1 Appl TP [**Hospital1 **] apply to rash under pannus
Citalopram 20 mg PO/NG DAILY
Ondansetron 4 mg IV Q8H:PRN nausea
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Tiotropium Bromide 1 CAP IH DAILY
Levothyroxine Sodium 200 mcg PO/NG DAILY
Discharge Medications:
1. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
4. Serevent Diskus 50 mcg/dose Disk with Device Sig: [**2-5**]
Inhalation twice a day.
5. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO at
bedtime.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q6H (every 6 hours).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Titrate to INR goal of [**3-8**].
9. oxycodone 5 mg/5 mL Solution Sig: [**2-5**] PO every 4-6 hours as
needed for pain: Hold for sedation, rr<10.
10. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical twice a day as needed for rash: under left breast,
pannus.
11. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal
twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Partial left lung collapse
Right sided pneumonia
Proteus Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital for evaluation of a possible
insulin secreting tumor (insulinoma). After further testing, it
was determined that you do not have an insulin secreting tumor
(insulinoma). You were transferred to the intensive care unit
for partial collapse of your left lung at [**Hospital3 417**]
Hospital. This was believed to be partially due to compression
of your lungs by an enlarged heart. You also developed a right
lung pneumonia and received a full course of antibiotics to
treat the infection. You also underwent a bronchoalveolar
lavage of your lungs which was unrevealing. However, it was
difficult to take you off the ventilator, and you underwent a
tracheostomy so it would be possible to discharge you from the
hospital while on a ventilator.
You were also found to have a urinary tract infection and you
were treated with a course of antibiotics.
The following changes were made to your home medications:
- Furosemide 80 mg daily was STARTED
- Prednisone 10 mg daily was STOPPED
- Percocet was SWITCHED to Oxycodone as needed for pain
Followup Instructions:
You should follow up with the interventionary pulmonologist as
an outpatient for further evaluation and management of your lung
function.
You should follow up with an endocrinologist as an outpatient
within 7-14 days after discharge from the hospital.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],[**First Name3 (LF) **]
Z. [**Telephone/Fax (1) 9347**], within 7-10 days of discharge from the
rehabilitation facility.
Name: [**Known lastname 12574**],[**Known firstname 1940**] Unit No: [**Numeric Identifier 12575**]
Admission Date: [**2108-9-17**] Discharge Date: [**2108-10-1**]
Date of Birth: [**2041-6-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalosporins /
Erythromycin Base
Attending:[**First Name3 (LF) 12576**]
Addendum:
CXR ([**9-29**]):
The Dobhoff tube still is in the stomach and coiled. Left
central catheter tip is in the left brachiocephalic vein. Mild
pulmonary edema is unchanged. Right lower lobe consolidation is
increased from prior, could be atelectasis but superimposed
infection cannot be excluded. Left lower lobe retrocardiac
opacity consistent with atelectasis is unchanged. If any, there
is a small left pleural effusion. ET tube tip is 6.5 cm above
the carina.
TTE ([**9-19**]):
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is mildly depressed (LVEF= ?45-50 %). The number of aortic valve
leaflets cannot be determined. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: poor technical quality due to patient's body
habitus. Moderate LV dilatation. Global left ventricular
function is probably mildly depressed, a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. No pathologic valvular abnormality seen. Pulmonary
artery systolic pressure could not be determined.
CT Chest/Abdomen ([**9-18**]):
FINDINGS: Please note that evaluation is extremely limited given
patient's
body habitus.
CT CHEST: There is complete collapse of the left upper lobe and
partial collapse of the left lower lobe with leftward shift of
mediastinal structures. The obstructing cause is not seen on
this study. This is new when compared to the chest radiograph of
[**2105-3-18**].
There are patchy opacities in the right lung apex, nonspecific,
but may be infectious or inflammatory in nature. Mosaic pattern
of ground-glass opacity within the right lung is consistent with
air trapping, and may represent underlying small airways
disease. There is a small right-sided pleural effusion and
adjacent compressive atelectasis.
There is cardiomegaly without pericardial effusion. No definite
mediastinal, hilar, or axillary lymphadenopathy is seen,
although again, evaluation is extremely limited.
CT ABDOMEN: The spleen, stomach, and liver are within normal
limits. Multiple small calcified gallstones are present within
the gallbladder. Evaluation of the kidneys is limited, although
they do appear grossly normal.
There may be a left adrenal nodule measuring up to 1.5 cm,
although it is unclear whether this is definitively part of the
left adrenal gland. Unfortunately, further assessment of this
nodule cannot be made on this study. The right adrenal gland
appears normal.
The pancreas is markedly atrophic and extremely difficult to see
on this study. However, no gross mass within the pancreas is
identified.
BONE WINDOWS: No concerning osseous lesions are identified.
IMPRESSION:
Extremely limited evaluation given patient's body habitus.
1. Complete collapse of the left upper lobe and partial collapse
of the left lower lobe. An obstructing cause is not seen.
Leftward shift of midline structures. Small right-sided pleural
effusion.
2. Patchy opacities in the right lung apex are nonspecific, but
may be infectious or inflammatory in nature. Mosaic ground-glass
pattern to the right lung is most consistent with air trapping
and may reflect underlying small airways disease.
3. Cardiomegaly.
4. The pancreas is not well seen given limitations of the
examination and is also likely atrophic. However, no gross mass
identified.
5. Possible left adrenal nodule measuring up to 1.5 cm. However,
it is unclear whether this actually part of the left adrenal
gland or adjacent to it and further characterization cannot be
made on this study.
6. Cholelithiasis.
MICROBIOLOGY:
Bronchoalveolar lavage ([**9-21**]):
[**2108-9-21**] 12:56 pm BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE/RLL BAL.
GRAM STAIN (Final [**2108-9-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2108-9-23**]):
Commensal Respiratory Flora Absent.
YEAST. ~4000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2108-9-24**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Urine Culture ([**9-20**]):
[**2108-9-20**] 4:47 pm URINE Source: Catheter.
**FINAL REPORT [**2108-9-26**]**
URINE CULTURE (Final [**2108-9-26**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
AZTREONAM SENSITIVITY REQUESTED PER DR [**First Name (STitle) 396**] ([**Numeric Identifier 12577**]).
Sensitive TO AZTREONAM.
sensitivity testing performed by [**First Name8 (NamePattern2) 5260**] [**Last Name (NamePattern1) **].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
Urine Culture ([**9-18**]):
[**2108-9-18**] 5:17 am URINE Site: NOT SPECIFIED
HEM# 0205L [**9-18**] USED.
**FINAL REPORT [**2108-9-22**]**
URINE CULTURE (Final [**2108-9-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
AZTREONAM REQUESTED BY DR.[**Last Name (STitle) 12578**] # [**Numeric Identifier 12579**] ON
[**2108-9-21**].
AZTREONAM SENSITIVE sensitivity testing performed by
[**First Name8 (NamePattern2) 5260**] [**Last Name (NamePattern1) **].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
Urine Culture ([**9-27**]):
[**2108-9-27**] 12:33 pm URINE Source: Catheter.
**FINAL REPORT [**2108-9-29**]**
URINE CULTURE (Final [**2108-9-29**]): NO GROWTH.
Admission Laboratory Values:
Lactic Acid:0.6 mmol/L
ABG: 7.17/106/199//6
O2 Delivery Device: Aerosol-cool, Face tent
SpO2: 90%
PaO2 / FiO2: 498
WBC 13.1
Hb 10.2
Hct 31.3
Plt 231
Na 141
K 4.1
Cl 101
HCO3- 35
BUN 18
Cr 0.7
Glucose 137
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 12580**] MD [**MD Number(2) 12581**]
Completed by:[**2108-10-1**]
|
[
"579.9",
"263.9",
"564.00",
"311",
"428.33",
"518.84",
"244.9",
"278.03",
"286.7",
"429.3",
"V46.2",
"278.01",
"V85.44",
"V58.61",
"493.20",
"251.1",
"E932.3",
"787.91",
"486",
"327.23",
"041.6",
"518.0",
"428.0",
"599.0",
"276.2",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.72",
"33.24",
"96.6",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
19519, 19760
|
4872, 8209
|
366, 372
|
10029, 10029
|
11264, 16482
|
4242, 4355
|
8695, 9799
|
9925, 10008
|
8235, 8672
|
10164, 11092
|
4370, 4849
|
11110, 11241
|
16712, 19496
|
16518, 16678
|
303, 328
|
400, 3912
|
10044, 10140
|
3934, 4120
|
4136, 4226
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,150
| 119,133
|
21857
|
Discharge summary
|
report
|
Admission Date: [**2138-12-2**] Discharge Date: [**2138-12-7**]
Date of Birth: [**2113-11-19**] Sex: F
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
upper endoscopy with variceal banding
History of Present Illness:
25 yo female with h/o AML s/p chemo at age 5, esophageal varices
of unknown etiology diagnosed [**2137**] who was on nadolol and nexium
until a few months ago was admitted with hematemesis x1 (4cc).
NGT lavage did not clear with 500 cc NS, found to have melena,
increased WBC, and Hct of 27. She had approximately 1.5 days of
dizziness, decreased PO intake, and intermittent, sharp
abdominal pain.
Past Medical History:
AML at age 5 s/p chemotherapy
esophageal varicies with h/o variceal bleed
s/p splenectomy for splenomegaly and thrombocytopenia [**2137**]
s/p liver biopsy x 3 showing hepatic fibrosis
Social History:
Lives with husband in [**Location (un) 7073**]. Works in advertising. Denies
alcohol, tobacco, or other drug use.
Family History:
CAD - grandfather
Unknown Metastatic Cancer - grandmother
Physical Exam:
T = 97.9; HR = 134; BP = 107/66; RR = 19; O2 = 97%
GEN: young female; appears comfortable; NAD
HEENT: PERRL, EOMI B, MMM, OP clear, anicteric, no nystagmus
CV: tachy, regular, normal S1S2, no M/R/G
RESP: CTA bilat, no W/R/R
ABD: soft, NT, ND, no masses
EXT: no c/c/e
SKIN: no rashes, no jaundice, no spider telangectasias
NEURO: non-focal
Pertinent Results:
[**2138-12-2**] 07:30PM WBC-16.3* RBC-3.00* HGB-9.6* HCT-27.0* MCV-90
MCH-31.9 MCHC-35.4* RDW-13.1
[**2138-12-2**] 07:30PM NEUTS-76.0* LYMPHS-20.3 MONOS-2.8 EOS-0.7
BASOS-0.2
[**2138-12-2**] 07:30PM PLT COUNT-293
[**2138-12-2**] 07:30PM GLUCOSE-122* UREA N-29* CREAT-0.6 SODIUM-139
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
[**2138-12-2**] 07:30PM ALT(SGPT)-20 AST(SGOT)-23 ALK PHOS-51
AMYLASE-29 TOT BILI-0.4
[**2138-12-2**] 07:30PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.7
MAGNESIUM-1.6
[**2138-12-2**] 07:30PM PT-13.4 PTT-20.4* INR(PT)-1.1
*
CHEST (PORTABLE AP) [**2138-12-3**] 3:42 PM
No previous films for comparison. Heart size is normal. The
lungs are clear. No pleural effusion. Extreme apices are partly
coned off the film. Mildly prominent azygous vein. Surgical
clips are present in the left upper abdomen. No significant
abnormalities in limited AP view.
*
DUPLEX DOPP ABD/PEL [**2138-12-3**] 11:09 AM
ABDOMEN U.S. (COMPLETE STUDY); DUPLEX DOPP ABD/PEL
FINDINGS:
-The liver echotexture is diffusely heterogeneous, particularly
within segments 6 and 7, though no focal liver lesion is
identified. No intrahepatic biliary ductal dilatation.
-The portal and hepatic veins are widely patent with appropriate
direction of flow. The hepatic arteries are likewise widely
patent; however, appear prominent, which may be related to
chronic liver disease.
-No varices are identified within the liver hilum.
-The gallbladder and common duct appear normal.
-There is small-to-moderate amount of ascites.
-There is a hypoechoic area surrounding the right kidney, which
may represent fluid, though considering the history of AML, may
less likely represent a mass. The right kidney is otherwise
unremarkable in appearance. Left kidney appears normal.
-The spleen has been removed.
IMPRESSION:
1. No evidence of portal or hepatic venous thrombosis.
2. Heterogenous liver echotexture, particularly within segments
6 and 7, though no focal masses identified.
3. Apparent fluid versus soft tissue surrounding the right
kidney of unknown significance.
*
CT ABDOMEN W/CONTRAST [**2138-12-4**] 2:53 PM
CT OF THE ABDOMEN WITH IV CONTRAST: There is minimal bibasilar
atelectasis. Small hiatal hernia is present. The liver
demonstrates heterogeneous enhancement, but no focal liver mass
is identified. The gallbladder, adrenals, pancreas, and kidneys
are normal in appearance. The patient is post splenectomy with
clips seen in the left upper quadrant. Residual splenic tissue
is seen in the left upper quadrant. A small amount of free fluid
is seen throughout the abdomen and surrounding the right kidney
as well. No soft tissue mass is noted adjacent to the right
kidney. Several small lymph nodes are seen scattered throughout
the abdomen. There is no free air. There is mild wall thickening
in the cecum and focal loops of small bowel in the left lower
quadrant. Low attenuation material is seen within the superior
mesenteric vein and main portal vein.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, uterus,
and ovaries are unremarkable in appearance. The bladder contains
a Foley catheter and a small amount of resultant air is seen
within the bladder. Free fluid is seen tracking into the pelvis
from the abdomen. There is no pathologic lymphadenopathy within
the pelvis or inguinal regions.
The soft tissues and osseous structures are unremarkable.
IMPRESSION:
1) Heterogeneously enhancing liver without focal mass. Low
attenuation material is seen within the superior mesenteric and
portal veins. This could represent thrombosis even though
arterial and vascular flow to the liver was noted to be widely
patent on the ultrasound of 1 day prior.
2) Ascites thoroughout the abdomen.
3) No soft tissue mass is identified adjacent to the right
kidney.
*
DUPLEX DOPP ABD/PEL [**2138-12-6**] 1:17 PM
LIMITED LIVER DOPPLER ULTRASOUND: 2D, color and Doppler wave
form imaging of the main portal vein shows wall-to-wall flow
without evidence of thrombosis. The flow within the portal vein
is hepatopetal. Flow is also identified in the appropriate
direction within the superior mesenteric vein.
IMPRESSION: No portal or splenic vein thrombosis identified on
liver Doppler ultrasound.
*
EGD [**2138-12-2**]:
1. Varices at the lower third of the esophagus.
2. Blood in the fundus and stomach body.
*
EGD [**2138-12-3**]:
1. Varices at the gastroesophageal junction.
2. Esophageal varices (ligation).
3. Fluids in stomach.
Brief Hospital Course:
Initially, Mrs. [**Known lastname **] was hypotensive with SBP to 70 and
tachycardic to 150s. She was admitted to the MICU and
drastically improved with aggressive fluid resuscitation.
*
After admission, GI performed an EGD showing Grade 2 nonbleeding
esophageal varices (patient had Grade 1 varicies on EGD from
[**6-3**]). There was also a clot in the fundus of the stomach. At
the time, GI was unable to remove the clot to look for gastric
varices. She was given aggressive hydration and IV erythromycin
overnight. The following morning, she was rescoped and fundal
clot was gone. No gastric varicies were seen. Two grade 2
esophageal varices were banded without complication. She was
also febrile on admission with leukocytosis, so
levo/flagyl/ampicillin were started. CXR, blood, and urine
cultures were negative.
*
The patient was then transferred to the floor for further
management. At the time of transfer, the patient's Hct was
stable. She was taken off octreotide and Nadolol was started.
She was afebrile, but WBC count was still elevated, so she was
continued on levofloxacin and flagyl. The Liver team continued
to follow the patient closely. A duplex ultrasound of the liver
was performed on two occasions which failed to reveal clot.
*
Eventually, her WBC count trended down so the antibiotics were
stopped. Her Hct remained stable and she was taking good PO's,
so the IV protonix was changed to Nexium PO (her outpatient
PPI). She was discharged in stable condition on Nadolol and
Nexium with close follow up with her GI physician based at an
outside hospital.
Medications on Admission:
Nexium PRN
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Variceal bleed
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or go to the ED if you have an episode of
blood in vomit, blood in stool, abdominal pain, chest pain,
shortness of breath, or dizziness.
Followup Instructions:
Follow up with your PCP and primary hepatologist within one
week.
|
[
"572.3",
"285.9",
"456.20",
"205.01",
"789.5",
"571.5",
"452",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.04",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8073, 8079
|
6012, 7606
|
282, 322
|
8138, 8146
|
1542, 5989
|
8352, 8421
|
1107, 1166
|
7667, 8050
|
8100, 8117
|
7632, 7644
|
8170, 8329
|
1181, 1523
|
231, 244
|
350, 750
|
772, 958
|
974, 1091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,133
| 167,883
|
48148
|
Discharge summary
|
report
|
Admission Date: [**2161-11-28**] Discharge Date: [**2161-12-7**]
Date of Birth: [**2108-12-6**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 11552**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
intubation, placement of temporary dialysis catheter
History of Present Illness:
Ms. [**Known lastname **] is a 52 year old type I diabetic, ESRD, admitted
with acute onset of shortness of breath and hemoptysis at 9AM.
She was nauseated and had vomiting and dry-heaved in the morning
with blood-tinged vomitus vs. emesis. She denied chest pain,
fevers, chills prior to admission. Per patient's daughter, she
had been noted to be coughing recently, however, did not
complain of fevers or chills to her daugher. No myalgias. No
sick contacts.
In the ED, vitasl were T 96.5F, BP 174/137, HR 96, RR 38, T
100.6, 97% on NRB. She was given lasix and nitroglycerin drip,
and placed on BIPAP. A chest x ray revealed RLL pneumonia, so
she was started on vanco/cefepime/levaquin, and so was intubated
because of concern for PNA. A right IJ was placed.
Past Medical History:
Type 1 DM
Non-ischemic Dilated cardiomyopathy, EF < 20% 4/08 by echo
Hypertension
CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
Chronic hepatitis C
Intracranial right ICA aneurysm; gets yearly imaging. 5mm [**2154**],
8mm on [**2159-2-7**] MRA.
H/o C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**], Dr. [**Last Name (STitle) 363**]
Ulnar nerve impingement bilaterally
S/p Rotator cuff repair
S/p release of right carpal tunnel
Social History:
Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially.
Family History:
Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.
Physical Exam:
VS: HR 83, BP 111/70, RR 30, 93%
Vent settings: Fio2 100%, PEEP 10, TV 500, RRs 15 (patietn
breathing at 15)
Gen: sedated, intubated
HEENT: PERRL, 3mm--> 2mm, intbuated
CV: difficult to appreciate due to coarse breath sounds
Pulm: coarse rhonchi diffusely
Abd: soft, NT, ND, bowel sounds present
Ext: cool, distal pulses present
Neuro: sedated, PERRL, withdraws to pain
Afebrile at discharge, O2 sats mid to high 90s on room air, lung
clear with slightly diminished air movement at bases
Pertinent Results:
Admission labs:
[**2161-11-28**] 11:30AM WBC-5.5 RBC-3.68* HGB-9.7* HCT-30.0* MCV-82
MCH-26.4* MCHC-32.4 RDW-16.8*
[**2161-11-28**] 11:30AM NEUTS-71.9* LYMPHS-24.4 MONOS-1.3* EOS-2.0
BASOS-0.5
[**2161-11-28**] 11:30AM GLUCOSE-470* UREA N-80* CREAT-4.5* SODIUM-135
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-21
[**2161-11-28**] 11:30AM CALCIUM-9.4 PHOSPHATE-6.6*# MAGNESIUM-2.0
Discharge Labs
[**2161-12-7**] 06:35AM BLOOD WBC-9.7 RBC-3.09* Hgb-8.5* Hct-25.4*
MCV-82 MCH-27.5 MCHC-33.5 RDW-18.3* Plt Ct-328
[**2161-12-7**] 06:35AM BLOOD Plt Ct-328
[**2161-12-7**] 06:35AM BLOOD Glucose-207* UreaN-74* Creat-4.4* Na-139
K-3.5 Cl-100 HCO3-27 AnGap-16
[**2161-12-7**] 06:35AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0
Other Lab Data
[**2161-11-29**] 04:45PM BLOOD WBC-11.8*# RBC-2.93* Hgb-7.7* Hct-23.3*
MCV-79* MCH-26.3* MCHC-33.1 RDW-17.4* Plt Ct-231
[**2161-11-30**] 01:46PM BLOOD WBC-17.4* RBC-2.88* Hgb-7.7* Hct-22.4*
MCV-78* MCH-26.7* MCHC-34.3 RDW-17.5* Plt Ct-254
[**2161-12-1**] 03:45PM BLOOD WBC-19.2* RBC-3.11* Hgb-8.5* Hct-24.4*
MCV-79* MCH-27.4 MCHC-34.8 RDW-18.0* Plt Ct-245
[**2161-12-3**] 02:01AM BLOOD WBC-14.1* RBC-3.32* Hgb-9.1* Hct-26.3*
MCV-79* MCH-27.3 MCHC-34.4 RDW-17.4* Plt Ct-204
[**2161-12-5**] 05:40AM BLOOD WBC-12.0* RBC-2.93* Hgb-8.2* Hct-24.3*
MCV-83 MCH-27.9 MCHC-33.6 RDW-17.8* Plt Ct-243
[**2161-11-30**] 09:50PM BLOOD Glucose-81 UreaN-113* Creat-7.1* Na-146*
K-3.9 Cl-109* HCO3-18* AnGap-23*
[**2161-12-2**] 03:25AM BLOOD Glucose-234* UreaN-124* Creat-7.3*
Na-148* K-2.1* Cl-104 HCO3-23 AnGap-23*
[**2161-12-3**] 02:01AM BLOOD Glucose-144* UreaN-112* Creat-6.0* Na-142
K-4.0 Cl-106 HCO3-23 AnGap-17
[**2161-12-5**] 05:40AM BLOOD Glucose-164* UreaN-97* Creat-5.3* Na-138
K-3.7 Cl-99 HCO3-25 AnGap-18
[**2161-11-30**] 01:46PM BLOOD ALT-26 AST-48* LD(LDH)-297* CK(CPK)-549*
AlkPhos-44 TotBili-0.5
[**2161-11-28**] 11:30AM BLOOD cTropnT-0.02*
[**2161-11-28**] 11:12PM BLOOD CK-MB-4 cTropnT-0.06*
[**2161-11-28**] 11:30AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier **]*
[**2161-11-30**] 08:41AM BLOOD CK-MB-6 cTropnT-0.05*
[**2161-11-30**] 01:46PM BLOOD CK-MB-6 cTropnT-0.04*
[**2161-12-2**] 08:29AM BLOOD calTIBC-177* VitB12-1296* Folate-14.7
Ferritn-558* TRF-136*
[**2161-12-2**] 01:58PM BLOOD Hapto-310*
[**2161-11-28**] 11:30AM BLOOD Acetone-NEGATIVE
[**2161-12-2**] 03:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2161-11-30**] 01:56AM BLOOD rapmycn-3.8*
[**2161-12-6**] 05:25AM BLOOD rapmycn-3.8*
[**2161-12-1**] 04:48AM BLOOD Lactate-1.5
[**2161-12-2**] 03:20PM BLOOD HEPATITIS C - RIBA-Test
Test Result Reference
Range/Units
HCV AB, RIBA POSITIVE A NEGATIVE
5-1-1 (P)/C100 (P) REACTIVE A NONREACTIVE
C33C REACTIVE A NONREACTIVE
C22P REACTIVE A NONREACTIVE
NS5 NONREACTIVE NONREACTIVE
HSOD NONREACTIVE NONREACTIVE
MICRO
Blood cx x 2 [**11-28**], [**12-6**] no growth
Urine cx [**11-28**] no growth; urine cx [**12-6**] 10-100L yeast
sputum cx [**11-28**] moraxella catarrhalis
BAL neg; legionella urinary ag neg
C diff neg x 2
CMV IgM neg, CMV VL not detected
IMAGING
Admission CXR: New large left lower lobe pneumonia.
TTE:The left atrium and right atrium are normal in cavity size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated with severe global
hypokinesis. The basal inferolateral and anterior walls contract
best (LVEF = 20 %). The right ventricular cavity is mildly
dilated with hypokinesis of the distal half of the free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension.
Compared with the prior study (images reviewed) of [**2161-4-17**],
the findings are similar.
CT neck: CONCLUSION: Extensive enlargement of the left
sternocleidomastoid muscle with heterogeneous density. In the
absence of obvious signs for infection, either clinically or
radiologically, the finding could potentially be either a
neoplastic or some other type of fibromatous process.
As we discussed by telephone, as it would be potentially
hazardous to
administer either iodinated contrast or gadolinium-DTPA
intravenously,
alternative imaging strategies could include a non-contrast MRI
scan of the neck, which can only be undertaken when there is
clarification that the aneurysm clip is MR compatible.
Additionally, [**Name (NI) 13416**] would offer a very efficacious means to
safely image this abnormality.
U/S Neck: Diffuse expansion and abnormal echogenicity and
hyperemia to the left sternocleidomastoid muscle. Findings could
be compatible with a myositis. Alternatively, hematoma would be
a differential consideration in the appropriate setting. If
there are no contraindications, MRI without contrast (given the
patient's history of end- stage renal disease) could potentially
assist with further characterization.
[**2161-12-3**] CXR
IMPRESSION: Left lower lobe opacity with air bronchograms,
consistent with LLL pneumonic infiltrate.
Brief Hospital Course:
Ms. [**Known lastname **] is a 52 year old female with Type 1 DM, ESRD s/p
failed transplant, admitted with respiratory failure secondary
to CHF versus pneumonia.
She was initially admitted to the MICU:
MICU Course
In the MICU, she was intubated upon admission [**11-28**] and
respiratory failure was thought to be a combination of pneumonia
and volume overload. Sputum cultures grew Moraxella, and
levaquin was started. The patient was intermittently
hypotensive but did not require pressors. She was also volume
overloaded and was diuresed with IV lasix. Creatinine rose as
high as 7, and she underwent 1 session of HD. Renal failure
improved thereafter. She also had an anion gap acidosis briefly
requiring insulin gtt. Subsequently her respiratory failure
improved, and she was extubated and then weaned off oxygen,
breathing comfortably on room air. Blood pressure rose into the
160s, and home BP meds were restarted. Home lantus and ISS
were also restarted. Central line was pulled. She was
transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service.
Remainder of floor course summarized below by problem
#) Pneumonia: Oxygen saturations remained mid 90s on room air at
rest and with ambulation. Levaquin was continued for a total 10
day course renally dosed. She had intermittent low-grade fevers
but was afebrile x 24 hours prior to discharge with Tmax 99s.
#) CHF: EF was 20% [**2161-11-30**], no change since [**4-14**]. Initial
respiratory decompensation may have been in part flash pulmonary
edema in the setting of hypertension. However, she had no
further evidence of volume overload and did not require Lasix on
the floor. Remained euvolemic at time of discharge.
#) Neck mass: Patient was noted to have a nontender L neck mass.
CT without contrast (given her renal failure) was done, showing
SCM enlargement of unclear etiology. Follow-up US was done,
showing similar findings. After discussion with her
nephrologist, it was felt that this was most likely a hematoma
since there was an attempted line placement at this site and the
pt did not have this mass prior to line placement. It should be
followed to resolution as an outpatient.
#) Hypertension: Home antihypertensive regimen was continued.
SBP was 140s at time of discharge.
#) ESRD s/p xplant: Creatinine continued to improve, and urine
output was high, consistent with resolving ATN. She did not
require further HD sessions. Prednisone and sirolimus were
continued as well as Zemplar. Tacrolimus was held per renal
recommendations.
#) Type 1 DM: [**Hospital1 **] Lantus and HISS were continued per home
regimen
.
#) Anemia: Erythropoeitin was continued at three times weekly
rather than twice weekly dosing.
Medications on Admission:
Epo 100 units q MWF
Zemplar 2 mcg daily
Pravastatin 20 mg daily
Prednisone 5 mg daily
Sirolimus 8 mg daily
Ferrous Sulfate 325 mg daily
Colace 100 mg [**Hospital1 **]
Senna [**Hospital1 **] prn
Metoprolol Succinate 200 mg daily
Tacrolimus 3 mg q 12 hours
Ranitidine 75 mg daily
Nifedipine 90 mg daily
Insulin
Discharge Medications:
1. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 vials* Refills:*0*
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sirolimus 2 mg Tablet Sig: Four (4) Tablet PO once a day.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Insulin
Please resume your outpatient lantus and insulin sliding scale.
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Zemplar 2 mcg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
primary: pneumonia, acute exacerbation of chronic systolic
heart failure
secondary: type 1 diabetes, hypertension, hepatitis C, chronic
kidlney disease s/p transplant [**2152**]
Discharge Condition:
hemodynamically stable, afebrile, shortness of breath improved,
ambulating without assist
Discharge Instructions:
You came to the hospital because you were short of breath. This
was likely because you had pneumonia and fluid in your lungs
because of high blood pressure. Your blood pressure was
treated, and you received antibiotics for your pneumonia. Your
kidney function was worse for a short time, and you underwent
one session of dialysis. You have completed your antibiotic
course for your pneumonia.
The following medications were changed in the hospital:
Tacrolimus was stopped
We changed your Epo dose to 4,000 units every Monday, Wednesday
and Friday. You were previously on 4000 units twice per week.
Please return to the emergency room if you have shortness of
breath, high fevers and chills, chest pain, or other symptoms
that are concerning to you.
Followup Instructions:
You are scheduled for a follow-up ultrasound of your neck next
Wednesday [**12-16**] at 2:45 pm. Please go to the [**Location (un) 10043**] of the
[**Hospital Ward Name 517**] to have this done.
Please follow up with Dr. [**First Name (STitle) 805**] on [**12-16**] at 1:30pm in clinic.
Provider: [**Name10 (NameIs) 72667**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1260**] Call to schedule
appointment
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2,093
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46006
|
Discharge summary
|
report
|
Admission Date: [**2145-6-10**] Discharge Date: [**2145-6-29**]
Date of Birth: [**2065-3-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
RIGHT UPPER ABDOMENAL PAIN
Major Surgical or Invasive Procedure:
OPEN CHOLECYSTECTOMY
History of Present Illness:
80 YEAR-OLD FEMALE WITH 2 WEEKS OF INTERMITTENT RIGHT UPPER
QUADRANT PAIN AND LEFT ARM PAIN. PAIN IS SHARP, RADIATING TO
THE BACK, AND LASTING 15-20 MINUTES. PAIN WAS CONSTANT ON THE
DAY OF ADMISSION, BUT HAD BEEN IMPROVING SINCE HER ADMISSION TO
THE EMERGENCY ROOM. SHE TOLERATES ORAL INTAKE AND PASSES GAS
FROM BELOW. SHE HAD BOWEL MOVEMENT THE DAY BEFORE ADMISSION.
IT WAS SLIGHTLY LOOSE. SHE WAS UNSURE IF THERE HAS BEEN BLOOD
IN HER URINE OR STOOL. SHE DENIES SHORTNESS OF BREATH,
NAUSEA/VOMITING, FEVERS/CHILLS. SHE HAS NO PERSONAL OR FAMILIAL
HISTORY OF GALLBLADDER DISEASE.
Past Medical History:
1) TYPE B AORTIC DISECTION S/P REPAIR [**10-1**]
2) BARRETT'S ESOPHAGUS
3) PEPTIC ULCER DISEASE
4) HYPERTENSION
5) HYPERLIPIDEMIA
6) SPINAL STENOSIS
7) ASTHMA
8) DIVERTICULOSIS
9) CATARACTS AND GLAUCOMA S/P BILATERAL EYE SURGERY
[**49**])S/P HYSTERECTOMY
11)S/P RIGHT KNEE SURGERY
Social History:
Lives at home with son, who is a teacher.Denies Tobacco or ETOH
use.She has a daughter, who is active in her health care and is
a nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 9012**]
Family History:
non-contribitory
Physical Exam:
AT TIME OF SURGICAL CONSULT:
TEMP 98.0 PULSE 60 BLOOD PRESSURE 184/81 RIGHT ARM, 188/90
LEFT ARM
RESP RATE 16 PULSE OX: 98% ROOM AIR
GENERAL: NO ACUTE DISTRESS
HEAD AND NECK: ANICTERIC, INJECTED SCLERA, EXTRAOCULO MOTORS
INTACT, NO JUGULAR VENOUS DISTENTION, NO LYMPHANOPATHY
HEART: REGULAR RATE RHYTHM
LUNGS: DECREASED BREATH SOUNDS BILATERALLY
ABDOMEN: SOFT, NON-DISTENDED, RIGHT UPPER QUADRANT IS TENDER TO
PALPATION, NO REBOUND, NO GUARDING, MIDLINE INCISION IS
WELL-HEALED
RECTAL: TONE NORMAL, GUIAC NEGATIVE
EXTREMITIES: TRACE LEFT LOWER EXTREMITY EDEMA
Pertinent Results:
[**2145-6-27**] 05:05AM BLOOD WBC-7.3 RBC-3.70* Hgb-11.1* Hct-33.9*
MCV-92 MCH-30.0 MCHC-32.7 RDW-15.1 Plt Ct-229
[**2145-6-16**] 04:37AM BLOOD WBC-10.7# RBC-4.33 Hgb-12.9 Hct-38.9
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.0 Plt Ct-157
[**2145-6-27**] 05:05AM BLOOD ALT-29 AST-34 AlkPhos-311* TotBili-0.8
[**2145-6-15**] 05:45AM BLOOD ALT-48* AST-67* AlkPhos-370* Amylase-44
TotBili-1.4
[**2145-6-14**] 09:30AM BLOOD ALT-52* AST-78* AlkPhos-379* TotBili-1.5
[**2145-6-12**] 05:45AM BLOOD ALT-48* AST-60* CK(CPK)-142* AlkPhos-443*
Amylase-44 TotBili-1.7*
[**2145-6-11**] 05:45AM BLOOD ALT-53* AST-65* AlkPhos-487* Amylase-43
TotBili-1.6*
[**2145-6-10**] 06:00AM BLOOD ALT-60* AST-82* AlkPhos-513* TotBili-1.0
[**2145-6-9**] 05:35PM BLOOD ALT-58* AST-86* CK(CPK)-87 AlkPhos-484*
Amylase-53 TotBili-0.9
[**2145-6-10**] 06:00AM BLOOD GGT-665*
[**2145-6-9**] 05:35PM BLOOD Lipase-24 GGT-612*
[**2145-6-13**] 02:23AM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-6-12**] 04:00PM BLOOD CK-MB-3
[**2145-6-12**] 05:45AM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-6-9**] 05:35PM BLOOD cTropnT-<0.01
[**2145-6-21**] 07:48AM BLOOD calTIBC-241* Ferritn-192* TRF-185*
[**2145-6-14**] 09:30AM BLOOD calTIBC-307 Ferritn-169* TRF-236
Brief Hospital Course:
UPON ADMISSION TO THE HOSPITAL, THE PATIENT WAS STARTED ON
LEVOFLOXACINQ AND METRONIDAZOLE IV. CARDIAC WORKUP FOR ACUTE
CARDIAC CHANGES WAS NEGATIVE. ULTRASOUND AND CT SCAN OF THE
ABDOMEN WERE INCONCLUSIVE FOR THE DIAGNOSE OF CHOLECYSTITIS; THE
PATIENT'S ABDOMENAL AORTA WAS OBSERVED TO BE STABLE POST-AORTIC
DISSECTION REPAIR. FROM CLINICAL SYMPTOMS, A DECISION WAS MADE
TO TAKE THE PATIENT TO THE OPERATING ROOM FOR OPEN
CHOLECYSTECTOMY. SHE TOLERATED THE SURGERY AND WAS ADMITTED TO
THE SURGICAL INTENSIVE CARE UNIT, AND SUBSQUENTLY TO THE
SURGICAL FLOOR.
POST-OPERATIVELY, SHE HAS BEEN HAVING NAUSEA AND GASEOUS
DISTENTION. THE NAUSEA IS NOW RESOLVED, BUT THE GASEOUS
DISTENTION IS RELATED TO THE [**Hospital **] MEDICAL CONDITION, IN WHICH
SHE HAS BEEN TAKING MEDICATIONS FOR AFTER SHE TOLERATED ORAL
NUTRITION.
HER HOSPITAL STAY WAS COMPLICATED BY DECREASED APPETITE, WHICH
RESULTED IN THE NEED FOR TOTAL PARENTAL NUTRITION.
SHE HAS STEADYLY IMPROVED SINCE THE SURGERY. HE APPETITE HAS
INCREASED. SHE HAS BEEN AMBULATING WITH THE ASSISTANCE OF HER
NURSE AND THE PHYSICAL THERAPY TEAM. SHE HAS BEEN AFEBRILE WITH
VITALS BEING STABLE AND MOSTLY WITHIN NORMAL LIMITS. SHE WILL
BE DISCHARGED TODAY TO A SKILLED NURSING FACILITY ([**Hospital **]) IN FAIR/GOOD CONDITON.
Discharge Medications:
1. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q 8H (Every 8 Hours).
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for PAIN.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Compazine 5 mg Tablet Sig: 1-2 Tablets PO four times a day:
NAUSEA.
Disp:*60 Tablet(s)* Refills:*2*
11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
CHOLECYSTITIS; STATUS POST-OPEN CHOLECYSTECTOMY
Discharge Condition:
FAIR/GOOD
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. [**Month (only) **] RETURN TO NORMAL ACTIVITIES AS TOLERATED, BUT
PLEASE BE AWARE OF ABDOMENAL DRAIN. PLEASE FOLLOW UP WITH DR.
[**Last Name (STitle) **] ON APPOINTMENT DATE (BELOW)
Followup Instructions:
PLEASE CALL DR.[**Doctor Last Name **] OFFICE FOR A FOLLOW UP APPOINTMENT TO
BE SEEN ON [**2145-7-5**] ([**Telephone/Fax (1) 376**] ([**Telephone/Fax (1) 57851**]
Completed by:[**2145-6-28**]
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] |
[
"51.22",
"38.93",
"88.43",
"99.15",
"51.41",
"87.53",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
5920, 5991
|
3366, 4650
|
341, 364
|
6083, 6094
|
2151, 3343
|
6399, 6592
|
1520, 1538
|
4673, 5897
|
6012, 6062
|
6118, 6376
|
1553, 2132
|
275, 303
|
392, 981
|
1003, 1286
|
1302, 1504
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,773
| 105,518
|
43133
|
Discharge summary
|
report
|
Admission Date: [**2151-4-2**] Discharge Date: [**2151-4-8**]
Date of Birth: [**2090-10-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins / pollen / Pineapple
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
ARF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo M with PMH of insulin dependent DM and
Chronic Kidney Disease. Patient underwent to peritoneal catheter
placement on [**2151-3-25**], surgical procedure was uneventfully, there
were no complications. According with patient and patient's
wife,
he did well the first couple of days after his surgery, pain was
well managed with oxycodone. Then patient started having fever,
chills and rigors, alterated mental status with somnolence and
lethargica and decreased urinary output.
Patient was taken to the [**Hospital3 417**] Medical Center, at the
emergency room he was found to be hypotensive and lethargic. SBP
in the 60's. s/p IVF resuscitation, Hydrocortisone, 2U RBC, 1
amp
HCo3. Patient was started Levophed gtt.
On arrival to the ED on OSH his labs were as followed:
124 86 133
------------< 151 10 > 7.2 < 170k ptT 41 / inr 1.4
5.9 9 12
Phosphorus 17
Mag 3.7
Cal 5.6
LFT's ALT 13 AST 14 Aphos Tbili 1.1
CT scan showed bilateral pleural effusion and atelectasis.
Gallbladder wall edema and trace of pericholecystic fluid.
RUQ US no cholelithiasis, mod gall bladder wall thickening and
small amount of pericholecystic fluid. Equivocal for
cholecystitis.
In settings of severe metabolic acidosis and ARF double lumen
RIJ
was placed HD was started.
Pressors were weaned off. Patient was found to have new onset
afib, HR under control with IV metoprolol.
Past Medical History:
DM II c/b neuropathy, retinopathy (followed by outside
endocrinologist)
HTN
CHF (TTE [**4-4**] EF > 55%, LVH)
Asthma
OSA on CPAP (unknown settings)
Gout (last flare in [**2118**]'s)
PD catheter placement [**2151-3-23**]
Thrombocytopenia [**2151-3-30**]
Social History:
Denies tobacco. Reports drinking 3-4 times per year for
holidays. + MJ, last use last pm. No IVDA.
Family History:
father and mother with HTN. Denies family h/o CAD, diabetes,
cancers.
Physical Exam:
Patient alert and oriented
Vitals:
97.9 HR: 83 BP 188/78 RR 20 O2Sat 99% 3 L NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Afib
PULM: Bilateral wheezing. Decreased respiratory sounds at the
bases bilaterally
ABD: Prominent, soft, nondistended, nontender, no rebound or
guarding. Peritoneal catheter in place. No erythema or purulent
discharge
Ext: No LE edema, LE warm and well perfused
Labs:
pH 7.36 pCO2 42 pO2 70 HCO3 25 BaseXS -1
Type:Art Lactate:0.9
Source: Catheter
Color Yellow Appear Hazy SpecGr 1.009 pH 5.5 Urobil Neg
Bili Neg Leuk Lg Bld Lg Nitr Neg Prot 100 Glu 100 Ket 40
RBC >182 WBC >182 Bact Many Yeast None Epi 3 Other Urine
Counts Mucous: Occ
Ucx : Pending
135 91 48
-----------<165 AGap=28
3.6 20 5.1
estGFR: [**11-12**]
Ca: 6.3 Mg: 2.2 P: 6.0 ∆
ALT: 22 AP: 155 Tbili: 0.4 Alb: 3.4
AST: 24 Lip: 17
8.9
7.4 >--< 18 ∆
26.5
N:89.5 L:4.9 M:4.6 E:0.8 Bas:0.2
PT: 14.7 PTT: 30.6 INR: 1.4
IMAGING:
EKG : Afib HR under control 99 bpm
CXR: RLL opacities / vascular congestion
MICRO:
Ucx : P
Blood Cx: P
Pertinent Results:
[**2151-4-8**] 05:55AM BLOOD WBC-10.3 RBC-3.28* Hgb-9.2* Hct-29.2*
MCV-89 MCH-28.2 MCHC-31.6 RDW-14.8 Plt Ct-17*
[**2151-4-2**] 07:14PM BLOOD Plt Smr-RARE Plt Ct-18*#
[**2151-4-4**] 03:20PM BLOOD Plt Ct-23*#
[**2151-4-6**] 06:00AM BLOOD Plt Ct-27*
[**2151-4-7**] 05:45AM BLOOD Plt Ct-16*
[**2151-4-8**] 05:55AM BLOOD Plt Ct-17*
[**2151-4-2**] 07:14PM BLOOD Glucose-165* UreaN-48* Creat-5.1* Na-135
K-3.6 Cl-91* HCO3-20* AnGap-28*
[**2151-4-8**] 05:55AM BLOOD Glucose-152* UreaN-74* Creat-5.7* Na-135
K-3.1* Cl-92* HCO3-27 AnGap-19
[**2151-4-2**] 07:14PM BLOOD ALT-22 AST-24 AlkPhos-155* TotBili-0.4
[**2151-4-3**] 01:55AM BLOOD ALT-18 AST-21 LD(LDH)-314* AlkPhos-134*
TotBili-0.3
[**2151-4-8**] 05:55AM BLOOD Calcium-6.7* Phos-4.1 Mg-1.9
[**2151-4-2**] 21:02
HEPARIN DEPENDENT ANTIBODIES
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES Negative
COMMENT: Negative for Heparin PF4 Antibody Test by [**Doctor First Name **]
Complete report on file in the laboratory.
Brief Hospital Course:
60 yo M with PMH of DM and CKD p/w Septic shock for unknown
origin, likely sources were Pneumonia, Peritoneal Cath
infection, Acute Cholecystitis, UTI. ARF requiring dialysis, now
stable off pressures. He was transferred from [**Hospital3 417**]
Hospital directly to SICU. He was alert and oriented upon
admission. New onset Afib was treated initially with IV
Metoprolol for rate control. Ceftriaxone and Zithromax were
continued for RLL pneumonia and positive UA.
RUQ US was done to evaluate for cholecystitis. Sludge in the
gallbladder without son[**Name (NI) 493**] evidence for acute cholecystitis
was noted.
Creatinine increased indicating acute on chronic renal failure
likely from hypotension. HD was performed via temporary HD line
for volume overload for a couple treatments. Nephrology
recommended continuing Lasix and increasing dose to 80mg [**Hospital1 **].
Foley was initially placed. Urine culture was negative. Urine
output averaged [**Telephone/Fax (1) 92973**] liter per day. Daily serum potassium
was low in the 2.8-3.1 range.
Once stable, he was transferred out of the SICU. The PD catheter
was hand flushed noting bloody effluent. Catheter was then
flushed with 500 ml of dialysate with bloody effluent. No
leaking occurred. Repeat flushing was done with one liter dwell
and drainage. Fluid was clearer. Cell count and culture were
negative for peritonitis. Dry gauze dressing was applied to
catheter insertion site that appeared dry and without redness.
UA and Blood cultures were negative to date.
He was also noted to have thrombocytopenia on admission with
level of 18. Hematology was consulted and w/u ensued. HIT was
negative and it was felt that thrombocytopenia was most likely
due to sepsis and exposure to new drugs including vancomycin,
aztreonam, Levaquin, famotidine, heparin and new HD. Levaquin
was likely drug culpert. Platelet count increased to 27, however
this level decreased to 17 again. He was hemodynamically stable.
Notation was made of bloody effluent from PD rapid exchange to
assess PD catheter on [**4-6**] and [**4-7**]. HCT remained stable during
admission (26 on admit/29 on day of discharge). Temporary HD
line was removed without incident.
Hematology recommended f/u PLT count as an outpatient on [**4-12**].
Recommendations were to f/u with Hematology if PLT count
remained less than 20,000.
Amlodipine was added to Toprol for SBP that was elevated in the
161/79 range. BP responded with SBP decreasing to 140s.
PT was consulted as he was unsteady and required a walker. After
a couple PT sessions of 2 days, he was declared safe for home
with VNA/PT. [**Hospital1 1474**] VNA services were arranged.
The plan was to discharge to home with f/u at [**Last Name (un) **] Dialysis
Unit with [**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], RN. PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **]
to review hospital course and discuss management/follow up of
PLT count and PD. Labs will be drawn on [**4-12**] at [**Last Name (un) **] with fax
to Dr. [**Last Name (STitle) **].
Medications on Admission:
ALLOPURINOL 100 mg '
- CALCIUM ACETATE 667 mg '''
- DARBEPOETIN ALFA IN POLYSORBAT 60 mcg/0.3 mL SC 1x month
- DOXAZOSIN 2 mg ''
- FLUTICASONE-SALMETEROL 100 mcg-50 mcg 2 pf'
- FUROSEMIDE 80' am / 40' pm
- LANTUS 12 units in am, 4-10 units in pm
- QUINAPRIL 40 mg''
- SIMVASTATIN
- ZAFIRLUKAST 20 mg Tablet'
- CHOLECALCIFEROL (VITAMIN D3) 1,000'
- FERROUS SULFATE 325 mg 65mg'
- MULTIVITAMIN
- OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 mg
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
8. amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
11. zafirlukast 20 mg Tablet Sig: One (1) Tablet PO daily ().
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
13. Outpatient Lab Work
[**4-12**] stat labs: CBC, chem 10
Fax to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 34311**]
14. Medications on hold
Quinapril
15. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: stool softner to avoid straining. Stop
if diarrhea.
17. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
Disp:*1 Bottle* Refills:*2*
18. Lantus 100 unit/mL Solution Sig: 4-10 units Subcutaneous at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
ESRD
PD catheter obstruction
thrombocytopenia
HTN
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:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you experience
any of the following:
temperature of 101 or greater, shaking chills, nausea, vomiting,
abdominal pain, malfunctioning PD catheter.
-call your pcp if you have any dizziness/easy bruising or any
bleeding ie., blood in urine/stool or any vomiting
-You need to have blood drawn on Monday [**4-12**] for platelet
monitoring. These labs can be drawn at [**Last Name (un) **] in dialysis unit.
-Visiting nurse services have been arranged with [**Hospital1 1474**] VNA to
include physical therapy
-Be extra careful with anything that is sharp. Do not use a
razor. [**Month (only) 116**] use an electric razor.
-If you fall or bump yourself, you need to go to emergency room
to get checked for any bleeding.
Followup Instructions:
-please schedule follow up appointment as soon as possible with
your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 10813**]
-Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2151-7-15**] 10:30
-follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **] Dialysis tomorrow [**4-9**]
Completed by:[**2151-4-8**]
|
[
"996.56",
"428.0",
"V85.34",
"486",
"250.60",
"V58.67",
"588.89",
"276.2",
"585.6",
"403.91",
"427.31",
"250.40",
"V15.05",
"V14.0",
"584.9",
"E947.8",
"278.00",
"V45.11",
"995.92",
"327.23",
"287.49",
"785.52",
"276.7",
"038.9",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
9859, 9914
|
4395, 7530
|
294, 301
|
10009, 10009
|
3327, 4372
|
11005, 11540
|
2118, 2189
|
8018, 9836
|
9935, 9988
|
7557, 7995
|
10192, 10982
|
2204, 3308
|
251, 256
|
329, 1709
|
10024, 10168
|
1731, 1985
|
2001, 2102
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,750
| 148,906
|
5544
|
Discharge summary
|
report
|
Admission Date: [**2129-11-16**] Discharge Date: [**2129-11-21**]
Date of Birth: [**2057-12-4**] Sex: F
Service: MEDICINE
Allergies:
Dilaudid / Morphine And Related / Adhesive Tape / Oxycodone
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Cardiac Catherterization
History of Present Illness:
71 year old woman with a recent right AK amputation (recovering
at [**Hospital **] [**Hospital **] Hospital), who was admitted to [**Hospital3 4107**] on
[**2129-11-14**] with severe shortness of breath of sudden onset that
woke her up at night. She had no chest pain at that time. Her
BNP was found to be [**2120**] and her troponin was elevated at 1.07
which decreased to 0.68 yesterday. Her CK yesterday was 63. No
other cardiac labs were sent. Given her acute respiratory
distress, she was admitted to ICU and diuresed. She was treated
with [**Year (4 digits) **], statin, BB and sq heparin, but no heparin gtt or
plavix. Total UOP not noted in OSH records. Echo at OSH showed
EF of 40%, and ? hypokinesis consistent with CAD, though no echo
report in OSH records. Patient transfered here for possible cath
tomorrow.
On admission here, patient denies SOB, no CP, no abdominal pain,
no change in vision, no N/V/D. Does report orthopnea, at PND as
described above.
At OSH VS: SR/bigeminy HR 80-90's, afebrile RR 18, 100% on 2
liters,
OSH Labs: K 3.7, bun 22, creat 0.6, Mag 1.9, Hct 34.1, plt 270,
INR 0.93 wbc 6.5
Past Medical History:
Polymyositis on long term prednisone
HTN
CHF
Diabetes - in OSH records, patient denies
COPD
Severe lymphedema and venous stasis
S/p recent right above the knee amputation
MI
PVD
Anxiety
Hx of sepsis over the past year
MRSA
Social History:
Non-smoker, non-drinker, no drugs.
Family History:
Mother with heart failure. HTN.
Physical Exam:
VS - 98.8 108/49 8220 98% on RA patient more comfortable on 2Lnc
Gen: NAD obese female. Oriented x3. Mood appropriate. Tangential
thought process.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm though difficult to assess given
body habitus.
CV: Regular rate, S1, S2 distant. No m/r/g.
Chest: Crackles at bases.
Abd: Obese +bs, Soft, NTND.
Ext: RLE with AKA, surgial wound well healed, no erythema, no
exudate, minimal TTP. LLE with evidence of venous statsis
dermatitis, no edema, 1+ DP pulse
Skin: no rashes.
.
Pulses:
Right: Carotid 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
CARDIAC CATHETERIZATION [**2129-11-17**]:
1. Selective coronary angiography of this right dominant system
revealed mild coronary artery disease. The LMCA had a 20%
stenosis.
The LAD had mild luminal irregularities. The LCx had 40%
disease at the
OM2. The RCA had mild disease.
2. Resting hemodynamics revealed elevated right sided filling
pressures
with RVEDP 11 mmHg. The LVEDP was within normal limits at 9
mmHg.
There was evidence of moderate systolic pulmonary artery
hypertension
with PASP of 46 mmHg. The PCWP was elevated at 21 mmHg. There
was
evidence of mild systemic arterial systolic hypertension with
SBP 146
mmHg. The cardiac index was preserved at 2.3 L/min/m2. There
was no
transvalvular gradient upon pullback of the catheter from the
left
ventricle to the aorta.
3. Resting ventriculogram revealed mild global hypokinesis with
an EF
of 45% and 1+ mitral regurgitation.
FINAL DIAGNOSIS:
1. Mild coronary artery disease.
2. Global hypokinesis.
3. Moderate pulmonary hypertension.
4. Mild systemic arterial systolic hypertension.
5. Elevated right sided filling pressures.
6. Mild mitral regurgitation.
CARDIAC ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The estimated pulmonary artery systolic pressure is normal.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Probable
diastolic dysfunction. Moderate mitral regurgitation.
CT C/A/P:
A large hiatal hernia persists with a small left pleural
effusion
and associated atelectasis. Non-contrast evaluation of the
liver, spleen,
pancreas, and adrenal glands appears unremarkable. Vicarious
excretion of
contrast is noted within the gallbladder, which otherwise
appears
unremarkable. The kidneys demonstrate residual contrast from
prior
intravenous administration. Atherosclerotic calcification of the
abdominal
aorta and its branches are noted, though the abdominal aorta
remains of normal caliber. Intra-abdominal loops of large and
small bowel are of normal caliber and there is no free air, free
fluid, or pathologically enlarged mesenteric or retroperitoneal
lymph nodes. No retroperitoneal fluid collection or hematoma is
identified. A moderately large fat-containing midline abdominal
hernia is reidentified.
The rectum and sigmoid colon are unremarkable. The patient is
status post hysterectomy and a Foley remains within the bladder.
No pathologically enlarged inguinal lymph nodes or free fluid is
identified. A hematoma in the right groin is not significantly
changed compared to a day prior and no increase in its size is
identified. The previously identified distal left common femoral
artery occlusion is not evaluated on the non-contrast images.
Bone windows reveal no worrisome lytic or sclerotic lesions.
Multilevel
thoracolumbar degenerative change and mild compression deformity
of the T12 vertebral body is reidentified.
IMPRESSION: 1. No evidence of retroperitoneal hematoma or
worsening of right groin hematoma.
2. Small left pleural effusion and lower lobe atelectasis in the
setting of large hiatal hernia again noted.
DISCHARGE LABS
-[**2129-11-21**] 06:20AM BLOOD WBC-7.5 RBC-3.38* Hgb-11.3* Hct-31.0*
MCV-92 MCH-33.4* MCHC-36.4* RDW-16.8* Plt Ct-194
-[**2129-11-21**] 06:20AM BLOOD Glucose-88 UreaN-11 Creat-0.4 Na-142
K-3.9 Cl-105 HCO3-30 AnGap-11
-[**2129-11-21**] 06:20AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.1
Brief Hospital Course:
Patient is a 71 yo F admitted to an outside hospital ICU with
CHF exacerbation, BNL to [**2120**], diuresed there, found to have
elevated troponin I of 1.07 and EF of 40% with hypokinesis.
EKG with T wave inverisons throughout. She was transfered here
to [**Hospital1 18**] for catheterization which showed essentially clear
coronaries. Echo after cath showed no hypokinesis, EF 50%.
Likely cause of elevated troponins and EKG changes was coronary
vasospasm that caused transient, reversible ischemia resulting
in acute exacerbation of chronic diastolic heart failure.
Following the cath, patient developed a cath site hematoma and
subsequently became hypotensive to the 70's and had a hct drop
from 27 to 21. She was transfused one unit pRBC and transfered
to the CCU for closer monitoring. CT showed a right common
femoral artery 5 x 2 cm hematoma, without evidence of active
extravasation or interval expansion following delayed imaging.
On [**11-18**] her Hct dropped down to 21.1 (was originally in the low
30's) and she became hypotenisve to the 80's and she was
transfered to the CCU for closer monitoring. A repeat CT at
that time showed no evidence of retroperitoneal hematoma or
worsening of right groin hematoma. Vascular surgery evaluated
her and felt she did not require surgical intervention. She was
transfused a total of 4 units PRBC with stabilization of her Hct
at 30 for the 24 hours. Her BP also remained stable following
the transfusions. Her BP meds were held in the setting of
hypotension and restarted upon transfer to the floor where she
was stable. Patient was discharged to rehab in stable condition
on all her home medications. She was instructed to follow up
with her PCP and cardiologist after discharge from rehab.
#. CAD: Patient with history of prior MI, echo at OSH showing
40% EF (unknown prior), with hypokinesis in an unknown location.
Clinically was in heart failure at OSH and was diuresed to 98%
on RA. Troponin at OSH elevated at peak of 1.07, CK 63. Of
note, she history of myositis with elevated CK's. Patient was
placed on heparin gtt and plavix loaded. Cardiac cath showed
essentially clear coronary arteries. Echo with EF of 50%.
Likely cause of elevated troponins and EKG changes was coronary
vasospasm that caused transient, reversible ischemia resulting
in acute exacerbation of chronic diastolic heart failure.
Continued home beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], statin.
#. Chronic Diastolic Heart Failure: EF 50% on echo here. BNP on
OSH admission [**2120**], agressively diuresed there with good effect.
Admitted here at 98% O2 sat on RA. Had crackles on admission
here and was diuresed with iv lasix and transitioned to po
dosing. Cause of acute exacerbation of outside hospital as
above. Started on lisinopril 5mg po qd as adds a mortality
benefit in this population. Lasix was discontinued as patient
continued to have clinical signs of volume overload with
crackles on lung exam in spite of IV lasix. Started on
torsemide 80mg po qd as altervative and discharged on this.
# Hypotension: Occurred in setting of hematocrit drop and
hematoma at cath site. Transfered to CCU for closer monitoring
where she received a total of 4 units pRBC with stabilization of
her HCT and of her blood pressure. She was transfered back to
the floor after 24 hours of stable hct and vital signs.
# Acute on Chronic Anemia: Has baseine anemia of chronic
disease and had hct drop 27 to 21 in setting of hematoma at cath
site. CT's as above. Received a total of 4 units pRBC with
stabilization of hct to her baseline of low 30's.
#. Ventricular Ectopy: Patient had no history of arrythmia. Was
in NSR throughout stay with multiple PVC's.
#. Lower Extremity Surgical Wound: From R AKA done in
[**Month (only) **]. Was clean, dry and intact. Wound care was consulted
and recommendations followed.
#. Groin Skin Breakdown: Occurred at site where pressure was
held for groin hematoma. Likely occurred because of pressure
and patient's long time treatment with oral steroid for her
polymyositis. Wound care was consulted and recommendations for
dressing was followed.
#. Polymyositis: Continued on long term prednisone 5mg po qd.
#. HTN: Hypotension as above, blood pressure medications held as
above and restarted as above. Discharged on home beta [**Month (only) 7005**].
Added ACE-I as above given heart failure.
#. Diabetes Type II: Per patient, no history of diabetes though
outside hospital records indicate that she does. Covered on
insulin sliding scale. No insulin on discharge. Should follow
up with PCP as out patient.
#. COPD: Continued home medications
#. Anxiety: Continued home medications
Medications on Admission:
Tylenol # 3
Lidoderm patch
Fentanyl patch
Albuterol nebs
IV lasix 80mg b.i.d.
Prednisone 5mg
Lopressor 50mg
Zocor
Xanax
Mucinex
Lyrica
SQ Heparin
Protonix
Senna
KCL
Lactobacillus
Zinc
Aspirin
Discharge Medications:
1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation TID (3 times a day).
4. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day) as needed for itching.
5. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed.
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO AT 6AM AND
AT 2PM ().
13. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO AT 2200 ().
14. Mupirocin Calcium 2 % Cream Sig: One (1) application Topical
[**Hospital1 **] ().
15. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS PRN
().
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-8**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheeze sob.
19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for pain.
23. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
25. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
26. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): 5000 unit sq tid.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Hospital1 392**]
Discharge Diagnosis:
Primary:
Acute on Chronic Heart Failure
NTEMI likely secondary to transient coronary vasospasm
Hypotension
Acute on Chronic Anemia
Secondary:
Polymyositis on long term prednisone
Hypertension
Diastolic Heart Failure
Diabetes
COPD
Severe lymphedema and venous stasis
S/p recent right above the knee amputation
History of MI
Severe peripheral vascular disease
Anxiety
Hx of sepsis over the past year
MRSA carrier
Discharge Condition:
Good, vitals stable.
Discharge Instructions:
You were admitted with labs suggestive of a heart attack and an
abnormal EKG. You had a cardiac catheterization that showed no
coronary artery disease. There is no clear cause of your heart
failure exacerbation. However, it is possible that the arteries
in your heart spasmsed briefly which caused a transient decrease
in oxygen delivery to your heart.
Because of your history of heart failure, you were started on
Lisinopril 5mg once a day. This medication is helpful in
prolonging life in people with heart failure. Additionally,
your lasix was stopped and you were started on torsemide a
medication that may better help your body rid itself of extra
fuild.
No other medication changes were made. You should continue all
your other home medications as directed.
If you have shortness of breath, chest pain, severe abdominal
pain, high fever, dizziness or lightheadedness or any other
concerning symptom, please seek medical care immediately.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
Please follow up with your PCP and your cardiologist when you
are discharged from rehab.
|
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icd9cm
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[
[
[]
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] |
[
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] |
icd9pcs
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[
[
[]
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1769, 1806
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,614
| 183,094
|
27470
|
Discharge summary
|
report
|
Admission Date: [**2174-5-9**] Discharge Date: [**2174-6-4**]
Date of Birth: [**2094-3-1**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Bactrim / Ace Inhibitors
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Endometrial Cancer, Uterine prolapse
Major Surgical or Invasive Procedure:
Total vaginal hysterectomy, [**Last Name (un) **] vault suspension., Left
salpingo-oophorectomy, Cystoscopy.
History of Present Illness:
Ms. [**Known lastname **] is an 80 year old female with grade I endometrial
cancer diagnosed by endometrial biopsy who presents for medical
optimization prior to anticipated staging surgery. She is at
her usual state of health right now. She reports continued
vaginal bleeding that is light to moderate. She denies any
abdominal pain, nausea, vomiting, fever, chills. Denies chest
pain, shortness of breath, or palpitations at this time. Denies
dysuria, hematuria.
Reports lower extremity discomfort that is chronic given her
history of peripheral arterial disease and venous insufficiency.
She also complains of groin discomfort from a yeast infection.
There is also a sore on her left buttock of unknown etiology.
Past Medical History:
OBGYN HX:
- Gravida 2 Para 2 - Spontaneous vaginal delivery x 2
- No abnormal pap smears
- Uterine prolapse
PMH:
- Diabetes, diabetic neuropathy
- Hypertension
- Hypercholesterolemia
- Coronary artery disease. Myocardial infarction x 2
- Ischemic cardiomyopathy
- Osteoarthritis
- Venous stasis disease w/ non-healing ulcers
- Renal insufficiency
- Cholelithiasis
- MRSA cellulitis
- Anemia
- DVT LLE [**2167**]
- GI bleed
- Morbid obesity
- Myocardial infarction x 2. Patient does not know when but
prior to [**2168**] based on
OMR notes.
PSH:
- Lower extremity vascular surgery x 3
- Tonsillectomy, adenoidectomy
- Angioplasty with stent x 3
- Appendectomy
- Back surgery
- Right carpal tunnel release
- Evacuation and drainage of infected lymphocele
- Multiple debridements of lower extremity ulcers
Social History:
Ms. [**Known lastname **] lives alone but requires assistance with activities of
daily living. Daughter [**Name (NI) **] in involved and accompanies her to
most appointments, etc. Impaired mobility. She denies tobacco,
drug, or alcohol use.
Family History:
Mother with diabetes, sister with breast cancer.
Physical Exam:
Admission Physical Exam ([**2174-5-9**])
VS 97 140/72 72 20 100% room air
GEN: alert, awake, oriented x3, comfortable, no acute distress
Heart: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abdomen: morbidly obese, nontender, non-distended, no rebound or
guarding
Pelvis: skin lesions consistent with yeast within groin
folds.Pad with scant spotting. No active bleeding from vagina.
Bimanual exam nontender but exam limited by habitus.
Extremities: multiple changes bilaterally consistent with
history of venous stasis and multiple procedures. No open
wounds.
Shallow erythematous abrasion over left buttock. ? early bed
sore.
Discharge Physical Exam ([**2174-6-3**])
VS
GEN: no acute distress, sitting up in chair
Heart: Regular rate and rhythm
Lungs:
Abdomen: soft, nontender, non-distended. +bowel sounds. No
rebound/guarding. Multiple areas of echymosis unchanged and
stable.
Extremities: non-tender, chronic skin changes consistent with
history of venous stasis. Left buttock abrasion well healed- no
erythema/drainage.
Pertinent Results:
Final Surgical Pathology ([**5-25**]):
Endometrial adenocarcinoma, endometrioid type, FIGO grade 1 of
3, involving a polyp. 70% myometrial invasion. Depth of
invasion: 11 mm. Myometrial thickness: 15.5 mm. pT1b (IB):
Tumor invades one-half or more of the myometrium. Unremarkable
cervix.Unremarkable fallopian tube and ovary.
Pertinent Labs:
ID:
WBC trend
[**2174-6-3**] 05:59 5.1
[**2174-6-2**] 04:20 5.7
[**2174-6-1**] 12:38 5.8
[**2174-6-1**] 06:00 6.6
[**2174-5-31**] 06:30 6.0
[**2174-5-30**] 04:30 6.3
[**2174-5-29**] 04:19 6.9
[**2174-5-28**] 05:04 10.1
[**2174-5-27**] 06:00 6.3
[**2174-5-26**] 15:33 9.9
[**2174-5-26**] 05:52 6.7
[**2174-5-25**] 15:05 7.6
[**2174-5-25**] 06:27 7.8
[**2174-5-24**] 15:35 8.1
[**2174-5-24**] 06:35 9.0
[**2174-5-23**] 14:57 9.5
[**2174-5-23**] 03:15 7.8
[**2174-5-22**] 06:40 12.4
[**2174-5-21**] 06:14 13.3
[**2174-5-20**] 17:20 10.4
[**2174-5-20**] 13:05 12.0
[**2174-5-20**] 07:23 9.2
[**2174-5-19**] 17:31 5.1
[**2174-5-18**] 12:45 5.9
[**2174-5-15**] 07:15 5.4
[**2174-5-14**] 06:49 5.5
[**2174-5-13**] 06:30 4.9
[**2174-5-12**] 06:55 5.5
[**2174-5-11**] 07:11 5.9
[**2174-5-9**] 21:15 8.0
Differential on day of discharge: Neutr 70.3 Lymphs19.9 Monos
5.4 Eos4.1 basos 0.4
Heme:
CBC on admission:WBC-8.0 RBC-4.03* HGB-11.9* HCT-36.1 MCV-90
MCH-29.4 MCHC-32.9 RDW-13.6 Plt 258
CBC on discharge: WBC-5.1 RBC-2.82 HGB-8.4 HCT-25.6 MCV-91
MCH-29.7 MCHC-32.8 RDW-14.4 Plt 289
Hct Trend-
[**2174-6-3**] 05:59 25.6
[**2174-6-2**] 04:20 25.6
[**2174-6-1**] 12:38 26.4
[**2174-6-1**] 06:00 23.1
[**2174-5-31**] 06:30 28.9
[**2174-5-30**] 17:25 27.6*
[**2174-5-30**] 04:30 27.2*
[**2174-5-29**] 04:19 27.2*
[**2174-5-28**] 16:00 27.6*
[**2174-5-28**] 05:04 * 27.9
[**2174-5-27**] 23:56 26.5*
[**2174-5-27**] 13:30 27.9*
[**2174-5-27**] 06:00 31.0*
[**2174-5-26**] 15:33 32.8
[**2174-5-26**] 05:52 31.3
[**2174-5-25**] 15:05 33.2
[**2174-5-25**] 06:27 32.7
[**2174-5-24**] 15:35 34.1
[**2174-5-24**] 06:35 35.1
[**2174-5-23**] 14:57 36.1
[**2174-5-23**] 03:15 32.9
[**2174-5-22**] 06:40 33.2
[**2174-5-21**] 06:14 33.6
[**2174-5-20**] 17:20 36.3
[**2174-5-20**] 13:05 36.6
[**2174-5-20**] 07:23 35.1*
[**2174-5-19**] 17:31 34.4*
[**2174-5-18**] 12:45 35.1*
[**2174-5-15**] 07:15 34.5
[**2174-5-14**] 06:49 35.2
[**2174-5-13**] 06:30 34.3
[**2174-5-12**] 06:55 35.0
[**2174-5-11**] 07:11 34.6
[**2174-5-9**] 21:15 36.1
Coagulation studies- [**5-9**] PT13.9* PTT27.9 INR1.2*
[**5-28**] PT 14.7 PTT 31.5 INR 1.3
Renal:
Urine dip ([**5-28**])- Bl NEG Nitr NEG prot TR gluc NEG ket NEG
bilirub NEG urobil NEG pH 5.0 leuk TR
Urine eos ([**5-24**]): pos
Urine electrolytes ([**5-24**]) Urea 483 Creat99 Na 40 K 67 Cl 32
([**5-28**]) Urea 536 Creat 65 Na41 K 47 Cl 22
Creatinine Trend:
[**2174-6-3**] 12:52 1.7
[**2174-6-3**] 05:59 1.8
[**2174-6-2**] 04:20 1.6
[**2174-6-1**] 06:00 1.6
[**2174-5-31**] 06:30 1.3
[**2174-5-30**] 15:35 1.2*
[**2174-5-30**] 04:30 1.3
[**2174-5-29**] 04:19 1.5
[**2174-5-28**] 16:00 1.5*
[**2174-5-28**] 05:04 1.6
[**2174-5-27**] 13:30 1.5
[**2174-5-27**] 06:00 1.4
[**2174-5-26**] 15:33 1.5
[**2174-5-26**] 05:52 1.4
[**2174-5-25**] 15:05 1.5
[**2174-5-25**] 06:27 1.4
[**2174-5-24**] 15:35 1.5
[**2174-5-24**] 06:35 1.3
[**2174-5-23**] 14:57 1.1
[**2174-5-23**] 03:15 1.1
[**2174-5-22**] 06:40 1.2
[**2174-5-21**] 06:14 1.2
[**2174-5-20**] 07:23 1.3
[**2174-5-19**] 17:31 1.2
[**2174-5-18**] 12:45 1.2
[**2174-5-15**] 07:15 1.7
[**2174-5-14**] 06:49 1.4
[**2174-5-13**] 06:30 1.1
[**2174-5-12**] 06:55 1.1
[**2174-5-11**] 07:11 1.2
[**2174-5-9**] 21:15 1.4
Chemistry Panel on Admission:
Gluc 169* BUN 48* Creat 1.4* Na 139 K4.8 Cl 102 HCO3 26 AGAP16
Chemistry Panel on Discharge:
Gluc 70 BUN 22* Creat 1.8* Na 141 K 4.2 Cl 105 HCO3 30 AGAP 10
Cardiovascular:
BNP ([**6-1**]) [**Numeric Identifier 67213**]
Triglycerides ([**5-26**]) 109
Endocrine:
TSH ([**5-9**]) 0.99
HbA1C ([**5-15**]) 7.3%
Microbiology:
Urine culture ([**5-27**]): No growth
Pertinent Imaging/Studies:
EKG ([**5-10**], [**5-19**], [**5-23**], [**5-27**], [**6-2**]): c/w old infarct, no new onset
of acute process as reviewed by cardiology fellow and internal
medicine resident.
ECHO ([**5-10**]): Right atrium moderately dilated. No atrial septal
defect is seen by 2D or color Doppler. Mild (non-obstructive)
focal hypertrophy of the basal septum. Left ventricular cavity
size is normal. Mild to moderate regional left ventricular
systolic dysfunction with inferior and infero-lateral
hypokinesis to akinesis (LVEF 40%). No masses or thrombi are
seen in the left ventricle. No ventricular septal defect. Right
ventricular chamber size is normal. with borderline normal free
wall function. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation. Mitral valve leaflets are mildly thickened. No
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Tricuspid valve leaflets are mildly thickened. Severe pulmonary
artery systolic hypertension.No pericardial effusion.
Pre-Operative Chest radiograph ([**5-10**]): 1. No acute intrathoracic
process. 2. Moderate-to-severe cardiomegaly. 3. Large hiatal
hernia (stable)
Sestamibi Stress Test ([**5-11**]): No anginal symptoms or ischemic ST
segment changes. Hypertensive at baseline with an appropriate
blood pressure response to the Persantine infusion. Flat heart
rate response. An ectopic atrial rhythm was noted at baseline.
Intermittent ectopic atrial rhythm and sinus rhythm were noted
throughout the procedure with rare isolated VPDs.
Cardiac perfusion ([**5-11**]): Fixed, moderate sized apical defect.
2. Partially reversible moderate sized inferior wall defect. 3.
partially reversible, moderate sized lateral wall defect. 4.
LVEF 36 %. Mild global dyskinesis. 5. Moderate enlargement of
the left ventricular cavity.
Transvaginal Pelvic US ([**5-11**]): uterus measures 7.5 x 4.1 x 4.9
cm, within which is a thickened echogenic endometrium measuring
up to 30 mm. There is loss of the usual interface between the
anterior and posterior myometrium and the endometrium indicative
of invasion. The depth of
invasion cannot be well assessed on this study. There is a
separate echogenic area within the left myometrium measuring 1.9
x 1.1 x 0.9 cm, likely representing a fibroid.
Within the left adnexa is a heterogeneously hypoechoic rounded
structure which measures up to 12 mm and might represent an
abnormal ovary, or lymph node. R ovary is normal.
Carotid series ([**5-12**]): Based on peak systolic velocities, there
is less than a 60% stenosis within the right internal carotid
artery. However, the ICA/CCA ratio of 1.81 suggestive of a
moderately severe stenosis and further assessment with CTA of
neck vessels is recommended. No hemodynamically significant
stenosis within the left common carotid or internal carotid
arteries.
CTA neck ([**5-13**]): 54% stenosis of the proximal left internal
carotid artery.
Abdominal radiograph ([**5-21**]) Probable ileus. Gas is seen in the
colon with the transverse colon being slightly dilated to 7 cm.
No dilated loops of small bowel are seen. No free air.
Chest radiograph ([**5-23**]): RUL infiltration with air bronchograms
consistent with PNA. RLL atelectasis.
Abdominal radiograph ([**5-25**]) normal abdominal bowel gas pattern.
Stool is seen within the colon. Gas is seen within the rectum.
No ileus or obstruction.
Renal Ultrasound ([**5-26**]) Atrophic kidneys without evidence of
hydronephrosis or nephrolithiasis.
Chest Radiograph ([**5-27**]): progression of right upper lobe nodular
opacities. Similar nodular opacity is new at the left base.
Vascular engorgement with upper lobe redistribution in the
setting of severe cardiomegaly is consistent with acute on
chronic cardiac decompensation. Large hiatus hernia is
unchanged. There is no pneumothorax.
Worsening multifocal pneumonia, new at the left base
CT Abdomen & Pelvis (Oral and Intravenous contrast) ([**5-30**]): 1)No
evidence of small bowel obstruction. 2)Large hiatal hernia and
loop of transverse colon herniated within the right hemithorax.
A large hiatal hernia was noted on the prior radiograph dated
[**2169-4-8**]. 3) Trace amount of fluid and soft tissue at the
resection bed, presumably representing postoperative changes, to
which attention can be paid on followup studies. 4) Collateral
vessels within the anterior subcutaneous tissues of the pelvis
suggesting chronic lower venous obstruction. 5) Cholelithiasis.
[**2174-5-9**] 09:15PM
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the gyn-oncology service for
[**Hospital 34306**] medical optimization prior to staging surgery. On
[**2174-5-19**], Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a total vaginal hysterectomy, [**Last Name (un) **]
vault suspension, left salpingo-oopherectomy and cystoscopy for
Stage IB Endometrial Cancer and uterine prolapse. Her hospital
course is as follows:
Cardiovascular:
Ms. [**Known lastname 67214**] cardiac work-up was significant for evidence of an
old infarct (history of myocardial infarction x2) and a stress
test revealing partially reversible defects in the inferior and
lateral wall, possible sequelae of prior myocardial infarction
with an ejection fraction of 36%. A CTA neck showed 54% stenosis
in the right internal carotid artery. Per cardiology
recommendations, cath/stent placement was unlikely to improve
Ms. [**Known lastname 67214**] pre-operative risk. Her home dose of metoprolol,
lasix, and statin were initially continued, while plavix was
held and changed to aspirin 81mg. She was subsequently cleared
for surgery and general anesthesia by cardiology and anesthesia.
Repeat EKGs (pre-operative and post-operative) performed while
inpatient showed no acute changes and were consistent with
changes from prior infarcts.
During her stay, Ms. [**Known lastname 67214**] blood pressures were labile and
difficult to control especially while NPO (see below). While
NPO, she was given IV metoprolol and hydralazine and was
transitioned to PO metoprolol as she started tolerating a
regular diet.
Pulmonary:
A chest radiograph taken on [**2174-5-23**] was consistent with a right
upper lobe pneumonia. Patient was started on vancomycin and
zosyn, which was re-dosed to Vancomycin 1g every 24 hours and
Zosyn 2.25 every 6 hours after a rising creatinine level was
noted. She received a 10 day course of vancomycin and zosyn. She
remained afebrile with normal white blood cell counts throughout
her stay.
On post operative day #8, Ms. [**Known lastname **] was transferred to the ICU in
the setting of acute hypoxia (desaturation down to 86% on room
air).This acute oxygen desaturation was attributed to a
combination of volume overload/flash pulmonary edema and
worsening pneumonia. After brief placement on an oxygen face
mask, volume correction, and continuation of antibiotics, she
was transfered back to the Gyn Oncology service two days later.
On transfer, Ms. [**Known lastname **] was maintaining good oxygen saturations on
nasal canula and was slowly weaned to room air.
Gastrointestinal:
Ms. [**Known lastname **] developed nausea/vomiting on the evening of
post-operative day #0 with a subsequent abdominal radiograph
revealing possible ileus. She was made NPO and all medications
were given IV including the addition of zofran and reglan to
manage her nausea/vomiting. As her ileus and symtpoms persisted
for over 6 days post operatively, a PICC line was placed and she
was started on peripheral parenteral nutrition. She was
maintained on this until she was able to tolerate clear liquids
and eventually a regular diet. A repeat abdominal radiograph on
[**5-25**] showed resolution of ileus. A CT scan of her abdomen showed
no evidence of a small bowel obstruction. On post operative day
# 14, Ms. [**Known lastname **] was tolerating a regular diet with evidence of
good bowel function.
Ms [**Known lastname **] [**Last Name (Titles) 1801**] had 2-3 episodes of coffee-ground emesis on
post-operative day#0-1, suspicious for a possible upper GI
bleed. She was transitioned to [**Hospital1 **] intravenous dosing of a
proton pump inhibitor and then to a drip, with resumption of [**Hospital1 **]
intravenous dosing on post operative day#2. A foley catheter
remained in place to monitor her urine output closely which was
removed on post-operative day#14. Her prophylactic heparin was
temporarily held for evaluation of this possible GI bleed but
was resumed on post op day 2. The GI team was consulted
regarding management of this questionable upper GI bleed.
Initially Ms. [**Known lastname 67214**] hematocrit was stable but a downward trend
was noted on post op day 8 (31 -> 27.9-> 26). On post-op day 16
a slight drop in her Hct was noted from 25->24 and medicine
recommended f/u CBC at her nursing care facility. Her vitals &
urine output remained stable and repeat trending of her
hematocrit was stable and showed minimal further decline. Her
hematocrit on day of discharge was 25.6. Per the GI consult and
Internal medicine consult service, her anemia is likely related
to fluctuating fluid shifts although a small [**Doctor First Name **]-[**Last Name (un) **] tear
cannot be ruled out. Ms. [**Known lastname 67214**] stools were tested for occult
blood on a daily basis and were negative throughout her stay. An
EGD was recommended for further evaluation but was decided
against as Ms. [**Known lastname 67214**] respiratory status was sub-optimal and she
reported that she would be unable to tolerate the procedure. She
will follow-up with GI as an outpatient.
Endocrine:
Ms. [**Known lastname 67215**]' diabetes was primarily managed by the [**Last Name (un) **]
consulting team. Post-operatively, blood sugars were difficult
to control in the setting of an ileus and NPO status. Dosages of
NPH and humalog SS were adjusted on a daily basis to maintain a
blood sugar goal of 120-150 while NPO and were appropriately
adjusted when she started tolerating a diet.
She was continued on her home dose of levothyroxine,and briefly
received it intravenously while NPO with resumption of oral
medication after resuming a diet.
Renal:
During her hospital stay, Ms. [**Known lastname **] developed acute on chronic
renal insufficiency with a peak creatinine of 1.8 (baseline
approximately 1.4). The etiology of this acute kidney injury was
thought to be secondary to the initiation of vancomycin/zosyn,
IV contrast received for CT abdomen, as well as over-correction
of positive volume. A renal ultrasound was negative for
obstruction. Her creatinine trended down upon completion of
antibiotics and better intake of PO fluids. She also had
intermittent hypernatremia which was attributed to a free water
deficit. (Peak sodium of 150, normalized to 140 on day of
discharge). She was repleted with D5W maintenance for 16 hours
and boluses as needed.
Skin Care:
Ms. [**Known lastname 67214**] wound was primarily managed by the wound care nursing
team. She was placed on an Atmos Air support mattress with
frequent repositioning, dressing changes every 3 days per wound
nurse recommendations for management of candidiasis, chronic
venous stasis, and a buttock wound. On day of discharge, her
buttock wound was noted to be well-healed with no further
management required.
Gyn Oncology:
Based on her final pathology results, Ms. [**Known lastname **] was diagnosed
with stage 1B endometroid adenocarcinoma. Given her multiple
co-morbidities, she will undergo surveillance and no further
interventions will be required.
Prophylactic management included subcutaneous Heparin
(temporarily held during evaluation of possible upper GI bleed),
TEDs, and ambulation with physical therapy.
Medications on Admission:
CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth every day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 2
Tablet(s) by mouth daily
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet
-
1 Tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily
NYSTATIN [NYSTOP] - (Prescribed by Other Provider) - 100,000
unit/gram Powder - apply to right groin and abdominal fold with
paper towel daily as needed for moisture
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40
mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth every evening
TRAMADOL [ULTRAM] - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth three times a day as needed for
pain
Medications - OTC
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - 1 Tablet(s) by mouth daily
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth daily
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider) - 30 QHS
SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical DAILY
(Daily).
Disp:*30 * Refills:*2*
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
9. 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*
10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day) as needed for abd discomfort.
Disp:*100 mL* Refills:*0*
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Eight
(8) units Subcutaneous once a day: Breakfast.
Disp:*360 Units* Refills:*0*
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Five
(5) Units Subcutaneous once a day: Dinner.
Disp:*180 Units* Refills:*0*
14. furosemide 20 mg Tablet Sig: 1-2 Tablets PO once a day: Hold
if volume negative .
Disp:*60 Tablet(s)* Refills:*2*
15. Metoprolol XL Sig: One (1) 75 mg once a day: Hold for
systolic<120, HR<60.
Disp:*30 * Refills:*2*
16. General Care
1) Please refer to PCP for further adjustment of
anti-hypertensive regimen and lasix.
2) Hold home plavix for now until patient follows up in [**Hospital **]
clinic on [**6-15**], 1PM. Continue aspirin.
3) Lasix 20-40mg PO in morning and follow urine output/intake
throughout day. If patient is positive for the day, consider
giving another 20-40mg lasix in the afternoon/evening so that
she does not become volume overloaded. Primary care physician
should decide final daily dosage.
4) Monitor daily creatinine
5) Monitor Hematocrit and guiac all stools/emesis.
6) Follow finger stick blood glucose and use attached Humalog
sliding scale in addition to NPH regimen. Refer to PCP for
adjustment of NPH insulin regimen.
17. Follow-Up Appointments
1) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**], [**2175-7-1**] PM, [**Hospital Ward Name 23**] Building [**Location (un) **]
2) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**6-15**], 1PM, [**Hospital Unit Name 1825**] [**Location (un) 448**]
3) On discharge from nursing facility, please contact PCP,
[**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24913**] ([**Telephone/Fax (1) 32949**]) to set up appointment.
18. Humalog 100 unit/mL Solution Sig: One (1) units Subcutaneous
four times a day as needed for hyperglycemia: Please use
attached sliding scale to administer appropriate dose based on
finger stick glucose. .
Disp:*300 units* Refills:*0*
19. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection three times a day: Continue until mobile or stop if
HCT drops.
Disp:*60 * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Port Healthcare Center - [**Location (un) 5028**]
Discharge Diagnosis:
Stage 1B Endometrial Cancer, Post-operative ileus, Acute on
chronic renal failure, Hospital acquired pneumonia
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:
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity, nothing in the vagina (no tampons, no
douching, no sex), no heavy lifting of objects >10lbs for 3
months
* You may eat a regular diet.
Followup Instructions:
Skilled nursing facility to call PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24913**]
([**Telephone/Fax (1) 32949**]) to set up appointment
Please call Dr.[**Name (NI) 27357**] office to set up an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2174-6-4**]
|
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icd9cm
|
[
[
[]
]
] |
[
"68.59",
"70.77",
"57.32",
"65.49",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
24462, 24538
|
12326, 19507
|
333, 444
|
24693, 24693
|
3432, 3763
|
25522, 25941
|
2295, 2346
|
20941, 24439
|
24559, 24672
|
19533, 20918
|
24876, 25499
|
2361, 3413
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7430, 12303
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256, 295
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472, 1191
|
7336, 7416
|
24708, 24852
|
3780, 4759
|
1213, 2020
|
2036, 2279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,802
| 172,474
|
5998
|
Discharge summary
|
report
|
Admission Date: [**2130-2-20**] Discharge Date: [**2130-2-27**]
Date of Birth: [**2077-9-15**] Sex: M
Service: TRANS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 52 year old gentleman
with end-stage renal disease secondary to poly-cystic kidney
disease. He has been on Hemodialysis for the past five years
via a left AV graft. He presents now for a cadaveric renal
transplant.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION:
1. Atenolol 100 mg p.o. q. day.
2. Zestril 5 mg p.o. q. day.
3. Prilosec 20 mg p.o. twice a day.
4. Celexa 20 mg p.o. q. day.
5. Rocaltrol one tablet p.o. q. day.
6. Renagel 3200 mg p.o. three times a day.
ALLERGIES: No known drug allergies.
BRIEF HOSPITAL COURSE: The patient was admitted to the
Transplant Surgery Service on [**2130-2-20**], and underwent
an uncomplicated cadaveric renal transplant. The patient
tolerated the procedure well and had a postoperative course
that was significant for delayed graft function. His
hospital course is summarized as follows by systems:
1. Neurologic: The patient had adequate pain control on a
morphine PCA postoperatively. When the patient was
tolerating p.o. intake on postoperative day three, the
patient's PCA was discontinued and he was started on Percocet
for pain control with good effect.
2. Respiratory: The patient was requiring an oxygen
supplementation for the initial five days postoperatively
with oxygen saturations ranging from 93 to 95% on two liters.
Once the patient began ambulating and using his incentive
spirometer, he no longer needed supplemental oxygen,
saturating 95% on room air.
3. Cardiovascular: Immediately postoperatively, the
patient's Atenolol was held. Back on postoperative day one,
the patient was noted to have a decrease in his systolic
blood pressure to around 90, coincident with a decrease in
his urine output. The patient was given fluid boluses but
his pressure continued to decline, reaching a nadir of 74
systolic. The decision was made to transfer the patient to
the SICU for closer monitoring of his volume status using his
CBP. Once in the Unit, the patient's systolic pressure
increased to the low 100's. He was started on a renal dose
Dopamine drip. It was believed that his episode of
hypotension coincident with some shaking chills, was
secondary to a gamma globulin reaction. His gamma globulin
was subsequently discontinued and he remained in the SICU
until postoperative day four.
At that time, the patient's systolic pressures were back up
into the 140s to 150s and he was making good urine. He was
subsequently discharged to the Floor where his pressures
remained in the normal range throughout the remainder of his
hospital stay. He had no complaints of chest pain or
shortness of breath throughout the hospital stay.
4. Gastrointestinal: The patient was tolerating a limited
p.o. intake by postoperative day two, but continued to
increase his p.o. intake to the point of tolerating a regular
renal diet by the day of discharge. He was on a bowel
regimen of Colace and Dulcolax suppositories p.r.n. He had a
bowel movement on postoperative day three.
5. Genitourinary: The patient's creatinine preoperatively
was 12.7, and in the PACU had dropped to 11.5 with a
potassium of 5.5. However, coincident with his episode of
hypotension on the morning of postoperative day one, his
potassium had risen to 7.2 and his creatinine had jumped up
to 12.6. Once in the SICU, the Renal Team decided to dialyze
the patient. He underwent one treatment of hemodialysis.
His creatinine dropped to 8.7 with a potassium of 5.6. Over
the next couple of days, his creatinine rose to level off at
a level of approximately 10.0. There it remained for the
remainder of his hospital stay. While he was in the
Intensive Care Unit he was receiving 80 mg of intravenous
Lasix twice daily to maintain his urine output.
After transferring to the Floor and maintaining an output of
approximately 250 cc an hour, his intravenous fluids were
discontinued on postoperative day five. On postoperative day
six, his intravenous Lasix was discontinued and the patient
continued to have an adequate urine output. At the time of
discharge, he still remained approximately 12 liters positive
from his preoperative dry weight. It was noted that the
patient had some unilateral swelling of his right arm
concerning for a thrombosis secondary to the right IJ central
venous line. On the [**2-24**], a right upper extremity
ultrasound was performed that demonstrated widely patent
venous outflow with no evidence of stenosis or occlusion.
It was felt that the unilateral swelling was secondary to the
patient's positive fluid status combined with poor venous
outflow secondary to his right AV fistula.
6. Infectious Disease: The patient had no infectious
complications throughout the course of his hospital stay.
7. Immunosuppression: The patient was initially started on
Thymoglobulin, CellCept, Solu-Medrol, postoperatively. After
it was believed that the patient was having a reaction to
Thymoglobulin, he received a dose of 100 mg of Zenapax on
[**2-22**]. The Thymoglobulin was discontinued and he was
loaded on Rapamune. The patient received a second dose of
Zenapax four days after the first dose. Rapamune levels were
sent after the third dose and are pending at the time of this
dictation. The patient's white count has levelled off at
around 5 to 6,000.
8. Tubes, Lines and Drains: The patient had a right
internal jugular line which was discontinued on postoperative
day five. The patient's Foley catheter was removed on
postoperative day five and had absolutely no trouble voiding.
His [**Location (un) 1661**]-[**Location (un) 1662**] drain continued to put out greater than 30
cc over a 24 hour period, and therefore, the patient will be
discharged home with the [**Location (un) 1661**]-[**Location (un) 1662**] in place.
DISPOSITION: The patient is expected to be discharged on
[**2130-2-27**].
DISCHARGE DIAGNOSES:
1. End-stage renal disease secondary to poly-cystic kidney
disease, status post cadaveric renal transplant.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg p.o. q. day.
2. Zestril 5 mg p.o. q. day.
3. Protonix 40 mg p.o. twice a day.
4. Celexa 20 mg p.o. q. day.
5. Rocaltrol 1 tablet p.o. q. day.
6. Renagel 3200 mg p.o. three times a day.
7. CellCept 1 gram p.o. twice a day.
8. Prednisone 20 mg p.o. q. day.
9. Bactrim Single Strength, one tablet p.o. q. day.
10. Colace 100 mg p.o. twice a day.
11. Amphojel 15 ml p.o. three times a day and with meals.
12. Ganciclovir 500 mg p.o. q. day.
13. Rapamune 5 mg p.o. q. day.
14. Nystatin 5 ml p.o. swish and swallow four times a day.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2130-2-26**] 14:46
T: [**2130-2-27**] 15:24
JOB#: [**Job Number 18839**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
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] |
icd9pcs
|
[
[
[]
]
] |
799, 6065
|
6086, 6196
|
6219, 7047
|
523, 775
|
191, 419
|
441, 497
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,069
| 146,500
|
12964
|
Discharge summary
|
report
|
Admission Date: [**2153-10-14**] Discharge Date: [**2153-11-9**]
Service: VSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
disabling cludication
Major Surgical or Invasive Procedure:
right femoral to peroneal bypass graft with insitu vein,
angioscopy and valvelysis [**2153-10-16**]
rt. 5th ray amputation with VAC dressing [**11-5**]
History of Present Illness:
70y/o nondiabetic with seizure disorder, hypertension,sleep
apnea with history of bilateral calf claudication at less than
[**2-2**] block.underwent outpatient angiogram. Returns for elective
vascular surgery.
Past Medical History:
seizure disorder, last seizure [**2141**]
hypertension
asthma
sleep apnea, uses CPAP
avascular necrosis of left hip
history of peptic ulcer disease
macular degeneration
colonic polyps
internal hemmroids
anxiety disorder
s/p left hip arthroplasty [**2128**]
s/ppartial gastrectomy [**2134**]
s/p left hip revision [**9-/2144**]
s//p umbilical hernia repair
BPH
Social History:
retired print shop worker. married lives with his wife.
former [**Name2 (NI) 1818**] d/c 19 years ago
3 beer / night
Family History:
unknown
Physical Exam:
Vital signs: 96.6-65-20 199/79 oxygen saturation 97% room air
General: alert ,cooperative white male . no acute distress
HEENT: carotids palpable no bruits
Lungs: clear to auscultation
Herat: regular rate rythmn without mumur
Abdomen: begnin
Pulses:palpable carotid, radial pulses bilaterally. Femorals not
palpable secondary to abdominal obesity.popliteal pulses
nonpalpable pedial pulses dopperable bilaterally
Neuro: intact
Pertinent Results:
[**2153-10-14**] 08:45PM GLUCOSE-249* UREA N-113* CREAT-3.0*#
SODIUM-130* POTASSIUM-5.2* CHLORIDE-94* TOTAL CO2-24 ANION
GAP-17
[**2153-10-14**] 08:45PM CK(CPK)-156
[**2153-10-14**] 08:45PM CK-MB-2 cTropnT-0.05*
[**2153-10-14**] 08:45PM CALCIUM-8.6 PHOSPHATE-4.5 MAGNESIUM-2.8*
[**2153-10-14**] 08:45PM WBC-12.9*# RBC-3.57* HGB-10.3* HCT-29.9*
MCV-84# MCH-28.9 MCHC-34.5 RDW-15.7*
[**2153-10-14**] 08:45PM PLT COUNT-289#
[**2153-10-14**] 08:45PM PT-31.5* PTT-62.6* INR(PT)-6.2
[**2153-10-14**] 06:27PM URINE COLOR-LtAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2153-10-14**] 06:27PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2153-10-14**] 06:27PM URINE RBC-791* WBC-52* BACTERIA-MANY
YEAST-MANY EPI-<1
Brief Hospital Course:
[**2153-10-14**] trnasfered to [**Hospital1 8482**] [**Last Name (un) 834**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for evaluation of
right foot wound.
Wound was sustaianed secondary to fall four weeks ago. Patient
suffered nondisplaced fracture of right hmerous and right
shoulder injury. Patient was placed in sling for immoblization.
He was noted to have a right foot necrotic wound.His anemia was
corrected with transfusion of 2 units packed red blood
cells.Blood and urine cultures were no growth.
[**2153-10-15**] PICC line placed for poor Iv access and IV
antibiotics.Cardology ;consluted for abnormal admitting EKG.A
flutter note as rythmn on EKG. Recommendations were Pmibi,ECHO,
EPS consult for consideration of electrical conversion to sinus
rythmn.
Echo: left artrial dilitation. lefet ventricular wall thickness
and cavity size normal. No thrombs,valves without structural
disease. akensis of anterior and apical wall of left ventricle.
FE 55%. Stress negative for symptoms or EKG changes. Study fixed
defect of inferior and apical wall (severe) and fixed defect of
basal inferior wall. EF 45%. CT head done for mental status
changes. Ct consisted with old left occiptual infract and left
frontal lobe old encephlomalicia no acute changes.
[**2153-10-16**] right excisionl foot wound debridment.Electrophysology
consulted. recommendations: af/flutter chronic. obtain PFT,
along with thyroid,and liver function test for base ine. Start
amidarone 400mgm tid x 4 days the 400mgm [**Hospital1 **]. No TEE required.
Patient can proceede with any surgical intervention.MRA obtained
.Bilateral femoral -tibial disease. recommend llimited angio
study to better define disease in affected foot.
[**2153-10-18**] patient converted to NSR on amidarone.betablocker and
losartan adjusted for
better for rate control and systolic hypertension.
[**2153-10-19**] angiogram toletated. thyroid and liver function studies
stable.Transfused 2 units for HCT. 26.
[**2153-10-22**] Vanco d/c oxycilin started.s/p right fem-pedal bypass
graft with composite svg.Transfered to PACU stable with palpable
pedal graft.
[**2153-10-23**] POD#1no overnight events. Nitro weaned. Chest Pt
continued . diet advanced as tolerated . qntbiotics continued
and patient remained in VICU.Thrombocytopenia noted.HIT
sent.result negative. Platlet count improved with d/c heparin.
[**10-26**] POD# 4 transfered to regular nursing floor.
[**2153-10-29**] POD# 7 rigth 5th ray amputation.transfused one unit
packed red blood cell for HCT of 25.8 secondary to wound
drainage.
[**2153-11-1**] POD# [**11-4**] VAc dressing to ray amputation last changes
[**2153-11-3**].Transfered to VICU for mental status changes and HCt.
of 24. Transfused.GI consulted for positive stool guiac and
positive NG drainage. Transfered to ICU for respiratory failure
secondary to hypercapnea ,reintubated.
Recommendations from GI, follow serial HCT's, hold
anticoagulation. consider GI scoping upper and lower when
medically stqable.
Required vasopressor support for his hypotension. head CT
negative for acute bleed or infract.
[**2153-11-5**] Vac dressing changed with excisional debridment at bed
side. Duplex of right upper extremity negative for DVT. [**Last Name (un) **]
consulted for glucose managment secondary to recurrent
hypoglycemic episodes on oral agents.Recommendations: hold oral
[**Doctor Last Name 360**], adjust regular insulin scale once taking by mouth.
[**2153-11-6**] POD#14/8 extubated and transfered to Vicu. No overnight
events. Aline discontinued. God large BM!!.glycemic control
improved with holding oral agents and using regular insulin
scale.Physical thearphy recommends rehabiltation prior to
discharge to home for continued strenghting and mobility.Foley
discontinued.
[**2153-11-7**] Central line taken out and D/C to rehab. Will need to
stay on coumadin 1mg for awhile before advancing. Will need to
follow up with Dr. [**Last Name (STitle) 1391**] in two weeks and need out patient GI
work up for the melena.
Medications on Admission:
see d/c rx
Discharge Medications:
1. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Pravastatin Sodium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
7. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**]
Discharge Diagnosis:
disabling claudication
respiratory failure secondary to hypercapnea
blood loss anemia, corrected
GI bleed, stable
Discharge Condition:
stable
Discharge Instructions:
VAC dressing change q3days.last change [**2153-11-2**]
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks . call for appointment. [**Telephone/Fax (1) 1393**]
followup with GI for evaluation of GI bleed?
Completed by:[**2153-11-9**]
|
[
"518.81",
"578.1",
"682.8",
"280.0",
"493.20",
"414.01",
"427.32",
"294.8",
"357.2",
"458.9",
"287.5",
"250.60",
"412",
"358.00",
"780.39",
"707.15",
"250.80",
"041.6",
"440.24",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.48",
"93.56",
"86.22",
"38.93",
"84.11",
"39.29",
"88.49",
"99.07",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7522, 7620
|
2503, 6533
|
282, 437
|
7778, 7786
|
1683, 2480
|
7889, 8056
|
1210, 1219
|
6594, 7499
|
7641, 7757
|
6559, 6571
|
7810, 7866
|
1234, 1664
|
221, 244
|
465, 676
|
698, 1060
|
1076, 1194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,678
| 114,536
|
24294
|
Discharge summary
|
report
|
Admission Date: [**2195-1-22**] Discharge Date: [**2195-1-23**]
Date of Birth: [**2133-4-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
intracerebral hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 61596**] is a 61 year old male presenting as transfer from
and
outside hospital with large ICH. He was found in his garage
unresponsive this evening with a bag of cocaine next to him. He
was last seen well ~6 hours prior. BP at the scene was
220's/110's. He was taken to an OSH where his temperature was
noted to be 88 degrees, head CT revealed a large Left basal
ganglia hemorrhage with extensive intraventricular spread to
lateral, 3, 4th, communicating hydrocephalus and dissection down
into the brainstem. His examination was notable mid position and
equal pupils unreactive to light, intact gag, no purposeful
withdrawal of extremities. He was intubated at the OSH and
transferred to [**Hospital1 18**] for further care. Neurosurgery was
consulted
and based on poor examination and CT findings was not felt to be
a candidate for decompression or drainage.
Past Medical History:
Hep C on interferon
GERD
HTN
Social History:
Lives with his wife, children in the area. No illicit drug use.
Family History:
Not elicited
Physical Exam:
Vitals: T 97 (on bear hugger), BP 160/96, HR 62, R 14, 100% CMV
Gen- critically ill, unresponsive to noxious stimulation
HEENT- NCAT, MMM, Anicteric sclera
Neck- C-collar
CV- RRR, no MRG
Pulm- scattered crackles.
Abd- soft, nd, bs+
Extrem- no CCE
NEUROLOGIC EXAM:
MS- no response to deep noxious stimulation.
CN- pupils equal at 4mm and unreactive to light, gaze
midposition, absent dolls, absent corneal reflex, intact gag. no
response to nasal tickle.
Motor/Sensory- no spontaneous movements. internally rotates
towards noxious stimulus in bilateral UE's. Triple flexion to
noxious in bilateral LE's.
DTR's- brisk, symmetric throughout.
plantar response upgoing bilaterally.
Pertinent Results:
[**2195-1-22**] 10:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
Head CT-
There is a large parenchymal hemorrhage in the left cerebral
hemisphere, measuring approximately 8.5 x 4.7 in greatest
dimension, with
surrounding edema. Blood products are present in both lateral
ventricles,
third as well as the fourth ventricle. There is mass effect on
the
ipsilateral lateral ventricle body as well as contralateral
ventricular
dilatation. There is 7-mm shift of the septum pellucidum as well
as rightward subfalcine herniation. There is global sulcal
effacement, highly concerning for cerebral edema. There is
obliteration of the suprasellar cistern, as well as
contralateral temporal [**Doctor Last Name 534**] enlargement.
Evaluation of the posterior fossa is limited by an artifact,
however there is high attenuation in the pons and possibly mid
brain, concerning for additional foci of hemorrhage.
Brief Hospital Course:
Mr. [**Known lastname 61596**] is a 61 year old male found unresponsive with
massive intracerebral hemorrhage. Etiology based on location is
likely hypertensive hemorrhage in the setting of cocaine use.
His condition upon arrival was consistent with severe neurologic
injury without chance of meaningful neurologic recovery. The
patient's condition was discussed at length with his wife and
family. He was admitted to the ICU and later extubated for
comfort measures only. The patient expired promptly following
extubation with his family at the bedside.
Medications on Admission:
Interferon
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
large L basal ganglia
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"070.70",
"305.61",
"331.3",
"530.81",
"E849.0",
"E854.3",
"401.9",
"970.8",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3750, 3759
|
3105, 3661
|
340, 347
|
3825, 3835
|
2141, 3082
|
3886, 3983
|
1409, 1423
|
3722, 3727
|
3780, 3804
|
3687, 3699
|
3859, 3863
|
1438, 1686
|
276, 302
|
375, 1260
|
1703, 2122
|
1282, 1312
|
1328, 1393
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
705
| 113,494
|
18104
|
Discharge summary
|
report
|
Admission Date: [**2156-8-23**] Discharge Date: [**2156-8-26**]
Date of Birth: [**2087-10-23**] Sex: M
Service: [**Hospital 11212**] [**Hospital6 733**] Firm
HISTORY OF PRESENT ILLNESS: The patient was a 68-year-old
gentleman with a history of stage IV colon cancer metastatic
[**Known firstname **] lung and liver who was transferred from a nursing home
status post developing tachypnea, hypoxia [**Known firstname **] 80% on room air,
and a change in mental status.
The patient was seen in the Emergency Department and was
hypotensive with blood pressures of 80/47 and a respiratory
rate in the 30s. The patient was in moderate respiratory
distress, and chest x-ray showed a retrocardiac density. The
patient was persistently hypotensive despite multiple fluid
boluses. Antibiotics were started. The patient was started
on pressors and intubated with an arterial blood gas on room
air of a pH of 7.21, a PCO2 of 60, and a PO2 of 86.
The patient's oncologist (Dr. [**First Name (STitle) **] from [**Hospital 10908**] was contact[**Name (NI) **] in order [**Known firstname **] gain more information on the
patient's stage IV colon cancer. Apparently, the patient
refused any further treatment about six months ago and
desired [**Known firstname **] be do not resuscitate/do not intubate. The
patient's course was also discussed with the family, and it
was decided [**Known firstname **] make the patient comfort measures only. The
patient was subsequently extubated on [**2156-8-25**].
Pressors were weaned off, and morphine drip was started. The
patient remained comfortable and in no apparent distress and
was transferred out of the Intensive Care Unit [**Known firstname **] the general
medical floor.
PAST MEDICAL HISTORY:
1. Stage IV colon cancer widely metastatic [**Known firstname **] lung and
liver. A computerized axial tomography on [**2156-8-5**]
showed a left pleural effusion, bilateral lung nodules, and
liver enlargement with increasing new liver masses, left
adrenal nodule, left moderate-[**Known firstname **]-severe hydronephrosis
secondary [**Known firstname **] retroperitoneal lymph nodes. The patient is
status post gastrojejunostomy tube placement secondary [**Known firstname **]
dysphagia and failure [**Known firstname **] thrive.
2. Hypertension.
3. Hypercholesterolemia.
4. Right cerebrovascular accident.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's temperature was 96.9 degrees
Fahrenheit, his blood pressure was 70s [**Known firstname **] 80s/30s [**Known firstname **] 40s, his
heart rate was 60s [**Known firstname **] 70s, and his oxygen saturation was 96%
on room air. In general, the patient was not arousable. Not
responsive [**Known firstname **] pain, but he appeared comfortable. Head, eyes,
ears, nose, and throat examination revealed nonreactive
pupils but equal. The mucous membranes were dry. Neck
examination revealed no jugular venous distention. Pulmonary
examination revealed coarse rhonchi throughout the lung
fields. Cardiovascular examination revealed a regular rate
and rhythm. Normal first heart sounds and second heart
sounds. No murmurs, rubs, or gallops. The abdomen was
distended, notable bowel sounds, and jejunostomy tube in
place. Extremity examination revealed 3+ pitting edema [**Known firstname **]
the lower extremities. Neurologic examination revealed
pupils were nonreactive. Positive corneal reflexes.
Negative doll's eyes. The patient did not withdraw [**Known firstname **] pain.
Negative Babinski.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was a
68-year-old gentleman with metastatic stage IV colon cancer
admitted with respiratory distress, hypotension, hypoxia,
acute renal failure, and unresponsiveness.
The patient was made comfort measures only; per family's
wishes. The patient was extubated. Pressors were withdrawn.
A morphine drip was started. The patient was comfortable and
in no apparent distress.
The patient expired on [**2156-8-26**] with the time of death
being approximately 11:15 in the evening. The patient was
examined by night float resident. The patient's family
friend [**First Name8 (NamePattern2) **] [**Name (NI) 724**]) was notified of the patient's death. She
helped [**Known firstname **] interpret this information [**Known firstname **] the patient's son who
was [**Name (NI) 46396**] only. The patient's attending was
contact[**Name (NI) **]. The patient's family declined autopsy.
The immediate cause of death was cardiopulmonary arrest
secondary [**Known firstname **] stage IV metastatic colon cancer.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2156-9-3**] 15:12
T: [**2156-9-6**] 09:30
JOB#: [**Job Number 50099**]
|
[
"197.0",
"584.9",
"197.7",
"V44.1",
"401.9",
"438.9",
"482.49",
"272.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3592, 4864
|
204, 1735
|
1757, 3563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,146
| 145,077
|
10124
|
Discharge summary
|
report
|
Admission Date: [**2201-5-6**] Discharge Date: [**2201-5-15**]
Service: CT [**Doctor First Name **].
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 33815**] is a 79-year-old male
with a history of coronary artery disease status post CABG
times three vessels in [**2193**] (Dr. [**First Name (STitle) **] at [**Hospital3 **]),
who currently presents with increasing chest pain with
shortness of breath times duration of past one year. Patient
has been known to have had aortic stenosis which had been
followed by Dr. [**Last Name (STitle) 7659**] for many years. Cardiac
catheterization today revealed three widely patent grafts,
however, aortic valve area was 0.9, indicating significant
aortic stenosis. The patient was referred to Cardiothoracic
Surgery at this time for aortic valve replacement.
PHYSICAL EXAMINATION: Vital signs: Temperature 99, pulse 75
and sinus, blood pressure 126/66, respirations 18, 94%
saturation on room air. HEENT: Sclerae are anicteric.
Cranial nerves II-XII intact. Mucous membranes moist. No
evidence of oral ulcers. No cervical lymphadenopathy noted.
Chest: Clear to auscultation bilaterally. Sternotomy signs.
No evidence of erythema, no evidence of drainage. Sternum
was stable to palpation. No click elicited. Cardiac:
Regular rhythm and rate. No evidence of murmur. Abdomen:
Positive bowel sounds. No hepatosplenomegaly. Soft,
nondistended, nontender. No inguinal lymphadenopathy noted.
Extremities: +1 edema symmetric. No evidence of rash.
PERTINENT LABS: [**2201-5-15**] - White blood cells 12.7, hematocrit
34, platelets 333. Sodium 138, potassium 4.3, chloride 100,
bicarbonate 27, BUN 21, creatinine 0.8, glucose 105. PT
15.9, PTT 60.7, INR 1.7. Calcium 8.9, phosphorus 3.7,
magnesium 2.1.
SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname 33815**] is a 79-year-old male
with a history of significant aortic stenosis status post
CABG times three V in [**2193**], who presented to the
Cardiothoracic Service for AVR. Upon successful completion
of preoperative evaluation, the patient underwent an
uncomplicated aortic valve replacement on [**2201-5-6**] (21 mm C-E
pericardial valve). Postoperatively, the patient was
maintained intubated and sedated on propofol and taken to the
CSRU for close observation. The patient remained in sinus
rhythm with no evidence of ectopy at this time. The patient
was started on diuresis and given CPAP trial for weaning to
extubation.
By postoperative day number two, the patient was extubated,
however, the patient developed atrial flutter which was
controlled with Lopressor. Atrial flutter resolved, however,
throughout the [**Hospital 228**] hospital course, the patient
developed intermittent atrial fibrillation which lasted less
than one minute. Given this finding, the patient was
initiated on heparin anticoagulation with target INR between
2.0-2.5.
By postoperative day number three, the patient was doing
well, transferred to the floor. However, the patient
developed persistent cough with decreased breath sounds over
the right lower chest with subsequent chest x-ray findings
consistent with right lower lobe pneumonia. The patient was
initiated on levofloxacin and closely monitored. By [**2201-5-13**],
the patient's respiratory symptoms had completely resolved
and repeat chest x-ray revealed almost complete resolution of
the right lower lobe consolidation. The patient's clinical
status had, also, dramatically improved, allowing achievement
of level-5 physical therapy status which is the discharge
criteria for patient's being able to return home without
rehabilitation.
By [**2201-5-15**], the patient's INR was 1.7 after having received 3
mg of Coumadin for the past three days. At this time, the
decision was made to discharge the patient in good condition
to home with a follow-up with Dr. [**Last Name (STitle) 7659**] on [**5-18**] at 3
p.m. for evaluation of Coumadin level and effectiveness of
anticoagulation therapy.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with physical therapy.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement (21 mm pericardial
valve).
2. Atrial flutter and intermittent atrial fibrillation -
anticoagulation.
3. Postoperative pneumonia.
DISCHARGE MEDICATIONS:
1. Lasix, 20 mg PO b.i.d. times seven days.
2. Metoprolol, 125 mg PO b.i.d..
3. Levofloxacin, 500 mg PO q d times eight days for a total
of two week treatment of pneumonia.
4. Potassium chloride, 20 mEq b.i.d. times seven days while
taking Lasix.
5. Colace, 100 mg PO b.i.d..
6. Percocet, one to two tablets PO q 4-6 hours p.r.n. pain.
7. Coumadin, 3 mg on [**5-16**], [**5-17**]. On [**5-18**], patient is
to have INR level checked and needs to meet with Dr.
[**Last Name (STitle) 7659**] at his office at 3 p.m. for Coumadin re-dosing.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2201-5-15**] 12:43
T: [**2201-5-15**] 12:41
JOB#: [**Job Number 33816**]
cc:[**Name8 (MD) 33817**]
|
[
"427.31",
"V45.81",
"272.0",
"424.1",
"427.32",
"486",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
4085, 4258
|
4281, 5142
|
1803, 3981
|
842, 1515
|
142, 819
|
1532, 1774
|
4006, 4064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,366
| 134,859
|
34713
|
Discharge summary
|
report
|
Admission Date: [**2138-8-24**] Discharge Date: [**2138-8-30**]
Date of Birth: [**2058-12-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Fever, malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 y/o male who was discharged to home on [**2138-8-14**] following
workup for jaundice. This is potentially due to a malignant
biliary stricture for which he had an [**Date Range **] with stent placement.
He returns now with increased malaise, chills and
lightheadedness earlier on day of admission. No fever noted at
home. Denies nausea, vomiting, diarrhea or abdominal pain. No
dysuria, hematuria or cough. He was seen at [**Hospital **] Hospital,
temp of 103 noted and was transferred to [**Hospital1 18**]
Past Medical History:
Type 2 Diabetes
Benign Hypertension
Hyperlipidemia
Interstitial Lung Disease less than 1 year
Arthritis
Gerd, gastritis
s/p cataract surgery b/l
Social History:
Former Smoker stopped 20 years ago, after 50
years of smoking, Drinks 1-3 beers/day, Former worker in
electronics plant where he was the floor supervisor in the paint
shop (worked with chemicals) and electronics
Family History:
Father with DM, mother died at 97
Physical Exam:
VS: 103, 84, 110/70, 18, 100% 2L
Gen: NAD, A+Ox3, MAE
Skin: no rash, + jaundice
HEENT: + icterus sclera, no cervical LAD,
Lungs: coarse BS bilaterally
Card: RRR, II/VI systolic murmur, + bruit, 2+ Fem pulses
ABD: Soft, non-tender, non-distended, no bruit, no hernia
Rectal: Guaiac negative, normal tone
Extr: 2+ DPs
Pertinent Results:
On Admission: [**2138-8-24**]
WBC-11.4* RBC-2.99* Hgb-9.0* Hct-26.7* MCV-89 MCH-30.2 MCHC-33.9
RDW-16.4* Plt Ct-270 Neuts-95.7* Lymphs-2.1* Monos-2.0 Eos-0.1
Baso-0
PT-14.7* PTT-28.4 INR(PT)-1.3*
Glucose-79 UreaN-28* Creat-1.3* Na-139 K-4.0 Cl-109* HCO3-20*
AnGap-14
ALT-156* AST-126* AlkPhos-405* TotBili-4.7* Lipase-67*
Albumin-3.8 Calcium-8.6 Phos-2.0* Mg-1.9
On Discharge: [**2138-8-28**]
WBC-6.0 RBC-3.07* Hgb-9.3* Hct-27.2* MCV-89 MCH-30.4 MCHC-34.3
RDW-16.2* Plt Ct-271
Glucose-57* UreaN-15 Creat-1.1 Na-143 K-3.5 Cl-108 HCO3-30
AnGap-9
ALT-87* AST-59* AlkPhos-279* Amylase-48 TotBili-2.5* Lipase-54
Brief Hospital Course:
Temperature was 101 on admission with WBC of 11.4. CXR showed
low lung volumes witout evidence of pneumonia and peripheral
interstitial fibrotic pattern, most consistent with IPF, similar
when compared to CT of [**2138-8-11**]. Blood and urine cultures
revealed UA with 3-5 wbc with moderate bacteria. Urine culture
was negative and the blood culture was negative to date. IV vanc
and zosyn had been started after cultures were sent.
LFTs were elevated (alt 156, ast 126, alk phos 405 and t.bili
4.7). A liver US demonstrated new intrahepatic biliary ductal
dilatation, and dilated, sludge filled gallbladder. A KUB showed
a non-obstructive bowel gas pattern with the stent projecting
over the expected location of the common bile duct in the
right upper abdomen. LFTs trendd down (alt 100, ast 57, alk phos
270 and t.bili 2.7).
TTE was done for preop workup. This demonstrated moderate mitral
regurgitation, mild symmetric LVH with preserved global and
regional biventricular systolic function, dilated thoracic aorta
with EF of >65%.
On [**8-29**] a repeat liver US was done to assess flows to liver and
check for obstruction/dilitation of ducts with known stent in
place. This showed an enlarged CHD and intra-hepatic biliary
dilatation. No stent was identified
in the common hepatic duct. Hepatic vasculature was patent. A
KUB was done to assess for migration of the biliary stent. This
showed unchanged appearance with the stent over the biliary
tree. LFTs fluctuated with the alk phos increasing to 401,
previously decreased to 270 and the t.bili decreased to 2.8 from
4.2.
IV antibiotics were switched to Augmentin on [**8-28**]. This was
continued at time of discharge. He was afebrile with stable
vital signs, tolerating a regular diet and ambulatory at time of
discharge on [**8-30**]. The plan was for him to return on [**9-2**] for ex
lap, bile duct excision, roux en y hepaticojejunostomy and
possible left hepatic lobectomy.
Medications on Admission:
nexium 40', lopressor 50", psyllium, prednisone 10',
fluticasone, glargine 22'
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) for 2 weeks.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
northeast home care
Discharge Diagnosis:
fever
bile duct dilatation
Discharge Condition:
good
Discharge Instructions:
please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if fever > 101,
chills, nausea, vomiting, abdominal pain, yellowing of eyes or
skin, inability to take or keep down food or medications.
NorthEast Home Care
Followup Instructions:
Dr [**Last Name (STitle) 9411**] office ([**Telephone/Fax (1) 673**]) will call you with details
regarding surgery for [**2138-9-2**]
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2138-9-25**] 12:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2138-9-25**] 12:00
Completed by:[**2138-9-1**]
|
[
"515",
"272.4",
"518.0",
"424.0",
"V15.82",
"530.81",
"401.0",
"V46.2",
"156.1",
"780.6",
"V18.0",
"716.90",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5139, 5189
|
2311, 4256
|
329, 336
|
5260, 5267
|
1679, 1679
|
5543, 5940
|
1292, 1328
|
4385, 5116
|
5210, 5239
|
4282, 4362
|
5291, 5520
|
1343, 1660
|
2057, 2288
|
275, 291
|
364, 876
|
1693, 2043
|
898, 1046
|
1062, 1276
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,399
| 157,775
|
51110
|
Discharge summary
|
report
|
Admission Date: [**2140-6-11**] Discharge Date: [**2140-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
88yo man with a h/o CAD s/p CABG on Plavix, PUD, diverticulosis,
duodenal ulcer perforation, who p/w BRBPR x 2. Pt had two
episodes of bloody stool, once this AM and once at 6pm. He
denies any LH, dizziness, CP, SOB.
.
In ED, initial vitals T 97.6, HR 64, BP 122/70, RR 14, Sat 99%
on RA. Appeared well, with ext hemmorrhoids and guaiac positive
stool. Hct 41. 2 large bore IVs placed. ED discussed with GI and
he was admitted for observation and plan for colonoscopy.
.
On the floor, he was intially feeling well, but then had another
BRBPR. No clots, but large amt of frank blood. Pt had mild
decrease in BP from SBP 120 to 96. HR in 60's. He also started
to feel more fatigued, lips and fingertips turning blue, but no
LDH, CP, dizzyness. Repeat Hct stable, but in setting of drop in
BP, he was transferred to MICU for closer monitoring. Tagged RBC
scan ordered and Pt given 1L bolus of NS.
Past Medical History:
1. Coronary artery disease
2. Prostate cancer
3. Nephrolithiasis
4. Spinal stenosis
5. Peptic ulcer disease
6. Hypercholesterolemia
7. Osteoarthritis
8. Chronic renal insufficiency
Past Surgical History:
1. Status post L4-L5 laminectomy
2. CABG [**2132**]
3. Status post appendectomy
Social History:
no etoh or tobacco; lives with wife of 66 years
Family History:
Non contributory
Physical Exam:
Physical Exam:
Vitals: HR66, BP 124/80, RR 19, O2 99%RA
Gen: elderly male, NAD, sitting comfortably in bed
HEENT: PERRL, EOMI, conjunctivae not pale, no nystagmus, MMM
Neck: supple, no LAD
CV: RRR, no m/g/r
Lungs: CTA bilaterally (anteriorally)
Abd: soft, NT/ND, normal bs, no r/g, no [**Doctor Last Name 515**]
Ext: scabs on shins, no edema, 1+ DP
Skin: warm and dry, not pale
Neuro: AAOx3
Pertinent Results:
[**2140-6-12**] GI Bleeding study IMPRESSION:
Active pooling of tagged RBCs after 40 minutes, in the sigmoid
colon/recto-sigmoid junction.
.
[**2140-6-14**] Colonoscopy:
Findings:
Contents: Liquid stool was found in the whole colon. There was
no blood in the colon.
Excavated Lesions Multiple diverticula with mixed openings were
seen in the ascending colon, transverse colon, descending colon
and sigmoid colon.Diverticulosis appeared to be of moderate
severity.
Impression: Diverticulosis of the ascending colon, transverse
colon, descending colon and sigmoid colon
Otherwise normal colonoscopy to cecum
Recommendations: Follow the patient clinically. If he rebleeds
the next step would be angiography.
.
Admission Labs:
[**2140-6-11**] 08:20PM UREA N-39* CREAT-1.7* SODIUM-135
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-12
[**2140-6-11**] 08:20PM WBC-7.9 RBC-4.58* HGB-14.2 HCT-41.8 MCV-91
MCH-31.0 MCHC-34.0 RDW-14.3
[**2140-6-11**] 08:20PM NEUTS-75.6* LYMPHS-16.4* MONOS-6.1 EOS-1.6
BASOS-0.3
[**2140-6-11**] 08:20PM PLT COUNT-253
[**2140-6-11**] 08:20PM PT-12.9 PTT-26.1 INR(PT)-1.1
[**2140-6-11**] 08:30PM HGB-14.3 calcHCT-43
.
Discharge Labs:
Hct [**2140-6-14**] 32.4 then 35.6.
Brief Hospital Course:
A/P 88 y/o M hx CAD s/p CABG on plavix and ASA, diverticulosis
p/w BRBPR admitted to floor and then had large GIB, mild BP drop
and transferred to ICU
.
# GIB: Patient was transferred to ICU for closer monitoring
given his GIB. In ICU tagged rbc scan positive for pooling of
blood in sigmoid colon/recto-sigmoid junction. The patient had q
8 hct checks that were stable, and given his positive rbc scan
he was prepped for a colonoscopy. He did not require any
transfusions in the ICU.
.
# Coronary artery disease: held ASA, Plavix initially. ASA
restarted on discharge.
.
# Chronic renal insufficiency: Stable at his baseline Cr
1.4-1.6.
.
# Alzheimer's disease: continued Aricept 10mg qd on M/W/F only
.
# Psych: cont''d Lexapro 5mg qpm
.
# BPH: cont'd Flomax 0.4mg qpm
.
# Incontinence: cont'd Detrol 2mg qpm
.
# Activity: PT evaluated and felt he was safe for home.
.
Code: FC
.
Comm: spouse
.
Dispo: pending workup and management as above
Wife: H [**Telephone/Fax (1) 106140**] ([**Doctor First Name **])
C [**Telephone/Fax (1) 106141**]
Medications on Admission:
aricept 10mg qd on M/W/F only
potassium chloride 10mEq qam on M/W/F only
lasix 20mg qd on M/W/F only
asprin 81 mg qd
imdur 30mg qd
plavix 75mg qd
protonix 40mg qd
MVI qd
lexapro 5mg qpm
lovastatin 40mg qpm
flomax 0.4mg qpm
detrol 2mg qpm
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO QMOWEFR
(MO,WE,FR).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO Every M/W/F.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO Every M/W/F.
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
GI bleed, likely diverticular bleed
.
Secondary
Coronary Artery Disease
Alzheimers
Depression
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a GI bleed. You were monitored carefully
in the ICU and then on the floor. You were stable after initial
low blood pressure resolved.
.
If you have any rectal bleeding or blood in your stool you must
go emergently to the emergency room.
.
Please seek medical attention if you are lightheaded, have chest
pain or any other symptoms that are of concern to you.
.
We have held your plavix in the setting of your bleed. Please
readdress this with your PCP after you are out of this acute
window. We have not made any other changes in your medical
treatment.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 14069**] ([**Telephone/Fax (1) 37171**])
on Friday [**6-17**] at 11am. Please also follow up with your PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**] when he returns.
|
[
"600.00",
"785.0",
"562.12",
"285.1",
"V10.46",
"585.9",
"458.9",
"V45.81",
"331.0",
"414.00",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
5643, 5649
|
3281, 4326
|
265, 279
|
5795, 5804
|
2048, 2757
|
6434, 6690
|
1603, 1621
|
4615, 5620
|
5670, 5774
|
4352, 4592
|
5828, 6411
|
3220, 3258
|
1438, 1522
|
1651, 2029
|
222, 227
|
307, 1203
|
2773, 3204
|
1225, 1415
|
1538, 1587
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,280
| 146,637
|
52529
|
Discharge summary
|
report
|
Admission Date: [**2135-12-18**] Discharge Date: [**2135-12-25**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
SOB, chest pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F [**Hospital **] Rehab res w/ mult med probs, including CAD w/ LBBB,
IDDM, CRI now p/w flu-like sxs (prod cough, rhinorrea) x 1 week,
and chest pressure reminiscent of her unstable angina x 1 day
which was relieved by 2 SL NTG. Of note, 3 other pts at [**Hospital **]
Rehab were dx'd w/ influenza, so pt was started on amantadine
prophylaxis on [**12-9**].
.
In ED, noted to be 99.8, HD stable, 95%RA. Labs notable for CK
of 391, trop 0.82. CXR w/ mild CHF and ?RML infiltrate. Given
levaquin and started on hep/ntg gtts.
Past Medical History:
1)CAD
2)CRI (bl 1.7)
3)OA
4)Gout
5)IDDM
6)neuropathy
7)mod MR
8)diastolic CHF
9)CVA [**1-8**] w/ residual L weakness
10)LBBB
11)hyperlipidemia
12)HTN
13)mod LVH
14)obesity
15)GERD
16)glaucoma
17)increased CKs on statins
Social History:
Lives at [**Hospital 100**] Rehab. Enjoys [**Location (un) 1131**]. Has a son who is her HCP.
Family History:
NC
Physical Exam:
Exam notable for 100% on 4L NC
speaking in full sentences
obese
palatal petechiae
dry MM
diffuse exp wheezes bilat
RRR II?VI murmur
2+ pitting lower ext edema to knees bilat (L sl > R) w/
venostatic changes, guiac negative
Pertinent Results:
[**2135-12-18**] 08:52PM CK(CPK)-376* TOT BILI-0.5
[**2135-12-18**] 08:52PM CK-MB-6 cTropnT-1.20*
[**2135-12-18**] 08:52PM IRON-28*
[**2135-12-18**] 08:52PM calTIBC-238* HAPTOGLOB-410* FERRITIN-453*
TRF-183*
[**2135-12-18**] 08:52PM PT-15.3* PTT-78.4* INR(PT)-1.5
[**2135-12-18**] 01:10PM GLUCOSE-122* UREA N-46* CREAT-1.5* SODIUM-140
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-32* ANION GAP-14
[**2135-12-18**] 01:10PM ALT(SGPT)-93* AST(SGOT)-86* CK(CPK)-391* ALK
PHOS-182* TOT BILI-0.5
[**2135-12-18**] 01:10PM CK-MB-7 cTropnT-0.82*
[**2135-12-18**] 01:10PM IRON-20*
[**2135-12-18**] 01:10PM calTIBC-246* FERRITIN-468* TRF-189*
[**2135-12-18**] 01:10PM URINE HOURS-RANDOM
[**2135-12-18**] 01:10PM URINE GR HOLD-HOLD
[**2135-12-18**] 01:10PM WBC-8.0 RBC-3.30* HGB-9.8*# HCT-30.1* MCV-91
MCH-29.7 MCHC-32.6 RDW-14.5
[**2135-12-18**] 01:10PM NEUTS-90.9* LYMPHS-6.5* MONOS-2.4 EOS-0.1
BASOS-0.1
[**2135-12-18**] 01:10PM HYPOCHROM-1+
[**2135-12-18**] 01:10PM PLT COUNT-208
[**2135-12-18**] 01:10PM PT-14.9* PTT-31.3 INR(PT)-1.4
[**2135-12-18**] 01:10PM RET AUT-1.7
[**2135-12-18**] 01:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2135-12-18**] 01:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2135-12-18**] 01:10PM URINE RBC-[**11-26**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0
Admission CXR:
CHEST (PA & LAT) [**2135-12-18**] 1:01 PM
CHEST (PA & LAT)
Reason: ro pna chf
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with mi, and flu being treated also for pna
REASON FOR THIS EXAMINATION:
ro pna chf
INDICATION: MI, flu, also being treated for pneumonia. Shortness
of breath.
TECHNIQUE: AP and lateral views of the chest were obtained
without comparisons.
FINDINGS: The cardiac silhouette is prominent. The hila are
promienntm but not ideally evaluated secondary to technique and
patient rotation. Mild diffuse prominence of interstitial
markings suggest mild CHF. There is no evidence of pleural
effusion or focal consolidation. There is diffuse osteopenia.
IMPRESSION: Likely mild CHF.
ECHO:
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is
mild regional left ventricular systolic dysfunction. [Intrinsic
left
ventricular systolic function may be more depressed given the
severity of
valvular regurgitation.] Resting regional wall motion
abnormalities include
inferolateral hypokinesis and inferior hypokinesis/akinesis.
Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
are mildly thickened. Mild (1+) aortic regurgitation is seen.
The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is no
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2125-11-7**], left
ventricular
systolic dyfunction is new.
SPUTUM:
RESPIRATORY CULTURE (Final [**2135-12-22**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
YEAST. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
[**Age over 90 **]F [**Hospital **] Rehab resident w/ viral bronchitis [**2-7**] ?influenza, with
possible superimposed pneumonia, anemia of unclear etiology, and
elevated troponin [**2-7**] NSTEMI vs demand ischemia.
1)Viral Bronchitis with evidence of PNA on CXR Kept on droplet
precautions and ruled out for influenza by negative nasal
washings. Treated bronchitis supportively with nebulizer
bronchodilator therapy and inhaled steroids.
Maintained oxygen saturation in 90s with oxygen by nasal canula.
Will complete 7 day course of levaquin for presumed CAP, as she
had a right hilar distribution opacity on CXR. She had a sputum
culture which grew out MRSA, likely colonized but conderning for
pneumonia. Started on Vanco on [**12-21**], renally dosed. Recieved a
midline for Vanoc administration for 7 days. Her vanco trough
will need to be checked before the next dose.
2) NSTEMI: Admission and follow up EKG's only demonstrated old
LBBB. No new
ischemic changes. She was managed medically with ASA, beta
blocker and started on [**First Name8 (NamePattern2) **] [**Last Name (un) **] (h/o cough with ACE-I). Enzymes
trended down, and Echo demonstrated new inferior and
infero-lateral wall motion abnormalities. Cardiology was
involved and recommended medical management and cath at a later
time, but the patient and family agreed that she would not want
catheterization.
3)Diastolic CHF: Maintained on outpatient regimen and kept a
negative fluid balance with lasix regimen. Echo continued to
show LVH, LAE and preserved EF,but also new wall motion
abnormalities compared to previous echo. Started [**Last Name (un) **] on this
admission. The patient developed a contraction alkolosis after
gentle diuresis )4 liters over length of stay) therefore can
decrease rate of diuresis with the goal being even - 500 cc
negative over 24 hours.
4) Anemia: Was guiaic negative on rectal exam, and anemia
studies were consistent with anemia of chronic disease. This
remained stable through hospital course.
5) Elevated LFTS - unclear etiology but possibly due to passive
congestion from CHF.
Trended down through hospital course.
6)CRI
Remained at baseline creatinine. Electrolytes and fluid balance
were monitored. Medications were dosed for her reduced
creatinine clearance.
7)Gout - stable; allopurinol held during this admission, then
restarted on [**12-21**] at a renal dosage (QOD)
8)DM - Continued on Insulin per home regimen and covered with
sliding scale insulin. [**Doctor First Name **] diet and finger sticks. Continued
gabapentin for peripheral neuropathy.
9)h/o CVA - Residual right sided weakness. Continued plavix
through hospital course.
10) Disposition: to MACU at [**Hospital 100**] Rehab today.
Medications on Admission:
combivent
allouprunol 100 daily
ceftriaxone (stopped [**12-16**])
colace
insulin
Ultram 25 q8
codiene 7.5 mg hs
folvent
asa 81
plavix 75
aldactone 25
lopressor
isordil 40 TID
NTG SL prn
lasix 40 q8 x3 doses
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: 58 units
Subcutaneous at bedtime.
2. Insulin Regular Human 100 unit/mL Solution Sig: ISS
Injection four times a day: as per SS.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Pyridoxine HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
16. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours): may hold if sleeping.
20. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours).
23. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
24. Dibucaine 1 % Ointment Sig: One (1) Appl Topical PRN (as
needed): apply to affected area.
25. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day): rinse mouth afterevery
administration.
26. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
27. Vancomycin HCl 1,000 mg Recon Soln Sig: 1gm Intravenous
q48 hours for 7 days.
28. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
29. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for HA.
30. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
pneumonia
CHF
NSTEMI
DM
HTN
CRI
transaminitis
Discharge Condition:
fair, on 2 L NC
Discharge Instructions:
Call your PCP if you have a fever, increased cough, have SOB, or
chest pain.
Followup Instructions:
f/u with PCP [**Last Name (NamePattern4) **] 1 - 2 weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
|
[
"438.20",
"786.6",
"285.9",
"486",
"424.0",
"593.9",
"V02.59",
"250.01",
"466.0",
"414.01",
"790.4",
"428.0",
"355.9",
"V09.0",
"428.30",
"276.3",
"410.71",
"V45.82",
"707.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11098, 11113
|
5453, 8189
|
244, 251
|
11203, 11220
|
1458, 2955
|
11345, 11527
|
1195, 1199
|
8447, 11075
|
2992, 3070
|
11134, 11182
|
8215, 8424
|
11244, 11322
|
1214, 1439
|
185, 206
|
3099, 5430
|
279, 825
|
847, 1068
|
1084, 1179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,141
| 126,838
|
46805
|
Discharge summary
|
report
|
Admission Date: [**2163-6-13**] Discharge Date: [**2163-6-16**]
Date of Birth: [**2088-12-17**] Sex: M
Service: MEDICINE
Allergies:
Neosporin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
SOB, hypoxia, transferred from OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 M with PMH of CHF, COPD steroid dependent, on 3 L oxygen at
home baseline, presented to OSH with SOB, with O2 sats 80s on
RA. At OSH he was given azithromycin/ceftriaxone, 40mg lasix,
nebulizers, and started on bipap 12/8 with good oxygenation, abg
7.4/57/97. In our ED he was given aspirin, nebulizers.
.
He states he noted acute onset of SOB 4am, while in bed, also
notes diaphoresis, rigors, which he has had chronically. He
denies any positional association with SOB. He does have a
productive cough which has been chronic. Regarding his COPD, he
denies having been intubated or hospitalized for his COPD,
however, he is on chronic steroids and uses 2-3.5L of home o2
continuously.
.
Otherwise, never incarcerated, no foreign travel, except [**Country 2784**]
during his military service.
.
ROS: He has transient CP, which self terminates, denies having
had an MI, cath, or CABG in the past.
Past Medical History:
- CHF
- COPD - steroid o2 dependant
- DM
- Atrial Fibrillation (on coumadin 2.5 mg)
- Neuropathy
Social History:
He lives with his wife and daughter, 60 packyear smoking hx,
quit 30 yrs ago, social drinker.
Family History:
NC
Physical Exam:
VS 101.1 64 172/73 24 100% 3L
GEN: NAD, speaking in full sentences, comfortable
HEENT: JVD non distended, OP clear, dry MM
CV: irreg irreg, no mrg
CHEST: coarse BS b/l midway up lung fields, crackles at bases
ABD: Midline hernia, +BS, nt, soft, distended
EXT: no c/c/ min 1+ pitting edema b/l
NEURO: aaox3 no focal deficita
SKIN: + facial and chest erythema (chronic per patient),
scattered ecchymoses
Pertinent Results:
[**2163-6-13**] 06:04AM PLT SMR-NORMAL PLT COUNT-232
[**2163-6-13**] 06:04AM PT-34.1* PTT-29.3 INR(PT)-3.7*
[**2163-6-13**] 06:04AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2163-6-13**] 06:04AM NEUTS-93* BANDS-0 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2163-6-13**] 06:04AM WBC-18.6* RBC-5.04 HGB-13.7* HCT-40.9 MCV-81*
MCH-27.3 MCHC-33.6 RDW-16.6*
[**2163-6-13**] 06:04AM cTropnT-0.05*
[**2163-6-13**] 06:04AM CK-MB-6 proBNP-488
[**2163-6-13**] 06:04AM CK(CPK)-271*
[**2163-6-13**] 06:04AM GLUCOSE-116* UREA N-43* CREAT-1.7* SODIUM-137
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-28 ANION GAP-21*
[**2163-6-13**] 06:09AM LACTATE-2.1*
[**2163-6-13**] 12:03PM LACTATE-3.8* K+-3.5
[**2163-6-13**] 01:41PM CK-MB-5 cTropnT-0.02*
[**2163-6-13**] 01:41PM CK(CPK)-163
[**2163-6-13**] 11:38PM LACTATE-1.9
[**2163-6-13**] 11:38PM TYPE-ART PO2-60* PCO2-48* PH-7.47* TOTAL
CO2-36*
LABS AT DISCHARGE
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2163-6-16**] 06:55AM 14.8* 4.85 12.7* 39.1* 81* 26.2* 32.5
17.1* 265
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2163-6-14**] 03:38AM 94.7* 0 3.2* 1.5* 0.4 0.2
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2163-6-16**] 06:55AM 265
[**2163-6-16**] 06:55AM 15.9* 24.1 1.5*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2163-6-16**] 06:55AM 111* 46* 1.1 139 3.0* 92* 34* 16
.
[**2163-6-13**] CHEST CT W/O CONTRAST: 1. Dependent lower lobe
consolidation and ground-glass attenuation accompanied by
multilobar, diffuse bronchiolitis (tree-in-[**Male First Name (un) 239**] pattern),
consistent with diffuse infectious process. In the setting of
hiatal hernia, aspiration pneumonia is also possible. 2.
Tracheobronchomalacia difficult to quantify due to lack of
standardized breathing instructions. If warranted clinically,
once the patient's acute infection has resolved, dedicated CT
trachea could be obtained to better assess this finding. 3.
Emphysema. 4. Increased number of mediastinal lymph nodes,
likely hyperplastic in the setting of acute infection. These
could also be reassessed at the time of followup CT. 5. Diffuse
coronary artery calcifications. 6. Small cystic lesions in the
liver and kidneys, incompletely characterized. These could be
more fully characterized by ultrasound if warranted clinically.
.
[**2163-6-13**] ECHO: EF = 50%. The left atrium is dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. There is mild regional
left ventricular systolic dysfunction with inferolateral
akinesis/hypokinesis. Overall left ventricular systolic function
is mildly depressed. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Brief Hospital Course:
# Hypercarbic respiratory failure: Initially the patient was
admitted to the MICU but not intubated. The CT was consistent
with viral pneumonia, although bacterial could not be excluded.
Sputum gram stain showed gram positive cocci. PCP was negative,
as was legionella urinary antigen. He received azithromycin and
ceftriaxone, ceftriaxone was later d/c, and he was discharged to
complete a 10 day course of antibiotics with cefpodoxime. He was
treated with solumedrol IV, then prednisone taper to achieve his
home dose of 10 mg in 2 weeks. He was given nebulizer treatment
as needed.
CHF was initially on the differential, however BNP was not
elevated. An echo showed a mildly decreased EF from baseline (
50%). A PE was never strongly in the differential due to the
patient's elevated INR>3.
.
# CHF: Echo showed mild systolic dysfunction. Responded well to
lasix x 1. He was continued on HCTZ and spironolactone.
.
# Afib: Continued beta blocker. He was supratherapeutic on
coumadin>3, therefore coumadin was held. On [**6-15**], INR <2,
therefore coumadin restarted at 2 mg hs, with close follow up at
discharge.
.
# HTN: ACE was initially held in view of high creatinine, then
restarted.
.
# CAD: No e/o active ischemia. Continued ASA, anticoagulated, on
BB, on telemetry with no significant events.
.
# ARF: Prerrenal, creatinine improved with hydration. (1.7 to
1.1)
.
# Hyperlipidemia: continued statin
.
# Chronic Pain: continued fentanyl, neurontin, oxycodone for
breakthrough.
.
# Psych: continued zoloft
.
# Allergies: seasonal, continued [**Doctor First Name 130**]
.
# FEN: [**Doctor First Name **]/cardiac diet, monitor lytes. Needed potassium
repletion daily.
.
# PPX: Bowel regimen, anticoagulated, PPI, OOB to chair
.
# Contacts: [**First Name5 (NamePattern1) 1060**] [**Known lastname 99335**] [**Telephone/Fax (1) 99336**] (C), [**Telephone/Fax (1) 99337**] (H)
.
# DISPO: Home with services
.
# FULL CODE
Medications on Admission:
Lasix 120 QD
Aldactazide (HCTZ, spironolactone) 5050
Coumadin 2.5/5mg alternating
Potassium
Prednisone 20 mg
Neurotin 600mg TID
Lisinopril 2.5 mg QD
Aspirin 81mg QD
B12 1000mcg
[**Doctor First Name **] 180 QD
Calcium
MVI
Flomax 0.4mg QD
Celebrex 200mg
Zoloft 50mg
Zebeta 2.5mg
Flexeral 10mg [**Hospital1 **]
Combivent
Fentanyl patch 50mcg patch
Percocet
Waltussin
Lipitor 80mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Furosemide 40 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO QOD
().
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: From [**6-17**] to [**6-19**].
Disp:*3 Tablet(s)* Refills:*0*
11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: From [**6-20**] to [**6-23**].
Disp:*6 Tablet(s)* Refills:*0*
12. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: From [**6-24**] to [**6-27**].
Disp:*9 Tablet(s)* Refills:*0*
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: From [**6-28**] to [**7-1**].
Disp:*3 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
From [**7-2**] onwards.
Disp:*30 Tablet(s)* Refills:*2*
15. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO QOD ().
17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
18. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*6 Tablet(s)* Refills:*0*
19. Zebeta 5 mg Tablet Sig: half Tablet PO daily ().
20. Combivent 103-18 mcg/Actuation Aerosol Sig: [**2-8**] Inhalation
twice a day.
21. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
22. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO twice a day.
23. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
24. Outpatient Lab Work
Please have your PT and PTT and INR checked on [**2163-6-18**] and have
results called into Dr[**Name (NI) 2056**] office at [**Telephone/Fax (1) 99338**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
COPD exacerbation
Viral pneumonia
CHF
Secondary diagnosis:
DM
Atrial Fibrillation
Discharge Condition:
Good. Ambulatory. Back at baseline oxygen of 3 L n/c
Discharge Instructions:
You were admitted to the hospital because you required more
oxygen to breathe. This was most likely a COPD exacerbation due
to an infection. Even though the infection was most likely
viral, we ask that you complete antibiotics as prescribed and
not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
You had an Echo of your heart which revealed a slightly
worsened pumping function. Please discuss this with your primary
doctor at your next visit.
You are taking a blood thinner (coumadin) for your heart
condition called atrial fibrillation. Your blood was too thin
and we stopped your coumadin briefly. Then we restarted it as
the thinning decreased. It is very important that you follow up
with coumadin clinic to check your INR (blood thinning)
carefully, otherwise you run serious health risks, such as
stroke, or bleeding.
We stopped your flexuril because it is contraindicated in your
condition.
Followup Instructions:
1) With a doctor at [**Name (NI) 99339**] office, Dr [**Last Name (STitle) **], tomorrow
[**6-17**] at 2 pm, to address your coumadin levels.
2) With Dr [**Last Name (STitle) **] [**2163-6-20**], at 4 pm.
|
[
"518.82",
"480.9",
"466.19",
"414.01",
"V46.2",
"553.3",
"428.22",
"V58.65",
"428.0",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9954, 10003
|
5267, 7198
|
305, 311
|
10150, 10205
|
1928, 5243
|
11174, 11382
|
1486, 1490
|
7628, 9931
|
10024, 10024
|
7224, 7605
|
10229, 11151
|
1505, 1909
|
231, 267
|
339, 1239
|
10104, 10129
|
10044, 10083
|
1261, 1359
|
1375, 1470
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,526
| 153,455
|
29573
|
Discharge summary
|
report
|
Admission Date: [**2101-2-25**] Discharge Date: [**2101-3-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Reason for admission: back pain and possible aortic dissection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 88 y/o man with hx of HTN, ESRD, hx of ?bladder
cancer who presented from home c/o severe back pain while
sitting on toilet. CT scan showed two small focal areas of
dissection in descending/abdominal aorta. CT surgery was not
impressed with
.
On review of systems, the patient denies any chest pain,
shortness of breath, fevers, chills, weight loss, night sweats,
fatigue, headaches, dizziness, blurred vision, sore throat,
nausea, vomiting, abdominal pain, any new rashes, denies
dysuria, hematuria, increased urgency, diarrhea, constipation,
hematochezia, melena, epistaxis. All other systems reviewed in
detail and negative except for what has been mentioned above.
Past Medical History:
HTN
ESRD on HD, T, Th, Sat ([**3-4**] hypertension)
Alzheimer's
Bladder ca s/p resection . 2, at 60 and 83 y/o
Social History:
daughter explains that he was fully functional at home prior to
admission
Family History:
noncontributory
Physical Exam:
Gen: arousable, but not answering questions appropriately
HEENT: NCAT, unable to assess pupils ( patient refusing to open
eyes), MM dry, OP clear
CV: Tachycardic, RR, II/VI SEM, no tenderness to palpation of
precordium,
Lungs: patient refusing to sit up, coarse breath sounds
anteriorly
Abdomen: voluntary guarding, +BS, no HSM
Ext: no cce, +PT bilaterally
Neuro: unable to assess
Skin: palpable L AV fistula; pink, warm, no rashes
Pertinent Results:
[**2101-2-25**] 12:51PM LACTATE-2.0
[**2101-2-25**] 12:42PM GLUCOSE-111* UREA N-67* CREAT-10.6*#
SODIUM-135 POTASSIUM-5.4* CHLORIDE-91* TOTAL CO2-32 ANION GAP-17
[**2101-2-25**] 12:42PM WBC-11.0 RBC-2.56* HGB-8.5* HCT-25.2* MCV-98
MCH-33.2* MCHC-33.8 RDW-13.9
[**2101-2-25**] 12:42PM PT-21.2* PTT-31.9 INR(PT)-2.1*
Brief Hospital Course:
Impression/Plan: 88 y/o man with HTN, ESRD, transferred for
aortic dissection, non-surgical, transferred to medicine for
workup of back pain, found to be febrile on transfer. was
diagnosed with a pneumonia and found to be hypoxic on the floor.
was then transferred to the MICU for management of his hypoxia
and pneumonia. .
.
# Hypoxic Respiratory Failure
Etiology unclear. CXR and CT-A is unimpressive for pna. However
given patient's worrisome respiratory status started on
Vanc/Zosyn. Blood cultures grew [**First Name9 (NamePattern2) 8974**] [**Last Name (un) 36**] to nafcillin so PICC
line was placed. Fluid overload is unlikely, patient was
recently dialyzed and no evidence on imaging. PE is unlikely
given negative CT-A and patient has been on Coumadin.
- cont nafcillin for a total of 2 weeks ending [**2101-3-16**].
- PICC line placed [**2101-3-2**]
.
#. Fever
Patient had been spiking fevers on the floor. He has been
afebrile in the MICU. He is being tx for [**Month/Day/Year 8974**] bacteremia [**3-4**] to
RIJ tunneled line infection. MRI of spine was negative for
epidural abscess.
- Surveillance cultures to date have been negative. Surface
echo was negative for endocarditis.
- continue nafcillin through PICC line
.
# Aortic dissection: CT [**Doctor First Name **] and vasc did not feel that the 2
areas of dissection/ulceration were enough to explain back pain.
They recommended BP control. (SBP <150).
- Will continue patient on lisinopril.
- start low dose metoprolol [**Hospital1 **]
- cardiac and vascular surgery have no further input, medical
management, contact if questions
.
Tachycardia: usually occurs in relation to movement and slight
dyspnea.
- start low dose metoprolol [**Hospital1 **]
.
# Anemia: continue to follow HCT 27.7 today (29.0 yesterday)
.
- continue to follow daily
- guiaic negative
- iron, TIBC, transferrin low; ferritin and folate high
- start Fe sulfate 325 [**Hospital1 **]
- consider EPO with HD
.
Fistula thrombosis: patient presented to the hospital on
coumadin for fistula graft thrombosis. his INR has continue to
be therapeutic during his stay .
- once INR<2.0 would consider restarting low dose coumadin
.
# Back pain: Cont percocets
.
# HTN: Control BP with lisinopril and hold off on beta blockers.
.
# ESRD: Dialysis M,W,F;
.
# FEN: Renal diet, heart healthy
.
# Prophylaxis: bowel regimen, INR therapeutic,
.
PT eval: recommends rehab;
.
# Code: Full confirmed with family
.
.
Medications on Admission:
Coumadin 2mg po daily
ASA 81mg daily
Simvastatin 80mg po qhs
Lisinopril 10mg po daily
Calcium acetate 667mg po bid with meals
Nephrocaps 1 cap po daily
Aricept 10mg po qam
Colace 100mg po daily prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO BID
W/MEALS ().
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for temp>101.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Nafcillin 2 gm IV Q6H Duration: 2 Weeks
stop [**2101-3-16**]
14. Outpatient Lab Work
please follow INR levels in order to determine when to restart
coumadin (2mg/ daily)
15. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Pneumonia with baseline O2 saturations of 93% on room air
Right iliac artery aneurysm
ESRD with HD
[**Location (un) 8974**] bacteremia from line sepsos
Discharge Condition:
stable and improving
stable and improving
Discharge Instructions:
You will be discharged to a rehabilitation facility today. You
should take the medications that are prescribed to you below.
Additionally, you should follow up with the cardiothoracic
surgery service as needed. At this point, your condition is
stable and does not require any further workup.
should develop any fever, chills, shortness of breath, chest
pain, back pain or any other concerns.
Followup Instructions:
Continued dialysis MWF.
Follow up with the PMD at [**Hospital3 **].
|
[
"996.62",
"441.01",
"585.6",
"442.2",
"486",
"038.9",
"996.73",
"995.91",
"518.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6101, 6171
|
2115, 4568
|
325, 332
|
6367, 6412
|
1768, 2092
|
6856, 6928
|
1284, 1301
|
4817, 6078
|
6192, 6346
|
4594, 4794
|
6436, 6833
|
1316, 1749
|
222, 287
|
360, 1042
|
1064, 1177
|
1193, 1268
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,850
| 153,205
|
7024
|
Discharge summary
|
report
|
Admission Date: [**2158-7-30**] Discharge Date: [**2158-7-31**]
Date of Birth: [**2122-9-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
EtOH intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs [**Known lastname 26248**] is a 35 yo lady with hx of EtOH abuse, and
withdrawal seizures who came in yesterday after ? assault with
facial trauma to L eye and EtOH intoxication. Pt was discharged
on [**7-25**] after being admitted for detox, however refused detox
once sober. On this occasion, she was reportedly found lying in
her [**Doctor Last Name **] without clothing and surrounded by alcohol nibs,
however patient denies any memory of the events leading up to
the hospitalization and does not allow us to call her husband.
Drinks 1 L vodka daily, pt does not know when her last drink
was.
.
In the ED, initial vitals were 96.8 82 106/70 16 98%. Labs were
notable for Na of 148, Etoh of 432, positive benzos. She
required q1 hr CIWA and received a total of 60 IV valium and 20
PO, and woke up this AM with shaking and visual hallucinations
however vitals were stable. She also received haldol x2. She
also received Keppra which she takes at home for hx of seizures
in setting of EtOH use. Imaging of the head, face, chest and
shoulder showed no acute process. Social work was consulted but
pt refused. Vitals on transfer were: 99.2 117 104/74 10 100%.
.
On the floor, pt appears anxious. C/o pain in chest, direcly
over the sternum, worse with palpation, and pain in R shoulder.
Past Medical History:
- Alcohol abuse/withdrawal with seizures
- Hepatitis C, not currently treated
- ETOH pancreatitis
- IVDU
- victim domestic violence
- multiple clavicle fractures (unclear acuity)
Social History:
- Tobacco: 1 ppd
- etOH: Liter of vodka daily
- Illicits: marijuana intermittently, h/o IVDU, none currently
- lives w/husband(he is non-drinker)
- Abused by her former fiance, pt denies current abuse and
states that she feels safe in her home.
Family History:
Father - DM2
Mother - Diverticulitis
Sister - Asthma
Aunt - breast [**Name2 (NI) 3730**] in her 60's as well as lung Cancer
Grandmother - lung [**Name2 (NI) 3730**]
Physical Exam:
On admission:
Vitals: T:98 BP:130/96 P:103 R:21 O2: 98% RA
General: Alert, aaox3, anxious
HEENT: Sclera anicteric, MMM, oropharynx clear, abrasion on
L-side of face, dried blood on outside of ear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aaox3, CNs2-12 intact, 5/5 strength throughout, nl finger
to nose
Pertinent Results:
Labs on admission:
[**2158-7-29**] 09:31PM BLOOD WBC-7.2 RBC-3.79* Hgb-12.0 Hct-34.8*
MCV-92 MCH-31.6 MCHC-34.4 RDW-16.6* Plt Ct-369
[**2158-7-29**] 09:31PM BLOOD Neuts-59.6 Lymphs-34.6 Monos-2.8 Eos-1.6
Baso-1.4
[**2158-7-29**] 09:31PM BLOOD PT-11.6 PTT-26.2 INR(PT)-1.0
[**2158-7-29**] 09:31PM BLOOD Ret Aut-1.8
[**2158-7-29**] 09:31PM BLOOD ALT-49* AST-79* AlkPhos-73 TotBili-0.2
[**2158-7-29**] 09:31PM BLOOD calTIBC-363 VitB12-402 Folate-9.9
Ferritn-55 TRF-279
[**2158-7-29**] 09:31PM BLOOD ASA-NEG Ethanol-432* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
.
Imaging:
Sternal films: Plain radiographs show no definite evidence of
fracture. If
clinically warranted, CT could be obtained.
.
Chest films: No acute intrathoracic process. Incomplete
assessment of the
known right distal clavicle fracture. Please refer to the
concurrent
dedicated right shoulder radiograph.
.
R Shoulder films: Essentially unchanged appearance of an old
right distal clavicle fracture. Assessment of possible
new-on-old fracture should be based on clinical grounds.
.
CT Head: 1. No acute intracranial traumatic injury.
2. Age-advanced global atrophy.
.
CT sinus: 1. No acute facial bone fracture. No suspicious
air-fluid levels.
2. Minimal right maxillary mucosal thickening
Brief Hospital Course:
Pleasant 35 yo F with hx of EtOH abuse, withdrawal seizures
admitted for EtOH withdrawal.
.
# EtOH withdrawal: pt with extensive EtOH abuse history and
withdrawal seizures, EtOH level >400 in ED. CT head, sinuses,
and plain films of sternum, chest and shoulder were performed
given concern for trauma. These were negative except for
possible acute on chronic R clavicular fracture. Pt was treated
with thiamine/folate/MV, IVF and dilaudid, aggressive CIWA
scale. Home keppra was continued. Patient continued to have
large valium requirements however voiced that she wanted leave
AMA. Despite extensive conversation including risks, patient was
left AMA. Prior to leaving, patient understood risks. Patient
was offered rebab and SW services however she refused.
.
# Legal guardianship: After patient left AMA, team was contact[**Name (NI) **]
by [**Name (NI) **] [**Name (NI) 26248**], father and apparent guardian of patient.
Team was not made aware of legal guardian upon admission. In
review of OMR, prior admissions also did not document a legal
document. Mr. [**Known lastname 26248**] was advised to have information sent to
[**Hospital1 18**] for documentation purposes.
.
# Hypernatremia: likely due to dehydration in setting of
excessive EtOH use. She was given fluid and sodium was trended
to normal
.
# Tachycardia: sinus, likely due to dehydration and EtOH
withdrawal. Resolved with fluids and treatment of withdrawal.
.
# Ketoacidosis: No evidence of renal failure or concern for
tissue hypoperfusion. Likely due to alcoholic ketoacidosis.
Lactate was normal
.
# Clavicular fracture: unclear acuity. Fracture is located
distally, seems like unusual location for fracture due to fall,
raises concern for abuse however pt denies. Ortho was consulted
and recommended sling but patient refused. She was treated with
tylenol and tramadol for pain control.
.
# Transaminitis: due to EtOH use, hep C. Not currently being
treated for Hep C. LFTs were trended and normalized. Outpt
hepatology follow up was recommended.
.
# Anemia: stable, at baseline, normocytic, most likely mixed
iron deficiency and macrocytic [**2-15**] b12/folate deficiency given
high RDW.
.
# Nausea/diarrhea: unclear cause, however pt states that these
sxs are typical of her usual withdrawal. Raises concern for
opiod withdrawal however pt denies opiod use. This was
monitored however full work-up could not be completed given that
patient left AMA.
Medications on Admission:
-levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day)
-dilaudid PRN pain
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses this admission:
1. Alcohol abuse
2. Alcohol withdrawal
3. Leaving the hospital against medical advice
Seconday diagnoses this admission:
- History of alcohol abuse/withdrawal with seizures
- Hepatitis C, not currently treated
- ETOH pancreatitis
- History of IVDU
- multiple clavicle fractures (unclear acuity)
Discharge Condition:
Actively withdrawing from alcohol and leaving AMA
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
ICU after being found down and had an extremely high alcohol
level. We treated you for alcohol withdrawal, but the day after
admission you decided you wanted to leave against medical
advice, despite our best efforts to keep you in the hospital to
treat you. You were able to voice your understanding that
alcohol withdrawal can be potentially fatal, but decided to
leave anyways. You were also found to have an acute on chronic
right clavicle fracture, but refused to wear a sling, and again
left the hospital against medical advice.
No changes were made to your medication regimen. We suggest you
STOP DRINKING ALCOHOL.
Followup Instructions:
Follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) **] R
[**Telephone/Fax (1) 26250**] within the next week.
Completed by:[**2158-8-1**]
|
[
"787.02",
"305.1",
"E887",
"291.81",
"303.91",
"276.2",
"276.0",
"V15.41",
"787.91",
"280.9",
"810.00",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6934, 6940
|
4252, 6692
|
322, 328
|
7314, 7365
|
2964, 2969
|
8079, 8279
|
2131, 2298
|
6834, 6911
|
6961, 7293
|
6718, 6811
|
7389, 8056
|
2313, 2313
|
265, 284
|
356, 1649
|
4028, 4229
|
2984, 4019
|
1671, 1852
|
1868, 2115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,322
| 151,234
|
23073
|
Discharge summary
|
report
|
Admission Date: [**2146-11-17**] Discharge Date: [**2146-11-23**]
Date of Birth: [**2082-4-25**] Sex: M
Service: MEDICINE
Allergies:
Zosyn / Morphine / Penicillins
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
fever, abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
ERCP ([**2146-11-17**])
History of Present Illness:
[**Known firstname **] [**Known lastname 7631**] is a 64-year-old gentleman with history of
non-resectable pancreatic cancer s/p CBD stent in [**2145**] who
presented to OSH with band-like abdominal pain, fevers, chills,
nausea, and vomiting that began 2d PTA. Evaluation included LFTs
which were elevated and seemed consistent with obstructive
biliary process (TBili 12.5; Alk Phos 343; ALT 168; AST 87). He
was given Cefoxitin and IVFs. Given history, patient was
transferred to [**Hospital1 18**] for further work-up and evaluation.
.
In the ED, VS were T 102.7; BP 128/71; HR 98; RR 18; 95% 2L. He
received cipro, flagyl, as well as ~4L IV fluids. He was then
transferred urgently to the ERCP suite. En route, patient
developed hypotension to 80s which responded to 2L IV fluid
boluses. In the ERCP suite, a single stricture that was 8mm long
was seen at the major papilla. This was c/w tumor ingrowth at
the level of the ampulla. Many stones ranging in size from 2mm
to 5mm along with large amount of sludge that were causing
obstruction were seen at the common bile and hepatic duct.
Sludge was drained and new stent was placed. He was transferred
to the [**Hospital Unit Name 153**] for further management.
.
On arrival to the ICU, VS were stable. Patient was slightly
lethargic but otherwise reported that he was doing well.
Abdominal pain was significantly improved. Denied breathing
difficulty or nausea.
Past Medical History:
Pancreatic CA s/p metal stent placement [**2145**]
HTN
Asthma
Diabetes
Cholecystectomy
Esophageal stricture
Social History:
retired maintenance technician for the [**Company 2318**].
Family History:
NC
Physical Exam:
VS: T 97.9; BP 108/43; HR 80; RR 12; O2 94% RA
GEN: Overwight gentleman appears stated age, lethargic, AOx3,
pleasant, communicative, alert
HEENT: PRRL. EOMI. sclerae mildly icteric. MM slightly dry. OP
clear
LUNGS: Fine crackles at base. No wheezes.
HEART: S1S2 RRR. No MRG
ABD: obese, soft, NT. + distension. No fluid wave. +BS
EXT: No C/C/E. Symmetric DPs.
NEURO: AO x 3. Lethargic. PRRL. Shrugs shoulders. Grimaces.
Protrudes tongue. EOMI. UE strength symmetric and intact.
Dorsiflexion/plantar flexion symmetric.
SKIN: + Jaundice
Pertinent Results:
ERCP ([**11-17**]):
Stent in the major papilla. Tissue ingrowth into the stent at
the level of the ampulla. Large amount of stones and sludge
with in the stent in the common bile and hepatic duct. Stones
and sludge were removed using a balloon. Tissue ingrowth was
treated by placing another wall stent within the first stent.
(stone extraction, stent placement)
Portable AP chest radiograph was reviewed with no prior films
available for comparison.
The heart size is normal. Mediastinal contours are unremarkable.
Bilateral vascular engorgement is demonstrated suggesting volume
overload. Linear opacity in the right lower lobe may represent
atelectasis. Left costophrenic angle was not included in the
field of view. No sizeable right pleural effusion is
demonstrated. There is no pneumothorax.
Cardiology Report ECG Study Date of [**2146-11-17**] 10:55:40 PM
Artifact is present. Atrial fibrillation. Probable right
bundle-branch
block. Diffuse non-specific ST-T wave changes. No previous
tracing available
for comparison.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 0 136 408/450 0 57 2
ECHO:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) Transmitral Doppler and tissue velocity imaging are
consistent with normal LV diastolic function. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is a probable small (0.5x0.5cm)
vegetation versus focal thickening on the non-coronary cusp of
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
IMPRESSION: Normal left ventricular systolic and diastolic
function. A possible small vegetation versus focal thickening of
the non-coronary cusp of the aortic valve. A TEE is recommended
if clinically indicated.
[**2146-11-22**] 05:50AM BLOOD WBC-6.9 RBC-3.68* Hgb-13.2* Hct-38.0*
MCV-103* MCH-35.9* MCHC-34.7 RDW-14.5 Plt Ct-209
[**2146-11-19**] 04:21AM BLOOD WBC-4.2 RBC-3.57* Hgb-12.7* Hct-36.3*
MCV-102* MCH-35.7* MCHC-35.1* RDW-14.2 Plt Ct-99*
[**2146-11-17**] 12:15AM BLOOD WBC-13.2*# RBC-4.36* Hgb-16.3 Hct-44.4
MCV-102* MCH-37.3* MCHC-36.7* RDW-14.8 Plt Ct-139*
[**2146-11-23**] 05:50AM BLOOD PT-14.7* INR(PT)-1.3*
[**2146-11-20**] 04:50AM BLOOD PT-12.2 PTT-28.7 INR(PT)-1.0
[**2146-11-17**] 05:26PM BLOOD FDP-0-10
[**2146-11-17**] 05:26PM BLOOD Fibrino-628*
[**2146-11-17**] 12:16PM BLOOD Ret Aut-1.1*
[**2146-11-23**] 05:50AM BLOOD UreaN-8 Creat-0.6 Na-136 K-4.1 Cl-102
HCO3-25 AnGap-13
[**2146-11-19**] 04:21AM BLOOD Glucose-220* UreaN-6 Creat-0.5 Na-130*
K-3.2* Cl-99 HCO3-23 AnGap-11
[**2146-11-19**] 04:21AM BLOOD Glucose-220* UreaN-6 Creat-0.5 Na-130*
K-3.2* Cl-99 HCO3-23 AnGap-11
[**2146-11-17**] 12:15AM BLOOD Glucose-391* UreaN-18 Creat-1.5* Na-132*
K-3.0* Cl-92* HCO3-24 AnGap-19
[**2146-11-23**] 05:50AM BLOOD ALT-51* AST-40 AlkPhos-262* TotBili-2.8*
[**2146-11-19**] 04:21AM BLOOD ALT-91* AST-44* LD(LDH)-132 AlkPhos-215*
TotBili-5.4*
[**2146-11-17**] 12:15AM BLOOD ALT-171* AST-80* LD(LDH)-166 AlkPhos-334*
Amylase-8 TotBili-13.5*
[**2146-11-22**] 05:50AM BLOOD Lipase-22
[**2146-11-23**] 05:50AM BLOOD Mg-2.1
[**2146-11-19**] 04:21AM BLOOD Albumin-3.1* Calcium-8.3* Phos-1.7*
Mg-2.0
[**2146-11-21**] 06:15AM BLOOD Phos-3.4#
[**2146-11-21**] 06:15AM BLOOD TSH-2.4
[**2146-11-17**] 12:29AM BLOOD Lactate-1.9
[**2146-11-17**] 05:45AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.023
[**2146-11-17**] 05:45AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-LG Urobiln-1 pH-6.5 Leuks-NEG
[**2146-11-17**] 05:45AM URINE RBC-0-2 WBC-[**3-14**] Bacteri-RARE Yeast-NONE
Epi-0-2
[**2146-11-19**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2146-11-18**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2146-11-18**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2146-11-17**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STREPTOCOCCUS
PNEUMONIAE}; ANAEROBIC BOTTLE-FINAL {STREPTOCOCCUS PNEUMONIAE}
EMERGENCY [**Hospital1 **]
[**2146-11-17**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STREPTOCOCCUS
PNEUMONIAE}; ANAEROBIC BOTTLE-FINAL {STREPTOCOCCUS PNEUMONIAE}
[**2146-11-17**] 12:15 am BLOOD CULTURE
**FINAL REPORT [**2146-11-19**]**
AEROBIC BOTTLE (Final [**2146-11-19**]):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
MEROPENEM PERFORMED BY E-TEST.
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >= 2.0 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PENICILLIN------------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2146-11-19**]):
REPORTED BY PHONE TO [**Location (un) **] [**2146-11-17**] 11:41AM.
STREPTOCOCCUS PNEUMONIAE.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
Brief Hospital Course:
The initial picture was consistant with cholangitis. ERCP was
done with biliary slude removal and new stent placement. LFT's
and hyperbilirubinemia improved.
Of ote, 4/4 bottles on blood cultures grew pneumococcus as
above. Initiall on levofloxacin and flagyl. tailored to
levofloxacin alone per ID recommendations. TTE was done that
showed a small vegetaion on aortic valve vs thickened vale. TEE
was recommended but patient left hospital against medical
advice. Surveillance are pending at discharge. No clear source
of strep pneumoniae bacteremia was found. CXR - no pneumonia.
Could be from biliary source.
Was initially hypotensive andin ARF - both resolved with volume
resuscitation.
Diagnosed with Afib: Was likely due to infection, septicemia.
Needed prn doses inaddition t standing doses of diltiazem for
rate control. In ICU also started on metoprolol to control RVR.
However, he then became hypotensive after each dose of lopressor
and lopressor was discontinued. He was then started on once
daily ER diltiazem to transition to easier home dosing. Dose
titrated to rate control. He was also started on Coumadin. He
was briefly on a heparin drip, however this was stopped after
transfer to the floor since his CHADS2 score is only 2. Coumadin
was however stopped after the results of TTE were obtained as
likely vegetation due risk of bleeding.
On telemetry a run of NSVT was noted. Cardiology was consulted
and they did not feel and specific Rx was needed for this.
Electrolytes were normal. Repeat ECG was requested, but patient
left AMA prior to this. Levofloxacin can sometimes cause
ventricular arrythmias, and ID team was reconsulted about this.
Given the penicillin allergy - no other appropriate alternative
was recommended by them especially since the patient could have
acute endocarditis.
The patient on the last two days insisted he wanted to go home
without any further work up. The risk of infective endocarditis,
need for potential IV and long term antibiotics, need for TEE,
possibility of thromboembolic phenomena due to endocarditis and
CVA, bacteremia, speard of infection to other parts of body and
potentially death etc was explained to him and he comprehended
the risks of leaving AMA. The patient was alert and oriented and
could relay the risks back to me appropriately. He did not tell
me or staff why he wanted to leave AMA. He informed me that he
would be visiting his PCP on the day of discharge.
On the evening of discharge after the patient had left the
hospital AMA, I recieved a tel call from [**Location (un) 535**] that
levofloxacin is to covered by his insurance. This was
substituted to ciprofloxacin 500 mg [**Hospital1 **] and the pharmacist was
informed to tell patient to see PCP [**Name Initial (PRE) 2678**]. He was advised that he
may need more than the prescribed days of antibiotics.
Patient known to have unresectable pancreatic cancer on history.
He reports follow up at [**Company 2860**].
Medications on Admission:
Glucotrol
Lasix
Combivent
Albuterol
Discharge Medications:
1. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
2. Ipratropium-Albuterol Inhalation
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
Cholangitis, Bile duct obstruction
Pneumococcal septicemia
New-Onset Atrial Fibrillation
Non sustained ventricular tachycardia
Possible infective endocarditis
Acute renal failure - resolved
Secondary:
Pancreatic Cancer (history of)
Hypertension
Diabetes mellitus type 2
Discharge Condition:
Poor.
Leaving against medical advice.
Discharge Instructions:
You have selected to leave against medical advice. We are
concerned about your heart. The ECHO shows that you may have an
infection of the heart valve. The cardiologists have recommended
another test to confirm this called transesophageal echo. If
this is indeed an infection of the heart vale or endocarditis,
you are at a risk of worsening arrythmias, stroke, serious blood
infection that may spread to other organs etc and potential
death. However, you have elected to leave prior to completion of
the work up. All information has been communicated to you by the
doctor and the cardiologist. You have understood and
comprehended the informtion provided to you, understand the
risks of leaving against medical advice and still wish to go
against medical advice.
Please report to your primary doctor today and discuss these
issues with him.
You had an infection of your biliary tree and a blocked stent.
As you are aware the stent was replaced. You were also found to
have bacteria in your blood. You were found to have new
arrythmia or irregular heart beat called atrial fibrillation.
Since your heart rate was very fast, a medicine called diltiazem
(extended release) has been started to control the heart rate.
Because of the fast and irregular heart rate, you are at an
increased risk of clots being formed in the heart and causing a
stroke etc. However, since you could have endocarditis,
anticooagulation is not recommended at this time.
Repeat liver tests are recommended as well. Discuss with your
primary doctor.
YOu will likely need antibiotics for a long time if the
diagnosis of endocarditis is confirmed. This may be intravenous
antibiotics. We advise you to discuss this with your primary
doctor today. While on the antibiotics, monitor your blood
sugars closely for too high or too low values.
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**]. [**Telephone/Fax (1) 18325**]. Please visit him today and
have him check an INR level to make sure it is not rising.
|
[
"250.00",
"276.8",
"427.1",
"584.9",
"038.2",
"276.51",
"496",
"427.31",
"287.5",
"574.50",
"285.22",
"421.0",
"995.92",
"157.9",
"401.9",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
11800, 11819
|
8366, 11323
|
334, 360
|
12142, 12182
|
2601, 8343
|
14044, 14276
|
2027, 2031
|
11409, 11777
|
11840, 12121
|
11349, 11386
|
12206, 14021
|
2046, 2582
|
254, 296
|
388, 1804
|
1826, 1935
|
1951, 2011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 157,671
|
22381+57298
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-5-3**] Discharge Date: [**2128-5-6**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Anxiety, shortness of breath, hyperglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
22 year old woman with Type I diabetes and multiple prior
admissions for DKA who presents with diabetic ketoacidosis
(blood sugar 720, ketones in urine, elevated anion gap). On the
morning of admission, patinet awoke at 5am with an episode of
anxiety, bilateral jaw pain, and mild shortness of breath. She
measured her blood sugar at 243, drank a glass of milk, and gave
herself 3 units of insulin. She awoke several hours later, with
continued mild shortness of breath, vomited once, and called the
EMS and brought to the ED where her sugar was 720. On review,
patient endorses loose stools that began on the night prior to
admission. She reporst that her four year old son has had some
conjunctivitis and runny nose with a low grade fever, but denied
other sick contacts. She denies any change in appetite, although
her weight increased from 108 to 117 over the past two months.
She denies any dysuria, vaginal discharge, new sexual partners,
or recent cough. She states that she takes her prescribed 31
units of lantus each night and covers herself with one units of
regular insulin for each 40 mg of sugar greater than 140. In
the emergency room, she was started on an insulin drip and
admitted to the medical ICU for further management.
Past Medical History:
- Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 10.4 % ([**7-/2125**])
- Hyperlipidemia
-S/P MVA [**5-3**] - lower back pain since then. + back muscle spasm
treated with tylenol.
- Goiter
- Depression
- Multiple DKA admissions
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
shots
- Genital Herpes
Social History:
The patient was born and raised in [**Location (un) 669**], where she lived in
house with siblings, mother, grandmother, and [**Name2 (NI) 12232**] when
growing up. Currently lives in her own apartment. Attended job
corp training following h.s., but presently unemployed feeling
too overwhelmed between diabetes care and caring for three year
old her son. She has a boyfriend. She is close to mother,
sister, and [**Name2 (NI) 12232**] who live nearby. Denies abuse in childhood
or adulthood. She denies tobacco, alcohol or illicit drug use.
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
Physical exam on admission
T:96.7 BP: 97/57 HR:109 RR:14 O2saturation: 100% on 2L NC
Gen: Pleasant, tired youg woman laying in bed.
HEENT: No conjunctival pallor. No scleral icterus. Dry mucous
membranes. Oropharynx clear.
NECK: [**Name2 (NI) 15262**]. No cervical or supraclavicular lymphadenopathy. No
JVD.
CV: Tachycardic. Regular rhythm. Normal S1 and S2. No murmurs,
rubs or [**Last Name (un) 549**] appreciated.
LUNGS: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonci appreciated.
ABD: Well healed surgical scar in lower abdomen, across midline.
Hypoactive/no bowel sounds in all four quadrants. Soft.
Nontender and nondistended. No guarding or rebound. Liver edge
not palpated. No splenomegaly appreciated.
EXT: Warm and well perfused. Hyperpigmented xerotic anterior
midshins, bilaterally. No clubbing or cyanosis. No lower
extremity edema, bilaterally. 2+ dorsalis pedis and radial
pulses, bilaterally.
Pertinent Results:
Laboratory studies on admission:
[**2128-5-3**]
WBC-24.6* HCT-48.5*# MCV-94# MCH-29.7 MCHC-31.7 RDW-13.5 PLT
COUNT-276
NEUTS-76* BANDS-11* LYMPHS-9* MONOS-4 EOS-0 BASOS-0 ATYPS-0
CK(CPK)-103 CK-MB-1 cTropnT-<0.01
CALCIUM-11.7* PHOSPHATE-8.4*# MAGNESIUM-3.2*
GLUCOSE-720* UREA N-25* CREAT-1.7*# SODIUM-143 POTASSIUM-5.3*
CHLORIDE-100 TOTAL CO2-6* ANION GAP-35*
U/A: BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-150
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0-2 WBC-[**2-2**]
BACTERIA-FEW YEAST-NONE EPI-[**2-2**]
LACTATE-1.5
Laboratory studies on discharge:
[**2128-5-6**]
WBC-5.3 Hgb-10.1* Hct-29.7* MCV-88 RDW-13.5 Plt Ct-151
Glucose-73 UreaN-5* Creat-0.6 Na-141 K-3.3 Cl-106 HCO3-24
AnGap-14
ALT-29 AST-29 AlkPhos-60 TotBili-1.1
Calcium-8.9 Phos-2.7 Mg-2.3
Iron-131 calTIBC-238* VitB12-480 Folate-9.9 Ferritn-233*
TRF-183*
TSH-2.3
Cortisol-27.9*
EKG [**5-3**] Sinus tachycardia. Right atrial abnormality. Borderline
right axis deviation. Tented T waves in the precordial leads,
consider hyperkalemia. Compared to the previous tracing of
[**2128-2-4**] heart rate has increased now with tented T waves
suggesting hyperkalemia.
Radiology:
[**5-3**] CXR: Comparison with [**2128-2-4**]. Angiocath is seen
overlying the right lung apex. Cardiac, mediastinal, and hilar
contours are within normal limits. No pleural effusion or
pneumothorax is present. Osseous structures are unchanged. Lung
fields are clear
Brief Hospital Course:
22 year old woman with type I diabetes and recurrent DKA, who
presents with diabetic ketoacidosis.
1) Diabetic ketoacidosis: The patient was admitted to the ICU on
an insulin drip. When her anion gap closed, she was transitioned
back to her home glargine (31 units) and humalog sliding scale
with good glucose control. The inciting event is unclear.
Although the patient had a markedly elevated wbc/bandemia on
admission, no clear infectious source could be found (U/A not
c/w infection, bcx NGTD, and CXR negative) and the patient's wbc
rapidly normalized, suggesting that her leukocytosis may have
been due to a stress reaction. It's possible that she had a
viral infection, given her son's recent illness. Her diarrhea,
nausea, chest pain, and shortness of breath resolved with
control of her fingersticks. Cardiac enzymes were cycled and not
consistent with myocardial ischemia. The patient denied
medication non-compliance, and a TSH level was normal. Her a.m.
cortisol was elevated, however this should be repeated as an
outpatient to avoid confounding of stress from acute illness
(DKA). At time of discharge, the patient's fingersticks were
well controlled; she will follow-up in [**Hospital **] clinic as an
outpatient.
2) Chest pain: This resolved with blood sugar control and
addition of a proton pump inhibitor, suggesting possible
contributors of DKA and GERD. D-dimer was negative, not
consistent with pulmonary embolism, and cardiac enzymes were not
suggestive of ischemia. The patient was continued on her home
dose of aspirin.
3) Depression: The patient was continued on fluoxetine. A social
work consult was obtained, who instructed the patient regarding
relaxation techniques/biofeedback. She was provided with the
number for [**Hospital1 2177**] outpatient psychiatry clinic to set up an
appointment through her PCP.
4) Full Code
Medications on Admission:
1. Aspirin 81mg daily
2. Docusate 100mg Po bid
3. Ezetimibe 10mg daily
4. Fluoxetine 20mg daily
5. Hydromorphone 2mg PO q4-6 hours PRN
6. Lisinopril 20mg daily
7. Tamsulosin 0.4mg PO qhs
Discharge Medications:
1. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Maalox MS [**First Name (Titles) **] [**Last Name (Titles) **] 400-400-40 mg/5 mL Suspension Sig:
Fifteen (15) ml PO every six (6) hours as needed for
indigestion.
6. Insulin Glargine 100 unit/mL Solution Sig: Thirty One (31)
units Subcutaneous QPM.
7. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous qAC and qhs: as directed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis.
Discharge Condition:
Good.
Discharge Instructions:
You were admitted with diabetic ketoacidosis
1) Please take all medications as prescribed. Do not take
lisinopril until directed to do so by your PCP given your blood
pressure was lower than usual during your admission.
2) Please follow-up as indicated below.
3) Please check your fingersticks before each meal and at
bedtime and take the insulin sliding scale as directed. If your
fingersticks are persistantly >250, please call you're [**Last Name (un) **]
provider
Followup Instructions:
1) Primary Care: Please follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 7538**]) on [**5-18**] at 11:15 a.m.
2) [**Last Name (un) **]: Please follow-up with NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] on [**5-10**] at
2:30 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2128-5-6**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 10792**]
Admission Date: [**2128-5-3**] Discharge Date: [**2128-5-6**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 9532**]
Addendum:
See below
Brief Hospital Course:
Anemia: He patient's hematocrit dropped from 48.5 to 29.7 with
agressive hydration. On review of prior lab valies, 29.7 appears
to be within the patient's baseline (when she is not dehydrated
in the setting of DKA). Iron studies were not consistent with
iron deficiency, and vitamin B12 and folate were within normal
limits. The patient's hematocrit should be closely followed as
an outpatient to ensure stability.
Discharge Disposition:
Home
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 9533**]
Completed by:[**2128-5-6**]
|
[
"311",
"724.5",
"250.11",
"535.50",
"285.9",
"530.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9946, 10102
|
9507, 9923
|
310, 318
|
8146, 8154
|
3692, 3711
|
8670, 9484
|
2615, 2726
|
7233, 8050
|
8100, 8125
|
7021, 7210
|
8178, 8647
|
2741, 3673
|
4265, 5117
|
227, 272
|
346, 1592
|
3725, 4251
|
1614, 2038
|
2054, 2599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,022
| 196,712
|
8986
|
Discharge summary
|
report
|
Admission Date: [**2185-1-3**] Discharge Date: [**2185-2-5**]
Date of Birth: [**2113-2-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
CC:[**CC Contact Info 31168**]
Major Surgical or Invasive Procedure:
endoscopy with variceal banding x2
History of Present Illness:
HPI: Mr. [**Name14 (STitle) 31169**] is a 71 y/o man with PMH notable for PSC
complicated by cirrhosis with known gastric varices who
presented to the [**Location (un) 620**] ED earlier this evening with diarrhea
and maroon stools after taking a laxative earlier today. He also
reported vomiting "cranberry juice" earlier today as well. He
reported no chest pain, difficulty breathing, or abdominal pain.
Of note, recent EGD (last admission, done [**12-28**]) demonstrated
esophageal varices and amotility of the esophagus.
.
In the [**Location (un) 620**] ED, vitals were HR 60, BP 70/40, RR 12. He
received 4 L NS. He was found to have a hct down to 29.1 (35.1
on [**12-31**]). His INR is 2.1. He also had a potassium of 6 (not
hemolyzed) which was treated with calcium gluconate, kayexalate.
He received 40 mg omeprazole IV X 1. He was transfused with 1 U
PRBCs prior to transfer. Repeat BP prior transfer not
documented. In the ambulance, the patient's blood pressure is
documented as 77/46 and then up to 160/133 (?). His FSBS was
110.
.
On arrival to the ICU, the patient is without complaint. He
denies any nausea, vomiting, hematemesis, or abdominal pain. He
denies any dizziness or lightheadedness. He had a frankly
melenotic stool on arrival to the ICU and BPs down to the 70s.
Attempted to place arterial line but unsucessful. Contact[**Name (NI) **]
Liver team to evaluate for EGD tonight given likelihood of
variceal bleeding.
Past Medical History:
PMH:
# Cirrhosis due to PSC:
- dx [**2178**] (s/p multiple ERCPs; atypical cytology in [**2178**], repeat
neg for atypical cells in [**2180**] and [**2181**])
- portal htn, portal gastropathy, ascites
- no EGDs, but multiple ERCPs with limited views of normal
esophagus
# CAD s/p MI with PTCA in [**2167**] and CABG in [**2176**]
# Chronic systolic heart failure, EF 36%
# Ulcerative colitis x 10-15 years
# Recurrent mild intermittent cholangitis
# GERD
# h/o Lyme disease [**8-24**]
# Hypercholesterolemia
# Hypertension
# Raynaud's disease s/p multiple finger and toe amputations
# OSA
# Esophageal stricture
# Depression
# ADHD
Social History:
SH: (from OMR) He is a retired carpenter. He is married and has
three grown children. He has no tobacco history. He drank 3 oz
EtOH daily
for 50 yrs, until appx [**2183**]. Denies illicit drug use. Lives with
wife, 1 son.
Family History:
Mother died of peritonitis. His father died from complications
of heart disease.
Physical Exam:
PE: T: 95.6 ax BP: 74/45 HR: 65 RR: 11 O2 100% RA
Gen: Pleasant, chronically illappearing male in no distress,
able to talk in full sentences
HEENT: + scleral icterus, MM slightly dry
NECK: supple, no elevation in JVP
CV: bradycardic, regular, no appreciable murmur
LUNGS: clear bilaterally
ABD: distended, + fluid wave, nontender to palpation, RUQ with
biliary drain with oozing around drain
EXT: dp pulses 2+ bilaterally
SKIN: + jaundice
NEURO: alert, interactive, face symmetric, moving all
extremities
Pertinent Results:
Labs on Admission:
[**2185-1-3**] 09:07PM PT-19.7* PTT-42.0* INR(PT)-1.8*
[**2185-1-3**] 09:07PM PLT COUNT-266
[**2185-1-3**] 09:07PM NEUTS-91.6* LYMPHS-4.1* MONOS-4.1 EOS-0.1
BASOS-0.1
[**2185-1-3**] 09:07PM WBC-20.0*# RBC-2.66*# HGB-9.5*# HCT-26.7*
MCV-100* MCH-35.5* MCHC-35.4* RDW-15.9*
[**2185-1-3**] 09:07PM ALT(SGPT)-36 AST(SGOT)-67* LD(LDH)-151 ALK
PHOS-87 TOT BILI-4.4*
[**2185-1-3**] 09:07PM GLUCOSE-246* UREA N-36* CREAT-1.0 SODIUM-134
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20
.
Studies:
Echo: [**1-4**] The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. LV systolic function appears depressed
(ejection fraction 40 percent) secondary to hypokinesis (and
dyssynchrony) of the interventricular septum. The right
ventricular cavity is small (extrinsic compression cannot be
ruled out). The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. Tricuspid regurgitation is present
but cannot be quantified. There is no pericardial effusion.
.
US abd: Moderate ascites.
.
CXR: Lungs low in volume, aside from small region of atelectasis
at the left base, clear. Probable small pleural effusions. Upper
lungs clear.
Cardiomediastinal silhouette unremarkable. Right upper quadrant
drains noted. No pneumothorax.
.
Para US guided: PFI: Uneventful ultrasound-guided paracentesis.
Approximately 3 liters were removed. Samples were sent for
laboratory analysis as ordered by the referring team.
.
Brief Hospital Course:
71 y/o man with PSC complicated by cirrhosis with known
esophageal varices and multiple epidoses of UGIB and banding
this admission, polymicrobial SBP, now with recurrent UGIB.
.
# GI bleed: During his initial presentation, he had a large
amount of melena and vomitted "cranberry juice" EGD performed on
arrival to the ICU demonstrated cherry red spots (stigmata of
recent bleeding). Two varices were banded during EGD. Bleeding
could have also been secondary to recent biopsy. Treated with
octreotide and IV protonix. Transfused 1 U PTA, 2 U pRBC, 2 U
FFP. No evidence of bleeding after banding. Covered with Cipro
for SBP in setting of GI bleed. Biliary drain in place PTA,
significant drainage of ascites from around drain. Culture of
fluid from biliary drain grew polymicrobials but no polys making
infection less likely. Given uptrending WBC GI wants para to r/o
SBP. Given unclear [**Name2 (NI) 4394**] pockets of US to be done by IR this
afternoon. To check bili on ascites as well to check for leak
from biliary tree. IR evaluated billiary drain, said ok.
Continued to leak large amount of ascites from around the site.
Per GI and IR no other intervention for leak. The patient was
transferred to the floor, but ultimately returned to the ICU
after a subsequent episode of UGIB. At that time, it was
determined to reverse his DNR/DNI status and pursue endoscopy
which required intubation. He was transfused an additional 3
units PRBC and 2 units FFP. The patient was continued on PPI
and octreotide gtt. It was apparent that the patient had
aspirated blood given it was suctioned from the ET tube after
intubation. The family was contact[**Name (NI) **] and the decision was made
to make the patient DNR again, with comfort being the goal.
Mechanical ventilation was discontinued.
.
# Hypotension: Related to blood loss as above. Received a total
of 6 L NS (4 l at [**Location (un) 620**] and 2 L here on arrival) in addition
to total of 3 U prbcs. Arterial line placed by Liver team prior
to endoscopy with SBPs ~ [**11-8**] points higher than cuff
pressures. The patient was maintained on pressor support on
transfer back to the MICU. After discussion with the family,
and the patient was made comfort measures only, the pressors
were discontinued.
.
# SBP/Leukocytosis: Diagnosed [**2185-1-5**], patient was on Cipro ppx
as outpatient and recently increased dose due to variceal bleed.
Placed on Aztreonam [**2176**] mg IV Q8H 5 days (Day 1 [**2185-1-5**] -
[**2185-1-10**]) due to Cipro resistance and pt's allergies. WBC count
kept rising, leading to repeat tap - SBP w GNR. Started on
Vanc/[**Last Name (un) **] [**1-11**]. No other evidence of infection causing
leukocytosis, Cdiff negative, blood and urine cultures negative,
no PNA seen on CXR. The patient was continued on vanco/[**Last Name (un) 2830**] to
cover for aspiration pna and peritonitis as well as caspofungin
for esophagitis and peritonitis with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**].
.
# Hypernatremia: Consistent with poor PO intake. Improved with
fluid challenge therefore most likely hypovolemic hyponatremia.
No fluid restriction. Hold diuretics Started D5W temporarily.
Discontinued all IV fluids.
.
# ESLD/cirrhosis: On liver transplant list. Complicated by
ascites, portal gastropathy, and SBP. No clear history of
encephalopathy. The patient was continued on ursodiol [**Hospital1 **],
lactulose 30 mg daily. Spironolactone, lasix and nadolol were
held in the setting of hypotension. Lactulose was continued.
.
# Biliary strictures: Pull back cholangiography on [**1-10**]
demonstrated no obstruction. PTC drain removed by IR [**2185-1-10**].
Bili peaked [**1-13**]. Trended LFTs.
.
# Ulcerative colitis: Continued outpatient Mesalamine.
.
# CAD s/p CABG: Continued statin. Held ASA and BB in setting of
bleed.
.
# Hyperlipidemia: Continued outpatient dose statin.
.
# Depression/ADHD: Continued sertraline. Held Ritalin.
.
# PPx: pneumoboots, ppi, lactulose
.
# Access: PIVs
.
# COMM: with patient and wife, [**Name (NI) 31170**] [**Telephone/Fax (1) 31171**]
Medications on Admission:
MEDS: (from d/c summary [**12-31**])
* Furosemide 20 mg PO DAILY (Daily): Hold until [**1-4**].
* Spironolactone 50 mg PO DAILY (Daily): Hold until [**1-4**]. .
* Mesalamine 800 mg PO TID
* Sertraline 75 mg PO DAILY
* Simvastatin 10 mg PO DAILY
* Aspirin 81 mg PO DAILY
* Ursodiol 600 mg in AM and 900 mg in pm.
* Ritalin 5 mg PO once a day as needed.
* Colace 100 mg PO twice a day.
* Metoclopramide 5 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
* Nadolol 20 mg PO DAILY (Daily).
* Ciprofloxacin 500 mg PO once a day: Start [**2185-1-1**] (when you
complete Cipro 500 twice a day)
* Omeprazole 40 mg PO twice a day
* Lactulose (30) ML PO ONCE (Once)
.
ALLERGIES: pcn / sulfa
Discharge Disposition:
Expired
Discharge Diagnosis:
Upper GI Bleed
End Stage Liver Disease
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2185-2-7**]
|
[
"550.90",
"112.89",
"428.22",
"V49.83",
"567.29",
"272.0",
"401.9",
"428.0",
"458.0",
"530.19",
"041.4",
"507.0",
"285.1",
"787.22",
"327.23",
"V45.82",
"276.0",
"530.81",
"789.59",
"V66.7",
"576.2",
"412",
"571.6",
"V45.81",
"530.3",
"263.9",
"414.00",
"572.3",
"518.5",
"584.9",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"87.54",
"97.55",
"45.13",
"96.6",
"42.33",
"45.16",
"54.91",
"96.72",
"99.07",
"99.04",
"38.93",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9879, 9888
|
5046, 9149
|
330, 366
|
9970, 10143
|
3372, 3377
|
2748, 2830
|
9909, 9949
|
9175, 9856
|
2845, 3353
|
261, 292
|
394, 1836
|
3391, 5023
|
1858, 2492
|
2508, 2732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,676
| 103,788
|
30687
|
Discharge summary
|
report
|
Admission Date: [**2125-9-18**] Discharge Date: [**2125-9-22**]
Date of Birth: [**2052-12-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
72 year old male with history of cholangiocarcinoma is having
fever and worsening mental status changes.
Major Surgical or Invasive Procedure:
[**2125-9-18**]: ERCP with stent placment
[**2125-9-18**]: Central line placement
History of Present Illness:
72 yo male with a history of metastatic cholangiocarcinoma
called from home because he was having increased jaundice,
abdominal pain, fever and confusion. He was advised to go into
the hospital for evaluation. In the ED he was found to have
worsening LFTs and a fever with elevated lactate.
Past Medical History:
Diabetes, peripheral vascular disease,
bilateral hip replacements, and back surgery x6.
Social History:
used to work as school custodian. has 2 daughters and 2 sons.
wife died in [**2108**]. has not smoked for 25 years, and he doesn't
drink.
Family History:
mother had [**Name2 (NI) 499**] ca, s/p colectomy
Physical Exam:
VS: Temp 97.0, BP 118/46, Pulse 62, RR 19, 99% on Cool neb mask,
pain currently 0/10
Gen: alert, oriented, jaundiced male currently doing well on
cool
neb mask
HEENT: sclera icteric, MMM, OP clear
Neck: no lymphadenopathy, no thyromegally
CV: RRR, nl S1S2, no murmers
Lungs: slight crackles at bases
Lymphatics: no axillary or inguinal lymphadenopathy
Abd: mild tenderness in LUQ, no rebound or guarding, positive BS
Ext: 2+ edema below pneumoboots
Neuro: alert and oriented, moving all extremities, sensation
intact.
Pertinent Results:
On Admission: [**2125-9-18**]
WBC-14.8* RBC-3.24* Hgb-10.5* Hct-28.9* MCV-89 MCH-32.5*
MCHC-36.5* RDW-14.2 Plt Ct-357 Neuts-94.3* Bands-0 Lymphs-4.3*
Monos-1.2* Eos-0 Baso-0.2
PT-16.2* PTT-30.0 INR(PT)-1.5*
Glucose-239* UreaN-45* Creat-1.2 Na-128* K-2.7* Cl-88* HCO3-22
AnGap-21*
ALT-67* AST-83* AlkPhos-352* Amylase-50 TotBili-12.2* Lipase-61*
Calcium-8.2* Phos-3.5 Mg-1.9
Albumin-2.6*
CRP-153.6*
Lactate-5.6*
Brief Hospital Course:
Patient having fever and mental status changes at home. In the
ED he was found to have worsening LFTs and a fever with elevated
lactate. He received Vancomycin and Cefepime in the ED.
An ERCP was performed on day of admission ([**2125-9-18**]) which showed
-The common bile duct demonstrated a filling defect in the upper
portion with no filling of the left intrahepatic duct. Per
endoscopy report, a balloon sweep was performed with sludge and
purulent drainage noted.
In addition, a CT of abdomen was performed on [**2125-9-18**], this
showed:
- Stable examination of the abdomen and pelvis without change in
the multiple lobar infiltrative cholangiocarcinoma with
left-sided biliary dilatation and decompression of the right
biliary tree, via a metallic stent, which is unchanged in
position.
-Worsening bibasilar atelectasis.
Due to the apparent cholangitis, he was initially admitted to
the SICU for close observation. He was trasnferred to [**Hospital Ward Name 121**] 10
once the fever defervesced and his blood pressure was more
stable.
He was changed to Meropenem for a 3 day course and then switched
to PO Cipro to discharge home. His blood cultures were no
growth, however his bile culture grew out Pseudomonas. He will
continue on the Cipro at home.
Medications on Admission:
finasteride 5 mg daily, folic acid 1 mg daily, gabapentin 300 mg
at bedtime, oxycodone 5 mg 1 to 2 q.4h., Colace 100 mg b.i.d.,
ursodiol 300 mg t.i.d., Lasix 80 mg daily, potassium chloride 20
mEq daily, metformin 500 mg twice a day, fexofenadine 60 mg
twice a day, Zeloda 1500mg [**Hospital1 **]. (held during hospitalization)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache/pain.
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
Discharge Condition:
good
Discharge Instructions:
please call the transplant office @ [**Telephone/Fax (1) 72722**] for fevers >
101.5, severe nausea, vomitting, pain, change in mental status
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-10-1**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-1**] 1:10
Please f/u with ERCP / GI team. call ([**Telephone/Fax (1) 2360**] for an
appointment
Completed by:[**2125-9-27**]
|
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68,905
| 104,312
|
46891
|
Discharge summary
|
report
|
Admission Date: [**2105-3-7**] Discharge Date: [**2105-3-20**]
Date of Birth: [**2035-12-6**] Sex: M
Service: MEDICINE
Allergies:
pseudoephedrine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3265**] is a 69y M with a history of C5/C7 injury 25 yrs ago
from a fall, who had a trach placed 3 years ago following a PNA
but is non-ventilator dependent living at home with 24 hr VNA,
who was found to be difficult to arouse by his VNA at 6 am this
morning. Per report by his wife, he had become increasingly
lethargic yesterday and was noted to have decreased urine output
(200cc for the day) despite pushing increased PO fluids. He has
a chronic indwelling foley catheter. He also had some nausea
and temp 99.7, but otherwise denies cough, shortness of breath,
URI symtpoms, emesis, diarrhea, abdominal pain. He was
vaccinated for flu this fall and had pneumovax 2 yrs ago. He is
followed by pulmonologist Dr. [**Last Name (STitle) **] at [**Hospital1 112**]. Of note he does
have a history of MRSA/klebsiella pna treated at [**Hospital1 112**]? as well as
UTI with citrobacter/ecoli/kleb/staph per record from [**Hospital1 882**].
.
This morning, when EMS arrived he was ambu-bagged and suctioned
at home then brought to [**Hospital 882**] hosp were he was noted to have
thick secretions and placed on vent via his trach, settings A/C
12, volume 450cc, FiO2 50%, 5 PEEP. He was noted to be hypoxic
and hypotensive to 81/50 and was resuscitated with 3L NS, which
improved his BP to 106/70. Chest X ray at [**Hospital1 882**] showed LLL
and RML pna. WBC was 18.9 and sodium was 118, urine na was 22.
Bld and urine cx were obtained. He was given levaquin and it
patient received flagyl. He was going to be transferred to [**Hospital1 112**],
but there were no ICU beds available so he was transferred to
[**Hospital1 18**] for ICU level care.
.
In the ED at [**Hospital1 18**] VS were 96.9 95/56 80 12 97% He was
alert and answering questions. He received 1 L IVF and 2 gm
cefepime. CXR showed right middle and lower lobe whiteout. Na
126 (improved from 118 at OSH).
.
On arrival to the ICU the patient's vent settings were: Pressure
support, 16/5, FI02 50%. Pt was alert and denied complaint.
.
ROS: As per HPI: Also denies history of cardiac problems, rash,
change in bowel habbits, muscle or joint pain, headache, vision
changes.
.
Past Medical History:
PUD
HL
SIADH
Hypothyroid
C5/C7 injury with resulting lower extremity paralysis
Aspiration pneumonia s.p trach placement in [**2102**]
MRSA/Klebsiella PNA
ESBL UTI
Social History:
Mr. [**Known lastname 3265**] is married with children. He lives at home in W
[**Location (un) 669**] with his wife and has 24 hr a day VNA care. He is
bedbound from his C5-C7 spinal cord injury but has movement of
his left hand and minimal movement of his right hand, which is
fused. He used to work as a carpenter prior to the injury. He
denies smoking or etoh use.
Family History:
non contributory
Physical Exam:
On Admission:
VS: Temp: 98.3 BP: 119/51 HR: 69 RR: 17 95%b O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: rhonchorous breath sounds throughout lungs
CV: RR, difficult to appreciate heart sounds
ABD: distended ad tympanic abdomen, +b/s, no tenderness
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. o/5 strength in lower
extremities blaterally although able to move left toe minimally.
[**4-11**] RUE strength with fused hand, [**5-12**] left UE strength.
Pertinent Results:
OSH labs
WBC 18.9 - 95% neut
Na 118, K 3.7, Cl 83, Co2 28, BUN 15, Cr 0.36
Glucose 159
trop T 0.012, TSH 4.25, albumin 2.9, LFTs WNL, INR 1.1
.
UA hazy, small leuks, nitrite neg, Ket 15, [**12-27**] WBC, 3+
bacteria, 2+ mucus, 2 gran casts
.
urine Na 22, K 43, Cl 36
.
[**Hospital1 18**] Labs
[**2105-3-7**] 11:05AM WBC-18.9*# RBC-3.27* HGB-9.4*# HCT-27.8*#
MCV-85# MCH-28.8 MCHC-33.8 RDW-14.8
[**2105-3-7**] 11:05AM NEUTS-93.6* LYMPHS-2.0* MONOS-3.8 EOS-0.4
BASOS-0.1
[**2105-3-7**] 11:05AM PLT COUNT-290
[**2105-3-7**] 11:05AM PT-14.2* PTT-31.0 INR(PT)-1.2*
[**2105-3-7**] 11:05AM GLUCOSE-113* UREA N-11 CREAT-0.2* SODIUM-126*
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-20* ANION GAP-13
[**2105-3-7**] 11:25AM GLUCOSE-116* LACTATE-1.0 K+-3.5
[**2105-3-7**] 11:25AM TYPE-ART RATES-/12 TIDAL VOL-450 PEEP-5
PO2-110* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0 -ASSIST/CON
INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2105-3-7**] 11:20PM URINE HOURS-RANDOM CREAT-48 SODIUM-10
POTASSIUM-65 CHLORIDE-82
[**2105-3-7**] 11:20PM URINE OSMOLAL-561
[**2105-3-7**] 11:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2105-3-7**] 11:05AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2105-3-7**] 11:05AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
.
Micro:
Urine cx: GNR>100,000
Pleural fluid:
[**2105-3-9**] 07:01PM PLEURAL WBC-475* RBC-2140* Polys-98* Lymphs-0
Monos-2*
[**2105-3-9**] 07:01PM PLEURAL TotProt-4.4 Glucose-46 LD(LDH)-1286
No PMNs or organisms on Gram stain
.
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
[**Hospital1 18**] LABS
MICRO:
urine cx - >100,000 GNR
[**Hospital1 **] cx - NGTD
.
STUDIES/IMAGING:
EKG: NSR 96 bpm, nml axis, 1st degree AV block, no ST changes
.
CXR: [**3-7**]
IMPRESSION: Right mid and lower lung opacification, concerning
for
consolidation, pneumonia and or atelectasis, and effusion.
Followup to
resolution.
.
[**2105-3-14**] sputum: PSEUDOMONAS AERUGINOSA
STENOTROPHOMONAS (XANTHOMONAS) MALTOPH
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
[**2105-3-7**] sputum: PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS (XANTHOMONAS)
MALTOPH
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 8 S 4 S 2 S
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ 8 I <=1 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- 0.5 S 0.5 S
PIPERACILLIN/TAZO----- 32 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
LEGIONELLA CULTURE (Final [**2105-3-14**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
[**2105-3-7**] urine:
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
69M with history significant for C5-C7 spinal injury bed bound
with trach and chronic foley who presented to OSH with altered
mental status, low urine output, hypotension, and was found to
have right and lower lobe infiltrates on CXR and development of
loculated pleural effusion, on pressure-support ventilation.
.
# Right and Middle lobe PNA: Patient with chronic trach, placed
on pressure support ventilation on admission. CXR showed absence
of right heart border and diaphragmatic border with interstitial
opacity concerning for pneumonia versus collapsed lung. Given
pt lives at home with no recent hospitalizations he was covered
for CAP however due to history of MRSA PNA, as well ESBL UTI
empirically covered with vancomycin and meropenem. Sputum
culture with GNRs and returned with pseudomonas and
stenotrophomonas. The pseudomonas was resistant to meropenem but
susceptible to ciprofloxacin. He should receive a 15 day course
of ciprofloxacin (day [**5-22**]). In regards to stenotrophomonas the
patient was started on bactrim (day [**7-22**]) and should receive a
15 day course of that medication as well.
.
#. Pleural effusion: Evidence of loculation on chest-x-ray and
CT scan. He had an U/S guided pigtail catheter insertion which
did not drain well. Labs were consistent with exudative effusion
with pH of 6.85 and elevated LDH of 1228. He underwent VATs with
2 chest tubes placed. The chest tubes were eventually
discontinued and pleural fluid was without growth.
.
# UTI: Pt has remote history of ESBL in urine and currently has
chronic indwelling foley catheter. Foley was changed at OSH. UA
from OSH with 100,000 gram negative rods, speciated to E. coli,
resistance to quinolones and Bactrim, sensitive to the penems.
Urine culture on admission to [**Hospital1 **] with >100,000 of speciated
E.coli, with sensitivity profile similar to [**Hospital1 882**] cultures.
He will be treated with a 14 day course of meropenem (day
[**1-21**]).
.
# Hypoxic respiratory failure: The patient had a chronic trach
at home although did not require ventilation. Upon presentation
he required mechanical ventilation for respiratory support. With
treatment of infection, aggressive chest PT with
insuflator/exsuflator we were able to wean to trach collar
during day with mechanical ventilation overnight at pressure
support [**6-11**], FiO2 40%. His SaO2 are 86-88 at baseline per
report. He did develop acute hypoxemia which was secondary to
mucous plug. This improved with chest physical therapy and
suctioning.
.
# Hypotension: Initially related to hypovolemia. The patient had
intermittent hypotension which was thought to be secondary to
decreased salt intake and autonomic dysregulation. HCT remained
relatively stable. The patient was started on salt tabs with
improved [**Month/Day (1) **] pressure. The patient remained asymptomatic even
during periods of relative hypotension. [**Name2 (NI) **] cultures remained
negative.
.
# L DVT: Unclear [**Name2 (NI) 99474**]. The patient was started on heparin
gtt for 48 hours without dropping hct. Switched to lovenox 60mg
[**Hospital1 **] while bridged to warfarin. INR currently subtherapeutic.
Will need monitoring and titration or warfarin dosing.
.
# L hip pain and displaced femoral neck fracture: Ortho
following. Hip fx old from 4-5 years ago but pt having increased
pain concerning for acute process such as displacement or
infection. Ortho evaluated and recommended pain management
without further imaging at this time.
.
# Anemia: Patient has normocytic anemia. Transfused s/p VATS and
slowly trending down. Guaiac negative. Likely anemia of chronic
disease.
.
# S/P C5-C7 spinal cord injury: continued neurontin, bisacodyl
suppositories, colace, senakot, lactulose, will add enemas prn
constipation, ditropan. He has a baclofen pump which will need
to be refilled prior to [**2105-4-3**]. This will need to be done
through [**Hospital1 112**] pain clinic.
Medications on Admission:
Medications at home:
ASA 81mg
Levothyroxine 75mcg
Prilosecmg
artifical tears to both eye TID
neurontin 400mg TID
bisacodyl 10mg PR every other day and prn (with bowel
stimulation)
Flonase spray to each nostril Qday
Colace 6 tabs every other PM with dinner
senakot 6 tabs every other PM with dinner
valium 5mg HS
ditropan 10mg XL qday
Nystatin poweder TID prn yeast infection
Ambien 5mg HS
Xenoderm ointment QID to pressure sore
baclofen pump
miralax 17g in 8 oz water every other day
Hydrocortisone 1% to penis prn rash
MV qday
Mortrin 200mg prn pain
Tyelnol 500mg 1-2 tabs prn pain
Preparation H prn
Metamucil Fiber Wafer 9-12g PO every other day
.
Medications at transfer:
Vancomycin 1000 mg IV Q 8H
Magnesium Sulfate IV Sliding Scale
Potassium Phosphate Replacement (Oncology) IV Sliding Scale
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Insulin SC (per Insulin Flowsheet) Sliding Scale
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
Docusate Sodium (Liquid) 600 mg PO/NG EVERY OTHER DAY
in PM, hold for loose stool
Multivitamins 1 TAB PO/NG DAILY liquid
Hydrocortisone Cream 1% 1 Appl TP [**Hospital1 **]:PRN
Polyethylene Glycol 17 g PO/NG EVERY OTHER DAY:PRN constipation
Miconazole Powder 2% 1 Appl TP TID:PRN yeast infection
Oxybutynin 5 mg PO BID
Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Diazepam 5 mg PO/NG HS hold for sedation, rr<12
Senna 6 TAB PO/NG EVERY OTHER DAY constipation
give in PM, hold for loose stool
Fluticasone Propionate NASAL 2 SPRY NU DAILY
one spray in each nostril= 2 sprays total/day
Bisacodyl 10 mg PR EVERY OTHER DAY
hold for loose stool [**3-8**] @ 1430 View
Gabapentin 400 mg PO/NG TID
Artificial Tears 1-2 DROP BOTH EYES TID [**3-8**] @ 1430 View
Azithromycin 250 mg IV Q24H
Acetaminophen 650 mg PO/NG Q6H:PRN fever
Meropenem 500 mg IV Q6H
Heparin 5000 UNIT SC TID
Bisacodyl 10 mg PR HS:PRN constipation
Levothyroxine Sodium 75 mcg PO/NG DAILY
Aspirin 81 mg PO/NG DAILY
Discharge Medications:
1. levothyroxine 75 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
2. bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. acetaminophen 650 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**2-8**]
Drops Ophthalmic TID (3 times a day).
5. gabapentin 400 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO TID (3
times a day).
6. fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Day (2) **]: Two (2)
Spray Nasal DAILY (Daily).
7. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day) as needed for constipation.
8. diazepam 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime).
9. zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. oxybutynin chloride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
11. polyethylene glycol 3350 17 gram/dose Powder [**Month/Day (2) **]: One (1)
PO EVERY OTHER DAY (Every Other Day) as needed for constipation.
12. therapeutic multivitamin Liquid [**Month/Day (2) **]: One (1) Tablet PO
DAILY (Daily).
13. docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: 600mg PO EVERY OTHER
DAY (Every Other Day).
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. glucagon (human recombinant) 1 mg Recon Soln [**Last Name (STitle) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
16. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane TID (3 times a day).
17. baclofen Intrathecal
18. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12hrs
on 12 hrs off.
21. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
22. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Hospital1 **]:
Fifty (50) ML PO TID (3 times a day).
23. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for rash.
24. sodium chloride 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
25. ciprofloxacin 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q12H
(every 12 hours).
26. warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at
4 PM.
27. enoxaparin 60 mg/0.6 mL Syringe [**Hospital1 **]: 60mg Subcutaneous Q12H
(every 12 hours).
28. acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Three (3) ML
Miscellaneous Q2H (every 2 hours) as needed for mucous plug.
29. meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
30. dextrose 50% in water (D50W) Syringe [**Hospital1 **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
32. 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.
33. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia, empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with a pneumonia. You were also found to have
a urinary tract infection. You were started on meropenem,
ciprofloxacin and bactrim. These antibiotics will need to be
continued (as described below). During your hospitalization you
had a video assisted thorascopy and bronchoscopy to evaluate
your respiratory status. The VATs helped drain a pulmonary
effusion. The bronchoscopy was for a mucous plug. Your
respiratory status improved and you were on trach collar during
the day and requiring pressure support [**6-11**], FiO2 40% overnight.
You were discharged to a long term acute care unit for further
weaning of your ventilation and continued antiobiotics.
.
You are on day [**1-21**] of meropenem. Day [**7-22**] of bactrim. Cipro
day [**5-22**]. These should be continued for the rest of the course.
.
You will need to have a follow up appointment with [**Hospital1 112**] pain
clinic for a baclofen pump refill. This will need to be done
prior to [**2105-4-3**] when your baclofen pump will run out. It is
very improtant that you make this appointment.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2105-4-28**] 9:30 [**Hospital1 **] 116
Get a chest xray 30 minutes prior to your followup on [**Location (un) 470**]
clinical center.
.
[**Hospital1 112**] pain clinic for refill of baclofen pump. This needs to be
done prior to [**2105-4-3**].
|
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icd9cm
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17448, 18524
|
11431, 13389
|
3119, 3119
|
6929, 7435
|
236, 246
|
318, 2494
|
3133, 3724
|
17328, 17424
|
2516, 2680
|
2696, 3070
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,274
| 117,430
|
3827
|
Discharge summary
|
report
|
Admission Date: [**2129-5-23**] Discharge Date: [**2129-6-22**]
Date of Birth: [**2093-5-18**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Common bile duct dilation, ERCP Perforation
Major Surgical or Invasive Procedure:
[**2129-5-23**] Endoscopic Retrograde Cholangiopancreatography
[**2129-5-24**] Exploratory laparotomy, debridement retroperitoneum,
kocherization of the duodenum and washout.
[**2129-6-5**] 1. Exploratory laparotomy. 2. Retroperitoneal
debridement.
3. Temporary abdominal closure.
[**2129-6-8**] Abdominal washout and closure.
History of Present Illness:
The patient is a 35F previously known to Dr[**Name (NI) 1369**] service in
evaluation prior to potential surgical resection of a
choledochal cyst. She was admitted today for an ERCP to further
characterized this lesion. A 4 CM type I choledochal cyst was
seen and, following a sphincterotomy, brushings and bipsy
samples
were taken from within the cyst. Post-procedure, she complained
of severe abdominal pain and there was concern for perforation
or other procedure-related complication such as pancreatitis.
She was admitted on the [**Hospital Ward Name 516**] and a CT scan obtained which
did demonstrate some evidence of a contained retroperitoneal
perforation with a small fluid collection.
In briefly reviewing her presentaion with the cyst itself, Ms.
[**Known lastname 16913**] undeerwent a left ovarian cyst excision with concomitant
D&C [**2129-4-20**], complicated by a portsite hematoma which required
evacuation [**2129-4-21**]. She resentd with recurrent abdominal pain
initiall thought to be PID. However, review of a CT obtained in
evaluation showed no evidence of pelvic pathology, but did
demonstrate a choledochal cyst. She endorses intermittent RUQ
and
epigastric pain with radiation to the right back, which she
prior to her recent surgery. The pain is worsened by eating and
improves slightly with ambulation. She denies nausea or
vomiting. Reports passing flatus and patient continues to stool
without difficulty and denies hematemesis, melena, BRBPR,
fevers, chills,
or rigors.
Past Medical History:
PMH: denies
PSH: Wisdom Teeth, D&C, left ovarian cystectomy and evacuation
of
hematoma-[**3-/2129**]
Social History:
Works in a lawyer's office, lives with daughter and husband.
Denies alcohol, tobacco, or illicit drug use. Immigrated from
[**Location (un) 6847**].
Family History:
Father with prostate cancer. Mother with hypertension. Denies
family history of biliary disease.
Physical Exam:
Vitals: Tm 98.1 76 113/70 18 99%RA UOP not recorded
Somnolent and in obvious pain when aroused
S1S2 no murmurs
decreased BS throughout
Abd soft and diffusely tender with redound and guarding
extremities without edema
Pertinent Results:
Labs on admission:
WBC-6.9 Hct-39.6 MCV-88 Plt-321
PT-12.8 PTT-33.1 INR-1.1
UreaN-10 Creat-0.6 Na-141 K-4.1 Cl-104
ALT-4 AST-19 AlkPhos-43 Amylase-52 TotBili-0.3 DirBili-0.1
IndBili-0.2
Lipase-40
.
Labs on discharge:
[**2129-6-16**] 01:12PM BLOOD WBC-12.8* RBC-3.45* Hgb-9.8* Hct-30.3*
MCV-88 MCH-28.6 MCHC-32.5 RDW-16.0* Plt Ct-563*
[**2129-6-6**] 12:06AM BLOOD Fibrino-900*
[**2129-6-21**] 05:50AM BLOOD Glucose-115* UreaN-17 Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
[**2129-6-19**] 12:40PM BLOOD ALT-15 AST-23 AlkPhos-127* TotBili-0.2
[**2129-6-17**] 05:42AM BLOOD Lipase-110*
[**2129-6-21**] 05:50AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
[**2129-6-10**] 04:53AM BLOOD Triglyc-294*
[**2129-5-26**] 08:26AM BLOOD PTH-179*
[**2129-6-3**] 05:49AM BLOOD Vanco-16.1
.
AMPULLA BIOPSY [**2129-5-23**]: Scant strips of superficial biliary
type mucosa, no evidence of malignancy.
KUB [**2129-5-23**]: No evidence of perforation with normal bowel gas
pattern
KUB [**2129-6-21**]: Findings suggestive of ileus, unchanged from
[**2129-6-16**].
ERCP [**2129-5-23**]:
- Normal major papilla
- Contrast medium was injected resulting in complete
opacification
- Severe diffuse dilation seen at the biliary tree
- CBD measuring 4 cm
- Sphincterotomy performed
- Cold forceps biopsies were performed for histology at the
Inta-ampullary bile duct
- Cytology samples were obtained for histology using a brush in
the biliary
- Excellent drainage of bile and contrast noted
- Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Mrs. [**Known lastname 16913**] is a 36 year old female who presents after
undergoing an diagnostic ERCP on [**2129-5-23**] for a type 1 choledochal
cyst complicated by a questionable perforated duodenum vs. ERCP
pancreatitis with subsequent RP phlegmon. She was initially
admitted for an ERCP to biopsy a 4cm type I choledochal cyst;
following a sphincterotomy, brushings and biopsy samples were
taken from within the cyst. Immediately after the procedure, the
pt developed diffuse abdominal pain and findings concerning for
perforation. She was admitted for IVF, abxs and pain control,
undergoing a CT scan abdomen later in the day which showed
evidence of a contained perforation. She was washed out in the
operating room on [**2129-5-24**], was transferred to the floor, and was
doing well. She was eating but her WBC was rising. CT showed a
large RP phlegmon. She kept eating and was on abx. She then
spiked a temperature to 102 on prior to her repeat washout on
[**6-3**], dropped her hct, received 2u PRBC, and developed
peritoneal signs. She was taken to the OR for exlap, debridement
of RP, and washout with pulse lavage on [**6-3**]. Multiple drains
were placed, and her abdomen was left open; pt was left
intubated and paralyzed s/p 2nd ex-lap. Abdomen was closed on
[**6-8**] with drains left in place; patient was extubated and
transferred to the regular floor.
.
Pt was initially covered on Daptomycin and Meropenem until [**6-16**];
final tissue and blood cultures negative. PICC line was placed
during admission, removed prior to discharge. Nutritional status
was suboptimal during admission and patient received TPN; this
was discontinued on day prior to discharge and PO intake was
encouraged. Pt's pain was well controlled on PO dilaudid prior
to discharge. Pt was tolerating regular PO diet, ambulating and
passing flatus and stool without difficulty prior to discharge.
Physical therapy worked with patient and cleared her for home.
Multiple KUBs revealed no evidence of obstruction or free air in
the abdomen. Surgical staples were removed prior to discharge.
Pt is being discharged home with VNA services to monitor
surgical incision and GI function, assess nutritional intake and
monitor for weight loss.
Medications on Admission:
Ibuprofen prn
Oxycodone prn
Acetaminophen prn
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn: every
8 hours: no more than 3000mg per day.
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
choledochal cyst
hemorrhagic pancreatitis
Retroperitoneal phlegmon and necrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Location (un) 932**] Visiting Nurse services have been arranged. They will
call you to set up a home visit.
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever (101 or greater), chills, nausea, vomiting, inability to
eat or drink, increased abdominal pain or distension, incision
redness/bleeding/drainage
You may shower
Please do not remove steri-strips; they will come off on their
own
No heavy lifting (no heavier than 10 pounds)/straining
No driving while taking pain medications
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2129-7-7**] at 1:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2129-8-17**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17194**], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
|
[
"789.59",
"576.8",
"038.9",
"E870.0",
"276.3",
"780.1",
"E878.8",
"567.29",
"998.2",
"309.9",
"569.83",
"577.0",
"459.0",
"998.59",
"790.01",
"995.91",
"557.0",
"567.82",
"567.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.72",
"51.85",
"51.14",
"93.59",
"54.25",
"54.62",
"83.39",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7240, 7303
|
4413, 6643
|
346, 675
|
7427, 7427
|
2873, 2878
|
8147, 8803
|
2521, 2619
|
6739, 7217
|
7324, 7406
|
6669, 6716
|
7578, 8124
|
2634, 2854
|
263, 308
|
3093, 4390
|
703, 2214
|
2892, 3074
|
7442, 7554
|
2236, 2339
|
2355, 2505
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,400
| 183,993
|
38627
|
Discharge summary
|
report
|
Admission Date: [**2102-3-28**] Discharge Date: [**2102-4-6**]
Date of Birth: [**2045-5-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Thoracic back pain and numbness and tingling of the thighs
Major Surgical or Invasive Procedure:
T7/8 Vertebrectomy
T5-11 Posterior Fusion
History of Present Illness:
56 yo M who was in his usual state of health until 5 weeks ago
he began to have new onset thoracic back pain. It was localized
and sharp and did not radiate to his legs or groin, it was not
associated with shortness of breath or palpitations. There was
no history of trauma and at his PCP plain films and blood work
were un revealing. 2 weeks ago he underwent an L-spine MRI
because the pain had worsened and he was beginning to have mild
tingling and numbness of his thighs. These images were not
concerning for cord compression or nerve entrapment but did
reveal some bony abnormalities so he returned for a CT of the
chest/abdomen/pelvis last Thursday. These images revealed
several bony lesions in the T spine with ? of compression
fracture at T5/T6. Over this past weekend he had worsening
numbness and difficulty walking, but no bowel/bladder
incontinence. His PCP urged him to present to the ED today on
seeing him in follow up and reviewing his films. Neurosurgery
was consulted given his acute onset of lower extremity symptoms
and concern for thoracic cord compression.
Past Medical History:
Car accident 3 years ago without injury
tonsillectomy as a child
Social History:
Works at a golf course, denies tobacco, 1-2 drinks ETOH / day
Family History:
Brother-Leukemia
Physical Exam:
ON ADMISSION:
O: T:98 BP:174/100 HR:76 R 18 O2Sats: 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4->3mm b/l EOMs: intact b/l, lateral gaze
nystagmus
Neck: Supple, no LND
Lungs: Left lower lung field rhonchi, otherwise clear
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.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Decreased sensation to light touch, temperature and
vibration BELOW T6 (xiphoid) vertebral level. Proprioception
absent from lower extremities. No 2 point descrim below T6.
ABOVE T6 has full sensation, two point discrimination, light
touch and temperature all intact.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 3
Left 2 2 2 3 3
Toes mute bilaterally.
Rectal exam: normal sphincter control, normal tone
Gait: ataxic and wide based, Romberg with profound instability
ON DISCHARGE:
awake and alert to person, place, and date, EOM's full, PERRL
bilaterally, face symmetric, tongue midline, no drift, strength
[**4-19**] in all extremities, decreased sensation below level of T6
although much improved since admission.
Pertinent Results:
MRI THORACIC SPINE [**2102-3-28**]:
1. Aggressive appearing invasive process, likely representing an
extramedullary, extradural bony neoplasm originating which
involves vertebral bodies of T6 through T9. At T7/T8 the lesion
involves both the vertebral bodies and the posterior elements
and encases the spinal cord causing complete effacement of the
thecal sac and extrinsic epidural compression of the spinal
cord. There is no signal abnormality within the spinal cord
indicating that this is a slowly developing process.
2. This most likely represents metastatic disease, much less
likely primary bone tumor or infectious origin like TB.
3. Pathologic vertebral body fractures at T7 and T8 without
evidence of
retropulsed bony fragments.
4. Hyperintense lesion in the left lower lobe which might
represent a lung
mass, pneumonia or atelectasis. Further workup with dedicated
chest CT should be considered if clinically indicated.
CT TORSO [**2102-3-28**]:
1. Large centrally necrotic left lower lobe lung mass, with
numerous adjacent satellite nodules compatible with primary lung
cancer with lymphangitic spread. Additional pulmonary nodules
identified in the left upper lobe measure up to 4 mm, and there
is a sub-3-mm nodule in the right upper lobe.
2. Extensive bony metastases, involving the T3, T6 through T9,
and L5
vertebral bodies. There is associated soft tissue component
extending into
the spinal canal and compressing the thecal sac tt T7-8, as
better
characterized on recent MRI.
3. Left adrenal adenoma.
4. Indeterminate hypodense lesions within the right kidney and
liver,
incompletely characterized on this single phase study, may
represent benign cysts, though additional metastatic disease is
not excluded.
5. Healed posterior rib fractures on the left.
Brief Hospital Course:
He was admitted to neurosurgery for surgical planning. On [**3-28**]
CT of the Chest, Abdomen, and Pelvis were obtained which
ultimately showed multiple pulmonary nodules bilaterally with
the largest being on the left. On [**3-29**] it was decided that he
would undergo surgery with Dr. [**Last Name (STitle) 548**] for a T7-8 vertebrectomy
and T2-11 fusion on [**3-30**]. Neuro-oncology, radiation oncology,
and medical oncology were all consulted to see the patient. His
exam remained stable prior to surgery with decreased sensation
to light touch below the T6 sensory level at the xiphoid process
and inability to distinguish proprioception in bilateral lower
extremities.
He went to the OR on [**3-31**] for a LECA T7-8 and fusion T5-11.
Although he had a 4 L blood loss during the case, he tolerated
the procedure well. A JP was left in place for drainage of
excessive bleeding. His pain was well controlled through the
weekend. He was OOB with PT on POD #2, but was very unsteady.
The patient continued to work with PT on [**4-3**] and his JP was
still draining a large amount. On [**4-4**] his JP was pulled and
steri strips were placed.Staples in incision clean dry and
intact. He was out of bed with PT and was still unsteady on his
feet. It was noticed that his hematocrit was 20.7. he was
trasnfused 2 units of packed red blood cells and his hematocrit
raised to 27.3. Orthostatic blood pressures were also obtained
which were normal. CXRs showed slowly resolving LLL patchy
infiltrate. PT/OT recommended him for rehab. He has scheduled
follow up for future oncological care determination [**2102-4-10**] at
9:30am with Dr. [**Last Name (STitle) 724**] at [**Hospital **] clinic.
Medications on Admission:
None
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: [**12-17**]
Injection ASDIR (AS DIRECTED): while on decadron.
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).
4. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
while on decadron.
Discharge Disposition:
Extended Care
Facility:
=
Discharge Diagnosis:
Thoracic Spine and lung lesions
spinal instability
post op blood loss anemai requiring transfusion
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:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/begin daily showers [**4-6**]
?????? Keep your incision dry until your staples are removed
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? If you are required to wear one, wear cervical collar
or back brace as instructed
?????? You may shower briefly without the collar / back brace
unless instructed otherwise
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR
STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
[**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2102-4-10**] 9:30. His
office is located on the [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] building on
the [**Location (un) **]
Completed by:[**2102-4-6**]
|
[
"401.9",
"788.29",
"733.13",
"162.5",
"336.3",
"198.5",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"03.53",
"81.63",
"81.05",
"99.79",
"81.04",
"80.51"
] |
icd9pcs
|
[
[
[]
]
] |
7568, 7596
|
4959, 6664
|
377, 421
|
7738, 7738
|
3158, 4936
|
9419, 9962
|
1715, 1733
|
6719, 7545
|
7617, 7717
|
6690, 6696
|
7920, 9396
|
1748, 1748
|
2903, 3139
|
279, 339
|
449, 1531
|
1762, 2062
|
7753, 7896
|
1553, 1620
|
1636, 1699
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,907
| 172,980
|
3471
|
Discharge summary
|
report
|
Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-4**]
Date of Birth: [**2076-12-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 49 year old gentleman with a history of EtOH
abuse, cervical DJD, and multiple psych issues admitted for EtOH
intoxication and fall.He was s/p elective Anterior/posterior
decompression and fusion C3-7 for chronic neck pain and arm pain
on [**2-28**] referred to surgery after failed conservative therapy.
The patient reportedly had a witnessed fall on the street and
EMS was called. A bottle of benzodiazepines were reportedly
found on scene by EMS. The patient was reportedly seen earlier
in the day at [**Hospital1 2177**] for overdose of unknown substance, however his
tox screen at [**Hospital1 **] was positive for cocaine. He does not remember
when he last took cocaine. He thinks that his last drink was [**12-1**]
pint liquor the day after his surgery. It is unclear if he
experienced LOC as he is a poor historian. His last admission
for EtOH intoxication was in [**5-/2125**] and required admission to
the [**Hospital Unit Name 153**], however following his neck surgery he was noted to be
confused, thought to be withdrawing from alcohol and placed on
CIWA. He was also seen taking his home ativan and required 1:1
sitter with d/c inhouse narcotics.
.
In the [**Hospital1 18**] ED, VS 97 104 122/80 20 97%RA. The patient received
diazepam 15mg,ativa 2mg, haldol total 15mg, folate, thiamine. CT
Spine/head showed no acute fracture or intracranial abnormality.
Ortho spine was consulted and said prevertebral edema on CT
likely represents postoperative changes but given new fall
history, will need to continue c-collar for now. Transferred to
the MICU given altered mental status, anticipated difficult
intubation if it were needed.
.
In ICU pt placed on CIWA scale requiring valium x 3 for
agitation. Also noted to be tachycardic [**1-1**] hypovolemia/pain.
Received IVF with mild improvement tachycardia.
.
On arrival to floor pt endorsing mild neck pain and mild sore
throat.
.
Past Medical History:
Substance Abuse
EtOH abuse - no history of withdrawl seizures or DTs.
Cervical DJD
s/p Spinal fusion C3-C7 [**2126-2-28**]
Bipolar disorder
PTSD
Social History:
Lives in [**Location 8391**]. On SSDI for bipolar disorder. EtOH as
HPI. Tobacco - [**12-1**] ppd (1/2-2ppd x 30 years). Denies IV,
illicit, or herbal drug use.
Family History:
NC
Physical Exam:
Exam on admission:
General: agitated appearing man, no acute distress
HEENT: Perrl, sclerae anicteric, MMM, OP clear without lesions,
exudate or erythema. Cervical collar in place.
CV: Nl S1+S2
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: No C/c/e
Neuro: disoriented, unable to answer questions or follow
commands
.
Exam on d/c
VS:Tc: 98.1 HR: 95 BP: 130/90 RR:20 96% RA
General: mild gurgling on vocalization.
HEENT: Perrl, Sclerae anicteric, MMM, OP clear without lesions,
exudate or erythema. Cervical collar in place.
4 follicular lesions in background of erythema at nape of neck
at edge of cervical collar,non tender, non pruritic
CV: Nl S1+S2
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: No C/c/e
Neuro: AOX3, able to follow commands.
Pertinent Results:
ADMISSION LABS:
[**2126-3-2**] 03:00AM GLUCOSE-93 UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
[**2126-3-2**] 03:00AM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.8
[**2126-3-2**] 03:00AM OSMOLAL-285
[**2126-3-2**] 03:00AM WBC-8.2 RBC-3.26* HGB-10.4* HCT-30.8* MCV-94
MCH-31.9 MCHC-33.8 RDW-15.0
[**2126-3-2**] 03:00AM PLT COUNT-529*
[**2126-3-1**] 08:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2126-3-1**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2126-3-1**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2126-3-1**] 07:50PM GLUCOSE-84 UREA N-12 CREAT-0.6 SODIUM-138
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-19
[**2126-3-1**] 07:50PM ASA-NEG ETHANOL-34* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2126-3-1**] 07:50PM WBC-9.5 RBC-3.41 HGB-10.9 HCT-32.0* MCV-94
MCH-31.9 MCHC-33.9 RDW-15.3
[**2126-3-1**] 07:50PM NEUTS-85.6* LYMPHS-9.6* MONOS-3.5 EOS-1.2
BASOS-0.1
[**2126-3-1**] 07:50PM PLT COUNT-536
.
[**2126-3-1**] CT HEAD: No acute fracture/hemorrhage; chronic nasal
deformity
.
[**2126-3-1**] CT SPINE: No fracture or malalignment. Prevertebral soft
tissue thickening; may be postoperative but no post-op
comparisons, and could instead represent softtissue swelling if
there is concern for ligamentous injury. Multilevel degenerative
change and post-operative appearance of anterior-posterior upper
C-spine fusion. Sub-cm locule gas adjacent right SCM muscle at
level of thyroid cartilage unclear significance. Atherosclerotic
calcs of great vessels, chronic. D/W Dr. [**Last Name (STitle) **] in ED.
.
[**2126-3-1**] CXR:
CHEST AP
Cardiac size is normal. The lung fields are clear. The
costophrenic angles
are sharp. Note is made of a fusion within the cervical spine.
IMPRESSION: Normal chest.
Brief Hospital Course:
Mr. [**Known lastname **] is a 49 year old gentleman with a PMH significant for
cervical DJD and EtOH abuse, discharged [**2126-2-28**] after cervical
spinal fusion admitted in the setting of witnessed fall and
polysusbstance abuse.
# Altered Mental Status: This was likely related to
polysubstance abuse. He was found by EMS with altered mental
status with an empty pill bottle at his side. Urine and serum
toxicology were positive for ethanol, benzodiazapines and
cocaine. He was admitted to the ICU given the potential for a
difficult intubation if needed, given his recent neck surgery.
He did not require intubation, and his sensorium cleared. He
required valium on a CIWA scale, but no longer required valium
by the time he transferred to the floor. He did have a history
of hallucinations and blackouts on withdrawing from alcohol, and
he was started on thiamine and folate. During his
hospitalization he briefly refused to wear his neck brace.He was
seen by the psychiatry service to evaluate competency and he was
deemed competent to make this decision. He then decided to
comply with wearing the neck brace.
.
# s/p Fall: This was likely related to polysubstance abuse. He
was found by EMS with altered mental status with an empty pill
bottle at his side. Urine and serum toxicology were positive for
ethanol, benzodiazapines and cocaine. The patient had recently
had C3-C7 fusion ([**2126-2-25**]). He was seen by the ortho spine
service, and the determination was made that he had no acute
fracture, but should continue to wear a heard collar until he
was seen by orthopedics for follow up as an outpatient. His pain
was controlled initially with tylenol, ultram and flexoril.
Oxycodone was eventually reintroduced and he was discharged on
the same dose recommended by orthopedics following his C3-C7
fusion.
.
Polysubstance Abuse: The patient has a history of alcohol,
cocaine and narcotic abuse. He engaged in extreme drug seeking
behavior during his hospitalization, including throwing himself
on the floor in order to obtain higher doses of narcotic
medications. He was discharged on the same dose recommended in
the post surgical period by his orthopedic surgeon. He was seen
by social work and routed to an outpatient addictions support
facility.
.
? Bipolar d/o, anxiety d/o: The patient was seen by psychiatry.
They felt that it was difficult to evaluate the patient's
reports of anxiety disorder or bipolar disorder in face of his
active substance abuse. He endorsed worsening of his anxiety and
moderate weight loss. He should have a TSH checked as an
outpatient with further work up of this complaint in the
outpatient setting.
Medications on Admission:
Medications (Discharge Meds [**2126-2-28**]):
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day:
please do not drink alcohol or perform activities that require
fast reaction time. [**Month (only) 116**] cause sedation.
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for prn constipation.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
11. Oxycodone 5 mg Capsule Sig: [**12-1**] Capsules PO every three
hours as needed for pain: please do not drink alcohol or perform
activities that require a fast reaction time while taking this
medication. [**Month (only) 116**] cause sedation. .
Disp:*80 Capsule(s)* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Altered mental status
Substance abuse.
.
Secondary
Cervical DJD
s/p Spinal fusion C3-C7 [**2126-2-28**]
Bipolar disorder
PTSD
Discharge Condition:
alert and oriented to person, place and time.
Fully ambulatory.
Discharge Instructions:
You were admitted to the hospital because you had suffered a
fall in the setting of overdosing on drugs and alcohol. You went
to the intensive care unit for concern that you would need a
breathing tube. You did not need a breathing tube and your
mental status cleared.
.
The following changes were made to your medications.
We ADDED
folate 1mg daily
thiamine 100mg daily
.
You can continue to take oxycodone 5-10mg every three hours as
needed for pain. You have sufficient supply to last you until
your doctor's appointment on Friday.
.
Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
.
Rehabilitation/ Physical Therapy:
2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
.
Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed. You should continue to
use this brace until you see Dr [**Last Name (STitle) **] in clinic and he gives
you further instructions.
Followup Instructions:
Primary Care Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 15989**] [**Name (STitle) **]
[**Hospital1 15990**], MA
friday [**2126-3-8**]
9:15 am
tel:[**Telephone/Fax (1) 8236**]
.
Orthopedics:
Dr. [**Last Name (STitle) 363**]
[**Name (STitle) 23**] 2, Orthopedics
[**Hospital Ward Name 516**]
[**Hospital1 18**]
[**2126-3-13**] 1pm
[**Telephone/Fax (1) 3573**]
|
[
"293.0",
"276.2",
"721.0",
"305.90",
"291.81",
"303.00",
"309.81",
"276.52",
"V45.4",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10281, 10287
|
5381, 5625
|
336, 342
|
10465, 10531
|
3420, 3420
|
11903, 12284
|
2660, 2664
|
8841, 10258
|
10308, 10444
|
8062, 8818
|
10557, 11302
|
2679, 2684
|
11320, 11880
|
275, 298
|
370, 2295
|
4579, 5358
|
3436, 4570
|
2699, 3401
|
5640, 8036
|
2317, 2464
|
2480, 2644
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,450
| 147,724
|
37713
|
Discharge summary
|
report
|
Admission Date: [**2191-9-20**] Discharge Date: [**2191-9-27**]
Date of Birth: [**2141-11-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Coffee ground emesis and melena
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
49M with PMHx significant for ESLD secondary to hepatitis C and
EtOH abuse who presents from [**Hospital1 1501**] with history of vomitting dark
fluid this am, reports he has been vomitting black for
approximately 2 days, also approximately a week of black stools.
Reports that he has had orthostatic dizziness also for
approximately 1 week, also feels more fatigued. Always has
chills, ?fevers 2 days ago. "Slight chest pain" spells. Patient
has known Grade 2 esophageal varices banded [**2191-6-29**] at [**Hospital1 1774**].
Patient was recently transfered from OSH and admitted [**Date range (1) 50550**]
with hepatic encephalopathy, hyponatremia, and hepatorenal
syndrome (in the setting of 12 L paracentesis). Patient was also
recently seen in clinic by Dr. [**First Name (STitle) **] on [**2191-9-13**] for follow up.
Per Dr.[**Name (NI) 28656**] clinic note, at that time patient did have a
peritoneal catheter in place which she requested be removed, and
per the patient this was done after he was seen by her.
Patient has h/o SBP requiring weekly taps & abx. Also previously
admitted to OSH for E. coli bacteremia secondary to SBP. Per
OMR, he was discharged from [**Hospital1 18**] on [**8-24**] on Cipro 250mg PO
daily; however, seen in clinic by Dr. [**First Name (STitle) **] on [**9-13**] and per her
notes he was not being given his Cipro at [**Hospital1 1501**], appears he did
not receive it after this visit as well. At [**Hospital1 1501**] [**9-20**] AM: T95,
WBC 37, INR 5.3.
Transplant status: patient had been evaluated at [**Hospital3 **]
for transplant, and was listed. Since then he had an ED visit at
[**Hospital6 19155**] on [**7-15**] that showed an alcohol level
of 16 (normal [**11-22**]), and he was removed from the transplant list.
This was confirmed with [**Hospital3 2358**] and [**Hospital3 12594**] during his last admission. Per Dr.[**Name (NI) 28656**] note, patient
and sister report that he was on cough syrup at that time, was
not abusing alcohol.
Review of systems is otherwise notable for thirst in patient.
Hasn't been hungry recently.
.
In the emergency department VS T 97, BP 91/40, HR 104, RR 14,
O2sat 99% 2L. Guaiac positive.
Recieved Vit K 5mg IV x1, 1L NS, Protonix 40mcg IV, Octreotide
gtt started at rate of 15mcg/hour. Central line placed.
EKG here w/minimal hyperK+ changes.
Past Medical History:
-HTN
-DM II
-ESLD
-Hep C
-Hepatorenal syndrome after large volume paracentesis
-H/o hepatic encephalopathy, per OMR was admitted to [**Hospital3 **]
[**Date range (1) 84505**] for ascites/HE with a serum ammonia of > 300,
was intubated [**12-20**] respiratory depression
-EGD from [**7-15**] showed esophagitis, grade II varices
Meds at [**Hospital1 1501**]: Nadolol 20mg PO daily, MVI, Lactulose 30mL PO QID,
Aldactone 100 mg PO daily, Lasix 40 mg PO daily, Levemir 28U SQ
daily, Humalog S/S.
Social History:
SOCIAL HISTORY: Non smoker, was living in his own apartment
since earlier this year, had been in a nursing home since he was
last discharged from [**Hospital3 **] on [**2191-8-4**]. Denied current
alcohol use, described drinking occasionally several years ago.
Denied regular alcohol use. No history of transfusions, no
IVDU.
Per OMR notes, patient was not listed for transplant because of
+ blood alcohol level [**2191-7-15**] at OSH. Sister [**Name (NI) **] is HCP.
Family History:
Emphysema in father
Physical Exam:
On Admission to ICU:
T=95.9 BP=109/51 HR=100 RR=27 O2=94% RA
PHYSICAL EXAM
GENERAL: Pleasant, acute on chronically ill appearing male in
NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. Sclera
markedly icteric. PERRLA/EOMI. Mucous membranes slightly dry,
bright red blood visible in oropharynx. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTA anteriorly.
ABDOMEN: NABS. Distended. Shifting dullness. Mildly tender, no
rebound/guarding. Dressing in place from peritoneal catheter.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses
SKIN: Spider angiomata, jaundice, greyish coloring, no palmar
erythema detected
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. Gait assessment deferred. No clonus,
+asterixis, tongue fasicullations.
PSYCH: Listens and responds to questions appropriately, pleasant
On Transfer to Floor:
RR 10 HR 100
PHYSICAL EXAM
GENERAL: somnolent, ill appearing male in NAD, opens eyes
briefly when prompted but does not track eyes to voice
HEENT: Normocephalic, atraumatic. Sclera markedly icteric.
Mucous membranes slightly dry, nasogastric tube with blood and
yellowish residuals
Neck: Supple, Left Internal Jugular catheter
CARDIAC: Regular rhythm, rate 100. Normal S1, S2. Harsh early
systolic murmur heard loudest at upper sternal border
LUNGS: CTA anteriorly and laterally.
ABDOMEN: NABS. Distended. Diffusely tender (pt's face grimaced
slightly with palpation), Stitch in place in mid abdomen from
previously removed peritoneal catheter.
EXTREMITIES: No pedal edema, but patient has edematous hands, 2+
dorsalis pedis/ posterior tibial pulses
SKIN: Spider angiomata, very jaundiced
NEURO: somnolent, limited exam
Pertinent Results:
[**2191-9-20**] 03:10PM BLOOD WBC-36.0*# RBC-2.87* Hgb-10.4* Hct-29.9*
MCV-104* MCH-36.1* MCHC-34.7 RDW-19.2* Plt Ct-135*#
[**2191-9-20**] 09:36PM BLOOD WBC-37.1* RBC-2.44* Hgb-8.9* Hct-25.6*
MCV-105* MCH-36.4* MCHC-34.7 RDW-19.4* Plt Ct-139*
[**2191-9-21**] 07:48AM BLOOD WBC-35.9* RBC-2.29* Hgb-8.1* Hct-24.6*
MCV-107* MCH-35.2* MCHC-32.8 RDW-19.0* Plt Ct-137*
[**2191-9-21**] 09:44PM BLOOD Hct-21.8*
[**2191-9-22**] 05:00PM BLOOD WBC-19.5* RBC-2.83* Hgb-9.3* Hct-27.5*
MCV-97 MCH-33.0* MCHC-34.0 RDW-21.4* Plt Ct-58*
[**2191-9-23**] 09:52PM BLOOD Hct-20.1*
[**2191-9-24**] 10:15PM BLOOD Hct-26.4*
[**2191-9-26**] 03:15AM BLOOD WBC-19.7*# RBC-2.52* Hgb-8.8* Hct-24.8*
MCV-99* MCH-35.1* MCHC-35.7* RDW-21.6* Plt Ct-32*
[**2191-9-20**] 03:10PM BLOOD PT-41.2* PTT-52.4* INR(PT)-4.3*
[**2191-9-20**] 09:36PM BLOOD PT-26.1* PTT-40.0* INR(PT)-2.5*
[**2191-9-21**] 09:44PM BLOOD PT-43.7* PTT-59.5* INR(PT)-4.7*
[**2191-9-26**] 03:15AM BLOOD PT-36.3* PTT-56.3* INR(PT)-3.7*
[**2191-9-20**] 09:36PM BLOOD Fibrino-176
[**2191-9-21**] 02:57AM BLOOD Fibrino-152
[**2191-9-20**] 03:10PM BLOOD Glucose-93 UreaN-93* Creat-4.6*# Na-119*
K-6.0* Cl-84* HCO3-15* AnGap-26*
[**2191-9-20**] 09:36PM BLOOD Glucose-97 UreaN-92* Creat-4.2* Na-122*
K-5.7* Cl-91* HCO3-14* AnGap-23*
[**2191-9-23**] 04:38AM BLOOD Glucose-181* UreaN-119* Creat-5.6*
Na-130* K-3.5 Cl-95* HCO3-17* AnGap-22*
[**2191-9-24**] 01:40PM BLOOD Creat-4.5* K-3.6 HCO3-18*
[**2191-9-26**] 03:15AM BLOOD Glucose-226* UreaN-142* Creat-5.4* Na-142
K-3.6 Cl-104 HCO3-17* AnGap-25*
[**2191-9-20**] 03:10PM BLOOD Albumin-2.3* Calcium-6.8* Phos-8.3*#
Mg-2.2
[**2191-9-26**] 03:15AM BLOOD Calcium-7.0* Phos-9.5* Mg-3.0*
[**2191-9-20**] 03:00PM BLOOD Ammonia-39
[**2191-9-20**] 10:03PM BLOOD Type-[**Last Name (un) **] pH-7.24*
[**2191-9-21**] 07:53AM BLOOD Type-[**Last Name (un) **] pO2-59* pCO2-33* pH-7.21*
calTCO2-14* Base XS--13
[**2191-9-26**] 12:24PM BLOOD Type-[**Last Name (un) **] Temp-36.0 pO2-50* pCO2-30*
pH-7.32* calTCO2-16* Base XS--9 Intubat-NOT INTUBA
[**2191-9-20**] 05:22PM BLOOD Lactate-6.8*
[**2191-9-21**] 06:42PM BLOOD Lactate-5.0*
[**2191-9-22**] 04:07AM BLOOD Lactate-2.9*
[**2191-9-26**] 12:24PM BLOOD Lactate-2.3*
[**2191-9-20**] 10:03PM BLOOD freeCa-0.79*
[**2191-9-22**] 04:07AM BLOOD freeCa-1.00*
Radiology Report PORTABLE ABDOMEN Study Date of [**2191-9-20**] 7:42 PM
FINDINGS: There is an about 7 cm measuring large bowel loop
transversing the
midline in the inferior abdomen. There is diffuse haziness of
the abdomen
secondary to ascites. There is no evidence of small bowel
obstruction or free
air.
IMPRESSION: There is diffuse ascites. There is no evidence of
small bowel
obstruction or free air.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2191-9-20**]
11:44 PM
FINDINGS: In comparison with the study of [**8-21**], there is
continued low lung
volume. The elevation of the lateral aspect of the right
hemidiaphragm is no
longer seen. Basilar opacification bilaterally most likely
represents
atelectasis. If there are appropriate clinical findings,
developing
consolidation would have to be considered.
Radiology Report CT PELVIS W/O CONTRAST Study Date of [**2191-9-21**]
4:55 AM
IMPRESSION:
1. Diffuse mild bowel wall thickening is likely secondary to
third spacing
in the setting of large volume ascites and anasarca. However,
more irregular
wall thickening in the transverse colon is noted and ischemia is
not excluded,
though evaluation is limited without contrast.
2. Cirrhosis with evidence of portal hypertension including
splenomegaly.
Distal esophageal wall thickening likely represents varices,
though evaluation
is limited without contrast.
3. Bibasilar lung consolidations are only partially imaged and
while they may
represent atelectasis, they are incompletely evaluated, as are
small pleural
effusion.
4. Gastric distention, with contrast passing through into
nonobstructed loops
of small bowel.
5. Nonobstructing small bilateral renal calculi.
Brief Hospital Course:
Patient was a 49 year old man with past medical history
significant for end-stage liver disease secondary to hepatitis C
and alcohol abuse who presented with sepsis in addition to
coffee ground emesis and melena, admitted directly to the
medical intensive care unit. The patient had multiple problems
during his MICU stay including encephalopathy, GI bleed, and
sepsis from possible SBP and endocarditis. In the setting of
multi-system organ failure with very poor prognosis and the
patient not being a liver transplant candidate, the health care
proxy decided to make the patient [**Name (NI) 9036**] Measures Only on
[**2191-9-26**] after conversation with the medical intensive care team
and the hepatology team.
# Sepsis:
Patient presented with tachycardia, significantly elevated WBC
count, tachypnea, and elevated lactate, likely in the setting of
tissue hypoperfusion. He had not reported any fevers and was
afebrile on presentation. Labs from the skilled nursing
facility on the day of admission showed WBC count 37 with 14%
bands, and labs from the ED showed an elevated WBC to 36. The
most likely source of his sepsis was initially thought to be SBP
given that patient had peritoneal catheter in place until
recently and was not on SBP prophylaxis. He was started on
empiric antibiotic treatment in the ED due to the very elevated
WBC count. The patient was empirically treated with Vancomycin
and Zosyn in the ICU, given exposures from recent
hospitalization and having been in the skilled nursing facility.
Right upper quadrant ultrasound showed nodular cirrhotic liver
with patent portal and hepatic venous systems in addition to
large-volume ascites. Diagnostic paracentesis was not done in
the ED because of elevated INR, but paracentesis was done in the
ICU, showing WBC of [**Numeric Identifier **] with 93% PMNs.
Blood cultures from admission grew out Staph Aureus, and
vegetation was noted on the posterior mitral leaflet by
transthoracic echocardiogram. Transesophageal echocardiogram
was not done because it would not have changed management. The
patient was started on high dose nafcillin for MSSA bacteremia.
Zosyn was discontinued.
#. GI bleed:
In the setting of elevated INR, the patient had potential to be
bleeding anywhere along the GI tract but there was concern for
variceal bleed and high suspicion for slow upper GI bleed, given
coffee grown emesis and melanotic stool. He had been
experiencing orthostatic symptoms for several days. His
hematocrit was roughly at baseline on presentation; it had
ranged in the high 20s during previous hospitalizations. The
patient was placed on and octreotide drip and intravenous
protonix twice daily, and an NG tube was placed. The patient
was transfused 1 units of pRBCs on two occasions during his ICU
stay for dropping Hct below 21.
.
#Hyperkalemia:
The patient had significantly elevated potassium on admission,
but EKG showed no evidence of cardiac instability secondary to
hyperkalemia. The patient was given calcium gluconate for
cardiac membrane stabilization and kayexalate to decrease
potassium level.
#Metabolic Acidosis:
Patient had significantly elevated lactate of 6.8 on arrival to
ED, which trended down to 6.1 on admission to ICU. His lactic
acidosis was most likely secondary to tissue hypoperfusion
secondary to sepsis, though there was some concern for possible
bowel ischemia. KUB showed no evidence of free air to indicate
bowel perforation. A non-contrast CT of his abdomen showed some
irregular wall thickening of his colon, which could not exclude
bowel ischemia, but the study was limited without contrast.
.
# Acute Renal Failure and Oliguria:
Patient had an increased bladder pressure of 22 on admission to
ICU, indicating that the increased abdominal pressure likely
contributed to renal failure via renal artery compression.
Renal failure likely also had a prerenal element secondary to
poor PO intake and intravascular volume loss secondary to GI
bleeding. He may have also had some aspect of hepatorenal
syndrome in the setting of acutely worsening end-stage liver
disease. The therapeutic paracentesis should have also relieved
some pressure on the renal arteries. He was also having
increased phosphate and started on phosphate-binders. The
patient was being followed by the Renal team and was considered
for hemodialysis, though it was felt that hemodialysis could not
solve his multi-organ failure. After the meeting with his
sister [**Name (NI) **], who is his Health Care Proxy, on [**2191-9-26**], the
patient was placed on [**Date Range 9036**] Measures Only.
#.Coagulopathy:
Patient's INR was elevated to 4.3 on admission, significantly
higher than his baseline though improved from 5.3 at skilled
nursing facility prior to sending him to the ED. It was
initially decreased to 2.5 with 4 units of FFP in the ICU. The
elevated INR may represent worsening synthetic function of his
liver and acute worsening of his chronic ESLD. It may also have
had a component of malnutrition as patient reported poor
appetite recently. His fibrinogen level was normal, so DIC was
felt to be very unlikely.
#ESLD:
Patient was being worked up for transplant per Dr.[**Name (NI) 28656**] clinic
notes. MELD score He was supposed to see a social worker on
[**10-7**] to further evaluate suitability for transplant. His
spironolactone and lasix were held in the setting of hypotension
on admission. His albumin was 2.3 on admission, significantly
decreased from baseline, likely representing synthetic
dysfunction of the liver. He was given albumin with the
paracentesis procedure in the ICU.
# Altered Mental Status:
The patient was becoming increasing encephalopathic by [**2191-9-22**]
and somnolent, though arousable. His encephalopathy was likely
multifactorial, secondary to endstage liver disease in addition
to uremia and possibly also his other metabolic abnormalities.
The patient had also presented with hyponatremia which improved
by the time of transfer to the floor. Patient was started on
[**Last Name (LF) 8005**], [**First Name3 (LF) **] Hepatology recommendations, during his ICU stay.
# [**First Name3 (LF) **] MEASURES:
Patient was confirmed to be Full Code on admission. On
[**2191-9-26**], the patient's sister met with the medical intensivist
team in addition to the hepatology team and social worker and
together decided that his multi-system organ failure was too
much to overcome. The patient was placed on [**Date Range 9036**] Measures
Only and transferred to the general medicine floor. All of his
antibiotics and other medications were stopped. He was placed on
a morphine drip for [**Date Range **] but was only requiring 1-2mg/hr due
to degree of encephalopathy. He was started on a scopolamine
patch for increased secretions on [**2191-9-27**] and passed away
around 3pm on the same day. His family was contact[**Name (NI) **] prior to
his passing but preferred not to be present. His sister and
[**Name2 (NI) 802**] did come to visit after his passing to say goodbye. A
postmortem was not obtained
.
# FEN/PPX:
The patient was kept NPO in the setting of GI bleed. He was
hypocalcemic on admission, so his calcium was being repleted as
needed. He was kept on pneumoboots for DVT prophylaxis, and he
was maintained on his home lactulose.
# ACCESS: PIV's, Right femoral line
# COMMUNICATION: Sister [**Name (NI) **] (HCP), #[**Telephone/Fax (1) 84506**]
Medications on Admission:
- Ciprofloxacin - 250 mg Tablet - prescribed but was not being
given to him at home
- Furosemide - 40 mg Tablet daily
- Insulin Glargine [Lantus] (100 unit/mL Solution)
28 units at bedtime
- Insulin Lispro [Humalog] (100 unit/mL Solution)
2 - 8 units per sliding scale Solution(s) four times a day
Starting at glucose 150 give 2 u SC insulin; for every 50
additional points of glucose, give 2 additional units.
- Lactulose (10 gram/15 mL Solution)
30 mL by mouth four times a day Hold for >5BMs/day
- Nadolol - 20 mg Tablet daily
- Spironolactone - 100 mg Tablet
- Multivitamin,Tx-Minerals daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Cirrhosis
Secondary Diagnoses:
Septic shock
Acute on Chronic Renal Failure
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
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"996.69",
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"421.0",
"275.41",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
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9597, 15220
|
349, 363
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17843, 17853
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278, 311
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391, 2724
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17744, 17755
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15235, 17016
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2746, 3241
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3273, 3730
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,889
| 102,621
|
3627
|
Discharge summary
|
report
|
Admission Date: [**2149-11-17**] Discharge Date: [**2149-11-21**]
Date of Birth: [**2080-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Hemodialysis tunnelled line placement
History of Present Illness:
69 yo male with severe PVD, DMI, CVA, CHF (EF >55%), COPD, CKD
and h/o rectal CA (treated with palliative radiation) who
presents with cough and fever. Cough has been progressing over
the past week minimally productive of white sputum. He developed
fever to 100 at home, with chills, therefore came to the ED. He
denies subjective SOB but his wife reports that he has been
tachypneic especially when lying flat. He denies PND, orthopnea,
or LE edema. He denies any chest pain, chest tightness or
palpitations. He has chronically a poor appetite, +
fatigue/malaise at baseline (up to 20 hours sleep/night for
months-years). Chronic diarrhea (?due to pancreatic insuff),
controlled with immodium/lipram. +Occasional blood in stool, no
melena. +Frequency for "months"; no dysuria, urgency. He denies
sick contacts or recent travel. At baseline pt is wheelchair
bound.
Past Medical History:
1. Ischemic colitis [**2-8**], s/p ex lap and rigid sigmoidoscopy
without evidence of ischemic bowel.
2. PVD: s/p right popliteal to dorsalis pedis bypass and left
femoral-popliteal and popliteal-anterior tibial bypass, R CEA,
and right SFA stent.
3. Type I Diabetes mellitus - brittle diabetic; episodes of
severe hypoglycemia and DKA
4. Status post CVA >10 yrs ago.
5. History of CHF with preserved EF
6. COPD- no PFTs in system
7. Hypertension
8. Glaucoma
9. CKD-baseline cr 2.1-2.4 (Cr clearance of 25-30, stage 4)is
preparing for PD with Dr. [**First Name (STitle) 805**] at [**Last Name (un) **]
10. h/o Duodenal ulcer but on EGD above not seen
11. Anemia of chronic disease.
12. Esophageal dysmotility.
13. h/o VRE UTI
14. Rectal CA-dx [**2148**] no surgery due to comorbidities; s/p
palliative XRT
Social History:
Lives with his wife. [**Name (NI) **] smoked for >50yrs at most 2ppd. Remote
heavy EtOH use in past (3+ drinks per day), quit 2-3 years ago.
No recreational drug use. Used to work in greenhouse supply
business, then sold real estate now disabled.
Family History:
Mother colon cancer. Father throat cancer,
brother died of colon cancer at age 62.
Physical Exam:
Gen- Sleeping in bed, mildly tachypnic.
VS: 98.3, 118/80, 75, 24, 93% 2L
HEENT- EOMI. R facial droop (old per pt). MM Dry.
Hrt- RRR. [**1-13**] SM at RLSB.
Lungs- [**Month (only) **] at R base, crackles, rhonchi R lung. Scattered exp
wheezes.
Abd- +BS, NT, ND, no palpable masses
Extrem- No c/c/e.
Pertinent Results:
[**11-17**] Renal US: RENAL ULTRASOUND: Comparison is made with the
prior ultrasound dated [**2149-6-25**]. The right kidney measures
10.7 cm, the left kidney measures 11.2 cm, without evidence of
hydronephrosis, mass, or stone.
.
[**11-17**]: CXR: AP AND LATERAL CHEST: There is consolidation in the
right lower lobe consistent with pneumonia. The heart and
mediastinal contours are normal. The left lung is clear,
although there is underlying hyperinflation. No pleural
effusions or pneumothoraces are seen.
IMPRESSION: Consolidation in the right lower lobe is consistent
with
pneumonia. Follow up radiographs should be obtained to document
resolution.
.
[**11-17**]: CT Chest w/o contrast: IMPRESSION:
1. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**].
2. Extensive soft tissue in the bronchus of the right lower
lobe, with post-
obstructive consolidation in the right lower lobe with effusion,
increased
since prior study dated [**2149-1-8**]. The endobronchial soft
tissue measures
30-40 [**Doctor Last Name **], and can represent protein-[**Doctor First Name **] mucus secretions.
However, in this
patient with history of heavy smoking and history of rectal
cancer, underlying
mass lesion such as primary lung cancer or less likely
endobronchial
metastasis cannot be totally excluded. Bronchoscopy is
recommended.
3. Increased bilateral extensive peribronchial opacities,
probably related to
infectious or inflammatory condition.
4. Unchanged dilated upper esophagus.
5. Extensive coronary artery calcification.
6. Unchanged low dense nodules in the thyroid gland.
.
[**2149-11-17**] 05:05PM URINE HOURS-RANDOM SODIUM-41 POTASSIUM-26
CHLORIDE-21 TOTAL CO2-LESS THAN
[**2149-11-17**] 05:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2149-11-17**] 05:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2149-11-17**] 05:05PM URINE RBC-[**2-9**]* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-[**2-9**] TRANS EPI-0-2
[**2149-11-17**] 03:50PM GLUCOSE-254* UREA N-69* CREAT-5.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-14* ANION GAP-19
[**2149-11-17**] 03:50PM CALCIUM-7.5* PHOSPHATE-9.8*# MAGNESIUM-2.3
[**2149-11-17**] 12:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2149-11-17**] 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2149-11-17**] 12:15PM URINE GRANULAR-0-2
[**2149-11-17**] 06:25AM GLUCOSE-139* UREA N-71* CREAT-5.4*#
SODIUM-136 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-12* ANION
GAP-24*
[**2149-11-17**] 06:25AM estGFR-Using this
[**2149-11-17**] 06:25AM proBNP-[**Numeric Identifier 16483**]*
[**2149-11-17**] 06:25AM WBC-8.7 RBC-3.49* HGB-10.6* HCT-31.8* MCV-91
MCH-30.4 MCHC-33.4 RDW-14.2
[**2149-11-17**] 06:25AM NEUTS-78.1* LYMPHS-10.5* MONOS-6.3 EOS-4.8*
BASOS-0.3
[**2149-11-17**] 06:25AM HYPOCHROM-1+
[**2149-11-17**] 06:25AM PLT COUNT-565*
[**2149-11-17**] 06:20AM LACTATE-0.9
Brief Hospital Course:
69 yo male with Type I DM, CKD-ARF, colorectal CA, new R lung
mass, COPD, CHF w/preserved EF who presents with SOB, cough and
fever.
.
#. Hyperglycemia: Pt w/Type I DM, w/known epsiodes of severe
hypoglycemia and DKA. Multifactorial process to account for
uncontrolled BS-inadequate insulin coverage per ED as well as
infectious process. No ketones in urine. Pt was treated with
Insulin gtt and then transitioned to sc insulin once anion gap
was closed. He was hydrated appropriately. [**Last Name (un) **] was consulted
and help with management. His insulin regimen was changed to NPH
12U QAM and 3U of HUmalog with meals in addition to a sliding
scale.
.
#. ARF: Pt w/CKD due to longstanding Type I DM, now w/Cr 5.6 up
from baseline 2.1-2.4. Significant acidemia in setting of
worsening renal failure. Renal team was consulted. Renal U/S
normal, no postobstructive etiology to account for worsening
renal failure. No recent dye load or change in meds. Pt was
given Bicarbonate. Tunnelled cath was placed per Renal to
prepare for possible CVVH vs HD if becomes fluid overloaded
w/current management of hyperglycemia and worsening acidemia.
The patients ARF improved and he never required HD, therefore
tunneled line was pulled on the day of discharge. ACE-I was held
in the context of ARF on CRF.
.
#. Respiratory: New O2 requirement in setting of new R lung
mass, post obstructive PNA. Received 2 doses of levoflox and
flagyl per ED and floor team. Also h/o CHF w/preserved EF-no
current evidence of volume overload. In fact, appears
hypovolemic.
Pt was continued on Levo and will have to complete a 10 day
course. D/c flagyl. Pt contiuned to improve over next days and
had no more O2 reuirement on the day of discharge. The patient
will need a bronchoscopy for tissue dx of new mass as an
outpatient. Cultures of sputum were unrevealing.
.
#. UTI: Initial UA contaminant followed by +UA, Urine culture
negative. Continue coverage w/levofloxacin.
.
#. HTN: Pt well controlled on home regimen. ACE-I were held in
the setting of ARF on CRF. Pt was continued on short acting BB,
Hydralazine. Amlodipine was held initially because of concern
for early sepsis but was restarted before discharge. ACE-I
should be considered again once renal function stable.
.
#. Anemia- baseline Hct is 28/pt currently at baseline. Takes
iron, folate, MVI at home, however, iron studies in the past
have been normal and folate has consistantly been >20. Anemia
likely [**1-9**] chronic disease, CRF (low epo); may have an element
of chronic blood loss due to rectal CA/trace blood in stool. Pt
was continued on supplements and Procrit TIW.
.
# Pancreatic insufficiency- continued Lipram w/meals.
.
# FEN- Diabetic diet. Swallow consult suggested PO diet of thin
liquids and soft consistency solids. Small single sips of thin
liquid and aspiration precuations.
.
# PPX- pneumoboots, PPI, hep sc
.
Code-full
Medications on Admission:
Hydralazine 50mg qd
Metoprolol 50mg [**Hospital1 **]
Insulin NPH 12 qam with Regular 14 qam with occasional night
dose
Amlodipine 5mg qd
Lisinopril 10mg qhs
Omeprazole 20mg qd
Iron
Imodium 1 tab qHS
Lasix 40mg qd
Lipram 4500 2 caps AC
?Phoslo
MVI
Folate
Hectorol 0.5 mg [**Hospital1 **]
Neurontin 100 mg qAM, 200mg qhs
Flaxseed Oil 1000 [**Hospital1 **]
Discharge Medications:
1. Lipram-PN16 Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO before meals ().
2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days: Please take two hours apart from iron
tablets.
Disp:*3 Tablet(s)* Refills:*0*
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*200 Capsule(s)* Refills:*2*
12. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*7 Patch 24HR(s)* Refills:*0*
13. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
14. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig:
Twelve (12) Units Subcutaneous QAM.
Disp:*qs Units* Refills:*2*
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: ASDIR
Subcutaneous ASDIR: per sliding scale.
Disp:*qs qs* Refills:*2*
16. Insulin Lispro (Human) 300 unit/3 mL Insulin Pen Sig: Three
(3) U Subcutaneous TID/with meals.
Disp:*qs qs* Refills:*2*
17. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
18. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes Ketoacidosis
Diabetes mellitus type I
Postobstructive pneumonia
Urinary tract infection
Acute renal failure
Chronic renal failure
Congestive heart failure
Discharge Condition:
Good, no oxygen requirement, good po intake
Discharge Instructions:
You were diagnosed with a postobstructive pneumonia, acute on
chronic renal failure and diabetes ketoacidosis. A mass was
found in your lung on CT scan. You will need to be evaluated for
that as an outpatient. We have arranged follow up for you as
below.
.
Please notify your physicians or come to the emergency room if
you notice any shortness of breath, chest pain, blood in your
sputum, abdominal pain, blood glucose > 400 or any other
concerns.
Followup Instructions:
You have the following appointments scheduled for you:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-12-4**] 10:15
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2149-12-9**] 9:30
.
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2149-12-9**] 10:00
Completed by:[**2149-12-4**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
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[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,920
| 146,643
|
28978
|
Discharge summary
|
report
|
Admission Date: [**2108-9-23**] Discharge Date: [**2108-10-2**]
Date of Birth: [**2039-1-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cefepime
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Abdominal distension and shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis
Paracentesis
History of Present Illness:
69 year old woman with primary sclerosing cholangitis with
cirrhosis (decompensated with ascites, hydrothorax, and
encephalopathy) who presents from rehab facility with 4/4 GNR in
blood.
She was recently admitted with worsening abdominal distension
and shortness of breath (like from increased ascites). She had
several issues that should be considered seperately:
.
1. CXR showed a RLL opacity that was concerning for pneumonia.
Found to have Klebsiella pneumoniae bacteremia, and completed a
2 week course of Cefepime and Bactrim (sensitive to both). Her
course ended [**8-31**]. Repeat blood cultures on [**8-28**] were negative.
She then spiked to 102.4 on [**9-7**] and was pancultured. She was
started back on vancomycin and cefepime. Her cultures then grew
out 4/4 bottles of VRE (unknown source). She was started on
daptomycin and developed a drug rash that was ultimately
determined (by conference with ID, derm and liver) to be related
to cefepime. She was discharged to complete a course on [**2108-9-23**]
and to resume GNR prophylaxis with ciprofloxacin 500mg daily (ID
wanted to start this given her large ascites)
.
2. She is s/p chest tube placement and removal for massive
pleural effusion.
.
3.She had a LGI bleed from external hemorrhoids on [**9-4**] and had
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and EGD which showed grade 3 varices. She got 2 units of
blood and remained stable.
.
She presents today with symptoms that recapitulate the excellent
dc summary from [**Hospital **] rehab. Namely, she was discharged to the
[**Hospital1 100**] MACU for rehab and to complete the course of her
daptomycin. Since then she was seen in daycare ofr a 4 para
w/albumin on [**9-20**]. On [**9-22**], she spiked to 102.0. Blood cultures,
CXR and UA/UCx were ordered in a reflexive fever workuup. A CXR
demonstrated a RUL and LLL infiltrate with persistent bilateral
effsuions, worse than those evaluated on [**9-15**]. On [**9-24**] bcx
came back postive for GNR. Urine was positive for 2 types of GNR
with 10 and 20K colonies. She had a WBC of 8.8, HCT 25.5, plt
163; Na 138, K 5.0, CO 20, cr 0.7 and bun of 24. She was given
20mg of IV lasix with nebulizers with 500 cc of UOP. A decision
was made to transfer. With stable vital signs, she was
transferred to [**Hospital1 18**] for a thorough evaluation. Much of which
was undertaken by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital1 18**] ED.
.
In the ED, Ms. [**Known lastname 69849**] VS were: 98 76 122/50 24 95on4L. By my
evaluation, these were 123/63, 93, 26, 97on4l. She received a
CXR that revealed, as above, new opacity in RUL, effusions as
before. A dx para was negative for SBP. And her labs, below,
were within her baseline. she received 1g of meropenem at 5:30
and two PIV's were placed.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, headache, congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.
Past Medical History:
* Primary sclerosing cholangitis: complicated by ascites,
hydrothorax, encephalopathy, portal vein thrombosis
* Common bile duct stricture s/p hepatojejunostomy ([**2104**])
* Diabetes mellitus
* Invasive ductal carcinoma on the right breast (~[**2104**]), s/p
Femara 2.5mg every other day and lumpectomy [**2107-11-13**] with
?recurrence. Portacath placed on left chest, never used for
chemo, recently removed. Managed at [**Hospital3 **]
* History of idiopathic thrombocytopenia
Social History:
Patient previously lived at home in [**Hospital1 **] with her husband,
[**Name (NI) **]. She recently went to rehab after her hospitalization in
late [**Month (only) 205**], with plans to return home soon. She was employed as a
nurse [**First Name (Titles) **] [**Last Name (Titles) 2025**]. Denies tobacco, alcohol, illicit drugs.
Family History:
non-contributory
Physical Exam:
VS: 98 76 122/50 24 95on4L.
at 6pm: 123/63, 93, 26, 97on4l
GEN: Comfortable, NAD, AAOx3 appears older than her stated age
HEENT: Anicteric, EOMI
CV: Normal rate, regular rhythm. Normal S1 and S2. 2/6 SEM
murmurs. No rubs, or gallops.
PUL: diffuse rales, r> L, bibasilar and RUL. not cleared with
cough
ABD: Soft, non-distended. non-tender to palpation, feels
pressure, no hepatosplenomegaly. Diffuse maculopapular rash
across her entire abdomen and back with increased confluence.
EXT: 2+ distal pulses bilaterally, 1+ pitting edema bilaterally
to midshin
SKIN: Thin, warm, dry.
Pertinent Results:
[**2108-9-23**] 03:00PM BLOOD WBC-5.8 RBC-2.56* Hgb-8.1* Hct-25.4*
MCV-100* MCH-31.8 MCHC-32.0 RDW-16.0* Plt Ct-153
[**2108-9-30**] 05:13AM BLOOD WBC-4.8 RBC-2.48* Hgb-8.0* Hct-24.8*
MCV-100* MCH-32.2* MCHC-32.2 RDW-15.5 Plt Ct-162
[**2108-9-23**] 03:00PM BLOOD Neuts-78.9* Lymphs-8.9* Monos-4.0
Eos-7.4* Baso-0.7
[**2108-9-28**] 03:02AM BLOOD Neuts-71.7* Lymphs-10.1* Monos-3.0
Eos-14.7* Baso-0.5
[**2108-9-23**] 02:15PM BLOOD PT-13.8* PTT-26.7 INR(PT)-1.2*
[**2108-9-30**] 05:13AM BLOOD PT-13.3 PTT-28.1 INR(PT)-1.1
[**2108-9-23**] 02:15PM BLOOD Glucose-194* UreaN-30* Creat-0.7 Na-136
K-4.3 Cl-103 HCO3-20* AnGap-17
[**2108-9-30**] 05:13AM BLOOD Glucose-115* UreaN-27* Creat-0.6 Na-138
K-5.1 Cl-105 HCO3-27 AnGap-11
[**2108-9-23**] 02:15PM BLOOD ALT-46* AST-46* AlkPhos-174* TotBili-1.1
[**2108-9-30**] 05:13AM BLOOD ALT-53* AST-56* LD(LDH)-212 AlkPhos-194*
TotBili-0.8
[**2108-9-24**] 06:05AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8
[**2108-9-30**] 05:13AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.4 Mg-2.2
[**2108-9-27**] 03:27PM BLOOD Type-ART pO2-64* pCO2-54* pH-7.29*
calTCO2-27 Base XS--1 Comment-4L NC
[**2108-9-23**] 02:47PM BLOOD Lactate-1.6
.
[**2108-9-24**] 04:41PM PLEURAL WBC-156* RBC-5300* Polys-13* Lymphs-60*
Monos-22* Meso-5*
[**2108-9-24**] 04:41PM PLEURAL TotProt-0.8 Glucose-123 LD(LDH)-46
Albumin-LESS THAN Cholest-10 Triglyc-66
[**2108-9-23**] 04:40PM ASCITES WBC-66* RBC-600* Polys-4* Lymphs-40*
Monos-0 Atyps-1* Plasma-4* Mesothe-2* Macroph-49*
[**2108-9-23**] 04:40PM ASCITES TotPro-0.4 Glucose-202 Albumin-LESS
THAN
.
Blood, urine, and peritoneal cultures - all negative
.
CXR ([**9-23**]):
IMPRESSION: New right upper lobe opacity concerning for
infection. Large
right effusion and left basilar atelectasis.
.
CXR ([**9-29**]) - after 2 thoracenteses during hospitalization
Large right pleural effusion with almost white-out of the right
hemithorax is unchanged. Cardiomediastinal contours cannot be
evaluated. Small left pleural effusion with adjacent atelectasis
is stable. There is no evident pneumothorax. Left PICC remains
in place.
.
MRI/MRCP ([**9-27**]):
IMPRESSION: Limited study due to motion, patient unable to
cooperate, IV and oral contrast was not administrated.
.
1. Cirrhosis and segments of hepatic atrophy affecting the liver
with
fibrosis in keeping with patient's underlying primary sclerosing
cholangitis.
2. Similar degree of intrahepatic biliary duct dilatation. No
evidence to
suggest infected bile lakes.
3. Non-occlusive thrombus in the main portal vein, suboptimally
evaluated due to motion; however has not propagated into
occlusive thrombus in the interval.
4. Moderate right pleural effusion and atelectasis at the lung
bases.
5. Ascites, with interval increase in size compared to most
recent MRCP.
6. Splenomegaly.
Brief Hospital Course:
69 yo female with 69F with PSC cirrhosis, previously
decompensated by ascites, hydrothorax, and encephalopathy, with
rapidly recurring hepatic hydrothorax and Klebsiella bacteremia
and multi-GNR UTI, with suspected HCAP. Recent change in code
status to DNR/DNI
.
#. Goals of care: After two recurrences of her hepatic
hydrothorax and declining clinical state, we had many
discussions concerning Ms. [**Known lastname 69849**] goals of care. Palliative
Care also visited with the patient. The results of these
conversations are as follows: Her code status has been changed
to DNR/DNI and she does not want to undergo any more invasive
procedures to temporarily correct her shortness of breath.
Instead, we have prescribed her 2-6mg of morphine (liquid form)
as needed for her shortness of breath. She also does not want
to be re-admitted to the hospital should her condition worsen.
However, this discussion will need to occur upon her arrival to
the rehab center as well. Our palliative care service will be
in touch with their counterparts at [**Hospital 100**] rehab. All of her
medications have been reviewed and we have only given her those
that we feel will help her symptoms and make her comfortable.
We have touched base with her oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 116**], who will
be deciding if she should continue on her Femara while at rehab;
she is aware that the patient is being transferred to [**Hospital 100**]
Rehab today.
.
# Respiratory failure, secondary to pneumonia and hydrothorax -
CXR upon admission showed a possible infiltrate and she was
empirically covered for healthcare-associated pneumonia with
Vancomycin and Meropenem. The patient was initially breathing
comfortably on room air, but then decompensated with hypoxemia
to the mid 80s. CXR showed a recurrent right-sided hydrothorax
and a thoracentesis was performed in the ICU. Within hours,
this fluid had re-accumulated, but she was satting well on 2-3L
as was transferred back to the floor. It was determined by
[**Hospital 3585**] that she is not a candidate for TIPS due to her
portal vein thrombosis and declining condition. She should
continue on lasix 40mg + spironolactone 100mg for diuresis,
re-started here on [**9-25**] in the setting of improved hyponatremia.
.
# Klebsiella bacteremia - Blood cultures from [**Hospital 100**] rehab
showed a pansensitive Klebsiella, but she was kept on Meropenem,
given her history of VRE bacteremia. All surveillance cultures
done here at [**Hospital1 18**] have been negative to date. A MRI/MRCP was
done to locate any possible sources that were causing recurrent
GNR bacteremia, but did not show any bile lakes, biliary tree
abnormalities, or abscesses. She should continue on meropenem
until [**10-7**].
.
#. Diabetes mellitus: She was continued on her Lantus 8 units
qhs and NPH 20 units qAM with blood glucose relatively well
controlled in the 100s to 200s. Upon addressing her goals of
care, her insulin sliding scale and fingersticks were
discontinued.
.
#. Primary sclerosing cholangitis: Previously complicated by
ascites, hydrothorax, encephalopathy. We continued lactulose,
with titration to [**3-15**] bowel movements, and ursodiol.
.
# Breast Cancer: Her oncologist, Dr. [**First Name (STitle) 116**], will decide if she
should continue taking Femara, given her change in her goals of
care.
.
Follow-up after discharge
.
1) Please continue IV Meropenem 500mg q6h until [**10-7**]
2) [**Month (only) 116**] pull PICC after antibiotic course completed
3) Please re-discuss her DNR/DNI as well as "do not hospitalize"
wishes
4) Coordinate with Palliative Care team at [**Hospital 100**] rehab (contact
at [**Hospital1 18**] is Dr. [**First Name8 (NamePattern2) 11894**] [**Last Name (NamePattern1) 406**])
5) Supplemental O2 as needed
6) No lab draws necessary
7) Please re-confirm her follow-up appointments with PCP,
[**Name10 (NameIs) 3585**], and ID, as listed above.
Medications on Admission:
* Rifaximin 600 [**Hospital1 **]
* Furosemide 40mg daily (down from 80)
* Glimepiride 4mg twice daily
* Glargine 9 units qHS
* Insulin 70/30 20 units qAM
* Regular Insulin SS.
* Lactulose 15-30cc by mouth twice daily, titrate to [**4-16**] bowel
movements
* Prilosec 40mg daily
* Spironolactone 25 mg [**Hospital1 **] (down from 200 daily)
* Ursodiol 500mg twice daily
* Calcium Citrate - Vitamin D3 315-200 units, two tabs twice
daily
* Dapto 500 q24
*Clobetasol
* Benadryl 25 q6
*Lovenox 40 qPM
* Albuterol, Atrovent nebs
* Sucralfate 1 gm QID
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
6. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for sob, cough.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for sob, cough.
9. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO qother day ().
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
12. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID PRN () as needed for rectal discomfort.
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
14. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous qAM.
15. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours): Please give until [**10-7**].
16. Lantus 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
17. Morphine 10 mg/5 mL Solution Sig: [**1-15**] ml PO q3h as needed
for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnoses:
Recurrent hepatic hydrothorax
Klebsiella bacteremia
Klebsiella and Enterobacter urinary tract infection
Hospital-acquired pneumonia
.
Secondary diagnoses:
Primary sclerosing cholangitis cirrhosis
Breast cancer
Diabetes mellitus
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:
It was a pleasure treating you at the [**Hospital1 827**]. You were admitted to the hospital after you
spiked a fever at [**Hospital 100**] Rehab after taking antibiotics
following your prior visit. We found that you had an infection
in your blood and your urine and treated this appropriately with
antibiotics. You were also short of breath upon arrival and a
thoracentesis was done to take the fluids out of your lungs.
During your time here, you got very short of breath again and
needed to be moved the intensive care unit for a short time so
they could take more fluid from your lungs. We had a discussion
with you concerning what measures you would like us to take to
make you feel better and it was decided that we would do our
best not to do any invasive procedures and to not re-admit you
to the hos[ital should your condition worsen once again. We
recommended medications and extra oxygen to treat your shortness
of breath. You were discharged to [**Hospital 100**] Rehab and will likely
require supplemental oxygen while you are there.
We have made the following changes to your medications, to focus
on comfort and symptom relief:
START Meropenem 500mg IV every 6 hours, until [**10-7**]
START morphine liquid 2-6mg every 3 hours as needed for
shortness of breath
STOP Calcium carbonate
STOP vitamin D
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**]: [**10-4**] at 1:15pm. Phone: [**Telephone/Fax (1) 14655**],
Fax: [**Telephone/Fax (1) 66123**]
.
[**Telephone/Fax (1) 3585**] ([**Hospital1 18**]): [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 805**], NP: [**10-8**] at 10:00am, Phone
[**Telephone/Fax (1) 2422**]
.
[**Name6 (MD) 9462**] FLASH, MD (Infectious disease, [**Hospital1 18**])
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2108-10-9**] 9:30
|
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"486",
"280.0",
"571.5",
"V66.7",
"693.0",
"174.9",
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icd9cm
|
[
[
[]
]
] |
[
"54.91",
"34.91",
"38.93",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13944, 14010
|
7809, 11783
|
328, 357
|
14301, 14301
|
5014, 7786
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15825, 16361
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4379, 4397
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12381, 13921
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4412, 4995
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14205, 14280
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3242, 3508
|
244, 290
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385, 3223
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14316, 14455
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3530, 4013
|
4029, 4363
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,616
| 153,089
|
8718+55968
|
Discharge summary
|
report+addendum
|
Admission Date: [**2162-3-14**] Discharge Date: [**2162-3-22**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p Aortic valve replacement (23mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] epic porcine valve),
Coronary artery bypass graft x3 (Left internal mammary artery >
left anterior descending, saphenous vein graft > obtuse
marginal, saphenous vein graft > diagonal) [**2162-3-16**]
History of Present Illness:
[**Age over 90 **] year old male with shortness of breath increasing over last 6
months. Transferred from [**Hospital3 **] to OSH for hypoxia,
underwent cardiac workup that revealed coronary artery disease
and aortic stenosis.
Past Medical History:
Aortic stenosis, Hypertension, Gastroesophageal reflux disease,
Depression, Benign Prostate Hypertrophy, Spinal Stenosis, s/p
Hernia repair
Social History:
Widowed for 2 years. He lives independently at [**Location (un) 5481**] in
[**Last Name (un) 30506**]. He is very active in the [**Location (un) 5481**] community. He is
completely competent in his activities of daily living and still
drives a car. He has one son and one daughter, both of whom live
locally. The patient does not smoke and only occasionally drink
a little bit of wine.
Family History:
Non-contributory
Physical Exam:
VS: 68 113/87 70" 72.7kg
HEENT: EOMI, PERRL, NCAT wearing hearing aides
Pulm: CTAB with some wheezes
Cardiac: RRR w/ SEM
Abd: Soft, NT ND +BS
Ext: Warm. well-perfused, no edema
Neuro: A&O x 3, non-focal
Pertinent Results:
[**3-16**] Echo: Prebypass: 1.The left atrium is elongated. No atrial
septal defect is seen by 2D or color Doppler. 2.There is severe
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is mildly depressed (LVEF= 50 %). 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 aortic arch. 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. There is mild tricuspid
stenosis (area >1.5cm2). There is a small to moderate sized
pericardial effusion. Dr. [**Last Name (STitle) 1290**] was notified in person of
the results on [**2162-3-16**] at 930am. Post Bypass: 1. Patient is
being AV paced. 2. Anterior wall and anterior septum are
moderately depressed. 3. Bioprosthetic valve seen in the aortic
position. Leaflets move well and the valve appears well seated.
No aortic insufficiency present. 4. Aorta intact post
decannulation. 5. Mild mitral regurgitation present.
[**3-21**] CXR: Improved aeration bilaterally with decrease in
bilateral effusions. Left greater than right effusion and
retrocardiac atelectasis persist
[**2162-3-14**] 04:45PM BLOOD WBC-7.1 RBC-3.25* Hgb-10.3* Hct-29.4*
MCV-91 MCH-31.8 MCHC-35.0 RDW-14.6 Plt Ct-221
[**2162-3-20**] 08:00AM BLOOD WBC-7.2 RBC-2.60* Hgb-8.4* Hct-23.9*
MCV-92 MCH-32.1* MCHC-35.0 RDW-13.6 Plt Ct-138*
[**2162-3-14**] 04:45PM BLOOD PT-12.9 PTT-30.4 INR(PT)-1.1
[**2162-3-16**] 01:15PM BLOOD PT-14.5* PTT-41.6* INR(PT)-1.3*
[**2162-3-14**] 04:45PM BLOOD Glucose-93 UreaN-29* Creat-1.5* Na-140
K-4.1 Cl-105 HCO3-23 AnGap-16
[**2162-3-20**] 08:00AM BLOOD Glucose-102 UreaN-26* Creat-1.5* Na-136
K-3.5 Cl-99 HCO3-26 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 30507**] was admitted preoperatively for further workup and
was cleared for surgery. On [**3-16**] he was brought to the operating
room and underwent aortic valve replacement and coronary artery
bypass graft surgery. Please see operative report for further
details. Following surgery he was transferred to the CVICU for
invasive management in stable condition. Later on op day he was
weaned from sedation, awoke neurologically intact and extubated.
Unfortunately immediately after extubation he had respiratory
distress and was re-intubated. On post-op day one he was again
weaned from sedation and re-extubated. His IV gtts were weaned
off later this day and was started on beta blockers and
diuretics. He was gently diuresed towards his pre-op weight. On
post-op day two his chest tubes and epicardial pacing wired were
removed. He did appear to have some sundowning overnight on
post-op day three. On post-op day three he to be stable and was
transferred to the telemetry floor for further care. He required
a sitter not only for sundowning at night, but for safety
reasons secondary to fall precaution. On post-op day five he had
a single episode of atrial fibrillation that was appropriately
treated and converted back to sinus rhythm. Due to the risk of
anticoagulation, and after a discussion with Dr. [**Last Name (STitle) 3503**]
(covering for pt's cardiologist, Dr. [**Last Name (STitle) 30508**], it was decided
that he will not be anticoagulated for this. He otherwise
continued to make a steady recovery and on post-op day six was
discharged to rehab facility with the appropriate medications
and follow-up appointments.
Medications on Admission:
Metoprolol 37.5 mg PO BID
Pantoprazole 40 mg PO Q24H
Hydrochlorothiazide 12.5 mg PO DAILY
Docusate Sodium 100 mg PO BID
traZODONE 12.5 mg PO HS:PRN
Heparin 5000 UNIT SC BID
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr 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).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Coronary artery disease s/p CABG
Aortic stenosis s/p AVR
Post-op Atrial Fibrillation
PMH: Hypertension, Gastroesophageal reflux disease, Depression,
Benign Prostate Hypertrophy, Spinal Stenosis, s/p Hernia repair
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**Last Name (Prefixes) 30509**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr [**Last Name (STitle) 5482**] [**Telephone/Fax (1) 5483**] please call for appointment
Dr [**Last Name (STitle) 30508**] in 1 weeks - please call for appointment
Completed by:[**2162-3-22**] Name: [**Known lastname 5336**],[**Known firstname 1523**] Unit No: [**Numeric Identifier 5337**]
Admission Date: [**2162-3-14**] Discharge Date: [**2162-3-22**]
Date of Birth: [**2071-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
Addendum:
Mr. [**Known lastname **] was reintubated shortly after his extubation due to
upper airway obstruction and hypoxia.
He requires IV epinephrine drip post-operatively due to mild
cardiogenic shock which resolved within 24 hours.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1267**] TCU
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2162-3-22**]
|
[
"600.00",
"428.0",
"998.0",
"401.9",
"414.01",
"424.1",
"427.31",
"E878.2",
"311",
"530.81",
"518.5",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"96.71",
"36.15",
"39.61",
"35.21",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8378, 8569
|
3665, 5323
|
288, 589
|
6917, 6923
|
1684, 3642
|
7435, 8355
|
1428, 1446
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5546, 6583
|
6682, 6896
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5349, 5523
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6947, 7411
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1461, 1665
|
229, 250
|
617, 846
|
868, 1009
|
1025, 1412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,061
| 127,362
|
53199
|
Discharge summary
|
report
|
Admission Date: [**2167-12-21**] Discharge Date: [**2167-12-23**]
Date of Birth: [**2089-8-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
# Left hip fracture s/p fall
# Hypoxia
Major Surgical or Invasive Procedure:
# Arterial line placement
# Right internal jugular central venous line placement
# Endotracheal intubation
History of Present Illness:
78F h/o COPD, presumed idiopathic pulmonary fibrosis on home O2,
CAD s/p MI, CHF and Afib, presented with L hip fracture s/p fall
[**1-9**] lightheadedness after transitioning from sitting to standing
while doing laundry on the day of admission. Pt reported no LOC
or seizure activity, and had fallen to the floor without
striking furniture or head, remaining down approximately 30-40
minutes until a nursing assistant found her. Pt was unable to
walk and needed to be lifted to bed, then was brought by EMS to
[**Hospital1 18**]. Pt stated that she also had noticed increased DOE and
SOB x 1 week with yellow sputum, occasionally blood-streaked
with recent epistaxis [**1-9**] nasal drying due to home O2 NC. Pt
denied fever, chills, diarrhea, decreased PO intake, or N/V; she
did report constipation at baseline. Pt had her flu vaccine
this year and confirmed annual pneumonia vaccinations for the
last 3 years.
.
In the [**Name (NI) **], pt was hypoxic to the mid 80s with venti mask 50%, 12
L; she was placed on 100% NRB with O2 sats rising to 100% (at
baseline, pt is 90% on 5L O2 NC). Pt was also noted to have STD
in lateral leads, notably different from baseline. Pt reported
a sensation of midsternum "heartburn" which quickly resolved,
and stated that her pain during her past MI felt more like
pressure and was different than this sensation. Pt received 2L
NS, fentanyl & morphine for pain, as well as aspirin. Ortho was
consulted about her L hip fracture as seen on x-ray and
recommended ORIF as soon as medically stable. Pt was therefore
admitted for further work-up of hypoxic respiratory distress,
EKG changes, and consideration for surgical repair of her L hip
fracture.
Past Medical History:
# Cardiovascular
--Diastolic heart failure: EF 60%
--Atrial fibrillation
--MR
[**Name13 (STitle) 109519**]
--CAD: h/o LCx stenosis on prior cardiac cath
--PFO
--HTN
--Hyperlipidemia
--Mesenteric ischemia
--Renal artery stenosis s/p R renal artery stent
--PVD
--Pulmonary hypertension
--CVA
.
# Pulmonary
--Home oxygen 5L
--COPD
--Presumed idiopathic pulmonary fibrosis
stable RML lung nodule and anterior mediastinal soft tissue
density
.
# Musculoskeletal
--Osteoporosis
--h/o fall with rib fractures
.
# Gastrointestinal
--GERD
.
# Hematological
--Fe deficiency anemia
Social History:
# Personal: Widowed. Lives in [**Hospital3 **] facility.
# Tobacco: 35 pack years of smoking, quit ~[**2146**].
# Alcohol: Occasional.
# Recreational drugs: None.
Family History:
# Mother: Rheumatic heart disease
# Siblings: Twin sister died, 78.
# Children: Two sons with MI, age 40s.
Physical Exam:
VS: Temp 96.8, BP 116/41, HR 70/NSR, RR 18/O2sat 96%
GEN: Pleasant, NAD; speaking in full sentences with face mask,
with decreased O2 sats with prolonged narration.
HEENT: PERRL, EOMI, anicteric, MM mildly dry
NECK: ?JVP = 10cm
RESP: CTAB anteriorly, faint crackles as bases posteriorly
CV: RR, S1 and S2 WNL, holosystolic murmur througout the
precordium, loudest at apex
ABD: Soft, ND, NT, BS+, no masses or hepatosplenomegaly
EXT: No c/c/e, warm, good pulses
SKIN: No rashes/no jaundice; 3cm skin tear on L distal shin
NEURO: AAOx3. No sensory deficits to light touch.
Pertinent Results:
Admission labs:
.
[**2167-12-21**] 06:24PM WBC-10.6# RBC-3.88* HGB-8.7* HCT-28.9*
MCV-75* MCH-22.4* MCHC-30.1* RDW-16.7*
[**2167-12-21**] 06:24PM NEUTS-85.4* LYMPHS-8.8* MONOS-2.3 EOS-3.2
BASOS-0.3
[**2167-12-21**] 06:24PM CK(CPK)-67
[**2167-12-21**] 06:24PM cTropnT-0.02*
[**2167-12-21**] 06:24PM GLUCOSE-127* UREA N-45* CREAT-1.6* SODIUM-139
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
.
Imaging:
.
PELVIS (AP ONLY) [**2167-12-21**] 7:55 PM
Extensively comminuted intertrochanteric fracture of the left
proximal femur, with marked varus angulation, as described.
.
CHEST (PORTABLE AP) [**2167-12-21**] 6:54 PM
Probable mild pulmonary vascular congestion, superimposed on
chronic, diffuse interstitial process which (according to
previous reports) represents known idiopathic pulmonary
fibrosis. There is no definite new airspace process.
.
TEE (Complete) Done [**2167-12-22**] at 2:49:50 PM
Emergency TEE performed in the operating room after cardiac
arrest. The right atrium is dilated. A patent foramen ovale with
flow across it is seen by color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%). The right ventricular cavity is dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. There are simple atheroma in the
aortic arch. There are focal calcifications in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. No thrombus/embolus is seen in the
pulmonary artery.
Brief Hospital Course:
78F h/o COPD, idiopathic pulmonary fibrosis, CAD s/p MI,
admitted to MICU with hypoxia and L intertrochanteric femur
fracture.
.
# PEA arrest: Pt was noted to enter into PEA arrest while
undergoing induction in the OR for ORIF. Pt was intubated and
received 20min CPR, after which she was placed on epinephrine
and norepinephrine gtt; per verbal report to this author, pt had
also received NS fluid resuscitation. Emergency TTE performed
in the OR demonstrated severe global free wall hypokinesis at
the dilated right ventricular cavity. Pt was returned to the
MICU, during which time she was ultimately placed on four
pressors (norepinephrine, phenylephrine, dobutamine, and
vasopressin), as well as NS boluses for hemodynamic support, and
increased FiO2 for respiratory support. Given her poor
prognosis, family members decided to withdraw care; pt expired
within minutes of withdrawing pressor and ventilatory support.
.
# L femur fracture: Orthopedics was consulted in the ED and
recommended ORIF after pt was deemed medically stable. Given h/o
pulmonary disease and cardiac disease, MICU team discussed with
the patient about risks associated with surgical repair,
specifically perioperative MI and difficult post-op extubation.
Pt stated her understanding of this risk, but that her quality
of life would be very diminished if she did not undergo surgical
repair. During a family meeting on [**12-22**] AM, all family members
present concurred that surgical repair was desired, and stated
their understanding of pt's high perioperative risk. Pt
reversed her DNR/DNI status in order to undergo surgery, and in
prepartion for surgery, received 2units PRBC given her low
hematocrit. During induction, pt entered into pulseless
electrical activity while on the OR table and underwent 20min of
CPR. Surgery was aborted and pt was returned to the MICU.
.
# CAD s/p MI: Lateral [**Known lastname **] depressions on admission EKG resolved
on repeat EKGs with troponin T elevated to 0.10, possibly
indicating some cardiac demand. Pt reported "heartburn" but no
chest pressure. Prior cardiac catheterizations demonstrated LCx
involvement, and given this constellation of data, pt was
considered a high peri-operative risk for MI. During induction,
pt did enter into PEA arrest.
.
# Hypoxia: Pt was noted to have increased O2 requirement from
baseline of 90% on 5L O2 NC, with DDx including PE (thrombotic
vs fat in the setting of fracture), COPD flare, worsening
idiopathic pulmonary fibrosis, infection, or worsening heart
failure with associated pulmonary congestion. Pt improved
rapidly overnight, indicating possible reversible cardiac
etiology as also evidenced on EKG changes. Based on the
considerations for her quality of life, pt's chronic pulmonary
pathologies were not considered obstacles to ORIF per
communication with her pulmonologist Dr. [**Last Name (STitle) 217**].
.
# Code status: Pt was initially DNR/DNI, but after deciding to
proceed with hip fracture repair, reversed her status to full
code. After coding during induction for surgery, pt was
intubated and received CPR. Pt's status was changed back to
DNR, and she was later made CMO after her family decided to
withdraw care based on her poor prognosis. Pt expired minutes
after pressors and ventilatory support were withdrawn.
Discharge Disposition:
Expired
Discharge Diagnosis:
Left hip fracture
Cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2167-12-23**]
|
[
"440.1",
"733.00",
"427.31",
"416.8",
"745.5",
"428.0",
"584.9",
"496",
"412",
"428.32",
"401.9",
"E885.9",
"V12.54",
"414.01",
"820.21",
"530.81",
"427.5",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"38.91",
"99.04",
"99.60",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9022, 9031
|
5682, 8999
|
356, 464
|
9115, 9124
|
3696, 3696
|
9180, 9219
|
2982, 3090
|
9052, 9094
|
9148, 9157
|
3105, 3677
|
278, 318
|
492, 2190
|
3712, 5659
|
2212, 2784
|
2800, 2966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,780
| 146,000
|
681
|
Discharge summary
|
report
|
Admission Date: [**2140-7-27**] Discharge Date: [**2140-8-1**]
Date of Birth: [**2085-3-8**] Sex: M
Service: CSU
CHIEF COMPLAINT: This is a 55 year old patient of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2450**] referred following cardiac catheterization for coronary
artery bypass grafting.
HISTORY OF PRESENT ILLNESS: The patient was admitted to [**Hospital1 1444**] with chest pain in [**Month (only) 404**].
He ruled out for a myocardial infarction. His pain was
thought not to be cardiac at that time. The patient
presented again [**2140-7-16**], with complaints of chest pain times
two weeks. Chest pain occurred with exertion and
occasionally at rest. He ruled out for a myocardial
infarction and did not have any ischemic electrocardiographic
changes. He had a stress test on [**2140-7-18**], stopped because
of chest pain and ST depression in leads I and V6. His
rhythm was sinus. Nuclear imaging revealed inferoapical
reversible defects with an ejection fraction of 55 percent.
Following stress test, the patient had a cardiac
catheterization done on [**2140-7-25**], which revealed two vessel
coronary artery disease. Please see catheterization report
for full details. In summary, the patient had extremely
short left main. Left anterior descending coronary artery
was diffusely diseased with 50 percent proximal stenosis and
a 95 percent distal lesion. D1 was diffusely diseased. The
circumflex had a 30 percent proximal, large obtuse marginal
had 40 percent stenosis at the origin and the right coronary
artery was totally occluded proximally.
PAST MEDICAL HISTORY: Hypertension.
Hyperlipidemia.
Diabetes mellitus.
Gastroesophageal reflux disease.
Unrepaired ventricular septal defect.
PAST SURGICAL HISTORY: Rectosigmoid polyp removal.
Knee surgery times four.
Appendectomy.
MEDICATIONS ON ADMISSION:
1. Metformin 500 mg twice a day.
2. Prazocin 2 mg twice a day.
3. Metoprolol 100 mg twice a day.
4. Glyburide 5 mg twice a day.
5. Mavik 6 mg p.o. once daily.
6. Protonix 40 mg twice a day.
7. Nifedipine XR 90 mg once daily.
8. Aspirin 81 mg once daily.
9. Niacin 500 mg once daily.
LABORATORY DATA: White blood cell count 6.4, hematocrit
40.8, platelet count 213,000. Prothrombin time 12.0, partial
thromboplastin time 26.8, INR 1.0. Urinalysis is negative.
Sodium 132, potassium 4.9, chloride 101, CO2 22, blood urea
nitrogen 26, creatinine 1.3, glucose 210, ALT 25, AST 27,
alkaline phosphatase 129, amylase 67, total bilirubin 0.6,
albumin 4.0, cholesterol 198.
Chest x-ray showed no radiographic evidence for acute
cardiopulmonary process.
SOCIAL HISTORY: The patient is married. He works for
American Alliance on the loading docks. He is also a driver
for the Israeli Consulate.
HOSPITAL COURSE: As stated previously, the patient was a
direct admission to the operating room on [**2140-7-27**]. Please
see the operating room report for full details. In summary,
the patient had coronary artery bypass grafting times four
with the left internal mammary artery to the left anterior
descending coronary artery, saphenous vein graft to the
obtuse marginal two, saphenous vein graft to diagonal,
saphenous vein graft to the posterior descending coronary
artery. His bypass time was 78 minutes with a cross clamp
time of 67 minutes. He tolerated the operation well and was
transferred from the operating room to Cardiothoracic
Intensive Care Unit. At that time, he was in sinus rhythm at
80 beats per minute. He had a mean arterial pressure of 61
with a PAD of 16. He had Neo-Synephrine at 0.3
mcg/kg/minute, insulin at two units per hour and Propofol at
30 mcg/kg/minute. The patient did well in the immediate
postoperative period. His anesthesia was reversed. He was
weaned from the ventilator and successfully extubated. He
remained hemodynamically stable overnight. On postoperative
day number one, he was weaned from all cardioactive
intravenous medications. His Swan-Ganz line was discontinued
and his chest tubes were removed. However, on a follow-up
chest x-ray, the patient was noted to have a pneumothorax and
he was therefore kept in the Intensive Care Unit for
pulmonary monitoring. Postoperative day number two, the
patient continued to have periods of desaturation with little
or minimal activity. His chest x-ray showed a small apical
left pneumothorax as well as atelectasis. He continued to
have periods where he would desaturate and he was kept in the
Intensive Care Unit again for vigorous chest physical therapy
and pulmonary toilet. On postoperative day number three, the
patient continued to do well. With increasing activity and
chest physical therapy, he no longer had periods of
desaturation and therefore he was transferred to the floor
for continuing postoperative care and cardiac rehabilitation.
At that time, his temporary pacing wires were removed. Once
on the floor, the patient had an uneventful hospital course
and on postoperative day number four, the patient's activity
level had progressed enough that he was considered ready for
discharge to home with visiting nurses. At that time, the
patient's physical examination was as follows: Vital signs
showed temperature 98.9, heart rate 82, sinus rhythm, blood
pressure 110/56, respiratory rate 18, oxygen saturation 96
percent in room air. Laboratories showed a white blood cell
count 6.1, hematocrit 24.9, platelet count 293,000. Sodium
140, potassium 4.5, chloride 103, CO2 30, blood urea nitrogen
21, creatinine 1.2, glucose 105, weight preoperatively 94.9
kilograms and at discharge 100.3 kilograms. On physical
examination, neurologically, alert and oriented times three,
moves all extremities, nonfocal examination. Respiratory -
diminished breath sounds in the left base and otherwise clear
to auscultation. Cardiovascular is regular rate and rhythm,
S1 and S2, with no murmurs. The sternum is stable. The
incision with staples open to air, clean and dry. The
abdomen is soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well perfused with
one plus edema, right saphenous vein graft harvest site with
Steri-Strips with large bullae underneath the Steri-Strips.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 75 mg twice a day.
2. Ferrous Sulfate 325 mg once daily.
3. Vitamin C 500 mg twice a day.
4. Metformin 500 mg twice a day.
5. Glyburide 10 mg q.a.m. and 5 mg q.p.m.
6. Plavix 75 mg once daily.
7. Aspirin 325 mg once daily.
8. Protonix 40 mg once daily.
9. Niacin 500 mg once daily.
10. Lasix 20 mg twice a day times two weeks.
11. Potassium Chloride 20 mEq twice a day times two
weeks.
12. Dilaudid 2 to 4 mg p.o. q4-6hours p.r.n.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass grafting times four with left internal
mammary artery to the left anterior descending coronary
artery, saphenous vein graft to obtuse marginal, saphenous
vein graft to diagonal and saphenous vein graft to posterior
descending coronary artery.
Hypertension.
Chronic renal insufficiency.
Hyperlipidemia.
Gastroesophageal reflux disease.
Knee surgery times four.
Rectosigmoid polyp removal.
Appendectomy.
Diabetes mellitus type 2.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: He is to be discharged home with visiting
nurses.
FOLLOW UP: He is to follow-up in the [**Hospital 409**] Clinic in two
weeks, follow-up with Dr. [**Last Name (STitle) 2450**] in two to three weeks and
follow-up with Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2140-8-1**] 16:51:14
T: [**2140-8-1**] 18:20:00
Job#: [**Job Number 5107**]
|
[
"250.00",
"401.9",
"512.1",
"530.81",
"411.1",
"593.9",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6733, 7230
|
6246, 6711
|
1888, 2640
|
2802, 6220
|
1792, 1862
|
7344, 7816
|
152, 340
|
369, 1620
|
1643, 1768
|
2657, 2784
|
7255, 7332
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
457
| 166,305
|
22760
|
Discharge summary
|
report
|
Admission Date: [**2146-1-30**] Discharge Date: [**2146-3-1**]
Date of Birth: [**2092-4-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Fevers and severe neck pain.
Major Surgical or Invasive Procedure:
Aortic valve replacement on [**2146-2-14**].
C3-C4 laminectomy on [**2146-2-2**].
History of Present Illness:
Mr. [**Known lastname 38829**] is a 53 yo male patient who began feeling poorly 2
weeks prior to admission with fevers, neck pain, myalgias, and
arthralgias. Laboratory work at his primary care provider's
office revealed a thrombocytopenia for which he was referred to
the oncology clinic. Upon eval at oncology clinic, Mr. [**Known lastname 38829**]
was confused and lethargic for 1-2 days and he was sent to an
OSH ED for evaluation. Blood cultures at this OSH grew GPC for
which he was initially treated with vancomycin and clindamicin.
He later grew Group B Strep and his antibiotics were changed to
gentamicin and pencillin. A tran-thoracic echocardigram
revealed a 1.5 cm vegetation on his aortic valve and at this
time he was transferred here for management of his endocarditis.
Past Medical History:
Asthma.
COPD.
Atrial fibrillation.
Surgery for rectal fissure and hemorrhoids.
Social History:
Married, lived with wife in [**Name (NI) 189**]. Works as real estate
attorney. Current smoker with 60 pack year history. Also
reporst ETOH use of approximately 8 beers/day.
Physical Exam:
PE on presentation:
VS: T 104.5; HR 121; BP 131/20; RR 39; SPO2 96% on 2L.
Skin: No visible rashes.
HEENT: Anicteric. Conjunctiva without hemmorhages. Neck very
stiff and painful with movement. Tender to palpation from
C5-T2. Positive Kernig's and Brudzinski's. No JVD.
Lungs: Bilateral diffuse rhonchi.
Cardiovascular: Tachycardic. II/VI diastolic murmur at right
USB.
Abd: Benign.
Extremities: Warm, well perfused. No osler nodes, petechiae,
lesions, or splinter hemmorhages.
Neuro: Minimally arousable to sternal rub. Genreally agitated.
Neuro exam as of [**2146-2-28**]:
MENTAL STATUS
Alert, and oriented to place, date, and person. No signs of
problems w
[**Name2 (NI) **]. Pt cooperates well with the examination. Attention intact
w MOYB
and DOWB. Language flow, content, repetition, and comprehension
normal. Has [**Last Name **] problem w [**Name2 (NI) **] twister jargons. No paraphasic
errors. Patient can register [**3-28**] and recall [**2-25**] after one and
five minutes. Naming intact for frequent or infrequently used
objects. No problems calculating. [**Name2 (NI) **] apraxia. Prosody of speech
intact.
CRANIAL NERVES:
Visual fields full. Dipolpia not present. Pupils are equal and
reactive. Accomodation intact. Gaze midline at rest. No ptosis.
EOMs intact. No nystagmus. Facial sensation intact for fine
touch, pinprick and temperature. No facial droop. Palate
elevates symmetrically. Shrug [**4-28**]. Head version in all
directions [**4-28**]. [**Month/Day (1) **] movement strong, and protrudes at
midline.
MOTOR:
Normal tonus. Pronator drift not present.
Upper extremities: deltoid R(c)-L(4); Triceps R(3+)-L(4); Biceps
R(4-)-L(4+); Extensor digitorum R(4)-L(4); Lower extremities:
Iliopsoas R(4+)-L(4+); quadriceps R(4)-L(4); adductors
R(4+)-L(4)hamstrings R(4)-L(4); anterior tibialis R(5-)-L(5-);
[**Last Name (un) 938**] R(4+)-L(4+).
COORDINATION:
No tremor. Finger to nose normal. Heel-to-shin affected by leg
weakness but non-ataxic. [**Doctor First Name **] normal.
REFLEXES:
Normal and symmetric in UE and LE except absent achilles No
clonus. Plantar reflexes downgoing on left and right.
SENSATION:
Fine touch, pin prick and temperature intact in all limbs.
Romberg: positive.
GAIT:
Patient can rise from bed without assistance but with
difficulties. The
initiation and the performance of the gait are normal but the pt
has wide based gait. Has tendency to fall if unsupported.
Pertinent Results:
[**2146-3-1**] 12:32AM BLOOD WBC-11.4* RBC-3.26* Hgb-9.9* Hct-29.7*
MCV-91 MCH-30.4 MCHC-33.4 RDW-15.6* Plt Ct-275
[**2146-2-14**] 03:53AM BLOOD Neuts-78.8* Lymphs-14.7* Monos-1.5*
Eos-4.6* Baso-0.3
[**2146-3-1**] 12:32AM BLOOD Plt Ct-275
[**2146-2-17**] 02:56AM BLOOD PT-14.2* PTT-32.0 INR(PT)-1.3
[**2146-3-1**] 12:32AM BLOOD Glucose-141* UreaN-14 Creat-1.1 Na-127*
K-3.9 Cl-95* HCO3-23 AnGap-13
[**2146-2-15**] 03:00AM BLOOD ALT-46* AST-92* AlkPhos-160* TotBili-0.4
[**2146-3-1**] 12:32AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.6
Brief Hospital Course:
Mr. [**Known lastname 38829**] was transferred from an OSH on [**2146-1-30**].
He was initially evaluated by cardiology and neurology. Head CT
and MRI rose question of epidural abscess and neuro-surgery was
consulted. An infectious disease consult was also initiated
immediately with recommendation for ongoing gent and Pen G.
A C3-C6 epidural abscess was suspected with associated
meningitis and sepsis and he was taken emergently to the OR for
C3-C6 laminectomy on [**2146-1-31**]. Addional findings of "weak bone"
associated with osteo but no findings of focal abscess.
The cardiac surgery team was consulted on [**2146-2-2**]. TEE on [**2146-2-2**]
supported diagnosis or endocarditis. Over the next several
days, Mr. [**Known lastname 38829**] went through a pre-operative evaluation and was
followed by neurology, neuro surgery, and infectious disease.
He continued to be in the ICU, intubated, and confused/agitated.
It was felt that he was not ready for surgery and that the
longer antibiotics could be continued prior to surgery the
better Mr. [**Known lastname 58889**] outcomes would be. He was also treated for
pneumonia.
He was successfully extubated on [**2146-2-7**] and remianed extubated
through [**2-11**] however he remained in the ICU for hemodynamic
monitoring.
Ongoing CHF with inability to obtain optimal hemodynamics pushed
Mr. [**Known lastname 38829**] to surgery emergently on [**2-14**].
On [**2146-2-14**] he proceeded to the OR with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] and
underwent an aortic valve replacement with a 25 mm perimount
pericardial valve. Please see OR report for full details.
On POD 1, Mr. [**Known lastname 38829**] failed to [**Doctor Last Name **] from the ventilator.
Infectious disease continued to follow Mr. [**Known lastname 38829**] with ongoing
recs for vancomycin and levofloxacin.
On POD 2 he was succcessfully weened and extubated. ID
discontinued his fluconazole. He continued with an altered
mental status.
POD 3 through 7 he continued with hemodynamic monitoring and abx
administration. He continued to be confused in the ICU.
A neuro consult on POD 7 stated significantly improved mental
status. He was continued on haldol but began to [**Doctor Last Name **] from it.
On POD 9 he was transferred to the inpatinet floor for ongoing
recovery and rehabilitation. His haldol was weened over the
next three days with ongoing dosing only at bedtime with
significant clearing of mental status to. Neuro surgery was
again consulted to eval need for ongoing use of cervical collar
that Mr. [**Known lastname 38829**] had been wearing since his laminectomy and it
was decided that he did not need to continue wearing it.
On POD 10 he was noted to have a worsening heart murmur and TTE
was obtained showing a ventricular septal defect. Further
evaluation of this VSD (as a TEE) was declined as no surgical
intervention was felt to be necessary.
He continued with physical therapy through POD 15 and it was
felt that Mr. [**Known lastname 38829**] would benefit greatly from rehabilitation.
Medications on Admission:
Pencillin G 4 million units IV q4h.
Acyclovir 400 mg IV TID.
Protonix 40 mg IV daily.
Gentamicin 50 mg IV q 12 hours.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: One
(1) Recon Soln Injection Q4H (every 4 hours) for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Endocarditis with severe aortic regurgitation, s/p aortic valve
replacement.
Cervical spinal stenosis/cervical spine infectious process, s/p
C3-C6 laminectomy for decompression of spinal cord.
Discharge Condition:
Stable.
Discharge Instructions:
Shower and wash incisions daily with soap and water. Rinse
well. Do not apply ANY creams, lotions, powders, or ointments.
No bathing in a tub or swimming.
No heavy lifting greater than 10 pounds.
Followup Instructions:
Schedule appointment with Dr. [**Last Name (STitle) 70**] in 4 weeks
([**Telephone/Fax (1) 170**]).
Schedule appointment with Dr. [**Last Name (STitle) 15378**] with infectious disease
within 4 weeks ([**Telephone/Fax (1) 457**]). Will need to have cervical spine
MRI prior to that visit.
Schedule an appointment with Dr. [**Last Name (STitle) **] with neurology within 4
weeks ([**Telephone/Fax (1) 2574**]).
Schedule appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24425**] with neuro-surgery in
[**3-30**] weeks ([**Telephone/Fax (1) 58890**]).
Echocardiogram at one month, three months, six months, and 1
year post discharge to be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**].
Please check weekly CBC, LFTs, and creatinine.
Completed by:[**2146-3-1**]
|
[
"486",
"995.92",
"421.0",
"041.89",
"324.1",
"428.0",
"320.2",
"287.5",
"493.90",
"038.0",
"723.0",
"584.9",
"305.00",
"289.7",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"88.72",
"99.07",
"99.05",
"35.22",
"89.64",
"99.04",
"39.61",
"96.72",
"03.09",
"00.17",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
8597, 8676
|
4556, 7652
|
350, 434
|
8913, 8922
|
4005, 4533
|
9168, 10002
|
7820, 8574
|
8697, 8892
|
7678, 7797
|
8946, 9145
|
1564, 2694
|
282, 312
|
462, 1253
|
2710, 3986
|
1275, 1355
|
1371, 1549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,964
| 107,831
|
22275
|
Discharge summary
|
report
|
Admission Date: [**2188-8-16**] Discharge Date: [**2188-8-18**]
Date of Birth: [**2112-8-8**] Sex: M
Service: UROLOGY
Allergies:
Ace Inhibitors
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 76M w/ Hx of bladder ca s/p cystoprostatectomy,
bilateral lymph node dissection and urinary ileal conduit on
[**2188-8-5**] who presents from rehab (he was d/c'd from the [**Hospital1 **] on
[**2188-8-13**]) with c/o abdominal pain and fever. At the rehab center,
he reportedly had a temperature to 100.5, poor po intake
requiring PPN, and abdominal distension prompting NGT and rectal
tube placement. Per the patient's family, the NGT emptied
bilious fluid intially but the output appeared coffee-ground and
melanotic this morning. (Of note, the NGT had a single suction
port and no air port which may have caused some trauma). His
wife notes that the patient was having some small bowel
movements daily but no substantial output. Her greatest concern
was his ongoing abdominal discomfort which had been present at
the time of discharge and attributed to a slight ileus. He did
not have any vomiting or unusual diarrhea. He was on keflex at
discharge for slight wound erythema but that had improved - no
purulent drainage was reported. Of note, he does have an
extensive history of UTIs, urosepsis and pyelonephritis.
The patient could not be fully interviewed as he was wearing a
nonrebreather O2 mask and eventually became intubated.
Past Medical History:
-Bladder Carcinoma
-Diabetes Type II
-Hypertension
-Frequent UTI
-Pulmonary hypertension
-Diastolic congestive heart failure (EF>55% on [**2188-2-5**])
Social History:
Lives with his wife in [**Name (NI) 1411**], MA. Now retired. Occasional
alcohol use,
with distant history of tobacco use.
Family History:
Noncontributory.
Physical Exam:
100.5 on arrival, 102 during assessment 120-160s afib
110/73 on arrival but dropped to systolics in the 90s, 89 on RA,
98 on 100% NRB
Moderate distress, anxious, dyspneic
Irreg, irreg
Clear with limitied inspiratory effort and rapid rate
Distended abdomen, tympanitic, diffusely tender, no peritoneal
signs
High pitched bowel sounds
Stoma pink and functioning, urine concentrated
Exam limited by elective intubation
Pertinent Results:
139 99 48 167 AGap=16
4.0 28 1.9
CK: 54 MB: Notdone Trop-T: 0.09
Ca: 8.7 Mg: 2.5 P: 3.4
ALT: 20 AP: 80 Tbili: 0.6 Alb: 3.0
AST: 16 LDH: Dbili: TProt:
[**Doctor First Name **]: 29 Lip: 31
25.5 D 10.3/31.2 704 D
N:88.8 L:7.6 M:2.4 E:0.7 Bas:0.5
PT: 15.0 PTT: 23.8 INR: 1.3
UA: Color Yellow Appear Clear SpecGr 1.019 pH 6.0 Urobil Neg
Bili Neg Leuk Mod Bld Lg Nitr Neg Prot 30 Glu Neg Ket Neg
RBC [**5-4**] WBC 21-50 Bact Mod Yeast None Epi 0-2
Urine and blood cultures pending
Past urine and blood cultures have grown MRSA, VRE, multidrug
resistent klebsiella
IMAGING:
CT C/A/P (prelim report): 11cm fluid collection in the lower
pelvis. Bil. ureteral stents and cysts. Lung nodules due to
metastasis. note that lung nodules are new and dedicated chest
imaging is recommended after stabilization of the acute issue.
CT head (prelim): Generalized brain atrophy, without acute
intracranial hemorrhage or mass effect.
Brief Hospital Course:
The patient was admitted to the SICU for possible urosepsis. He
required intubation and admission due to respiratory distress.
He did improve clinically in the ICU and was able to extubate
successfully. He was doing ok on [**8-18**] other than some
tachycardia. However, in the afternoon around noon his
tachycardia began to worsen to the 160s-180s. He became
agitated and dyspneic complaining of belly pain but no chest
pain. His blood pressure began to drop at this point with a
systolic of 70. Eventually the patient required intubation.
During intubation the patients pulse was lost and his BP dropped
to less than 50. CPR was initiated and a code was called. In
the ensuing hours the patient regained vital signs on and off
requiring CPR, multiple pressors to maintain his blood pressure,
and even a few shocks from the defibrillator. He never regained
consciousness throughout the code. An echo was done during this
time which showed hardly any ventricular filling on either side
of the heart. His Hct also appeared to be dropping. It was
unclear if the patient was hypovolemic from some type of
possible intraabdominal bleeding as his belly became more and
more distended. There was also the possibility that he had an
MI or PE. Unfortunately, the clinical picture was not clear and
it was poorly understood what manifested this event. Eventually
the patients family arrived and they requested to stop any
additional heroic efforts. At that point he had a blood
pressure and pulse and was not requiring CPR. However, his MAP
continued to fall over the next hour or so. At 1759 the patient
was pronounced dead. The family did not want an autopsy and the
medical examiner did not require one either. The attending and
chief residents were aware of the situation the entire time. I,
the intern, was present for most of the code and assisted as
much as possible and relayed information to the attending and
chief as much as possible.
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
|
[
"428.0",
"560.1",
"997.4",
"428.32",
"250.00",
"197.0",
"V10.51",
"785.0",
"786.09",
"785.52",
"V45.74",
"038.9",
"V15.82",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"99.60",
"99.04",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
5319, 5328
|
3337, 5296
|
306, 312
|
5380, 5391
|
2399, 3314
|
1928, 1947
|
5349, 5359
|
1962, 2380
|
245, 268
|
340, 1596
|
1618, 1771
|
1787, 1912
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,199
| 175,493
|
24729
|
Discharge summary
|
report
|
Admission Date: [**2162-5-26**] Discharge Date: [**2162-6-7**]
Date of Birth: [**2123-2-19**] Sex: F
Service: SURGERY
Allergies:
Remicade / Prednisone / Vancomycin
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, drainage of intraperitoneal intraloop
abscess, and small bowel resection.
History of Present Illness:
Ms. [**Known lastname **] is a 39-year-old female with Crohn's disease which was
first diagnosed 3 years ago, and she reports that it has never
been fully controlled. She awoke yesterday morning with
abdominal pain and subsequently presented to her local ED ([**Location (un) **],
[**State 1727**]) for evaluation. There, a CT scan of the abdomen revealed
evidence of a likely bowel microperforation, and she was
transferred to [**Hospital1 18**] for further care. She has been on TPN
since [**10-15**], and has been off of all medications for Crohn's
disease for approximately a month (has taken steroids, pentasa,
and methotrexate in the past). She denies having been on
steroids for "months". She had been feeling well until earlier
yesterday. Her abdominal pain is diffuse and non-radiating, not
improved by anything, and felt worse while going over bumps
during the ambulance transfer. She had nausea and vomiting
early yesterday afternoon, but currently denies either of those
symptoms. Denies any subjective fevers. Last bowel movement
was yesterday, and
she cannot recall if she has passed flatus recently.
Past Medical History:
Past Medical History:
1. Severe Crohn's disease of small bowel/colon (dx [**2156**])
2. Severe malnutrition
3. Iron deficiency anemia- s/p IV Fe infusions
4. Osteoporosis- thought [**1-9**] steroids
5. Pelvic organ prolapse
6. Periumbilical hernia
7. GERD
Past Surgical History: Denies
Social History:
Married, lives with husband and 2 children. Former 5th grade
teacher. No alcohol, tobacco, or IVDA.
Family History:
Daughter with VSD. Mother with history of breast CA. Father with
psoriasis. Two younger brothers are healthy.
Physical Exam:
Physical exam on Admission:
T 96.8 HR 130 BP 127/81 RR 16 SaO2 97% RA
Alert & oriented x 3, visibly uncomfortable
Dry mucous membranes
Regular rhythm, tachycardic
Lungs are clear bilaterally
Abdomen is firm, distended, and diffusely tender with guarding.
There is no rebound tenderness and no discomfort with
movement. There is a reducible umbilical hernia. No masses.
Rectal exam is deferred
Extremities are warm, palpable pedal pulses, no edema.
Cranial nerves II-XII intact grossly.
Pertinent Results:
[**5-26**] CT scan of abdomen from OSH: revealed evidence of a likely
bowel microperforation
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 62361**],[**Known firstname **] [**2123-2-19**] 39 Female [**-7/2343**]
[**Numeric Identifier 62362**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc
SPECIMEN SUBMITTED: small bowel.
Procedure date Tissue received Report Date Diagnosed
by
[**2162-5-26**] [**2162-5-26**] [**2162-5-31**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/axg
Previous biopsies: [**-5/3949**] SIGMOID COLON, RECTUM, PROXIMAL
(JEJUNUM) & DUODENUM PART.
[**-4/4454**] Consult slides referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DIAGNOSIS:
Small bowel, segmental resection:
1. Small intestine with chronic active enteritis demonstrating:
a. Foci of ulceration, focally transmural necrosis and
associated perforation with abscess formation and extensive
serositis.
b. Focally prominent lymphoid aggregates, transmural.
c. No granulomas or dysplasia seen.
d. Resection margins free of active enteritis.
2. Uninvolved mucosa with focally, mildly increased
intraepithelial lymphocytes; see note.
Note: The finding of increased intraepithelial lymphocytes,
while non-specific, raises the possibility of concomitant celiac
disease, a drug effect, or other immune-mediated injury.
Correlation with clinical and serological findings is
recommended.
Clinical: Perforated small bowel.
Gross: The specimen is received fresh labeled with the
patient's name "[**Known lastname **], [**Known firstname **]" and additionally labeled "small
bowel". The specimen consists of a portion of unoriented
segment of bowel that measures 36 cm in length x 4.5 cm in
diameter. The specimen is stapled at both ends. One stapled
margin measures 3 cm and the other measures 4 cm. Located 11 cm
away from the 4 cm stapled margin is a single suture. This area
is inked black on the serosal surface. The remainder of the
serosa is hemorrhagic and granular. The specimen is opened to
reveal a lumen filled with fluid and fecal matter. The mucosa is
cobblestoned, focally ulcerated with two separate ulcers, and
hemorrhagic at the area of the stitch. The ulcerated areas
measure up to 4.5 cm. The specimen is represented as follows:
A=4 cm staple margin, B=3 cm staple margin, C=representative
section of ulcerated mucosa, D-E=representative sections of
grossly unremarkable mucosa, F=representative section of
possible lymph node and mesentery.
[**2162-5-26**] 03:49AM WBC-8.0# RBC-4.98 HGB-13.6# HCT-42.5# MCV-85
MCH-27.3 MCHC-32.1 RDW-16.3*
[**2162-5-26**] 03:49AM NEUTS-83* BANDS-13* LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2162-5-26**] 03:49AM GLUCOSE-178* UREA N-16 CREAT-0.7 SODIUM-138
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13
[**2162-5-26**] 07:26AM LACTATE-4.8*
[**2162-6-6**] 04:02AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.2* Hct-24.4*
MCV-88 MCH-29.2 MCHC-33.4 RDW-15.2 Plt Ct-481*
[**2162-6-7**] 04:38AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-141
K-4.6 Cl-108 HCO3-24 AnGap-14
[**2162-6-7**] 04:38AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0
[**2162-6-6**] 04:02AM BLOOD calTIBC-191* Ferritn-210* TRF-147*
[**2162-5-27**] 02:16PM BLOOD Lactate-1.2
[**2162-6-6**] 04:02AM BLOOD Albumin-2.5* Iron-15*
Brief Hospital Course:
39-year-old female with severe Crohn's disease and now with what
appears to be a contained microperforation in the area of the
distal ileum. She was afebrile and hemodynamically stable,
though with persistent tachycardia even after resuscitation.
She had a normal WBC but with a bandemia. Due to the clinical
picture it was decided to take her to the OR for exploratory
laparotomy, drainage of intra loop abscess and small bowel
resection.
1. Neuro: Immediately post-op she was on a propofol gtt and a
fentanyl gtt which was switched to a Dilaudid PCA after she was
extubated on POD 1. When she was tolerating clear liquid she
was switched to PO Dilaudid. Her pain is well controlled on PO
Dilaudid. She also has anxiety at baseline and was given Ativan
prn. Her PCP is going to work on a regimen as an outpatient.
2. Cardiovascular: Patient has been tachycardiac since
admission. It was sinus tachycardia. HR ranged up to 140s while
she was in the ICU immediately post-op. She was always
hemodynamically stable and tachycardia did not improve even with
PRBCs. Talking to her PCP she is always tachycardiac in the
office and it has never been treated previously so her baseline
is HR of 100-110. Her heart rate now ranges at her baseline.
3. Respiratory: Immediately after the OR she was intubated but
on POD 1 she was extubated and has been weaned off the oxygen.
No issues.
4. GI: She was continued on TPN during this hospitalization.
She had an NGT and was NPO until POD 8. On POD 8 her NGT was
removed when she started having flatus and she was started on
sips. POD 9 she was started on clear liquid diet which she
tolerated without nausea or vomiting. On POD 9 she started
having numerous bowel movements which were sent for c.diff.
C.diff was negative times two. On POD 10 she was started on low
residue diet. She is in control of her diet and her diarrhea
has since improved to her baseline.
5. Renal: no issues. she is voiding on her own. creatinine
stable
6. Heme: immediately post-op her HCT was 19. She received a
total of 4 units of PRBCS during this hospitalization and her
HCT has been stable at approximately 25.
7. ID: since she had perforation of her abdomen she was started
on broad spectrum antibiotics. She spiked a temp on POD 9 and
cultures were sent which at this time are preliminary negative.
She will go home on her Cipro and Flagyl. Her temp max for 24
hours was 100.0 at time of discharge.
8. Endo: she is on a regular insulin sliding scale for her TPN.
9. prophylaxis: heparin subcutaneous, venodyne boots, and she is
ambulating.
10. Disp: home with services. Continuing TPN.
Medications on Admission:
ALENDRONATE-VITAMIN D3 [FOSAMAX PLUS D] - (Prescribed by Other
Provider) - 70 mg-2,800 unit Tablet - 1 Tablet(s) by mouth
weekly pill
CIPROFLOXACIN [CIPRO] - (Not Taking as Prescribed: Not taking
for 3 1/2 weeks.) - 500 mg Tablet - 1 Tablet(s) by mouth twice a
day
FOLIC ACID - (Not Taking as Prescribed: Not taking for 3 1/2
weeks.) - 1 mg Tablet - 2 Tablet(s) by mouth once a day
MESALAMINE [PENTASA] - (Not Taking as Prescribed: Not taking
for
3 1/2 weeks.) - 500 mg Capsule, Sustained Release - [**1-10**]
Capsule(s) by mouth three times a day take as 3/2/3 capsules
three divided doses(total 8/day)
METHOTREXATE SODIUM - (Dose adjustment - no new Rx) (Not Taking
as Prescribed: Not taking for 3 1/2 weeks.) - 25 mg/mL Solution
-
17.5 weekly shot Will hold for now and see how she is doing
METRONIDAZOLE - (Not Taking as Prescribed: Not taking for 3 1/2
weeks.) - 375 mg Capsule - 1 Capsule(s) by mouth twice a day
OXYCODONE - (Prescribed by Other Provider) (Not Taking as
Prescribed: Not taking for 3 1/2 weeks.) - 5 mg Tablet -
Tablet(s) by mouth as needed
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) (Not
Taking as Prescribed: Not taking for 3 1/2 weeks.) - 40 mg
Tablet, Delayed Release (E.C.) - Tablet(s) by mouth once a day
SODIUM-K+-MAG-CA-CHLOR-ACETATE [TPN ELECTROLYTES] - (Prescribed
by Other Provider; Not listed) - Dosage uncertain
VALACYCLOVIR [VALTREX] - (Prescribed by Other Provider) - 1,000
mg Tablet - as needed Dosage uncertain
Medications - OTC
CALCIUM - (Prescribed by Other Provider) (Not Taking as
Prescribed: Not taking for 3 1/2 weeks.) - 500 mg Tablet -
Tablet(s) by mouth three times a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) (Not Taking as Prescribed: Not taking for 3 [**12-9**]
weeks.)
- 400 unit Tablet - Tablet(s) by mouth twice a day
GLUTAMINE - (OTC) - Powder - 10grams three times a day
MULTIVITAMIN - (Prescribed by Other Provider) (Not Taking as
Prescribed: Not taking for 3 1/2 weeks.) - Tablet - 1
Tablet(s)
by mouth once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
(Not Taking as Prescribed: Not taking for 3 1/2 weeks.) - 1,000
mg Capsule - 1 Capsule(s) by mouth twice a day
PROBIOTICS - (OTC) - - taking 50,000,000 3 strains in the
preparation
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED). unit
[**Unit Number **]. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Mesalamine 500 mg Capsule, Sustained Release Sig: not taking
as prescribed Capsule, Sustained Release PO three times a day:
she takes 3/2/3 tablets during the course of the day.
5. Metronidazole 375 mg Capsule Sig: One (1) Capsule PO twice a
day.
6. Sodium Chloride 0.9 % 0.9 % Piggyback Sig: One (1) mL
Intravenous every twelve (12) hours as needed for PICC line
flush.
7. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Five (5)
ML Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Home With Service
Facility:
SOUTHERN [**State **] VNA
Discharge Diagnosis:
Crohn's disease with perforation
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**9-22**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. You will be given pain medication which may make
you drowsy. No driving while taking pain medicine.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2162-6-22**] 10:15
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2162-8-10**] 11:20
Completed by:[**2162-6-7**]
|
[
"567.22",
"569.83",
"555.2",
"780.6",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.19",
"45.62",
"99.77"
] |
icd9pcs
|
[
[
[]
]
] |
12012, 12068
|
6169, 8799
|
308, 408
|
12144, 12153
|
2654, 6146
|
13065, 13369
|
2005, 2116
|
11144, 11989
|
12089, 12123
|
8825, 11121
|
12177, 13042
|
1863, 1871
|
2131, 2145
|
253, 270
|
436, 1560
|
2159, 2635
|
1604, 1840
|
1887, 1989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,868
| 124,510
|
52920
|
Discharge summary
|
report
|
Admission Date: [**2163-7-13**] Discharge Date: [**2163-7-21**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
Non-successful AFlutter albation
PICC d/ced in [**7-21**], right antecub
History of Present Illness:
PT is a 73 y.o woman with h.o diastolic HF, HTN, HL, PVD, DM,
ESRD on HD, PAF who presents after episode of CP/feeling
fatigued during her HD session today. Pt reports that she was
discharged from the hospital yesterday and was admitted for
chest discomfort+headache attributed to glaucoma. Pt reports
that her CP was midsternal/R.sided, dull ache, lasting for >1hr.
She reports an associated discomfort in the l.side of her neck.
She denies associated LH/Dizziness/diaphoresis,
nausea/vomiting/SOB, but does report feeling tired. States pain
resolved after being given "morphine" in the ED. In addtion, pt
reports no SOB/DOE, exertional CP at home. PT reports getting CP
2x/wk while lying flat in bed. Reports never exertional or while
standing/sitting up. Pt also states she experienced hypotension
during HD with BP 75.
.
Pt was taken to the ED where she was also found to be in
afib/RVR-rate to 114(not new), EKG showing ST depressions in
"v5-v6, I, II) that are reported as new but in comparison to
prior EKG are not. Pt found to be hypotensive to the 70's, given
500cc bolus and started on neosynephrine. BP up to 105 prior to
transfer. HR in 90's. L.IJ was placed for access. In addition,
pt was given 1 dose of Vanco/levo in ED for hypotension.
.
Currently, pt denies all ROS including headache/LH/Dizziness,
changes in vision, f/c, appetite/weight changes,
odynophagia/dysphagia, abdominal pain/n/v/d/c/melena/brbpr,
dysuria/hematuria, (makes urine), joint pain/skin rash,
paresthesias/weakness.
Past Medical History:
- Hypertension
- Hypercholesterolemia
- Diastolic CHF with LVOT obstruction at rest
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Chronic 2L NC at night
- Diabetes
- GERD/PUD
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
-L.eye "blind"
Social History:
Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.
Family History:
Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.
Physical Exam:
Vitals: T. 97.4, BP 96/54, HR 86, CVP 2, RR 14, sat 100% on RA
Gen: NAD, appears her stated age
HEENT: NC/AT, perrla, s/p cataract [**Doctor First Name **], EOMI, anicteric,
slightly dry MM, no oropharyngeal lesions/exudates
Neck: No JVP, no LAD. L.IJ c/d/i
Chest: B/L AE no w/c/r
Heart: S1S2 RRR, [**2-24**] diastolic murmur heard throughout
precordium, loudest in axilla crescendo/decrescendo in quality,
no r/g
Abd: + BS, soft, NT, ND, no bruits
Ext: No C/C/E, 2+radial/carotid/femoral pulses without bruits.
L.arm with fistula, C/D/I, non-tender, no erythema.
Neuro: AAOx3, CN2-12 intact, non-focal.
Pertinent Results:
[**2163-7-12**] 03:25PM BLOOD WBC-6.4 RBC-4.58 Hgb-13.2 Hct-42.8 MCV-94
MCH-28.9 MCHC-30.9* RDW-18.9* Plt Ct-249
[**2163-7-13**] 04:46PM BLOOD PT-53.8* PTT-47.1* INR(PT)-6.2*
[**2163-7-12**] 03:25PM BLOOD Glucose-112* UreaN-56* Creat-8.0*# Na-137
K-4.0 Cl-91* HCO3-27 AnGap-23*
[**2163-7-12**] 03:25PM BLOOD Calcium-8.2* Phos-7.9*# Mg-2.4
[**2163-7-13**] 09:50AM BLOOD ALT-12 AST-22 CK(CPK)-62 AlkPhos-94
[**2163-7-13**] 09:50AM BLOOD Lipase-20
[**2163-7-13**] 09:50AM BLOOD CK(CPK)-62
[**2163-7-13**] 04:46PM BLOOD CK(CPK)-67
[**2163-7-14**] 01:10AM BLOOD CK(CPK)-222*
[**2163-7-14**] 02:31PM BLOOD CK(CPK)-162*
[**2163-7-13**] 09:50AM BLOOD cTropnT-0.06*
[**2163-7-13**] 04:46PM BLOOD CK-MB-NotDone cTropnT-0.42*
[**2163-7-14**] 01:10AM BLOOD CK-MB-33* MB Indx-14.9* cTropnT-1.21*
[**2163-7-14**] 02:31PM BLOOD CK-MB-20* MB Indx-12.3* cTropnT-1.32*
[**2163-7-13**] 09:50AM BLOOD Acetone-MODERATE
EKG [**2163-7-13**]: Atrial fibrillation. Left ventricular hypertrophy
with secondary repolarization abnormality. Cannot rule out
anteroseptal infarct - age undetermined. Inferior/lateral ST-T
changes may be due to hypertrophy and/or ischemia. Since
previous tracing of the same date, the heart rate is slower,
wide QRS eats not seen.
ECHOCARDIOGRAM [**2163-7-13**]: There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). A mid-cavitary gradient is identified (50-55 mmHg).
There is no definite dynamic LVOT gradient present. There is no
ventricular septal defect. The aortic valve leaflets (3) are
mildly thickened. The study is inadequate to exclude significant
aortic valve stenosis. No aortic regurgitation is seen. There is
severe mitral annular calcification. There is moderate
functional mitral stenosis (mean gradient 5 mmHg) due to mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared to the prior study dated [**2163-3-24**], no definite change is
seen.
IMPRESSION: Severe LVH with signficant intracavitary gradient.
Tachycardia/AF. No regioanl LV systolic dysfunction.
CXR [**2163-7-13**]: No acute cardiopulmonary process.
CXR [**2163-7-14**]: Moderate-to-severe pulmonary edema is new. Mild
cardiomegaly unchanged. Pleural effusion, if any, is small.
There is no appreciable atelectasis. Left internal jugular line
tip projects over the junction of the brachiocephalic veins.
Brief Hospital Course:
Brief Hospital course: 73 year old female with hypertension,
hyperlipidemia, diastolic heart failure, hypertrophic
obstructive cardiomyopathy-like physiology secondary to left
ventricular hypertrophy, PVD, DM with ESRD on HD, paroxysmal
atrail fibrillation who presents after episode of chest pain and
hypotension during HD session on [**7-13**]. Patient transfered to the
CCU and requiring pressors to maintain her blood pressure. She
was given fluids and was eventually weaned off of pressors. Her
INR was elevated at 8 and she went in and out of normal sinus
rhythm, AFLutter and Afib. She was dialysed on monday and
wednesday and was eventually brought down to a weight of 53kg
with a CVP of 5. It was thought that this is her optimal weight
for her heart failure. To avoid hypotension she was dialized
over the course of 4 hours instead of 3. Pt. had a PICC line
placed while she was here which was removed before discharge.
She also underwent an EP study for ablation of atrial flutter
however no foci of flutter could be found in the right atrium
and the left atrium was not examined. No ablation occured, and
patient remained on Amiodarone. She was given follow up
appointments with her cardiologist, primary care and she sees
renal for dialysis three days a week.
Problem [**Name (NI) **]:
# CHF: History of diastolic HF; pt with EF > 75%, severe LVH
without regional LV systolic dysfunction, no dynamic LVOT
obstruction at [**Name (NI) 5348**] but HOCM physiology when tachycardic. 4
kg taken off during HD likely resulted in hypotension, CP. No
longer required pressors after fluid bolus. Dry weight (without
prosthesis) is 53kg.
- Conservative HD for volume management; CVPs checked durring
dialysis, was 5 when dialized to weight ot 53kg.
- Pt restarted on home BP meds for BP control; should have beta
blocker pre-dialysis per Renal
.
# HTN: Pt with tenuous status as above, exacerbated by anxiety
- Restarted on home BP meds - CCB, ACE I, [**Last Name (un) **], beta blocker; all
but beta blocker held prior to dialysis this AM
- Was on Nitro drip, which was succesfully weaned
- Metoprolol IV prn for BP control
.
# Rhythm: Pt with paroxysmal afib with HR in 80s. Pt in and out
of A-Fib, A-Flutter and Normal Sinus Rhythm. At risk of
worsening pump function if RVR present.
- Anticoagulation restarted.
- Continue beta blocker and CCB for HR control.
- Follow up with cardiologist as outpatient for lab testing
while on amiodarone. Thyroid function tests and Liver function
tests twice a year; chest x-ray and pulmonary function tests
yearly.
- Given Amiodarone taper upon discharge.
.
# CAD/ischemia: Cardiac cath in [**1-28**] shows nonobstructive
disease in coronary arteries. Pt complained of chest pain on
admission which resolved with morphine. She had essentially
unchanged EKGs (ST segment depressions in I, II, V4-V6, AVL),
likely secondary to demand ischemia related to hypotensive
episode/afib with rapid ventricular responce. Currently remains
chest pain free, Her cardiac enzymes trended down.
- Continue apririn, statin, beta blocker, ACE I for primary
prevention
.
# Valves: Pt with mild functional MS [**First Name (Titles) **] [**Last Name (Titles) 113**].
.
# DM: history of DM type 2, on NPH [**Hospital1 **] at home; finger sticks
well controlled
- Continue with NPH and humalog sliding scale for blood sugar
coverage
- finger sticks four times a day while inpatient
- Continue with ACE I and [**Last Name (un) **]
.
# ESRD on HD: M/W/F, session today. Pt also with secondary
hyperparathyroidism
- Continue with dialysis schedule.
- continue renal meds, nephrocaps.
- Electrolytes were closely monitored.
.
# Pulmonary: Significant smoking history. Lungs hyperinflated on
CXR during last admission, on 2L nasla cannula at home.
Currently on nasal cannula, although she did require
nonrebreather when in flash pulmonary edema.
- Continue spiriva, albuterol
- Monitor O2 status
.
# Prophylaxis: Coumadin, spirometry, bowel regimen
.
# Access: Pt had PICC inserted and IJ inserted. All lines
pulled for discharge/
.
# Code: Full discusssed with pt
.
# Communication: With pt
Medications on Admission:
B Complex-Vitamin C-Folic Acid 1 mg daily
Warfarin 2 mg Tablet daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops 1 drop QHS
Tiotropium Bromide 18 mcg Capsule 1 inh daily
Ranitidine HCl 150 mg Tablet daily
Lisinopril 30 mg 1 Tablet PO DAILY
4 units NPH [**Hospital1 **]
albuterol 1 puff [**Hospital1 **]
Aspirin 325 mg Tablet daily
Simvastatin 80 mg Tablet (1) Tablet PO once a day.
Diltiazem HCl 120 mg Capsule, SR 1 daily
Irbesartan 150 mg 1 daily
Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]
Sevelamer HCl 800 mg Tablet TID with meals.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic twice a
day: each eye.
8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): right eye.
12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO BID (2 times a day).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Insulin NPH Human Recomb Subcutaneous
15. Humalog Pen 100 unit/mL Insulin Pen Sig: as per sliding
scale Subcutaneous four times a day.
16. Outpatient Lab Work
INR on Monday [**7-25**], please call results to PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 109103**] at [**Telephone/Fax (1) 250**] and [**Hospital6 733**] coumadin
clinic [**Telephone/Fax (1) 2173**].
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: continue through [**7-28**]. .
Disp:*28 Tablet(s)* Refills:*0*
18. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: continue through [**8-4**].
Disp:*14 Tablet(s)* Refills:*0*
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**8-5**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Chest pain and hypotension during dialysis.
Hypertrophic Obstructive Cardiomyopathy
Acute on Chronic Diastolic Congestive Heart Failure.
Acute delirium
Discharge Condition:
Dry weight is 53 kg.
PICC line d/c'ed on [**2163-7-21**]
Delirium has cleared, MS [**First Name (Titles) **] [**Last Name (Titles) 5348**]
Discharge Instructions:
Your [**Last Name (Titles) 5348**] weight is 53 kg without your prostheses. That
should be your goal weight for after dialysis. Weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in one day or >6 lbs
over three days. Make sure your dialysis is over four hours not
three.
Please take your Lisinopril, irbesartan at night and take your
diltiazem after dialysis on Monday/Wednesday and Friday.
Please have your INR checked at dialysis and results called to
the coumadin clinic at [**Hospital6 733**]. [**Telephone/Fax (1) 2173**].
Adhere to 2 gm sodium diet, information was given to you at
discharge with detailed instructions on following a low sodium
diet.
Your amiodarone will be tapered over the next 3 weeks. you will
take 400mg twice a day until [**7-28**], then decrease to 400mg
once a day until [**8-4**], then decrease to 200mg daily and
continue indefinitely.
.
Your toprol was increased from 100mg twice a day to 150mg twice
a day.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**8-10**] at 11:20am.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2163-8-29**]
11:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2163-12-7**]
1:40
Primary Care:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (resident) for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 26455**],
MD Phone: [**Telephone/Fax (1) 250**]. Date/Time: Tuesday [**8-2**] at 2:20pm.
|
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"V49.75",
"443.9",
"518.81",
"403.91",
"427.31",
"414.01",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
13275, 13352
|
6562, 10663
|
346, 420
|
13548, 13689
|
3788, 6516
|
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|
2889, 3148
|
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|
13373, 13527
|
10689, 11247
|
13713, 14774
|
3163, 3769
|
275, 308
|
448, 1955
|
1977, 2619
|
2635, 2873
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,043
| 113,893
|
13976
|
Discharge summary
|
report
|
Admission Date: [**2167-6-1**] Discharge Date: [**2167-6-2**]
Date of Birth: [**2137-1-10**] Sex: M
Service: ENT
PRINCIPAL DIAGNOSIS:
1. Supraglottitis.
ASSOCIATED DIAGNOSES:
Laryngeal papillomatosis.
PROCEDURES:
1. Flexible fiberoptic laryngoscopy times two.
HISTORY OF PRESENT ILLNESS: The patient is a 30 year old
gentleman with known laryngeal papillomatosis status post
seven excisional procedures, now with known recurrences, who
reports a new onset complaint of odynophagia and sore throat
over the last three days. The patient describes having
something stuck in his throat. He denies any shortness of
breath. He is found to be hoarse, although he describes it
as being much worse than usual. He, furthermore,
subjectively describes that he feels his lungs are getting
worse. The patient denies fevers, weight loss or any new
medications. He furthermore has not undergone any recent
laryngeal procedures.
PAST MEDICAL HISTORY:
1. Ventricular septal defect, coarctation of the aorta.
2. Laryngeal papillomatosis, status post seven excision
procedures with CO2 lasers, with the most recent one
performed approximately four years prior to the current
presentation, in [**State 531**].
ALLERGIES: No known drug allergies.
MEDICATIONS: None.
SOCIAL HISTORY: The patient has a past history of tobacco
use, described as a half a pack a day for seven years. He
describes quitting approximately four years ago. He uses
minimal alcohol. He currently is a Master's student.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: On physical examination, the patient
is found to be awake and oriented times three. He has an
obviously hoarse voice. There is no shortness of breath,
stridor or distress appreciated. Examination of the ears is
normal. Nasal examination finds a moist mucosa with
significant erythema throughout. There is no evidence of
purulent discharge. Oral cavity and oropharynx examination
reveal no lesions or exudate. There is no asymmetry
appreciated. Examination of the neck reveals mild shotty
lymphadenopathy bilaterally. A mobile 1 cm lymph nodes at
levels 2 and 3 is appreciated. Airway is midline.
Fiberoptic examination was performed and was found to be
remarkable for a normal appearing epiglottis, however,
significantly swollen area of epiglottic folds as well as
arytenoid complexes bilaterally. The patient also has
evidence of edema over the vocal cords bilaterally,
associated with obvious papillomas on both vocal cords, right
greater than left. There is mild decrease in mobility of the
vocal cords. Otherwise, the patient is found to have a
regular rate and rhythm on cardiovascular examination with a
V/VI systolic ejection murmur. Lungs are found to be clear
to auscultation bilaterally. Abdominal examination revealed
it to be soft, nontender, nondistended. Examination of the
extremities revealed no evidence of cyanosis, clubbing or
edema. He was found to be neurologically grossly intact.
LABORATORY: On admission the patient was found to have a
white blood cell count of 12.8, hematocrit of 44, platelets
of 1216; polys were 65%, with 25% lymphocytes. Sodium 142,
potassium 3.8, chloride 105, CO2 24, BUN 7, creatinine 0.9.
In summary, the patient is a 30 year old with known laryngeal
papillomatosis who now has the acute onset of symptoms and
physical examination findings suggestive of supraglottitis.
The patient is found in no frank distress. He is, however,
admitted for airway observation as well as intravenous
steroids and antibiotics.
HOSPITAL COURSE: The patient was admitted for observation
into the Trauma Surgical Intensive Care Unit. He was there
monitored overnight with very rapid improvement once
receiving steroids as well as intravenous Unasyn. By
hospital day number two, the patient was able to tolerate a
diet without issue. He described full resolution of
symptoms.
The patient, however, was very anxious about his stay in the
hospital secondary to a lack of insurance. Services were
offered repeated times in order to assure him that at the
moment cost was of little importance, however, the patient
threatened numerous times with leaving Against Medical
Advice. Given the high degree of anxiety as well as the
clinical improvement which was confirmed on repeat fiberoptic
laryngoscopy examination (full resolution of arytenoid and
area epiglottic fold edema), a compromise was reached by
which the patient will be discharged on oral Medrol as well
as high-dose Augmentin.
The patient is to follow-up with Dr. [**Last Name (STitle) 1837**] three days
after discharge and earlier if any of his symptoms worsen or
recur. The patient understands that this is not the usual
protocol for management of his current medical problem, as
well as he understands that it will be of utmost importance
for him to follow-up closely with Dr. [**Last Name (STitle) 1837**].
The latter issues were discussed at length and agreed with
Dr. [**Last Name (STitle) 1837**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
1. The patient was discharged with prescriptions for
Augmentin 875 mg p.o. twice a day for ten days; Medrol
Dosepak.
2. The patient has no dietary or activity restrictions.
3. The patient is to follow-up with Dr. [**Last Name (STitle) 1837**] on
[**Last Name (LF) 2974**], [**6-5**].
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 6152**], M.D.
[**MD Number(1) 6153**]
Dictated By:[**Last Name (NamePattern1) 41760**]
MEDQUIST36
D: [**2167-6-2**] 14:28
T: [**2167-6-4**] 11:13
JOB#: [**Job Number 41761**]
|
[
"464.50",
"300.00",
"V15.82",
"212.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
1532, 1550
|
3611, 5046
|
5095, 5666
|
1608, 3593
|
5062, 5071
|
1570, 1585
|
311, 944
|
966, 1284
|
1301, 1515
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,082
| 154,926
|
30804
|
Discharge summary
|
report
|
Admission Date: [**2115-7-3**] Discharge Date: [**2115-7-8**]
Service: MEDICINE
Allergies:
Nsaids / Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Fever, nausea, vomiting and abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy, small stone/sludge extraction and
stent placement
History of Present Illness:
88 y/o man with CAD s/p CABG, presented to osh for chest pain,
he ruled out, but had n/v/abd pain, low grade fever, slight ams.
Found to have biliary obstruction on labs, sent here.
GNR grew from [**Hospital1 **] [**Location (un) 620**] cx. after pt. transfered here. S and
S pending. Here went to ERCP, had sphincterotomy and stent
placement, and is now improving. At ercp ? if he has a biliary
[**Doctor Last Name **]/focal collection/early abscess, as contrast at ERCP pooled
focally in liver. Now on cipro/flagyl. ERCP recommends
continuing this for two weeks minimum.
Pt. did have some CP in the ED o/n, but ECG without changes, and
troponin flat. Foley removed today and passed voiding trial.
Diet advanced to clears.
.
Pt reports CP 1 hour ago which has since resolved. He reports
that he didn't tell anyone because he thought it was GERD. He
denies N/V. He states that his abdominal pain is much improved.
He reports that he does not have any CP at all now. Otherwise he
is without c/o. All other ROS is otherwise negative. He reports
that he has throat soreness after the procedure. He reported
difficulty swallowing to the nurse.
Past Medical History:
CAD status post CABGx4, [**3-/2112**]
reportedly has diastolic CHF
GERD.
BPH.
Diverticulitis.
Hypertension.
Hyperlipidemia.
Skin cancer.
Orthostatic hypotension.
Possible Parkinson's disease.
history of TIA/CVA
- story of chronic dizziness, chronic chest pain and he has had
previous episodes to [**Hospital1 **] for chest pain and dizziness
Social History:
The patient lives at home and is independent. He uses a cane. He
is a retired state worker. Also WWII veteran. He denies any
history of smoking, alcohol or drug abuse. He walks with a
walker.
Family History:
Father died of pancreatitis and heart disease at age 84 and
mother died of PD at age 72. + for TB
Physical Exam:
T: 97.7 BP: 159/80 P: 65 R: 18 O2: 97% on RA
General: Alert, oriented, no acute distress
HEENT: icteric sclera, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles at the base
CV: Regular rate and rhythm, normal S1 + S2, early peaking soft
2/6 SEM at LUSB
Abdomen: soft, LLQ tenderness but patient says that this is
improved compared to yesterday.
GU: deferred
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3- Knows [**Last Name (un) 2753**] is president, speech fluent, affect
appropriate, pleasant, good historian, 5/5 strength in upper and
lower extremities, gait assessment deferred.
+ intention tremor
Skin: No lesions
Pertinent Results:
Images:
FROM [**Location (un) **]
RUQ US [**2115-7-3**]: Abdominal ultrasound showed a negative [**Doctor Last Name **]
sign, showed increased density of the liver, slight sludge in
the gallbladder, no stones. No son[**Name (NI) 493**] evidence of
cholecystitis.
.
CT/CTA TORSO/CHEST [**2115-7-3**]
IMPRESSION: NO EVIDENCE OF AORTIC DISSECTION. NO EVIDENCE OF
PULMONARY EMBOLISM. ASCVD. CHOLELITHIASIS. DIVERTICULOSIS.
DISTENTION OF THE URINARY BLADDER. DEGENERATIVE ARTHRITIC CHANGE
IN THE SPINE.
CXR [**2115-7-3**] no pneumonia, no CHF
TTE, [**2112**], normal EF, no valvular disease
Persantine MIBI [**3-/2115**]: EF 56%, no e/o ischemia
.
EKG: SR at 61 bpm, + PVCs, non-specific lateral TW changes.
[**2115-7-4**] 03:07AM BLOOD WBC-7.0 RBC-3.26* Hgb-11.8* Hct-32.6*
MCV-100* MCH-36.2* MCHC-36.2* RDW-11.6 Plt Ct-132*
[**2115-7-8**] 07:15AM BLOOD WBC-5.5 RBC-3.59* Hgb-12.6* Hct-35.8*
MCV-100* MCH-35.2* MCHC-35.3* RDW-11.9 Plt Ct-160
[**2115-7-4**] 03:07AM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-21* AnGap-16
[**2115-7-8**] 07:15AM BLOOD Glucose-137* UreaN-18 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2115-7-4**] 03:07AM BLOOD ALT-514* AST-326* CK(CPK)-28*
AlkPhos-150* TotBili-5.2* DirBili-3.6* IndBili-1.6
[**2115-7-8**] 07:15AM BLOOD ALT-115* AST-35 AlkPhos-180* TotBili-0.9
[**2115-7-5**] 02:57AM BLOOD Lipase-12
[**2115-7-4**] 03:07AM BLOOD CK-MB-2 cTropnT-<0.01
.
Blood culture:
[**2115-7-3**]: E Coli Resistant to ampicillin and bactrim, otherwise
sensitive to all tested antibiotics.
06.23 and 24.11 are without growth to date.
.
Urine culture: No growth.
Brief Hospital Course:
88 yo M with CAD, chronic diastolic CHF and HTN with
cholangitis and E Coli bacteremia.
Cholangitis and E Coli bacteremia. Pt presented with nausea,
chest pain, fever and was found to have transaminitis and
hyperbilirubinemia. His blood cultures from [**Location (un) 620**] were
positive for E.Coli sensitive to levofloxacin. He was
transferred from [**Hospital3 628**] and underwent ERCP with
stone/sludge removed. He had a sphincterotomy with stent
placement. He had findings of a biliary [**Doctor Last Name **] vs abscess in the
right intrahepatic system. He was placed on cipro/flagyl with
resolution of clinical symptoms and normalization of LFT's and
bilirubin. He will complete 2 total weeks of antibiotics. His
home simvastatin and acetaminophen were held due to LFTs and can
be restarted 4 days after discharge. For recurrent fevers he
should have an U/S or MRI of the liver to rule out abscess. He
needs a f/u ERCP for stent removal in [**4-17**] weeks. The patient did
not have gallbladder stones on RUQ U/S done at [**Hospital1 **] [**Location (un) 620**] and
based upon the ERCP report, this seems mostly to have been
sludge mediated. For now he appears to have adequate biliary
drainage and there is no plan for cholecystectomy.
HTN, CAD. The patient presented with chest pain complaints. He
had no ECG changes and normal cardiac enzymes. He continues on
his home medication regimen except statin which can be restarted
4 days after discharge.
Dysphagia. The patient complained of intermittent dysphagia.
Speech and swallow eval was within normal limits. He can
continue on a regular diet.
Code: Full
The patient is discharge home with home services including
nursing assistance with medications and physical therapy.
Medications on Admission:
aspirin 325 mg p.o. daily
Tylenol 1000 mg p.o. b.i.d.
meclizine 12.5 mg p.o. b.i.d.
vitamin B12 1000 mcg p.o. b.i.d.
omeprazole 20 mg p.o. b.i.d.
Metamucil 1 tablet t.i.d.
hydrocodone with Tylenol 5/352 one tablet b.i.d.
Zocor 20 mg p.o. daily
lisinopril 20 mg p.o. daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO twice a day.
3. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Vitamin B-12 1,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Metamucil
1 tablet TID
7. hydrocodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO twice a day as needed for pain.
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day: Restart
4 days after discharge.
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8
days.
Disp:*16 Tablet(s)* Refills:*0*
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Cholangitis
E Coli Bacteremia
CAD
Chronic diastolic CHF
HTN
HLD
GERD
Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of an infection in the bile system
that spread into your blood stream. You must continue to take
the prescribed antibiotics for 8 more days to complete
treatment.
You had a procedure to open up the bile system, called ERCP. You
need to have a repeat ERCP in [**4-17**] weeks to remove a stent that
was left in place. If you do not hear from the ERCP group at
[**Hospital3 **] to schedule this appointment in 4 weeks, please call
to schedule this at [**Telephone/Fax (1) **].
Do not restart your home lipitor until 4 days after discharge.
Followup Instructions:
Name:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21373**],MD
Specialty: Primary Care
Address: [**Street Address(2) 21374**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 6163**]
When: Wednesday, [**7-11**] at 1:30pm
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46,904
| 144,038
|
30562
|
Discharge summary
|
report
|
Admission Date: [**2136-12-23**] Discharge Date: [**2136-12-26**]
Date of Birth: [**2085-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Fever, nausea, vomiting and shortness of breath
Major Surgical or Invasive Procedure:
Right IJ central venous catheter placement [**2136-12-23**]
History of Present Illness:
51 yo man with hx of BOOP, OSA, obesity hypoventilation
syndrome, PE, tracheobronchomalacia, HTN, HLD, Diabetes [**3-6**] PNA,
and persistent back pain presents with fevers SOB and general
malaise. Pt said that he was recently discharged from [**Hospital1 18**] and
was feeling well, but noticed he was immediately gaining weight
after his discharge. 2 weeks prior to admission, he started to
have increasing SOB and back pain that was limiting his activity
and he stopped leaving the house. These symptoms worsened and he
said it would take him 40 minutes just to shave his face. In
addition, a couple of days prior to admission, he began to feel
generally unwell. He said he just felt "crappy", lightheaded
when he would stand up and his breathing was significantly
worse. He daughter visited him, who he said was sick with a
possible cold. The day prior to admission the patient began to
have fevers, recorded at a Tmax of 101 at home. He also had 4
episodes of vomiting and 3-4 episodes of loosely formed stool.
On the day of admission, th patient was very uncomfortable and
difficult to walk. He didn't feel well and whole body aches and
felt he needed further evaluation so he called the clinic to
arrange for ride to the ED.
.
On review of systems pt noted that he also has been coughing up
clear sputum over the past couple of days and has had a sore
throat for 1 day. He also reports abdominal cramping over the
past 2 days. He denies rhinorrhea, nasal congestion, chest pain,
abdominal pain, bloating, dysuria, increase in frequency or
change in color of his urine or stools. Pt states that he has
been drinking 3 12 ounce bottles of water daily along with
coffee and some juice. However, he has not been eating much
recently over the past few days.
.
In the ED VS were 97.2 (Tmax 100.1) 89 71/41 18 92% RA. He was
hypotensive SBP ranged from 70-100s, though mentating well.
Complained of back pain. On exam, he had bl LE, signs of venous
stasis, and erythema concerning for cellulitis. His labs were
notable for Na 126, Cr 2.9 (baseline 1), Hct 29, lactate 4.4
(down to 1.7 after ivfs). He had ct abd/pelvis that was
unremarkable for acute process, CXR w/ stable appearing opacity,
LENIs negative for dvt, and plain films of tibia/fib. He
received vanc, flagyl, zosyn, levo, solumedrol,
morphine/fentanyl for pain.
Past Medical History:
-Cryptogenic organizing pneumonia, dx via RML wedge resection
[**2-/2136**], on chronic prednisone.
-PEs; subsegmental, d/x [**2136-6-7**].
-Fracture of L2 and multiple ribs after mechanical fall.
-Crush injury to his legs after being involved in a [**Doctor Last Name 9808**]
collapse in [**2116**], leading to right knee replacement and
bilateral femoral pins.
-Multiple gunshot wounds to legs/back/buttocks, complicated by
osteomyelitis, in [**2106**] after being involved in an altercation
with a neighbor.
-Obesity
-tracheobronchomalacia with difficult intubation
-Severe obstructive sleep apnea -- restarted biPAP [**5-/2136**]
-HTN
-Hyperlipidemia
-Diastolic CHF, EF>55% in [**8-11**]
-Diabetes mellitus -- developed secondary to steroids
-Depression and PTSD
-Tobacco abuse
-Alcohol abuse
-Squamous cell carcinoma on dorsum of right hand s/p Mohs
micrographic surgery
-Back pain s/p multiple surgeries in cervical through lumbar
spine on narcotics contract
-Questionable h/o pericarditis with pericarial effusion
requiring drainage at [**Hospital1 **] (patient report.
-Obesity hypoventilation syndrome
-Suicidal ideation (passive and contracting for safety)
Social History:
Lives alone in [**Location (un) 5289**]. On disability, but formerly worked in
construction doing wrecking. He was a certified asbestos
remover and had significant asbestos exposure 20-30 years ago.
- Tobacco history: Smoked 1.5 pk/day x30 years, recently
restarted smoking a couple cigarettes per day.
- ETOH: Last drink 3 days ago. Has drank 1-2 drinks of vodka on
two occasions this week. deneis daily ETOH use. Reports history
of occasionally drinking more than 20 beers at a sitting but not
recently. Asserts that he drinks minimally now because of his
health.
- Illicit drugs: None.
- Herbal/alternative therapy: None.
- He is divorced, but close with his ex-wife. Two children, son
died last year in [**Location (un) 8751**].
Son passed away last year in a car accident, has a daughter in
early 20's. Drinks alcohol several times per week & some weeks
none. Trying to quit smoking or recently quit.
Family History:
- Brother with heart transplant for pericarditis
- No other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
- mother had melanoma and died of perforated peptic ulcer at 71
Physical Exam:
Admission Physical Exam:
VS: Temp:99.9 BP: 111/49 HR:86 RR:17 O2sat 93% 2L
GEN: pleasant, morbidly obese man, in NAD on nasal cannula
HEENT: PERRL, rubor in a butterfly distribution, bilateral
ulcerations at the edges of the mouth,
Neck: no LAD, difficult to evaluate JVD with RIJ in place
RESP: Decreased breath sounds in the posterior lung fields
bilaterally, tubular breath sounds in the upper lung fields
posteriorly bilaterally. clear to ausculatation anteriorly
CV: RRR, S1 and S2 present, no S3/S4 no m/r/g
ABD: +b/s, soft, nt, nd, no rebound tenderness or gaurding
EXT: 2+ radial pulses, Lower extremities with 4+ pitting edema,
diffuse erythema below the knees b/l, non-tender, not warm to
the touch, no induration or crepitus, with overlying areas of
white scaling and patchiness. pt also has bilateral surgical
scars at the level of the knees b/l
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
[**2136-12-23**] 02:55PM BLOOD WBC-9.1 RBC-3.64* Hgb-10.3* Hct-29.7*
MCV-82 MCH-28.3 MCHC-34.7 RDW-20.9* Plt Ct-330#
[**2136-12-23**] 02:55PM BLOOD Neuts-78.3* Lymphs-16.0* Monos-4.5
Eos-0.6 Baso-0.7
[**2136-12-24**] 04:40AM BLOOD WBC-7.6 RBC-3.50* Hgb-9.5* Hct-29.0*
MCV-83 MCH-27.1 MCHC-32.8 RDW-20.2* Plt Ct-299
[**2136-12-23**] 02:55PM BLOOD Glucose-148* UreaN-26* Creat-2.9*#
Na-126* K-3.1* Cl-79* HCO3-29 AnGap-21*
[**2136-12-23**] 11:44PM BLOOD Glucose-222* UreaN-24* Creat-2.1* Na-131*
K-3.2* Cl-84* HCO3-34* AnGap-16
[**2136-12-24**] 04:40AM BLOOD Glucose-135* UreaN-24* Creat-1.8* Na-134
K-3.4 Cl-87* HCO3-35* AnGap-15
[**2136-12-24**] 12:30PM BLOOD Glucose-201* UreaN-23* Creat-1.4* Na-133
K-3.6 Cl-88* HCO3-39* AnGap-10
[**2136-12-23**] 02:55PM BLOOD ALT-16 AST-23 AlkPhos-75 TotBili-0.4
[**2136-12-23**] 02:55PM BLOOD cTropnT-<0.01
[**2136-12-23**] 03:14PM BLOOD Lactate-4.4*
[**2136-12-23**] 07:38PM BLOOD Lactate-1.7
[**2136-12-23**] 04:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2136-12-23**] 04:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2136-12-23**] 04:55PM URINE Hours-RANDOM UreaN-82 Creat-49 Na-35 K-37
Cl-44
[**2136-12-23**] 04:55PM URINE Osmolal-192
[**2136-12-26**] CBC: WBC 8.2, HCT 29.5, PLT 283
[**2136-12-26**] Na 138, K 3.1, Cl 89
[**2136-12-23**]
IMPRESSION: Stable-appearing upper lobe lung opacities which
have been seen on multiple prior studies dating back to a chest
CT from [**2136-5-5**]. Please correlate clinically as the
differential diagnosis is broad and includes cryptogenic
organizing pneumonia or hypersensitivity pneumonitis.
[**2136-12-23**] CT ABD/PELVIS
FINDINGS: At the imaged lung bases, there is stable linear
hyperdensity along the right anterior lung base, unchanged. No
evidence of pneumonia. Prominent extrapleural fat is noted. The
imaged portion of the heart is unremarkable.
ABDOMEN: The non-contrast appearance of the liver, spleen,
pancreas is
unremarkable. The gallbladder is contracted. Right adrenal gland
is
unremarkable. As previously noted, there is a tiny
fat-containing lesion in the left adrenal gland, most likely an
adrenal myelolipoma, approximately 10 x 14 mm, seen best on
series 300B, image 47. The kidneys appear unremarkable without
hydronephrosis or stone. The aorta is normal in course and
caliber with scattered areas of atherosclerotic calcification
noted. No free air or free fluid is seen. The stomach and
duodenum appear unremarkable.
PELVIS: Loops of small bowel demonstrate no evidence of ileus or
obstruction. A fat-containing ventral and umbilical hernia is
again noted. The large bowel contains mild fecal load and there
is no definite sign of colitis, diverticulosis, or
diverticulitis. The urinary bladder contains a Foley catheter
and is mostly decompressed. No free fluid is seen in the deep
pelvis. No pelvic lymphadenopathy.
BONES: Old healed right lower rib fractures are again noted. Old
laminectomy defect in the lower lumbar spine is again seen. No
worrisome lytic or sclerotic osseous lesions are seen. A defect
in the left proximal femur is likely related to prior fixation.
IMPRESSION: No acute findings in the abdomen or pelvis.
LENI - IMPRESSION: No evidence of DVT. Calf veins not
visualized.
[**2136-12-23**] Portable AP CXR
FINDINGS: Single AP upright portable chest radiograph is
obtained. Since the prior study, there has been placement of a
right IJ central venous catheter with its tip in the expected
location of the superior vena cava. Scattered lung opacities are
again noted, which are slightly more prominent in the right
lower lung. Cardiomediastinal silhouette is unchanged.
11/21/10TWO VIEWS OF BOTH TIBIAS AND FIBULAS: There is no
subcutaneous gas or foreign body in either distal lower
extremity. Note is made of extensive bilateral subcutaneous
edema. Bony structures are intact, specifically with no
fracture, dislocation, or erosion.
ECHO [**2136-12-25**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Diastolic function
could not be assessed. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The number of aortic valve leaflets cannot be determined. There
is no aortic valve stenosis. No aortic regurgitation is seen.
Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
Hypotension - Likely related to diuresis with torsemide and
metolazone. He was very volume overloaded as an outpatient but
his peripheral edema improved. He initilaly had a fever and
rec'd broad spectrum antibiotics in the ER but these were
subsequently held and his cultures remained negative and he had
no signs or symptoms of any infeciton. His acute renal failure
and hypotension completely resolved with IV fluid resuscitation
and the patient was discharged home on torsemide 100mg po daily.
He was told to no longer take metolazone and to stop taking
lisinopril, the lisnopril may be restarted in follow up. He has
had multiple admissions for the same reason in the past,
medication non compliance issues have been raised and that he
may be taking extra diuretic occasionally; however he does have
a VNA and takes his medication from a bubble pack. The issue of
long term placement was raised but the patient adamantly refused
this.
Acute kidney injury - Creatinine improved with volume
resuscitation.
BOOP - Prednisone increased to 30 mg from 20 mg daily in the
event that recent [**Month/Day/Year 15123**] may have exacerbated baseline
cardiopulmonary status. Continued bactrim prophylaxis.
OSA - Continued BIPAP qhs.
Chronic pain - Continued home narcotic regimen.
DM - Continued basal and sliding scale insulin.
Medications on Admission:
Citalopram 20mg PO Daily
Lantus 15 units Daily
Lisinopril 5mg PO daily
Mitolazone 5mg PO tuesdays and Fridays
Omeprazole 20mg PO daily
KCL 20 mEq PO Daily
simvastatin 40mg PO Daily
Bactrim 1 DS mon-wed-fri
Torsemide 100mg PO Daily
Prednisone 20mg PO Daily
Vitamin D2 50,000 Units weekly
oxycontin 80mg PO Q 8 hours
oxycodone 30mg Q4hrs:PRN
aspirin 81mg PO Daily
Insulin sliding scale
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
7. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. vitamin d2 Sig: 50,000 units once a week.
9. oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
10. oxycodone 15 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
your pulmonary doctor [**First Name (Titles) **] [**Last Name (Titles) 15123**] this medication.
Disp:*90 Tablet(s)* Refills:*2*
13. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Hypotension
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You were admitted for a low blood pressure and kidney failure
which improved with IV fluids. This was likely a result of your
medications. Please make the following changes to your
medication regimen:
MEDICATION CHANGES:
STOP taking METOLAZONE
STOP taking LISINOPRIL
INCREASE dose of PREDNISONE back to 30mg daily
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2137-1-2**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2137-1-2**] at 1:30 PM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2137-1-2**] at 1:30 PM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**1-7**] at 11:30 a.m. with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in the
cardiology clinic, [**Hospital Ward Name 23**] 7.
[**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"276.51",
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"309.81",
"E947.8",
"249.00",
"V10.83",
"V43.65",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.49",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13768, 13827
|
10703, 12038
|
364, 425
|
13922, 13922
|
6125, 10680
|
14504, 15457
|
4916, 5126
|
12473, 13745
|
13848, 13848
|
12064, 12450
|
14073, 14366
|
5166, 6106
|
14386, 14481
|
277, 326
|
453, 2781
|
13867, 13901
|
13937, 14049
|
2803, 3972
|
3988, 4900
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,480
| 177,964
|
32839
|
Discharge summary
|
report
|
Admission Date: [**2145-1-17**] Discharge Date: [**2145-1-25**]
Date of Birth: [**2070-3-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
abdominal pain, acute renal failure, hypotension
Major Surgical or Invasive Procedure:
left subclavian central line
Upper endoscopy
Transfusion of packed red blood cells
History of Present Illness:
Ms. [**Known lastname 4886**] is a 74 year old woman with a history of CHF, chronic
renal insufficiency, peptic ulcer disease, CAD, HTN, who is
admitted to the MICU for management of acute renal failure,
abdominal pain, and hypotension. She was brought in to the
[**Hospital6 10353**] ED yesterday after reportedly having
several days of poor PO intake and abdominal pain at her
[**Hospital3 **] facility, per her daughter. The patient gives a
vague history of recent URI symptoms, and she reports a
mechanical fall yesterday, without any head trauma or loss of
consciousness.
.
At the [**Hospital3 **] ED, she was noted to be in
acute-on-chronic renal failure with a creatinine of 4.9 and a
serum HCO3 of 6. She had a SBP in the mid-80s and was reportedly
hypothermic to 95.8, with a leukocytosis to [**Numeric Identifier 2686**]. An ABG showed
a metabolic acidosis (7.22/22/175 on 2L n.c.). She was noted to
vomit 200cc of "blood-tinged mucous". She underwent an abdominal
CT with PO (no IV) contrastwhich showed no acute process. She
was given a dose of metronidazole and moxifloxacin for empiric
antibiotics. She was also given a dose of IV ondansetron, a
1000cc NS bolus, and 150 mEq of NaHCO3. A left-sided subclavian
central line was placed and she was transferred to [**Hospital1 18**].
.
Upon arrival to the [**Hospital1 18**] ED, she was afebrile with a
temperature of 98.2, BP 91/59, HR 84. She was given 1000cc NS
bolus and 1000cc D5W with 150 mEq HCO3. She reportedly had a
decrease in her BP to 56/44 which improved to 102/58 with a
250cc NS bolus and low dose of norepinephrine. She was also
given 10 mg of IV dexamethasone for unclear reasons. She had a
CT which showed no acute process and an abdominal ultrasound
which showed a mildly dilated (1.1cm) CBD; no gallbladder was
identified. Per the [**Hospital1 18**] ED resident, she was noted on two
separate rectal examinations to have black tarry stool which was
Guaiac negative.
.
Upon arrival to the MICU, she had a dry black stool which was
Guaiac positive. Her norepinephrine was weaned off upon arrival
to the MICU.
.
Of note, she had a similar presentation to [**Hospital 882**] Hospital in
[**9-/2144**] when she presented with acute-on-chronic renal failure,
decreased PO intake, and left-sided abdominal pain. An EGD on
that admission showed a nonbleeding gastric ulcer, and her ppi
was changed from pantoprazole to omeprazole and increased [**Hospital1 **].
She also had a question of antral thickening on a CT scan, and
antral biopsies were taken, the results of which are unavailable
to us at the time of this note.
Past Medical History:
Past Medical History:
- congestive heart failure (by report, LVEF 50% om [**4-/2144**])
- CAD with ?MI
- peptic ulcer disease with ? bleeding ulcer in distant past;
EGD in [**11/2143**] showed nonbleeding gsatritis; EGD in [**9-/2144**]
showed nonbleeding erythematous gastritis and nonbleeding
gastric ulcer
- short-term memory loss
- ?CVA vs TIA
- chronic renal insufficiency (baseline creatinine 1.6) with
multiple recent episodes of acute exacerbations
- HTN
- hx C2 fracture with hardware in place
- "moderate" right-sided RAS
- s/p appendectomy
- s/p cholecystectomy
- s/p partial colectomy for diverticulitis
- osteoporosis
- hyperlipidemia
- COPD
.
Social History:
Social History:
Quit smoking >15 yrs ago. No alcohol or drugs. Lives in River
Bay Club [**Hospital3 **] facility.
Family History:
Family History:
Per daughter, the patient's father died at an early age from an
MI.
Physical Exam:
T 97.8 BP 121/58 HR 93 RR 23 Sat 100% on 2L n.c.
CVP 4cm
General: uncomfortable, but in no acute distress
HEENT: no scleral icterus, MM moderately dry
Neck: JVP 6cm, no thyromegaly
Chest: clear to auscultation throughout, no w/r/r
CV: regular rate/rhythm, normal S1S2, no m/r/g
Abdomen: soft, mild voluntary guarding esp. in LLQ; tenderness
to moderate palpation mostly in LLQ; no rebound
Extremities: no edema, 2+ PT pulses
Skin: no rashes
Neuro: alert, oriented to self, "[**2142-1-3**]" and "River Bay
Club".
Pertinent Results:
From [**Hospital3 **] Ctr:
ABG (9:45pm)
7.22/22/175 on 2L n.c.
.
Labs on admission:
[**2145-1-17**] 12:30AM BLOOD WBC-16.2* RBC-3.56* Hgb-11.1* Hct-32.5*
MCV-91 MCH-31.3 MCHC-34.3 RDW-14.1 Plt Ct-253
[**2145-1-17**] 12:30AM BLOOD Neuts-95.9* Bands-0 Lymphs-2.8*
Monos-1.2* Eos-0.1 Baso-0
[**2145-1-17**] 12:30AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1
[**2145-1-18**] 06:09AM BLOOD Ret Aut-0.7*
[**2145-1-17**] 12:30AM BLOOD Glucose-196* UreaN-119* Creat-4.0* Na-137
K-4.7 Cl-110* HCO3-13* AnGap-19
[**2145-1-17**] 12:30AM BLOOD ALT-14 AST-25 CK(CPK)-164* AlkPhos-143*
Amylase-68 TotBili-0.2
[**2145-1-17**] 12:30AM BLOOD Lipase-80*
[**2145-1-17**] 12:30AM BLOOD CK-MB-8 cTropnT-0.01
[**2145-1-17**] 12:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.3
[**2145-1-18**] 06:09AM BLOOD calTIBC-148* Ferritn-397* TRF-114*
[**2145-1-19**] 06:05AM BLOOD Osmolal-307
[**2145-1-21**] 06:15AM BLOOD PEP-NO SPECIFI
[**2145-1-17**] 06:02AM BLOOD Type-ART pO2-123* pCO2-22* pH-7.36
calTCO2-13* Base XS--10
[**2145-1-17**] 12:31AM BLOOD Lactate-1.3
[**2145-1-17**] 06:02AM BLOOD freeCa-1.28
.
Labs on discharge:
[**2145-1-24**] 11:00AM BLOOD WBC-9.5 RBC-2.75* Hgb-9.1* Hct-26.0*
MCV-95 MCH-33.2* MCHC-35.1* RDW-14.5 Plt Ct-266
[**2145-1-25**] 06:04AM BLOOD Glucose-83 UreaN-8 Creat-1.2* Na-140
K-4.0 Cl-108 HCO3-22 AnGap-14
[**2145-1-25**] 06:04AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.5*
.
Microbiology:
[**2145-1-17**] blood culture - negative
[**2145-1-17**] Urine culture - negative
[**2145-1-17**] c diff - negative
[**2145-1-18**] blood culture - negative
[**2145-1-19**] h pyloi - negative
.
Other Studies:
Abd CT ([**2145-1-16**]- from [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]):
Appendix is not identified. Atrophic kidneys. Gallbladder is not
visualized. Atherosclerotic aorta. Old healed deformity of left
anterior and superior pubic rami.
.
Head CT ([**2145-1-17**]):
Examination is mildly limited by motion artifact. There is no
hemorrhage, mass effect, shift of the normally midline
structures, or vascular territorial infarct. Mild
periventricular white matter hypodensity is consistent with
chronic microvascular ischemia. There is no hydrocephalus. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. Orthopedic
hardware is seen within the dens. The visualized paranasal
sinuses and mastoid air cells are well aerated.
.
Abd US ([**2145-1-17**]):
The liver is unremarkable without focal or textural abnormality.
The portal vein is patent with appropriate hepatopedal flow.
There is no intrahepatic biliary dilatation. The common bile
duct is dilated measuring 1.1 cm. The gallbladder is not
definitively identified. The structure interrogated on multiple
views located near the gallbladder fossa most likely represents
bowel/stomach with gallstone-filled gallbladder.
.
ECG ([**2145-1-17**]):
NSR at 93 bpm. Normal axis, normal intervals. Poor baseline.
Biphasic T waves noted in I, aVL, II, aVF, and V5-V6.
.
CT Abd/Pelvis ([**2145-1-17**]):
IMPRESSION:
1. Mild colonic wall thickening extending from the splenic
flexure to the distal sigmoid, suggestive of infectious or less
likely, ischemic etiology. No perforation or fluid collection.
No abscess. Following recuperation of renal function, a CT
angiogram of the mesenteric vessels could be performed if
clinically indicated.
2. Likely subacute fracture of the left symphysis pubis and
rami. Correlation with prior outside imaging studies may be of
assistance.
3. LLL 6 mm pulmonary nodule. 6 month fllow-up exam advised.
.
CT Abd/Pelvis, repeat ([**2145-1-24**]):
IMPRESSION:
1. Resolution of mild colonic wall thickening seen on prior
study.
2. No additional evidence to explain patient's symptoms.
Brief Hospital Course:
74 year old woman with abdominal pain, Guaiac-positive black
stool, and acute-on-chronic renal failure.
.
1) Guaiac-positive black stool: Patient was initially admitted
to the ICU for management. GI consulted and recommended
endoscopy, [**Hospital1 **] PPI, and C. Diff studies. Endoscopy was
performed demonstrating a non-bleeding duodenal ulcer w/o
exposed vessels, and gastritis. Continued on [**Hospital1 **] PPI with
stable Hct thereafter. H. Pylori negative.
.
2) Abdominal Pain: Certainly could be due to PUD, though the
location of her pain is not classic for PUD. Abdominal CT scan
report from OSH unrevealing (status post cholecystectomy and
appendectomy). Pancreatic/hepatic labs within normal limits.
Abdominal CT without contrast here with mild distal colonic
thickening - unclear if infectious vs. inflammatory vs. ischemic
(less likely). GI consulted for guiac + stool. Recommended C.
Diff studies (negative x1). On transfer to the floor abdominal
pain remained mild, but persisted over several days. Patient
had unimpressive abdominal exam, but with definite tenderness to
palpation in the LLQ and RLQ. Repeat CT of the abdomen was
performed demonstrating clearance of the colonic thickening.
Her abdominal pain was ultimately attributed to constipation, as
she had not had a bowel movement in 7 days. Bowel regimen was
uptitrated resulting in multiple bowel movements (and some
diarrhea) with some resolution of abdominal discomfot.
.
3) Acute renal failure: Likely due to hypovolemia/prerenal
azotemia given CVP of 4 on initial presentation to ICU, poor PO
intake, known renal artery stenosis. Creatinine improved with
IV hydration and reached nadir of 1.1 - 1.2, patient's baseline.
.
4) Metabolic Acidosis/hypophosphatemia: Patient was noted to
have metabolic acidosis in setting of renal failure. Renal
consulted. They felt this was likely due to the patients renal
failure, and did not recomend chronic bicarbonate repletion.
Unable to clearly diagnose type I or type II RTA in setting of
acute renal failure. Upon resolution of renal failure, acidemia
resolved.
.
5) Hyphophatemia: Floor course complicated by severe
hypophosphatemia requiring aggressive repletion and thought due
to chronic poor PO intake and refeeding syndrome. Resolved by
time of discharge.
.
6) Tachypnea: Patient notably tachypneic throughout most of her
ICU course, but without SOB, cough or other pulmonary
complaints. All pulmonary work up was negative and this was
felt due to her metabolic acidosis with respiratory
compensation. Resolved with resolution of metabolic acidosis.
.
7) Hypotension: Patients SBP improved with IV hydration.
Cultures were negative. Was orthostatic on transfer to the
floor, but resolved with further hydration. Felt all to be due
to dehydration/GI bleed. Completely resolved at time of
discharge.
.
8) Leukocytosis: Patient with prominent leukocytosis on
admission. C. Diff negative, cultures NGTD. Steadily improved
over hospitalization and thought to be due to low level GI bleed
and UTI. Urine culture was negative, but treated for UTI as
below.
.
9) Urinay tract infection: During work up for leukocytosis
above, urinalysis was sent, which was borderline positive. She
was treated with 7 day course of levofloxacin, as this was felt
to be a foley catheter related UTI. Urine culture returned
negative.
.
10) Pulmonary Nodule: Patient had right lower lobe lung nodule
noted incidentally on abdominal CT scan. This will require
follow up with repeat chest CT in 6 months
Medications on Admission:
Home Medications:
ferrous sulfate 325 mg daily
lisinopril 10 mg daily
aspirin 81 mg daily
multivitamin 1 tab daily
calcium carbonate/vitamin D 1 tab daily
docusate 100 mg [**Hospital1 **]
ipratropium/albuterol MDI 2 puffs [**Hospital1 **]
mirtazapine 7.5 mg qhs
atorvastatin 80 mg daily
acetaminophen 500 mg tid
omeprazole 20 mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): [**Month (only) 116**] take an extra 2 tablets per day as needed for
constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
13. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
14. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Elder Services Plan
Discharge Diagnosis:
Primary:
Acute renal failure
Hypotension-Dehydration
Mixed metabolic acidosis
Left sided colitis NOS
Hypophosphatemia
Duodenal ulcer
Left lower lobe 6 mm pulmonary nodule
Constipation
Secondary:
Osteoporosis
Subacute fracture - left symphysis pubis and rami
CKD Stage III
COPD
C2 fracture s/p instrumentation
Hyperlipidemia
CAD NOS
Diastolic heart failure NOS
Depression
s/p appendectomy
s/p cholecystectomy
s/p partial colectomy for diverticulitis
Discharge Condition:
Good. Patient ambulating, symptoms improved.
Discharge Instructions:
You were admitted to the hospital for evaluation of a mechanical
fall, and treatment of low blood pressure, acute renal failure
and abdominal pain. During your hospital course, your low blood
pressure and acute renal failure resolved with fluid hydration.
You were also evaluated for a low blood level with an endoscopy
that demonstrated an ulcer, and inflammation of your stomach.
You were started on pantoprazole 40mg twice daily. Your
abdominal pain was evaluated with a CT scan, repeat was normal.
However it did incidentally note a small left sided pulmonary
nodule which will need to be followed up in 6 months time.
Otherwise your abdominal pain was treated with giving you
medications to help you have a bowel movement.
.
Please take all medications as directed.
.
Please follow up with all appointments as directed.
.
Please contact physician if develop worsening abdominal pain,
diarrhea, blood in stool, weakness/dizziness, black colored
stools, any other questions or concerns.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 724**] ([**Telephone/Fax (1) 76456**] in [**2-4**] weeks time.
.
Of note, you had a left lower lobe lung nodule that was 6mm in
size that was noted on a CT scan during your hospital course.
You will need a 6 month follow-up CT scan that should be
scheduled by your primary care physician.
.
Please have your primary care physician set you up with follow
up with gastroenterology, for follow up of your duodenal ulcer.
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
13532, 13582
|
8212, 11745
|
328, 413
|
14076, 14124
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4501, 4571
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11789, 12108
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240, 290
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5584, 8189
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441, 3039
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4585, 5565
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3083, 3719
|
3751, 3851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,980
| 181,394
|
41728
|
Discharge summary
|
report
|
Admission Date: [**2192-8-14**] Discharge Date: [**2192-9-26**]
Date of Birth: [**2161-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
[**2192-8-14**]: Right-sided hemicraniectomy for decompression,
evacuation of hematoma, repair of laceration, durotomy,
duraplasty.
[**2192-8-24**]: Percutaneous endoscopic gastrostomy
[**2192-8-31**]: ex-lap, PEG removal, partial gastrect, J-tube
[**2192-9-20**]: Right Cranioplasty
History of Present Illness:
Ms. [**Known lastname **] [**Known lastname **] was witnessed to be crossing route 9 per report
and was struck by a vehicle and became airborne. She was
minimally responsive at the scene and found vomiting. EMS got no
control for Versed administration but were unable to
intubate her. She was easily bagged with an oral pharyngeal
airway in place. She was hemodynamically stable en route.
Neurosurgery was consulted for poor GCS and head injury.
Past Medical History:
none
Social History:
Here on business from the [**Country 26232**], no tobacco, no ETOH
Family History:
non contributory
Physical Exam:
On Admission:
Constitutional: Obtunded. Vomited on her face. Moaning to
painful stimuli
Temp 97 BP: 144/67 HR: 57 R 17 O2Sats 100%
Gen: Intubated and sedated
HEENT: Blood draining from her left ear. Right pupil fixed
at 6 mm and nonreactive. Left pupil 4 and sluggish
Vomiting and airway. C-spine immobilized. No stepoffs
Chest: Bilateral breath sounds, no step-offs or crepitus
Cardiovascular: Bradycardic. Regular
Abdominal: Soft
GU/Flank: No step-offs
Extr/Back: No extremity injury
Neuro: Patient moans to pain. No purposeful movement. No
verbalization. Right pupil unreactive
At Discharge: EO spont-eye contact-tracks,verbal, follows simple
commands intermittently, moves all 4 but least on LLE; Attends
and interacts with examiner; less agitated/resltless, incision
c/d/i
Pertinent Results:
[**2192-8-14**] 07:42PM WBC-13.9* RBC-4.03* HGB-12.5 HCT-34.5* MCV-86
MCH-31.0 MCHC-36.2* RDW-12.3
[**2192-8-14**] 07:42PM PLT COUNT-281
[**2192-8-14**] 07:42PM PT-14.5* PTT-28.9 INR(PT)-1.3*
[**2192-8-14**] 07:48PM GLUCOSE-173* LACTATE-2.5* NA+-140 K+-2.8*
CL--103 TCO2-26
[**2192-8-14**] 07:42PM UREA N-10 CREAT-0.7
[**2192-8-14**] 07:42PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-8-14**] Head CT :
1. Multi-compartmental intracranial hemorrhage, with 11 mm right
cerebral
subdural hematoma, and right inferior frontal hemorrhagic
contusions with
adjacent subarachnoid blood.
2. Significant intracranial mass effect, with 5-mm leftward
midline shift
and diffuse sulcal effacement, cisternal effacement, and
fullness of the
foramen magnum suggesting downward brain herniation secondary to
diffuse brain edema.
3. Complex left temporal bone fracture, extending to the skull
base, crossing the left carotid canal. CTA of the head is
recommended for further evaluation.
[**2192-8-14**] CTA Head :
1. Right subdural hematoma and right frontal hemorrhagic
contusions with
complex left temporal bone fracture are redemonstrated. There is
no CT
evidence of stenosis, occlusion or dissection of the carotid
arteries or the vertebral arteries. An MR is, however, more
sensitive to rule out arterial dissection.
2. A possible left ICA bifurcation aneurysm is seen; however,
artifact due to concurrent venous filling is not entirely
excluded.
[**2192-8-14**] Head CT :
1. Post-surgical changes from evacuation of a right-sided
subdural hematoma.
2. No subfalcine herniation, though persistent uncal, downward
transtentorial and tonsillar herniation, unchanged.
3. Comminuted fracture of the left parieto-occipital skull, and
the left
temporal bone, involving the left mastoid air cells;
better-characterized
previously.
4. New developing left parieto-occipital extra-axial, likely
epidural
hematoma subjacent to the skull fracture.
5. Bifrontal linear hyperdensities suggestive of subarachnoid
hemorrhage.
[**2192-8-14**] CT Torso :
1. Left lower lobe consolidation, with associated opacification
of the left lower lobe bronchus, compatible with aspiration.
2. Left 1st and right 2-4th non-displaced posterior rib
fractures, with
associated small left apical pneumothorax. No evidence of
hemothorax.
3. Small amount of hyperdense free fluid in the pelvis, which
may reflect an occult mesenteric or bowel injury not apparent on
this study.
4. 1.6 cm hyperdensity within the mid esophagus, adjacent to the
patient's
nasogastric tube, which may reflect a swallowed tooth. Clinical
correlation is advised, as this may also represent a swallowed
foreign body.
[**2192-8-14**] CTA head and neck
1. Right subdural hematoma and right frontal hemorrhagic
contusions with
complex left temporal bone fracture are redemonstrated. There is
no CT
evidence of stenosis, occlusion or dissection of the carotid
arteries or the vertebral arteries. An MR is, however, more
sensitive to rule out arterial dissection.
2. A possible left ICA bifurcation aneurysm is seen; however,
artifact due to concurrent venous filling is not entirely
excluded.
[**2192-8-14**] Head CT post-op
1. Post-surgical changes from evacuation of a right-sided
subdural hematoma. 2. No subfalcine herniation, though
persistent uncal, downward transtentorial and tonsillar
herniation, unchanged.
3. Comminuted fracture of the left parieto-occipital skull, and
the left
temporal bone, involving the left mastoid air cells;
better-characterized
previously. 4. New developing left parieto-occipital
extra-axial, likely epidural hematoma subjacent to the skull
fracture.
5. Bifrontal linear hyperdensities suggestive of subarachnoid
hemorrhage
[**2192-8-15**] CT head 10am
1. Post-surgical changes from recent extensive right
craniectomy.
2. Reappearance of the suprasellar and quadrigeminal plate
cisterns,
suggestive of improving edema; the degree of cerebellar
tonsillar herniation appears unchanged.
3. Small left parieto-occipital epidural hematoma, unchanged,
with overlying non-displaced fracture.
4. Bifrontal superficial linear hyperdensities, also unchanged
and suggestive of subarachnoid hemorrhage, diffuse axonal injury
or both
[**2192-8-15**] MRI c-spine
Unremarkable MRI of the cervical spine.
[**2192-8-16**] CT head
1. No change in edema or degree of cerebellar tonsillar
herniation.
2. Multiple nondisplaced fractures as described above,
unchanged.
3. No new hemorrhage.
4. Post-surgical changes from recent right craniectomy and right
temporal
lobectomy.
[**2192-8-19**] MRI neck
New edema in the posterior paravertebral soft tissues of the
upper cervical spine compared to [**2192-8-15**], which is of
uncertain
etiology, but may sometimes be seen secondary to prolonged
supine positioning. Otherwise, unchanged normal appearance of
the cervical spine.
[**2192-8-24**] Abdomen
No evidence of ingested foreign body within the abdomen
[**8-27**] Gtube check
Large pneumoperitoneum with tip of PEG tube within lumen of the
stomach. No evidence of contrast leak from the stomach.
CT head [**2192-8-30**]
Rim enhancing fluid collections seen within the right temporal
fossa, right frontoparietal subcutaneous tissue and right
frontal lobe, which is concerning for abscess formation. An MRI
with diffusion-weighted imaging can be done for more specific
diagnosis.
CT torso [**2192-8-30**]
1. Massive pneumoperitoneum and mixed density free fluid as well
as findings consistent with peritonitis throughout the abdomen.
The findings are in keeping with a bowel perforation. The site
of the perforation cannot be determined with certainty, though
the majority of extravasated oral contrast is located in the
left upper quadrant and a leak from the stomach seems most
likely. Alternative considerations would include the colon in
the right lower quadrant.
2. Diffuse bowel edema, small bowel distention with a transition
point in the right lower quadrant, findings that are concerning
for bowel ischemia and possibly superimposed right lower
quadrant small-bowel obstruction. In this setting, the contrast
in the colon could have resulted from prior passage after a
G-tube study, which was done two days earlier.
3. Previously seen left first and right second through fourth
rib fractures.
4. Small bilateral pleural effusions and bibasilar atelectasis.
[**2192-8-30**] ECG
Sinus tachycardia versus atrial tachycardia at the rate of 150
beats per
minute. Compared to the previous tracing of [**2192-8-16**] the
morphology of the
P waves is distinct and suggests an ectopic focus of the
probable atrial
tachycardia. Clinical correlation is suggested
[**2192-9-1**] MR [**First Name (Titles) **]
[**Last Name (Titles) 2221**] somewhat limited by difficulties with patient positioning
and motion, as well as the extensive post-surgical changes with
abundant
residual blood products,
1. The right-sided extra-axial and scalp fluid collections
demonstrate
"simple" fluid with only thin and discontinuous rim enhancement
more
suggestive of post-surgical seromas. However, there is material
demonstrating slow diffusion, apparently sedimenting within the
dependent posterior component of the right parafalcine subdural
collection, and purulent material related to pyogenic
superinfection is a consideration. Again, no organized abscess
is identified at this site.
2. Extensive fluid-opacification of the mastoid air cells with
layering fluid within the right sphenoid air cell; while this
finding is commonly seen in intubated patients with protracted
supine positioning, it should be correlated clinically.
[**2192-9-3**] MR [**Name13 (STitle) **]
1. Decreased posterior paraspinal soft tissue edema without
evidence for
ligamentous injury. Normal alignment of the cervical spine.
2. Fluid within the mastoid air cells
[**2192-9-3**] LENS
No lower extremity DVT.
[**2192-9-8**] CT abdomen
1. Significantly decreased (compared to [**8-30**]), but residual mild
to moderate amount of free fluid in the pelvis and lower
quadrants with peritoneal enhancement, consistent with
peritonitis (peritonitis was also seen on [**2192-8-30**]).
2. The fluid seems to be interconnecting, but follow-up exam is
recommended to monitor for loculation and abscess formation.
3. Currently, the pelvic free fluid is not amenable for
drainage.
[**2192-9-13**] CT chest
1. Moderate left inferior and anterior pneumothorax which has
increased in
size since [**9-8**]. Small posteromedial hydropneumothorax with
some
septations and loculation also increased since [**2192-9-8**].
2. Left lower lobe consolidation, stable.
3. Slight interval healing of bilateral upper rib fractures.
[**2192-9-17**] portable abdomen
Limited study, no evidence of obstruction.
[**2192-9-20**] CT head
1. Since the prior study, patient is now status post
cranioplasty with a
small extra-axial collection with a dense linear-appearing area
withing in
which may be related to duraplasty but close followup to exclude
hemorrhage is recommended.
2. Stable moderate ventriculomegaly from recent CT Head of
[**2192-8-30**] with
improvement in mass effect - likely communicating hydrocephalus-
close
followup if no intervention is contemplated.
Brief Hospital Course:
Admission synopsis: 30F ped struck, mass lesion from multi-focal
ICH s/p R craniectomy, PEG for enteral access c/b leak s/p
ex-lap, JT placement, L sc CVL c/b ptx requiring CT, now
resolved convalescing well with improving mental status,
tolerating tube feeds, and without CT.
Trauma SICU Course:
The patient was admitted to [**Hospital1 18**] following polytrauma as a
pedestrian struck with , primary survey notable for impending
airway compromise and asymmetric fixed pupillary exam. She was
subsequently intubated and underwent CT scan following
completion of primary and secondary survey revealing
intracranial hemorrhage with signs of midline shift and
herniation. Pt was emergently brought to the operating theater
for R craniectomy and subsequently admitted to the Trauma
Surgical Intensive Care Unit for further treatment and
management of her traumatic brain injury.
Injuries:
- Complex L temporal bone fracture
- Multi-compartment ICH (R SDH, R frontal contusions, SAH,
+midline shift, +herniation)
- R ptx
Neuro: Mass effect from multifocal ICH s/p R craniectomy. The
patient received seizure prophylaxis without evidence of seizure
activity during ICU course. R craniectomy site oversewn with
concern for superficial separation without CSF leak or evidence
of frank dehiscence. Mental status progressively improved during
ICU course.
CV: The patient arrived to the ICU hemodynamically stable in
NSR. No hemodynamic instability Pressors:
(-EKG/CE-)
(-ECHO-)
Pulmonary: The patient arrived to the ICU with an oxygen
saturation of (-) and an ABG demonstrating (-).
(-CXR-)
(-CT-) Pt arrived to floor with (-) chest tube to low continuous
wall suction. CXR on post-operative day (-) demonstrated
resolution of pneumothorax and chest tube was placed to wall
suction. Repeat CXR demonstrated no reaccumulation of
pneumothorax and chest tube was removed with final CXR
demonstrating fully re-expanded lung (-). The patient was
discharged with an oxygen saturation of (-).
(-Home oxygen therapy-)
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
(-TPN-) PICC line established with proper position confirmed
and was started on TPN for (-). Pt was discharged with VNA
services for PICC line monitoring and TPN administration as
needed.
Pt was discharged on a (-) diet.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Wound care: Incisional wounds were regularly monitored for
signs of infection of which there were none.
Antibiotics: The patient received peri-operative intravenous
antibiotics.
(-Abx-)
(-Ostomy-) Pt received ostomy teaching post-operatively with
understanding and agreement to care plan verbalized.
(-Vac-) Wound was opened bedside on post-operative day (-) and
drained of seroma fluid. The wound was probed and no evidence
of fascia defect was demonstrated. A VAC dressing was placed at
bedside and changed (-). The patient received wound vac
teaching.
(-VNA-) VNA services were arranged for wound monitoring and
dressing changes.
Endocrine: The patient's blood sugar was monitored throughout
this admission. Insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
(-Tx-) The patient was transfused (-) units pRBC for a
hematocrit of (-) with post-transfusion hematocrit of (-).
Patient was anticoagulated postoperatively with (-) a heparin
drip
Coumadin was (-re-) started prior to discharge and titrated to
(-) therapeutic levels with close outpatient follow-up arranged
for continued monitoring.
(-) Pt was discharged on lovenox bridge and received lovenox
teaching prior to discharge.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots during this admission and was encouraged to get
up and ambulate as early as possible.
Disposition:
(-DNR/DNI-)
(-CMO-)
ACS/Trauma Surgery Floor Hospital course:
The patient was initially transferred to the floor on [**2192-8-19**]
and did well on tube feeds using a dobhoff. Her dobhoff was
pulled out by the patient. She received a PEG on [**8-24**] and TF
were resumed the next day. However, she had low-grade
temperatures in the 100s but on [**8-30**] triggered for a temp of
103.5 for which cultures were sent. Her tachycardia worsened to
the 170s and she was hypertensive, febrile to 104. A CT scan was
done, which showed intraperitoneal fluid collection. She was
transferred to the ICU and went to the OR on [**8-31**] for ex-lap,
which found a leak around the PEG site with TFs in the abdomen.
She underwent a partial gastrectomy, abdominal washout, and
placement of a J-tube. She was relatively stable
post-operatively in the ICU, although she remained initially
febrile.
ICU Course [**Date range (1) **] by system:
N: Pt w baseline TBI. Left OR [**8-31**] early AM initially
intubated/sedated. Was kept intubated given concern for
evolving sepsis. Extubated [**9-2**]. Neurologic status continued
to improve over subsequent days with patient interactive and
following commands on intermittent basis. Noted by family to be
improving as well. Her scalp incision was noticed to have
dehisced slightly and neurosurgery saw the patient and closed
her incision at bedside. Given concern for possible brain
abscess MRI was repeated [**9-1**] and likelihood of abscess based on
this was considered low. MRI c-spine obtained [**9-4**] shown to be
negative for ligamentous injury and c-collar removed.
CV: Fluid resuscitation continued postop with combination
crystalloid/colloid fluids. Beta blockage [**9-4**] for persistent
sinus tach.
P: In the ICU, an attempt was made to place a L subclavian CVL
but was complicated by a L PTX. A chest tube was placed and put
on suction [**8-31**]. Chest tube re-positioned [**9-1**] for persistent
PTX. Re-positioned [**9-4**] and placed to water seal at midnight
[**9-4**]. Persistent PTX seen and placed back to suction [**9-5**].
GI/GU: Patient was NPO postop and resuscitation was carried out
with crystalloid/colloid fluids. Trophic TFs started [**9-2**].
Advanced slowly to goal and tolerated well with normal bowel
function.
Patient had indwelling foley postop. Urine output was closely
monitored. Autodiuresed significantly [**9-2**].
ID: ID consulted given spillage of TFs into abdomen and
significant peritoneal contamination related to gastric
perforation. They agreed with 14 day course broad spectrum abx
including fluconazole. Patient was febrile to 101.2 [**9-3**] and
cultures were sent. LENIs were negative. Central line removed
[**9-5**] and sent for culture.
Dispo: PT/OF consulted [**9-3**] and continued to work with patient.
Xferred floor [**9-6**]
On [**9-6**], patient was transferred back to the floor and did well.
Her chest tube was put to water seal without leak and was pulled
on [**9-7**]. Her JP drain was pulled out on [**2192-9-10**] after minimal
serosanguinous output. Her scalp incision sutures were removed
on [**9-12**]. Her neurological status continued to slowly improve
while on the floor, to the extent that she was able to interact
with her family members, verbal a few words and appeared to
understand questions asked of her. She followed commands
although she was intermittently confused and continued to pull
on her lines and at her scalp. She was continued on TF through
her J-tube without further complications. Swallow evaluation on
[**9-10**] showed that she was unable to safely swallow at that time
and repeat evaluation on [**9-19**] again confirmed that conclusion
despite her improving neurological status. Thus, she remained
NPO with only J-tube feeds. She was taken to the OR on [**9-20**] by
neurosurgery for a cranioplasty. ID recommended per-operative
Meropenum for a bone flap swab result of phingomonas.
Previous discharge summary provided by the ACS service.
On [**9-20**] the patient was transferred to the neurosurgery team
s/p cranioplasty. Postoperatively the patient remained
neurologically intact and stable. She received perioperative
antibiotic therapy with Meropenem, gentamycin and ciprofloxacin.
Postop head CT demonstrated no new hemorrhage. Two
[**Location (un) 1661**]-[**Location (un) 1662**] drains were removed on POD1 [**9-21**] as output
tapered to less than 30cc over 8 hours, staples were placed for
closure of the drain sites. Once the drains were removed
Ciprofloxacin and gentamycin were discontinued. Meropenem will
continue for a 2 week postoperative course for prophylaxis of
the bone flap.
She remained very restless in the first few days after surgery
and she was unable to sleep. Careful titration of pain
medications as well as PRN ativan and trazadone for sleeping
helped to improve her symptoms of restlessness and insomnia and
by POD4 the patient was less restless and her family noted that
she had returned to her pre-cranioplasty sleep patterns.
Her tubefeeds were titrated up to goal and at the time of
discharge she is tolerating her tube feeds at goal, afebrile
with stable vital signs.
Overnight on POD 4 into POD 5 she was restless again and
recieved trazadone and ativan. The ativan was not well tolerated
so Seroquel was given. The seroquel was well tolerated and she
was not agitated overnight. On [**9-25**] she received 2 doses of
Geodon IM for her agitation and then had an episode of emesis
likely related to the Geodon administration. As such it was
discontinued and Seroquel was again ordered standing for
agitation. On [**9-26**] she was offered a bed at [**Hospital 90665**] rehab and
was deemed fit for discharge to there. She was sent with
instructions for followup with both neurosurgery for
postoperative evalaution and with plastic surgery for evalaution
of her incision and removal of her sutures.
Medications on Admission:
none
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
S/P Pedestrian struck
1. Left temporal bone fracture
2. Traumatic head injury
3. Acute right sided subdural hematoma and incipient herniation
4. Left apical pneumothorax
5. Left posterior 1st rib fracture
6. Right posterior 2nd-4th rib fractures
7. Hemoperitoneum
8. Acute bloodloss anemia
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - always.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? You do not need to wear your helmet now that the bone flap has
been replaced.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? 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.
?????? You have been discharged on Keppra (Levetiracetam), Continue
to take this antiseizure medication as prescribed.
?????? 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.
* You were admitted to the hospital after your accident with
multiple injuries including a fractures skull, bruising on your
brain, rib fractures and internal bleeding which required
surgery.
* Currently you are slowly improving. Your broken bones and
internal injuries are healing but you have a traumatic brain
injury that will take lots of speech and occupational therapy to
help with improvement.
* Currently you are getting nutrition from a tube in your stomch
but once you can safely swallow and take in enough calories by
mouth, the tube can be removed.
* You will need to work hard in Physical Therapy and
Occupational Therpy so that in time you can get back home and
continue therapy.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office [**2192-10-2**] for CT head at 8:45 and
then in Clinic at 9:30AM for removal of your staples, sutures
for a wound check with Dr. [**Last Name (STitle) **]. During this visit we will
discuss clearance to fly to return to [**Location (un) 22627**]. Please make this
appointment by calling [**Telephone/Fax (1) 1669**]. For CT scan beofre you
appointment with Dr. [**Last Name (STitle) **] please go to [**Hospital Ward Name **] CC CLINICAL
CENTER, [**Location (un) **] RADIOLOGY
??????You will need a CT scan of the brain without contrast in 4
weeks to follow the cranioplasty and brain injury. This would
either be scheduled with Dr. [**Last Name (STitle) **] in [**Location (un) 86**] or in [**Location (un) 22627**] with
your following Neurosurgeon. To see Dr. [**Last Name (STitle) **] call ([**Telephone/Fax (1) 18865**].
??????You will not need an MRI of the brain.
- Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-12**] weeks.
. If there are any concerns about the scalp suture line then
please follow up with Plastic and Reconstructive surgery, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**].
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]: ([**Telephone/Fax (1) 36264**]
Dr.[**Name (NI) 2989**] clinic is located on the [**Hospital Ward Name **], [**Hospital Ward Name 23**]
building, [**Location (un) 470**], Surgical Specialties.
Completed by:[**2192-9-26**]
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31,794
| 178,223
|
14316
|
Discharge summary
|
report
|
Admission Date: [**2106-10-8**] Discharge Date: [**2106-10-20**]
Date of Birth: [**2042-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
Shortness of breath, cough, right-sided chest pain
Major Surgical or Invasive Procedure:
Thoracentesis
Placement of thorocostomy drain
VATS with placement of chest tube
History of Present Illness:
HPI: 64M PMH EtOH/PBC cirrhosis and new diagnosis HCC s/p RFA
admitted with DOE and a 5 pound weight gain (268lb from recent
discharge 263lb [**2106-10-6**]; patient had been admitted for fluid
overload). He noted progressive shortness of breath, right
sided chest pain, and cough after discharge on [**2106-10-6**]. He was
originially admitted last earlier in the month with weight gain
and edema after RFA in late [**Month (only) 216**]. A pleural effusion was
noted during his last admission, but as it was improving
radiologically upon discharge, it was not tapped. He denied
hemoptysis, worsening abdominal pain.
Past Medical History:
-Cirrhosis secondary to PBC and alcoholism. Portal Hypertension,
Grade 1 varices. Not yet evaluated/listed fro transplant.
-Hepatocellular carcinoma--diagnosed on [**2106-9-29**] biopsy
-Prostate cancer s/p prostatectomy
-Hemorrhoids
-Hypertension--diet controlled
Physical Exam:
General: NAD
HEENT: nc/at, EOMI grossly, OP clear, MMM, no LAD
CV: RRR, no murmur
Resp: [**Month (only) **] BS right [**2-2**] of lung, [**Month (only) **] left base
Abd: soft, obese, mild distention, mild ttp RUQ, liver edge palp
with
insp, + splenomegaly, NABS
Ext: 1+ edema to mid shin bilaterally
Neuro: AOx4, CN II-XII intact grossly, no asterixis
Pertinent Results:
Admission Labs:
[**2106-10-8**] 01:30PM BLOOD WBC-14.5* RBC-3.72* Hgb-14.8 Hct-40.7
MCV-110* MCH-39.9* MCHC-36.5* RDW-16.7* Plt Ct-183#
[**2106-10-8**] 01:30PM BLOOD Neuts-72.9* Lymphs-12.1* Monos-12.3*
Eos-2.3 Baso-0.4
[**2106-10-8**] 01:30PM BLOOD PT-21.6* INR(PT)-2.1*
[**2106-10-8**] 01:30PM BLOOD UreaN-31* Creat-1.2 Na-126* K-4.5 Cl-90*
HCO3-27 AnGap-14
[**2106-10-8**] 01:30PM BLOOD ALT-40 AST-65* AlkPhos-135* TotBili-4.7*
[**2106-10-9**] 06:25AM BLOOD TotProt-5.4* Albumin-2.5* Globuln-2.9
Calcium-8.1* Phos-2.6* Mg-2.3
.
Discharge Labs:
[**2106-10-20**] 06:15AM BLOOD WBC-3.8* RBC-2.72* Hgb-10.1* Hct-29.5*
MCV-108* MCH-36.9* MCHC-34.1 RDW-16.5* Plt Ct-65*
[**2106-10-20**] 06:15AM BLOOD PT-20.0* PTT-40.5* INR(PT)-1.9*
[**2106-10-20**] 06:15AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-136
K-3.8 Cl-106 HCO3-24 AnGap-10
[**2106-10-20**] 06:15AM BLOOD ALT-13 AST-33 AlkPhos-89 TotBili-2.7*
[**2106-10-20**] 06:15AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.8
.
Studies:
CXR [**2106-10-8**]:
A large right pleural effusion has increased in size with
adjacent atelectasis in the middle and lower lobes. There is no
substantial left pleural effusion. Cardiomediastinal contours
are stable in appearance allowing for increased obscuration of
the right heart border.
IMPRESSION: Enlarging right pleural effusion.
.
RUQ U/S [**2106-10-9**]:
IMPRESSION:
1. Cirrhotic liver. Limited doppler interrogation demsontrates
patent portal veins with possible slow flow within main portal
vein.
2. Complex right pleural fluid consistent with provided history
of
hemothorax.
.
CT chest with contrast [**2106-10-10**]:
IMPRESSION:
1. Moderate, partially loculated right pleural effusion with
increased
density compared to simple peritoneal fluid, likely reflecting
recent
hemorrhage, although no evidence od active bleeding is present.
Small amount of pleural air, most likely related to recent
thoracentesis.
2. Atlectatic right middle lobe and right lower lobes adjacent
to effusion.
3. Multifocal patchy lung parenchymal opacities, new since
[**2106-10-5**], and mostly in the left lung. Differential
diagnosis includes aspiration, infection, and hemorrhage.
4. Small mediastinal and 1 cm right and midline paracardiac
lymph nodes.
5. Tiny left pleural effusion.
6. Coronary calcifications, extensive.
7. Significant gynecomastia, related to known liver cirrhosis.
Subcutaneous fat stranding might be atributed to
hypoalbuminemia.
8. Intra-abdominal findings consistent with liver cirrhosis.
For evaluation of the intra-abdominal pathology, please refer to
dedicated abdomen CT from [**2106-10-2**].
Brief Hospital Course:
A/P: 64 yo with cirrhosis and new diagnosis HCC s/p RFA with
resulting right hemothorax and left pneumonia.
.
# Right sided pleural effusion: The pleural effusion was tapped
with over 2L of bloody pleural fluid removed from his right
chest. This resulted in very little improvement radiologically.
The effusion was noted to be loculated by CT and CXR. A
pigtail catheter was then placed to drain and flushed, resulting
in little extra drainage. He was then taken to thoracic surgery
for VATS to remove the loculated hemothorax. He was in the MICU
for one day following the VATS because of difficulty weening
from the ventilator after the surgery. He was stabilized,
extubated, and returned to the floor where the chest tube was
removed a couple days later. Of note, he also had a left upper
lobe infiltration which was treated with vanc and zosyn for nine
days and finished before he went home. Upon D/C, he was
symptomatically and radiologically improved. He was set up with
VNA to help him with any continued draining through the chest
tube site.
.
# Weight gain: received albumin and was fluid restricted. His
edema improved through his stay and his weight was decreased
upon discharge. He was discharged on low dose diuretics, lasix
20mg and spironolactone 50mg daily.
.
# anemia: He was anemic throughout his stay and required 2U
pRBCs while in the MICU. He required no further blood
transfusions on the floor. He likely has a new baseline due to
decreased epo production from liver.
.
# Cirrhosis/HCC: s/p RFA, in transplant workup. He had a slight
LFT elevation upon admission, likely related to the recent
procedure. It trended toward baseline during his stay. He was
continued on [**Last Name (un) **] Forte, and given lactulose. Recent slight LFT
elevation from baseline, likely related to recent procedure, now
normalized.
Medications on Admission:
1. Ursodiol 250 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)).
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*15 Tablet(s)* Refills:*0*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: Take in between the 5-10mg (at 2 hours) doses
if needed.
Disp:*15 Tablet(s)* Refills:*0*
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**2-2**] Adhesive Patch, Medicateds Topical APPLY FOR 12HRS/DAY ():
Do not leave on for more than 12 hours per day.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*2*
Discharge Medications:
1. Ursodiol 250 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)).
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Do not
leave patch on for more than 12 hours per day.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1 bottle* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please draw CBC, Chem7, LFTs, INR, PTT, PT. Please fax results
to [**Telephone/Fax (1) 697**], attn. [**Doctor Last Name 1022**].
Please fax results also to [**Telephone/Fax (1) 42485**], attn. [**Doctor First Name 6480**].
Discharge Disposition:
Home With Service
Facility:
SE VNA
Discharge Diagnosis:
Primary:
Right sided hemothorax
.
Secondary:
PBC and alcoholic liver cirrhosis
Hepatocellular carcinoma
Hypertension
Hypercholesterolemia
prostate cancer s/p prostatectomy
Discharge Condition:
good, improved SOB and cough, ambulating
Discharge Instructions:
You were seen at [**Hospital1 18**] for a right hemothorax (blood in your
chest cavity). You had a thoracentesis, followed by surgery to
remove the fluid and break up any loculations. The chest tube
was removed on [**2108-10-20**]. You will be provided with home nursing
care to help you manage your chest tube wound site.
.
You will need to have your labs checked in one week on [**10-27**]. You
can do this at [**Hospital3 **]. The labs should be faxed to Dr. [**Name (NI) 8390**] office at [**Telephone/Fax (1) 697**].
.
We made the following changes to your medication regimen:
- Your lasix is now 20mg daily
- Your aldactone is now 50mg daily
- We added lactulose 30ml twice daily
- We sent you out with a limited supply of oral dilaudid for
pain
.
You have follow-up as below.
.
You should return to the ED or call your primary care provider
if you experience worsening shortness of breath, abdominal pain,
coughing blood, increase in chest tube site drainage or blood in
the drainage, fever greater than 101.4 degrees F, blood in your
stool, increasing swelling in your legs, or any other symptoms
that concern you.
.
You should maintain a low sodium sodium diet with less than 2
grams of sodium a day. You should also restrict your fluid
intake to less than 2 or 2.5 liters.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-10-27**] 11:45
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2106-10-27**] 1:00
.
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2106-10-28**] 10:30. This is the thoracic surgery follow
up. You will need your sutures removed at this time.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2106-11-3**] 10:30. Address: [**Last Name (NamePattern1) **]. [**Location (un) **]
[**Hospital Ward Name **] Bld. [**Location (un) 86**], [**Numeric Identifier 718**].
.
Provider: [**Last Name (NamePattern4) 42486**], MD Phone:[**Telephone/Fax (1) 35930**]
Date/Time:[**2106-11-5**] 2:00
.
Please call if you need to reschedule.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
|
[
"571.2",
"789.5",
"V10.46",
"285.29",
"584.9",
"303.91",
"611.1",
"511.8",
"998.11",
"272.0",
"155.0",
"456.8",
"455.6",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"33.23",
"34.91",
"34.04",
"34.51",
"99.07",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
8955, 8992
|
4397, 6247
|
367, 449
|
9208, 9251
|
1776, 1776
|
10586, 11650
|
7503, 8932
|
9013, 9187
|
6273, 7480
|
9275, 10563
|
2323, 4374
|
1403, 1757
|
277, 329
|
477, 1100
|
1792, 2307
|
1122, 1388
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,150
| 164,495
|
52171+52172
|
Discharge summary
|
report+report
|
Admission Date: [**2166-12-29**] Discharge Date: [**2167-1-12**]
Date of Birth: [**2092-2-13**] Sex: M
Service: ACOVE
ADMISSION DIAGNOSIS:
Renal cell carcinoma. (Of note, the patient was originally
admitted to the Urology Service under attending [**Doctor Last Name 986**] and
was transferred to the Medicine Service on [**2167-1-6**].
CHIEF COMPLAINT: Status post right nephrectomy.
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old man
with a history of insulin dependent diabetes mellitus,
diabetic neuropathy, hypertension who presented on [**12-29**] to
[**Hospital1 69**] for a partial right
nephrectomy of his right kidney inferior pole. Subsequent
pathology demonstrated it to be papillary renal cell
carcinoma. During the procedure there was a reported 1 liter
blood loss while the renal artery was clamped. The patient
at that time received 1 unit of packed red blood cells and 6
liters of lactated Ringers. The patient was transferred to
the Intensive Care Unit with an epidural. Subsequently the
patient was found to be hypotensive with a blood pressure of
70/30 and a heart rate of 90. The patient was bolused and
subsequent enzymes were significant for a CK of 1170, MB of
79, index of 6 and a troponin of 19. Electrocardiogram
showed V2 and V3 segment depression. The patient was in the
MICU from [**12-29**] to [**1-4**] ([**Hospital Unit Name 153**]). Arterial blood gas at 12/12
was 7.38, 36, 56. The subsequent hospitalization was
complicated by a left lower lobe consolidation and a sputum
notable for MRSA and increasing O2 liter requirement. Of
note the patient required 10 liters at one time with
nebulizer. The patient was treated with Vancomycin and
Levofloxacin for MRSA positive staph sputum.
A subsequent bedside swallow study on [**1-5**] was noted for
aspiration. Neurology and psychology was also consulted for
reported mental status change. MRI of the head on [**1-6**]
showed no intracranial hemorrhage and no stenosis or carotid
bifurcation and chronic periventricular white matter changes.
PAST MEDICAL HISTORY: Insulin dependent diabetes diagnosed
seven years ago. Diabetic nephropathy, hypertension, renal
cell cancer papillary, status post right partial nephrectomy,
depression.
ALLERGIES: Penicillin.
MEDICATIONS: From last discharge from the MICU the patient
was on insulin sliding scale, Glucotrol, Maalox, Neurontin,
Nortriptyline, Trazodone, heparin and subQ Protonix, Tylenol,
Zestoretic and Norvasc. From transfer the patient was on
insulin sliding scale, Metoprolol 10 mg intravenous q day,
sodium phosphate, Furosemide, albumin, Pantoprazole,
Atorvastatin, Tylenol, Colace, Paroxetine, Gabapentin,
Metoclopramide, Albuterol and Vancomycin.
SOCIAL HISTORY: The patient is a former lawyer. [**Name (NI) **] has home
health from 7:00 a.m. to 7:00 p.m. He travels with a
scooter. No history of alcohol or tobacco use.
PERTINENT LABORATORIES: On [**1-6**] his white blood cell count
was 13, hematocrit 34.5, platelets 402. Electrolyte panel
sodium 149, K 4.1, chloride 110, bicarb 29, BUN 25,
creatinine 1.3, glucose 180, calcium 7.9, phosphate 3.1,
magnesium 2.4, Vancomycin level was subtherapeutic.
Urinalysis on [**12-31**] negative blood, red blood cells of 11.
Blood cultures from [**12-31**] was notable for no growth. Urine
culture from [**12-31**] was notable for no growth.
Electrocardiogram from [**12-29**] showed ST segment depressions in
V2 and V3. Echocardiogram showed an EF of greater then 50%
focal wall motion abnormalities, mild LA, mild left
ventricular hypertrophy, mild left ventricular systolic
function. Pathology from [**12-29**] showed papillary renal cell
carcinoma changes consistent with diabetic glomerulosclerosis
and multiloculated cystic structure. Sputum from [**12-31**]
showed heavy growth, gram negative diplococci, gram positive
cocci. Radiology, x-ray from [**1-7**] showed nasogastric tube,
no pneumonia. X-ray from [**1-6**] showed a left lateral pleural
thickening versus loculated effusion, right PICC, scattered
discoid atelectasis. MRI of the head on [**1-6**] showed
negative MR, intracranial, negative stenosis, carotid
bifurcation negative, territorial infarct, chronic
paraventricular white matter changes. Video swallow study
from [**1-6**] showed penetration with silent aspiration,
moderate to severe oropharyngeal dysphagia. MRI kidney,
abdominal imaging [**12-5**] showed a 2 by 1 by 1.5 by 1.8 right
upper pole posterior mass pancreatic cyst. No renal vein
invasion. CT of the abdomen [**11-10**] had shown a positive mass
in the right kidney. No abdominal or bowel obstruction. TTE
from [**7-21**] showed an left ventricular of 80%, mild left
ventricular hypertrophy, borderline pulmonary hypertension.
ASSESSMENT: The patient is a 74 year-old man who presents to
[**Hospital1 69**] for a partial right
nephrectomy on [**12-29**]. Hospital course complicate by
perioperative myocardial infarction, positive oxygen
requirement and variable mental status changes.
HOSPITAL COURSE: 1. Cardiac: The patient's operation was
complicated by a perioperative myocardial infarction with
elevated CK and troponin levels. Subsequent to the event the
patient's heart rate, blood pressure, electrocardiogram
remained stable. It was felt the patient should be
catheterized as an outpatient. The patient was maintained on
an aspirin, beta blocker, HCTZ, ace, Lipitor. Of note, the
patient had a dobutamine stress echocardiogram performed on
[**2166-12-15**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The interpretation at the time
had been low probability for flow limiting coronary artery
disease to the achieved work load, frequent APB with
occasional beat and more frequent isolated premature
ventricular contractions with increased dobutamine dose.
Nonsustained supraventricular tachycardia rate 160 to 170
BPM. Normal intrinsic heart values. The patient was
discharged on Atorvastatin, Metoprolol, Lisinopril and
aspirin.
2. Renal: The patient was status post a right partial
nephrectomy. The patient's creatinine remained relatively
stable throughout the remainder of his hospitalization
course. Creatinine varied between 1.2 and 1.4. We suggest
continued outpatient monitoring of the patient's ins and outs
as well as his creatinine level.
3. Pulmonary: The patient obtained a seven day course in
house for a possible MRSA sputum positive culture. The
patient, however, remained afebrile when the patient's
antibiotics were discontinued on [**1-6**]. We suggested
outpatient continued monitoring of the patient's white blood
cell count. Of note, blood cultures were always negative.
4. Endocrine: The patient has a history of insulin
dependent diabetes. In house he was consulted by [**Last Name (un) **].
The patient's sugar remained relatively well controlled with
the addition of tube feeds. We suggest monitoring of his
glucose levels q.i.d. finger sticks. He is maintained on
Glargine and other regular insulin.
5. ENT: Of note the patient was consulted by ENT in house
for possible aspiration and have normal swallow study. The
patient's ENT evaluation showed global function with
incomplete epiglottis detection, premature spillage and
silent aspiration. The ENT recommendation was for PEG tube
and reevaluation within one to two weeks.
6. Neurology: The patient in the hospital had an episode of
delirium treated with Haldol. MRI/MRA performed in house was
negative. The patient was discontinued on a number of
narcotic agents. We suggest continued rehab. Neurology was
consulted in house. It was felt that variable mental status
differential included an anoxic damage versus narcotic
overdose. On discharge the patient was alert and oriented to
person.
7. Gastrointestinal: The patient in house required PEG
tube for feeding. PEG placement was performed on [**1-9**].
Tube feeds were initiated. We recommend outpatient
monitoring of PEG tube and advance his PEG tube diet as
tolerated.
8. Psychiatric: The patient has a history of depression.
Psychiatry was consulted throughout.
9. Hematology: The patient's hematocrit was stable
following the initial blood loss during the procedure. We
continued to monitor.
10. Oncology: The patient has a history of renal cell
carcinoma. The patient will need outpatient follow up with
Dr. [**Last Name (STitle) **]. Will obtain Medicine/Oncology follow up.
11. Code: The patient was full code throughout hospital
stay. Of note, the patient's sister is his health care
proxy.
DISCHARGE CONDITION: Fair.
DISCHARGE DIAGNOSES:
1. Renal cell cancer.
2. Perioperative myocardial infarction.
3. Change in mental status.
4. Diabetes.
5. Hypertension.
6. Depression.
DISCHARGE MEDICATIONS: Insulin sliding scale Lantus regimen,
Atorvastatin 10 mg po q day, Paroxetine HCL 10 mg po q.d.,
Gabapentin 600 mg po q.i.d., Metoclopramide 10 mg q 6 hours
per PEG, Albuterol nebulizers one h q 6, hours prn. Docusate
sodium 100 mg po b.i.d., Acetaminophen 325 to 650 mg po q 4
to 6, Metoprolol 37.5 mg po b.i.d., Lisinopril 10 mg po q
day, Olanzapine 5 mg po h.s., aspirin EC 325 mg po q day,
Pantoprazole 40 mg intravenous q day, Ipratropium bromide
nebulizers q 6, Bisacodyl 10 mg pr b.i.d. prn, Milk of
Magnesia 30 ml po q 6 h prn.
TREATMENT: Outpatient PEG care, follow swallow study in one
to two weeks. Treatments include PEG tube treatment PTO as
increased assistance with ambulation, assistance with
activities of daily living, follow with psychiatry, diabetes
care q.i.d. finger sticks and electrolytes q three days, CBC
q three days to monitor creatinine and electrolyte function.
Renal function, the patient will follow up with Dr. [**Last Name (STitle) 986**]
within two weeks. The patient will follow up with Medicine
and Cardioloyg within one month. The patient is to be
discharged to rehabilitation center.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2167-1-12**] 10:48
T: [**2167-1-12**] 11:00
JOB#: [**Job Number 23252**]
Admission Date: [**2166-12-29**] Discharge Date: [**2167-1-12**]
Date of Birth: [**2092-2-13**] Sex: M
Service: ACOVE
CORRECTION T0 DISCHARGE MEDICATIONS: Metoclopramide 10 mg q
6 per PEG.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2167-1-12**] 10:54
T: [**2167-1-12**] 11:36
JOB#: [**Job Number **]
|
[
"280.0",
"410.71",
"997.5",
"428.0",
"584.9",
"189.0",
"997.3",
"507.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.4",
"96.6",
"38.93",
"44.32"
] |
icd9pcs
|
[
[
[]
]
] |
8608, 8615
|
8636, 8778
|
10357, 10634
|
5060, 8586
|
160, 359
|
377, 409
|
438, 2074
|
2097, 2744
|
2761, 5042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,083
| 151,654
|
40400+58413
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-6-15**] Discharge Date: [**2177-7-2**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Pedestrian struck by car, traumatic brain injury
Major Surgical or Invasive Procedure:
[**2177-6-24**]: tracheostomy and percutaneous endoscopic gastrostomy
History of Present Illness:
The patient is an 87 y.o. man who was a pedestrian struck by a
car and sustained multiple head injuries including: bilateral
frontal cerebral contusions, falcine subdural hematoma, sub
arachnoid hemorrhage of the cistern, right frontal sinus
fracture, and a right supero-medial wall orbital fracture. He
also sustained a L knee contusion. He was taken initially to
[**Hospital **] Hospital, then transferred to [**Hospital1 18**] ED.
Past Medical History:
PMH: hypertension, diabetes melitus, hyperlipidemia, CRI,
vitamin D deficiency
PSH: unknown
Social History:
Prior to the accident, the patient lived at home and was
independent in his ADLs.
Family History:
non-contributory
Physical Exam:
Tmax: 38.6 ??????C (101.4 ??????F)
T current: 38.5 ??????C (101.3 ??????F)
HR: 110 (74 - 115) bpm
BP: 144/52(86) {88/33(51) - 148/59(92)} mmHg
RR: 35 (15 - 39) insp/min
SPO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 65.2 kg (admission): 69 kg
O2 Delivery Device: Aerosol-cool, Trach mask
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 345 (345 - 364) mL
PS : 5 cmH2O
RR (Spontaneous): 31
PEEP: 5 cmH2O
FiO2: 40%
SPO2: 100%
General Appearance: No acute distress, Cachectic
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: Rhonchorous : Mild b/l)
Abdominal: Soft, Non-distended, Non-tender
Right Lower Extremity : (Edema: Absent), (Pulse - Posterior
tibial: Present +2)
Left Lower Extremity: (Edema: Absent), (Pulse - Posterior
tibial: Present +2)
Neurologic: Follows simple commands, (Responds to: Verbal
stimuli), Moves all extremities, Pt not fully oriented. At times
Ox2
Pertinent Results:
[**2177-6-15**] Head CT:
1. Interval increase of right frontal parenchymal hemorrhage,
stable
subarachnoid and subdural hematoma.
2. Non-displaced fracture of the right frontal bone and sinus
extending into
the right orbital roof. Please refer to CT sinuses for further
detail.
[**6-15**] CT neck:
1. Moderate amount of blood within the trachea above the
endotracheal tube
balloon.
2. No obvious hematoma in the soft tissues of the neck
[**6-15**] CT SINUS/MANDIBLE/MAXILLOFACIAL:
1. Right frontal bone fracture extends to the right orbital roof
with small
ssociated right extraconal hematoma. Fracture extends though the
right frontal
sinus involving both inner and outer tables which could result
in a CSF leak
and clinical correlation is advised.
2. Opacity in the paranasal sinuses, likely a combination of
blood and
mucosal thickening.
3. Large forehead hematoma
[**6-15**] Bilateral Knee XR:
No fracture or dislocation; soft tissue swelling over the
knees,
but no joint effusion.
[**2177-6-15**] 08:30PM HGB-11.3* calcHCT-34 O2 SAT-97 CARBOXYHB-3
MET HGB-0
[**2177-6-15**] 08:30PM PO2-153* PCO2-35 PH-7.36 TOTAL CO2-21 BASE
XS--4 COMMENTS-GREEN TOP
[**2177-6-15**] 08:30PM GLUCOSE-219* LACTATE-3.3* NA+-138 K+-4.4
CL--108 TCO2-19*
Brief Hospital Course:
The patient was transferred to the [**Hospital1 18**] ED from [**Hospital **]
Hospital for management of his traumatic injuries. He was
evaluated in the ED and transferred to the Trauma ICU.
Neuro: The patient sustained moderate traumatic brain injury
(see HPI for details of injuries). Neurosurgery was consulted
upon his admission to the ED and followed him during his
hospital course. He was initially placed on dilantin for seizure
prophylaxis, then transitioned to Keppra on [**6-19**] which was
discontinued on [**6-22**]. Follow-up head CTs on [**6-16**] and [**6-18**] were
stable.
Pulmonary: The patient was successfully extubated on [**6-16**].
However, he later experienced respiratory distress and required
re-intubation on [**6-18**]. As he was unable to protect his airway
during attempts at ventilator weaning, an open tracheostomy was
performed in the operating room on [**6-24**]. Following tracheostomy,
the patient was gradually weaned from the ventilator and
tolerated increasing intervals on trach mask alone, however
still required periods of mechanical ventilation. By the time of
discharge, he had been off mechanical ventilation for 4 days and
his oxygen requirements were stable. He was treated with one
week of cefepime prior to discharge for presumed pneumonia
(sputum cultures grew out enterobacter and serratia) as he had
persistent fever spikes. Despite improving pulmonary function
and normal white count he continued to spike fever. This was
decided to be a neurogenic fever by diagnosis of exclusion, but
we recommend continuing cefepime to [**2177-7-4**] to complete a 7 day
course.
Cardiovascular: Tachycardia and episodes of a-flutter were
managed with beta blockade as needed.
GI: A Dobhoff feeding NG tube was placed on [**6-18**]. Tube feeds were
started the following day. On [**6-24**] a PEG was placed and the
patient began receiving feeds through the G-tube on [**6-25**].
Renal/fluid/electrolytes: IVF was adjusted and electrolytes
repleated as necessary.
Heme: The patient required a transfusion of 2 units PRBC on [**6-19**]
for a hematocrit of 23.9 (from 26.3) and responded
appropriately, rising to a HCT of 29.7. Due to a drop in
platelet count, a HIT panel was was sent and the patient was
temporarily taken off heparin. The test was negative and heparin
was restarted. Aspirin was restarted on [**6-25**] for baseline
anticoagulation.
Endocrine: The patient has known DM. He was initially placed on
an insulin sliding scale, but did require an insulin drip from
[**6-19**] to [**6-22**], after which glycemic control was adequate to return
to a sliding scale.
ID: Vancomycin and Zosyn were started emirically for concern of
hospital acquired pneumonia after the patient went into
respiratory distress on [**6-18**]. These were stopped on [**6-22**]. On
[**6-25**],cipro was started for sputum cultures showed a sensitive
enterobacter infection. This was changed to cefepime for better
coverage on [**6-27**].
Disposition: Due to the patient's ventilator dependence, plans
were made for placement at a ventilator capable LTAC facility.
Medications on Admission:
[**Last Name (un) 1724**]: Avandia 4', glyburide 5'', atenolol 50'', diltiazem 120',
HCTZ 50', simvastatin 10', Cal w Vit D
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever > 101F.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
6. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection three times a day.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
8. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
9. CefePIME 1 g IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
traumatic brain injury, respiratory failure
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:
Please call your doctor if you experience the following:
*New chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*Vomiting and cannot keep down fluids or your medications.
*Dehydration due to continued vomiting, diarrhea, or other
reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*Blood or dark/black material when you vomit or have a bowel
movement.
*Burning when you urinate, blood in your urine, or urinary
discharge.
*Your pain doesn't improve in [**7-25**] hours or is not gone within
24 hours. Call or return immediately if your pain becomes
severe, changes location or moves to your chest or back.
*Shaking chills or fever greater than 101.5F or 38C.
*An acute change in your symptoms, or new symptoms that concern
you.
*Increased pain, swelling, redness, or drainage from your G-tube
or tracheostomy site.
*Resume all regular home medications, unless specifically
advised not to take a particular medication. Take any new
medications only as prescribed.
*Give yourself adequate rest, continue to mobilize several times
per day, and drink adequate amounts of fluids.
*Do not drive or operate heavy machinery while taking narcotic
pain medications.
Followup Instructions:
Please schedule a follow-up appointment in the [**Hospital 2536**] clinic for 2
weeks from discharge. Call [**Telephone/Fax (1) 600**] to schedule.
Name: [**Known lastname 1516**],[**Known firstname 422**] Unit No: [**Numeric Identifier 14173**]
Admission Date: [**2177-6-15**] Discharge Date: [**2177-7-2**]
Date of Birth: [**2090-5-5**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 844**]
Addendum:
Please see Medications:
Discharge Medications:
To clarify his olanzapine, Mr [**Known lastname **] was not on this
medication prior to admission. He was started on it for acute
delerium in the ICU setting. He continued to require nightly
dosing, but it is our hope and expectation that he will not need
the medication long term.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 95**]
([**Hospital3 96**] Center)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**]
Completed by:[**2177-7-2**]
|
[
"250.00",
"585.3",
"507.0",
"293.0",
"599.71",
"428.21",
"403.90",
"787.22",
"801.12",
"780.61",
"287.5",
"427.32",
"425.4",
"348.5",
"518.5",
"800.12",
"276.0",
"E814.7",
"924.11",
"458.29",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.29",
"96.6",
"31.1",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
9936, 10222
|
3298, 6398
|
297, 368
|
7591, 7591
|
2026, 2042
|
9058, 9606
|
1062, 1080
|
9629, 9913
|
7524, 7570
|
6424, 6549
|
7769, 9035
|
1095, 2007
|
209, 259
|
396, 831
|
2051, 3275
|
7606, 7745
|
853, 947
|
963, 1046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,253
| 183,505
|
31888
|
Discharge summary
|
report
|
Admission Date: [**2159-10-29**] Discharge Date: [**2159-11-17**]
Date of Birth: [**2093-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2159-11-12**] Aortic Valve Replacement(21mm Pericardial Valve) and
Two Vessel Coronary Artery Bypass Grafting(LIMA to LAD, vein
graft to Ramus Intermedius)
[**2159-11-12**] Re-exploration for Bleeding
[**2159-11-5**] PTA/Stenting of Left Renal Artery with Bare Metal Stent
[**2159-10-30**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 65yo male with PMH significant as listed below
who was transferred from OSH for management of an NSTEMI. Per
patient, he woke up with chest pain. He localized the pain to
the right side of his chest and described it as a pressure in
his chest which remained constant until he presented in the
emergency room at the OSH. Troponins at that time came back at
2.85, 3.68, and then 2.83. He was started on Nitro gtt, Heparin
IV, ASA, Plavix, Atenolol, and Lisinopril with improvement of
his symptoms. EKG did not demonstrate significant changes.
Patient admits to some worsening SOB but denies any fevers,
chills, PND, or orthopnea. On further questioning, patient does
admit to worsening fatigue in regards to his activity over the
past 6-8 weeks. He was stablized and transferred to the [**Hospital1 18**]
for cardiac catheterization.
Past Medical History:
1)CAD; hx of MI in [**2122**]'s, ? single vessel angioplasty and stent
placed 6 years ago. ? 50% LM, RCA occluded
2)CHF with EF~40%
3)Esophageal cancer s/p radiation and chemotherapy in [**2155**]; pt
has yearly surveillance endoscopies.
4)Type 2 DM
5)Hypertension
6)Aortic stenosis
7)CVA x5, last event ~8 years ago
8)SAH secondary to Cerebrovascular aneurysm s/p clipping
9)Chronic renal insufficiency
10)Hyperlipidemia
11)Hx of acute and chronic mesenteric ischemia
12)Peripheral vascular disease s/p aortic endrterectomy with an
aortofemoral bypass graft with SMA revascularization in [**6-24**],
complicated by acute thrombosis of L aortobifemoral bypass graft
13)Hernia repair x2
[**66**])Osteoarthritis
15)GERD
Social History:
Social history is significant for 50 year history of current
tobacco use. Patient smokes 1ppd. There is no history of alcohol
abuse. Patient is very active.
Family History:
There is a significant family history of premature coronary
artery disease in father, paternal uncles, and paternal
grandfather. One brother has diabetes.
Physical Exam:
VS - T 100 BP 110/68 AR 85 RR 18 O2 sat 94% RA
Gen: Pleasant male, NAD, lying in bed, does not appear acutely
ill
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: No evidence of JVD, no lymphadenopathy or thyromegaly
CV: Distant heart sounds, no S3/S4, no m,r,g
Chest: CTAB, +crackles at posterior lung bases, poor air
movement posteriorly
Abd: Soft, NT/ND. + midline scar, No HSM or tenderness. 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:
[**2159-10-29**] 06:42PM BLOOD WBC-16.1* RBC-5.10 Hgb-15.6 Hct-45.9
MCV-90 MCH-30.7 MCHC-34.1 RDW-13.5 Plt Ct-243
[**2159-10-29**] 06:42PM BLOOD PT-13.5* PTT-57.3* INR(PT)-1.2*
[**2159-10-29**] 06:42PM BLOOD Glucose-106* UreaN-30* Creat-2.2* Na-138
K-4.8 Cl-101 HCO3-26 AnGap-16
[**2159-10-29**] 06:42PM BLOOD CK-MB-NotDone cTropnT-1.06*
[**2159-10-30**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.91*
[**2159-10-29**] 06:42PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
[**2159-10-30**] 03:00PM BLOOD %HbA1c-5.7
[**2159-10-30**] 05:15AM BLOOD Triglyc-88 HDL-39 CHOL/HD-3.1 LDLcalc-63
[**2159-10-30**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA had
60-70%
stenosis. The LAD was patent. The LCX had a 90% stenosis
proximally. The
RCA was occluded proximally and was filled by collaterals. The
left
subclavian artery had a 40-50% stenosis. The left renal artery
had an
80% stenosis at its origin. The right kidney was not visualized.
2. Limited resting hemodynamics were performed. The left sided
filling
pressures were mildly elevated (LVEDP was 17mmHg). The systemic
artery
pressures were within normal range measuring 133/67mmHg. There
was no
significant gradient across the aortic valve upon pull back of
the
catheter from the left ventricle to the ascending aorta.
[**2159-10-31**] Renal Ultrasound:
The left kidney measures 11.7 cm and demonstrates unremarkable
echotexture without evidence of stones, hydronephrosis, or mass.
Appropriate Doppler flow is demonstrated to the left kidney
without evidence of stenosis. The right kidney is small and
atrophic, measuring 8.9 cm without any Doppler flow detected.
This correlates with lack of visualization on angiography study.
The right kidney is otherwise unremarkable without evidence of
stone, hydronephrosis, or mass.
[**2159-10-31**] Carotid Ultrasound:
No significant right ICA stenosis(graded as less than 40%).
Approximately 60-69% left ICA stenosis.
[**2159-10-31**] Echocardiogram:
The left atrium is mildly dilated. There is an inferobasal left
ventricular aneurysm. There is mild to moderate regional left
ventricular systolic dysfunction with basal inferior and
inferolateral akinesis and hypokinesis of the mid inferior and
inferolateral segments. The basal inferolateral segment is
aneurysmal. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (area 1.0-1.2cm2), best seen on image 101. Trace
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.
[**2159-11-2**] Head CT Scan:
1. No acute intracranial hemorrhage. 2. Chronic right frontal
cortex and right basal ganglia infarcts with associated right
ventricular dilation and right temporal lobe encephalomalacia.
[**2159-11-7**] Chest CT Scan:
1. Left lower lobe nodule, lung carcinoma until proved
otherwise. No good evidence for metastasis, aside from small
liver lesion warranting axial imaging. 2. Small bilateral
pleural and pericardial effusions, more likely related to
cardiac decompensation than malignancy. 3. Aortic and mitral
valvular calcification, hemodynamic significance indeterminate,
but conceivably significant. 4. Atherosclerotic calcification,
including coronary arteries, aorta and splanchnic vessels. 5.
Granulomatous calcifications, peripancreatic, lower mediastinal
lymph nodes in liver.
[**2159-11-9**] PET Scan:
1. Abnormal FDG-avidity in a 12mm left lower lobe pulmonary
nodule
highly concerning for lung carcinoma. 2. Mild to moderate FDG
uptake in the
left adrenal gland. No corresponding nodule identified on CT.
Attention to
this region on follow-up studies is recommended. 3. Bilateral
pleural
effusions and moderate pericardial effusion. 4. Increased
FDG-avidity
throughout the aorto-bifemoral graft.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted under cardiology and underwent cardiac
catheterization which revealed severe multi-vessel coronary
artery disease, left renal artery stenosis and moderate
subclavian stenosis. Based upon the above results, cardiac
surgery was consulted. Prior to surgical intervention, extensive
preoperative evaluation was performed given his multiple medical
issues. Given the complexity, his hospital course will now be
broken down by systems.
CARDIAC: He remained pain free on medical therapy which included
intravenous Heparin. Preoperative echocardiogram notable for
moderate aortic valve stenosis and moderate LV dysfunction with
an LVEF of 40-45%. On [**11-12**], Dr. [**Last Name (STitle) **] performed an
aortic valve replacement along with coronary artery bypass
grafting. See seperate dictated operative note for surgical
details. Postoperative course was complicated by bleeding which
required re-exploration on postoperative day zero. Experienced
atrial fibrillation on postop day two which was treated with
Amiodarone infusion and beta blockade. Within 24 hours, he
converted back to a normal sinus rhythm. For the remainder of
his hospital stay, he remained mostly in a normal sinus rhythm.
Brief episodes of paroxsymal atrial fibrillation were noted.
Beta blockade was gradually advanced as tolerated while
Amiodarone is to weaned, given his COPD this should be watched.
At discharge, his BP was 100/60 with a HR of 72. His HTN
medications were were adjusted accoedingly.
PULMONARY: Preoperative chest CT scan notable for a left lower
lobe nodule. PET scan showed abnormal FDG-avidity in the left
lower lobe pulmonary nodule highly concerning for lung
carcinoma. Thoracic surgery was consulted(Dr. [**Last Name (STitle) **] but
the presence of lung nodule was not a contraindication to
proceed with coronary revascularization. He will follow up with
Dr. [**Last Name (STitle) **] as an outpatient.
RENAL: Admission creatinine was 2.2. Renal ultrasound showed
normal left kidney and an atrophic right kidney. Nephrology was
consulted to evaluate finding of renal artery stenosis in the
setting of chronic renal insufficiency. It was decided to
proceed with PTCA/stenting of his left renal artery prior to
cardiac surgical intervention, Plavix was therefore not
initiated. Renal function post-stent remained stable. Creatinine
throughout his hospital stay remained in the 1.4 - 2.2 range.
His discharge creatinine was ********.
NEURO: Given history of cerebrovascular disease, he underwent
carotid ultrasound which showed moderate disease of his left
internal carotid artery(see result section). Preoperative head
CT scan was notable for chronic right frontal cortex and right
basal ganglia infarcts with associated right ventricular
dilation and right temporal lobe encephalomalacia. Aneurysm
clips were noted in the anterior clinoid process. Folllowing
cardiac surgery, there were no neurologic complications.
ID: Admitted with leukocytosis, white count 16K. There was no
evidence of infection. He remained afebrile with negative
cultures throughout his hospital stay. His leukocytosis did
persist throughout, ranging between 11K to 20K. At discharge,
white count was *****.
ENDOCRINE: Endocrine service was consulted for pre and
postoperative management of his diabetes mellitus. Blood sugars
were well controlled regular insulin sliding scale. At
discharge, his regimen is glipizide. He is to followup with his
PCP for BS management
Medications on Admission:
MEDICATIONS ON TRANSFER:
Aspirin 81mg PO daily
Atenolol 50mg PO daily
Lisinopril 10mg PO daily
Plavix 75mg PO daily
Zetia 10mg PO daily
Protonix 40mg PO daily
Lipitor 10mg PO daily
Heparin gtt
Nitro gtt
Regular insulin sliding scale
Albuterol/atrovent
Tylenol
Morphine
MEDICATIONS AT HOME:
Plavix 75mg PO daily
Prilosec 40mg PO daily
Glipizide 2.5mg PO daily
Imdur 30mg PO daily
Zetia 10mg PO daily
Lisinopril 10mg PO daily
HCTZ 25mg PO daily
Januvia 100mg PO daily
Atenolol 50mg PO daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): take 400 mg po bid x 7 days, then 200 mg po bid x 7
days, then 200 mg po qd.
Disp:*120 Tablet(s)* Refills:*2*
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. 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*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. JANUVIA 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Loconia VNA
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Postop Bleeding - s/p Re-exploration
Left Renal Artery Stenosis - s/p PTA/stenting
Postop Atrial Fibrillation
Left Lower Lung Nodule
Systolic Congestive Heart Failure
Recent NSTEMI
Hypertension
Type II Diabetes Mellitus
Esophageal Cancer s/p Radiation and Chemotherapy
Cerebrovascular Disease - history of multiple CVAs
Carotid Disease - Left Sided
History of Cerebral Aneurysm and Subarachnoid Hemorrhage
Chronic Renal Insufficiency
Hyercholesterolemia
History of Mesenteric Ischemia
Peripheral Vascular Disease
Moderate Left Subclavian Stenosis
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-26**] weeks, call for appt
Dr. [**Last Name (STitle) **], call for appt
Dr. [**Last Name (STitle) 11250**] in [**2-24**] weeks, call for appt
Dr. [**First Name (STitle) 5699**] in [**2-24**] weeks, call for appt
Completed by:[**2159-11-17**]
|
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"424.1",
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icd9cm
|
[
[
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[
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] |
icd9pcs
|
[
[
[]
]
] |
13054, 13096
|
7607, 11089
|
359, 678
|
13743, 13750
|
3439, 7584
|
14086, 14368
|
2503, 2659
|
11630, 13031
|
13117, 13722
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11115, 11115
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|
11406, 11607
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|
706, 1570
|
11140, 11385
|
1592, 2313
|
2329, 2487
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,216
| 167,377
|
10444
|
Discharge summary
|
report
|
Admission Date: [**2155-8-1**] Discharge Date: [**2155-8-11**]
Date of Birth: [**2070-2-11**] Sex: F
Service: MEDICINE
Allergies:
Ceclor
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Pleural effusion
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
Ms. [**Known lastname 34521**] is a 85 yo F with history of hyperlipidemia,
hypertension, CAD and PAF with recent PPM placement s/p lead
revision who presents with fevers, SOB, and pleuritic chest
pain.
.
Of note, she was recently admitted to [**Hospital1 18**] [**Date range (1) 427**] for
pericardial effusions and was found to have small RV perforation
during initial PPM placement. Her pacer leads were
repositioned, and the effusion was monitored. Patient was
initially off of warfarin given concern for hemorrhagic
conversion of pericardial effusion but was restarted on warfarin
prior to discharge. At discharge, patient continued to complain
of SOB and pleuritic chest pain but these were felt to be
related to being in Afib given the presence of her debilitation
and pleural effusions/atelectasis. Last CXR on [**7-23**] prior to
discharge showed small L pleural effusion and trace R pleural
effusion.
.
At rehab she was doing well until 2 days ago when, after her
cardiology appointment, she suddenly felt very cold and began
having chills. She then continued to have chills, began having
fevers up to 101.3, developed a productive cough with greenish
sputum and felt more SOB. Of note, she has also been having CP
on inspiration but this has been going on since her procedure.
She was transferred from rehab to the ED today.
.
In the ED, initial vs were: 97.6, 80, 102/58, 24, 93% 4L Nasal
Cannula. Her baseline SBP is 130s-140s, and she was in the 90s
in the ED so she was admitted to the ICU for monitoring. She
received 1L of NS and was given vancomycin and zosyn. EKG
showed LBBB (unchanged from baseline). CXR showed L pleural
effusion and bedside echo showed a small pericardial effusion
that was measured as 0.4cm. Cardiology was consulted and felt
this was insignificant. Vitals on transfer were 92/61, 78, 20,
97% 3-4L NC.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2145**]: NSTEMI, LAD and RPDA
stenting; [**2147**]: PTCA of jailed diagonal branch, LAD and PDA
stents widely patent
-PACING/ICD: recent ICD placement [**6-26**] at OSH
3. OTHER PAST MEDICAL HISTORY:
Paroxysmal atrial fibrillation (not currently on Coumadin)
Spasmodic Dysphonia s/p Botox injections
Arthritis
s/p Hysterectomy
Panic attacks
Bilateral cataract surgery
Prior D&C
Mastoid surgery
Hx of falls
Small hiatal hernia
s/p Rectocele surgery
Left knee replacement
s/p bone grafting to left knee approximately two years ago
Social History:
Patient is widowed and lives alone. She has one son that lives
five minutes down the road and a daughter in [**Name (NI) 4565**]. She
walks with a cane due to a history of falls.
- Tobacco history: 7 pack-year history in distant past
- ETOH: none
- Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
Physical Exam:
Vitals: T: 97.3 BP: 98/58 P: 91 R: 23 O2: 99% 3L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~10 cm, no LAD
Lungs: Decreased BS ~1/2 up on the left side with dullness to
precussion. No w/r/r
CV: irregularly irregular rhythm, rate within normal limits,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Multiple
resolving hematomas over areas previous injections
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
Physical Exam:
Vitals: T:99.3 BP:95/55 P: 58 R:20 O2: 95-99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, No elevated JVP, no LAD
Lungs: Decreased BS ~1/4 up on the left side with dullness to
precussion. No w/r/r
CV: irregularly irregular rhythm, rate within normal limits,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
GU: within normal limits, no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
GLUCOSE-140* UREA N-18 CREAT-0.7 SODIUM-133 POTASSIUM-4.2
CHLORIDE-97 TOTAL CO2-26 ANION GAP-14
PT-34.6* PTT-37.9* INR(PT)-3.5*
PLT COUNT-330
WBC-13.2*# RBC-3.11* HGB-9.8* HCT-28.6* MCV-92
NEUTS-85.4* LYMPHS-10.2* MONOS-3.9 EOS-0.4 BASOS-0.2
cTropnT-<0.01
LD(LDH)-206
estGFR-Using this
LACTATE-1.2
URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0
URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0
URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**8-1**] formal TTE:
LV systolic function appears depressed (ejection fraction 30
percent) primarily due to marked pacemaker-induced mechanical
dyssynchrony (although focal wall motion abnormalities cannot be
excluded with certainty). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-2**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2155-7-23**], the findings are similar.
[**2155-8-8**] PLEURAL FLUID.
GRAM STAIN (Final [**2155-8-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
URINE CULTURE (Final [**2155-8-9**]): NO GROWTH.
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Meso
[**2155-8-8**] 14:23 140* 1030* 4* 83* 0
13
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin
[**2155-8-8**] 14:23 3.5 140 109 2.2
Serum Chemistry TotProt LD(LDH)
[**2155-8-8**] 07:50 159
[**2155-8-8**] 07:50 5.7*
DISCHARGE LABS:
[**2155-8-11**] 07:15AM BLOOD WBC-8.0 RBC-3.23* Hgb-10.0* Hct-30.2*
MCV-94 MCH-30.9 MCHC-33.1 RDW-15.5 Plt Ct-482*
[**2155-8-11**] 07:15AM BLOOD Glucose-104* UreaN-13 Creat-0.8 Na-137
K-3.7 Cl-98 HCO3-29 AnGap-14
Brief Hospital Course:
Ms. [**Known lastname 34521**] is a 85 yo F with a past medical history
significant for hyperlipidemia, hypertension, CAD and PAF with
recent PPM placement s/p lead revision who presents with fevers,
SOB, and pleuritic chest pain due to an exudative pleural
effusion thought to be caused inflammatory reaction to the
recent pacemaker placement verse pneumonia.
# Systolic Congestive Heart Failure: Her systolic blood pressure
during this admission ranged from 90s-140s. We found her to be
fluid over loaded on arrival to the floor, and noted that [**2155-8-1**]
ECHO showed EF in 30% felt to be due to pacer-induced mechanical
dysynchrony of pacing, and began diuresis with IV lasix. She
received one to two doses daily depending on her fluid status on
physical exam. She did have episodes of chest pain on the floor
with unchanged EKG's and flat cardiac enzyems that responded to
another dose of IV lasix. It is unclear whether she was lasix
naive prior to this admission. Her EKG is notable for a prior
LBBB as well as a wide QRS complex and atrial fibrillation. She
had a pace maker recently placed by the EP department in this
hospital. The EP team was made aware of her admission to the
hospital. Her fluid overload symptoms resolved prior to
hospital discharge, and she was started on a low dose
ACE-inhibitor as indicated per her EF.
# Pleural effusion: Patient had a small left pleural effusion
prior to discharge last hospitalization on [**7-23**] which was
enlarged on film on admission. Given her fevers, this was
concerning as a possible source of infection. Initially a
Diagnostic/therapeutic thoracentesis was deferred because of her
elevated INR =3.7 on admission, and she was treated for possible
pneumonia. Coumadin therapy was held and her INR dropped down to
a safe level for thoracentesis. The procedure was performed and
1250ml of fluid was drained. Analysis of the pleural fluid
revealed a exudative effusion with lymphocytic predominance.
This would be inconsistent with parapneumonic effusion, but
could be consistent with her prior ventricular disruption from
prior pacer wire procedure. Cytology showed mesothelial cells,
but no malignancy. The pig-tail catheter was removed and oxygen
was quickly weaned. She should be monitored for recurrence.
.
# Fevers: Her fevers at rehab and new leukocytosis were
concerning for infection likely pulmonary source. Blood and
urine cultures were obtained and were negative. A MRSA as well
as a legionella screen were also negative as well. On arrival
to the floor she was on Vancomycin and Zosyn for antibiotic
coverage and her symptoms of cough and fever subsided. We felt
these fevers were most likely due to her pleural effusion rather
than a pneumonia. Antibiotic coverage was continued until a
thoracentesis was performed and then discontinued after >1L of
fluid was drained. The pleural fluid was sent for culture and
was finalized with no bacterial growth. Since that time her
breathing has improved, was weaned off supplement O2, and the
antibiotic coverage was discontinued.
.
# Paroxysmal atrial fibrillation: Her INR on admission was
supratherapeutic. Coumadin was held and amiodarone was
continued. Metoprolol was restarted at 25mg TID which kept her
rate controlled. After completion of thoracentesis Coumadin was
restarted at 3mg. Upon discharge her INR was 1.3. The patient
was instructed to follow up with her Primary Care Provider to
ensure proper dosing of Coumadin.
.
# Normocytic Anemia: Likely mixed picture with iron deficiency
and anemia of chronic disease based on iron studies done last
admission. Her hematocrit on admission and through out remained
within her recent baseline.
.
#. RUL nodule: 7mm nodule noted in RUL on [**Hospital3 7571**]CTA
chest on [**2155-6-28**]. The patient was reminded to follow this
finding up with her PCP as outpatient.
.
# Dyslipdemia: Continued pravastatin.
.
# GERD: Omeprazole and sucralafate were continued.
.
# Panic attacks: Continued sertraline. Held clonazepam.
#Transitional: Her INR should be followed up regularly to
determine whether INR remains in theraputic ranges for a.fib.
She will need to be followed for possible recurrence of her
effusion.
Medications on Admission:
acetaminophen 975mg PO Q8H
carvedilol 3.125mg PO BID
Citalopram 20mg PO daily
docusate 100mg PO BID
ferrous sulfate 300mg PO daily
fluconazole 100mg PO Q12H
folic acid 1 mg po daily
lasix 40mg PO daily
gabapentin 300mg PO Q12H
heparin 5000U SC Q12H
lisinopril 2.5mg PO daily
MVI daily
omeprazole 20mg PO daily
protein supplement daily
albuterol inhaler 4 puffs Q2H prn wheezing
simethicone 80mg PO Q8Hprn
oxycodone 5-10mg po q4h prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
9. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety, insomnia.
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
13. warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please draw INR and fax results to Dr. [**Last Name (STitle) 27542**], the fax
number is [**Telephone/Fax (1) 34527**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary Diagnosis: Pneumonia with Exudative Pleural Effusion
Secondary Diagnosis:
Atrial Fibrillation
Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted to the hospital with fevers,
cough and fluid surrounding your lungs. We have determined that
you had a pneumonia and we have treated you with antibiotics. We
also were able to drain the fluid around your lungs to help you
breath easier. We have now restarted Coumadin for you diagnosis
of atrial fibrillation and you will have to have your INR
checked regularly to insure you are on the appropriate dose.
Your visiting nurse will check this on Wednesday [**8-13**] and fax it
to your PCP.
Changes to your medications:
START taking warfarin again, 3 mg daily
START taking lisinopril 2.5 mg daily
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Address: [**Last Name (un) 28705**]., [**Location (un) 28706**],[**Numeric Identifier 28707**]
Phone: [**Telephone/Fax (1) 27541**]
Appointment: Friday [**2155-8-15**] 11:00am
We are working on a follow up appointment in Interventional
Pulmonary with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] within 2 weeks. The office will
contact you at home with an appointment. If you have not heard
within 2 business days or have any questions please call
[**Telephone/Fax (1) 3020**].
|
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icd9cm
|
[
[
[]
]
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[
"34.91"
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icd9pcs
|
[
[
[]
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283, 299
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,697
| 118,606
|
40979
|
Discharge summary
|
report
|
Admission Date: [**2163-7-17**] Discharge Date: [**2163-7-27**]
Date of Birth: [**2085-1-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fall with IVH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78 yo M on Coumadin for TIAs, on ASA and dyperimidol, with
an unwitnessed fall with dizziness around 1:30 this AM. Wife
was
sleeping when she heard a bang and found pt seated on the floor
with head against wall. Patient reported to family that he had
felt dizzy just prior to fall and slid down onto his buttock
then
against wall. No LOC reported. The patient then became more
lethargic and less verbal and was taken to OSH where CT head
showed IVH and pt transferred to [**Hospital1 18**] for further care.
Past Medical History:
-TIAs and CVAs, anticoagulated on warfarin
-DM
-Hypertension
-Hx renal artery stenosis, s/p bilateral stenting
PSH:
-Renal artery stent placement
Social History:
married, lives with wife
Family History:
NC
Physical Exam:
O: BP: 149/ 80 HR: 80 R 12 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: equal and brisk EOMs full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert but somewhat lethargic. Closes
eyes periodically during exam but attends when addressed,
cooperative with exam.
Orientation: Oriented to person, "hospital", and "[**2163**]".
Language: Speech fluent but minimal verbal output.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 mm to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. At times pt appears
tremulous in UE but has no lasting tremor. Strength full power
[**5-19**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
No signs of trauma on scalp trunk or extremities
Exam on discharge: PERRL 3-2mm bilaterally. Alert, oriented to
slef only, moves all extremities, and follows simple commands
Pertinent Results:
CT Head [**7-17**]
Large left intraventricular hemorrhage is increased from 5:19
a.m.
with 12 mm rightward shift of midline structures, previously 8
mm. Small
extension into the right lateral ventricle is new.
CT Head [**7-18**]
Stable repeat CT head, no increase in ventricular size.
Renal ultrasound [**7-18**]
1. Severely limited exam due to body habitus and patient's
inability to
participate in breath-hold techniques. Probable small
non-obstructing stone
identified in the right renal lower pole.
2. Gross patency identified in the right main renal vein and
artery. Left
kidney cannot be assessed.
CT Head [**7-19**]:
IMPRESSION:
1. Stable large hemorrhage in the left lateral ventricle with
associated
ventricular dilatation and possible transependymal CSF
migration. Stable
blood in the occipital [**Doctor Last Name 534**] of the right lateral ventricle.
Decreased blood in the third ventricle.
2. Persistent loss of [**Doctor Last Name 352**]/white matter differentiation in the
left occipital pole, which may indicate a non-hemorrhagic
contusion, given recent trauma, or an evolving infarct.
3. Stable focus of right parietal subarachnoid hemorrhage.
4. Stable chronic infarcts in the right frontal lobe, left
parietal lobe, and right posterior inferior cerebellar
hemisphere.
Carotid U/S [**7-20**]:
Duplex evaluation was performed of both carotid arteries.
Minimal plaques
noted. On the right, velocities are 100, 65, 82 in the ICA, CCA,
and ECA
respectively. The ICA to CCA ratio is 1.3. This is consistent
with less than 40% stenosis.
On the left, velocities are 97, 86, 82 in the ICA, CCA, and ECA
respectively. ICA to CCA ratio is 1.2. This is consistent with
less than 40% stenosis.
There is minimal diastolic flow in the right vertebral artery
which may be
consistent with intracranial occlusion. On the left, there is
antegrade flow.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Right vertebral artery disease as described above.
CT head [**7-22**]
1. Stable appearance of large hemorrhage in the left lateral
ventricle with associated ventricular dilatation, transependymal
CSF migration, and shift of the septum pellucidum to the right.
Stable amount of blood in the occipital [**Doctor Last Name 534**] of the right
lateral ventricle. Multiple expected foci of subarachnoid
hemorrhage.
2. Persistent loss of [**Doctor Last Name 352**]-white matter differentiation in the
left occipital lobe likely representing an evolving subacute
infarct.
3. Stable chronic infarcts involving the right frontal lobe,
left parietal
lobe, and right posterior inferior cerebellar hemisphere.
Brief Hospital Course:
Pt was admitted to the neurosurgery service and to the ICU for
continued neuro monitoring and strict blood pressure control. A
repeat CT head was obtained on [**7-18**] that showed no increase in
bleed or ventricle size. His exam remained stable and he
continued to follow commands. He did require an antihypertensive
IV drip and given his history of renal stenting a renal
ultrasound was obtained.
Renal ultrasound findings did not show any abnormalities. His
blood pressure improved on [**7-19**], a repeat CT was preformed that
showed stable ventricular size and less blood in the third
ventricle.
Continued improvement on Neurological exam was noted on [**7-20**].
Patient underwent a speech and swallow eval and was cleared for
a PO diet: thin liquids, ground solids, 1:1 supervision with
POs, Meds whole or crushed with applesauce.
On [**7-21**], PT/OT was asked to evaluate him and rehab was
recommended. On [**7-22**], a repeat Head CT was performed to evaluate
and prepare for discharge. The CT appeared stable, but no rehab
placement could occur so the patient was kept inpatient over the
weekend. His neurologic exam remained stable. His BP was
persistently about 160 and hydrochlorothiazide was added to his
regimen.
On [**7-26**] a medical consult was obtained given the patient's
rising BUN and elevated Creatinine in the setting of known
bilateral renal artery stenosis s/p stenting. Recommendations
were made to start IV fluids and check daily labs, resend a
urine sample including urine electrolytes and hold his home dose
of Lasix.
Medications on Admission:
ASA, Coumadin, dyperimodol,
simvastatin,levothyroxine .075 [**1-16**] tab qd, tamsulosin lasix,
novolog 23U QAM, 19U QPM
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
12. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. multivitamin, stress formula Tablet Sig: One (1) Tablet
PO DAILY (Daily).
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
17. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO
DAILY (Daily): Restart at this dose when patient placed back on
home lasix dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
Intraventricular hemorrhage
Aphasia
Hypertension
Urinary retention
CKD
pre renal Azotemia
Electrolyte imbalance
protien/calorie deficiency
UTI
Hypertension nos.
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? You were on a medications: Coumadin (Warfarin)and Dyridamole,
prior to your injury, you may safely resume taking this when
cleared by your neurosurgeon.
Special instructions for rehab:
Patient has been taken off his home dose of Lasix 40 mg daily on
this admission for a rising BUN and Creatnine. Please keep the
patient off this medication and recheck his electrolytes in [**3-18**]
days prior to restartin this medication.
Patient was on Novolog 70/30 at home, this medication has been
held during his hospitalization given his poor nutritional
intake. He has been covered with an insulin sliding scale, when
his nutritional intake is more consistant he should be restarted
on this medication.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2163-7-27**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
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1016, 1043
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,273
| 134,972
|
11706
|
Discharge summary
|
report
|
Admission Date: [**2103-10-12**] Discharge Date: [**2103-10-19**]
Date of Birth: [**2055-10-16**] Sex: M
Service: SICU/KURLA
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37046**] is a 47 -year-old
gentleman with a history of alcohol abuse and prior delirium
tremens who had four witnessed seizures at home on the day of
admission. EMTs were called and found the patient confused
and lethargic, with dried blood in his mouth. He was also
tachycardic and had a fingerstick of 142. In transport to an
outside hospital Emergency Department, the patient had two
more thirty second seizures and in the outside hospital
Emergency Department, he was witnessed to have another
seizure. He was intubated secondary to agitation,
combativeness, and airway protection and was given Ativan,
fosphenytoin, Phenergan, and phenobarbital, as well as
Versed, succinylcholine, and pancuronium. He was transferred
to the [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] Surgical
Intensive Care Unit where a head CT scan was negative for
acute intracranial process.
PAST MEDICAL HISTORY:
1. Alcohol abuse, status post alcohol withdrawal with
delirium tremens.
2. Status post appendectomy in [**2100**].
3. Polysubstance abuse.
4. Hypertension.
5. Thrombophlebitis.
ALLERGIES: No known drug allergies.
ADMITTING MEDICATIONS: Unknown.
FAMILY HISTORY: The patient's father has emphysema, his
sister had breast cancer, his brother had esophageal varices,
and his mother has emphysema.
SOCIAL HISTORY: The patient is unemployed and is living with
four roommates who apparently also engaged in alcohol abuse.
The patient has an extensive history of alcohol use and they
said he has had withdrawal seizures in the past.
PHYSICAL EXAMINATION: On admission, temperature 100.4 F,
heart rate 100, blood pressure 170/70. In general, this
patient was intubated and sedated, not responding to voice or
painful stimuli. Head, eyes, ears, nose, and throat: the
patient had blood in his mouth and on his tongue, pupils were
pinpoint and reactive. The neck was supple. Chest was clear
to auscultation bilaterally. The abdomen was soft. On
extremity examination, the patient had equal tone in all four
extremities and no response to painful stimulus in his
extremities. He did have rhythmic movements bilaterally in
the arms, but these were also very stimulus sensitive.
ADMISSION LABORATORY DATA: Initial laboratory studies
indicated valproic acid level of less than 0.7, Dilantin
level of less than 0.5, TSH of 2.27, glucose 134, BUN 4.0,
creatinine 1.1. Sodium 140, potassium 4.2, chloride 104,
bicarbonate 18. Total bilirubin 0.9, AST 68, ALT 33,
alkaline phosphatase 135, ammonia 39. White blood cell count
10.8, hematocrit 39, platelets 93,000. Cardiac enzymes were
negative. Arterial blood gas indicated a pH of 7.3, CO2 of
37, O2 of 330.
HOSPITAL COURSE: The patient was admitted initially to the
Surgical Intensive Care Unit, intubated for airway
protection. A head CT scan was negative for acute
intracranial process; however, there was a small old right
subdural hematoma. Initial electroencephalogram was negative
for epileptiform activity. The patient did have mildly
elevated transaminases and elevated lipase and amylase.
Serum toxicology screen was negative and rapid plasma reagent
was negative.
In the Surgical Intensive Care Unit the patient was noted to
be febrile. A chest x-ray showed possible left lower lobe
and a right lower lobe pneumonia which was presumed to be
aspiration. He was started on Levaquin and metronidazole.
He was weaned off of the Ativan drip and extubated on
hospital day three with some improvement in his mental
status, although he was still obtunded, but rousable on the
day of transfer.
An abdominal ultrasound was completed which indicated an
echogenic appearing liver with no biliary tree abnormalities
and no ascites. The patient continued to be febrile on the
floor. Blood cultures from hospital day four grew out coag
negative Staphylococcus in one out of four bottles. He
received one dose of vancomycin while awaiting speciation. A
second electroencephalogram was conducted on hospital day two
with results pending at the time of this dictation. To this
point, the patient has been continued on Dilantin during his
hospital stay.
On hospital day seven, the patient was alert and oriented
times three. A Physical Therapy evaluation indicated the
patient was unsafe for discharge to home due to poor balance
and lack of safety awareness and therefore the patient was
being screened for discharge to a rehabilitation facility at
the time of this dictation. The patient was refusing alcohol
rehabilitation; however, was amenable to a substance abuse
consult which has been ordered at the time of this dictation.
DISCHARGE DIAGNOSES:
1. Alcohol abuse.
2. Alcohol withdrawal seizures.
3. Hypertension.
4. Polysubstance abuse.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg po bid.
2. Folate 1.0 mg po q day.
3. Thiamine 100 mg po q day.
4. Multivitamin one tablet po q day.
5. Enteric coated A.S.A. 81 mg po q day.
6. Metronidazole 500 mg po tid through [**10-22**].
7. Levofloxacin 250 mg po q day through [**10-22**].
DISPOSITION: At the time of this dictation, the patient was
being screened for discharge to an acute rehabilitation
facility.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 9783**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2103-10-18**] 14:44
T: [**2103-10-18**] 14:48
JOB#: [**Job Number 37047**]
|
[
"305.01",
"507.0",
"038.19",
"401.9",
"291.81",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1410, 1543
|
4861, 4957
|
4980, 5640
|
2925, 4840
|
1800, 2907
|
175, 1116
|
1138, 1393
|
1560, 1777
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,605
| 176,029
|
52458
|
Discharge summary
|
report
|
Admission Date: [**2102-5-11**] Discharge Date: [**2102-5-18**]
Date of Birth: [**2054-4-13**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Shellfish / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
chest pain, weakness, hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 48y/o females with a past medical history HTN,
iron deficiency anemia secondary to menorrhagia who was seen by
her PCP today with complaints of lightheadedness and DOE of a
several day duration. Her DOE occurs with 1 flight of stairs or
walking a short distance. She also reported 2 episodes of chest
pain, the first of which occurred last evening. She describes it
ass a substernal pressure associated with SOB and diaphoresis
lasting for 90 minutes. She had a second episode this am when
walking to the subway station. She rested and her symptoms
resolved. At [**Company 191**] she was found to have a BP of 190/108. ECG was
done and showed no acute changes. EMS was called for transfer to
the ED for treatment of hypertensive emergency.
Past Medical History:
# Hypertension
# Menorrhagia secondary to uterine fibroids. Baseline HCT 26-29
# Appendectomy
# C-section X 4, bilateral tubal ligation
# Sickle cell trait per the patient.
Social History:
married, lives w/ husband and 7 children ([**11-1**]). Works at
federal govt. appeals office.
-Tobacco history: quit 20 years ago
-ETOH: no
-Illicit drugs: no
Family History:
+HTN in mom and DM in aunt.
Physical Exam:
General: Alert, oriented, no acute distress, resting comfortably
in bed, aroused from sleep
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: fluent speech, lower extremities strength 5/5, sensation
grossly intact, remainder of exam deferred to am
.
On Discharge:
VSS
L-sided weakness of L arm and leg which is fluctuating in
severity and location. Soft voice. Exam otherwise unchanged
from admission
Pertinent Results:
On admission:
.
[**2102-5-11**] 06:00PM BLOOD WBC-10.4 RBC-3.84* Hgb-5.5* Hct-22.2*
MCV-58* MCH-14.3*# MCHC-24.8* RDW-21.1* Plt Ct-209#
[**2102-5-11**] 06:30PM BLOOD PT-11.7 PTT-22.0 INR(PT)-1.0
[**2102-5-11**] 06:00PM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-138
K-5.6* Cl-107 HCO3-17* AnGap-20
[**2102-5-12**] 12:56PM BLOOD ALT-7 AST-15 CK(CPK)-133 AlkPhos-91
TotBili-1.2
[**2102-5-11**] 06:00PM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
.
On discharge:
.
[**2102-5-18**] 07:50AM BLOOD WBC-12.4* RBC-4.69 Hgb-8.4* Hct-29.6*
MCV-63* MCH-17.8* MCHC-28.3* RDW-27.4* Plt Ct-305
[**2102-5-18**] 07:50AM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-141
K-4.4 Cl-108 HCO3-24 AnGap-13
.
Studies:
.
[**2102-5-12**] CXR: Cardiomediastinal silhouette is stable. Lungs are
essentially clear. There
is no evidence of pulmonary edema, focal areas of consolidation
or
pneumothorax as well as there is no evidence of appreciable
pleural effusion.
.
[**2102-5-12**] No acute intracranial pathology. Specifically, no
findings of intracranial hemorrhage or large territory infarct.
Can consider further evaluation with MRI as it is more sensitive
for acute ischemia.
.
[**2102-5-15**]: MRI/MRA head neck
No acute intracranial pathology. Specifically, no findings of
intracranial
hemorrhage or large territory infarct. Can consider further
evaluation with
MRI as it is more sensitive for acute ischemia.
.
EEG: prelim negative. final read pending
Brief Hospital Course:
# HTN/weakness/CP: On [**5-12**] in the setting of patient 3rd prbc
transfusion, patient developed rigors and HTN. Remained
hypertensive to SBP 180 despite hydralazine 30 mg IV, 2 inches
of intro paste, and SLN x3. She developed LLE weakness and
headache and started on a nitro drip. She was transferred to the
MICU for further care however BP was quickly controlled and she
was returned to the floor later the same night. Neuro was
consulted for possible code stroke, however was felt to be
unlikely given her presentation and head CT was negative.
Evaluation for transfusion rxn was negative. She continued to
have L-sided weakness and several similar episodes of
htn/weakness/cp, which resolved with
hydralazine/ativan/morphine. CEs and ECGs were unremarkable.
Subsequent neuro w/u with MRI/MRA and EEG were unrevealing
(final EEG read pending).
She was evaluated by psych who felt that her sxs were consistent
with Conversion Disorder and prior presentations of similar sxs,
all of which have occurred in the hospital. She continued to
have l-sided weakness and hoarse voice, with some improvement
and fluctuating sxs in terms of character and location. She was
sent home with assistive devices for ambulation and sl ativan.
Her htn was otherwise controlled on home meds of lisinopril,
metoprolol and hydrochlorothiazide (amlodipine was not needed to
maintain her pressures in the hospital and discontinued on
discharge). Plasma metanephrines were sent to eval for pheo in
the setting of labile bps and were pending on discharge.
.
# Anemia: Improved with blood transfusion and stable with no
further blood loss. Her anemia was attributed to blood loss
from fibroids. EKG changes resolved and CE negative x 5 sets.
Asa was held in the setting of bleed and crit was improved on
discharge. Could consider dc'ing PPI in outpt setting for
better iron absorption.
.
# Leukocytosis: thought to be secondary to stress reaction. No
systemic sxs concerning for infection or localizing sxs. She
should receive outpt f/u with repeat labs to ensure resolution.
.
# ARF: resolved with fluid repletion
.
# Out-pt follow-up:
-final read eeg
-plasma metanepherines (ordered to r/o pheo in setting labile
bps)
-amlodipine-consider restarting if pressures poorly controlled
-consider dc'ing PPI to increase iron absorption in setting of
anemia
-fibroids-consider embolization as outpt
-leukocytosis-repeat labs to ensure resolution
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - two inhalations every 6 hours as
needed
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
ECONAZOLE - 1 % Cream - apply to left axilla twice a day
LISINOPRIL-HYDROCHLOROTHIAZIDE - 20 mg-25 mg Tablet - 1
Tablet(s)
by mouth daily
METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr - 1
Tablet Sustained Release 24 hr(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth once a day
Medications - OTC
IRON - 325(65)MG Tablet - ONE BY MOUTH TWICE A DAY
.
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule 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 DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache, pain.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for episodes of weakness, CP, inability to speak: please
take sublingually during episodes.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Conversion disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Discharge Instructions:
You were admitted for hypertension, chest pain and L-sided
weakness. After further evaluation, we do not think that your
symptoms were caused by stroke, seizure or heart attack. You
were still weak on admission and therefore discharged by
ambulance with crutches to help you walk. We expect that your
symptoms will get better at home over the next few days.
.
Please follow up with you doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. Continue
to take your home medications as prescribed with the following
changes:
1) Stop taking amlodipine. Your blood pressures were well
controlled on your hospital regimen which did not include this
medication. You should continue to take
lisinopril/hydrochlorothiazide and metoprolol.
2) Additionally, if you have additional episodes similar to the
ones you were having in the hospital, you should take 0.5 mg of
sublingual ativan. If your symptoms change or progress, please
contact your physician.
.
Also, please contact your physician if you have new fever,
weakness that does not improve over time, unresolving chest
pain, or any other sympomts that are concerning to you.
Followup Instructions:
Please follow up with your PCP as [**Last Name (Titles) 4030**] below:
.
Department: [**Hospital3 249**]
When: THURSDAY [**2102-5-25**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"300.00",
"530.81",
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"288.60",
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"218.9",
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"280.0",
"300.11",
"V15.82",
"626.2",
"584.9",
"401.0"
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7777, 7783
|
3799, 6227
|
345, 351
|
7847, 7847
|
2360, 2360
|
9172, 9515
|
1528, 1557
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|
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271, 307
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379, 1137
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2374, 2792
|
7862, 7977
|
1159, 1335
|
1351, 1512
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,402
| 192,684
|
3177
|
Discharge summary
|
report
|
Admission Date: [**2162-7-22**] Discharge Date: [**2162-7-30**]
Date of Birth: [**2100-3-3**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Hypotension, decreased UOP
Major Surgical or Invasive Procedure:
Tunneled line placement
History of Present Illness:
Mr [**Known lastname 14953**] is a 62 year old male with hx of ESRD from
diabetic/hypertensive nephropathy, s/p LRRT in [**2146**] on double
immunosuppression with cyclosporine and prednisone (b/l
creatinine 2.2), who is sent to [**Hospital1 18**] from rehab facility today
for hypotension, decreased urine output and acute on chronic
renal insufficiency. He was being treated for a soft tissue
infection at rehab (abx unknown) and finished the antibiotics 5
days ago (saturday). Over the past serveral days he has been
hypotensive with orthostatic changes (SBP decreased from 118 to
80 from supine to sitting). He has had decreased urine output
and, though usually continent of urine, has required straight
catheterization to obtain gradually decreasing of quantities of
urine over the past three days.
He was recvently hospitalized at [**Hospital3 2783**] for leg
weakness which the patient states has been ongoing. He was
discharged to rehab with a diagnosis of steroid myopathy since
he has been on prednisone 10 mg for years.
Cyclosporine decreased (50 mg [**Hospital1 **] to 25 mg [**Hospital1 **]) a few days ago
per patient.
Review of systems: Currently, the patient denies dyspnea, chest
pain, palpitations, fevers, chills, abdominal pain, nausea,
vomiting, lightheadedness, dizziness, tingling or numbness. He
has limited strength in both legs. He does usually urinate, but
has required straight catheterization over the past couple of
days; he thinks his overall urine output has decreased. Full
10-system review otherwise negative except as noted above
In the ED, initial vs were 97.2 78 93/57 99%. Initial labs were
notable for Na 131, HCO3 16, BUN 150, Cr 6.4 and HCT 28.6. UA
showed 178 RBC and 14 WBC. CXR showed severely enlarged heart
but no acute pulmonary process. EKG showed afib, RBB, and
indertemniate axis. Echo showed longstanding pericardial
effusion without tamponade. Patient received regular insulin for
Glc of 295 and 2 L NS. BP responded to small boluses 250cc.
Past Medical History:
1. ESRD s/p renal transplant: Patient believes this was
secondary to diabetes and hypertension
- Dialysis from ~'[**44**]-'[**46**]
- Left fistula ~95
- Liver donor transplant '[**46**] (sister with 6/6 match)
- Admitted ([**Date range (1) 14954**]) with ARF; biopsy was consistent with ATN.
During this admission, Cellcept was discontinued.
2. Diabetes mellitus: (+)Nephropathy and neuropathy; denies
retinopathy
3. Hypertension
4. Hypercholesterolemia
5. History of TIA ([**8-29**]): Presented with left leg weakness; MRI
showed "TIA".
6. Osteoarthritis, left knee
7. History of gout ([**2139**]); no episodes since that time
8. History of lumbar disc herniation
9. History of conjunctivitis ([**2150**])
10. History of Bell's Palsy (in his early 30s)
11. s/p Right hip fracture with repair with 3 screws
12. s/p Right 3rd toe distal amputation for non-healing
infection
13. s/p Vasectomy
Social History:
Previously owned a catering truck business. Divorced; raised two
sons. Currently lives alone in [**Location (un) 246**]. Denies tobacco, alcohol,
drugs.
Family History:
Father died of pancreatic cancer at 86; he also had DM. Mother
alive at 95 with alzheimers.
Physical Exam:
Admission PHYSICAL EXAM:
Vitals: 97.2, 86, 20, 94/48, 100% ra
General: awake, alert, oriented, pleasant, well-nourished adult
male in NAD
HEENT: no conjunctival icterus, injection or pallor, MMM, OP
clear, no exudates
Neck: obese, supple, no JVD
Lungs: mildly decreased breath sounds at bilateral bases. no
wheeze or rhonchi
CV: non-distant heart sounds, RRR, normal S1/S2, no rubs or
murmurs
Abdomen: soft, NT/ND, +BS, no rebound/guarding, no organomegaly
Ext: warm, scattered skin tears and wounds, 1+ symmetric
bilateral pitting edema in lower extremities
Neuro: Sensation to light touch intact throughout. Able to move
all extremities at will. 4/5 strength in lower extremity muscle
groups (proximal > distal), symmetrically
Discharge PE:
VS: T 98.2, Tm 98.3, HR 60-70s, BP 140/52, RR 20, 96-100% RA
GENERAL: chronically ill appearing male, lying in bed, A&Ox3, in
NAD
HEENT: sclera anicteric
CARDIAC: distant heart sounds, RRR, no murmurs appreciated,
unable to appreciate JVP secondary to body habitus
LUNGS: CTAB, no wheezing, rales, or rhonchi.
ABDOMEN: soft, obese, nondistended, nontender, +BS
EXTREMITIES: 2+ bilateral LE edema with distal dressings in
place; R arm edema with pinkness and weaping with demarcation
just proximal to the elbow; dressing overlying distal R arm with
underyling skin breakdown, R hand cool to touch with pinkness
with purple discoloration of distal R arm with clear , dopplers
of R radial and ulcer with biphasic pulse; AV fistula in L UE
without thrill or bruit
Pertinent Results:
Admission Labs:
[**2162-7-22**] 04:01PM URINE COLOR-DKAMB APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018
[**2162-7-22**] 04:01PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-TR
[**2162-7-22**] 04:01PM URINE RBC-178* WBC-14* BACTERIA-MANY
YEAST-NONE EPI-1 NONSQ EPI-1 TRANS EPI-1
[**2162-7-22**] 03:51PM LACTATE-1.6
[**2162-7-22**] 03:40PM GLUCOSE-295* UREA N-150* CREAT-6.4*#
SODIUM-131* POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-16* ANION
GAP-22*
[**2162-7-22**] 03:40PM CALCIUM-7.6* PHOSPHATE-6.3*# MAGNESIUM-2.9*
[**2162-7-22**] 03:40PM WBC-9.1 RBC-3.01*# HGB-9.2*# HCT-28.6*#
MCV-95 MCH-30.6 MCHC-32.2 RDW-17.7*
[**2162-7-22**] 03:40PM NEUTS-91.8* LYMPHS-5.9* MONOS-2.2 EOS-0
BASOS-0
[**2162-7-22**] 03:40PM PLT COUNT-264
[**2162-7-22**] 03:40PM PT-23.3* PTT-35.1 INR(PT)-2.2*
Other pertinent labs:
SPEP- no specific abnormalities seen
PPD- negative
HepBsAg- negative
HepBsAb- negative
HepBcAb- negative
HepC Ab- positive
Cyclosporine level on discharge 44 (goal <70)
Microbiology:
[**7-22**] Blood culture- pending, NGTD
[**7-22**] Urine culture- no growth, final
[**7-23**] MRSA screen- no MRSA isolated
[**7-26**] Urine culture- no growth, final
[**7-26**] Blood culture- pending, NGTD x 2
.
Studies:
- [**2162-7-22**] ECHO: Moderate circumferential pericardial effusion no
tamponade, LV hypertrophy and small cavity. LVEF >55%. There is
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. Overall left ventricular ejection
fraction is normal (LVEF>55%). However, the left ventricular
cavity is small, and the stroke volume is likely to be
significantly reduced. There is a moderate sized pericardial
effusion.
- [**2162-7-22**] CXR: Moderate-to-severe cardiomegaly.
- [**2162-7-23**] Renal U/S:
1. Patent main renal artery and vein, but high resistance
pattern of flow within the transplanted kidney with absent
antegrade diastolic flow throughout the kidney, and absent
antegrade diastolic flow in the main renal artery.
2. No evidence of perinephric fluid collection or
hydronephrosis.
- [**2162-7-23**] TTE: There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is mildly dilated
with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is a moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2162-7-22**], no
change. The morphology and echotexture of the LV and RV are
suggestive but not diagnostic for infiltration (I.e. amyloid).
If indicated, a cardiac MR with contrast may provide better
diagnostic accuracy for myocardial infiltrative processes (vs
biopsy).
Bilateral LENIs [**2162-7-26**]: no DVT to level of popliteals
UE Venous mapping [**2162-7-27**]:
1. Waveform within the right brachial artery as well as low
flow within the right radial artery, all suggest impending, if
not present, arterial insufficiency to the right upper
extremity.
2. Occluded left AV fistula as indicated by a normal
triphasic-appearing left radial artery as well as normal
waveforms involving the left subclavian vein.
3. No indirect evidence of central venous occlusion on either
the left or right.
4. Subcutaneous edema scattered throughout the upper
extremities.
5. Slow flow within the left radial artery
6. Bilateral radial artery calcifications.
Noninvasive arterial study [**2162-7-29**]:
1. Occluded ulnar artery.
2. Patent brachial and radial arteries to the palmar arch.
3. Decreased flow distal to the palmar arch
EKG: RBBB. atrial fibrillation. Low voltage in the limb leads.
.
Discharge Labs:
[**2162-7-30**] 07:30AM BLOOD WBC-11.2* RBC-3.34* Hgb-10.0* Hct-31.1*
MCV-93 MCH-30.0 MCHC-32.2 RDW-17.1* Plt Ct-179
[**2162-7-30**] 07:30AM BLOOD PT-16.3* INR(PT)-1.5*
[**2162-7-30**] 07:30AM BLOOD Glucose-169* UreaN-83* Creat-4.0* Na-136
K-4.5 Cl-97 HCO3-25 AnGap-19
[**2162-7-30**] 07:30AM BLOOD Calcium-7.5* Phos-5.6* Mg-2.3
[**2162-7-29**] 05:50AM BLOOD Cyclspr-58*
Brief Hospital Course:
62 y/o M with ESRD s/p LRRT on double immunosuppression with
cyclosporine and prednisone, admitted from rehab with acute on
chronic renal failure in the setting of several days of
hypotension and orthostasis.
# Acute on Chronic renal failure: Most likely prerenal vs late
rejection vs ATN from hypotension. Late rejection possible in
setting of reportedly decreased dose of cyclosporin before
admission and possible decrease in prednisone for steroid
myopathy. Per Renal, most likely represents decreased renal
perfusion and ongoing pre-renal azotemia, although duration of
hypotension is concerning for perfusion-related injury that has
already progressed to ATN. Consideration for role of
rhabdomyolysis given steroid myopathy and generally bedbound
state but CKs WNL. Alternatively, could represent GN or other
primary renal process; note made of suspicious degree of IgA
deposition on [**2157**] allograft biopsy. Could also consider
contribution from calcineurin inhibitor toxicity or AIN from
allopurinol or antibiotics that he recently finished though
urine eos negative. Ulytes mostly c/w prerenal etiology. Pt
started on HD during admission. Urine prot:Cr rate 0.9. Renal
U/S with with absent antegrade diastolic flow and absent
antegrade diastolic flow in the main renal artery of unclear
significance; no evidence of hydro on U/S. Cyclosporin levels
were followed daily and were found to be within target range of
<70 with 25mg [**Hospital1 **] dosing. The patient was started on steroid
stress dose and taper. A Foley was placed to monitor urine
output. Pt continued on HD. Tunneled line placed by IR.
Transplant [**Doctor First Name **] consulted for eval for permanent HD access in
setting of L UE AV-fistula without thrill or bruit. Pt had vein
mapping of bilateral UE. Pt had neg PPD and hepatitis labs sent
in preparation for resuming HD. Held off on renal biopsy to
assess for late rejection per renal recs. SPEP/UPEP negative.
# Hypotension: Etiology not immediately clear, but thought most
likely hypovolemia given history of orthostatic hypotension and
decreased urine output. Unclear what initiated hypotension but
possible etiologies included bacteremia from soft tissue
infection, obstructive shock from pericardial effusion,
restrictive cardiomyopathy, and adrenal insufficiency in setting
of chronic prednisone use. AM cortisol at rehab was low. Pt s/p
volume resuscitation in ICU (3L NS). Pt started on stress dose
steroids, which were tapered on the floor back to home dose of
10mg PO prednisone daily. Bl cx NGTD. Ucx negative. In the
setting of negative cultures, he was not placed on Abx. VIP port
was placed for HD, and an echocardiogram confirmed hypotension
was not due to tamponade. BPs improved to 100-120s/30-50s. BPs
consistently difficult to get accurate measures with cuff on
RUE. Occasional BPs in 80s but recheck normalized at times
requiring doppler BP measurement to confirm BP. In setting of AV
fistula in L UE, no BP measurements in left arm for now. Ok to
perform right UE blood pressures at dialysis, but would
otherwise recommend not check BPs, or measuring in thighs (as
patient has arterial insufficiency in right UE).
# Arterial insufficiency, R UE: Pt noted to have R UE edema
distally upon MICU callout. Edema improved but pinkness and
demarcation proximal to the elbow persisted. Arterial
insufficiency suggested on venous mapping and c/w cool R hand
with pink-purplish discoloration. Doppler of R radial and ulners
pulses present. Vascular surgery consulted. Pt had noninvasive
arterial study, which showed distal flow through the palmar
arch, with no urgent need for vascular intervention. Patient is
scheduled to follow-up with vascular surgery as an outpatient.
# Pericardial effusion: Known pericardial effusion dating back 4
years reportedly. Unclear if pericardial effusion had worsened.
Echo did not show tamponade physiology. Likely uremic effusion
if worsened from chronic effusion and will likely improve with
dialysis. Cardiology consulted.
# Possible restrictive cardiomyopathy: TTE with morphology and
echotexture of ventricles suggestive but infiltrative process,
likely amyloid from HD (beta2-microglobulin). SPEP/UPEP
negative. Cardiology consulted, and recommended no need for
cardiac MRI or biopsy.
# Atrial Fibrillation: longstanding, on coumadin at home. INR
therapeutic. Coumadin restarted [**2162-7-26**] with home dose 1mg,
increased to 2mg for subtherapeutic INRs.
# Lower extremity venous stasis ulcers: Recently (1 week prior
to adm) finished a course of antibiotics. No evidence of
infection on exam. Held off on ABX. Pt afebrile during stay.
WBC uptrended. Ulcers did not appears grossly infected but this
was only possible source for white count. Started pt on 1wk
course of cefazolin with 1g on [**7-29**]. Pt will need 2g on [**7-31**] and
2g post-HD on [**8-2**], then course completed. Vascular surgery
recommended ACE wraps to LE bilaterally + elevation of legs, in
addition to UNA boots bilaterally. Wound care recommendations
also included in paperwork.
# LE edema: R>L on MICU callout but became more symmetric. LENIs
neg for DVT to level of popliteals.
# Leukocytosis: WBC count uptrended to 12.2--> 12.6 --> 13.7
starting [**2162-7-26**], afebrile. LENIs negative per above. Culture
data NGTD. Only localizing source of infection includes LE
ulcers but without worsening appearance to suggest fevers.
# Anemia: normocytic, normochromic with iron studies c/w anemia
of chronic disease with low iron sat. Started Fe supplementation
in setting of low iron sat.
# Hyperphosphatemia: Hyperphosphatemia likely related to
decreased GFR. Started phos binder.
# Hyponatremia: Mild, improved. [**Month (only) 116**] be pseudohyponatremia since
it corrects to nearly normal after accounting for hypoglycemia.
[**Month (only) 116**] also be related to ATN and decreased ability to excrete free
water.
# Diabetes: Continued home NPH 26 units qAM with sliding scale
Transitional Issues:
# Tunneled line placed [**2162-7-28**] for HD access on discharge. Temp
HD line pulled [**2162-7-29**].
# Pt will need f/u with surgery re: fistula for more permanent
HD access if renal function does not improve. Vein mapping done.
Pt may benefit from meeting with transplant surgeons for
ligation of L AV-fistula so that pt could have L UE available
for future BP monitoring.
# Pt will need weekly cyclosporin levels. Goal <70.
# BPs in this patient are very difficult to obtain accurately
with a cuff. Pt has AV fistula in L UE, arterial insufficiency
in R UE, and significant LE edema. Recommend BPs in thighs, if
not possible, then R UE will be the next best choice. BPs
running high 80s- to 120s/ 30-50s. If having difficulty getting
accurate BP [**Location (un) 1131**], can check a doppler BP in the R UE if
necessary but should otherwise avoid BPs in UE bilaterally. BP
parameters for concern: SBP <85 and clinical correlation of
symptoms
# Continue wound care of LE ulcers. Please ACE wrap LE and
elevate legs. Una boots bilaterally.
# Labs for outpatient HD: Hep B labs neg, HCV Ab positive, PPD
neg.
# Pt discharged off allopurinol, consider restarting in future
when renal function more stable.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Rehab.
1. PredniSONE 10 mg PO DAILY
2. Allopurinol 150 mg PO DAILY
3. Calcitriol 0.4 mcg PO M, W, F
4. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO BID
7. Gabapentin 100 mg PO EVERY OTHER DAY
8. Hydrocortisone 100 mg PO Q8H
9. NPH 26 Units Breakfast
10. Multivitamins 1 TAB PO DAILY
11. Nystatin Cream 1 Appl TP [**Hospital1 **]
12. Pravastatin 40 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 1 mg PO DAILY16
15. Enalapril Maleate 1.25 mg PO DAILY
Discharge Medications:
1. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
2. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose BMs
3. FoLIC Acid 1 mg PO BID
4. Gabapentin 100 mg PO EVERY OTHER DAY
5. NPH 26 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Multivitamins 1 TAB PO DAILY
7. Pravastatin 40 mg PO DAILY
8. PredniSONE 10 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
11. Calcium Acetate 667 mg PO TID W/MEALS
12. Collagenase Ointment 1 Appl TP DAILY venous ulcers
L posterior venous ulcer and 2 R anterior lower leg ulcers
13. Ferrous Sulfate 325 mg PO TID
14. Miconazole Powder 2% 1 Appl TP TID:PRN fungal infection
15. Senna 1 TAB PO BID:PRN Constipation
16. CefazoLIN 2 g IV POST HD Duration: 1 Doses
on [**2162-8-2**]
17. Warfarin 2 mg PO DAILY16
18. CefazoLIN 2 g IV ONCE Duration: 1 Doses
on [**2162-7-31**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary diagnosis:
Hypovolemic hypotension
Acute on chronic renal failure
Lower extremity venous stasis ulcers
Secondary diagnosis:
s/p kidney transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 14953**],
It was a pleasure taking care of you in the hospital. You were
admitted with low blood pressures requiring a stay in the ICU.
You were given IV fluids and steroids to help your blood
pressure. Your cultures did not show signs of infection. Your
blood pressures improved.
Your kidney function worsened during your hospitalization and
you had to restart on dialysis. You had a tunneled line placed
so that you may continue dialysis at rehab; but the doctors
there [**Name5 (PTitle) **] continue to watch you closely for return of your
renal function.
Please follow-up at the appointments listed below. Please see
the attached list for changes to your outpatient medications.
Followup Instructions:
Please follow-up with the doctor at your extended care facility.
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2162-9-8**] at 9:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2162-8-12**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
We are working on a follow up appointment for your
hospitalization in Vascular Surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
You need to be seen within 1 week of discharge. The office will
contact you with an appointment. If you have not heard within 2
business days please call the office at [**Telephone/Fax (1) 2625**].
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2162-7-30**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
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icd9pcs
|
[
[
[]
]
] |
18436, 18508
|
9700, 15668
|
297, 323
|
18707, 18707
|
5079, 5079
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|
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|
5949, 9289
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18722, 18818
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3276, 3431
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,502
| 197,495
|
22232
|
Discharge summary
|
report
|
Admission Date: [**2103-7-19**] Discharge Date: [**2103-7-29**]
Date of Birth: [**2056-6-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Liver and Renal Failure
Major Surgical or Invasive Procedure:
Intubation
R IJ
CVVHD
History of Present Illness:
47 year old male with hx HCV, EtoH abuse and cirrhosis
transferred from OSH for worsening liver and renal failure.
Presented [**7-14**] with abd pain, n/v, fever and decreased PO. On
exam he was febrile and had marked ascities and jaundice.
Started on flagyl and cipro for presumed SBP. Paracentesis
showed neutrophils of 477. During that hopsitalization he
developed coagulopathy with INR increasing from 2.7-->3.9, bili
12-->21.6, Cr 2.1-->8.1. Transferred to [**Hospital1 18**] for transplant
evaluation, hemodyalisis, and HD support.
Past Medical History:
HTN
HCV
IVDU
EtOH abuse
Cirrhosis
Depression
Social History:
+ IVDU, Tob, EtoH
Family History:
non-contributory
Physical Exam:
Pt expired at end of hospital stay.
Pertinent Results:
[**2103-7-28**] 02:12AM BLOOD WBC-7.3 RBC-3.20* Hgb-9.9* Hct-28.5*
MCV-89 MCH-31.1 MCHC-34.9 RDW-18.5* Plt Ct-45*
[**2103-7-27**] 03:03AM BLOOD Neuts-84.0* Lymphs-8.4* Monos-5.0 Eos-2.2
Baso-0.3
[**2103-7-27**] 03:03AM BLOOD Anisocy-2+ Poiklo-1+ Macrocy-1+
[**2103-7-28**] 02:12AM BLOOD Plt Ct-45*
[**2103-7-28**] 02:12AM BLOOD PT-23.2* PTT-58.3* INR(PT)-3.6
[**2103-7-28**] 02:12AM BLOOD Fibrino-125*
[**2103-7-28**] 08:25AM BLOOD Glucose-125* UreaN-24* Creat-2.5* Na-128*
K-3.6 Cl-90* HCO3-25 AnGap-17
[**2103-7-28**] 02:12AM BLOOD ALT-97* AST-176* AlkPhos-132*
TotBili-42.7*
[**2103-7-26**] 02:45AM BLOOD Lipase-114*
[**2103-7-22**] 04:26AM BLOOD Lipase-1536*
[**2103-7-28**] 02:12AM BLOOD Calcium-11.6* Phos-1.7* Mg-3.1*
[**2103-7-20**] 04:08AM BLOOD Albumin-2.8* Calcium-9.0 Phos-7.7*
Mg-2.9*
[**2103-7-20**] 07:35AM BLOOD calTIBC-116* Ferritn-GREATER TH TRF-89*
[**2103-7-21**] 04:15PM BLOOD AFP-5.3
[**2103-7-28**] 07:07AM BLOOD Type-ART Temp-36.2 Rates-/18 Tidal V-400
PEEP-5 O2-40 pO2-110* pCO2-43 pH-7.34* calHCO3-24 Base XS--2
Intubat-INTUBATED Vent-SPONTANEOU
[**2103-7-25**] 10:19AM BLOOD Lactate-2.2*
[**2103-7-22**] 05:37AM BLOOD Lactate-3.7*
[**7-20**] ECHO: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
top normal/borderline dilated. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
There is no aortic valve stenosis. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. There is mild to moderate pulmonary
artery systolic hypertension.
[**7-24**] CTA abd: Cirrhosis, with changes of portal hypertension.
Normal vascular anatomy, with patent portal and splenic veins.
[**7-25**] CXR: NGT with tip coiled in the stomach. No other
significant
interval change in the appearance of the chest with continued
mild congestive
heart failure and multifocal patchy opacities within the left
upper and right
lower lobes, likely representing pneumonic infiltrates.
Brief Hospital Course:
1. Cirrhosis: Pt with severe Child's C class cirrhosis with
hepatorenal syndrome. Severe encephelopathy, hypoabluminemia,
edema, coagulopathy. Started on midodrine, octreotide and
lactulose. FFP given for coagulopathy. He was put on fluid
restriction to 1L per day. Biliruben increased to 42.7 at end
of hospital stay. Pt removed from transplant list and made DNR
with major goal of care comfort--he was extubated [**2103-7-29**] and
passed away that day.
2. Renal Failure: Pt with hepatorenal syndrome. He was put on
CVVHD during most of hosptial course in anticipation for
possible liver transplant, which unfortunately was not feasible.
3. Infection: Pt initially presented with SBP, treated with
numerous antibiotics including ceftriaxone, zosyn, vancomycin.
Pt also developed yeast in sputum while on ventilator.
4. Respiratory: Pt intubated for aspiration risk [**7-22**].
Maintained on pressure support during part of hospital course.
Extubated for comfort [**2103-7-29**].
5. Pancreatitis: Peak lipase 1536. Made NPO, and eventually
cleared.
6. Hypotension: Pt required dopamine transiently.
Medications on Admission:
albumin 12.5 g IV q6
lopressor 25 mg po BID
norvasc 2.5 mg po qD
Protonix 40mg po qD
Midodrine 10 mg po TID
flagyll 500 mg IV q6h
Octreotide 100mcg IV TID
cipro 200mg IV q12
Discharge Medications:
pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatorenal syndrome
Cirrhosis
Pancreatitis
Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2103-10-31**]
|
[
"276.7",
"567.2",
"070.51",
"304.00",
"585",
"304.20",
"571.2",
"572.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
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"99.04",
"99.15",
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"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
4795, 4804
|
3409, 4536
|
338, 361
|
4911, 4920
|
1142, 3386
|
4976, 5015
|
1052, 1070
|
4760, 4772
|
4825, 4890
|
4562, 4737
|
4944, 4953
|
1085, 1123
|
275, 300
|
389, 933
|
955, 1001
|
1017, 1036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,355
| 129,628
|
32004
|
Discharge summary
|
report
|
Admission Date: [**2167-10-6**] Discharge Date: [**2167-10-11**]
Date of Birth: [**2112-8-27**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Called by ED to evaluate patient for brain lesion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is a 55 yo female w/ no significant past medical history
who woke up in her USOH this morning and went to work. This
afternoon when she was found by her husband to be fumbling her
hands and appeared confused. She was also noted to have garbled
speech. She was brought to an OSH where a CT head showed
multiple brain lesions with vasogenic edema. The patient was
then medflighted to [**Hospital1 18**] for further management.
Pt denies headache, visual changes, nausea, vomiting, fevers,
chills, night sweats, bowel/bladder incontinence.
Past Medical History:
Past Medical History: none
Social History:
Social History: Lives with husband. 1 ppd x 30 years
Family History:
Family History: father - lung cancer, mother - emphysema
Physical Exam:
Physical Exam:
Vitals: T 97.5; BP 152/71; P 56; RR 16; O2 sat
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Skin: tanned, no obvious lesions identified
Neurological Exam:
Mental status: Awake, oriented to self, city - [**Hospital1 6687**].
Multiple phonemic paraphasias. Adequate comprehension. Closes
eyes, shows two fingers.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-16**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. 4+ UMN
weakness of LUE.
Sensation: intact to light touch
Reflexes: 2+ symmetric. R toe up. L toe down.
Coordination: FNF intact.
Pertinent Results:
Labs:
139 103 14 88 AGap=18
4.5 23 0.5
CK: 127 MB: 4
Ca: 9.9 Mg: 2.1 P: 3.6
ALT: 6 AP: 90 Tbili: 0.3
AST: 21 LDH: 266
[**Doctor First Name **]: 31 Lip: 19
WBC 10.5 HCT 35.3 PLT 325
N:77.1 L:18.0 M:4.2 E:0.3 Bas:0.4
PT: 13.3 PTT: 36.1 INR: 1.2
Radiology:
CT head - 1. Large amount of vasogenic edema and mass effect
involving the left frontal, parietal, and bilateral temporal
lobes is identified, consistent with underlying metastatic
lesions. Mild rightward shift of the midline.
3. 9-mm hyperdense focus in the right basal ganglia consistent
with a hemorrhagic metastasis.
Brief Hospital Course:
Ms. [**Known lastname 5450**] was admitted to the neurosurgery service after CT
and MRI of the head revealed multiple mass lesions. She also had
a CT torso that revealed a lung mass. This was biopsied via
bronchoscopy and pathology revealed non-small cell lung
carcinoma. It was felt that no further surgery was therefore
required. She was seen by oncology, neuro-oncology, and
radiation oncology. She will follow-up with an Oncologist in her
area and has elected to have radiation therapy at [**Hospital1 3325**], near her home.
Medications on Admission:
Medications: none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): continue while on narcotics (Percocet).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): continue while on steroids.
Disp:*60 Tablet(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed: No driving while on narcotics.
Disp:*60 Tablet(s)* Refills:*0*
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
brain metastases
non-small cell lung cancer
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR BRAIN TUMOR
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed.
?????? Clearance to drive and return to work will be addressed at
your follow-up office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
Followup Instructions:
You have an oncology appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 19895**], MD
Phone:[**0-0-**] Date/Time:[**2167-10-22**] 10:30 am.
Contact [**Hospital3 **] regarding your radiation treatment.
Completed by:[**2167-10-11**]
|
[
"293.0",
"162.3",
"162.5",
"198.3",
"784.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.27",
"96.56",
"33.26"
] |
icd9pcs
|
[
[
[]
]
] |
4199, 4205
|
2831, 3362
|
371, 378
|
4293, 4317
|
2209, 2808
|
5253, 5516
|
1113, 1156
|
3431, 4176
|
4226, 4272
|
3388, 3408
|
4341, 5230
|
1187, 1555
|
1574, 1574
|
281, 333
|
406, 958
|
1749, 2190
|
1589, 1733
|
1002, 1009
|
1041, 1081
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,582
| 199,728
|
13063
|
Discharge summary
|
report
|
Admission Date: [**2184-3-5**] Discharge Date: [**2184-3-11**]
Date of Birth: [**2115-1-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 y/o male w/history of UC status post abdominal colectomy and
ileostomy on [**2184-2-24**], now presents to ED with progressive
abdominal pain over the past 2 days. Elevated WBC count at
20.Tachycardia to 150, AF with normal BP. Lactate mildly
elevated at 2.2. The patient has been given abx. Given the renal
failure we will perform a CT abd/pelvis with po contrast only.
Surgery consulted. The patient will need admission.
Past Medical History:
DM-Type 1
Ulcerative Colitis
h/o recent DVT
Factor V Leiden
Factor II mutation
b/l cataract surgery
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
vital signs:98.5,86, 136/74,20, 94% room air
Neuro: alert and oriented x3
Pulmonary: clear
Cardiovascular:regular rate rhythm
GU/Flank: Normal
Musc/Extr/Back: Normal
[**Date Range **]: stoma dusky, protruding, gas and stool in bag
Extremities:+2 dorsalis pedis, LE +2 edema
Pertinent Results:
[**2184-3-10**] 11:00AM BLOOD WBC-6.4 RBC-3.78* Hgb-10.4* Hct-33.1*
MCV-88 MCH-27.5 MCHC-31.3 RDW-15.1 Plt Ct-520*
[**2184-3-9**] 05:20AM BLOOD WBC-6.4 RBC-3.58* Hgb-9.9* Hct-30.6*
MCV-85 MCH-27.6 MCHC-32.3 RDW-14.6 Plt Ct-486*
[**2184-3-5**] 06:50PM BLOOD WBC-19.8*# RBC-4.60 Hgb-13.3* Hct-39.5*
MCV-86 MCH-28.9 MCHC-33.6 RDW-15.0 Plt Ct-865*#
[**2184-3-5**] 06:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2184-3-11**] 05:25AM BLOOD PT-18.3* INR(PT)-1.7*
[**2184-3-10**] 11:00AM BLOOD Plt Ct-520*
[**2184-3-5**] 06:50PM BLOOD PT-19.0* PTT-24.8 INR(PT)-1.7*
[**2184-3-9**] 05:20AM BLOOD Glucose-237* UreaN-17 Creat-1.1 Na-136
K-4.3 Cl-101 HCO3-28 AnGap-11
[**2184-3-8**] 05:45AM BLOOD Glucose-227* UreaN-19 Creat-1.1 Na-136
K-4.0 Cl-100 HCO3-26 AnGap-14
[**2184-3-5**] 06:50PM BLOOD Glucose-315* UreaN-26* Creat-1.7* Na-133
K-5.8* Cl-98 HCO3-20* AnGap-21*
[**2184-3-5**] 06:50PM BLOOD ALT-14 AST-30 AlkPhos-78 TotBili-0.5
[**2184-3-9**] 05:20AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7
[**2184-3-8**] 05:45AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8
[**2184-3-5**] 06:50PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.2 Mg-1.6
[**2184-3-6**] 02:43AM BLOOD Glucose-298* Lactate-1.2 Na-135 K-4.6
Cl-99*
[**2184-3-5**] 06:50PM BLOOD Lactate-2.2* K-5.0
[**2184-3-6**] 02:43AM BLOOD freeCa-1.14
Brief Hospital Course:
Patient was admitted ED with progressive abdominal pain over
the past 2 days and with a leukocytosis 20, tachycardia 150, and
a mildly elevated lactate 20. Patient had an abdominal CT showed
fluid collection on right side and across midline not amenable
to drainage. Patient was started on antibiotics
Vancomycin/Cipro/Flagyl and had a brief stay in the surgical
intensive care unit. He was then transferred to the general
surgical inpatient unit.
Neuro: The patient received Dilaudid intravenously with good
effect and adequate pain control. Patient remained alert and
oriented x3 throughout his stay.
CV: The patient was tachycardic on admission to 150's and was on
intravenous metoprolol which was transitioned to PO. The
patient blood pressure stabilized SBP 130.
Pulmonary:Good pulmonary toilet, early ambulation and incentive
spirometry were encouraged throughout hospitalization. The
oxygen was weaned as tolerated however was noted to have
decrease oxygen saturation 91%-93% on room air and required
intermittent oxygen. The patient however denied shortness of
breath or dyspnea on exertion. A chest XRay was done which
showed atelectasis and pleural effusion.
GI/GU/FEN:
Serial abdominal exams were done. Patient was advanced from on
clear sips and advanced to clear liquids. By hospital day 4 was
tolerating a regular/carbohydrate diet. However in the evening
developed increase nausea and abdominal distension was made NPO.
By hospital day 5 had no further nausea or distension and the
diet was resumed to clears to regular.
The foley catheter was discontinued on hospital day 4 and
patient failed to void after 8 hours was bolused with LR 500 cc
and responded appropriately. On hospital day 5 was unable to
void and was straight catheterized for urinary retention. At
that time urology were consulted and per their recommendations a
foley catheter was placed. The patient was discharged home with
foley and leg bag and will follow-up with urology for voiding
trial. During his hospitalization the electrolytes were
monitored closely, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient was started on
Vancomycin, Cipro and Flagyl. The Vancomycin was discontinued on
hospital day 7.
Endocrine: Patient was steroid dosed with Hydrocortisone which
were discontinued on hospital day # 4 and his home dose
Prednisone 10 mg PO twice a day was restarted. patient was
hyperglycemic with blood glucose levels 200-400 thus [**Last Name (un) **] was
re consulted and his insulin dose was adjusted accordingly per
endocrine.
Hematology: Patient had a drop in hematocrit 36.0 to 27.9 on
admission. The hematocrit were monitored closely and was
otherwise stable. The patient did not require any blood
transfusions.
Prophylaxis: The patient received warfarin for history of deep
INR checks. Venodyne boots were used during this stay. Patient
was encourage to ambulate to avoid complications.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
The patient will be discharged home with VNA for [**Last Name (un) 9341**] care.
Mr. [**Known lastname 39946**] was discharged home on Ciprofloxacillin and
Flagyl for 2 weeks. He has been advised to monitor his blood
sugars closely and to follow up with his endocrinologist for his
hyperglycemia. In addition he will continue on Coumadin 2 mg PO
and follow-up with primary care provider for INR/Coumadin
dosing. He will follow-up with the gastroenterologist for
tapering of his steroids. He will schedule a follow-up
appointment with Dr. [**Last Name (STitle) **] in 6 weeks who will determine
if a repeat abdominal CT is neccessary.
Medications on Admission:
prednisone 10 [**Hospital1 **]
Levimir insulin 20, 10 daily
Humalog Insulinn Sliding Scale
Lipitor 10 mg QD,
Flomax 0.4 QD
Iron 325 mg [**Hospital1 **],
Oxycodone PRN
Coumadin
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
Fevers
Intra-abdominal fluid collections
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the emergency room with abdominal pain and
abdominal distension and had a CT scan which showed an abdominal
fluid collection. You were started on antibiotics and we would
like you to continue to take Cipro and Flagyl for 2 weeks.
Please take all antibiotics as prescribed. Call or return to
emergency department for fever greater then 101, severe nausea,
vomiting dehydration and being unable to maintain oral
hydration, pain > 24 hrs and unresolved, redness or purulent
drainage to the incision, shortness of breath or chest pains.
You had difficulty urinating after your foley catheter was
removed and urology were consulted who recommended placement of
a foley catheter for 5 days and to follow-up with your primary
care provider or urologist for a voiding trial.
We would like you to continue taking Prednisone 10 mg twice a
day and follow-up with your endocrinologist for steroid
tapering. Your blood sugars were elevated during your
hospitalization and your insulin was adjusted by the
endocrinologist. Please follow up with your endocrinologist for
further monitoring of your blood sugars and insulin adjustment.
Please continue to monitor your ileostomy. The most common
complication from a new ileostomy placement is dehydration. The
output from the stoma is stool from the small intestine and the
water content is very high. The stool is no longer passing
through the large intestine which is where the water from the
stool is reabsorbed into the body and the stool becomes formed.
You must measure your ileostomy output for the next few weeks.
The output from the stoma should not be more than 1200cc or less
than 500cc. If you find that your output has become too much or
too little, please call the office for advice. Keep yourself
well hydrated, if you notice your ileostomy output increasing,
take in more electrolyte drink such as gatoraide. Please monitor
yourself for signs and symptoms of dehydration including:
dizziness (especially upon standing), weakness, dry mouth,
headache, or fatigue. If you notice these symptoms please call
the office or return to the emergency room for evaluation if
these symptoms are severe.
Followup Instructions:
Primary care provider [**Name Initial (PRE) 263**]/ Coumadin dosing in 1 week.
Urologist for removal of foley and voiding trial.
Gastroenterologist regarding steroid tapering.
Dr. [**Last Name (STitle) **] in 6 weeks [**Telephone/Fax (1) 9**].
Completed by:[**2184-3-11**]
|
[
"V12.79",
"289.81",
"V44.2",
"250.01",
"V58.61",
"V58.65",
"E878.8",
"780.60",
"788.29",
"567.22",
"V12.51",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94"
] |
icd9pcs
|
[
[
[]
]
] |
6794, 6850
|
2634, 6568
|
314, 321
|
6935, 6935
|
1280, 2611
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9269, 9544
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952, 970
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6871, 6914
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6594, 6771
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7086, 9246
|
985, 1261
|
260, 276
|
349, 777
|
6950, 7062
|
799, 901
|
917, 936
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,851
| 130,396
|
14271
|
Discharge summary
|
report
|
Admission Date: [**2129-3-11**] Discharge Date: [**2129-3-16**]
Service:
HISTORY OF PRESENT ILLNESS: The patient was transferred from
[**Hospital3 **] due to hypoxia and mild hypotension secondary
to newly diagnosed pulmonary embolism.
The patient is a 79-year-old female with a known history of
coronary artery disease, chronic obstructive pulmonary
disease and recent diagnosis of non-small cell lung cancer.
The patient was admitted to [**Hospital3 **] on [**2129-2-21**] for
elective wedge resection of a right lower lobe mass. The
mass was found to be non-small cell lung cancer. The patient
did well postoperatively and was transferred to the
Transitional Care Unit for rehabilitation. Reportedly, the
patient was ambulating freely until five days ago. Two days
prior to admission to [**Hospital6 256**],
she developed dyspnea with oxygen saturation decreasing to
the 80s in room air. The patient was transferred to the MICU
at [**Hospital3 **]. There, she was hypotensive. Her blood
pressure improved with fluid administration. She was found
to have bilateral pulmonary emboli on CT angiogram. Since
the patient had recently undergone wedge resection of the
right lower lobe, she was not a candidate for systemic
thrombolytic therapy. The patient was transferred to [**Hospital6 1760**] for further management.
At [**Hospital6 256**], review of chest CT
disclosed segmental bilateral pulmonary emboli. Doppler
ultrasound of the lower extremities did not disclose evidence
of deep venous thrombosis. The patient was admitted to the
MICU for further management.
PAST MEDICAL HISTORY:
1. Squamous cell carcinoma. The patient is status post
wedge resection of the right lower lobe on [**2129-2-21**].
2. Chronic obstructive pulmonary disease.
3. Coronary artery disease, status post right coronary
artery stent placement in [**2126-8-13**]. Cardiac
catheterization in [**2128-8-12**]: Ejection fraction 57%,
inferior hypokinesis
4. Osteoporosis, status post compression fracture.
5. Peptic ulcer disease.
6. Status post cesarean section x2.
7. Status post appendectomy.
8. Status post hysterectomy.
9. Renal artery stenosis, status post bypass in [**2122**].
10. Hypertension.
11. Hypercholesterolemia.
12. Esophageal stricture, status post dilation.
13. Psoriasis.
Outpatient medications include Pepcid 20 mg b.i.d., Flovent 2
puffs b.i.d., Serevent 2 puffs b.i.d., Digoxin 0.25 mg q day,
Miacalcin 1 spray nasally q day, Ambien q h.s. and Albuterol
and Atrovent nebulizer treatments p.r.n.
ALLERGIES: E-Vista, Fosamax, Darvocet, Percocet,
Erythromycin.
MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL: Risperidone
2 mg q h.s., Coumadin 5 mg q h.s., Lopressor 25 mg b.i.d.,
Neutra-Phos 1 t.i.d., enteric coated aspirin 325 mg q day,
Guaifenesin p.r.n., Miacalcin spray, Digoxin 0.25 mg q day,
Albuterol and Atrovent nebulizer treatments p.r.n.,
Salmeterol 1-2 puffs b.i.d., Fluticasone inhaler 2 puffs
b.i.d., Pepcid 20 mg b.i.d., intravenous Heparin.
SOCIAL HISTORY: The patient is a widow and lives at home.
She has a 60+ pack/year history of tobacco use, quit smoking.
Patient lives with her daughter.
FAMILY HISTORY: Father had a history of coronary artery
disease. Mother and two uncles had [**Name2 (NI) 499**] cancer.
PHYSICAL EXAMINATION: General: Well-appearing, resting in
bed. Vital Signs: Afebrile, heart rate 90-105, respiratory
rate 20-29, blood pressure 84/36, saturation 97% on 2 liters.
HEENT: Pupils equal, round and reactive to light.
Extraocular movements intact. Sclerae anicteric.
Edentulous. Neck: Well-healed mediastinoscopy scar. No
lymphadenopathy. No thyromegaly. Lungs: Poor air movement.
Right posterior incision healing well. Heart: Tachycardiac.
Normal S1 and S2. No murmurs. Abdomen: Soft, non-tender
and non-distended with positive bowel sounds. Extremities:
No clubbing, cyanosis or edema. No cords and no swelling.
Neurologic: Alert and oriented to name and place.
EKG: Sinus tachycardia at 105, QRS interval 60??????, normal
intervals, Q waves in 2, 3 and F, V3 through V6, right bundle
branch block, biphasic T in V2 through V6.
Laboratories from the outside hospital showed a white count
of 68, a hematocrit of 39.2, a glucose of 123, a sodium of
132, a potassium of 3.5, a chloride of 98, a bicarbonate of
30, a BUN of 5, a creatinine of 0.6, a glucose of 105, a
calcium of 8.1 and a magnesium of 2.3.
IMPRESSION: 79-year-old female with chronic obstructive
pulmonary disease, coronary artery disease and non-metastatic
squamous cell lung carcinoma, status post resection, who
presents with shortness of breath, desaturation and
hypotension. She was found to have bilateral pulmonary
emboli on CT angiogram. The patient was transferred from
[**Hospital3 **] for further management.
HOSPITAL COURSE:
1. Pulmonary: The patient was admitted to the MICU for
management. The patient was maintained on 2 liters of oxygen
by nasal cannula. CT angiogram from [**Hospital3 **] was
reviewed by radiology. Review confirmed bilateral pulmonary
emboli but no saddle emboli. The patient was placed on
Heparin. The patient underwent lower extremity Doppler
ultrasounds which were negative. The cause of the pulmonary
emboli was thought to be multifactorial and due to
malignancy, a history of smoking, immobility and the presence
of a recent internal jugular central line. Inferior vena
cava filter was considered, but, since there were no clots by
lower extremity ultrasound, it was decided that the patient
would not benefit from this procedure. The patient was also
administered her inhalers and Atrovent and Albuterol
nebulizer treatments. During her hospital stay, she began to
feel less short of breath. She was transferred out of the
MICU on [**2129-3-12**] to the medical floor. Her oxygen saturation
was stable on [**2-15**] liters of oxygen by nasal cannula. It was
decided that the patient would be initiated on Lovenox for
treatment of her pulmonary emboli.
2. Cardiovascular: On admission, the patient was
hypotensive and required fluid boluses to maintain her
systolic blood pressure over 80. An arterial line was
placed, and it was noted that her systolic pressure was
significantly greater with the arterial line [**Location (un) 1131**] than
with the non-invasive pressure. The patient's blood pressure
should be checked in the right arm. On EKG, the patient has
evidence of an old infarction. The patient's cardiac enzymes
were cycled and found to be negative. She was administered
aspirin and beta blockers.
Regarding the patient's rhythm, she was noted to be
tachycardiac. Rhythm seemed consistent with multifocal
atrial tachycardia. The patient's rate has been controlled
with beta blockers. The patient is also on Digoxin 0.25 mg q
day.
3. Infectious Disease: The patient has a history of MRSA in
her sputum. The patient remained afebrile during her
hospital stay.
4. Oncology: As noted above, the patient is status post
wedge resection of the right lower lobe for non-small cell
lung cancer. The patient also underwent mediastinoscopy
which was negative for metastatic disease to the lymph nodes
of the mediastinum.
5. Hematology: On [**2129-3-13**], the patient was noted to have a
hematocrit of 24.8. The patient was administered two units
of packed red blood cells. DIC panel and Hemophilus workup
were negative.
The patient was anticoagulated with Heparin and Coumadin
during her hospital stay. Due to difficulty maintaining the
patient's INR, she will be anticoagulated with Lovenox.
6. Neurology/Psychiatry: The patient was noted to have
periods of delirium during her hospital stay. She was
managed with Risperidone q h.s.
7. Physical Therapy: The patient underwent evaluation by
Physical Therapy. The patient will continue to require
physical therapy upon discharge.
8. Nutrition: The patient was seen by the Nutrition
Service. The patient has refused supplements but is willing
to try other supplemental forms of nutrition.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: The long term plan is for the patient to
live in an [**Hospital3 **] facility in [**State 108**]. The patient
will require rehabilitation prior to discharge to the
[**Hospital3 **] facility.
DISCHARGE DIAGNOSES:
1. Non-small cell lung cancer, status post wedge resection
of right lower lobe in [**2129-2-12**].
2. Chronic obstructive pulmonary disease.
3. Coronary artery disease.
4. Osteoporosis.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Enteric coated aspirin 325 mg p.o. q day.
3. Miacalcin 1 spray to nostril q day.
4. Digoxin 0.25 mg p.o. q day.
5. Salmeterol 1-2 puffs b.i.d.
6. Fluticasone propionate 110 mcg, 2 puffs b.i.d.
7. Lovenox 40 mg subcutaneously b.i.d. x6 months.
8. Pepcid 20 mg p.o. b.i.d.
FOLLOW UP: The patient will follow up with her new primary
care physician in [**Name9 (PRE) 108**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 40444**], M.D. [**MD Number(1) 40445**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2129-3-16**] 10:16
T: [**2129-3-16**] 10:19
JOB#: [**Job Number 42395**]
|
[
"496",
"696.1",
"414.01",
"415.19",
"162.9",
"293.0",
"427.89",
"458.9",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8052, 8271
|
3188, 3294
|
8292, 8501
|
8524, 8838
|
4835, 7723
|
7742, 8030
|
8850, 9223
|
3317, 4818
|
113, 1594
|
1617, 3016
|
3033, 3171
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,920
| 187,572
|
6449
|
Discharge summary
|
report
|
Admission Date: [**2127-11-26**] Discharge Date: [**2127-12-8**]
Date of Birth: [**2054-4-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
Resection and repair of suprarenal aneurysm with 20-mm Dacron
graft and aorto left renal bypass with 6 mm Dacron graft.
History of Present Illness:
This gentleman underwent abdominal aortic aneurysm repair with
an aortobi-iliac graft about 12 years ago. He has developed an
aneurysm proximal to the graft
involving the visceral segment of his aorta just proximal to the
graft involving mostly the renals but also part of the aorta
where the supraceliac and superior mesenteric artery are
located. He is now undergoing repair.
Past Medical History:
PMH:
CAD,
HTN,
MI,
Bladder CA,
GERD
PSH:
s/p CCY,
cataract,
CABG, AAA repair '[**15**],
prostatectomy,
hernia
Social History:
Pos hx smoking / quit [**2104**]
Pos alcohol 2 per day
Family History:
Non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2127-12-6**]
WBC-9.9 RBC-3.29* Hgb-10.1* Hct-30.4* MCV-93 MCH-30.7 MCHC-33.1
RDW-13.7 Plt Ct-631*#
[**2127-12-8**]
Plt Ct-650*
[**2127-12-2**]
PT-13.0 PTT-30.0 INR(PT)-1.1
[**2127-12-7**]
Calcium-8.7 Phos-3.6 Mg-2.0
[**2127-12-8**]
Glucose-111* UreaN-52* Creat-2.2* Na-138 K-4.4 Cl-107 HCO3-19*
AnGap-16
[**2127-12-1**]
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-1 pH-8.0 Leuks-SM
URINE RBC-[**4-5**]* WBC-[**12-21**]* Bacteri-FEW Yeast-NONE Epi-0
[**2127-12-3**] 8:06 am
STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2127-12-3**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2127-12-4**] 10:30 AM
CHEST (PA & LAT)
FINDINGS: The patient is status post sternotomy and CABG and
there is stable appearance of the heart size and
cardiomediastinal contours. There has been interval decrease in
size of bilateral pleural effusions, now with a tiny residual
right pleural effusion and small left pleural effusion. There
remains linear atelectasis at the left base. Otherwise, the
lungs are clear. There is no overt evidence of CHF.
IMPRESSION: Interval decrease in size of bilateral pleural
effusions. No evidence of CHF.
[**2127-11-27**]
ECG
Sinus rhythm. Late transition with lateral and anterolateral
ST-T wave changes consistent with old anterior myocardial
infarction. Low voltage in the limb leads. Compared to the
previous tracing there is no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 176 94 384/397 55 8 123
Brief Hospital Course:
Pt admitted on [**2127-11-26**]
Pt underwent a, Resection and repair of suprarenal aneurysm
with 20-mm Dacron graft and aorto left renal bypass with 6 mm
Dacron graft. There were no complications. Pt tolerated the
procedure well. Pt remained intubated after the procedure.
Transfered to the TSICU in stable condition.
[**2127-11-27**] - [**2127-11-28**]
Pt remained intubated / extubated on [**2127-11-28**].
Pt was on fentynal / propofol / dopamine
Pt diuresed / sub q hep. / FISS
[**2127-11-29**]
IV was heplocked / diet was advanced / lytes repleted / SWAn
pulled back to CVP / pulmonary toilet
[**2127-11-30**]
SWAN DC'd / diuresed / PT
[**2127-12-2**]
Pt with temp / pan cx
Pt c/o diarhea - flagyl started
Vancomycin started
c/w diuresis
[**2127-12-3**]
Foley Dc'd
OOB / IS / PT
[**2127-12-4**]
Pt afebrile
pt remained slightly confused
Bood cx - species indeterminant
Flagyl DC'd
Pt remains on Vanco / Levo
[**2127-12-5**]
rehab screening
CX negative
IV AB DC'd
OOB / PT continued
[**2127-12-6**]
Pt ambulatory
PT / Rehab screen cont.
[**2127-12-7**] - [**2127-12-8**]
c/w ambulation
pt on full diet
Staples DC'd
Pt stable on DC, taking PO / ambulating / pos BM / urinating
Medications on Admission:
ASA 81,
lipitor 20,
Coreg 3.125,
valsartan,
coumadin 2.5 6d/wk, 3 1d/wk,
diovan 80,
MVI
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
11. Diovan 80 mg Capsule Sig: One (1) Capsule PO once a day.
12. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a week.
13. Coumadin 3 mg Tablet Sig: [**2-2**] tablet Tablet PO daily 6 x
week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24806**] Care Center - [**Hospital1 1562**]
Discharge Diagnosis:
Suprarenal abdominal aortic aneurysm.
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING AORTIC SURGERY
.
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 no specific restrictions on activity other than no
lifting an object heavier than twenty-five (25) pounds for the
first three (3) months. Gradually increase your level of
activity back to normal depending on how you feel. Fatigue is
normal, especially for the first month postoperative. Resume
driving when you feel strong enough and comfortable enough
without needing pain medication.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Severe and worsening abdominal pain .
.
Pain or swelling in one of your legs.
.
Increasing pain, redness or drainage related to your incision(s)
.
.
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 8 weeks.
.
Resume driving when you feel strong enough and comfortable
enough without needing pain medication .
.
No heavy lifting greater than 20 pounds for 8 weeks.
.
Avoid excessive bending at the hips and stooping for 4 weeks.
.
BATHING/SHOWERING:
.
You may shower immediately if the incision is dry upon coming
home. No baths until sutures / staples are removed. Dissolving
sutures may have been used. In either case, you can wash your
incision gently with soap and water.
.
WOUND CARE:
.
Suture / 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 / staples 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
two weeks after surgery.
.
MEDICATIONS:
.
You may resume taking medication you were on prior to your
surgery unless specifically instructed otherwise by your
physician [**Name9 (PRE) **] will be given a new prescription for pain
medication, which should 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 heavy lifting (over 20 pounds) for 8 weeks after surgery.
.
No strenuous activity for 4-6 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) **] office and schedule an appointment for 2
weeks. He can be reached at [**Telephone/Fax (1) 3121**].
Completed by:[**2127-12-8**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,269
| 123,569
|
54752
|
Discharge summary
|
report
|
Admission Date: [**2169-6-19**] Discharge Date: [**2169-6-22**]
Date of Birth: [**2104-4-5**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
Temporary hemodialysis line placement
History of Present Illness:
This is a 65yo F hx of DM (not on meds) who presents with
lethargy for the last several weeks. Patient denies any chest
pain or shortness of breath. She endorses generalized weakness.
Denies any fevers or chills, urinary symptoms, cough, headaches.
She has noted an itchy rash all over her body which her son who
lives with her. Also, pt has cataracts and is blind in both
eyes.
.
In the ED, initial VS were: 97.4 65 131/54 16 100%. On exam, pt
appeared pale. Lungs are clear bilaterally, but pitting edema
bilat 3+ was noted. Guaiac was postive with dark brown stool.
Labs were remarkable for Hct 15. Cr was 14.3 and K was 8.2.
WBC and lactate were wnl. UA showed 14 and mod bacteria. Urine
and blood cx were sent. CXR showed R>L pleural effusion.
proBNP was >70,000. Pt was given 40mg IV of lasix, glucose,
insulin, calcium. Pt has not really urinating much since then,
maybe 100cc. Also got 1L NS, now sodium bicarb per renal. Pt
has been ordered for 2U pRBCs. CTX was started for UTI and
repeat chem showed Cr improved to 13 and K improved to 7.2. On
transfer to MICU, vitals were HR 71 RR 17 O2 sat 100 RA BP
124/52.
.
On arrival to the MICU, pt is comfortable in bed. Complains of
fatigue, no other specific complaints. Denies chest pain,
fevers. Endorses shortness of breath with standing up and
exertion. Also, endorses dizziness but no syncopal episodes.
Denies abdominal symptoms. Endorses diffuse body rash with
itchiness for several weeks. Son also has similar milder rash.
Past Medical History:
-Diabetes Mellitus, complicated by diabetic retinopathy (last
A1C <6)
- Hypertension
- Dyslipidemia
- CKD IV
- Bilateral cataracts (legally blind)
Social History:
lives at home with son. denies T/E/D.
Family History:
mother with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: BP: 136/52 P: 71 R: 18 O2: 100% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, pupils with obvious cataracts, pale
conjunctivae, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: no clubbing, cyanosis or edema
Neuro: strength and sensation grossly intact
Skin: diffuse body rash, sparing face, red 1-2mm lesions that
are scratched, with scabs
.
DISCHARGE PHYSICAL EXAM:
Vitals: 99.2 99.6 126/74 [126-170/74-85] 89-95 20 99% RA
I/O: 360/450
General: elderly asian F in NAD, AAOx3, talking comfortably
HEENT: pupils with +BL cataracts, EOMI, sclera anicteric, pale
conjunctivae, OP clear
Neck: supple, no JVD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild inspiratory crackles at bases b/l, no wheezes or
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: No clubbing, cyanosis, 1+ pitting edema b/l
Neuro: Strength and sensation grossly intact
Skin: Diffuse erythematous body rash with excoriation marks and
scabs overlying the majority of the skin, sparing the face,
feet, and hands
Pertinent Results:
admission labs
[**2169-6-19**] 06:30PM BLOOD WBC-6.4 RBC-1.61* Hgb-4.4* Hct-15.3*
MCV-95 MCH-27.2 MCHC-28.7* RDW-18.3* Plt Ct-312
[**2169-6-19**] 06:30PM BLOOD Neuts-91.7* Lymphs-4.7* Monos-2.8 Eos-0.6
Baso-0.2
[**2169-6-19**] 06:30PM BLOOD PT-13.1* PTT-31.1 INR(PT)-1.2*
[**2169-6-19**] 06:30PM BLOOD Glucose-96 UreaN-261* Creat-14.3* Na-141
K-8.2* Cl-105 HCO3-9* AnGap-35*
[**2169-6-19**] 06:30PM BLOOD ALT-54* AST-52* AlkPhos-132* TotBili-0.1
[**2169-6-19**] 06:30PM BLOOD Lipase-178*
[**2169-6-19**] 06:30PM BLOOD proBNP-GREATER TH
[**2169-6-19**] 06:30PM BLOOD Albumin-3.6 Calcium-4.7* Phos-13.3*
Mg-2.3
[**2169-6-19**] 06:45PM BLOOD Lactate-1.7
.
urine
[**2169-6-19**] 10:40PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2169-6-19**] 10:40PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2169-6-19**] 10:40PM URINE RBC-3* WBC-14* Bacteri-MOD Yeast-NONE
Epi-<1
[**2169-6-19**] 10:40PM URINE Mucous-RARE
.
MICROBIOLOGY:
-Urine cx ([**2169-6-19**]): Proteus Mirabilis 10,000-100,000 CFU.
Sensitivities:
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood cx ([**2169-6-19**]): NEGATIVE
.
CXR: 1. Moderate cardiomegaly. In addition to true enlargement
of the myocardium, the possibility of a pericardial effusion
could be considered.
2. Basilar opacification, greater on the right than left with a
suspected
pleural effusion, at least on the right side.
3. Moderate thoracolumbar compression deformity.
TTE ([**2169-6-20**]): The left atrium is elongated. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%) secondary to apical hypokinesis. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size and free
wall motion are normal. There are focal calcifications in the
aortic arch. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild to moderate ([**1-30**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is severe pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
RENAL ULTRASOUND ([**2169-6-20**]): Diffuse increased echotexture
involving the renal cortices
bilaterally consistent with medical renal disease. no
hydronephrosis
Brief Hospital Course:
65yoF with bilateral cataracts, HTN, DLP, DM, non-compliant with
medications, who presents with lethargy for several weeks and
found to be in acute renal failure with hyperkalemia and anemia.
# UREMIA, HYPERKALEMIA: The patient presented with fatigue and
was found to be in acute renal failure with hyperkalemia,
hypocalcemia, uremia, and volume overload. She received calcium,
insulin and bicarb in the ED. She was admitted to the MICU,
where temporary tunneled HD line was placed and she received
dialysis with appropriate improvement in BUN/Cr and potassium,
also gave 2 units of blood with HD for anemia. On HD#3 she was
stable from electrolyte, acid-base and hemodynamic standpoint
and was transferred to the floor. On the floor, she underwent
second HD session, where she received 2 more units of blood.
Etiology of her uremia was unclear, initially thought to be
prerenal due to UTI causing urosepsis, but nephrology ultimately
felt this was more likely natural history of her advancing CKD
in setting of no treatment for her underlying HTN or DM. Also
considered multiple myeloma given T spine compression fx on CXR,
SPEP/UPEP pending on discharge. Renal US showed medical renal
disease. Nephrology advised patient would almost certainly
require permanent hemodialysis going forward. However, patient
refused further dialysis after her second session, stating
clearly that she wanted no further treatment or medicine and
insisted on being discharged home. After extensive discussion
with patient, son, nephrology and PCP, [**Name10 (NameIs) **] tunneled line was
removed and she was discharged home with plans for close F/U
with nephrology and her PCP. [**Name10 (NameIs) 19083**] care was consulted but
patient left before they could see her; they contact[**Name (NI) **] PCP and
will [**Name Initial (PRE) **]/U outpt if desired by patient. Given her severe
hypocalcemia she was started on calcium acetate (and rx on
discharge); however she refused this med in the hospital.
# UTI: Patient had positive UA on admission, UCx growing proteus
mirabilis (sensitive to everything except cefazolin). She was
started on Ciprofloxacin to complete three day course; however,
she refused antibiotics on her third day. She was discharged
with rx for final day of Cipro.
# Rash: The patient has a diffuse, erythematous rash, likely [**3-2**]
uremia causing pruritis. Also possible is an infectious etiology
given the son has a similar rash, and Dermatology was consulted.
They scraped the lesions, no e/o scabies but recommended empiric
treatment with permethrin. Patient's pruritis greatly improved
with dialysis and permethrin. She was discharged with rx for
permethrin. She was provided phone number for Derm outpatient
f/u if she desires.
# sCHF (EF 45%) WITH 3+ MR: Pt presented with volume overload
likely [**3-2**] renal failure but also noted to have BNP>70,000 and
cardiomegaly on CXR. Echo showed depressed EF (45%) with apical
hypokinesis, and severe 3+ MR. [**Name13 (STitle) **] previous echos for comparison,
no known cardiac history so unclear whether changes are
acute/chronic. Findings could be worse in setting of severe
volume overload and/or high-output failure [**3-2**] profound anemia.
Her volume overload was treated with HD; she refused other
interventions.
# ANEMIA: Likely multifactorial with renal failure as a
significant contributor, no signs of active bleeding, negative
hemolysis labs (elevated LDH but normal bili, high hapto), and
elevated retic count showing appropriate marrow response. Hct 15
on admission, improved to 29.1 on discharge after total 4 units
blood. Iron studies, B12 and folate were checked and are pending
on discharge. Patient needs screening colonoscopy as outpatient.
# Diabetes: Patient diagnosed with "pre-diabetes" as outpatient,
on Metformin in past but has not been taking for over a year.
Last A1C was ~6.5 per Atrius records. She had no hyperglycemia
on fingersticks during hospitalization, did not require insulin.
# Hypertension: The patient stopped all her antihypertensives
one year ago. Her blood pressure was controlled through volume
removal via HD.
# Bilateral cataracts: The patient is legally blind due to
bilateral cataracts. She refused evaluation for home services on
discharge.
============================
TRANSITION OF CARE:
-Studies pending on discharge: PTH, B12, folate, iron studies,
hepatitis panel
Medications on Admission:
none, supposed to be on Metformin
Discharge Medications:
1. permethrin 5 % Cream Sig: One (1) Topical Once weekly () for
1 weeks: On the evening of [**6-25**], please apply cream to body
from the neck down. Wash off the following morning. Wash all of
your sheets after using.
Disp:*1 tube* Refills:*0*
2. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day for 1
days.
Disp:*1 Tablet(s)* Refills:*0*
3. calcium acetate 667 mg Tablet Sig: Two (2) Tablet PO TID with
meals.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE ISSUES:
1. Uremia
2. Rash (due to uremia vs. scabies)
CHRONIC ISSUES:
1. Chronic kidney disease
2. Hypertension
3. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital for
confusion, weakness, dizziness and rash. You were found to have
severe kidney failure (uremia) requiring dialysis to filter the
toxins out of your blood, as well as a urinary tract infection.
Your rash was likely either due to the kidney failure or a
parasitic infection called scabies. After thorough discussion of
the fact that you could die without long-term dialysis, you
stated clearly that you would not like further treatment at this
point and would like to follow up as an outpatient to discuss
all of these issues. You also refused to finish the antibiotic
treatment for your urinary tract infection or take any other
medications to treat your condition.
.
Please attend the appointment with your primary care doctor
tomorrow to discuss your medical issues and continue working on
deciding whether you would like further medical treatment in the
future.
.
We made the following changes to your medications:
1. STARTED permethrin 5% cream (for scabies) to be applied once
on the evening of [**2169-6-25**]. Please apply from neck down, and wash
all sheets the following morning.
2. STARTED Ciprofloxacin 250mg by mouth daily for 1 (one) day
(first day = [**2169-6-20**], last day = [**2169-6-22**])
.
Please weigh yourself daily and call your doctor if your weight
goes up by more than 3 pounds.
3. STARTED Calcium acetate 1334mg by mouth three times daily
with meals (for kidney failure. VERY IMPORTANT to take this to
prevent serious arrythmias leading to cardiac arrest).
Followup Instructions:
-PRIMARY CARE APPOINTMENT:
Name: [**Doctor Last Name **],[**Last Name (un) **] Y. MD
Location: [**Location (un) 2274**] [**Location **]
Address: [**Street Address(2) 12773**], [**Location **],[**Numeric Identifier 12774**]
Phone: [**Telephone/Fax (1) 12775**]
Appt: Tomorrow, [**6-23**] at 10:10am
-If you decide you would like to see a kidney doctor for your
kidney failure, please call ([**Telephone/Fax (1) 27787**] to schedule an
appointment with Dr. [**First Name8 (NamePattern2) 18819**] [**Name (STitle) 14005**] (who took care of you in the
hospital). He would ideally prefer to see you on Wednesday
[**2169-6-28**].
-If you would like to see a dermatologist to follow up on your
skin rash, please call ([**Telephone/Fax (1) 34896**] to set up an appointment.
|
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"585.6",
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icd9cm
|
[
[
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[
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,159
| 161,342
|
27937
|
Discharge summary
|
report
|
Admission Date: [**2175-7-3**] Discharge Date: [**2175-7-10**]
Date of Birth: [**2116-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
[**2175-7-3**] intubation
History of Present Illness:
58yo M with h/o alcoholic cirrhosis presenting with AMS. Per
daughters patient has a long history of EtOH abuse, and a new
diagnosis of ETOH cirrhosis. Went to OSH a few days ago after a
fall; diagnosed with rib fractures and treated with vicodin. Per
daughters patient has been an "addict" his entire life. He
drinks at least 12 beers daily and does various other drugs
including marijuana, cocaine, and valium whenever he can get
access to it. He has several friends that live next door to him
who told the daugthers that over the past few months they have
noticed that he's been increasingly paranoid, unsteady, and
occasionally hallucinating but over the last few weeks weeks
this has gotten even worse. According to them on Thursday fell
in his bathroom at home. He has also fallen several times before
this and was once even found with the TV on top of him in his
apt. On thursday after he fell he refused to be evaluated at the
hospital but on Sunday his friends finally convinced him to go
to the ER in NH where they were vacationing. In the ED at the
OSH he underwent head CT and had no bleed but was diagnosed with
rib fractures. The ED there wanted to admit him but he refused
admission so he was sent home with an Rx for vicodin.
According to his friends he has been taking the vicodin 1-2 tabs
Q6H since Sunday. He has been hallucinating, all day yesterday
and today to the point that the friends drove him back to [**Name (NI) 86**]
to be evaluated by the doctors [**Name5 (PTitle) **]. On the way back to [**Location (un) **]
his friends bought him a 16ounce beer and he also had a few
beers this morning. His daughters met him at home and noted that
he was seeing things and not making any sense so they brought
him to the ED.
In the ED, initial vs were: T 97.8 78 122/94 18 100 . shaky,
diaphoretic, hallucinating on exam. no abd pain on exam. FAST
was negative. ETOH level was only 13 so thought in withdrawal.
Patient was given 20mg Iv valium total, most recently 10mg Iv
valium within the hour. Head Ct was negative. CXR negative.
.
T 97.6, HR 83, BP 113/41, RR 18 O2 95% on RA.
.
On the floor, patient was tremulous and complained of abdominal
pain. Rest of history was limited [**12-20**] his mental status.
.
Review of systems: Unable given AMS
Past Medical History:
Hypertension
Anemia
Ventral Hernia s/p repair
ETOH cirrhosis
([**2175-3-29**] labs: ALT 14 AST 49 Bili 1.3 albumin 3.4)
PVD treated by Dr. [**Last Name (STitle) **]
PSA
Social History:
Lives alone.
- Tobacco: heavy smoker
- Alcohol: 12 beers at least daily
- Illicits: daughters report pot daily, cocaine in past, valium
recently and "any drug he can get his hands on"
Family History:
non contributory
Physical Exam:
Vitals: T:96.9 BP:112/69 P:90 R: 18 O2: 97% on RA
General: Somnolent, confused, tremulous
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, bowel sounds present, TTP in the epigastrium
with guarding although exam limited by AMS
GU: no foley
Ext: warm, no edema
BACK: ecchymoses on left flank
NEURO: positive visual hallucinations, tremulous, no asterixis
Pertinent Results:
[**2175-7-3**] 04:15PM WBC-4.0 RBC-3.46* HGB-11.4* HCT-32.6* MCV-94
MCH-32.9* MCHC-34.9 RDW-16.4*
[**2175-7-3**] 04:15PM NEUTS-50 BANDS-0 LYMPHS-42 MONOS-6 EOS-2
BASOS-0
[**2175-7-3**] 04:15PM PLT COUNT-97*
[**2175-7-3**] 04:15PM PT-15.9* PTT-34.6 INR(PT)-1.4*
[**2175-7-3**] 04:15PM ASA-NEG ETHANOL-13* ACETMNPHN-7* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2175-7-3**] 04:15PM AMMONIA-33
[**2175-7-3**] 04:15PM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-1.6
[**2175-7-3**] 04:15PM LIPASE-25
[**2175-7-3**] 04:15PM ALT(SGPT)-29 AST(SGOT)-94* ALK PHOS-132* TOT
BILI-1.7*
[**2175-7-3**] 04:15PM GLUCOSE-71 UREA N-7 CREAT-0.7 SODIUM-134
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-14
[**2175-7-3**] 04:18PM LACTATE-1.8
[**2175-7-3**] 06:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2175-7-3**] 06:07PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2175-7-3**] 06:07PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
.
RAPID PLASMA REAGIN TEST (Final [**2175-7-5**]): NONREACTIVE.
.
URINE CULTURE (Final [**2175-7-5**]): <10,000 organisms/ml
.
[**2175-7-3**] ECG: Sinus rhythm. Right bundle-branch block. Left axis
deviation may be due to left anterior fascicular block and/or
possible prior inferior myocardial infarction. Clinical
correlation is suggested. Since the previous tracing of [**2174-3-1**]
there is no significant change.
.
[**2175-7-3**] CT Head W/Out Contrast: IMPRESSION: 1. No acute
intracranial process. 2. Atrophic changes. 3. Dense calcified
atherosclerotic disease of the cavernous internal carotid
arteries.
.
[**2175-7-3**] CT Abd/Pelvis W/ IV Contrast: 1. No etiology for
epigastric pain identified. Please note endoscopy is far more
sensitive examination for evaluation of underlying peptic or
duodenal ulcer disease.
2. Unchanged sequelae of underlying cirrhosis and portal
hypertension
including a recanalized paraumbilical vein. No significant
intra-abdominal
ascites.
3. Dense atherosclerotic disease involving the coronary
circulation aorta,
and branch vessels.
[**2175-7-5**]
ABDOMINAL ULTRASOUND: The liver demonstrates a nodular,
heterogeneous
appearance consistent with a history of known cirrhosis. There
is a small
degree of ascites, splenomegaly, and reactive gallbladder wall
thickening.
The gallbladder is otherwise unremarkable. A tiny shadowing
calcification
measuring 6 mm in the left lobe of the liver likely represents
granuloma,
possibly from prior infection. The spleen is enlarged, measuring
16.3 cm. No
focal liver lesion is seen.
IMPRESSION: Cirrhosis, splenomegaly and ascites without focal
liver lesion.
Brief Hospital Course:
Mr. [**Known lastname **] is a 58y/o gentleman who presented to [**Hospital1 18**] with
hallucinations in the setting of EtOH withdrawal.
# AMS, likely [**12-20**] ETOH withdrawal/DTs. Had hallucinations,
diaphoresis, low ETOH level on admission in known alcoholic.
Other etiologies include hepatic encephalopathy but does not
have asterixis, ammonita level nl and TBili not incredibly high.
Infectious etiologies unlikely given afebrile without a white
count but in cirrhotic always concerned that infection has
precipitated his encephalopathy. In addition, given daughters'
history that he has been declining over several months rather
than days concerning that he may have some ETOH-induced brain
disease including wernickes encephalopathy or ETOH-related
dementia.
Pt received banana bag and started on high dose thiamine, with
the reasoning that he may have an element of Wenicke's. Sedating
medications including vicadin were held.
Pt started on CIWA protocol. Initially requiring 10 mg of valium
q1, which was tepared to q4 on [**7-4**] and then none by [**7-5**].
Blood cultures are still pending, urine cultures were negative.
RPR was neg. B-12 normal.
Speech and swallow eval ordered on [**7-5**] for concern of
aspiration. Pt passed his evaluation and his diet was advanced
to normal.
He was transferred to the medical floor. His vital signs
remained stable and he did not require any IV or PO doses of
Valium. He declined to consider AA or any help with quitting
EtOH, but he agreed that he needs to quit. By the end of his
sdmission, he was able to ambulate but did not appear fully
stable without assistance. He had a nonfocal neuro exam. Was
able to follow 3-step commands accurately, and finger-to-nose
test was accurate. He was d/c'd to rehab.
# Cirrhosis: Likely from ETOH.
PCP was called and patient's information was faxed over. Liver
serologies were negative. Home dose of Atenolol reintroduced on
[**7-7**]. We made the patient an appointment to meet with Hepatology
to further work u/manage his cirrhosis. No abdominal tenderness,
no increased abdominal girth from baseline.
# Abdominal Pain: Unclear etiology and patient is poor historian
so unable to provide localization of symptoms. FAST in ed was
negative for intraabdominal fluid.
CT abdomen for acute abdominal pathology did not show any acute
process.
Pt was guaic pos with dark brown stools. HCT stable throughout
stay in MICU.
Serial abd exams during MICU stay showed improvement in abd
signs and symptoms. RUQ on [**7-4**] showed cirrhosis and
splenomegaly as well as some ascites. By the time he reached
the floor, he had no abdominal pain, and no tenderness.
Remained afebrile without leukocytosis.
# PVD: Patient has h/o PVD and sees Dr. [**Last Name (STitle) **]. Plavix was
initially held and restarted on [**7-4**] with ASA. Platelets were
low but stable. He had no leg pain during admission.
# Thrombocytopenia: likely due to EtOH. Gave ASA and Plavix but
held Heparin prophylaxis.
Medications on Admission:
Plavix 75 mg PO daily
Potassium 10 meQ [**Hospital1 **]
Atenolol 25 mg PO daily
MVI
Fish Oils
ASA 325 mg PO daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain: please do not exceed 2g total
daily .
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fish Oil Oral
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Thiamine HCl 100 mg/mL Solution Sig: Five (5) mL Injection
once a day for 4 days.
Disp:*20 mL* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
alcohol intoxication
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were brought to the hospital because of alcohol intoxication
and withdrawal hallucinations. We treated you to prevent
withdrawal, and now your vital signs are stable. Because of
your instability when walking, you are being discharged to a
rehab facility.
.
It is VERY important that you stop drinking alcohol, especially
because you have underlying liver disease (cirrhosis) that is
likely a result of your alcohol use. Though you declined to
discuss your alcohol use with our Social Worker, we urge you to
seek help in quitting.
.
We made the following changes to your medications:
-you can take Tylenol as needed for pain (do not take more than
2 grams total per day)
-added folic acid 1mg daily
-added Thiamine 500mg IV for 4 more days
Followup Instructions:
PRIMARY CARE DOCTOR:
Name:[**Name6 (MD) **] [**Name8 (MD) **],MD
Specialty: Primary Care
When: [**Last Name (LF) 2974**], [**7-14**] at 11am
Phone: [**Telephone/Fax (1) 68047**]
**Please talk to your PCP about ways that you can quit using
alcohol.
LIVER CENTER
When: THURSDAY [**2175-8-10**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"275.2",
"291.0",
"443.9",
"291.1",
"401.9",
"303.91",
"292.81",
"E939.4",
"305.1",
"572.2",
"287.4",
"571.2",
"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10216, 10286
|
6414, 9406
|
336, 364
|
10351, 10351
|
3682, 6391
|
11306, 12032
|
3075, 3093
|
9571, 10193
|
10307, 10330
|
9432, 9548
|
10536, 11097
|
3108, 3663
|
11126, 11283
|
2643, 2662
|
275, 298
|
392, 2624
|
10366, 10512
|
2684, 2855
|
2871, 3059
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,957
| 135,231
|
30498+57674
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-10-30**] Discharge Date: [**2137-11-11**]
Date of Birth: [**2068-9-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Aricept / Influenza Virus Vaccine /
Hydrochlorothiazide / Zyprexa
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
DOE with minimal exertion
Major Surgical or Invasive Procedure:
[**11-4**] MV repair(26mm CE Physio ring)/CABGx1(LIMA->LAD)/PFO
closure
History of Present Illness:
69 yo F with 5 yr history of increasing SOB and MR followed by
echo. Transferred to the CCU last evening after presented to
[**Location (un) **] ED with SOB.
Past Medical History:
AF, HTN, Dementia, Parkinson's like syndrome, Schizoaffective
d/o, CHF, gout, CVA [**2130**], COPD, lacunar infarcts, anemia, s/p
PPM.
Social History:
retired
80 pack year smoking history, quit 10 yrs ago
no etoh
Family History:
father deceased from MI at age 52
Physical Exam:
Admission:
NAD, mild SOB sitting in bed. 70 VP RR 26 BP 133/85
Chest Lungs CTAB x crackles right base
Heart RRR 1/6 SEM
Abdomen Obese, benign
Extrem warm, no edema
Discahrge
VS 96.9 HR 69SR BP 118/58 RR 18 O2sat 93%/2LNP
Gen: NAD
Pulm: diminished L base
CV: RRR, sternum stable incision CDI
Abdm: soft, NT/+BS
Ext: warm, well perfused, no edema
Pertinent Results:
[**2137-10-30**] 05:42PM GLUCOSE-103 UREA N-31* CREAT-1.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
[**2137-10-30**] 05:42PM WBC-4.7 RBC-3.24* HGB-9.4* HCT-27.8* MCV-86
MCH-28.9 MCHC-33.6 RDW-19.0*
[**2137-10-30**] 05:42PM PLT COUNT-284#
[**2137-10-30**] 05:42PM PT-42.3* PTT-34.0 INR(PT)-4.7*
[**2137-11-10**] 10:42AM BLOOD WBC-6.7 RBC-3.16* Hgb-9.0* Hct-26.5*
MCV-84 MCH-28.4 MCHC-33.9 RDW-17.3* Plt Ct-209#
[**2137-11-11**] 06:00AM BLOOD PT-19.5* INR(PT)-1.8*
[**2137-11-10**] 10:42AM BLOOD Glucose-120* UreaN-35* Creat-1.3* Na-134
K-4.3 Cl-96 HCO3-27 AnGap-15
RADIOLOGY Final Report
CHEST (PA & LAT) [**2137-11-10**] 8:43 AM
CHEST (PA & LAT)
Reason: eval for effusions
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman s/p MV repair/CABGx1
REASON FOR THIS EXAMINATION:
eval for effusions
STUDY: PA and lateral chest [**2137-11-10**].
HISTORY: Evaluate for pleural effusion.
FINDINGS: Comparison is made to previous study from [**2137-11-5**].
The single lead pacemaker and median sternotomy wires are
unchanged. There is unchanged cardiomegaly. There is improvement
of the left-sided pleural effusion since the previous study.
There remains some atelectasis at both lung bases.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 72445**], [**Known firstname 420**] [**Hospital1 18**] [**Numeric Identifier 72446**] (Complete)
Done [**2137-11-4**] at 11:43:42 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2068-9-19**]
Age (years): 69 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Coronary artery disease. Left ventricular function.
Mitral valve disease. Preoperative assessment.
ICD-9 Codes: 745.5, 440.0, 424.0
Test Information
Date/Time: [**2137-11-4**] at 11:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.0 cm <= 5.0 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aorta - Annulus: 1.7 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Findings
LEFT ATRIUM: Marked LA enlargement. No mass/thrombus in the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in
the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. PFO is
present. Left-to-right shunt across the interatrial septum at
rest.
LEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic
dysfunction.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild thickening of mitral valve
chordae. Mild to moderate ([**12-18**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**12-18**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE BYPASS
The left atrium is markedly dilated. No mass/thrombus is seen in
the left atrium or left atrial appendage. The right atrium is
moderately dilated. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. The left ventricular cavity size is normal. There is mild
regional left ventricular systolic dysfunction with mild
inferior waqll hypokinesis. The remaining left ventricular
segments contract normally. The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-18**]+) mitral regurgitation is seen
with a systolic BP of 100mm Hg. SBP was raised to 160mmHg with
phenylephrine and Trendelenberg position. This resulted in
moderate to severe (3+) MR with a posteriorly directed MR jet..
The tricuspid valve leaflets are mildly thickened.
POST BYPASS
Biventricular function remains unchanged from prebypass. There
is a ring prosthesis in the mitral position. NoMR is visualized.
Peak and mean gradient across MV is 7 and 3 mm Hg respectively.
Flow by Color Doppler is still visualized across the patent
foramen ovale.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2137-11-4**] 12:46
Brief Hospital Course:
She was admitted to the CCU and diuresed. Her comadin was held,
and she awaited normalization of her INR, and was started on
cipro for a UTI. She was taken to the operating room on [**11-4**]
where she underwent a MV repair and CABG x 1. She was
transferred to the ICU in critical but stable condition. She did
well in the immediate postop period and was extubated that
evening. On POD 1 her chest tubes were removed. On POD2 her PPM
was interegated and she was transferred to the step down floors
for continuing care. Over the next several days her Beta
blockade was adjusted, she was actively diuresed and her
coumadin was adjusted to a target INR of [**1-18**].5. On POD7 it was
decided she was stable and ready for discharge to rehab at [**Hospital **]
Medications on Admission:
at home:
toprol XL 50 mg daily
coumadin 5 mg daily ( stopped [**10-30**])
seroquel 25 mg [**Hospital1 **]
colchicine 0.6 mg [**Hospital1 **]
namenda 5 mg [**Hospital1 **]
in hosp:
lopressor 50 mg [**Hospital1 **]
lisiniopril 5 mg daily
ASA 325 mg daily
lipitor 80 mg daily
colchicine 0.6 mg daily
seroquel 25 mg at 6 PM; 25 mg at 11 PM
namenda 10 mg [**Hospital1 **]
sub q heaprin
nitroglycerin IV gtt
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY AT 1800
().
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY AT 2300
().
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Warfarin 1 mg Tablet Sig: as directed to target INR 2-2.5
Tablets PO DAILY (Daily): dose 11/26 :5 mg today only; then
daily dosing per rehab provider; INR checked daily until
therapeutic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
CAD, MR now s/p MV Repair, CABG x 1 ;PFO closure
PMH: AF, HTN, Dementia, Parkinson's like syndrome,
Schizoaffective d/o, CHF, gout, CVA [**2130**], COPD, lacunar
infarcts, anemia,obesity, s/p PPM
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower DAILY, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving for one month or until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 1911**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2137-11-11**] Name: [**Known lastname 12022**],[**Known firstname **] J Unit No: [**Numeric Identifier 12023**]
Admission Date: [**2137-10-30**] Discharge Date: [**2137-11-11**]
Date of Birth: [**2068-9-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Aricept / Influenza Virus Vaccine /
Hydrochlorothiazide / Zyprexa
Attending:[**First Name3 (LF) 265**]
Addendum:
To clarify, Ms. [**Known lastname 12024**] CHF is acute on chronic systolic CHF as
documented by history and echo results].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5025**] & Rehab Center - [**Location (un) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2137-11-22**]
|
[
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"599.0",
"294.8",
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icd9cm
|
[
[
[]
]
] |
[
"39.61",
"89.64",
"35.12",
"88.72",
"99.04",
"36.15",
"39.64"
] |
icd9pcs
|
[
[
[]
]
] |
11405, 11611
|
7362, 8120
|
373, 447
|
10224, 10232
|
1308, 2019
|
10568, 11382
|
887, 922
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8574, 9875
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10005, 10203
|
8146, 8551
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10256, 10545
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5675, 7339
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937, 1289
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308, 335
|
2124, 5626
|
475, 634
|
656, 792
|
808, 871
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,046
| 117,302
|
48784
|
Discharge summary
|
report
|
Admission Date: [**2162-12-1**] Discharge Date: [**2162-12-10**]
Date of Birth: [**2095-9-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
lung nodules
Major Surgical or Invasive Procedure:
[**2162-12-1**]
Video-assisted thoracoscopic surgery, left upper
lobe wedge resection (lingular wedge resection), and
mediastinal lymph node dissection
[**2162-12-2**]
Right chest tube thorocostomy for hemothorax
History of Present Illness:
67 year old female with two right apical lesions and one left
lingular lesion that have grown substantially in size over the
past year and were shown to be FDG avid on PET scan. Due to the
inconsistent growth rate of left lingula versus
right apical lesions, they are believed to be separate
processes. She is s/p mediastinoscopy complicated with
mediastinal hematoma s/p evacuation and electrocautery control
of a bleeding lymph node vessels as well as a right sided
hemothorax s/p pig tail placement and removal with pathology of
all lymph nodes negative for carcinoma. Her right sided pleural
effusion is small and stable on chest radiograph from [**2162-11-29**]
following removal of the pig tail catheter.
Currently she states she is without any new symptoms. She has
baseline SOB and wheezing consistent with her known emphysema.
She continues to complain of shortness of breath unchanged. Sent
on home oxygen but currently doesn't needed based on good o2
sats. Mild cough in the morning. Denies erythema around
mediastinoscopy site. Sore throat is intermittent. Hoarseness is
the same. No chest pain. Overall tired. Denies any headache,
weight change, or any new bony pain. No other complaints.
Past Medical History:
PMH: Breast Ca s/p lumpectomy and 35 rounds of radiation in
[**2138**], hypertension, tobacco abuse.
PSH: Mediastinoscopy and takeback for bleed [**2162-11-24**], lumpectomy
[**2138**], Bilateral Knee Replacements - Right [**9-10**], Left [**6-12**].
C-section x2.
Social History:
Cigarettes: [ ] never [X] ex-smoker [ ] current
Pack-yrs:_40_ quit: _2 weeks_
ETOH: [ ] No [X] Yes drinks/day: _2-3__
Drugs:
Exposure: [X] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation: Retired Office worker
Marital Status: [X] Married [ ] Single
Lives: [ ] Alone [X] w/ family [ ] Other:
Other pertinent social history:
Travel history: None
Family History:
Sister - lung Ca (smoker).
Brother - pulmonary fibrosis (unknown).
Physical Exam:
Before Admission: BP: 139/83. Heart Rate: 105. Weight: 157.1.
BMI: 29.7.
Temperature: 97.7. O2 Saturation%: 97.
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings: Mediastinoscopy wound well healed.
RESPIRATORY [ ] All findings normal
[X] CTA/P [X] Excursion normal [X] No fremitus
[ ] No egophony [ ] No spine/CVAT
[x] Abnormal findings: Decrease breath sounds b/l.
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
On Discharge:
VS: 97.1 94 105/62 18 96RA
GEN: NAD, AOx3
CV: RRR, nl S1 and S2
PULM: mild wheezes bilaterally, no respiratory distress.
Incisions clean, dry, and intact without erythema
ABD: Soft, NT, ND
EXT: No c/c/e. Skin dry.
Pertinent Results:
[**2162-12-1**] Pathology
1. Lingula, left, lingulectomy (A-E):
Squamous cell carcinoma, poorly differentiated, see synoptic
report.
2. Lymph node, level 5, excision (F):
No malignancy identified.
[**2162-12-1**] CXR: New moderate enlargement of the cardiac
silhouette, mediastinal widening, large right pleural effusion,
haziness of the hilar contours and vessels is consistent with
moderate pulmonary edema. Left lower lobe opacities are
consistent with atelectasis. There is a left apical chest tube.
There is no evidence of pneumothorax.
[**2162-12-2**] ECHO: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF ?60%). Right ventricular chamber size and free wall
motion are grossly normal. The aortic valve is not well seen.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a prominent
fat pad.
IMPRESSION: very suboptimal image quality. Ventricular function
appears grossly preserved
[**2162-12-2**] EKG: Normal sinus rhythm. RSR' pattern in lead V1.
Within normal limits. Compared to tracing #1, except for the
decrease in rate, probably no other diagnostic interval change.
[**2162-12-2**] CXR: Comparison is made with prior study performed the
day earlier. There is mild-to-moderate cardiomegaly. Widened
mediastinum is unchanged. Large right pleural effusion with
adjacent atelectasis has increased. Left pneumothorax is very
small. Left chest tube is in place. Patient has known emphysema.
Mild vascular congestion has worsened. Left chest wall
subcutaneous catheter is new.
[**2162-12-2**] CTA Chest: IMPRESSION: 1. No evidence of pulmonary
embolism. 2. Moderate, nonhemorrhagic posteriorly layered right
pleural effusion with associated right lung atelectasis. 3.
Post-wedge resection changes in the left lung including small
loculated pneumothorax, minimal atelectasis of the left anterior
lung, subcutaneous air, and mediastinal hematoma. 4. Dominant
right lower lobe nodule is stable whereas a 11-mm spiculated
right upper lung nodule has been slowly increasing in size and
is concerning for neoplasia.
[**2162-12-3**] CXR: IMPRESSION: Moderate left and mild right pleural
effusion with adjacent lung atelectasis is stable. No
pneumothorax.
[**2162-12-3**] CXR: In comparison with the earlier study of this date,
there is again increased opacification in the left mid and lower
zones consistent with pleural effusion and atelectasis. The
right effusion appears less prominent, though this could relate
to patient position.
Left chest tube is in place and there is no definite
pneumothorax. Central
catheter again extends to the right atrium. Right chest tube is
also seen and there is no definite pneumothorax.
[**2162-12-4**] CXR: IMPRESSION:
1. Interval repositioning of the right subclavian central line
which now has its tip in the mid-to-distal superior vena cava in
satisfactory position. Right basilar and left apical chest
tubes remain unchanged in position. Bibasilar opacities are
seen, with probable associated layering effusions and therefore
likely reflecting compressive atelectasis. Overall, the
pulmonary vascularity appears slightly more well defined,
suggesting resolving interstitial edema, although there is
likely residual perihilar edema on the current examination.
Cardiac size is difficult to assess due to the airspace process
at the left lung base, but likely is stable.
[**2162-12-5**] CXR: IMPRESSION:
Right subclavian central line has its tip in the mid to distal
SVC, unchanged. Left apical chest tube remains unchanged. The
right apical pneumothorax is either unchanged or even slightly
smaller than on the previous study. Persistent blunting of the
right costophrenic angle, which may reflect changes related to
recent removal of the chest tube versus a small effusion. Patchy
opacity at the left base likely reflects some atelectasis. There
is mild perihilar vascular congestion, but no overt pulmonary
edema. Heart remains enlarged but stable in contour. Mediastinal
contours are unchanged.
[**2162-12-6**] CXR: IMPRESSION: Interval removal of left apical chest
tube with stable small left basilar pneumothorax.
[**2162-12-7**] CXR: IMPRESSION: Interval development of layering right
pleural effusion. Otherwise, little change. No evidence of
pneumothorax.
[**2162-12-8**] CXR: Right subclavian line in lower SVC. 14 mm nodular
opacity overlapping posterior end of right seventh rib is better
evaluated on the prior chest CT. An irregular nodule in the
right upper lobe seen on chest CT is beyond the resolution of
the radiograph. Small right pleural effusion and minimal right
lung base atelectasis are unchanged since [**2162-12-5**]. Left
mid and lower lung opacity obscuring the left cardiac margins is
due to a combination of atelectasis, effusion and post operative
changes following resection of the lingular nodule is stable.
Mediastinal and hilar contours are unchanged. There is no
evidence of pulmonary edema or pneumonia.
[**2162-12-9**] CXR: IMPRESSION: No significant change from [**2162-12-8**]
with continued expected postoperative change status post
lingular wedge resection.
Brief Hospital Course:
Mrs. [**Known lastname 102527**] was admitted to the hospital and taken to the
Operating Room where she underwent Left VATS with a linular
wedge resection. (See formal Op note for details). She
tolerated the procedure well and returned to the PACU in stable
condition. She maintained stable hemodynamics and her pain was
well controlled.
Following transfer to the Surgical floor she remained stable
until the early morning of post op day #1 when she suddenly
became tachycardic and desaturated to the mid 80's. Her chest
xray showed a large left pleural effusion and atelectesis and
subsequent CTA of the chest ruled out PE and confirmed a large
right effusion. The IP service placed a right chest tube and
soon she desaturated to the mid 80's. She was transferred to the
Surgical ICU and eventually intubated. Over the next few days
she maintained stable O2 saturations and was weaned and
extubated from the respirator on [**2162-12-3**]. She required BIPAP
for periods during the day and over night after extubation but
that was short lived and eventually she was weaned off of oxygen
completely with room air saturations of 94%. Her chest tubes
were removed without difficulty and she was much more
comfortable.
Following transfer to the Surgical floor she was tolerating a
regular diet and her port sites were dry. She was evaluated by
the Physical Therapy service to assess her endurance and
mobility and was cleared to return home without PT services.
She was noted to be tachycardic with ambulation and lopressor
was restarted. Patient was kept overnight with heart rate well
controlled and ambulating with nursing on POD9 with heart rate
not exceeding 95 and was allowed to be discharge home with
visiting nurse care.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg 2 puffs q 4-6h PRN for chest
tightness/SOB, AMLODIPINE 5 mg Po daily, SPIRONOLACTONE 25 mg PO
daily, VARENICLINE 1 mg PO prn
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
Disp:*1 MDI* Refills:*1*
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Eastern MA
Discharge Diagnosis:
Left upper lobe/lingula nodule.
Right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for lung surgery and despite
a return trip to the ICU you've recovered well. You are now
ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed. If it starts to
drain, cover it with a clean dry dressing and change it as
needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
* Take Tylenol 650 mg every 6 hours as needed. You may also
take Ibuprofen to help relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
We started you on a medication called Lopressor/Metoprolol.
This is a medication known as a beta blocker which helps control
your heart rate. You should let your PCP know you are now
taking this medication. You will be seen in clinic in 2 weeks
and we can discuss at that time continuation of this medication.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2162-12-23**] at 3:30 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report to the [**Location (un) **] [**Location (un) **] Department in the
[**Hospital Ward Name 23**] Clinical Center 30 minutes before your appointment with
Dr. [**Last Name (STitle) **] for a chest xray.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2163-4-21**] at 11:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2163-4-21**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please continue to follow up with your Primary Care Physcian.
Also, update them on a medication change: Addition of
metoprolol/lopressor for heart rate control.
|
[
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"458.9",
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icd9cm
|
[
[
[]
]
] |
[
"40.3",
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icd9pcs
|
[
[
[]
]
] |
13335, 13383
|
10350, 12428
|
323, 539
|
13482, 13482
|
4817, 10327
|
15216, 16429
|
2526, 2594
|
12630, 13312
|
13404, 13461
|
12455, 12607
|
13634, 15193
|
2609, 4568
|
4582, 4798
|
271, 285
|
567, 1775
|
13497, 13609
|
1797, 2065
|
2487, 2510
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,809
| 105,610
|
48893
|
Discharge summary
|
report
|
Admission Date: [**2136-8-31**] Discharge Date: [**2136-9-5**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name14 (STitle) 102673**] is a 57 YOF with a history of type I diabetes,
complicated by polyneuropathy and gastroparesis, as well as a
history of CVA, [**Doctor Last Name 933**] disease, and untreated hep C from blood
transfusion who has had multiple admissions for DKA (last
admitted [**8-20**] to [**8-29**] for DKA, previously in [**Month (only) 116**], and two other
times before that this year) who presented to the ED with
hyperglycemia. Her VNA came to her house today and noted the bg
>600 so she gave her 19 units of humalog at 11:30 am. She
reports that her bg usually run in the 300s when she checks
them. However yesterday and today (since her discharge) her
sugars were elevated to over 500. She states she has been
taking her glargine 24 units at bedtime. In the past her DKA
had been precipitated by UTIs, but currently she denies any
infectious symptoms. She states that she did not start "feeling
bad" until today and this was due to her urinating a lot and
feeling fatigued. She otherwise denies dysuria, CP, SOB,
rhinorrea, sinus pain, HA, cough, nausea, [**Month (only) **], diarrhea, or
rash.
Of note, the patient's recent hospitalization was complicaetd by
an episode of unresponsiveness. A full work up was negative
other than the presence of benzodiazepines on tox screen when
the pt was reportedly not prescribed any. Her room was serached
and no medications were found. It was recommended after her
hospitalization that she discontinue her diazepam and percocet.
She was also evaluated by psychiatry who thought she should
establish care as an outpatient and undergo neuropsychological
testing. SW was also called to investigate options for [**Hospital 4382**] placement. Her only medication change was a decrease in
losartan for her outonomic neuropathy causing hypotension.
In the ED, initial vitals were: 98.9 110 113/58 14 100%. The
patient was well appearing. Labs were notable for Na 125,
bicarb 10, and anion gap 29, glucose 665. She had >1000 glucose
and 40 ketones on UA, but neg LE, nitrites, or bld. WBC was
11.4, Hct 29.5. Lactate was 3.6 and pH 7.38. Cxr: no focal
infiltrate, no effusion, no acute intrathoracic process. She
was given 3 L IVF in ED, given 10 units regular insulin, and
started on an insulin gtt at 7U/hr. Repeat fs was in the 400s.
SHe was then given NS with 40 mEq K. Access: 22G L hand, 20G
PIV.
On the floor, pt appeared comfortable. ROS as per HPI, + for
diffuse abd pain, that she says is there chronically and is from
her gastroparesis. Otherwise, denies fever, chills, headache,
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, [**Hospital **],
diarrhea, constipation, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
---Type I DM: diagnosed at age 5, multiple hospitalizations for
DKA and hyperglycemia. Complicated by retinopathy, severe
peripheral
neuropathy, and gastroparesis with marked constipation.
-- DKA has been complicated by CVA, 3 episodes suspected
(including [**2135-5-14**] episode)
--Diabetic polyneuropathy
--Hypertension
--Grave's disease, on MMI
--Reactive airway disease
--Seronegative arthritis, followed in rheumatology
--Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
not on antiviral therapy; acquired from a blood transfusion in
[**2110**]. Had previous liver biopsy without significant fibrosis.
Never been treated with antivirals.
--GERD
--Status post bilateral knee arthroscopies
--Migraine headaches
-Asthma
-s/p TAH
-Depression
-Mouth surgery for removal of tumors
--Bilateral foot drop requiring wheelchair use
Social History:
Patient lives in an apt building. She has a son, daughter and
another brother who live on another floor. She is a never smoker
and does not use alcohol or drugs. She has not worked for many
years. She uses a wheelchair at baseline.
Family History:
Mother died of colon cancer. There are multiple family members
with DM.
Physical Exam:
Admission Physical Exam:
Vitals: T: 100 BP: 143/60 P: 103 R: 11 O2: 99%
General: somnolent, closes eyes and drifts off to sleep during
conversation, oriented, no acute distress
[**Year (4 digits) 4459**]: Sclera anicteric, hyperpigmentation around right eye, dry
MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: + BS, soft, mildly tender to palpation, non-distended,
no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema.
Neuro: CN 2-12 intact, 4/5 strength in all extremities, but poor
effort with rest of neuro exam
Discharge Physical Exam:
Vitals: 98.3, 150/94, 94, 20, 97% RA
General: Awake, alert, NAD
[**Year (4 digits) 4459**]: Sclera anicteric, hyperpigmentation around right eye, dry
MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: + BS, soft, moderately tender on left, non-distended,
no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema.
Neuro: CN 2-12 intact, 4/5 strength in all extremities
Pertinent Results:
# Admission Labs:
[**2136-8-31**] 01:50PM BLOOD WBC-11.4*# RBC-3.11* Hgb-9.8* Hct-29.5*
MCV-95 MCH-31.4 MCHC-33.2 RDW-15.2 Plt Ct-485*
[**2136-8-31**] 01:50PM BLOOD Neuts-86.3* Lymphs-11.4* Monos-1.9*
Eos-0.2 Baso-0.2
[**2136-8-31**] 01:50PM BLOOD PT-11.9 PTT-24.8 INR(PT)-1.0
[**2136-8-31**] 01:50PM BLOOD Glucose-665* UreaN-35* Creat-1.8* Na-125*
K-4.4 Cl-86* HCO3-10* AnGap-33*
[**2136-8-31**] 01:50PM BLOOD ALT-48* AST-28 AlkPhos-87 TotBili-0.3
[**2136-8-31**] 01:50PM BLOOD Lipase-38
[**2136-8-31**] 01:50PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.5# Mg-2.0
[**2136-8-31**] 02:05PM BLOOD Type-ART Temp-37.1 Rates-/16 FiO2-20
pO2-133* pCO2-19* pH-7.38 calTCO2-12* Base XS--10 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-GREEN TOP
[**2136-8-31**] 02:05PM BLOOD Glucose-GREATER TH Lactate-3.6* Na-126*
K-4.3 Cl-93*
# CBC:
[**2136-8-31**] 01:50PM BLOOD WBC-11.4*# RBC-3.11* Hgb-9.8* Hct-29.5*
MCV-95 MCH-31.4 MCHC-33.2 RDW-15.2 Plt Ct-485*
[**2136-9-1**] 07:36AM BLOOD WBC-14.9* RBC-3.17* Hgb-9.7* Hct-29.4*
MCV-93 MCH-30.7 MCHC-33.1 RDW-15.7* Plt Ct-526*
[**2136-9-1**] 12:48PM BLOOD WBC-14.8* RBC-3.22* Hgb-10.0* Hct-29.6*
MCV-92 MCH-31.0 MCHC-33.8 RDW-15.6* Plt Ct-555*
[**2136-9-2**] 01:51AM BLOOD WBC-10.4 RBC-3.05* Hgb-9.3* Hct-28.3*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.9* Plt Ct-474*
[**2136-9-3**] 06:05AM BLOOD WBC-7.7 RBC-2.70* Hgb-8.3* Hct-25.2*
MCV-93 MCH-30.7 MCHC-32.9 RDW-16.2* Plt Ct-384
[**2136-9-4**] 05:55AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.7* Hct-25.5*
MCV-93 MCH-31.7 MCHC-34.3 RDW-16.5* Plt Ct-315
[**2136-9-5**] 06:31AM BLOOD WBC-5.7 RBC-2.82* Hgb-8.9* Hct-26.9*
MCV-96 MCH-31.6 MCHC-33.0 RDW-16.8* Plt Ct-334
[**2136-8-31**] 01:50PM BLOOD Neuts-86.3* Lymphs-11.4* Monos-1.9*
Eos-0.2 Baso-0.2
# Coags:
[**2136-8-31**] 01:50PM BLOOD PT-11.9 PTT-24.8 INR(PT)-1.0
[**2136-8-31**] 01:50PM BLOOD Plt Ct-485*
[**2136-9-1**] 07:36AM BLOOD Plt Ct-526*
[**2136-9-1**] 12:48PM BLOOD Plt Ct-555*
[**2136-9-2**] 01:51AM BLOOD Plt Ct-474*
[**2136-9-3**] 06:05AM BLOOD Plt Ct-384
[**2136-9-4**] 05:55AM BLOOD Plt Ct-315
[**2136-9-5**] 06:31AM BLOOD Plt Ct-334
# Lytes:
[**2136-8-31**] 01:50PM BLOOD Glucose-665* UreaN-35* Creat-1.8* Na-125*
K-4.4 Cl-86* HCO3-10* AnGap-33*
[**2136-9-1**] 03:55AM BLOOD Glucose-112* UreaN-22* Creat-1.2* Na-135
K-4.2 Cl-104 HCO3-23 AnGap-12
[**2136-9-1**] 12:48PM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-134
K-4.4 Cl-102 HCO3-20* AnGap-16
[**2136-9-1**] 11:50PM BLOOD Glucose-123* UreaN-11 Creat-0.9 Na-134
K-4.1 Cl-103 HCO3-20* AnGap-15
[**2136-9-2**] 03:30PM BLOOD Glucose-268* UreaN-10 Creat-1.0 Na-133
K-4.0 Cl-101 HCO3-25 AnGap-11
[**2136-9-3**] 06:05AM BLOOD Glucose-29* UreaN-10 Creat-0.9 Na-136
K-3.5 Cl-104 HCO3-29 AnGap-7*
[**2136-9-4**] 05:55AM BLOOD Glucose-75 UreaN-11 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-30 AnGap-9
[**2136-9-5**] 06:31AM BLOOD Glucose-279* UreaN-16 Creat-0.9 Na-132*
K-4.5 Cl-96 HCO3-30 AnGap-11
# LFTs:
[**2136-8-31**] 01:50PM BLOOD ALT-48* AST-28 AlkPhos-87 TotBili-0.3
# Lipase:
[**2136-8-31**] 01:50PM BLOOD Lipase-38
# Alb, Ca, Mg, Phos:
[**2136-8-31**] 01:50PM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.5# Mg-2.0
[**2136-9-1**] 03:55AM BLOOD Calcium-8.3* Phos-2.1*# Mg-1.7
[**2136-9-1**] 12:48PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7
[**2136-9-2**] 01:51AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.7
[**2136-9-3**] 06:05AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.7
[**2136-9-4**] 05:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
[**2136-9-5**] 06:31AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.7
# Tox Screen:
[**2136-9-1**] 12:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-8-31**] 10:38PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
# Blood Gases:
[**2136-8-31**] 02:05PM BLOOD Type-ART Temp-37.1 Rates-/16 FiO2-20
pO2-133* pCO2-19* pH-7.38 calTCO2-12* Base XS--10 Intubat-NOT
INTUBA Vent-SPONTANEOU Comment-GREEN TOP
[**2136-8-31**] 08:46PM BLOOD Type-ART pO2-154* pCO2-37 pH-7.40
calTCO2-24 Base XS-0
[**2136-8-31**] 11:46PM BLOOD Type-ART pH-7.35
[**2136-9-1**] 04:18AM BLOOD Type-CENTRAL VE pH-7.39
# U/A
[**2136-8-31**] 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
# Blood Cultures:
[**2136-8-31**] BCx: Pending
# Urine Culture:
[**2136-8-31**] UCx: Negative
# MRSA:
[**2136-8-31**] MRSA Screen: Negative
# [**2136-8-31**] EKG:
Sinus tachycardia. Compared to the previous tracing of [**2136-8-24**]
there is no
change.
# [**2136-8-31**] Cxr:
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
Assessment:
Ms. [**Known lastname 18741**] is a 57 YOF with DMI with multiple admissions for
DKA who presented in DKA.
Active Diagnoses:
# Diabetic Keto Acidosis: BG > 600 with anion gap 29 and
ketonuria. Pt was given 4 L NS in the ED (the 4th with K+) and
started on insulin gtt. Upon arrival to the floor, she was
continued on the insulin gtt and on repeat fs her bg was 100.
Insulin gtt was stopped and she was given [**1-22**] amp D50. She
recieved 25 units of Lantus. However, patient was not able to
take po [**2-22**] nausea, so insulin and D10 were continued and she
was given Reglan and Zofran for nausea. Her gap remained closed.
[**Last Name (un) **] was consulted who felt it was OK to stop the gtts and
check FS q4 hours. She was placed on 20 of Lantus [**Hospital1 **], and ISS
when she started to eat. She remained stable taking PO and was
transferred to the general medical floor. On the floor she had
two episodes of hypoglycemia, one to the 30's and one to the
40's. These were treated with glucose and resolved. [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recs her evening dose of Lantus was stopped completely and she
had no further episodes of hypoglycemia. She was sent on 20
units of lantus in the am with humalog SSI. Given her multiple
admissions for DKA and her poor glycemic control it is
questionable that the patient has been compliant with her
insulin, which may have been the cause for this current
presentation. Pt discharged from hospital 2 days prior to
admission with bg reportedly 180-280 the day of discharge. She
has many admission for DKA and is followed closely by [**Last Name (un) **].
She has no other obvious signs of infection on history to
precipitate DKA and UA and CXR do not support UTI or PNA.
We had a long meeting with the pt, her daughter, nursing, social
work, case management to discuss her multiple admissions for
DKA. The patient explained that her social situation has been
so stressful lately that she "may miss" insulin doses because
she is so distracted with other aspects of her life. She is
wheel chair bound and her biggest request is to get a letter
(which was written and given to the daughter) saying that she
needs a wheel chair accessible apartment. We stressed to her
that close follow up with VNA and her endocrinologist were
integral to controlling her Diabetes and not bouncing back to
the hospital in DKA. She explained that she does not want to
burden her family but will accept daily VNA if this will help
her to control her Diabetes. A plan was set in place to have
daily home VNA and close endocrine follow up to make sure that
she does not bounce back to the hospital.
# Abdominal Pain: Left sided abdominal pain. Pt reports this
pain is baseline. Been worked up extensively per past notes in
OMR without clear etiology. No periotneal signs on exam.
Possibly just due to DKA. Pain treated with home oxycodone.
# Hypoglycemia: Exact etiology unknown. Pt was on less insulin
than she is supposedly on at home. Pt had BG in the 30's on
[**2136-9-3**]. In the 40's on [**2136-9-4**]. Insulin scale adjusted [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recs. [**Last Name (un) **] docs believe the best way to titrate her
insulin dose would be as an outpatient where she is home and
eating what she would normally eat. Pt has an appointment with
[**Last Name (un) **] [**2136-9-6**].
# Somnolence: Pt was drowsy and fell asleep easily early during
admission. She remained oriented when aroused. On previous
admission concern for benzodiazepine use causing somnolence. She
is also on many anticholinergic medications which could be
contributing. Her urine tox screen was negative. Her sedative
medications were held during this admission but she was sent on
them at discharge.
# ARF: Likely from volume depletion in the setting of DKA. She
was given IVF with resolution of her [**Last Name (un) **]. Cr 0.9 on discharge.
Chronic issues:
# Diabetic polyneuropathy and gastroparesis. Pt continued on
reglan, amitriptyline.
# Hypertension. Pt hypertensive througout most of admission.
Losartan initially held in the setting of [**Last Name (un) **]. Restarted later.
She was not aggressively diuresed given dehydration on
admission. Will leave definitive management up to the PCP.
# Grave's disease; s/p RAI [**2129**]. Pt continued on methimazole
througout admission.
# Reactive airway disease, allergies. Pt continued on albuterol
PRN, advair and montelukast.
# Seronegative arthritis. Pt continued on sulfasalazine.
# Depression. Pt continued on amitriptyline.
# Ecchymotic right eye. Was noted on prior admission, pt states
this is from itching her eye. INR normal on [**2136-8-31**]. Not
further worked up.
Transitional Issues:
1. Further titration of insulin regimen to ensure that she has
adequate glucose control in her home environment.
2. Possible titration of BP medications.
3. Her social situation will need further attention. There is
real question as to whether the patient is omitting insulin
doses in order to go into DKA in an attempt to show how disabled
she is so that she can get a different apartment. From our
perspective, we have given her the letter she requested saying
that she needs a wheel chair accessible apartment. We stressed
to her that she needs to take her insulin and that the VNA will
help with this. She does not want help with her insulin from
her family because she does not want to burden them but we
explained that it is much more of a burden to them if she keeps
bouncing back to the hospital in DKA. This should be restressed
to the patient in the future. This patient is at very high risk
to present yet again in DKA in the future if her social/psych
issues are not further addressed.
Medications on Admission:
(from previous d/c summary)
1. amitriptyline 50 mg HS
2. fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
3. methimazole 10 mg TID
4. montelukast 10 mg Qday
5. pantoprazole 40 mg Qday
6. polyethylene glycolQday
7. simvastatin 10 mg Qday
8. sulfasalazine 500 mg [**Hospital1 **]
9. prochlorperazine maleate 10 mg [**Hospital1 **]
10. docusate sodium 100 mg [**Hospital1 **]
11. gabapentin 300 mg [**Hospital1 **]
12. metoclopramide 10 mg QIDACHS
13. calcium carbonate 200 mg TID
14. cholecalciferol (vitamin D3) 400 unit Qday
15. ferrous sulfate 300 mg (60 mg iron) Qday
16. hyoscyamine sulfate 0.375 mg ER [**Hospital1 **]
17. oxycodone-acetaminophen 5-325 mg [**Hospital1 **] PRN pain
18. losartan 25 mg Qday
19. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
20. Humalog Mix 75-25 13 units Q day
21. Humalog 100 unit/mL Solution Sig: Per sliding scale
Discharge Medications:
1. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
twice a day as needed for nausea: as needed for nausea.
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr
Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a
day).
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
18. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Humalog 100 unit/mL Solution Sig: Dose Per Sliding Scale
units Subcutaneous four times a day: Please take insulin dosages
based on your home sliding scale.
20. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: Please give patient 300 unit insulin
pen. Please take 20 units in the morning.
Disp:*1 pen* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Diabetic Ketoacidosis
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 Ms. [**Known lastname 18741**],
You were admitted to the hospital with high blood sugars. While
you were here we treated you with IV fluids and insulin and you
improved. Unfortunately, while you were here you also had 2
episodes of low blood sugars which we treated and you improved.
As we discussed in our family meeting today, the key to
preventing rehospitalization lies in close follow up with [**Last Name (un) **]
(appointment tomorrow), daily home nursing visits, and allowing
close supervision by members of your family to help you manage
your challenging disease. We also encourage you to visit your
gastroenterologist (appointment this fall) to better manage your
gastroparesis, which contributes to the difficulties in
controlling your blood sugar.
The following changes were made to your medications:
CHANGE Lantus Insulin from twice per day to one dose per day, 20
units, in the morning.
STOP the Humalog Mix
We have made you an appointment to follow up with your Diabetes
doctor tomorrow, [**2136-9-5**]. Additionally we have made you an
appointment with your regular doctor below.
Thank you for allowing us to participate in your care. We wish
you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Thursday [**2136-9-6**] 11:00am
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9241**]
Location: UPHAMS CORNER HEALTH CENTER
Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**]
Phone: [**Telephone/Fax (1) 7538**]
Appointment: Friday [**2136-9-14**] 1:30pm
|
[
"250.63",
"584.9",
"250.13",
"311",
"536.3",
"070.70",
"357.2",
"242.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18878, 18932
|
10129, 10250
|
285, 292
|
18998, 18998
|
5626, 5628
|
20394, 21030
|
4332, 4405
|
16856, 18855
|
18953, 18977
|
15935, 16833
|
19174, 20371
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4445, 5080
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232, 247
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320, 3203
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5644, 10106
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19013, 19150
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14097, 14883
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10269, 14080
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3225, 4066
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4082, 4316
|
5105, 5607
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,377
| 152,565
|
54565
|
Discharge summary
|
report
|
Admission Date: [**2159-8-4**] Discharge Date: [**2159-8-15**]
Date of Birth: [**2109-7-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Lower extremity pain and weakness
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
50 F with history of polysubstance abuse, pulmonary hypertension
on home O2, recent fevers and ?granulomatous disease with
mediastinal adenopathy; admitted to neurology yesterday with
back pain and bilateral foot numbness. Started treatment for
?epidural abscess with plans for MRI today. Patient triggered
overnight for tachypnea and O2 sats in 80s on RA. ABG
7.46/27/66. Placed on O2 with symptomatic improvement. This AM
patient again triggered for BP 89/52. This was following getting
2 mg IV ativan prior to MRI.
Patient also with multiple lab abnormalities including elevated
coags, leukocytosis with left shift, ARF, elevated LDH. In ED,
patient 95% on 2L (on 2 L at home "when I need it"; discharged
last admit with sats low 90s on RA with desats to mid 80s with
exertion). Says she has been relatively short of breath since
prior to last admission (no recent change). Back pain better
after received toradol early AM, denies currently. Feels
bothered by parasthesias of hands and feet.
Past Medical History:
1. asthma -does not use inhalers
2. HTN -off meds for several years
3. rheumatoid arthritis -seronegative
4. chronic severe back pain
5. 4 C-sections.
6. History of secondary syphilis, treated.
7. Polysubstance abuse, notably cocaine
8. Depression
9. Pulmonary hypertension TR gradient 61
10. Restrictive lung disease
11. Seizures in childhood
Social History:
Lives with boyfriend. 4 children. Smokes [**3-6**] cigarettes per day.
Drinks 3 drinks most nights, last 2 days ago. Admits to cocaine
(smoked) last on Thursday. Denies IVDU. Denies other drugs.
Denies TB contacts/risks.
Family History:
Noncontributory, no history of stroke.
Physical Exam:
Vitals: T 99.8, HR 99, 119/56, R24, 95% on 4L
General: Slightly tachypneic but speaking in full sentances, NAD
HEENT: PERRL (3->2.5), sclera anicteric, MMM
Neck: + multiple small cervical and supraclav palpable nodes
Chest: CTA bilat, few basilar crackles
Heart: RRR, slightly tachy, loud S2
Abdomen: soft, ND, describes diffuse mild TTP "where I had
heparin shots"
Extrem: Warm, no edema
Back: no current TTP.
Neuro: A/O x 3, describes paresthesias of bilat LE at feet and
dorsal/palmar hands. Strength grossly preserved.
Skin: No rashes/lesions.
Pertinent Results:
Blood
[**2159-8-15**] WBC-9.0 RBC-3.64* Hgb-10.6* Hct-32.7* Plt Ct-248
Chemistry
[**2159-8-15**] Glucose-83 UreaN-11 Creat-0.9 Na-129* K-5.4* Cl-98
HCO3-29
8/3WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
21.3* 3.74* 11.1* 33.1* 89 29.7 33.5 16.2* 197
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
8/367 11* 14* 1* 6* 0 1* 0 0
[**8-5**] Fibrinogen 167
8/3Glucose UreaN Creat Na K Cl HCO3
73 23* 2.3* 132* 3.9 106 16*
8/3ALT AST LD(LDH) AlkPhos
15 22 506* 121*
[**2159-8-4**] pOs pCO2 pH calTCO2
66* 27* 7.46* 20*
Blood cultures x2, lyme serology pending
Last creatinine [**7-21**] - 0.9
.
Micro from last admit:
HIV neg, CMV neg, monospot pos
LN on [**7-9**] with ?exophiala jeanselmei on fungal cx (AFB neg to
date)
.
Studies:
.
ECG:
.
Pathology - Lymph node excisional biopsy [**2159-7-13**]: REACTIVE
LYMPHOID TISSUE WITH NECROTIZING GRANULOMAS, SEE NOTE. Tissue
sections show fragments of a lymph node and soft tissues with
necrotizing granulomas (two), which contain neutrophils and
eosinophils. Special stains for fungal, bacterial, and
mycobacteria organisms (GMS, PAS, [**Doctor Last Name 6311**], AFB) are negative
with adequate controls. There is no morphologic or
immunophenotypic evidence of lymphoma. Necrotizing granulomas
containing neutrophils are suggestive of an infectious process
and are most typical of Bartonella (Cat scratch disease),
Tularemia, Yersinia, and lymphogranuloma venereum. Fungal and
mycobacterial infections remain formal possibilities and are far
more common that the ones above.
.
CXR [**2159-8-3**]: There is no focal consolidation or superimposed
edema. Again noted is marked bilateral hilar and
aorticopulmonary window lymphadenopathy. This is stable across
multiple studies and has been diagnosed by biopsy. The
mediastinum is otherwise stable. No effusion or pneumothorax is
noted. The osseous structures again demonstrate markedly
atrophic bilateral first ribs. IMPRESSION: Stable mediastinal
lymphadenopathy. No acute pulmonary process.
.
CT head [**2159-8-3**]: no hemorrhage.
Brief Hospital Course:
50 year-olf female with history of cocaine abuse, pulmonary
hypertension, mediastinal adenopathy, recent extensive admit to
medicine for the above issues, initially admitted with lower
extremity pain and eventual progressive weakness. Her hospital
course will be briefly reviewed by problems.
1) [**First Name9 (NamePattern2) 7816**] [**Location (un) **]. Progressive neurologic symptoms (worsening
weakness in particular) led to LP on [**2159-8-6**]. This revealed [**8-14**]
WBCs and very high protein at 177. NIFs and vital capacities
were monitored and noted to be initially -20 and <1 liter
respectively. She was again transferred to the MICU on [**2159-8-6**].
NIFs and VCs were closely monitored and improved slightly during
her course. Despite continued poor values, clinical respiratory
status remained stable and she never required intubation. She
received IVIG x 5 daily doses. Strength improved slightly. A
slow and protracted recovery is expected.
2) Hypotension: She had transient hypotension while on the
floor, which resolved with IV bolus prior to going to MICU.
Occured in setting of getting IV ativan earlier in the morning
and few days of poor PO intake. Encouraged PO intake. For her
infection/sepsis workup, MRI spine without evidence of epidural
abscess. Positive for C.diff; flagyl started. ID consulted
regarding Exophilia fungus in past lymph node biopsy (from FNA
bronch); though to be a contaminant.
3) Hyponatremia: Sodium nadir 121. Renal was consulted, and the
possibility of pseudohyponatremia [**2-3**] IVIG versus SIADH was
raised. Urine lytes suggestive of SIADH, and fluid restriction
1000 mL instituted, liberal salt intake. On discharge, sodium
was 129.
4) Coagulopathy: She developed a mild coagulopathy with elevated
INR, mild thrombocytopenia to 122K. Hematology was consulted,
picture overall most consistent with low-grade DIC, possibly in
the setting of C. diff. Improved with antimicrobial therapy,
vitamin K.
5) Mediastinal adenopathy: Mediastinoscopy during last admit.
During this hospital stay, she continued to have palpable
supraclav and cervical adenopathy (though seems improved per
previous notes). Necrotizing granulomas identified on prior
biopsy. Etiology remains elusive, to follow-up with pulmonary as
an out-patient with F/U CT scan chest.
6) Acute renal failure: Peak creatinine 2.4, improved with
hydration, nephrotoxic agents held.
7) Chronic back pain: MRI spine negative for abscess (though
limited study). Pain control achieved with oxycontin and
oxycodone.
Medications on Admission:
1. Tizanidine 2mg TID
2. Supplemental oxygen
3. Ipratropium-Albuterol Q6H PRN
4. Motrin 800 mg TID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze or shortness of breath.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheeze.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days: Ten day course will be completed on
[**2159-8-20**].
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] syndrome
C. difficile colitis
Mild asymptomatic hyponatremia
Resolved coagulopathy secondary to low grade DIC
Resolved acute renal failure
Secondary diagnoses:
Pulmonary hypertension
Chronic back pain
Polysubstance abuse
Granulomatous disease with bulky mediastinal and hilar
lymphadenopathy
Discharge Condition:
Stable for acute rehab.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to the hospital because of
[**Location (un) 7816**]-[**Doctor Last Name **]?????? Syndrome for which you were treated with IVIG.
You continued to improve, but still had residual weakness in
your upper and lower extermeities. Your respiratory status also
improved and you remained on 2L of oxygen.
You are being discharged to [**Hospital1 1319**] for rehab.
Because you sodium levels were low you will need to continue on
a water restriction to one liter per day. We also encourage you
to take in salty foods.
Please follow the medications prescribed below
Please follow up with the appointments below.
Followup Instructions:
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2159-8-13**]
1:10
PFT,INTERPRET W/LAB NO CHECK-IN PFT INTEPRETATION BILLING
Date/Time:[**2159-8-13**] 1:30
DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2159-8-13**]
1:30
Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**]. Please call for appt at [**Telephone/Fax (1) **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
|
[
"799.02",
"518.89",
"287.5",
"286.9",
"416.8",
"786.06",
"714.0",
"110.8",
"253.6",
"276.1",
"357.0",
"008.45",
"285.9",
"401.9",
"518.81",
"288.60",
"686.1",
"356.8",
"724.5",
"584.9",
"V46.2",
"458.8",
"785.6",
"305.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8575, 8645
|
4762, 7297
|
348, 365
|
9049, 9075
|
2645, 4739
|
9820, 10379
|
2021, 2061
|
7447, 8552
|
8666, 8874
|
7323, 7424
|
9099, 9797
|
2076, 2626
|
8895, 9028
|
275, 310
|
393, 1398
|
1420, 1765
|
1781, 2005
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,673
| 103,151
|
17086
|
Discharge summary
|
report
|
Admission Date: [**2145-7-28**] Discharge Date: [**2145-7-30**]
Date of Birth: [**2100-5-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Morphine / Temodar
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
recurrent right occipital tumor
Major Surgical or Invasive Procedure:
Right Craniotomy for resection of recurrent tumor
History of Present Illness:
[**Known firstname **] [**Known lastname 48029**] is a 45-year-old right-handed man with a right
parietal anaplastic oligodendroglioma with 1p & 19q chromosome
deleted. He is here with his sister after a head MRI done in
[**Name (NI) 1727**] on [**2145-4-12**]. This had shown new enhancement and Dr.
[**Last Name (STitle) 48030**]
referred him back to Dr. [**Last Name (STitle) 724**] for a treatment plan. He has
remained unchanged neurologically. Denies any headaches,
seizures, vision problems, or personality/memory changes. For
the
past several years he has noted left hand and leg tingling
"twinge" that lasts seconds. He notices it most when he is not
working and tends to drink more coffee those days. This has not
changed. He is s/p:
1. Craniotomy [**2137-6-12**] at [**Hospital 1727**] Medical Center by Dr. [**Last Name (STitle) **]
2. Monthly Temodar for one year ending [**10/2139**]
3. Resection of recurrence on [**2143-3-13**] by Dr. [**Last Name (STitle) **]
4. Dose-dense temozolomide (7 on/7 off) [**Date range (1) 48031**]/09
5. PCV [**2143-5-30**] to [**1-/2144**] x 6 cycles
Past Medical History:
Past Medical History: noncontributory.
Social History:
Social History: He has 3 boys ages 9, 13, and 17. Works full
time
as a manager at Lumber Liquidators.
Family History:
NC
Physical Exam:
VITAL SIGNS: Blood pressure 126/62, heart rate of 60,
respiratory rate of 16, temperature 96.8.
GENERAL: Well appearing, pleasant, no acute distress.
HEENT: Anicteric sclerae. Oropharynx clear. Tongue pink.
Mucous membranes moist.
CARDIOVASCULAR: Regular rate and rhythm; no murmurs, rubs, or
gallops.
RESPIRATORY: Even and unlabored respirations. Clear to
auscultation bilaterally. No wheezes, crackles, or rhonchi.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No edema.
NEUROLOGIC: Cranial nerves II through XII intact. Pupils
equal.
No visual field defects appreciated. Strength is full in upper
and lower extremities. Reflexes 1+ and symmetrical.
Finger-to-nose intact bilaterally. Tandem gait intact.
Negative
Romberg. No pronator drift. Speech is fluent. He is alert,
appears oriented.
On Discharge: neuro intact, ambulatory in halls without
assistance, pain well controlled, incision c/d/i, taking
adequate diet
Pertinent Results:
CT Head Post-op
Interval resection of a large right parietooccipital mass, with
expected post-surgical changes, and no evidence of large
post-surgical
hemorrhage or large vascular territorial infarct.
MRI Brain Post-op
expected post-op change
Brief Hospital Course:
Patient presented electively on 6.22 for right sided craniotomy
for resection of recurrent oligodendroglioma, he tolerated the
procedure well and was extubated in the operating room and
trasnferred to the ICU post-operatively. He recieved his post-op
CT scan of the ehad which showed expected post-op changes and he
remained stable overnight. On the morning of 6.23 he recieved
his post-op MRI Brain and was deemed stable for transfer to the
floor. He remained stable overnight on the floor and was
ambulatory in the halls. On the morning of [**7-30**] he was deemed
fit for discharge to home without services. He was given
instructions for follow-up and prescriptions for any needed
medications and discharged.
Medications on Admission:
Keppra 1000mg [**Hospital1 **]
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
3. Zofran 4 mg Tablet Sig: One (1) Tablet PO q8hours as needed
for nausea.
Disp:*15 Tablet(s)* Refills:*0*
4. dexamethasone 2 mg Tablet Sig: per taper Tablet PO per taper:
Take 3mg (1.5 tabs) every 6 hours on [**7-30**], Take 2mg (1 tab)
every 6 hours on [**7-31**], take 2mg (1 tab) [**Hospital1 **] on [**8-1**] and
continue until follow-up.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent Right occpitital oligodendroglioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-15**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**8-23**] at
2pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain
Completed by:[**2145-7-30**]
|
[
"V14.8",
"V14.5",
"V10.85",
"191.3",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"38.91",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
4310, 4316
|
2947, 3660
|
314, 366
|
4405, 4405
|
2679, 2924
|
6394, 7276
|
1693, 1697
|
3741, 4287
|
4337, 4384
|
3686, 3718
|
4556, 6371
|
1712, 2532
|
2546, 2660
|
243, 276
|
394, 1494
|
4420, 4532
|
1538, 1557
|
1589, 1677
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,224
| 170,917
|
8797
|
Discharge summary
|
report
|
Admission Date: [**2143-5-23**] Discharge Date: [**2143-6-1**]
Date of Birth: [**2115-10-17**] Sex: M
Service: MEDICINE
Allergies:
Flagyl
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
27 year-old man with a history of Crohn's disease admitted
through the ED to the MICU with bright red blood per rectum. He
was in his normal state of health (one brown stool a day, no
bloody stools, no fevers, no abdominal pain) until approximately
7:00 PM on [**4-21**] when he began to have BRBPR. This was
associated with bilateral lower abdominal discomfort. He
describes this as intermittent "full" or "moving" sensations
that are most promintent in the right lower quadrant. The
sensations are relieved by moving his bowels. He reported that
he had two episodes of a large amount of liquid red blood at
home (one liter). He then went to [**Hospital3 **] Hospital for
further care. There, he felt nauseated but did not have any
further episodes of BRBPR. However, he had two syncopal
episodes. One was during the placement of an IV and the other
was after seeing a large volume of bloody stool. His hematocrit
at [**Hospital1 498**] was 36.7. He received 2 liters of NS and was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
1. Crohn's disease- with ileal and perianal Crohn's. Diagnosed
[**2135**].
2. S/P perirectal abcess
3. S/P fistulotomy in [**5-/2138**]
4. EGD in [**2139**] positive for H pylori. Pt was treated and
subsequent breath test in [**2141**] was negative.
5. Vitamin B 12 deficiency
Social History:
Pt is married and lives with his wife. Pt works at Target. He
denies any ETOH, tobacco, or drug use. His sister is a nurse.
Family History:
no family history of colon cancer or IBD
Physical Exam:
98.1 88 151/72 12 100% RA
Gen- Well appearing man in NAD. Alert and oriented x3. Resting
comfortably on the strecher
Cardiac- RRR. No m,r,g
Pulm- CTAB. No wheezes, rales, or rhonchi
Abdomen- Soft. ND. Tender in the bilateral lower quadrants and
epigastric region. No rebound or gaurding. Positive bowel
sounds. No appreciable organomegaly
Extremities- No c/c/e
Pertinent Results:
HCT 43 -> 27.3
ABD CT Scan ([**5-23**]) - Active Crohn disease in the distal ileum.
No abscess. No evidence of bowel obstruction.
Bleeding Scan ([**5-24**]) - No evidence of active gastrointestinal
bleed at the time of study.
Colonoscopy ([**2143-5-23**]) - Blood in the entire colon, more so in
the right colon. Polyp in the sigmoid colon. Edema, ulceration,
granularity, erythema and friability in the terminal ileum
compatible with crohn's disease (biopsy). Posterior anal
fissure.
Brief Hospital Course:
Mr. [**Known lastname 6955**] was initially admitted to the MICU due to his large
volume of bright red blood per rectum and his HCT drop from 43
in [**2142-8-26**] to approximately 27 on admission. He was
transfused one unit of packed red blood cells, and his HCT
remained stable post transfusion in the high 20's. A CT scan
and a colonoscopy revealed active crohn's of the terminal ileum
which was felt to be his bleeding source. He was seen by
colorectal surgery and by gastroenterology, and was started on
IV hydrocortisone and IV ciprofloxacin. He was transferred out
of the ICU, but subsequently had a few additional episodes of
maroon stool. He was then briefly transferred to the surgical
ICU, but again stabilized and was transferred back to medicine.
He received one additional unit of blood (two units total for
the hospitalization) on the medicine [**Hospital1 **], and his HCT responded
appropriately and remained in the 28-30 range for the last [**3-29**]
days of his admission. He was changed to an oral diet, and was
started on PO ciprofloxacin and Prednisone. He was discharged
on 60 mg of Prednisone daily to be tapered by 10 mg weekly. He
will also continue his Ciprofloxacin 500 mg PO BID. He will
follow-up with his gastroenterologist in 4 weeks.
In addition, he was given IM vitamin B12, oral iron, MVI, and
folate. He was dischared on these oral viatmins/minerals and
will have monthly B12 injections at home.
He and his wife are planning on having a child soon, and they
were given the phone number of [**Location (un) 86**] IVF as Mr. [**Known lastname 6955**] was
interested in sperm banking - given his gastroenterologist's
plan of starting 6-MP in approximately one month.
During his hospital stay, Mr. [**Known lastname 6955**] had his roommate's IV
solution connected to his own IV and had some solution infused.
He was seen by infection control and had baseline HIV and
hepatitis serologies drawn. His roommate was tested as well by
infection control, and Mr. [**Known lastname 6955**] will follow-up with his PCP
and infection control for these results.
Medications on Admission:
1. Pentasa 8 pills [**Hospital1 **]
2. Multivitamin tablet daily
3. Calcium with vitamin D
4. Vitamin B 12 injections- Pt received his first injection on
[**5-19**].
5. [**Name (NI) 30723**] Pt self started this from some left over
medication. He reports taking three pills for two days followed
by two pills for one day. Probably 30 mg and 20 mg. He did not
take any on [**5-22**].
Discharge Medications:
1. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day for 30 days.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day for
30 days.
5. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: Please take 60 mg daily for one week, then 50 mg daily for
one week, then 40 mg daily for one week, then 30 mg daily for
one week. Then follow-up with Dr. [**Last Name (STitle) **] for further
adjustments.
Disp:*150 Tablet(s)* Refills:*1*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
terminal ileitis secondary to active crohn's disease
acute blood loss anemia secondary to a lower gastrointestinal
bleed
vitamin B12 deficiency
Discharge Condition:
stable
Discharge Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] as needed.
Please follow-up with Dr. [**Last Name (STitle) **] in one month - Please call to
schedule an appointment.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2143-10-24**] 8:00
|
[
"285.1",
"555.0",
"780.2",
"565.0",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6053, 6059
|
2782, 4882
|
294, 307
|
6247, 6255
|
2270, 2759
|
6474, 6670
|
1832, 1874
|
5316, 6030
|
6080, 6226
|
4908, 5293
|
6279, 6451
|
1889, 2251
|
227, 256
|
335, 1374
|
1396, 1674
|
1690, 1816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,965
| 144,181
|
48643
|
Discharge summary
|
report
|
Admission Date: [**2109-9-10**] Discharge Date: [**2109-9-11**]
Date of Birth: [**2035-6-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
74F with recent D/C from [**Hospital1 18**] s/p fall down stairs with c-spine
fractures presents today with Nausea, headache, and feeling dry
x4 days. She was admitted on [**2109-9-2**] with multiple fractures of
the spinous process of C4, C7and T1 as well as a retropharyngeal
hematoma. She was placed in aC-collar and remaine neurologically
stable. She was discharged torehab on [**2109-9-4**] and completed a
dexamethasone taper. She represented to the ED today complaining
of HA and Patient states she was d/c from [**Hospital1 18**] on [**9-4**] feeling
well. 4 days ago she began to feel nausea with decreased ability
to tolerate PO. Patient developed constant frontal headache and
felt dehydrated. Patient with labs done at rehab center today
showing Na+ = 119, at that time patient sent to ER for
evaluation. Patient denies f/c, CP, sob, diarrhea, joint pain,
or rash. No change in mental status or seizures.
Vital signs in the ED were - 97.8, 64, 138/59, 18, 100%
Patient in c-collar, in NAD, dry mucus membranes
Patient with left arm weakness, no other focal deficits
abdomen soft, NT/ND. She was given 500 ml fluid bolus followed
by NS at 100 cc/hr. Patient reported improvement in her
headache.
Past Medical History:
osteoporosis
Social History:
Lives and takes care of husband, denies ETOH or tobacco
use.
Family History:
non-contributory
Physical Exam:
Admission PEx:
VS: 98.7 66 141/69 14 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge PEx:
VS: 98.1 63 125/68 12 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, with collar
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2109-9-10**] 01:48PM BLOOD WBC-12.2* RBC-3.97* Hgb-12.4 Hct-34.0*
MCV-86 MCH-31.2 MCHC-36.4* RDW-13.3 Plt Ct-303
[**2109-9-11**] 04:43AM BLOOD WBC-11.7* RBC-4.08* Hgb-12.6 Hct-35.7*
MCV-88 MCH-30.9 MCHC-35.3* RDW-13.0 Plt Ct-328
[**2109-9-10**] 01:48PM BLOOD Plt Smr-NORMAL Plt Ct-303
[**2109-9-10**] 01:48PM BLOOD Osmolal-254*
Labs on Discharge:
[**2109-9-11**] 04:43AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-129*
K-4.3 Cl-98 HCO3-23 AnGap-12
[**2109-9-10**] 01:48PM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-120*
K-3.7 Cl-89* HCO3-25 AnGap-10
[**2109-9-11**] 04:43AM BLOOD TSH-1.5
[**2109-9-11**] 04:43AM BLOOD Cortsol-26.4*
.
.
[**2109-9-10**] CT head:
FINDINGS: There is no evidence of hemorrhage, edema, or
infarction. There is a relative increase in the size of
bilateral CSF attenuation extra-axial frontal spaces compared to
the prior outside study. There is associated mild mass effect on
the posterior brain. No herniation is seen. The ventricles and
sulci are normal in configuration. No fractures are identified.
IMPRESSION:
1. Relative increase in size of bilateral CSF-attenuation
frontal extra-axial spaces suspicious for symmetric subdural
hygroma. Chronic subdural hematomas are felt less likely given
the time course and CSF attenuation.
2. No evidence of hemorrhage, edema or herniation.
.
[**2109-9-11**] CT Head:
preliminary read as no change in hygromas or edema
Brief Hospital Course:
Assessment:
The patient is a 74 year old female sent from rehab s/p fall
down stairs with c-spine injury presents with nausea, headache,
and dehydration, and found to have hyponatremia.
.
#Hyponatremia: Her sodium improved with IV fluids suggesting a
significant component of hypovolemia hyponatremia, likely in the
setting of dehydration from nausea and vomitting. Her sodium
improved from 121 on admission to 129 at transfer. Her
neurological exam was monitored closely in the intensive care
unit overnight and she was asymptomatic during her
hospitalization with mental status at baseline.\
.
#Subdural hygromas: She was found to have small subdural
hygromas on head imaging. She was evaluated by neurosurgery who
felt that they were likely to resolve with time. Repeat head CT
the following day showed stable appearance without evidence of
cerebral edema. Neurosurgery recommendations at discharge were
...
.
#Cervical fracture: The hard C-collar was continued.
.
# Scalp stitches were removed on [**2109-9-11**] prior to discharge.
# Code: Full (discussed with patient)
# Disposition: Rehab facility
Medications on Admission:
-bisacodyl 10mg daily
-colase 100mg [**Hospital1 **]
-senna [**Hospital1 **]
-dilaudid 2mg 1-2mg Q4 PRN for pain
-dexamethasone taper
Discharge Medications:
none; calcium may be started as outpatient and followed up on by
PCP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 771**]. You presented to the hospital with
nausea, vomiting. Your sodium (an electrolyte) was found to be
much lower than normal. This is most likely due to being
dehydrated from the nausea/vomitting. Your sodium improved with
IV fluids.
Please continue your home medications with no changes.
Followup Instructions:
PCP
[**Name Initial (PRE) **]
Completed by:[**2109-9-11**]
|
[
"787.01",
"733.00",
"276.52",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5608, 5705
|
4219, 5327
|
316, 324
|
5761, 5761
|
2790, 2795
|
6352, 6413
|
1698, 1716
|
5514, 5585
|
5726, 5740
|
5354, 5491
|
5944, 6329
|
1731, 2771
|
264, 278
|
3160, 3457
|
352, 1566
|
4144, 4196
|
2809, 3141
|
5776, 5920
|
1588, 1603
|
1619, 1682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,835
| 153,083
|
50783
|
Discharge summary
|
report
|
Admission Date: [**2193-10-4**] Discharge Date: [**2193-10-9**]
Date of Birth: [**2122-2-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Erythromycin Base / Augmentin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe lung cancer
Major Surgical or Invasive Procedure:
[**2193-10-4**] Video-assisted thoracoscopic surgical right upper
lobe wedge resection followed by video-assisted thoracoscopic
surgical right upper lobectomy and mediastinal lymph node
dissection.
History of Present Illness:
Mrs. [**Last Name (un) 105627**] is a 71 year-old female with a right upper
lobe 2.5cm spiculated mass found on Chest CT. Cervical
mediastinoscopy pathology was concerning for squamous cell ca.
She was admitted for right upper lobectomy.
Past Medical History:
Diabetes insipitus
Thyroid nodules - followed and appear benign
Chronic renal insufficiency
Hyperplastic rectal polyp removed [**2190**]
Hypertension
Hyperlipidemia
Skin CA
Social History:
She is of Italian descent. She is not currently working. She
used to smoke one pack a day for about 40 years, but has
currently quit. She drinks about two glasses of alcohol per
day. She is divorced.
Family History:
Both her brothers salivary gland adenocarcinoma, on the right
side.
Brother with heart disease.
Sister with rheumatologic issues.
Physical Exam:
VS: 98.0 HR 85 SR BP: 132/80 Sats:
General: 71 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy\
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Incision: right VATs site clean dry intact. no erythema
Neuro: awake, alert and oriented
Pertinent Results:
[**2193-10-8**] WBC-5.8 RBC-3.37* Hgb-10.9* Hct-31.6 Plt Ct-353
[**2193-10-7**] WBC-6.7 RBC-3.07* Hgb-10.1* Hct-28.9 Plt Ct-270
[**2193-10-5**] WBC-10.8 RBC-3.52* Hgb-11.3* Hct-34.1 Plt Ct-303
[**2193-10-4**] WBC-11.5*# RBC-3.57* Hgb-11.5* Hct-34.2 Plt Ct-287
[**2193-10-9**] Glucose-105* UreaN-7 Creat-0.7 Na-134 K-5.2* Cl-98
HCO3-27
[**2193-10-8**] Glucose-95 UreaN-9 Creat-0.7 Na-135 K-4.5 Cl-98 HCO3-27
[**2193-10-8**] Na-134 K-4.6 Cl-98
[**2193-10-8**] Glucose-90 UreaN-4* Creat-0.6 Na-131* K-4.3 Cl-95*
HCO3-28
[**2193-10-8**] Glucose-107* UreaN-6 Creat-0.6 Na-127* K-3.5 Cl-92*
HCO3-28
[**2193-10-7**] Glucose-113* UreaN-6 Creat-0.5 Na-129* K-3.7 Cl-94*
HCO3-26
[**2193-10-7**] Na-122* K-4.1 Cl-89*
[**2193-10-7**] Glucose-116* UreaN-8 Creat-0.5 Na-124* K-3.7 Cl-88*
HCO3-26
[**2193-10-6**] Glucose-117* UreaN-11 Creat-0.5 Na-127* K-4.1 Cl-91*
HCO3-27
[**2193-10-5**] Glucose-137* UreaN-15 Creat-0.8 Na-133 K-4.6 Cl-98
HCO3-24
[**2193-10-9**] Mg-2.2
[**2193-10-8**] BLOOD Osmolal-284
[**2193-10-8**] TSH-1.7 T4-7.6
[**2193-10-8**]: 10:17 Cortsol-12.9
Urine:
[**2193-10-8**] URINE Sp [**Last Name (un) **]-1.010
[**2193-10-8**] URINE Sp [**Last Name (un) **]-1.010
[**2193-10-8**] URINE Na-58 K-22 Cl-46
[**2193-10-8**] URINE UreaN-83 Creat-18 Na-16 K-3 Calcium-3.3 Phos-<5
Mg-2.6
[**2193-10-8**] URINE Creat-23 Na-12 K-4 Cl-LESS THAN Calcium-3.8
Phos-<5
[**2193-10-7**] URINE UreaN-72 Creat-11 Na-15 K-4 Cl-12 Calcium-2.4
[**2193-10-7**] URINE UreaN-122 Creat-17 Na-59 K-14 Cl-56 Calcium-6.4
[**2193-10-8**] URINE Osmolal-254
[**2193-10-8**] URINE Osmolal-82
[**2193-10-8**] URINE Osmolal-92
[**2193-10-7**] URINE Osmolal-79
CXR:
[**2193-10-7**]; Post-surgical changes, consistent with right upper
lobe resection. Small right apical hydropneumothorax.
[**2193-10-5**]: There are low lung volumes. Bibasilar
atelectasis greater on the left side are new. There is no
evident
pneumothorax or enlarging pleural effusions. Right chest tube
remains in
place. Right subcutaneous emphysema is grossly unchanged.
Brief Hospital Course:
Mrs. [**Last Name (un) 105627**] was admitted following Video-assisted
thoracoscopic surgical right upper lobe wedge resection followed
by video-assisted thoracoscopic
surgical right upper lobectomy and mediastinal lymph node
dissection. She was extubated in the operating room, monitored
in the PACU prior transfer to the floor with an anterior apical
[**Doctor Last Name 406**] drain.
Respiratory: aggressive pulmonary toilet, nebs, incentive
spirometer she titrated off oxygen with saturations of 97% on
room air and 93% with ambulation.
Chest tube; right [**Doctor Last Name 406**] drain was removed on [**2193-10-5**].
Chest films: serial chest films showed bibasilar atelectasis, no
pneumothorax.
Cardiac: hemodynamically stable sinus rhythm 70-80's.
GI: PPI and bowel regime
Nutrition: tolerated a regular diet
Renal: renal function remained normal.
Endocrine: she developed hyponatremia with symptoms of severe
nausea and lethargy. Endocrinology was consulted and she was
transferred to the SICU for further management. The desmopressin
was stopped, her electrolytes, urine sodium and osmolarity were
followed closely. Cortisol level, TSH, T4 were within normal
limits. Over the next 24 hours her hyponatremia, urine output
decreased and symptoms improved. Her discharge Na was 134.
Disposition: she was seen by physical therapy who recommended
home PT. She follow-up with her endocrinologist Dr. [**Last Name (STitle) 6092**]
on Friday with labs. She follow-up with Dr.[**Last Name (STitle) **] in 2
weeks as an outpatient.
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day
take one pill the night before the procedure, then 1 pill 1 hr
prior to the procedure
DESMOPRESSIN - 0.1 mg/mL Solution - 1 spray(s) intranasal every
30 hrs - No Substitution
EZETIMIBE [ZETIA] - 10 mg Tablet - 1 Tablet(s) by mouth daily
FUROSEMIDE - 20 mg Tablet - half Tablet(s) by mouth daily
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by
mouth every four (4) hours as needed for pain
LISINOPRIL - 20 mg Tablet - 2 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 50 mg Tablet - one Tablet(s) by mouth
twice
daily
NORVASC - 10 mg Tablet - 1 Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth once a day
CALCIUM + VITAMIN D - (OTC) - 600 mg (1,500 mg)-200 unit Tablet
- 2 Tablet(s) by mouth daily
MULTIVITAMIN [MULTI-VITAMIN HI-PO] - (OTC) - Tablet - 1
Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 1,200 mg-144 mg
Capsule
- 2 Capsule(s) by mouth daily
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-25**]
hours as needed for pain.
9. Desmopressin 0.1 mg.mL
1 spray intranasal every 30 hours.
Restart only if has increased thirst or large urine output.
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-19**]
inhaler Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Right upper lobe nodule
Diabetes Insipitus
Thyroid nodules - followed and appear benign
CRI
Hyperplastic rectal polyp removed [**2190**]
Hypertension
Hyperlipidemia
skin CA
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:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-You may shower. No tub bathing or swimming until all incisions
healed.
Please restart your desmopressin only if you develop increased
thirst and large urine output.
Call Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 16956**], MD Phone:[**Telephone/Fax (1) 1803**] office for
fatique,
weakness, unusal thirst, or nausea.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2193-10-24**] 1:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**].
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
[**Location (un) **] [**Last Name (NamePattern4) 16956**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2193-10-11**]
11:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] Medical
Specialities.
Labs will be drawn on [**Hospital Ward Name 23**] 7 Friday [**2193-10-11**]
Provider: [**First Name4 (NamePattern1) 2353**] [**Last Name (NamePattern1) 2354**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2193-11-1**] 10:30
Completed by:[**2193-10-9**]
|
[
"253.6",
"496",
"V15.82",
"241.1",
"272.4",
"934.9",
"253.5",
"585.9",
"162.3",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.20",
"40.3",
"32.41"
] |
icd9pcs
|
[
[
[]
]
] |
7503, 7574
|
3832, 5382
|
347, 548
|
7791, 7791
|
1790, 3809
|
8491, 9310
|
1251, 1383
|
6438, 7480
|
7595, 7770
|
5408, 6415
|
7942, 8468
|
1398, 1771
|
279, 309
|
576, 816
|
7806, 7918
|
838, 1013
|
1029, 1235
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,716
| 114,396
|
52606
|
Discharge summary
|
report
|
Admission Date: [**2199-6-27**] Discharge Date: [**2199-7-2**]
Date of Birth: [**2147-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
etoh withdrawl
Major Surgical or Invasive Procedure:
sutures in ED
History of Present Illness:
52 yo M with a history of EtOH abuse presented to ED after a
fall onto face day prior to admission. He notes that he had been
clean and sober for 17 months, though "fell off the wagon" and
went into a 3 week drinking "bender". He sat at home on couch
for two days straight with only minimal movement, noting that he
soiled himself to avoid having to get up. He finally did arise
from the couch the evening prior to admission and fell forward
into his TV stand, hitting his left brow and ear. He notes that
his last drink of EtOH was on the evening prior to presentation.
.
Past Medical History:
# Alcohol abuse: Binges, no hx of DTs or seizures
# Depression
# R wrist fracture ([**7-/2196**])
# Acute pancreatitis s/p drinking binge
# Hemorrhoids
Social History:
# Personal: Lives alone, recently divorced
# Professional: Real estate developer for [**Hospital3 **]
communities
# Alcohol: Began drinking in college on weekends. Moderate
social drinking after college. Binge-drinking began in
mid-[**2179**], during a period of high work stress. Longest period
of sobriety lasted 18 months; longest binge lasted three weeks.
Pt had Alcoholics Anonymous sponsor, and had undergone
"self-detox" previously by himself, as well as inpatient alcohol
rehabilitation.
# Tobacco: Social smoking, quit in ~[**2186**].
# Recreational drugs: Experimental marijuana in youth.
Family History:
# M a: Dementia
# F: Prostate CA
# Siblings (1 brother, 1 sister): No known illnesses
Physical Exam:
Physical Exam On Admission:
VS: T afebrile, BP 123/88, P 65, R 18, 98% on RA
GEN: NAD
HEENT: PERRL, oral mucosa slightly dry, oropharynx benign,
multiple facial abrasions and large left brow laceration with
sutures, ecchymotic and tender left ear
NECK: Supple
PULM: CTAB
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND
EXT: no C/C/E
Skin: shallow sacral ulcerations covered with a dry dressing
NEURO: Oriented x 3, slight resting tremor that attenuates with
distraction, tounge wag present
Pertinent Results:
Labs on Discharge:
CBC WBC-4.4 RBC-3.13* Hgb-10.2* Hct-31.4* MCV-101* MCH-32.7*
MCHC-32.6 RDW-14.3 Plt Ct-281
Coags: BLOOD PT-11.6 PTT-28.8 INR(PT)-1.0
Panel 10 Glucose-103* UreaN-12 Creat-0.7 Na-139 K-4.2 Cl-104
HCO3-25 AnGap-14 Calcium-9.0 Phos-4.6* Mg-2.0
[**2199-6-27**] BLOOD ALT-88* AST-146* CK(CPK)-475* AlkPhos-77
TotBili-1.1
[**2199-6-29**] BLOOD ALT-87* AST-136* CK(CPK)-148 AlkPhos-83
TotBili-0.7
[**2199-6-30**] BLOOD ALT-84* AST-103* AlkPhos-82 TotBili-0.4
[**2199-6-27**] BLOOD calTIBC-204* VitB12-1475* Folate-GREATER TH
Ferritn-611* TRF-157*
Brief Hospital Course:
Pt is 52yo male with hx of alcohol abuse, but sober for 17
months, who went on a 3-week binge. He was brought into the
hospital for head trauma after fall (no acute intracranial or
cervical process), and was subsequently found to have Stage 1
pressure ulcer in buttocks region. Pt was started on Valium
overnight, and received a total (inc standing orders and PRN
CIWA>10) of 120mg. Pt was given thiamine, folate, multivitamin,
and SW consult. Iron panel was also checked, and revealed
Ferritin 611, Fe 46, TIBC 204. B12 and folate wnl. Pt was
transferred to floor when valium needs decreased. Dry dressings
and frequent positional changes for buttock ulcer. He received a
total of 160+mg of Valium during his hospital stay. At the time
of discharge he was not tremulous or anxious, was able to
ambulate well and his ulcer on his buttock region was healing
well.
Medications on Admission:
None
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for sacral decubitus wound.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Laceration to head
Pressure wounds
ETOH withdrawl
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for withdrawing for alcohol. It was from
drinking too much the last few weeks. You also had sores on
your bottom from sitting in one place too long. You should stop
drinking and seek help as social work has directed. You have
been to treatment programs before and should start going back
again.
As for your wounds, we recommend an antifungal cream for a short
period of time while it heals. If it gets worse, you have
fevers or chills, or other concerns about it, you should seek
medical treatment because you're at a higher risk of infection.
And as for your stitches, you should see a doctor in our
[**Hospital 1944**] clinic to have them removed as outlined below.
Please take a multivitamin, thiamine and folate supplements
after leaving.
Please DO NOT drive for at least 48 hours.
Followup Instructions:
To remove your stitches please go to the following appointment:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2199-7-10**] at 8:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please schedule an appointment to follow up with your PCP in the
next week.
|
[
"707.05",
"707.21",
"276.1",
"303.91",
"873.42",
"311",
"E885.9",
"287.5",
"291.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
4549, 4555
|
2964, 3835
|
328, 344
|
4668, 4668
|
2376, 2376
|
5656, 6103
|
1756, 1843
|
3890, 4526
|
4576, 4576
|
3861, 3867
|
4819, 5633
|
1858, 1872
|
274, 290
|
2395, 2941
|
372, 948
|
4595, 4647
|
1886, 2357
|
4683, 4795
|
970, 1123
|
1139, 1740
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,493
| 193,202
|
44182
|
Discharge summary
|
report
|
Admission Date: [**2133-11-18**] Discharge Date: [**2133-11-23**]
Date of Birth: [**2066-3-25**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
postmenopausal vaginal bleeding
Major Surgical or Invasive Procedure:
Exam under anesthesia, cervical biopsy
History of Present Illness:
This is a 67 yo G4P3104 who presents from the [**Location (un) 620**] ED with
heavy vaginal bleeding. She reports bleeding began overnight
last night, and she woke up with bright red blood staining her
underwear. She went to work all day. At the end of her
workday, she began "gushing" bright red blood and her husband
drove her to the [**Name (NI) 620**] [**Name (NI) **]. There, her Hct was 30, her vagina
was packed, and she was sent to the [**Hospital1 18**] ED.
The patient reports no abdominal or pelvic pain. She denies
dizziness, lightheadedness, syncope or presyncope, CP, SOB,
n/v/d, fevers or chills. She does endorse a recent weight loss
of 20 pounds since [**Month (only) 404**] without trying to lose weight or
changing her dietary habits (reports attributing this to a "very
active job," but also notes she has been doing it for 10 years).
Following our discussion, she did feel "cold sweats" and felt
better when placed in Trendelenberg. She reports she has not
received medical care since the birth of her last child. She
reports going through menopause at age 55, and having no
bleeding until labor day weekend, when she had one day of
bleeding saturating one pad, which then spontaneously resolved.
Past Medical History:
GynHx: patient does not remember if she has ever had a Pap, but
does not remember ever having an abnormal Pap. Denies STI.
.
ObHx: SVD x3, C/S via vertical midline at 7 months GA for
placenta previa.
.
PMH: none (report no history of mammogram, colonoscopy ever, no
Pap within recent memory, possibly during reproductive years)
.
PSH: C-section as above, appendectomy age 6
Social History:
lives with husband. [**Name (NI) **] four children and 3 stepchildren.
Works full time at the Department of Deeds, which she describes
as physical work lifting heavy books. Walks 1.5 miles to work
each day. Reports distant social tobacco history, denies
illicits. Reports heavy EtOH use, consisting of [**3-23**] shots
of whiskey after work, for five years. She and her husband both
quit "cold [**Country 1073**]" in [**Month (only) 205**], which she describes as not
difficult.
Family History:
non contributory
Physical Exam:
99.6, 100, 149/92, 100% 2L
94, 124/88, 18, 100% 4L
99.5 , 82, 132/75, 18, 100% 4L
100.1, 82, 108/74, 16, 100% 4L
99.9, 83, 104/67, 16, 100% 4L
Gen: pleasant, comfortable appearing, matter-of-fact attitude,
appearing of nl BMI
CV: RRR
lungs: CTAB
abd: soft, nontender throughout, nondistended, +bs, well healed
vertical midline scar
pelvic: vagina packed and packing soaked through. foley in
place. active bright red bleeding from the os. Cervix appears
grossly abnormal, papillary and caulliflower-like, without
easily
discernable edges, os able to be identified as source of
bleeding. Os able to accommodate 1cm scopette, after which
bleeding increased. On palpation, cervix papillary and with
nodule at 8 o'clock, 1cm, rubbery in consistency. Uterine size
approx 8-10 cm, fundus not easily delineated. Adnexa without
palpable mass appreciated.
Extr: NT, NE
Pertinent Results:
22 -> 4u pRBC -> 28 -> 24 -> 1u -> 31 -> 29 -> 31->28.3
[**11-19**]: Invasive keratinizing squamous cell carcinoma, moderately
differentiated.
[**11-19**]: CT abdomen/ pelvis
1. Findings concerning for cervical carcinoma. Please note that
the mass is not separable from the rectum and the sigmoid colon
and direct extension into these structures is of concern.
2. No evidence for metastatic disease in the pelvis.
3. The mass causes cervical stenosis with fluid accumulating in
the uterine cavity. Incidental note is made of a uterine fibroid
and a left renal cyst.
[**11-19**]: MRI pelvis
Large cervical tumor with superior vaginal and parametrial
extension, at least MRI stage FIGO IIb. Findings also suspicious
for invasion of the posterior wall of the bladder and cannot
exclude mucosal involvement (stage of FIGO [**Doctor First Name 690**]).
[**11-20**]: PET
1. A 8.5 x 5.5 cm FDG-avid cervical mass extending into
endometrial
cavity and closely abutting vesicular and recto-sigmoid wall.
There is no
FDG-avid pelvic, inguinal, mesenteric or retroperitoneal
lymphadenopathy. There is no evidence of distant disease
involvement.
2. Multiple non-FDG avid hypodense hepatic lesions, as described
above, likely hepatic cysts.
Brief Hospital Course:
Ms. [**Known lastname 94806**] initially presented to the [**Location (un) 620**] ED secondary
very heavy postmenopausal vaginal bleeding. At [**Location (un) 620**], she had
a CBC drawn which was significant for HCT of 30 and
heavy/persistent bleeding on exam. Her vagina was packed and
she was transferred to [**Hospital1 18**].
On arrival, she was initially mildly tachycardic which resolved.
Her blood pressure remained wnl. On exam, she was noted to
have a markedly abnormal appearing cervix with what felt to be a
8cm mass. She had bleeding from the cervix thus the vagina was
packed. Her labs were notable of a HCT 23, plts 254, INR 1.2.
Given 7 point HCT drop in short period of time the decision was
made to transfuse with 4u PRBC's, 2u FFP, and 1 u plts. She was
transferred to the ICU given ongoing bleeding and potential for
hemodynamic instability. She was monitored closely over night
and transferred to the floor the following day as her bleeding
significantly improved. On HD 2 she did receive 1u PRBC as her
HCT fell from 28-->24. Following this second transfusion her
HCT stabilized.
On HD 2 she had a CT scan and MRI of her abdomen/ pelvis which
confirmed a large cervical mass with extension into the
parametria but without clear invasion of bladder or rectum. She
was taken to the operating room for an exam under anesthesia and
biopsy of the cervical mass. This returned as c/w squamous cell
carcinoma of the cervix. She had a PET scan w/out evidence of
metastasis. Radiation and medical oncology were consulted. The
patient was set up for outpatient radiation and chemotherapy
scheduled for the Wednesday following discharge.
She was discharged in stable condition on HD 6.
Medications on Admission:
MVI
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
cervical cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Nothing in your vagina (no sex, no tampons, no douching)
No vigorous activity
Do not drive while taking narcotics
Call for:
- increased vaginal bleeding (soaking > 1pad per hour, passing
large clots)
- dizziness, shortness of breath, palpitations, chest pain
- abdominal pain not responsive to your medications
- difficulty urinating
- fever > 100.4
Followup Instructions:
You will be receiving radiation on Wednesday, [**2133-11-25**].
Radiation Oncology department, [**Hospital Ward Name **] [**Hospital1 18**], [**Hospital Ward Name 332**]
basement. Please call [**Telephone/Fax (1) 9710**] if you are having any
trouble finding the correct location.
You will be starting chemo on wednesday, [**2133-11-25**], at 9:00 am on
[**Hospital Ward Name 23**], [**Location (un) **], [**Hospital Ward Name 516**], [**Hospital1 18**]. Call [**Telephone/Fax (1) 18574**] with
any issues.
Please call Dr.[**Name (NI) 27357**] office to make an appointment for the
2nd-3rd week of [**Month (only) 404**]. Phone # [**Telephone/Fax (1) 5777**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2133-11-26**]
|
[
"627.1",
"V11.3",
"285.9",
"V15.82",
"180.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"67.12",
"57.32"
] |
icd9pcs
|
[
[
[]
]
] |
6808, 6814
|
4753, 6469
|
351, 392
|
6874, 6874
|
3496, 4730
|
7400, 8219
|
2567, 2585
|
6523, 6785
|
6835, 6853
|
6495, 6500
|
7025, 7377
|
2600, 3477
|
280, 313
|
420, 1650
|
6889, 7001
|
1672, 2049
|
2065, 2551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,537
| 142,969
|
29405
|
Discharge summary
|
report
|
Admission Date: [**2152-12-1**] Discharge Date: [**2152-12-20**]
Date of Birth: [**2133-2-27**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Status post motor vehicle collision.
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy and splenectomy and fiberoptic
bronchoscopy.
2. Evaluation under anesthesia left knee.
3. EUA left ankle.
4. Irrigation, debridement of left open knee.
5. Close treatment left ankle fracture.
6. Placement of inferior vena cava filter.
History of Present Illness:
19 year old man s/p motor vehicle crash vs tree with prolonged
extrication ~ 45 minutes. He was transported via [**Location (un) **] to
[**Hospital1 18**] where his BP was found to be 80/palp; FAST exam was
grossly positive; he was taken for an emergent ex-lap and
splenectomy.
Past Medical History:
Denies
Social History:
Substance use
Family History:
Noncontributory
Physical Exam:
GEN: intubated, sedated.
HEENT: PERRL, pupils 3+, TMs clear, +chin lac
PULM: breath sounds equal bilaterally
ABD: FAST+, abd soft, pelvis stable
EXT: left infrapatellar laceration
Pertinent Results:
[**2152-12-1**] 10:29PM LACTATE-1.7
[**2152-12-1**] 10:14PM GLUCOSE-124* UREA N-13 CREAT-0.9 SODIUM-143
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-24 ANION GAP-13
[**2152-12-1**] 10:14PM WBC-18.5* RBC-4.08*# HGB-12.7*# HCT-34.5*#
MCV-85 MCH-31.0 MCHC-36.7* RDW-13.9
[**2152-12-1**] 10:14PM PLT COUNT-141*
[**2152-12-1**] 05:37PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
--------------
TRAUMA #2 (AP CXR & PELVIS POR Clip # [**Clip Number (Radiology) 70606**]
IMPRESSION:
1. No evidence of acute cardiopulmonary process.
2. Left superior ramus fracture extending into the symphysis
and right
anterior acetabular fractures.
-------------
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 70607**]
IMPRESSION:
1. Small right frontal intraparenchymal hemorrhage consistent
with a
contusion.
2. Small amount of subarachnoid blood within the sulci and
cisterns and
right sylvian fissure.
---------------
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70608**]
IMPRESSION:
1. No evidence of cervical spine fracture.
2. Small apical left pneumothorax.
-----------------
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # [**Clip Number (Radiology) 70609**]
IMPRESSION:
1. Small left pneumothorax. Multiple left upper and lower lobe
patchy
opacities likely represent contusions. A more nodular opacity
in the left
upper lobe likely also represents a contusion, but follow up
study could be performed to ensure resolution.
2. Status post splenectomy with large amounts of intraabdominal
free air and small amounts of free fluid.
3. Left first, second and third rib fractures.
4. Right superior acetabular fracture and left superior and
inferior pubic rami fractures.
-------------------
CT SINUS/MANDIBLE/MAXILLOFACIA Clip # [**Clip Number (Radiology) 70610**]
IMPRESSION: No facial fracture is identified.
-------------------
CT PELVIS ORTHO W/O C Clip # [**Clip Number (Radiology) 70611**]
IMPRESSION: No appreciable change in right acetabular and left
superior and inferior pubic ramus fractures as compared to the
CT of [**2152-12-2**].
--------------------
Brief Hospital Course:
He was admitted to the Trauma service and was immediately taken
to the operating room following a positive FAST exam, for an
exploratory laparotomy and splenectomy.
Orthopedics was consulted given his multiple injuries; he was
taken to the operating room on [**12-2**] for evaluation under
anesthesia left knee, EUA left ankle, irrigation, debridement of
left open knee and closed treatment left ankle fracture.
Neurosurgery was consulted for his right frontal contusion,
intraparenchymal and subarachnoid hemorrhages; these injuries
were non operative. Repeat head imaging showed stable appearance
of the head bleed.
He did have pain control issues, PCA was initiated and was not
effective he was later changed to long acting narcotics with prn
Oxycodone for breakthrough pain. His pain has been under control
with this regimen.
He has had difficulty maintaining his non weight bearing status;
he was previously allowed to pivot transfer on his right lower
extremity. A CT scan of his pelvis was order by Orthopedics to
assess worsening of his pelvic fractures given his inability to
maintain non weight bearing. A slight change was noted;
possibility for surgical repair was discussed. He underwent
repeat CT scan several days later which was unchanged; he will
not require surgical intervention of these fractures at this
time; instead he will follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics,
in 1 week for repeat imaging studies. He is to remain strict non
weight bearing both lower extremities and may pivot transfer
only on his LLE.
Physical and Occupational therapy were consulted and have
recommended short term rehab stay.
Medications on Admission:
None
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for headache.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) dose
Subcutaneous Q12H (every 12 hours).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for insomnia, pruritus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Splenic rupture
right frontal intrparenchymal hemorrhage and subarachnoid
hemorrhage
Rib fractures, left 1.2.3
Small left pneumothorax
Right anterior acetabular fracture
Left superior/inferior pubic rami fracture
Left knee laceration
Left ankle fracture
Discharge Condition:
Good
Discharge Instructions:
DO NOT bear any weight on either of your lower extremities.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 1 week. Inform the
office that you will need a repeat CT of your pelvis for this
appointment; call [**Telephone/Fax (1) 1228**].
Follow up in Trauma clinic in 2 weeks, call [**Telephone/Fax (1) 6429**] for an
appointment.
Completed by:[**2152-12-20**]
|
[
"285.1",
"861.21",
"808.0",
"E912",
"865.02",
"934.1",
"780.96",
"808.2",
"860.0",
"891.0",
"844.1",
"851.01",
"824.0",
"807.03",
"E823.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.05",
"38.7",
"86.28",
"81.95",
"41.5",
"99.04",
"93.90",
"99.07",
"79.06",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6348, 6418
|
3361, 5014
|
309, 572
|
6740, 6747
|
1189, 3338
|
6855, 7176
|
956, 973
|
5069, 6325
|
6439, 6719
|
5040, 5046
|
6771, 6832
|
988, 1170
|
233, 271
|
600, 879
|
901, 909
|
925, 940
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,385
| 119,261
|
37206
|
Discharge summary
|
report
|
Admission Date: [**2141-2-15**] Discharge Date: [**2141-2-28**]
Date of Birth: [**2073-10-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info 83775**]
Major Surgical or Invasive Procedure:
[**2141-2-15**]: Cerebral Angiogram
[**2141-2-22**]: Cerebral Angiogram
History of Present Illness:
HPI: 67 year old man with the sudden onset of the worst headache
of his life this morning. Was bending over at work and had the
sudden onset of a [**11-12**] bifrontal headache approximately 7:40am.
No trauma. Had transient hearing difficulties, have since
resolved. Pain now [**3-15**] lying down. +photophobia, neck pain,
nausea. Denies visual changes, lightheadedness, dizziness,
weakness, numbness.
Past Medical History:
PMHx: CAD s/p MI 3 years ago, HTN, L3-4 disc, s/p b/l shoulder
surgery
Social History:
Social Hx: lives with wife, works as engineer. quit tob 15-20
years ago. denies EtOH/drugs.
Family History:
Family Hx: no hx of aneursyms
Physical Exam:
PHYSICAL EXAM:
O: T: 97.1 BP: 140/77 HR: 68 R: 18 O2Sats: 93%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs: full
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.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to
3mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial sensation intact and symmetric. Slight left droop
at corner of mouth.
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 [**6-7**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ -------->
Left 2+ -------->
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
ON DISCHARGE ++++++++++++++++++++++++++++++++
Pertinent Results:
[**2-15**] NCHCT IMPRESSION: Aneurysmal pattern of moderate
subarachnoid hemorrhage is
present, asymmetric to the left side, for which further
evaluation with CT
angiogram or catheter arteriography is recommended. There may be
early
hydrocephalus.
[**2-15**] CTA IMPRESSION:
1. Similar moderate volume of subarachnoid hemorrhage in a
pattern suggestive of aneurysmal rupture with intraventricular
hemorrhage and mild hydrocephalus.
2. Mild fullness of the anterior communicating artery without a
discrete
aneurysm. It should be noted that evaluation for aneurysm is
limited given
the extensive subarachnoid hemorrhage, which could obscure the
presence of a partially thrombosed aneurysm.
3. Fenestration of the left P1 segment and focal region of
apparent narrowing of the distal basilar artery, which may be
related to the adjacent subarachnoid hemorrhage, though would be
better evaluated on the arteriogram, which is to follow
[**2-16**] NCHCT IMPRESSION:
Diffuse subarachnoid hemorrhage centered in the basilar cisterns
with
intraventricular extension, with interval increase in the amount
of hemorrhage layering the posterior horns of the lateral
ventricles. Stable enlargement of the bilateral temporal horns
and third ventricle consistent with early
hydrocephalus.
[**2-19**] CTA BRAIN IMPRESSION:
IMPRESSION: Persistent diffuse subarachnoid hemorrhage; however,
less evident on this examination, compared to two days prior,
persistent intraventricular hemorrhage with blood layering in
the bilateral occipital ventricular horns.
The vascular images demonstrate irregular configuration of the
basilar artery with narrowing in the caliber compared to the
study dated [**2141-2-15**], likely representing basilar
vasospasm, followup is recommended.
No aneurysm larger than 2 mm in size is detected. Normal
appearance of the
perfusion maps.
[**2-20**] MRI C-SPINE
FINDINGS: The visualized elements of the craniocervical junction
demonstrate a possible anatomical variation consistent with os
odontoideum versus possible remote fracture at the odontoid
process, there is no evidence of narrowing of the foramen
magnum. The signal intensity throughout the cervical vertebral
bodies is heterogeneous, likely reflecting bone marrow
replacement for fat.
This study is partially limited due to motion artifact.
At C2/C3 level, there is mild bilateral uncinate process
hypertrophy, causing mild bilateral neural foraminal narrowing
(4:24), additionally there is mild bilateral articular joint
facet hypertrophy.
At C3/C4 level, there is disc desiccation, posterior central
disc protrusion, causing moderate-to-severe spinal canal
stenosis and bilateral neural foraminal narrowing. Additionally,
there is hypertrophy of the uncinate processes and moderate
articular joint facet hypertrophy (4:20). No frank evidence of
signal abnormality within the cervical spinal cord at this
level, however, this type of cervical stenosis predispose to
spinal cord injury with minor trauma.
At C4/C5 level, there is bilateral neural foraminal narrowing
related with
bilateral uncinate process hypertrophy and mild osteophytic disc
bulge complex formation, causing anterior thecal sac deformity,
there is also moderate articular joint facet hypertrophy (4:16).
At C5/C6 level, there is posterior osteophytic disc bulge
complex formation, causing anterior thecal sac deformity, there
is also bilateral uncinate process hypertrophy and moderate
articular joint facet hypertrophy resulting in severe bilateral
neural foraminal narrowing (4:12).
At C6/C7 level, there is disc desiccation, posterior osteophytic
disc bulge complex, causing anterior thecal sac deformity,
bilateral articular joint facet hypertrophy resulting in
bilateral neural foraminal narrowing (4:7).
C7/T1 appears unremarkable.
At T1/T2 level, there is mild posterior disc bulge, slightly
right greater
than left, no axial images were provided at this level.
The visualized paravertebral structures are grossly normal.
There is no
evidence of abnormal enhancement.
IMPRESSION: Multilevel disc degenerative changes throughout the
cervical
spine as described in detail above, more significant at C3/C4
level with
severe spinal canal stenosis and posterior central disc
protrusion, causing significant anterior thecal sac deformity
and bilateral neural foraminal narrowing. No frank evidence of
spinal cord signal abnormality, however, this is a limited study
due to motion artifact, the severity of the spinal canal
stenosis predispose to spinal cord injury with minor trauma.
There is no evidence of abnormal enhancement.
Brief Hospital Course:
67M admitted to ICU with non aneurysmal SAH. He had subsequent
scans showing no hydrocephalus. He had an angiogram on [**2-15**]
which showed no source of bleeding He developed severe
headaches for which pain service was consulted and Tobramax was
started with good relief. He had a CTA on [**2-19**] with questionable
basilar artery vasospasm for which he was monitored closely. His
exam remained nonfocal. On [**2-22**] A angiogram showed mid-basilar
mild-to-moderate degree of vasospasm treated with intra-arterial
5 mg of verapamil. Hypertensive therapy was started with a goal
BP of 180. He had period of low sodiums which required
hypertonic saline and salt tabs. On discharge his Na was 134. He
had a repeat CTA on [**2-25**] which showed no sign of vasospasm. He
was transferred to the surgical floor on [**2-27**]. He was tolerating
a regular diet,voiding without difficulty he worked with PT who
felt he was safe to go home. On discharge he had a nonfocal
exam.
Medications on Admission:
Lisinopril, Tamsulosin, Rosuvastatin
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 7 days.
Disp:*84 Capsule(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while on pain medication.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
8. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*60 Tablet(s)* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take while on dilaudid.
Disp:*60 Capsule(s)* Refills:*2*
10. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four
(4) hours for 1 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
NON ANEURYSMAL SUBARACHNOID HEMORRHAGE
SEVERE CERVICAL STENOSIS
CEREBRAL VASOSPASM
HYPONATREMIA
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
- Increase salt intake in your diet for the next week, your
sodium levels have been slightly low. This is part of your brain
hemorrhage it will self resolve. Have your primary care check a
NA level in one week.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
CALL DR. [**First Name (STitle) **] AT [**Telephone/Fax (1) **] FOR AN APPOINTMENT TO BE SEEN IN
1 Month with CTA of the brain;
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN REGARDING YOUR
CERVICAL SPINAL STENOSIS WE HAVE PROVIDED YOU A CD. We recommend
you follow up a neurosurgeon in 1 month closer to home or if you
like we would be happy to see you for this issue.
Completed by:[**2141-2-28**]
|
[
"786.50",
"430",
"401.9",
"412",
"437.0",
"784.0",
"276.1",
"435.8",
"723.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.41",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9135, 9141
|
7068, 8043
|
348, 422
|
9281, 9281
|
2452, 7045
|
11480, 11884
|
1076, 1108
|
8130, 9112
|
9162, 9260
|
8069, 8107
|
9426, 10538
|
10564, 11457
|
1138, 1372
|
278, 310
|
450, 855
|
1624, 2433
|
9295, 9402
|
877, 950
|
966, 1060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,556
| 199,466
|
8106
|
Discharge summary
|
report
|
Admission Date: [**2155-2-22**] Discharge Date: [**2155-3-6**]
Date of Birth: [**2074-11-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
Temporary hemodialysis line placement [**2155-2-25**]
Blood Transfusion
Removal of Dialysis Line
Removal of Portacath
Hemodialysis
History of Present Illness:
80 year-old man with multiple myeloma was recently hospitalized
at the [**Hospital1 18**] for a fall while on narcotics. Discharged home on
[**2155-2-13**]. Pt was on oxycontin and oxycodone, but started Fentanyl
patch 50mcg on [**2155-2-19**] at home. 4 hours later his wife found
him unresponsive. He had been also taking his his long and short
acting oxycontin/oxycodone. EMS found him to be 68% on room air.
Narcan given and he awoke immediately. He was taken to an OSH
where he was found to have elevated troponins. ASA, Plavix, and
IV heparin were started (pt already on coumadin for afib). He
subsequently developed UGIB with 10-pt drop in HCT. S/p EGD
that found [**Known lastname **] bleeding ulcer that was injected. The patient
had received vitamin K, 2 units of FFP, and 1 unit of blood
during his stay. He was on a PPI and octreotide drip. He was
considered to be high risk per surgery at OSH and they had
suggested embolization if he rebleeds. The patient was
transferred from the OSH ICU to the [**Hospital1 18**] ICU to have access to
embolization services if needed.
Past Medical History:
MULTIPLE MYELOMA TREATMENT HISTORY:
# Multiple Myeloma: on treatment with Revlimid
Initially presented with T12 compression fracture, ARF,
hypercalcemia and SMV thrombosis in [**2143**]. During this evaluation
he was diagnosed with MM. Treated with 6 cycles of VAD then on
Thalidomide in [**12-13**]. He received monthly Pamidronate from the
time of diagnosis to [**8-/2147**] when he was switched to Zometa. He
continued thalidomide until [**10/2148**] when it was stopped due to
debilitating symptoms of ataxia and peripheral neuropathy. He
continued monthly Zometa until [**12/2150**], when he was switched to
every other month. In [**4-/2151**], the Zometa was stopped for
concern of right lower jaw osteonecrosis. Mr. [**Known lastname 4460**] was off all
therapy for his myeloma since that time. Bone marrow biopsy done
on [**2152-10-30**] showed a marrow cellularity of 28-30%,
interstitial infiltrate of plasma cells occurring singly and in
clusters. By CD138 immunohistochemical staining, plasma cells
were 5-10% of marrow cellularity. Kappa restricted. He started a
Decadron burst on [**2152-11-15**]. After this first cycle of Decadron
he developed an infection in his mouth and lower extremity
weakness so he did not start his second cycle until [**12-20**]. He
started cycle 1 Velcade on [**2153-1-30**]. He had radiation to the
T11-L3 spine given 300 x 8 fractions for a total of 2400 cGy
from [**2-14**] to [**2153-2-23**]. He started cycle 2 Velcade on
[**2153-3-6**] - he received 2 doses but the rest was held due to
shortness of breath and weakness. He started cycle 3 on [**2153-4-17**].
This course was complicated by a hospitalization for EColi
sepsis with unclear source. EMG showed diffuse complicated
neuropathy. The Bence [**Doctor Last Name **] Proteins in his urine were
negligible since he received his last cycle of Velcade until
[**7-21**] when they again begain to rise. His FLR also began to rise
at that time. As his UPEP began to double and FLR rose, the
decision was made to start him on Revlimid. He started Revlimid
5 mg weekly x 1 wk, 10 mg weekly x 1 wk, 15 mg weekly x 1wk for
21/28 days in [**11-20**].
OTHER PAST MEDICAL HISTORY:
# T12-L2 vertebral compression fractures
# Hyperlipidemia
# Chronic kidney disease stage 3, recent baseline Cr 1.3
# Peripheral neuropathy
# Paroxysmal atrial fibrillation
# Osteonecrosis of the jaw
# Melanoma of left thigh s/p resection and LN dissection at age
28
# H/o superior mesenteric vein thrombosis and possible [**Known lastname **]
vessel arterial disease, s/p colostomy [**2143**]
Social History:
Married, non-smoker, no alcohol, retired. Previously worked as a
printer and a chicken farmer
Family History:
Brother died of a metastatic poorly differentiated
neuroendocrine tumor of unknown primary in his 60s. Mother died
of an MI at age 62. Father died of unknown causes at age [**Age over 90 **].
Physical Exam:
On admission
Vitals: T:96.0 BP:111/81 P:64 R:18 O2:95ra
General: pleasant, conversant, alert. Oriented only to person
and place
HEENT: clera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular, normal S1 /S2, sys murmur LSB/APEX, NO RUB
Abdomen: soft, NON-TENDER, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Induration with overlying non-blanching erythems on R
fore-arm c/w with phlebitis vs early cellulitis.
.
On discharge
Vitals - T: 97.1 BP: 139/95 (117/72-140/73) HR: 58 (40's-120's)
RR: 20 02 sat: 94 on RA
GENERAL: NAD, answers appropriately
HEENT: MMM
CARDIAC: bradycardic, regular
LUNG: CTAB, right chest stitches with [**Known lastname **] amount of erythema
surrounding them- no drainage
ABDOMEN: soft, +BS, NT, colostomy on right side.
EXT: Warm, 1+ DP/PT pulses, trace LE edema (L>R)
NEURO: A&Ox3
Pertinent Results:
LABS:
[**2155-2-22**]
WBC-6.4 Hct-25.1 Plt Ct-247: Neuts-71.1 Lymphs-22.4 Monos-5.7
Eos-0.4
PT-25.3* PTT-30.4 INR(PT)-2.4*
ALT-22 AST-45* LD(LDH)-266* CK(CPK)-187 AlkPhos-104 TotBili-0.3
[**2155-2-27**] 07:29AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2155-3-4**] 07:30AM BLOOD PT-12.8 PTT-25.7 INR(PT)-1.1
[**2155-3-6**] 06:55AM BLOOD WBC-6.2 Hct-31.0 Plt Ct-214
BUN: 82 ([**2-22**]) -> -> -> 117 ([**2-25**]) -> -> 39 ([**3-7**])
Creatinine: 4.7 ([**2-22**]) -> -> -> 8.0 ([**2-25**]) -> -> 3.8 ([**3-7**])
MICRO:
BCx positive [**2-25**]:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
MICROCOCCUS/STOMATOCOCCUS SPECIES.
VIRIDANS STREPTOCOCCI.
VIRIDANS STREPTOCOCCI. SECOND MORPOLOGY.
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| VIRIDANS STREPTOCOCCI
| | VIRIDANS
STREPTOCOCCI
| | |
CLINDAMYCIN----------- =>8 R S =>2 R
ERYTHROMYCIN---------- =>8 R <=0.25 S =>4 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- <=0.06 S <=0.06 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S <=1 S <=1 S
All repeat surveillance cultures negative.
Urine culture neg x 2, and line tip cultures neg.
IMAGING:
CXR [**2155-2-22**]: IMPRESSION: No acute cardiopulmonary disease.
RUE U/S [**2155-2-23**]: IMPRESSION: No evidence of deep vein
thrombosis.
ECHO [**3-4**]: No evidence of endocarditis
Brief Hospital Course:
Mr. [**Known lastname 4460**] is an 80 year-old man with multiple myeloma who
presented to [**Hospital1 18**] with ARF [**1-14**] ATN from UGIB related
hypotension vs myeloma related nephropathy. He progressed to
having uremic encephalopathy, so temporary HD line placed on
[**2155-2-25**] and hemodialysis initiated on [**2155-2-25**]. Course also
complicated by bacteremia requiring removal of central access
and initiation of Vancomycin for 2 wk course.
# Acute renal failure on stage 3 CKD secondary to multiple
myeloma: Mr. [**Known lastname 4460**] had chronic kideny disease secondary to his
multiple myeloma. He developed acute renal failure in the
setting of hypoperfusion during his NSTEMI and GI bleed vs
light-chain cast nephropathy. His renal function deteriorated
and pt became uremic with BUN >110. A temporary dialysis line
was placed on [**2-25**] and he subsequently underwent two sessions of
hemodialysis. His mental status improved to baseline and his
renal function slowly improved. Therefore, his dialysis was not
continued.
# Bacteremia: Pt remained afebrile without leukocytosis
throughout admission but given concerning fluid from portacath,
blood cultures were drawn and grew coag negative staph and 2
strains of strep viridans on [**2-25**]. Pt's portacath and recently
placed HD line were removed for line holiday while on Vancomycin
treatment. Luckily pt did not require reinitiation of dialysis
and was able to have PICC line placed for continued Vancomcyin.
Repeat blood cultures were all negative as were line tip
cultures. ECHO ruled out endocarditis and pt should complete a
14 day course of Vancomycin, last day [**3-12**]. Given slowly
improving renal function and good urine output, daily vancomycin
troughs were checked and doses given accordingly ranging from
500mg daily to every other day.
# Multiple Myeloma with T12-L2 vertebral compression fractures:
His pain medications were gradually tapered. He was intially
given Oxycontin 10mg [**Hospital1 **] and Oxycodone 5mg prn. He was noted to
be somewhat sleepy with these doses. The Oxycontin was
eventually stopped. He was discharged with oxycodone prn and
lidocaine patches. Long term treatment plan to be determined by
outpt oncologist based on recovery from renal failure.
# Upper GI Bleed: Pt developed GI bleed in setting aspirin,
plavix and heparin initiated for NSTEMI treatment. He underwent
an EGD at OSH with [**Known lastname **] bleeding ulcer injected (biopsies not
taken). In the ICU at [**Hospital1 18**], he received 2 units of PRBC and 2
units FFP. His HCT rose from 25->29. A PPI gtt was switched to
PO BID. He tolerated an advanced diet. His HCT was stable for
the remainder of the hospitalization. Aspirin and
anticoagulation was not restarted.
# NSTEMI: Mr. [**Known lastname 4460**] had an NSTEMI at an OSH in the absence of
chest pain. Troponin I only mildly elevated and also in the
setting of ARF. The troponin elevation is likely from demand
ischemia related to hypoxemia/hypercarbic respiratory failure in
addition to a probable stress response with narcan use and his
rebound pain and agitation. ASA, Plavix, and heparin were
stopped for GIB.
# Paroxysmal atrial fibrillation: Patient was going in and out
of afib with ventricular rates in the 130s. He was not on rate
control agents at home. Administration of 500cc IVF and
Metoprolol 25mg helped rhythm return to sinus. Metoprolol 12.5
mg PO BID started and uptitrated to TID. Anticoagulation was
held while concern was for bleeding (s/p reversal of INR with
FFP at OSH as per HPI). Pt's baseline is NSR in 70s but would
often be temporarily bradycardic to 40s-50s after breaking out
of afib. Pt was asymptomatic while both tachycardic and
bradycardic and after discussion with pt's cardiologist, it was
decided that there is no indication for pacemaker and low dose
metoprolol TID is the appropriate treatment. There is no need to
monitor on telemetry or treat tachy or bradycardias unless pt
symptomatic.
Medications on Admission:
Multivitamin PO Daily
Oxycontin 20 mg po BID
Percocet 5-325 mg [**12-14**] po Q3 hrs (had been using 12 per day)
Fentanyl patch 50mcg
Coumadin 5mg po Daily
Revlamid per Oncology
Discharge Medications:
1. Vancomycin 500 mg Recon Soln Sig: [**Telephone/Fax (1) 1999**] mg Intravenous
daily to every other day as needed for vancomycin trough 15-20
for 6 days.
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Three (3) Adhesive Patch, Medicated Topical daily to back: 12
hrs on, 12 hrs off.
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Renal Failure
Upper GI bleed
Atrial Fibrillation
Bacteremia
Secondary:
Multiple Myeloma
Discharge Condition:
A+Ox3
Ambulating with assistance
Discharge Instructions:
You were admitted to [**Hospital1 18**] from another hosptial and had quite a
complicated hospital course.
It seems that everything started with some narcotic pain
medications causing oversedation. You were found unresponsive at
home and taken to the ER where it was found that you had
significant strain on your heart. To treat your heart you were
started on several medications that thin you blood and in this
setting you started bleeding from an ulcer in your stomach. You
had an endoscopy to visualize the bleeding vessel and had the
area cauderized which stopped the bleeding. You were transferred
to [**Hospital1 18**] at this point. You were briefly monitored in the ICU
without any furthur signs of bleeding. However due to poor
perfusion of your kidneys (due to the GI bleed, low blood
pressure from the narcotic pain medications) you developed
worsening kidney function and failure. Because the kidneys were
not clearing toxins and this was leading to confusion, you had
an emergency IV placed and were initiated on hemodialysis, of
which you had 2 sessions. Meanwhile it was noted that your
chemotherapy port that you have had for years appeared infected
and you were shown to have bacteria in your blood stream.
Because of this infection it was necessary to remove both your
port and your new dialysis line which may have been harboring
bacteria. You were started on antibiotics and responded very
well, with all furthur blood cultures negative. Luckily your
kidney function was slowly improving, which allowed us to avoid
additional dialysis at the time.
Because the antibiotics are cleared through the kidneys and your
kidney function was changing daily, it was necessary to measure
the level of your antibiotics daily to determine appropriate
dosing. You will need to continue antibiotics for 2wks total,
ending on [**3-12**]. You will need frequent monitoring of drug
levels as your kidney function improves as high levels can be
toxic and low levels are not effective.
We made the following changes to your medications:
1) STOP: Oxycontin
2) STOP: Revlamid
3) STOP: Coumadin
4) STOP: Percocet
5) START: Oxycodone 5mg every 6 hours as needed for new pain
control
6) START: 3 Lidocaine patches to the back daily, 12 hrs on 12
hrs off for additional pain control
7) START: Pantoprazole 40mg twice daily to decrease risk of
bleeding
8) START: Atorvastatin 20mg daily for heart disease prevention
9) START: Metoprolol 12mg three times daily to prevent very fast
heart rates with atrial fibrillation
10) START: Vancomycin varying doses based on trough (currently
getting 500mg every day to every other day)
Followup Instructions:
Please follow up with:
1) DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 13016**], please call to schedule a
follow up appointment within 1-2 weeks
2) DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**Last Name (LF) 766**], [**5-5**] at 4:40pm. [**Telephone/Fax (1) 62**]
These providers will determine if you also need to be seen by a
kidney specialist and a gastroenterologist.
Completed by:[**2155-3-6**]
|
[
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"V44.3",
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"V10.82",
"276.7",
"041.19",
"427.31",
"531.40",
"V58.61",
"041.09",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.95",
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"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11998, 12064
|
7100, 11091
|
286, 418
|
12205, 12239
|
5530, 7077
|
14909, 15389
|
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|
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|
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|
12263, 14274
|
4468, 5511
|
14303, 14886
|
232, 248
|
446, 1537
|
3739, 4133
|
4149, 4244
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,043
| 198,451
|
1718
|
Discharge summary
|
report
|
Admission Date: [**2160-4-22**] Discharge Date: [**2160-5-1**]
Date of Birth: [**2091-4-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
You had a PICC line placed for IV Milrinone
RHC w/ milrinone challenge
History of Present Illness:
69M DMII recent [**Hospital1 1516**] admit for severe R-sided CHF c/b ascites
requiring therapeutic paracentesis admitting to MICU for
hypotension and dyspnea. Fine yesterday but this AM felt unwell,
had diarrhea x 6, chills but no fevers, retching. No appetite
since yesterday. Originally no trouble breathing, CP, back pain,
dysuria. Noticed increasing abdominal girth, weight labile, now
having SOB. Baseline BPs appear to be 110-140s/70-80s.
.
In the ED inital vitals were, 98.2 56 90/45 16 100%/RA. LIJ was
placed for access and eventual CVP monitoring. Cardiology
consulted and recommended [**Hospital Unit Name **] admission but bed was changed to
ICU level given hyponatremia and hypotension. CVL was placed.
Received 1.5L IVF per resident (RN note document 400cc only). No
abx. Most Recent Vitals: 97.9,65 paced rhythm,16,99/42,100% r.a.
0 c/o pain. Labs notable for lactate 1.0, wbc 5.4, Na 117, Creat
4.4, BUN 130, AG 11, Ca 8.2, UA wnl, BNP 2500 and trop 0.06.
Urine lytes showed Na<10. Random cortisol level 20 and TSH 2.5.
.
On arrival to the ICU, pt c/o dyspnea on exertion and diarrhea 3
days ago. Wife reports that patient was confused today and
experience diarrhea (approx 6 episodes since this AM). No sick
contacts. Also nauseated wo vomiting. Pt has been gaining weight
after torsemide dose decreased for hypotension (incr'd 7lb up
from baseline 120lb) and abdominal distension over 3 days with
rapid loss of 4lb today after taking full dose of torsemide. No
dietary changes or med changes since discharge. Has chills
without fever. Wife also measures BP daily and notes hypotension
70/40s for the past 3 days (baseline 120-140s). He denies SOB at
rest, chest pain, cough, or abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
vomiting, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. Ischemic cardiomyopathy with LVEF at 15% to 20% at its
worst,
was started on milrinone in [**2151**] for at least seven years, has
been weaned off this infusion for a couple of years.
2. CAD, status post CABG with percutaneous coronary
intervention.
3. Diabetes.
4. Nephropathy related to diabetes.
5. Anemia of chronic disease.
6. Lichen simplex chronicus.
7. Left subclavian vein occlusion.
8. Hernia repair.
9. Left-sided pleurodesis with past Pleurx catheter placed in
[**2157**].
10. Recent pancreatitis with a laparoscopic cholecystectomy and
ERCP.
11. Gout.
12. Severe tricuspid regurg
13. Severe pulmHTN
Social History:
Lives with wife and daughters. [**Name (NI) **] five children and two
grandchildren. Born in [**Country 9819**] - has lived in USA for 15
years. Previous leather goods importer/exporter. Never smoked
cigs, drank ETOH or used recreational drugs.
Family History:
Several first degree family members with positive
PPD. Brother had MI at 48. Mother had DM, CHF and MI at unknown
age.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.7 BP: 110/54 P: 70 R: 21 O2:100/RA
General: Alert, oriented thin Pakistani male in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar rales and occasional wheezes
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
best over LLSB, no rubs or gallops
Abdomen: soft, non-tender, distended and tympanic with fluid
wave, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no stigmata of end stage liver disease
D/C:
Vitals - Tm/Tc:98.0 HR:82-88 BP: 81-96/48-51 RR:18-24 02 sat:
98-100% RA
In/Out:
Last 24H: 1240/1900
Last 8H: [**Telephone/Fax (1) 9826**]
Weight: 55.9
Tele: v paced
FS: 183
GENERAL: 69 yo M in no acute distress, sitting in bed.
HEENT: mucous membs moist, JVP still elevated at 20 cm
CHEST: Crackles left base
CV: S1 S2 Normal in quality and intensity RRR, [**3-17**] holosystolic
murmur at the RUSB
ABD: soft, non-tender, moderately distended. BS normoactive. no
rebound/guarding.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: 4/5 strength in U/L extremities.
SKIN: no rash
PSYCH: alert, oriented.
Pertinent Results:
Lab results on Admission:
[**2160-4-22**] 05:00PM BLOOD WBC-5.4 RBC-3.20* Hgb-9.9* Hct-28.2*
MCV-88 MCH-31.0 MCHC-35.2* RDW-15.4 Plt Ct-175
[**2160-4-22**] 05:00PM BLOOD Neuts-79.6* Lymphs-7.9* Monos-8.6 Eos-3.6
Baso-0.3
[**2160-4-22**] 05:00PM BLOOD PT-11.1 PTT-37.0* INR(PT)-1.0
[**2160-4-22**] 05:00PM BLOOD Glucose-134* UreaN-130* Creat-4.4*#
Na-117* K-4.7 Cl-84* HCO3-22 AnGap-16
[**2160-4-22**] 05:00PM BLOOD ALT-7 AST-7 CK(CPK)-32* AlkPhos-107
TotBili-0.8
[**2160-4-22**] 05:00PM BLOOD CK-MB-4 proBNP-2547*
[**2160-4-22**] 05:00PM BLOOD cTropnT-0.06*
[**2160-4-22**] 05:00PM BLOOD TotProt-5.2* Albumin-2.9* Globuln-2.3
Calcium-8.2* Phos-7.5*# Mg-2.4 UricAcd-8.1* Cholest-136
[**2160-4-22**] 05:00PM BLOOD Triglyc-107 HDL-43 CHOL/HD-3.2 LDLcalc-72
[**2160-4-22**] 05:00PM BLOOD Osmolal-295
[**2160-4-22**] 05:00PM BLOOD TSH-2.5
[**2160-4-22**] 05:00PM BLOOD Cortsol-20.0
[**2160-4-22**] 05:00PM BLOOD Digoxin-1.2
[**2160-4-22**] 05:16PM BLOOD Lactate-1.0
[**2160-4-23**] 02:24AM BLOOD Lactate-0.8
[**2160-4-22**] 05:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2160-4-22**] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2160-4-22**] 07:55PM URINE Hours-RANDOM UreaN-398 Creat-56 Na-LESS
THAN K-40 Cl-LESS THAN Uric Ac-3.9
[**2160-4-22**] 07:55PM URINE Osmolal-234
Studies:
Abd U/S [**4-23**]:
1. Small cirrhotic liver consistent with cirrhosis. The portal
vein is
patent.
2. Moderate-to-large amount of ascites throughout the abdomen
and pelvis.
3. No evidence for hydronephrosis.
TTE [**4-25**]:
Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to akinesis of the
interventricular septum and hypoikinesis of the inferior and
posterior walls. The right ventricular free wall thickness is
normal. The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior study (off milrinone)
(images reviewed) of [**2160-4-16**], left ventricular ejection
fraction is increased, the tricuspid regurgitation is decreased
(was frankly severe on prior study), and ventricular chamber
dimensions are decreased.
Labs on dc:
[**2160-5-1**] 05:54AM BLOOD WBC-4.2 RBC-2.74* Hgb-8.5* Hct-26.4*
MCV-96 MCH-31.0 MCHC-32.2 RDW-16.1* Plt Ct-253
[**2160-5-1**] 05:54AM BLOOD Glucose-141* UreaN-55* Creat-1.6* Na-134
K-4.4 Cl-100 HCO3-26 AnGap-12
[**2160-5-1**] 05:54AM BLOOD Mg-1.8
Brief Hospital Course:
Assessment and Plan: 68yoM with h/o CHF EF 25% 2/2 iCMP,
recurrent ascites and possible cirrhosis, severe tricuspid
regurg, pulm HTN, DM2, gallstone pancreatitis, presenting with
c/o SOB.
# Chronic systolic CHF, EF 25%: Patient with significant cardiac
history, and has an ICD in place. Patient did not appear volume
overloaded on exam on admission, and given his hypotension, his
diuretics and antihypertensives were held initially. Digoxin
level was wnl, which was however dc/ed. He was on milrinone a
few years back which was dc/ed as he was doing well. However, pt
now again required milrinone so underwent RHC w/ milrinone
challenge in CCU. The results of the RHC found a favorable
repsonse and he was dc/ed on milrinone with a PICC placed via
IR.
Pre-Milrinone:
RA ~25 mmHg
PA: 60/28 (39)
PCWP: ~24 mMHg with v-waves to 45 mmHg
MvO2: 69%
SaO2: 99%
CI/CO: 3.2/5.4 L/min
PVR: 222 dyn-cm/sec5
Post Milrinone initiation:
Bolus of 50 mcg/kg/min over 10 min, followed by an infusion of
0.25 mcg/kg/min x 15 minutes
RA: ~10 mmHg
PA: 60/2 (33)
PCWP: ~ 15 mmHg with v-waves to 40 mmHg
MvO2: 75%
SaO2: 99%
CI/CO: 3.9/6.7 L/min
PVR: 215 dyn-cm/sec5
# ARF/uremia: Patient presented with creatinine of 4.4, up from
baseline of ~1.6 during last hospitalization. Differential
includes ATN, HRS, post-obstructive physiology. Pt voided 300 cc
immediately after foley placement. Negative urine protein,
Na<10, and acute insuffiency concerning for hepatorenal syndrome
despite unconfirmed cirrhosis dx. FeUrea 24% less suggestive of
ATN, though history of increased diuretics at home and
hypovolemia can lead to hypovolemia/prerenal azotemia and ATN.
Large volume urine output suggests more post-obstructive
etiology. However, pt's output increased after milrinone and was
dc.ed on po torsemide. Patient had infectious work up with blood
and urine culture which showed enterococci for which he was
started on augmentin.
# Hyponatremia: Patient presented with Na of 117, baseline Na
~135. Possible pseudo-hyponatremia [**3-13**] severe uremia (corrected
Sosm 287) vs hypovolemic hyponatremia. Random cortisol wnl.
Urine sodium suggest sodium avid state and clinically
hypovolemic. His sodium corrected with fluid resuscitation from
ED and with holding his diuretics. His lytes were monitored.
# Pulmonary HTN: Mean PA pressure and PVR elevated on last right
heart cath, raising concern for portopulmonary HTN vs. pulmonary
HTN from left sided heart failure. He was started on sildenafil
after recent R heart cath on prior hospitalization and was
continued on it. However, sildenafil was dc/ed after starting
milrinone.
# Encephalopathy/Altered mental status: Concern for uremic vs
hepatic encephalopathy vs hyponatremia. No evidence of
asterixis. His mental status improved with improvement in uremia
and hyponatremia.
# Cirrhosis/ascites: New dx [**3-/2160**] with evidence of
cirrhosis/nodular liver based on RUQ u/s (no biopsy). No family
hx of liver disease or jaundice. Previous hepatitis serologies
negative. Liver eval in clinic suggested other possible
etiologies including congestive hepatopathy, myxedema, or
cirrhotic cardiomyopathy. Most recent large volume therapeutic
para [**4-16**]. His LFTs and coags were monitored and repeat RUQ
ultrasound was obtained, which showed cirrhotic liver.
# CAD: CABG [**2135**] (LIMA -> diagonal, SVG -> LCx known totally
occluded, SVG -> RCA known totally occluded, and SVG -> LAD with
PTCA/stent [**2148**]). His plavix and ASA had been held on [**2160-3-27**]
for paracentesis, with ASA only restarted during that
hospitalization.
# Diabetes: His home oral hypoglycemics were held and he was
covered with sliding scale insulin in house.
# HTN: His home lisinopril was initially held for hypotension
but then restarted. He was also started on toprol 25.
# Gout: Not active. His allopurinol was held initally for [**Last Name (un) **].
# Communication: Patient, Wife [**Name (NI) 9827**] [**Name (NI) 9818**] [**Telephone/Fax (1) 9828**]
# Code: Full confirmed discussed with patient
Transitional issues: consider urology follow-up given UTI;
follow up arranged with Dr [**First Name (STitle) 437**] for continued workup. We
advised the pt to STOP his Sildenafil, Carvedilol and Digoxin,
start milrinone and toprol and continue augmentin for UTI for 2
more days to complete course.
Medications on Admission:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*6*
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
Discharge Medications:
1. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Multi-Day Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Milrinone 0.25 mcg/kg/min IV INFUSION
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours).
Disp:*4 Tablet(s)* Refills:*0*
10. 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.
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Heart failure
Chronic kidney disease
Diabetes
Cornary artery disease
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you during your hospitalization at
[**Hospital1 69**].
You were admitted to the hospital with fluid overload, we have
adjusted your medications, your breathing is better now and you
will need to go home on Milrinone.
Medication Changes:
STOP your Sildenafil
STOP your Carvedilol
STOP your Digoxin
ADD Milrinone 0.25 mcg/kg/min continuous infusion
ADD Augmentin (antibiotic) for 2 more days (for urine infection)
ADD Toprol 25mg daily
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 days or 5 lbs in
3 days. Follow a low salt diet, restrict your fluids to
1500ml/day or about 6 cups.
If you become short of breath, notice swelling in your feet or
ankles, have worsening swelling in your abdomen, develop fevers
or chills then call Dr. [**First Name (STitle) 437**].
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2160-5-5**] at 10:30 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2160-6-19**] at 9:50 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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[
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,317
| 168,434
|
29110
|
Discharge summary
|
report
|
Admission Date: [**2174-11-2**] Discharge Date: [**2174-11-5**]
Date of Birth: [**2100-9-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
R IJ Central line placement
Arterial line placement
History of Present Illness:
Ms. [**Known lastname **] is a 74 yo female with PMH significant for atrial
fibrillation, hypertension, and CRI. According to her son, her
health care proxy, she became acutely short of breath around 9pm
after dinner. She called her son who felt that she was wheezing
over the phone. During the course of the day she felt well with
SBP~90's. Her SBP increased to the 120's during this episode.
She was otherwise asymptomatic: no chest pain, nausea, vomiting,
diaphoresis, LE edema, PND, or orthopnea. The patient was
brought to [**Hospital1 18**] ED via ambulance and had received Nitro SL X 2
and ASA 325mg.
In the ED, initial vitals were T 100.6 BP 214/99 AR 76 RR 36 O2
sat 88% NRB. Cxray suggested pulmonary edema. She was then
placed on CPAP with no improvement in her oxygen saturations and
was then intubated in the ED. EKG showed sinus bradycardia, LVH,
and 1st degree AV block. The patient was started on a nitro gtt
for elevated blood pressures but became hypotensive and was
started on a Dopamine gtt. CVP between [**9-29**]. She was then
transferred to the CCU for closer monitoring.
Patient was also given one dose of Vancomycin, Ceftriaxone,
Azithromycin, and Clindamycin for possible pneumonia given her
low grade fever and mildly elevated WBC. She was also given ASA
600mg and multiple Versed boluses.
Per the patient's son, she has otherwise been feeling well. He
states that she had heart failure symptoms 2-3 years ago and was
placed on Lasix for a brief period of time, which had to be
stopped given worsening renal function. In regards to her afib,
she normally has a HR~50's but when she is in afib her rate
increases to 70's. No recent fevers, chills, or sputum
production. She was found to be in atrial fibrillation over the
weekend and was started on Amiodarone 400 TID and converted into
sinus rhythm. Patient is currently being treated with Penicillin
for UTI.
Past Medical History:
1)Atrial fibrillation: Diagnosed 3 years ago, cardioverted,
placed on Amiodarone for 1 year and then d/c'ed; cardioverted in
[**7-24**] to NSR, restarted on Amio [**10-24**] when she was found to be in
afib.
2)Hypertension
3)Chronic renal insufficiency, baseline Cr 2.1-2.4
4)Glucose intolerance
5)Hypothyroidism
6)Urosepsis
7)Colon cancer s/p total colectomy 4-5 years ago
Social History:
Lives with husband, independent in regards to [**Name (NI) 5669**]. No history
of alcohol or tobacco use.
Family History:
NC
Physical Exam:
Ventilation settings: AC FIO2 1.0 TV 400 RR 16 PEEP 5
vitals T 96.8 BP 91/48 AR 54 RR 13
Gen:Pt sedated, not responsive to commands/voice
HEENT:ETT in placed
Heart:nl s1/s2, no s3/s4, no m,r,g
Lungs:Course breath sounds, diffuse wheezes
Abdomen:soft, NT/ND, +BS, no hepatomegaly
Extremities:no edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
Laboratory results:
[**2174-11-1**] 11:00PM BLOOD WBC-11.4* RBC-3.72* Hgb-10.9* Hct-31.5*
MCV-85 MCH-29.2 MCHC-34.5 RDW-14.0 Plt Ct-204
[**2174-11-3**] 04:15AM BLOOD WBC-7.5 RBC-3.59* Hgb-10.5* Hct-29.8*
MCV-83 MCH-29.3 MCHC-35.3* RDW-14.3 Plt Ct-174
[**2174-11-5**] 06:30AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.4* Hct-29.7*
MCV-84 MCH-29.4 MCHC-35.1* RDW-14.1 Plt Ct-189
[**2174-11-1**] 11:00PM BLOOD Neuts-77.0* Lymphs-18.5 Monos-2.2 Eos-2.1
Baso-0.3
[**2174-11-1**] 11:00PM BLOOD Glucose-209* UreaN-41* Creat-2.6* Na-139
K-3.8 Cl-106 HCO3-23 AnGap-14
[**2174-11-3**] 04:15AM BLOOD Glucose-122* UreaN-28* Creat-2.1* Na-138
K-3.6 Cl-105 HCO3-24 AnGap-13
[**2174-11-5**] 06:30AM BLOOD Glucose-97 UreaN-35* Creat-2.0* Na-143
K-3.2* Cl-106 HCO3-28 AnGap-12
[**2174-11-1**] 11:00PM BLOOD PT-27.2* PTT-34.3 INR(PT)-2.8*
[**2174-11-3**] 04:15AM BLOOD PT-31.5* PTT-42.7* INR(PT)-3.4*
[**2174-11-4**] 05:30AM BLOOD PT-27.5* PTT-56.9* INR(PT)-2.8*
[**2174-11-5**] 06:30AM BLOOD PT-23.8* PTT-59.9* INR(PT)-2.4*
[**2174-11-1**] 11:00PM BLOOD ALT-19 AST-23 CK(CPK)-181* AlkPhos-66
Amylase-43 TotBili-0.3
[**2174-11-2**] 05:30PM BLOOD CK(CPK)-271*
[**2174-11-1**] 11:00PM BLOOD cTropnT-0.03*
[**2174-11-2**] 06:43AM BLOOD CK-MB-7 cTropnT-0.03*
[**2174-11-2**] 05:30PM BLOOD CK-MB-4 cTropnT-0.03*
[**2174-11-1**] 11:00PM BLOOD Albumin-3.1* Calcium-6.8* Phos-5.1*
Mg-2.0
[**2174-11-3**] 04:15AM BLOOD Calcium-8.6 Phos-1.6*# Mg-2.1
[**2174-11-5**] 06:30AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1
[**2174-11-2**] 06:43AM BLOOD calTIBC-282 VitB12-1056* Folate-GREATER
TH Ferritn-48 TRF-217
[**2174-11-2**] 04:25AM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE
[**2174-11-2**] 06:43AM BLOOD Triglyc-123 HDL-56 CHOL/HD-2.5 LDLcalc-58
[**2174-11-2**] 06:43AM BLOOD TSH-2.4
[**2174-11-2**] 03:51PM BLOOD Cortsol-24.7*
[**2174-11-2**] 06:51AM BLOOD freeCa-1.07*
[**2174-11-2**] 09:02AM BLOOD freeCa-1.00*
Relevant Imaging:
1)Cxray ([**11-1**]): Probable asymmetric pulmonary edema, right
worse than left.
2)Cxray ([**11-1**]): No evidence of pneumothorax, interval
improvement in pulmonary edema.
3)ECHO ([**11-2**]): 1. The left atrium is markedly dilated. 2.There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic
(EF>75%). The apex is not well seen and may be particularly
hypertrophied, consistent with a possible apical septal
hypertrophy. 3.The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. 4.The mitral valve leaflets are structurally normal. No
mitral regurgitation is seen. 5.There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
4)Cxray ([**11-3**]):Continued improvement in the appearance of the
lungs with a small left-sided pleural effusion
Brief Hospital Course:
Ms. [**Known lastname **] is a 74 yo female with a history significant for atrial
fibrillation with controlled rate, HTN, and who presents with an
episode of acute shortness of breath due to flash pulmonary
edema.
1) Flash pulmonary edema:
She was diagnosed with a urinary tract infection positive for
Strep at an outside hospital a week ago. In the ED, she was
found to have leukocytosis and T 100.6. It is possible that she
reverted into AFIB in the context of infection, and had
pulmonary edema as a result of myocardial stunning and irregular
rhythm. She does not have rapid ventricular rate, as her
typical HR is 50-60, and in AFIB her HR is 70-80. She has been
in and out of AFIB during her admission.
It is also possible that she had pulmonary edema in response to
hypertension, as her SBP was 215/115 in the ED on admission.
She had been eating salty foods earlier in the day, and it is
possible that a salt load contributed. Regarding an ischemic
etiology, her cardiac enyzmes were negative x3. TTE showed EF
75-80% on dopamine (she had developed septic physiology
immediately before TTE was performed), no wall motion
abnormalities, possible apical septal hypertrophy, no MR, AR,
TR. She should follow up with an outpatient stress test to
assess for possible ischemic etiology of pulmonary edema. She
was intubated for proper oxygenation/ventilation, and tolerated
extubation well after 36 hrs.
2) Sepsis:
All blood cultures, sputum cultures, urinalysis, urine cultures
were negative. On the morning after admission, patient's SBP
was 75 and T101. It was unclear whether the patient had
received Ceftriaxone before she arrived in the CCU, and she was
given Ceftriaxone and Vanco. She was placed on Dopamine, but
dopamine was rapidly weaned down after several hours. She
remained afebrile with SBP 150-170, and she was restarted on BP
meds. Vancomycin was discontinued. Ceftriaxone was switched to
Cefpodoxime, the last dose of which should be given on [**11-11**].
4) Prolonged QT:
For her recurrent UTIs which were diagnosed as an outpatient,
she had been on Bactrim for UTI prophylaxis, Penicillin VK for
Group B Strep treatment for a recent positive urinalysis. She
was started on Amiodarone 400 TID last Saturday since she had
reverted to AFIB from NSR (she had been in NSR since [**7-24**]). For
her leukocytosis and T100.6 in the ED, she was given one dose of
Ceftriaxone, Azithromycin, Clindamycin for possible pneumonia
that could not be visualized on CXR due to edema. On admission
in the ED, her EKG showed a QT 420. On admission to CCU, her
EKG showed QT 600. Her Amiodarone and Azithromycin were
stopped, and antibiotics were switched to Ceftriaxone and
Vancomycin. Followup EKG showed QT 470 with U waves. She was
assessed by Electrophysiology, who recommended maintaining her
on Amiodarone 200 PO QD, which was included in her discharge
medications.
5) Hypertension:
She was on Metoprolol, Norvasc, Imdur as an outpatient. Her
medications were changed to Toprol XL 75 QD, Lisinopril 5 QD.
Since she has chronic renal insufficiency, her renal function on
lisinopril should be followed up as an outpatient.
6) Chronic renal insufficiency:
Baseline Cr 2.1-2.4. She ranged from Cr 2.0 to 2.8 inhouse, and
was discharged with Cr 2.0. She had a metabolic acidosis due to
acute on chronic renal insufficiency during admission. She was
started on lisinopril 5 QD inhouse, and renal function should be
re-assessed as an outpatient.
7) Atrial fibrillation:
Rate control is Toprol 75 QD, anticoagulation is Coumadin.
Patient was taking Coumadin 2.5 PO QD x 6days/week, 5 PO x 1
day/week. Her admission INR was elevated to 3.8, possibly due
to amiodarone that had been started on Saturday before
admission. Her coumadin dose was decreased to 2 mg QD x 7
days/week. Her INR should be checked as an outpatient, with INR
goal [**1-21**]. Her INR was therapeutic on discharge.
8) Glucose intolerance:
She is not on meds at home, diet controlled. She was maintained
on insulin sliding scale inhouse with good control of blood
glucose.
9) Anemia:
Baseline Hct was unknown, but Hct on admission was 29, MCV 83,
MCHC 35.3. She was found to have iron deficiency anemia, and
was started on FeSO4 325 QD. She was given a prn bowel regimen
on discharge. She should follow up with a colonoscopy as an
outpatient.
.
10) Recurrent UTI:
She takes Bactrim 3 days/week for prophylaxis.
.
11) Hypocalcemia:
On admission, her Ca was [**5-25**], free Ca 1.00. Her calcium was
corrected after receiving 8 g calcium gluconate. PTH was
checked but the result had not returned. She should have her
hypocalcemia followed up as an outpatient.
Medications on Admission:
Coumadin 2.5mg X 6 days, 5mg
Metoprolol 25mg PO TID
Norvasc 2.5mg PO daily
Imdur 60mg PO BID
Levothyroxine 125 micrograms daily
Lipitor 40mg PO daily
Bactrim 100mg PO 3x/week
Penicillin VK 250mg PO QID (stop [**11-2**])
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: 1.5 Tablet
Sustained Release 24HRs PO once a day.
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1)Respiratory distress
2)Atrial fibrillation
3)Hypertension
4)Sepsis physiology
Secondary diagnoses:
1)Anemia
2)Hypocalcemia
3)Glucose intolerance
4)Recurrent UTI
Discharge Condition:
Stable
Discharge Instructions:
1)You are being discharged on several new medications: Coumadin
2.0mg, Amiodarone 200mg, Lisinopril 5mg, Toprol XL, and
Cefpodoxime (an antibiotic which you will finish on [**11-11**]). You
will no longer be taking Norvasc and Metoprolol. Also, please
note that the dose of Coumadin has changed.
2)You are being discharged on Coumadin, which requires you to
have your blood monitored closely. Please follow-up with your
primary care physician.
3)Please schedule follow-up with your cardiologist and primary
care providers at [**Hospital1 2025**].
4)If you have any chest pain, SOB, palpitations, or any other
concerning symptoms please return to the ED.
Followup Instructions:
Please schedule follow-up with your cardiologist and primary
care physician at [**Name9 (PRE) 2025**] within the next 1-2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2174-11-5**]
|
[
"585.9",
"486",
"428.0",
"V10.05",
"427.31",
"276.2",
"275.41",
"403.90",
"244.9",
"599.0",
"038.9",
"995.92",
"518.81",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"96.04",
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11975, 11981
|
6059, 10732
|
335, 388
|
12208, 12217
|
3215, 5082
|
12922, 13211
|
2846, 2850
|
11003, 11952
|
12002, 12102
|
10758, 10980
|
12241, 12899
|
2865, 3196
|
12123, 12187
|
276, 297
|
5100, 6036
|
416, 2308
|
2330, 2706
|
2722, 2830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,490
| 191,731
|
5830+5831+5846+55702
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2144-10-14**] Discharge Date: [**2144-12-3**]
Date of Birth: [**2074-1-11**] Sex: F
Service: MEDICAL
CHIEF COMPLAINT: Abdominal pain.
Initial evaluation was in the Emergency Room. The patient
was admitted to Medicine with Surgical consultation.
HISTORY OF PRESENT ILLNESS: This is a 70 year old lady with
a history of chronic abdominal pain since the beginning of
this year with known peripheral vascular disease, with a
history of ischemic bowel one year ago, and now with
worsening abdominal pain, mostly in the epigastric region,
more intense post-prandially. It is now more intense and
almost constant and radiates to lower abdomen. She complains
of diarrhea, nausea, anorexia, and a ten pound weight loss.
An outside abdominal MRI on [**2144-9-1**], showed a 65 to 75%
narrowing of the proximal SMA with a 45 to 55% narrowing of
the celiac axis. The [**Female First Name (un) 899**] was patent. There was
atherosclerotic plaque in the aorta and the common iliacs
with bilateral renal artery stenosis. The patient is now
admitted for further evaluation and treatment of her
abdominal pain.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Captopril 50 mg q. day.
2. Norvasc 5 mg q. day.
3. Lopressor 50 mg q. day.
4. Diovan 150 mg q. day.
5. Lasix 40 mg q. day.
6. Lipitor.
7. Aspirin.
8. NPH insulin.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Coronary artery disease.
4. History of congestive failure.
5. History of diastolic dysfunction.
6. History of type 2 diabetes mellitus.
7. History of peripheral vascular disease.
8. History of renal artery stenosis.
9. History of chronic renal insufficiency.
10. History of chronic obstructive pulmonary disease.
11. History of sarcoidosis.
12. History of diverticulosis.
13. History of chronic anemia.
14. History of hypothyroidism.
15. History of ischemic bowel in [**2143-12-5**].
16. History of chronic back pain and degenerative joint
disease.
PAST SURGICAL HISTORY:
1. Left femoral-popliteal in [**2140**] and a right
femoral-popliteal in [**2143**].
2. History of breast cancer status post left mastectomy in
[**2126**].
PHYSICAL EXAMINATION: The patient was afebrile and vital
signs were stable. General appearance is a white female,
cachectic, in no acute distress. HEENT examination was
unremarkable. On chest examination, lungs were clear to
auscultation bilaterally. Heart was a regular rate and
rhythm. Abdominal examination was bowel sounds were present,
soft. There were no bruits. Abdomen was nondistended,
nontender. Pulse examination showed palpable bilateral
femoral-popliteal bypass grafts with palpable dorsalis pedis.
Rectal examination was guaiac negative.
LABORATORY: In the Emergency Room, white blood cell count
was 16.9, hematocrit 40.1, platelets 502, BUN 52, creatinine
2.1, potassium 3.5. ALT was 13, AST was 23, total bilirubin
was 0.6, LD was 129. Amylase was 70, lipase was 27, albumin
was 3.9.
DIAGNOSTIC STUDIES: On admission included an abdominal
ultrasound which showed uncomplicated cholelithiasis with no
intra or extrahepatic ductal dilatation.
HOSPITAL COURSE: The patient then underwent an MRA of the
abdomen because of renal insufficiency. This demonstrated
pan-colitis which is a non-specific finding. Infectious
causes are Clostridium difficile and more likely ischemic
colitis given the distribution of the thickened bowel.
The patient then underwent an arteriogram which demonstrated
a significant, greater than 50% diameter reduction of the
ostium of the celiac artery with severe ostial stenosis of
the SMA secondary to complex aortic plaque within a small
caliber of an SMA beyond the region of the ostial narrowing
and a patent [**Female First Name (un) 899**]. There was delayed filling of the marginal
artery of [**Doctor Last Name 23128**] from the [**Female First Name (un) 899**] up until the mid-transverse
colon suggestive of focal stenosis at the region of the
splenic flexure.
There was moderate ostial plaque of the right renal artery.
There were bilateral extraphylic plaques in the main common
iliac arteries. Duplex of the right femoral-popliteal graft
was obtained which showed a widely patent graft but there was
a common femoral artery stenosis of about 50% of native
artery.
Ultrasounds of the carotids showed 60 to 69% stenosis
bilaterally with antegrade flow of both vertebrals. Vascular
Surgery was consulted soon after admission and the studies
were done above. Cardiology was consulted on [**10-16**] for
preoperative risk assessment evaluation. She underwent a
Persantine thallium which was normal. Recommendations were
beta blockers and PA catheter for hemodynamic monitoring
volume status intraoperatively and perioperatively.
It was also noted by thyroid function studies that the
patient had a subclinical thyroid hyperthyroidism with was
iatrogenically secondary to Synthroid dosing. She was on 175
alternating with 150 UG q. other day. This was converted to
150 UG q. day.
Pulmonary was also consulted regarding the patient's
long-standing history of sarcoidosis. After the patient was
evaluated by Pulmonary, they felt there was no
contraindication for any abdominal surgery.
On [**10-17**], the patient's creatinine began to rise and peaked
at a high of 5.8. Renal was consulted. She had acute renal
failure secondary to contrast induced ATN. Recommendations
were to hold the offending agents, to serial monitor her
creatinine, transfuse her to maintain her hematocrit greater
than 30. She received one unit of packed red blood cells for
a hematocrit of 27.4. Post transfusion hematocrit was 30.0.
On [**10-18**], she had a right PICC line placed for intravenous
antibiotics and TPN. Nutrition saw her and they felt that
her caloric needs were 1180 to 1475 calories per day and her
protein needs were 59 to 71 grams protein per day. She was
begun on TPN and her glucoses were serially monitored.
She received another unit of packed red blood cells on [**10-20**]
for a hematocrit of 27. Post-transfusion hematocrit was 31.
On [**10-21**], her creatinine showed some improvement to 4.0. The
patient complained of arm swelling in the PICC; it
demonstrated brachial vein thrombosis and the patient had the
right PICC line removed and a left PICC line was placed in
Interventional Radiology the following day.
Her creatinine continued to show an improving trend. On
[**10-23**], it was 2.1 and on [**10-24**], it was 1.7. During this
admission, she was placed on Vancomycin, Flagyl and
Levofloxacin for concern of infectious etiology for abdominal
pain. On [**10-27**], the patient underwent an upper
esophagogastroduodenoscopy. She showed a Grade I esophagitis
and a sigmoid polyp, at 32 cm and Grade I internal
hemorrhoids with no bleeding.
The patient underwent on [**10-28**], aorta-SMA bypass graft. The
Acute Pain Service followed the patient and managed her
epidural analgesic control. Immediately postoperatively, she
remained intubated on propofol for sedation. She was
hemodynamically stable; systolic blood pressure 140/30; CVP
11; PAP of 37/14; index 3.2.
EKG was without ischemic changes.
Chest x-ray was unremarkable. Hematocrit was 33.3. Her BUN
was 34, creatinine 1.3. She was transferred to VICU for
continuing monitoring and care. On [**10-30**], the patient
underwent an abdominal CT scan of the abdomen which
demonstrated SMA occluded graft. She returned to surgery and
had graft revision with a thrombectomy of SMA, and returned
to the SICU for continued hemodynamic monitoring care.
On [**11-1**], the epidural catheter was discontinued. The
patient required Nitroglycerin for afterload and systolic
hypertension control. She also had intravenous Hydralazine
and Lopressor added to her anti-hypertensive regimen. Her
hematocrit was [**11-2**] was 33, her creatinine was 1.5.
The patient continued to remain intubated. On [**11-12**], the
central line was changed and on [**11-4**], the patient underwent
endoscopy. Findings were consistent with ischemic regional
duodenal changes and active bleeding. General Surgery was
consulted. She underwent an exploratory laparotomy. The
mucosa was ischemic. The remaining muscularis was without
ischemia.
The patient continued to show improvement and underwent
extubation on [**2144-11-6**]. Tube feeds will begin on [**11-12**].
The patient's hematocrit hovered at 31.2, creatinine remained
stable at 1.6. She required aggressive diuresis requiring
both intravenous Lasix drip and
DICTATION ENDS
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2144-11-24**] 14:37
T: [**2144-11-24**] 15:21
JOB#: [**Job Number 23129**]
Admission Date: [**2144-10-14**] Discharge Date: [**2144-12-3**]
Date of Birth: [**2074-1-11**] Sex: F
Service: VASCULAR
This is a continuation of the initial discharge summary,
which was dictated on [**2144-11-24**].
HOSPITAL COURSE: Over the next 24 hours her nausea improved
with Reglan and her diet was slowly advanced. The Renal
Service continued to follow the patient for her renal needs.
Urine cultures taken at the time of the initial symptoms,
which the urinalysis showed yeast and the cultures showed
10,000 to 100,000 yeast colonies, which was sensitive to
Fluconazole. This was discussed with infectious disease and
they felt this was a colonization and clinically indicated
should be treated. Podiatry was consulted secondary to her
right foot pain on [**11-30**]. The initial examination showed
tenderness along the dorsal surface of the transverse arch
and the medial aspect of the inner aspect of the transverse
arch. X-rays were obtained, which were unremarkable.
Podiatry was requested to see the patient. They felt she had
a plantar fascitis and that there was no specific
recommendations. The patient should ambulate with shoes or
slippers on, not barefooted. The patient should follow up
with Podiatry in several weeks post discharge. Appointments
can be called to [**Telephone/Fax (1) **]. Her diet was advanced to pureed
diet on [**11-27**], which she tolerated with Boost supplements.
Her BUN and creatinine remained stable at 17 and 1.8. Her
liver function tests were normal. Hematocrit 29.9. She did
receive 2 units of packed cells with a post transfusion
hematocrit of 37.6. The urine culture on [**11-22**] showed
Klebsiella, which was sensitive to Meropenem only. This was
discussed with Infectious Disease and they felt that this was
colonization and would not be treated at this time.
Zosyn was discontinued on [**11-30**]. The Foley was discontinued
at that time. Repeat blood and urine cultures were obtained
on [**11-29**] and at that time of dictation were not finalized,
but showed no growth. Catheter tip, was is CVL, which was
removed on [**11-22**] was negative and finalized on [**11-24**].
Physical therapy felt the patient would benefit from a rehab
stay post discharge. Case management will discuss this with
the patient and appropriate arrangements will be made. At
the time of discharge she was in stable condition, tolerating
po and supplements. She was afebrile. Wounds were clean,
dry and intact.
DISCHARGE MEDICATIONS: Miconazole powder to affected area
b.i.d., Captopril 25 mg t.i.d. hold for systolic blood
pressure less then 120, calcium carbonate 500 mg t.i.d. in
between breakfast, lunch and dinner. Insulin sliding scale
see flow sheet. Sodium nasal spray one to two sprays NU
q.i.d. prn. A statin oral suspension 5 cc t.i.d. swish and
swallow this was started on [**2144-11-21**]. Metoprolol 100 mg
b.i.d., Protonix 40 mg q 24 hours, Levothyroxine 100 mcg
q.d., heparin 5000 units subQ q 12 hours. Ipratropium
bromide nebulizer q 6 hours, Albuterol nebulizer q 6 hours
prn, hydromorphine 0.5 mg IM intravenous, subQ q 3 to 4 hours
prn. Brimonidine tartrate 0.15% ophthalmic drops one OU
q.d., Flovent 110 mcg puffs two b.i.d. and Salmeterol one to
two puffs b.i.d.
DISCHARGE DIAGNOSES:
1. Mesenteric ischemia status post aorta SMA bypass graft.
2. Cholelithiasis status post endoscopic retrograde
cholangiopancreatography and sphincterectomy.
3. Chronic obstructive pulmonary disease, stable.
4. Chronic renal insufficiency, stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2144-11-30**] 11:39
T: [**2144-11-30**] 12:08
JOB#: [**Job Number 23130**]
Admission Date: [**2144-10-14**] Discharge Date: [**2144-12-3**]
Date of Birth: [**2074-1-11**] Sex: F
Service: Vascular
NOTE: This is an addendum to the initial discharge summary
which was dictated on [**11-24**] and the first addendum which was
dictated on [**11-30**].
The [**Hospital 228**] transfer to rehabilitation was deferred on
[**11-30**] because of episodes of hypoxia. A chest x-ray was
obtained which was negative for infiltrates or pulmonic
process. Blood gas that was obtained just showed PCO2 in the
80s. A CTA was done for suspicion of pulmonary embolism.
This was negative. The patient clinically improved with no
further hypoxic episodes. She is, at the time of transfer,
stable. Wounds are clean, dry and intact. She should follow
up with Dr. [**Last Name (STitle) 1476**] in three weeks time. The patient should
call for an appointment at his office, which is
([**Telephone/Fax (1) 23177**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2144-12-3**] 09:12
T: [**2144-12-3**] 10:17
JOB#: [**Job Number 23178**]
Name: [**Known lastname 183**], [**Known firstname **] Unit No: [**Numeric Identifier 3927**]
Admission Date: 09/11/200 Discharge Date: [**2144-12-3**]
Date of Birth: [**2074-1-11**] Sex: F
Service:
CONTINUATION: The patient was transferred out of the SICU to
the VICU on [**2144-11-10**]. Her clinical course continued to remain
stable. She did require transfusion of a unit of packed red
blood cells for a fall in hematocrit of 29.6 with post
transfusion hematocrit of 35.5 which remained stable.
Physical therapy was requested to see the patient and began
assessment for potential rehab screening. General surgery
was reconsulted because of bloody stools. Endoscopy was held
because patient's acidosis and hematocrit remained stable.
Over the next 48 hours hematocrit remained stable at 35.1,
patient had no further bloody stools. TPN was continued and
the tube feeds were reinstituted. The rectal bag was
discontinued and telemetry was discontinued and patient was
transferred to the regular nursing floor on [**2144-11-12**].
Repeat CT, MRI was done which demonstrated that the patient
had entire small bowel with thickened chronic ischemic
changes and MRA demonstrated a patent graft. The patient was
advanced to clears. Then hematocrit drifted again to 28.1
and patient was transfused a unit of packed cells to
hematocrit of 34.2.
The patient's diet was advanced slowly. She continued to
show improvement. TPN rates were adjusted for po intake.
The patient had episodes of right upper quadrant discomfort
and nausea and underwent an ultrasound of the gallbladder on
[**2144-11-19**] which demonstrated dilated common bile duct so
patient underwent an ERCP on [**2144-11-19**] under general
anesthesia. She required overnight stay in the SICU for
respiratory support and monitoring. She had a
sphincterectomy with stone removal. She continued to remain
stable, was extubated and transferred to the regular nursing
floor on [**2144-11-20**]. TPN was discontinued on [**2144-11-22**]. She
continued on po. She continued to show elevated white count
and then on [**11-23**] was 28.4, hematocrit was stable, BUN and
creatinine were stable. A C. diff was sent which was
negative. Blood cultures and urine cultures were no growth
but not finalized.
This discharge summary covers up to [**11-24**]. The patient had
onset of emesis times two of bilious material. Abdominal
exam showed mildly increased abdominal distention but active
bowel sounds times four. There was no tenderness on
palpation and no bruits. Incisions were clean, dry and
intact. White count was 26.3, hematocrit 30.2, PMNs 85,
bands 2, lymphs 4, monos 1. BUN 35, creatinine 1.9,
potassium 4.3, ALT, AST 6 and 17, alkaline phosphatase 198,
total bilirubin 1.0, lipase 76, amylase 99. The patient was
made npo, IV hydration once again and patient's clinical
course was monitored.
The remainder of this discharge summary will be dictated from
this date - [**2144-11-24**]; to be continued.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], M.D. [**MD Number(1) 144**]
Dictated By:[**Last Name (NamePattern1) 145**]
MEDQUIST36
D: [**2144-11-24**] 15:13
T: [**2144-11-24**] 15:51
JOB#: [**Job Number 3928**]
|
[
"578.9",
"574.91",
"276.2",
"790.7",
"557.1",
"584.5",
"276.6",
"996.74",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"96.6",
"99.15",
"96.72",
"45.13",
"39.26",
"88.47",
"03.90",
"38.93",
"54.11",
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
12155, 17215
|
11374, 12134
|
1212, 1387
|
9116, 11350
|
2031, 2190
|
2213, 3163
|
160, 290
|
319, 1186
|
1409, 2008
|
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