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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
25,962
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11937
|
Discharge summary
|
report
|
Admission Date: [**2107-1-1**] Discharge Date: [**2107-1-2**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This 82-year-old white male with
a history of CVAs and severe rheumatoid arthritis who
presented to the [**Hospital6 256**] as a
transfer from an outside hospital with rapid atrial
fibrillation and chest pain. The patient initially presented
to his urologist's office the morning of the 29th complaining
of right-sided chest pain and flank pain, which had been
present for one month, but was worse on the day of admission.
The patient pain presented as sharp, nonexertional, mildly
pleuritic, not associated with shortness of breath, nausea,
vomiting or diaphoresis. The patient was sent home from the
doctor's office after being told he was fine but called his
doctor when he found himself unable to rise from a chair at
home. The patient was found by EMS to be tachypneic with
heart rates in the 220s, irregular, with stable blood
pressure. He was given adenosine up to 12 mg with no effect.
He then received 20 mg intravenous diltiazem with heart rate
in the 150s.
The patient arrived at [**Hospital3 **] in the Emergency Room
with a heart rate of 136. Systolic blood pressure of 92. He
was given diltiazem .25 mg intravenous times one and then a
drip was started at 15 mg per hour. On interview, patient
gave clear history of sudden onset of chest pressure at 2
p.m., mildly pleuritic with diaphoresis, mild shortness of
breath, no electrocardiogram changes. The first enzymes were
negative. Blood pressure support was attempted with two
liters normal saline. The 02 saturations decreased. Patient
was given esmolol drip, GTT, and then his heart rate down to
the 90s but systolic blood pressure continued to be in the
90s. Dopamine drip was then added when the systolic blood
pressure went down to the 60s. Chest x-ray was consistent
with congestive heart failure and D dimer returned positive
so heparin was started. The decision was made to transfer
the patient to the [**Hospital6 256**] at
that point. They added Levophed to increase the blood
pressure and Ceftriaxone was given empirically without blood
cultures being drawn. The patient was transferred to [**Hospital6 1760**] with stable blood pressure on
Levophed, dopamine, diltiazem drip and esmolol drip. The
Esmolol drip and the diltiazem drip were discontinued on
arrival at [**Hospital6 256**]. Also
discontinued secondary to his low blood pressure. Vancomycin
and Flagyl were given for presumptive sepsis.
[**Hospital **] MEDICAL HISTORY: Significant for rheumatoid
arthritis, CVA in [**2100**] with no deficiencies and a
questionable possibility of having a transurethral resection
of prostate back in [**2097**].
ALLERGIES: He had no known drug allergies.
MEDICATIONS ON ADMISSION: Codeine, Celebrex, prednisone 5 mg
po q.d., Prilosec, Methotrexate, aspirin, folate, Axid and
Xanax.
SOCIAL HISTORY: Patient quit cigarettes when he was in his
60s. He does not drink alcohol. Lives in [**Location (un) 5503**],
[**State 350**] with his wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 99.1. Heart rate of
121-126. Heart rate 16-20. Blood pressure 112/72. 02
saturation 96% on 100% nonrebreather. Patient was alert and
responsive. Pupils equal, round and reactive. Extraocular
motions intact and full. Oropharynx was unremarkable. Neck
was in a tag collar, no lymphadenopathy, no jugular venous
distention noticed. Heart was irregularly irregular with no
murmurs, rubs or gallops. Lungs showed diffuse loud crackles
bilaterally. Abdomen was soft, nondistended, nontender with
positive bowel sounds. Extremities showed trace pedal edema,
1+ pedal pulses bilaterally, the right groin femoral line was
in place and was a triple lumen catheter.
HOSPITAL COURSE: On admission to the Medical Intensive Care
Unit, the patient began to decompensate both from a blood
pressure and a respiratory prospective. He was ultimately
intubated around 3 p.m. and his blood pressure was maintained
with four different pressor agents including vasopressin,
dopamine, phenylephrine and Levophed. He was also given
antibiotics including ceftazidime, vancomycin and Flagyl
overall for presumed sepsis. The patient's blood pressure
did not increase and in conversation with the family, the
patient was made "Do Not Resuscitate." His blood pressure
and heart rate continued to decline. He was unable to be
maintained and his heart eventually stopping and the
ventilator was then discontinued. He was pronounced dead at
12:55 a.m. on the [**1-2**] for presumed sepsis leading to
cardiovascular collapse, respiratory failure, respiratory
arrest and cardiac arrest. The family agreed to having an
autopsy performed.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2107-1-7**] 13:54
T: [**2107-1-7**] 13:54
JOB#: [**Job Number 37581**]
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13,702
| 167,118
|
176
|
Discharge summary
|
report
|
Admission Date: [**2119-5-4**] Discharge Date: [**2119-5-25**]
Service: CARDIOTHORACIC
Allergies:
Amlodipine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty [**5-5**]
s/p perc trach [**5-13**]
Major Surgical or Invasive Procedure:
bronchoscopy 3/31,4/2,3,[**6-12**], [**5-17**], [**5-19**]
s/p trachealplasty [**5-5**]
percutaneous tracheostomy [**5-13**] after failed extubation
down size trach on [**5-25**] to size 6 cuffless
History of Present Illness:
This 81 year old woman has a history of COPD. Over the past five
years she has had progressive difficulties with her breathing.
In
[**2118-6-4**] she was admitted to [**Hospital1 18**] for respiratory failure
due
to a COPD exacerbation. Due to persistent hypoxemia, she
required
intubation and a eventual bronchoscopy on [**2118-6-9**] revealed marked
narrowing of the airways on expiration consistent with
tracheomalacia.
She subsequently underwent placement of two
silicone stents, one in the left main stem and one in the
trachea. During the admission the patient had complaints of
chest
pain and ruled out for an MI. She was subsequently discharged to
[**Hospital1 **] for physical and pulmonary rehab. Repeat bronchoscopy
on
[**2118-8-1**] revealed granulation tissue at the distal right lateral
wall of the tracheal stent. There was significant malacia of the
peripheral and central airways with complete collapse of the
airways on coughing and forced expiration. Small nodules were
also noted on the vocal cords. She has noticed improvement in
her
respiratory status, but most recently has been in discussion
with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] regarding possible tracheobronchial plasty
with mesh. Tracheal stents d/c [**2119-4-19**] in anticipation of
surgery.
In terms of symptoms, she describes many years of intermittent
chest pain that she describes as left sided and occurring at any
time. Currently, she notices it about three times a week, and
states that it seems to resolve after three nitroglycerin.
She currently is dependent on oxygen and wears 1.5-2 liters
around the clock. She has frequent coughing and brings up "dark
sputum".
Past Medical History:
COPD flare [**6-7**] s/p intubation, s/p distal tracheal to Left Main
Stem stents placed [**2118-6-9**]. Stents d/c'd [**2119-4-19**], CAD w/ atypical
angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn,
hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib
fx, depression
PMH:
COPD, s/p admit [**6-7**] for exacerbation requiring intubation
tracheobronchomalacia, s/p bronchial stenting
Large hiatal hernia
Lacunar CVA
Hypothyroidism by records in CCC, although patient denies and is
not taking any medication
Depression
MVA, s/p head injury approximately 10 years ago
Hypertension
Hysterectomy
Social History:
Social History: The patient is married and worked as a clinical
psychologist. Her husband is a pediatric neurologist at
[**Hospital3 **]. They have several children, one of which is
a nurse.
Family History:
Family History: (+) FHx CAD; Father with an MI in his 40's, died
of a CVA at age 59
Physical Exam:
Admit H+P
General-lovely 81 yr old feamle in NAD.
Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis,
symetrical smile, gossly intact.
HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema
Resp-clear upper, diffuse ronchi, intermit exp wheezes
Cor- RRR, No M, R, G
Abd- soft, NT, ND, no masses. Slight protrusion at area of
hiatal hernia
Ext- no edema or clubbing
Brief Hospital Course:
82 y/o female admitted [**2119-5-4**] for consideration of
tracheoplasty.
Bronchoscopy done [**5-4**] confirming severe TBM. Underwent
tracheoplasty [**5-5**], complicated by resp failure d/t mucous
plugging, hypoxia requiring re-intubation resulting in prolonged
ICU and hospital course. Also developed right upper extrem DVT
from mid line.
Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid
PCA intermittently w/ fair pain control. Pt required
re-intubation for resp failure d/t secretions and PCA d/c at
that time. Propofol for sedation while intubated. Sedation d/c'd
[**5-12**] for weaning trial w/ ETT- failed trial. Trach [**5-13**]-weaning
efforts as below. Minimal c/o pain since [**5-13**]. Presently pain
free.
Neuro- Initially intact- post op aggitation, inhibiting weaning
efforts [**5-16**]. Psych eval [**5-18**]-Started on zyprexa and ativan w/
improvement in anxiety. Presently A+Ox3- cooperative and lovely.
Resp- Extubated POD#2 then required re-intub [**5-7**] for hypoxia
d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night
x4-5d, with CPAP attempts during day.
Bronchoscopy qd [**Date range (1) 1813**] for secretion management. Bronch [**5-9**]
revealed swollen epiglottis, bronch [**5-10**] - good leak w/ ETT cuff
deflated. Bronch [**5-13**] for eval/trach placement. Last bronch [**5-19**]
w/ min secretions present, sputum sent.
[**5-13**] perc trach done(#8 Portex- cuffed low pressure maintained to
preserve tracheoplasty site). [**5-13**] CPAP15/peep5 initiated post
trach placement. Weaning ongoing. [**Date range (1) 1814**]- Aggressive weaning
w/ increasing episodes of CPAP, progressing to Trach Mask.
[**2033-5-20**]-Trach mask overnight w/ no episodes of SOB, or
hemodynamic instability. Trach changed to #6 portex- capped and
[**Last Name (un) 1815**] well x48hrs on 2LNP. productive cough. Aggressive PT as
well w/ OOB > chair [**Hospital1 **]-tid to total 4-6hr qd. Ambulation
~100-120 ft [**5-22**] w/ PT assist.
ID- Vancomycin started post-op for graft prophylaxis. Fever
spike [**2119-5-8**] w/ BAl & sputum sent> + MRSA. Vanco cont to [**4-7**]
weeks post trachealplasty. Fever low grade [**5-12**], [**5-15**]> cultured-
no new results. [**5-19**]- WBC 20.8 .
Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and
cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg
IV qd.
[**5-15**]- RUE redness and swelling at site of midline, RUE DVT by
ultrasound, midline d/c; heparin gtt started and therapeutic
range monitored. [**5-22**] changed to Lovenox sq [**Hospital1 **]. Coags in good
control [**5-23**] (48.2/13.8/1.2)
Access- R midline placed [**2119-5-9**] for access- clotted [**2119-5-15**] and
d/c'd. RUE redness and swelling and DVT via ultrasound. [**5-15**]- L
brachial PICC line placed- TPN resumed.
GI-Large hiatal hernia- unable to place enteral feeding tube at
bedside or underfluoro. Re-attempt [**5-17**] by EGD doboff tube
placed distal esophagus, dislodged in 12hours and removed.
Nutrition- PPN/TPN initiated [**2119-5-8**]- [**2119-5-25**]. PICC placed
[**2119-5-15**]. Speech and Swallow eval [**5-22**]- rec change trach form #8
to #6 Portex to allow improved epiglotis and oropharyngeal
movement to assist w/ swallowing. Then re-eval. Trach changed
[**5-23**] to #6 cuffless portex trach. Passed repeat swallow eval and
[**Last Name (un) 1815**] diet of regular solids w/ thin liquids- CHIN TUCK to
swallow thin liquids. Give meds whole w/ apple sauce. WOULD
RECOMMEND repeat video swallow eval in [**8-17**] days to possibly
eliminate chin tuck- see page 3 referral.
Endo- Hypothyroid, maintained on levoxyl.
Muscu/Skel- OOB> chair 4-6hours/day, PT consulting.
Medications on Admission:
advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20',
lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol
LA 4', ambien 5', trazadone 75', melatonin prn
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal
QID (4 times a day) as needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime) as needed.
11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%,
EF 63%), hypercholesterolemia, hypothyroidism, Hypertension,
hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle
Colision-> head injury & rib fracture.
TBM- s/p tracheoplasty.
Discharge Condition:
good
Discharge Instructions:
please update Dr.[**Name (NI) 1816**] [**Telephone/Fax (1) 170**] office for: fever,
shortness of breath, chest pain , productive cough or if you
have any questions or concerns.
Completed by:[**2119-5-25**]
|
[
"519.1",
"453.40",
"553.3",
"518.5",
"496",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"31.79",
"31.1",
"38.91",
"99.15",
"96.6",
"96.04",
"96.05",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
9125, 9204
|
3632, 7320
|
328, 528
|
9497, 9503
|
3145, 3216
|
7541, 9102
|
9225, 9476
|
7346, 7518
|
9527, 9736
|
3231, 3609
|
192, 290
|
556, 2262
|
2284, 2903
|
2935, 3113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,246
| 180,334
|
4249
|
Discharge summary
|
report
|
Admission Date: [**2145-3-6**] Discharge Date: [**2145-3-16**]
Date of Birth: [**2084-8-19**] Sex: M
Service:
CHIEF COMPLAINT: Chief complaint is coronary artery disease
and valvular dysfunction.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with a history of diabetes and hypertension, status post
cardiac catheterization showing 3-vessel disease.
The patient was at an outside hospital roughly three weeks
ago when he began to notice orthopnea relieved with the use
of multiple pillows. He was initially treated by his primary
care physician for [**Name Initial (PRE) **] pneumonia but then returned and had a
further workup showing changes in his electrocardiogram which
consistent with coronary artery disease. At that time, the
patient was admitted to an outside hospital and had a cardiac
catheterization.
The patient currently presents to [**Hospital1 190**] for surgical intervention. The patient denies
a history of chest pain, diaphoresis, arm pain, or weight
loss, or weight gain.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Increased cholesterol.
3. Hypertension.
4. Carotid stenosis; status post right endarterectomy.
MEDICATIONS ON ADMISSION:
1. Glucotrol-XL 10 mg p.o. once per day.
2. Zocor 10 mg p.o. once per day.
3. Tylenol 1 g p.o. q.4h. as needed.
4. Lisinopril 10 mg p.o. once per day.
5. Lasix 20 mg p.o. once per day.
6. Aspirin 325 mg p.o. every day.
7. Metformin 850 mg p.o. twice per day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Family history is significant for father who
passed away secondary to a myocardial infarction at the age
of 60.
SOCIAL HISTORY: The patient does not smoke. He is a social
drinker. He is married with two children.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination revealed temperature was 98.4, heart rate was 66,
blood pressure was 110/71, respiratory rate was 18, and
oxygen saturation was 95% on room air. Blood sugar was 226.
Preoperative weight was 103.7 kilograms. In general, alert
and oriented. In no acute distress. Head, eyes, ears, nose,
and throat examination revealed pupils were equal, round, and
reactive to light and accommodation. Extraocular muscles
were intact. The oropharyngeal mucosa were clear and without
signs of erythema or swelling. Cardiovascular examination
revealed a respiratory rate. The lungs were clear to
auscultation bilaterally. The abdomen was soft, nontender,
and nondistended. Extremity examination revealed
varicosities in the legs. Radial pulses were 2+. Dorsalis
pedis pulses were 1+. Neurologic examination revealed
cranial nerves II through XII were intact.
PERTINENT RADIOLOGY/IMAGING: Cardiac catheterization
revealed an ejection fraction of 40%, left ventricular distal
and wall hypokinesis, a 100% occlusion of the mid left
anterior descending artery, a 95% occlusion of the
pulmonary artery proximally, and a 30% left main, and a 100%
proximal right coronary artery.
HOSPITAL COURSE: The patient was admitted to the
Cardiothoracic Service. The patient had a dental
consultation who cleared the patient for valvular surgery.
On [**3-8**], the patient was taken to the operating room with
an initial diagnosis of mitral regurgitation and coronary
artery disease. The patient had a coronary artery bypass
graft times six with a left internal mammary artery to the
left anterior descending artery, and saphenous vein graft to
the diagonal, a saphenous vein graft to the first obtuse
marginal and second obtuse marginal, and a saphenous vein
graft to the posterior descending artery and pulmonary
artery. The patient also had a 28-mm [**Doctor Last Name 405**] band placed
around the mitral valve.
The patient tolerated the procedure well and was transported
to the Cardiothoracic Surgery Recovery Unit in stable
condition.
On postoperative day one, the patient had low urine output
and a normal cardiac index; for which the patient was treated
with Lasix.
On [**3-10**], the patient's cardiac index and his SvO2 were
low on postoperative day two values. The patient had an
echocardiogram which was suboptimal. No conclusions were
made using that echocardiogram.
On postoperative day two, the patient had a second
echocardiogram which showed possible left ventricular
dysfunction. Due to the low index, low SvO2, and abnormal
echocardiogram, the patient was brought to the cardiac
catheterization laboratory for further evaluation. At that
time, the saphenous vein graft to right coronary artery was
occluded or not patent. The other grafts were all intact.
It was decided at that time that the graft was most likely
placed to an ischemic or dead area of the precordium and/or
the patient had collateralization of that area or blood flow.
The patient was then transferred back to the Cardiothoracic
Intensive Care Unit in stable condition. The patient's
further Intensive Care Unit stay was uncomplicated. His
cardiac index improved. His SvO2 improved, and the milrinone
was weaned off.
On postoperative day seven, the patient continued to do well
and was transferred to the floor. On the Cardiothoracic
floor, Physical Therapy cleared the patient to a level V, and
it was decided that the patient would be able to be
discharged home in stable condition.
PHYSICAL EXAMINATION ON DISCHARGE: Discharge physical
examination revealed temperature was 99.9, 99.6, heart rate
was 95, blood pressure was 120/60, respiratory rate was 18,
and oxygen saturation was 95% on room air. Blood sugars
ranged from 195 to 235. Preoperative weight was 105
kilograms. Discharge weight was 106.6 kilograms.
PERTINENT LABORATORY VALUES ON DISCHARGE: White blood cell
count was 12, hematocrit was 34.7, and platelets were 352.
Sodium was 132, potassium was 4.5, chloride was 95,
bicarbonate was 28, blood urea nitrogen was 18, creatinine
was 0.8. Cardiovascular examination revealed a regular rate
and rhythm. The lungs were clear to auscultation. The
abdomen was soft, nontender, and nondistended. The chest
incision was clean, dry, and intact. The lower extremity
showed mild erythema and minimal drainage. At this point,
the lower extremity incision did not appear to be infected or
cellulitic.
PRIMARY DISCHARGE DIAGNOSIS: Status post coronary artery
bypass graft times six and mitral valve replacement
angioplasty.
SECONDARY DISCHARGE DIAGNOSES:
1. Diabetes mellitus; controlled with oral medications.
2. Hypercholesterolemia.
3. Hypertension.
4. Carotid stenosis; status post right endarterectomy.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice per day (times seven days).
2. Lasix 20 mg p.o. once per day.
3. Potassium 10 mEq p.o. twice per day (times seven days).
4. Colace 100 mg p.o. twice per day.
5. Zantac 150 mg p.o. twice per day.
6. Aspirin 325 mg p.o. every day.
7. Tylenol p.o. as needed.
8. Percocet one to two tablets p.o. q.4-6h. as needed.
9. Plavix 75 mg p.o. once per day (times three months).
10. Captopril 37.5 mg p.o. three times per day.
11. Keflex 500 mg p.o. four times per day (times seven
days).
12. Simvastatin 10 mg p.o. once per day.
13. Glucotrol-XL 10 mg p.o. once per day.
14. Zocor 10 mg p.o. once per day.
15. Metformin 850 mg p.o. twice per day.
DISCHARGE DISPOSITION: The patient was discharged to home
with [**Hospital6 407**] for wound checks to the lower
extremity and chest and blood sugar checks.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to change his Lasix dose from twice per
day to once per day after seven days.
2. The patient was to continue on a cardiac and diabetic
diet.
3. The patient was to follow up with his primary care doctor
within the next two days for tight blood sugar control.
4. The patient was to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
in roughly one month.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2145-3-16**] 10:30
T: [**2145-3-16**] 10:43
JOB#: [**Job Number 18465**]
|
[
"E849.7",
"414.01",
"411.1",
"272.0",
"250.00",
"401.9",
"996.72",
"424.0",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"35.12",
"39.61",
"37.22",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7276, 7411
|
1532, 1645
|
6381, 6539
|
6256, 6360
|
6566, 7252
|
1210, 1515
|
3006, 5314
|
7444, 7854
|
7869, 8244
|
5672, 6234
|
148, 218
|
247, 1037
|
1059, 1184
|
1662, 2988
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,191
| 161,747
|
38094
|
Discharge summary
|
report
|
Admission Date: [**2171-11-5**] Discharge Date: [**2171-11-27**]
Date of Birth: [**2088-7-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Abdominal pain and distension
Major Surgical or Invasive Procedure:
[**2171-11-5**]:
Exploratory laparotomy, partial transverse colectomy with
primary anastomosis, partial gastric resection, placement of
gastrostomy tube.
[**2171-11-11**]:
Exploratory laparotomy and closure of fascial dehiscence.
[**2171-11-20**]:
Therapeutic bilateral thoracocentesis.
[**2171-11-21**]:
Bronchoscopy with bronchoalveolar lavage.
[**2171-11-22**]:
Bronchoscopy with bronchoalveolar lavage.
Gastrostomy/jejunostomy tube placement.
History of Present Illness:
83M with multiple medical problems, s/p CABGx4 on [**2171-7-29**].
Post-op course was complicated by hemodynamic instability
requiring vasopressor support, as well as ventricular ectopy and
bradycardia requiring a temporary pacer. This was removed. Of
note the patient required re-intubation several times during the
[**Hospital **] hospital course, and eventually received a trach and PEG
on [**2171-8-30**]. He was transferred to rehab on [**2171-9-12**] and returned
on [**2171-9-13**] with fever and hypotension. During this
hospitalization he was found to have C. Diff in the stool and
was placed on flagyl and PO vanc. There was question of
malposition of G-tube on CT scan, so urgent EGD was performed.
Tube was re-positioned without complication. Contrast study was
negative for extravasation. Tube feeds were resumed and finally
discharged to a vented rehab on [**2171-9-23**]. The patient comes back
with increased abdominal distention and output from the PEG. He
exhibited peritoneal signs and there was CT evidence of free
air, dislodged PEG and dilated small bowel in mid abdomen with
distally decompressed small bowel - read as partial vs early
SBO. He was immediately taken to the OR for ex-lap.
Past Medical History:
Coronary Artery Disease s/p off pump coronary artery bypass
grafts
Respiratory failure- s/p Tracheostomy/PEG
Loculated left sided pleural effusion s/p Pigtail toracentesis
Sternal dehiscence s/p sternal debridement,plating,pectoral flap
advancement
Endoscopic vein harvest infection
[**Date Range **] decubitus ulcer
Ischemic cardiomyopathy
Chronic atrial fibrillation
Peripheral vascular disease
Hypertension
chronic obstructive pulmonary disease
Hypercholesterolemia
Social History:
Lives with wife (in-law apartment- daughter +fam live nearby)
but came to [**Hospital1 18**] from rehab, at baseline he uses Canadian
crutches for ambulation ([**3-12**] OA of knees). He is retired.
Tobacco: 1ppd x 64yrs. ETOH: occasional but none recent.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
awake and alert, trach in place, unable to talk
tachycardic, no MRG appreciated
B/L rales at bases
distended, tender on entire right side, tympanitic
+ 2 edema throughout
Pertinent Results:
[**2171-11-5**] 01:00PM GLUCOSE-78 UREA N-70* CREAT-1.9* SODIUM-139
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-36* ANION GAP-15
[**2171-11-5**] 01:00PM WBC-13.1* RBC-3.14* HGB-9.3* HCT-28.7* MCV-91
MCH-29.5 MCHC-32.4 RDW-17.7*
[**2171-11-5**] 01:00PM NEUTS-91.4* LYMPHS-5.5* MONOS-2.8 EOS-0.1
BASOS-0.2
[**2171-11-5**] 01:00PM PLT COUNT-204
[**2171-11-5**] 01:00PM PT-13.6* PTT-27.9 INR(PT)-1.2*
[**2171-11-5**] 01:00PM ALT(SGPT)-28 AST(SGOT)-44* ALK PHOS-158* TOT
BILI-2.1* DIR BILI-1.5* INDIR BIL-0.6
[**2171-11-5**] 01:00PM LIPASE-12
[**2171-11-5**] 01:00PM ALBUMIN-3.0*
[**2171-11-5**] 05:11PM LACTATE-1.2
[**2171-11-5**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2171-11-11**]**
Blood Culture, Routine (Final [**2171-11-11**]): NO GROWTH.
[**2171-11-5**] 5:05 pm BLOOD CULTURE
**FINAL REPORT [**2171-11-11**]**
Blood Culture, Routine (Final [**2171-11-11**]): NO GROWTH.
[**2171-11-5**] 2:10 pm URINE Site: CATHETER
**FINAL REPORT [**2171-11-6**]**
URINE CULTURE (Final [**2171-11-6**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
ECG [**2171-11-5**] showed:
Atrial fibrillation. Q-T interval prolongation. T wave
abnormalities. Since the previous tracing of [**2171-9-13**] there is
probably no significant change.
CT abdomen/pelvis [**2171-11-5**] showed:
1. Small left and moderate right pleural effusions, incompletely
imaged, with underlying atelectasis/consolidation.
2. Free intraperitoneal air, mostly anterior to the liver. PEG
tube appears to be external to the stomach, and may have become
dislodged since the recent G-tube check, which would account for
the free intraperitoneal air. This could be further [**Year (4 digits) 6349**]
with formal fluoroscopic G-tube study.
3. Moderate-to-severe right hydronephrosis. 7-mm right proximal
ureteral stone.
4. Small amount of ascites, increased from [**2171-9-13**].
5. Dilated small bowel in the mid abdomen, with distally
decompressed small bowel. Early or partial small-bowel
obstruction cannot be excluded, although ileus is favored given
the concurrent processes.
6. Small bowel herniating through a small umbilical hernia. Both
the entering and exiting loops of bowel are collapsed.
Therefore, this is not a transition point.
CXR [**2171-11-5**] showed:
Interval development of large right pleural effusion
predominantly layering posteriorly. There is superimposed
pulmonary edema likely cardiogenic in origin. Incomplete
evaluation given lack of inclusion of costophrenic angles.
[**2171-11-5**] 10:55 pm SWAB Site: PERITONEAL
Fluid should not be sent in swab transport media. Submit
fluids in a
capped syringe (no needle), red top tube, or sterile cup.
**FINAL REPORT [**2171-11-10**]**
GRAM STAIN (Final [**2171-11-6**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2171-11-10**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2171-11-10**]): NO ANAEROBES ISOLATED.
[**2171-11-6**] 2:17 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2171-11-25**]**
GRAM STAIN (Final [**2171-11-6**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2171-11-9**]):
~1000/ML Commensal Respiratory Flora.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
CHLORAMPHENICOL AND TIMENTIN sensitivity testing
performed by
Microscan. SENSITIVE TO CHLORAMPHENICOL (<=8 MCG/ML).
RESISTANT TO TIMENTIN (>64 MCG/ML).
KLEBSIELLA PNEUMONIAE. ~[**2161**]/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>32 R <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- <=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
FUNGAL CULTURE (Final [**2171-11-22**]):
YEAST.
KUB [**2171-11-8**] showed:
1. Diffuse dilatation of central loops of bowel, which likely
represent small bowel loops. No definitive colonic distention is
seen on this limited examination. These findings are concerning
for postoperative ileus or early small-bowel obstruction.
2. A nasogastric catheter is seen with the tip in the region of
the gastric body. A gastrostomy tube is seen overlying the left
mid abdomen.
3. Surgical staples are seen in the midline consistent with
recent laparotomy. No other significant change compared to
prior.
[**2171-11-18**] 9:00 am SWAB Source: midline abdominal wound.
**FINAL REPORT [**2171-11-22**]**
GRAM STAIN (Final [**2171-11-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2171-11-22**]):
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ENTEROCOCCUS SP.
| |
AMIKACIN-------------- =>64 R
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- 2 S
VANCOMYCIN------------ =>32 R
CT chest/abdomen/pelvis [**2171-11-19**] showed:
1. Large right and small left pleural effusions with compressive
atelectasis.
2. Cardiomegaly, status post CABG, and vascular congestion.
3. Right renal hydronephrosis and mid to proximal ureter stone.
4. Penile pump is in place.
[**2171-11-20**] 3:11 pm PLEURAL FLUID
**FINAL REPORT [**2171-11-26**]**
GRAM STAIN (Final [**2171-11-20**]):
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 (Final [**2171-11-23**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2171-11-26**]): NO GROWTH.
[**2171-11-20**] 8:00 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2171-11-22**]**
GRAM STAIN (Final [**2171-11-20**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2171-11-22**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD(S). HEAVY GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
PROTEUS SPECIES. HEAVY GROWTH.
GRAM NEGATIVE ROD #4. SPARSE GROWTH.
YEAST. SPARSE GROWTH.
[**2171-11-22**] 3:28 pm Mini-BAL
**FINAL REPORT [**2171-11-25**]**
GRAM STAIN (Final [**2171-11-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2171-11-25**]):
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
OF FIVE COLONIAL MORPHOLOGIES.
Brief Hospital Course:
On [**2171-11-5**], the patient was started on vancomycin,
ciprofloxacin, and metronidazole and transferred to the
operating theatre for emergent exploratory laparotomy.
Post-operatively, he was admitted to the SICU on acute care
surgery with a new G-tube in place. On [**2171-11-7**], tube feeds
were started and were intermittently held when the patient
developed abdominal pain or distention. Tube feeds were
advanced to goal, which the patient tolerated by the time of
discharge. Fluconazole was started for yeast growing from urine
and broncheoalveolar lavage. The patient underwent bronchoscopy
on multiple occasions during this admission for lavage and
clearance of secretions. Starting on [**2171-11-8**], the patient
received lasix boluses and continuous drip infusions for
diuresis. On [**2171-11-11**], vancomycin and fluconazole were
stopped. The lower pole of the midline abdominal incision
produced serous drainage and dehisced. The patient returned to
the operating theatre for wound closure. On [**2171-11-12**],
ciprofloxacin was switched to levofloxacin. Serial CXRs showed
pleural effusions, which were treated with diuresis by lasix and
thoracocentesis. On [**2171-11-14**], all antibiotics were stopped.
On [**2171-11-15**], the patient was weaned to tracheostomy collar,
though he continued require ventilatory support intermittently.
On [**2171-11-18**], the inferior pole of the midline abdominal
incisoin was re-opened for surrounding erythema. Serous fluid
drained. No antibiotics were started. The patient passed
stools and tube feeds continued. On [**2171-11-19**], CT chest showed
large pleural effusions, and on [**2171-11-20**], 1600 mL were drained
by thoracocentesis. Diuresis and broncheoalveolar lavage
continued in an attempt to improve his respirations. On
[**2171-11-22**], the G-tube was exchanged for G-J tube for more
distal enteral feedings. At the time of discharge, the patient
was tolerating tube feeds at goal but continued to require
mechanical ventilation at times. Surgically, he was stable. On
[**2171-11-27**], he was discharged to rehabilitation facility in good
condition.
Medications on Admission:
Budensoide, 160/4.5 [**Hospital1 **], phoslo 1334 TID, chlorhexidine, cod
liver oil, dorzolamide, finasteride 5 QD, lasix 40 [**Hospital1 **],
hydrocodone 2.5 PRN, lopressor 25 TID, risperidone 0.25 @ 430pm
and QHS prn sleep, simethicone 80 TID, tamulosin QD, Spiriva 18
mcg PRN, albuterol, [**Doctor First Name **]-gay, morphine2 mg Q4 hrs
Discharge Medications:
1. budesonide-formoterol 160-4.5 mcg/Actuation HFA Aerosol
Inhaler Sig: One (1) puff Inhalation twice a day.
2. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a
day.
3. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. dorzolamide 2 % Drops Sig: One (1) drop Ophthalmic twice a
day.
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**7-16**]
Puffs Inhalation Q4H (every 4 hours).
8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day) as needed for DVT
prophylaxis while non-mobile.
9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
12. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. fluoxetine 20 mg/5 mL Solution Sig: Twenty (20) mg PO DAILY
(Daily).
14. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Three
Hundred (300) mg PO DAILY (Daily).
15. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. quetiapine 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for continuing medical care- cambrideg
Discharge Diagnosis:
Perforation of the transverse colon.
Tracheostomy.
Pleural effusions.
[**Hospital **] decubitus ulcer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the acute care surgery service for
perforation of the transverse colon.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*You are left with an open wound, which will heal and close over
time. Continue daily dressing changes and keep the wound clean.
G-J Tube Care:
*Please look at the G-J tube site every day for signs of
infection (increased redness or pain, swelling, odor, yellow or
bloody discharge, warmth, and fever).
*If the tube is connected to a collection container, record the
color, consistency, and amount of fluid in the drain. Call the
surgeon, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*You may shower and wash the tube site gently with warm, soapy
water.
*Keep the insertion site clean and dry otherwise. Place a drain
sponge for cleanliness.
*Avoid swimming, baths, and hot tubs. Do not submerge yourself
in water.
*Attach the tube securely to your body to prevent pulling or
dislocation.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2537**] to schedule a follow-up appointment
in the Acute Care Surgery Clinic in [**4-11**] weeks.
Completed by:[**2171-11-27**]
|
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icd9cm
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[
[
[]
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[
"33.23",
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"43.89",
"33.24",
"99.15",
"96.72",
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icd9pcs
|
[
[
[]
]
] |
16422, 16512
|
12362, 14509
|
346, 799
|
16658, 16658
|
3114, 12339
|
19772, 19935
|
2825, 2907
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14901, 16399
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16533, 16637
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14535, 14878
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16833, 17816
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18610, 19749
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2922, 3095
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17848, 18595
|
276, 308
|
827, 2041
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16673, 16809
|
2063, 2534
|
2550, 2809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,620
| 128,318
|
23155
|
Discharge summary
|
report
|
Admission Date: [**2106-8-17**] Discharge Date: [**2106-8-25**]
Date of Birth: [**2076-7-26**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Cefepime
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Bright red blood per recturm with hemodynamic instability
Major Surgical or Invasive Procedure:
1. Right femoral line placement
2. EGD with vessel clipping
History of Present Illness:
30 y/o female with history of AML s/p allo BMT in [**12-7**] and
relapse detected in [**5-8**] now s/p MEC treatment ([**6-8**]) and DLI on
[**7-29**] and GVHD (leg pain, high LFT's) admitted to [**Hospital1 18**] [**2106-8-17**]
for hematochezia. She is now transferred to the [**Hospital Unit Name 153**] for BRBPR
and hemodynamic instability.
.
The current presentation started on Sunday, [**2106-8-15**], when the pt
recalls that she had 1 episode of painless, bright red bloody
emesis. She says that the amount was small, less than 1 cup.
Monday, [**2106-8-16**], she had dark clotted blood with BM and less
yesterday [**2106-8-17**]. She was transferred from an OSH today for
further management.
.
On transfer to [**Hospital1 18**], she appeared comfortable to the admitting
resident and had no complaints (and specifically denied
abdominal pain). At about 2:30 am today, she had a large,
marroon stool mixed with melena. Her BP, which was 120s/70s on
arrival went to 90/60; her HR which was 70s on arrival went to
130s. 2 emergency-released units of prbcs were initiated. She
was bolused 1000cc NS and an 80 mg pantoprazole bolus was
ordered.
.
On arrival to the [**Hospital Unit Name 153**], HR had decreased to the 90s but BP was
86/39. She was mentating well and c/o rle pain and mild nausea.
Pt denied current LH/dizziness, abd pain, CP, dyspnea/SOB. 2
events quickly ensued.
.
First, the blood bank called to let us know that the 2 units
running were JKB incompatible. The transufusion was stopped,
the BMT fellow and blood bank resident on call were apprised and
2 units of cross-matched blood were rapidly procured.
.
Next, as the units ran in, the pt c/o LH and vomited
approximately 200c BRB. A femoral line was inserted and 3 units
were rapidly transfused. The GI fellow, who had been called on
transfer to the [**Hospital Unit Name 153**], arrived with the attending for emergent
EGD.
Past Medical History:
ONCOLOGY HX: She was first noticed to have leukocytosis and
thrombocytosis several years ago and a bone marrow bx at that
time revealed reactive marrow without dysplastic changes. At the
time of the birth of her daughter in [**12-6**] she was found to be
anemic and thrombocytopenic with immature circulating blasts and
a bone marrow showed 9% blast forms and cytogenetics showed an
8;21 translocation. She underwent 7+3 induction in [**1-7**] followed
by consolidation with HiDAC times three. She underwent an
alloSCT with cyto/TBI on [**2105-12-3**]. Her course was c/b mucositis,
neutropenic fever, and vaginal bleeding, resolved by the time of
her discharge. She had a positive blood cultures thought due to
line infection with coag-neg. Staph in [**2-8**] and [**3-8**], and her
Hickman was d/c'd. She had some acute stage I skin GVHD in [**4-7**]
that responded to low dose steroids.
.
Relapse detected in [**5-8**], confirmed with FISH. During admission
in [**2106-6-3**], patient received MEC therapy with good result;
repeat bone marrows have been without evidence of AML. She is
status post DLI on [**7-29**].
.
PMH:
1. AML/MDS: as above
2. HTN
3. s/p gastric bypass 2 yrs ago
4. s/p tonsillectomy
5. h/o MRSA, VRE, C.diff
6. Line sepsis CNS Ox resistant [**3-8**] with hickman removal
7) hx MRSA bacteremia late [**2105**]
Social History:
Originally from [**Country 3587**] but moved to the US when she
was 2 yrs old, currently lives in [**Doctor Last Name 792**]with her husband
and daughter, used to work as a [**Name (NI) **] and phlebotomist until [**9-6**].
+Tobacco- ~10pk-yrs, quit 2 yrs ago. Denies EtOH and drugs.
Family History:
MGM - CLL, mom DM [**Name (NI) **], HTN, dad HTN, sister asthma
Physical Exam:
Vitals: t 97.3/ Hr 96// BP 86/39// RR 22// O2 Sat 100% RA
Gen: Anxious female, quietly crying, AAOx3, speaking in full
sentences, pale but jaundiced, odor of melena
HEENT: MMM, OP with palatal petecchiae vs ulcer, otherwise
clear, no blood in mouth, icteric sclera
Neck: Obese and fleshy, no JVD
Heart: Tachy, rr, no m/g/r appreciated
Lungs: CTAB
Abd: Soft, obese, NT/ND, hypoactive BS, melena and blood
emerging from anus
Ext: No c/c/e, warm, weak DPs
Brief Hospital Course:
# GI Bleed: The patient was initially admitted to BMT for
management of her GIB. However, her Hct dropped from 27-20 over
a couple hours, and had a bloody bowel movement. She had
hemodynamic instability, with decreased BP to the 80's systolic
and HR >130. She was transfused 3 units PRBCs. The ICU team
was called, and she was transferred to the [**Hospital Unit Name 153**] for urgent EGD.
In the ICU, she had 200ml of hematemesis. A protonix drip was
started. A right femoral line was successfully placed for fluid
resusitation. She was given NS and 2 additional units at that
time. GI arrived and performed a EGD. They found a bleeding
vessel but could not cauterize it. They then successfully
clipped the vessel. Post procedure, she was given 2 units of
FFP and 1 unit Platelets with a good response. Her Hct was
followed q4. Overnight, her Hct fell from 32 - 27. She was
given 2 more units of PRBCs with an appropriate response. On
[**8-19**], GI re-scoped her to re-assess the clips. The clips were
shown to be intact. Over the course of her ICU stay she received
a total of 11 units of blood products. She was transferred back
to floor on [**2106-8-21**] and her henatocrit has been stable since.
.
# GVHD: The patient has known graft versus host disease of the
liver. She was recently started on Cellcept [**Pager number **] TID. Also, she
is receiving Prednisone 50mg daily. Her bilitubin has been high
but slowly declining during her stay. She should continue on the
regimen above with the goal of decreasing her steroid dose.
.
# Bacteremia: Three bottles of blood cultures on two different
days were positive for coagulase negative staphylococci. The
patient's line was not pulled per attending (Dr. [**First Name (STitle) 1557**], but
therapy with vancomycin through the line was initiated on
[**2106-8-19**]. Ms. [**Name14 (STitle) 59575**] remained afebrile during the entire stay on
the floor. She will need continued IV antibiotic therapy for a
total of forteen days (last day [**2106-9-1**]).
.
# CMV Infection: Mrs [**Known lastname 59574**] was started on onduction therapy for
CMV infection. We switched her on oral Valganciclovir 900 [**Hospital1 **]
the day before discharge. During the induction period (21 days)
valganciclovir is taken twice daily and then reduced to once
daily. The patient's viral load decreased progressivly during
the course of her stay and was undetectable on they of
discharge.
Medications on Admission:
Prednisone 60 mg daily
Fluconazole 200 mg daily
Cell Cept
Discharge Medications:
Valganciclovir HCl 900 mg PO BID
Fluconazole 400 mg PO Q24H
Prednisone 60 mg PO DAILY
Mycophenolate Mofetil 500 mg PO TID
Vancomycin HCl 1000 mg IV Q 12H
Sulfameth/Trimethoprim DS 1 TAB PO MWF
Omeprazole 40 [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
Clinical IV Network
Discharge Diagnosis:
1) Upper gastrointenstinal bleeding
2) Graft versus host disease
3) Bacteremia
4) Cytomegaly Virus infection
Discharge Condition:
Good, afebrile, stable hematocrit, no henorrhage, no diarrhea,
needs IV vancomycin at home
Discharge Instructions:
Please take all medication as prescribed. In case of bleeding,
increasing dirrhea, fever >100.4 or sudden onset of pain please
call the hematology clinc, after hours please call the [**Hospital1 18**] and
ask for the BMT fellow on call.
Please note your next appointment with Dr. [**First Name (STitle) 1557**].
Followup Instructions:
Appointment with Dr. [**First Name (STitle) 1557**]: Friday, [**2106-8-27**], 1.00 PM
Completed by:[**2106-9-14**]
|
[
"276.2",
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"285.1",
"287.5",
"078.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.05",
"38.93",
"45.13",
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
7390, 7440
|
4588, 7033
|
339, 400
|
7592, 7684
|
8044, 8160
|
4031, 4096
|
7141, 7367
|
7461, 7571
|
7059, 7118
|
7708, 8021
|
4111, 4565
|
242, 301
|
428, 2345
|
2367, 3712
|
3728, 4015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,421
| 115,724
|
2546
|
Discharge summary
|
report
|
Admission Date: [**2116-6-20**] Discharge Date: [**2116-7-8**]
Date of Birth: [**2062-10-17**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Seroquel / Heparin
Agents
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
dyspnea/hypoxia
Major Surgical or Invasive Procedure:
[**6-21**]: Chest tube placement on left
[**6-24**]: IR fluoroscopy guided pigtail drain placement into
loculated left pleural effusion
History of Present Illness:
Mr. [**Known lastname 449**] [**Last Name (Titles) **] 53-year-old male with history of CAD status post MI
in '[**12**] with bypass, chronic systolic CHF, EF of 30%-35%, hep C
untreated with thrombocytopenia, history of IVDU, chronic pain
on chronic methadone, status post history of laryngeal nerve
injury, status post a history of multiple lower extremity
orthopedic surgeries who presents with L-sided pleuritic chest
pain and cough for 4 days. Patient denies fevers but has been
fatigues for the past week, coughing up "pus like" sputum that
is occasionally streaked with blood. He has lost 14 lbs in 3
weeks with decrease in appetite. He denies night sweats but
reports significant left sided pleuritic CP which has been
progressing.
.
In the ED 100.0 134 113/56 20 95%. CXR: large L pleural
effusion. Given [**Last Name (un) **]/ceftriax and morphine. Labs notable for Cr
1.3 and WBC 19 and lactate normal. 100.6 126 115/92 30 96% on
4L. Given 1L fluids.
.
Upon arrival to the ICU, patient was endorsing [**11-2**] sharp, left
sided pleuritic CP with radiation to left shoulder and neck and
to left side of abdomen. He took 2 nitros for this 5 days ago
which did not provide relief of his pain. He endorses cough
productive of yellow mucus but that is hurt to cough or move at
all the left side. Denied shortness of breath or palpitations.
Also endorsed chronic aspiration given previous C2 injury. He
was febrile but denied feeling chilled on admission or at home.
He also endorses right hip pain that has been progessing and
limiting his walking. Orthopedics had told him this was likely
arthritis.
.
ROS:
(+) Per HPI
(-) Denies night sweats, recent weight gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denied cough. Denied
chest tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
-CAD status post STEMI in 07, LIMA to LAD
-chronic systolic CHF, EF 30%-35%. Most recent echo was
from [**7-2**]
-HCV with possible cirrhosis, never treated
-COPD
-HTN
-HL
-Hepatitis B with reported cleared infection
-Depression/Anxiety/PTSD
-Chronic back pain
-Psoriasis
-L3 spinal fusion
-[**2083**]: L knee gun shot wound; [**2104**]: L knee total arthroplasty;
-[**2105**]: L knee fusion
-DM2, diet controlled
-hep C genotype 1 cirrhosis
-thrombocytopenia
-history of CVA with small left thalamic infarction
-GERD/Barrett's
-history of question BPH,
-PTSD status post C2 injury with fall with subsequent surgery
complicated by laryngeal nerve injury
-recurrent aspiration pneumonitis
-history of isolated MAC in his sputum
-history of MSSA plus GBS tibial osteomyelitis [**Date range (1) 12917**]/11
Social History:
Recently noncompliant with medications. He lives at [**Location 12918**] St
[**Company 3596**] has VNA QD. Smoking five cigarettes per day down from
onepack, history of IV drug use, none in the last 16 years.
Denies alcohol.
Family History:
Mother died of lung cancer when he was three years old. Father
was murdered when he was 7.
Physical Exam:
VS: Temp: 100.7 BP: 133/78 HR:124 RR:27 O2sat96%4L
GEN: pleasant but uncomfortable, in obvious distress in pain
from left sided pain with rapid shallow breaths
HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, JVP to 8mmHg, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Poor inspiratory effort [**2-26**] pain, but coarse BS at right
base and decreased BS at left base anteriorly
CV: tahcy regular, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, TTP in lower upper and lower quadrants,
with involuntary guarding, no rebound, no masses or
hepatosplenomegaly
EXT: no c/c/e, left knee is reconstructed and fused
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength in upper
extremites, LLE 4+/5, RLE [**3-28**]. LLE decreased sensation,
otherwise intact. No pass-pointing on finger to nose. 2+DTR's
biceps unble to elicit in lower ext
.
Discharge Exam:
Vitals: VSS, breathing at 20 94 RA
.
Gen: NAD
HEENT: NCAT PERRL MMMs
Neck: No LAD supple
**Pulm: No accessory muscle use, Right lung field CTA with
basilar expiratory crackles, no wheezes or rhonci; Left lung
improving, still with bronchial BS and crackles
Chest Wall: Chest tube draining from left chest; chest tube
draining yellow fluid
CV: RRR nml S1/2 no m/r/g
Ab: +BS. Non-tense distended abdomen, mildly TTP. FOS.
Ext: No edema
Left knee: Well healed scar
Skin: No lesions, no rashes
Neuro: grossly non-focal.
Pertinent Results:
Admission Labs:
[**2116-6-20**] 10:10PM URINE HOURS-RANDOM CREAT-48 SODIUM-44
POTASSIUM-17 CHLORIDE-35
[**2116-6-20**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.046*
[**2116-6-20**] 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
[**2116-6-20**] 07:22PM PT-18.5* PTT-29.2 INR(PT)-1.7*
[**2116-6-20**] 03:25PM GLUCOSE-85 UREA N-23* CREAT-1.3* SODIUM-134
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
[**2116-6-20**] 03:25PM estGFR-Using this
[**2116-6-20**] 03:25PM ALT(SGPT)-18 AST(SGOT)-28 LD(LDH)-171 ALK
PHOS-84 TOT BILI-1.0
[**2116-6-20**] 03:25PM TOT PROT-7.8
[**2116-6-20**] 03:16PM COMMENTS-GREEN TOP
[**2116-6-20**] 03:16PM LACTATE-1.6
[**2116-6-20**] 03:00PM cTropnT-<0.01
[**2116-6-20**] 03:00PM WBC-19.7*# RBC-3.88* HGB-12.1* HCT-34.6*
MCV-89 MCH-31.0 MCHC-34.9 RDW-15.5
[**2116-6-20**] 03:00PM NEUTS-91.4* LYMPHS-4.6* MONOS-3.4 EOS-0.4
BASOS-0.2
[**2116-6-20**] 03:00PM PLT COUNT-147*#
.
EKG: NSR at 129 bpm, LAD, NI, Q in AVF, V1, V2, upsloping 1mm
STE in V2, 2mm STE V3 with poor baseline, compared to prior
elevated in V3 on new but may be related to lead placement.
Ischemic cannot be excluded.
.
Imaging:
CXR [**6-20**] : prelim, left sided white out
.
Bedside U/S: loculated pleural effusion
.
[**6-20**] CT Ab/P/Ch c Contrast:
IMPRESSION:
1. Multiloculated large left pleural effusion with visceral and
parietal
pleural enhancement concerning for empyema.
2. Mediastinal adenopathy, likely reactive.
3. Cirrhosis. Splenomegaly and evidence of umbilical vein
recanalization,
suggestive of portal hypertension.
4. Left renal cyst.
.
[**6-24**] CT-Guided Pigtail
IMPRESSION:
Moderate to large residual loculated left upper effusion now
status post
successful 8 French modified pigtail drain catheter placement
into the pleural space. 165 mL of serosanguineous fluid was
aspirated. The findings were discussed with caring resident, Dr.
[**Last Name (STitle) **], shortly after exam completion at approximately 5:15 p.m.
via phone by Dr. [**Last Name (STitle) 12919**]. System should be placed to suction
overnight.
.
[**6-25**] CXR:
IMPRESSION: AP chest compared to [**6-23**] through [**2116-6-25**]:34
a.m.:
The volume of residual left pleural effusion is smaller today
than it was
yesterday and a closer apposition of pleural surfaces may
account for increase in pain. The pigtail catheter ends at the
level of the carina. Left lower lobe is essentially collapsed.
Less severe atelectasis at the right lung base is unchanged. No
right pneumothorax. Small volume of left apical pleural air is
decreasing as that compartment fills with fluid. Basal pleural
tube also unchanged in position but difficult to localize on the
single frontal view.
.
[**6-28**] CXR PA-L:
FINDINGS: In comparison with the study of [**6-27**], there again are
areas of
air-fluid levels in the lateral aspect of the left hemithorax,
consistent with a complex hydropneumothorax. Chest tubes remain
in place. Right lung remains essentially clear.
.
[**6-30**] CT-Ab/P/C
Wet Read: JBRe TUE [**2116-6-30**] 3:18 AM
1. No acute process of the abdomen or pelvis including no
ascites, splenic
infarct, abd abscess or diverticulitis.
2. Significant fecal loading of the entire colon, increased from
prior exams.
3. Unchanged splenomegaly and left renal cyst.
4. Since [**6-24**], significant interval decrease in size of the
left empyema,
but remaining LLL opacity (atelectasis vs. PNA).
5. Stable RML opacity, likely atelectasis.
6. Unchanged reactive mediastinal LAP.
.
FINAL Read:
1. Significant interval decrease in the size of the left-sided
complex pleural effusion / empyema with thoracostomy tube
placement. Residual tethering of the left lower lobe is noted;
however, there has been reasonable reexpansion of the left lung.
2. Unchanged splenomegaly.
The study and the report were reviewed by the staff radiologist.
.
[**7-3**] CT-Chest c contrast:
IMPRESSION: 1. Interval marked decrease in size of loculated
pleural collections, with no new fluid collections seen. A left
pleural pigtail catheter and left thoracostomy tube are
unchanged in position. There is residual moderate atelectasis at
the left lung base.
.
[**7-7**] CXR
FINDINGS: Low lung volumes result in bronchovascular crowding.
The small
left pleural effusion and left basilar atelectasis are unchanged
from
[**2116-7-6**]. The right lung is clear. A chest tube projects over
the left
hemithorax. A right PICC ends in the mid SVC. There is no
pneumothorax.
Cervical spinal hardware is incompletely evaluated.
IMPRESSION: No change from [**2116-7-6**]. No pneumothorax.
Discharge Labs:
.
[**2116-7-6**] 05:44AM BLOOD WBC-5.3 RBC-2.99* Hgb-8.9* Hct-26.8*
MCV-90 MCH-29.6 MCHC-33.1 RDW-15.7* Plt Ct-145*
[**2116-7-7**] 09:08AM BLOOD Glucose-99 UreaN-11 Creat-1.0 Na-136
K-4.2 Cl-101 HCO3-30 AnGap-9
[**2116-7-7**] 09:08AM BLOOD Calcium-7.4* Phos-3.6 Mg-2.1
Brief Hospital Course:
53 yoM admitted to the ICU with hypoxia due to aspiration PNA
associated empyema, now s/p chest tube and pigtail drain
(removed) on ceftriaxone, who has a history of recurrent
aspiration pneumonitis, MAC isolated from his sputum, and COPD
in the setting thrombcytopenia, HCV, and chronic pain/heroine
abuse on methadone.
.
ACTIVE ISSUES:
.
#Empyema: Patient presented with large located left-sided
pleural effusion. Thoracic surgery was consulted and placed a
left-sided chest tube. Pleural fluid studies were consistent
with empyema. IR was consulted for drainage of a loculated
effusion not drained by chest tube, with a pigtail catheter
placed on [**6-24**]. Cultures of the pleural fluid showed Strep
Anginosis. Was treated initially with Levofloxacin, then
broadened to Vanc/Zosyn, then narrowed to ceftriaxone for a
planned course of [**4-29**] weeks. Serial imaging as detailed above
showed interval improvement in the empyema with serial
injections of TPA and drainage by wall suction. VATS was
considered, with both Liver and Cardiology clearing the patient
for surgery, but ultimately deferred due to the improvement with
conservative management and with the patient's comorbidities
making the risk to benefit ratio unfavorable. The pigtail was
pulled before discharge. The patient was discharged on
Ceftriaxone with one chest tube in place and plans to follow-up
with cardiothoracic surgery.
.
#Pleuritic Chest Pain: The pain service consulted. The patient
was initially managed on a Dilaudid PCA, which was transitioned
to dilaudid PO before transfer to the floor from the ICU.
Breakthrough was managed with PO Dilaudid then transitioned to
Percocet the day before discharge. Longacting pain control was
provided by convertin the patient's daily methadone to q6h with
an increase to 200mg total daily before being decreased back to
once daily 155mg, the patient's baseline, before discharge. A
fentanyl patch was started and uptitrated to 50mg. The patient
was discharged with follow-up with the pain clinic. Adjunctive
pain management was provided with lidocaine patches, gel, and
tizanidine, with little effect.
.
#Constipation: The patient had marked abdominal pain on transfer
to the floor from the ICU. CT-Abd showed no acute pathology
other than constipation. The patient's symptoms improved with an
aggressive bowel regimen, which included mag-citrate and
methylnaltrexone every other day.
.
#Acute renal failure: The patient presented with creatinine 1.3.
His acute renal failure was felt to be secondary to volume
depletion, and he was treated with IV fluids, bicarb and
mucomyst after contrast study. Lisinopril was held. The
patient's urine output increased, and his renal function rapidly
returned to [**Location 213**]. On [**2116-6-25**], the patient's renal function
worsened again, which was attributed to contrast nephropathy. Cr
returned to [**Location 213**] with supportive measures.
.
#Methadone overdose: [**7-7**] the patient was given his home dose of
methadone 155mg daily twice; he was only prescribed for once
daily dosing as documented in POE. Fentanyl and percocet were
stopped. He was ordered for naloxone but this was never given
because he remained AO x 3 and sats remained stable. Serial EKGs
showed stable QTc peaking in 470s. He was discharged on his home
dose of methadone, fentanyl patch, and percocet. The patient
said that he did not refuse the second dose because he forgot
receiving the first dose; he also noted that the morning prior
he was almost given a second dose but refused it.
.
INACTIVE ISSUES:
.
#DM2: Diet controlled at home. While inpatient, the patient was
managed with an insulin sliding scale. Insulin sliding scale was
stopped on [**6-24**] given lack of significant hyperglycemia. Remained
euglycemic.
.
#Chronic Pain: Methadone was continued at the patient's home
dose. The patient's acute left-sided pleuritic chest pain was
managed as above. Chronic Pain Service followed patient
in-house. QTC remained ~ 460.
.
# COPD: No e/o flare. Was managed on Ipratropium Bromide Neb 1
NEB IH Q6H and Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN.
.
# Hep C Cirrhosis: Was never encephalopathic this admission.
Maintained on Lactulose TID.
.
# Anemia: Remained Stable.
.
# Thrombocytopenia, Coagulopathy: Working Dx = Cirrhosis
related. Remained stable. Coagulopathy was corrected with
Vitamin K when the patient was under consideration for VATS.
.
# CHF: Clinically euvolemic throughout admission. Discharged in
euvolemic condition.
.
# CAD, HTN: Continued home regimen as detailed below.
-Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **] (home dose 25mg succinate
daily)
-CloniDINE 0.3 mg PO DAILY
-Aspirin 81 mg PO/NG DAILY
-Simvastatin 40 mg PO/NG DAILY
-Lisinopril 5mg DAILY
.
# Psych issues: Anxiety, PTSD, Depression. Continued home
regimen as below.
-Clonazepam 1 mg PO/NG TID:PRN anxiety
-Doxepin HCl 300 mg PO/NG HS
.
# GERD: Stable. Continued home regimen as below.
-Omeprazole 40 mg PO DAILY
.
TRANSITIONAL ISSUES:
# Chest Tube: Will be managed by the cardiothoracic surgical
service with outpatient follow-up.
# Chronic pain: Will be managed by the pain service with
outaptietn follow-up.
# Methadone: Will be overseen by new PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 9434**].
Medications on Admission:
CLONAZEPAM - (Prescribed by Other Provider) - Dosage uncertain
CLONIDINE [CATAPRES-TTS-1] - (Prescribed by Other Provider) -
Dosage uncertain
DOXEPIN - (Prescribed by Other Provider) - Dosage uncertain
LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL
Solution - 30 ml by mouth daily as needed for prn for
constipation
LISINOPRIL - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day
METHADONE - (Prescribed by Other Provider) - 40 mg Tablet,
Soluble - 5 Tablet(s) by mouth once a day Total dose 170 mg
daily
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth daily
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 mins as needed for angina call 911 if no
relief after 3rd pill.
NITROGLYCERIN [NITROSTAT] - (Prescribed by Other Provider) -
0.4
mg Tablet, Sublingual - 1 Tablet(s) sublingually Q5 min X3 for
chest pain as needed for PRN
OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
OXYCODONE - 30 mg Tablet - 1 Capsule(s) by mouth once a day as
needed for pain do note drink or drive under the influence of
this medicaion. Do not operate dangerous equipement.
POTASSIUM CHLORIDE - (Prescribed by Other Provider) - Dosage
uncertain
PROMETHAZINE - 50 mg Tablet - 1 Tablet(s) by mouth daily at
bedtime for nausea
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by
Other Provider) - 18 mcg Capsule, w/Inhalation Device - 1 puff
daily
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety .
2. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. doxepin 150 mg Capsule Sig: Two (2) Capsule PO once a day.
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for Cirrhosis patient, prevent
encephalopathy.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. methadone 10 mg Tablet Sig: 15.5 Tablets PO DAILY (Daily).
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual once a day as needed for chest pain.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) puff Inhalation once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
16. magnesium citrate Solution Sig: Three Hundred (300) ML
PO DAILY (Daily).
17. methylnaltrexone 12 mg/0.6 mL Solution Sig: Twelve (12) mg
Subcutaneous every other day as needed for constipation for 2
weeks.
18. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
19. oxycodone-acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q6H (every 6 hours) as needed for pain.
20. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) g Intravenous Q24H (every 24 hours) for 3 weeks: Last
day [**2116-7-27**] for total course of 5 weeks (day 1 [**6-22**]).
21. sodium chloride 0.9 % 0.9 % Solution Sig: One (1) Flush
Injection PRN (as needed) as needed for line flush: PICC,
non-heparin dependent: Flush with 10 mL Normal Saline daily and
PRN per lumen.
22. Chest tube to suction
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY:
-Empyema
SECONDARY:
-Chronic pain
-Opiate dependence on Methadone maintenance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were hospitalized for a puss collection in your left chest
called an empyema; the empyema was probably caused by aspiration
pneumonia, which you have had in the past due to your vocal cord
paralysis. The cardiothoracic surgeons saw you during this
hospitalization, and placed a chest tube as well as a pigtail
catheter; they injected enzymes into your chest to dissolve the
pus. Overtime the pus has drained from the chest cavity as seen
by serial x-rays. The pigtail catheter was removed, but you are
being discharged with the chest-tube in place; it will remain in
place until you see your cardiothoracic surgeons in [**Hospital 702**]
clinic after discharge. You are being discharged on intravenous
antibiotics, which you will need to continue for several weeks.
.
The pain service saw you during this hospitalization. They
started a number of new medications for your pain, but you are
being discharged on your home dose of methadone, which is 155mg
daily.
.
Abdominal imaging was performed because you were experiencing
abdominal pain. The imaging showed that you were very
constipated. You are being discharged on anti-constipation
medications.
.
No changes were made to your medications other than as detailed
below.
START:
-Ceftriaxone antibiotics until the prescription is complete.
-Fentanyl patch for pain
-Percocet as needed for pain
-Duonebs for shortness of breath, wheeze
-MagCitrate daily to prevent constipation
-Miralax to prevent constipation
-Colace to prevent constipation
-Compazine for nausea
-Methylnaltrexone to prevent constipation - this medication acts
only on the intestine - it does not cause withdrawal, and you
have been receiving it this hospitalization without any problems
-Aspirin to prevent heart disease
.
STOP:
-Promethazine
-Potassium chloride
Followup Instructions:
Department: Thoracic Surgery (in HEMATOLOGY/ONCOLOGY suite)
When: THURSDAY [**2116-7-16**] at 4:00 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
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2116-7-24**] at 10:30 AM
With: [**Name6 (MD) 10720**] [**Last Name (NamePattern4) 10721**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Your new PCP will be Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 9434**]. Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 250**] to make this appointment once
you leave rehab.
|
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icd9cm
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,488
| 188,355
|
23275+23276+57343
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2200-12-15**] Discharge Date: [**2200-12-20**]
Date of Birth: [**2200-12-15**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **], Twin Number 2
is an infant delivered at 26 5/7 weeks gestation, admitted to
the [**Known lastname **] Intensive Care Unit for prematurity. The infant
was born at 2:56 PM on the afternoon of [**12-15**]. He is
an 875 gm product of a 26 [**5-2**] week twin gestation to a 45
year old gravida 4, para 0, now 2 mother with estimated date
of confinement of [**2201-3-18**]. Pregnancy was a
monochorionic/diamniotic twin gestation via donor egg and
sperm. This pregnancy was complicated by growth discordance
noted approximately one week prior to delivery with maternal
admission on [**2200-12-11**] with hypertension and
proteinuria. An ultrasound at that time showed growth
restriction and oligohydramnios of Twin A. She was given a
course of betamethasone that was completed on [**12-13**].
She was monitored for several days prior to delivery and then
on the date of delivery was noted to have increasing liver
function tests, prompting delivery for worsening
preeclampsia. Membranes were intact at the time of delivery
and no particular risk factors for infection were identified.
Delivery was by cesarean section.
This twin emerged with moderate tone and cry, becoming more
vigorous with drying and stimulation. Blow by oxygen and
positive pressure ventilation were given for duskiness and
increased work of breathing and the infant was intubated at
approximately five minutes of age with a 2.5 endotracheal
tube. The heart rate was greater than 100 throughout.
|Apgar scores were 7 at one minute and 8 at five minutes of
age. The infant was briefly shown to the mother and then
brought to the [**Name (NI) **] Intensive Care Unit on positive
pressure ventilation.
PHYSICAL EXAMINATION ON ADMISSION: Weight 875 gm, 50th
percentile. Head circumference 25.75 cm, 50th percentile.
Length 33.5 cm, 25th percentile. Vital signs: Temperature
95.4, heart rate 140s, respiratory rate 40s, blood pressure
50/22 and a mean arterial pressure of 33. Oxygen saturation
98 percent in FIO2 of 40 percent. Ventilator settings on
admission, positive inspiratory pressure of 24, positive end-
expiratory pressure of 5, rate of 30, FIO2 40 percent. This
was a premature infant, active with examination. Fontanelles
soft and flat. Lips, gums and palate intact. Ears and nares
patent. Chest, poorly aerated, very coarse breath sounds.
Moderate grunting, flaring and retracting. Cardiac, regular
rate and rhythm, no murmur. Abdomen, soft, three vessel
cord, no masses, no hepatosplenomegaly, quiet bowel sounds.
Genitourinary: Normal male, anus patent. Extremities, no
edema. Skin, warm, pink and well perfused. Neurologic:
Appropriate tone and activity.
HOSPITAL COURSE: Respiratory - The infant was intubated in
the Delivery Room, then brought to the [**Name (NI) **] Intensive Care
Unit where he received a total of two doses of Surfactant.
He has had a persistent mixed respiratory and metabolic
acidosis requiring several sodium bicarbonate boluses. His
current ventilator settings are positive inspiratory pressure
of 19 and positive end-expiratory pressure of 5, rate of 36
with an FIO2 of 31 percent. His latest arterial blood gas
with PH of 7.24, pCO2 of 55, pO2 of 67, total carbon dioxide
of 25 with a base deficit of -4.
Cardiovascular - The infant received one normal saline bolus
for decreased blood pressure shortly after admission to the
[**Name (NI) **] Intensive Care Unit. The blood pressure responded
nicely and no pressors have been required. He was started on
his first course of Indomethacin [**12-16**], for a presumed
patent ductus arteriosus. An echocardiogram on [**12-17**]
showed a persistent patent ductus arteriosus. A second
course of Indomethacin was started on [**12-17**] and ended
late on [**12-18**]. An echocardiogram on [**12-19**],
showed a persistent moderate to large patent ductus
arteriosus.
Fluids, electrolytes and nutrition - Upon admission to the
[**Month (only) **] Intensive Care Unit umbilical artery and umbilical
venous catheters were placed. Intravenous fluids of D10/W
were started at 100 cc/kg/day, half normal saline with
heparin infusing via the umbilical artery catheter. Fluid
volume was advanced to a maximum of 130 cc/kg/day.
Parenteral nutrition of D12.5/W and interlipids infusing via
a double lumen umbilical venous catheter. D-sticks have been
stable in the 90 range. Urine output was 2.3 cc/kg/day. He
has not stooled yet. Electrolytes on [**12-19**], sodium
139, potassium 4.7, chloride 107 and bicarbonate of 20. His
weight on [**1001-12-20**] gm, up 15 gm from [**12-19**].
Gastrointestinal - Phototherapy was started on day of life
Number 1 for a bilirubin of 4.3. He remains under single
phototherapy. His last bilirubin on [**12-19**], was 3.1.
Hematology - Hematocrit on admission was 48.2. He received
15 cc/kg of packed red blood cells on day of life Number 3.
The latest hematocrit on [**12-20**] was .
Infectious disease - A complete blood count and blood culture
was drawn upon admission to the [**Month (only) **] Intensive Care Unit.
Complete blood count showed white count of 3,100, hematocrit
48.2, and platelet count of 183,000 with 8 percent polys and
0 percent bands. Repeat complete blood count on day of life
Number 1 showed a white count of 3,700, hematocrit of 45.2,
platelet count of 190,000 with 34 percent polys and 0 percent
bands. Blood culture was negative at 48 hours. The infant
did receive a 48 hour course of ampicillin and gentamicin.
No concerns for infection at this time.
Neurology - Head ultrasound has not been done yet on this
infant.
Sensory - Hearing screen and eye examinations have not been
performed on this five day old infant.
Psychosocial - [**Hospital6 256**] social
worker has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **]. Of note, the mother of
these twins suffered a subarachnoid hemorrhage on [**12-18**]. She is mentating and able to follow the care of her
infants.
CONDITION ON TRANSFER: Infant with persistent patent ductus
arteriosus stable on current ventilator settings.
DISCHARGE DISPOSITION: Transport to [**Hospital3 1810**] for
patent ductus arteriosus ligation via ambulance.
CARE/RECOMMENDATIONS: Feeds - Total fluids at 130 cc/kg/day.
Medications - Vitamin A 5000 units every Monday, Wednesday
and Friday.
State [**Hospital3 19402**] screen - First state [**Hospital3 19402**] screen was sent
[**12-19**], no abnormal results have been reported.
Immunizations received - None.
TRANSFER DIAGNOSIS: Prematurity at 26 6/7 weeks gestational
age.
Twin gestation, Twin Number 2.
Rule out sepsis.
Respiratory distress syndrome.
Persistent patent ductus arteriosus.
Hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 59783**]
MEDQUIST36
D: [**2200-12-20**] 03:41:33
T: [**2200-12-20**] 08:57:41
Job#: [**Job Number 59784**]
Admission Date: [**2200-12-15**] Discharge Date: [**2201-3-12**]
Date of Birth: [**2200-12-15**] Sex: M
Service: NB
HISTORY: [**Known lastname **] [**Known lastname **], twin number two, is a [**Known lastname 19402**] 26-5/7-
weeks gestation infant admitted to the [**Known lastname **] Intensive Care
Unit for prematurity. He was born at 2:56 in the afternoon as
the 875-gram product of a 26-5/7-weeks twin gestation to a 45-
year-old gravida 4, para 0 now 2 mother with estimated date
of confinement of [**2201-3-18**]. Pregnancy was a
monochorionic-diamniotic twin gestation via donor egg and
sperm. Pregnancy was complicated by growth discordance noted
approximately one week prior to delivery with maternal
admission on [**2200-12-11**] with hypertension and
proteinuria. Ultrasound at that time showed growth
restriction and oligohydramnios of twin A. She was given a
course of betamethasone and was beta complete on [**12-13**].
She was monitored for several days prior to delivery and on
date of delivery, was noted to have increasing liver function
tests prompting delivery for worsening preeclampsia.
Membranes were intact at time of delivery and no particular
risk factors for sepsis were noted. Delivery was by cesarean
section. This twin emerged with moderate tone and cry
becoming more vigorous with drying and stimulation. Blow-by
oxygen and positive pressure ventilation were given for
duskiness and increased work of breathing, and infant was
intubated at approximately five minutes of age with a 2.5
endotracheal tube. Heart rate was greater than 100
throughout. Apgars were 7 at 1 minute and 8 at 5 minutes of
age. Infant was briefly shown to the mother and brought to
the [**Name (NI) **] Intensive Care Unit on positive pressure
ventilation.
PHYSICAL EXAM ON ADMISSION: Weight: 875 grams (50th
percentile). Head circumference 25.75 cm (50th percentile).
Length 33.5 cm (25th percentile). Vital signs: Temperature
95.4, heart rate 140's, respiratory rate 40's, blood pressure
50/22, mean arterial pressure 33. Oxygen saturation 98
percent on 40 percent FIO2. Initial vent settings: PIP of 24
over a PEEP of 5, rate of 30. Well-developed premature
infant, active with exam. Head, eyes, ears, nose, and throat:
Fontanel soft and flat. Palate intact, ears and nares patent.
Chest: Poorly aerated, very coarse, moderate grunting,
flaring, and retracting. Cardiac: Regular rate and rhythm, no
murmur. Abdomen is soft, three-vessel cord, no masses, no
hepatosplenomegaly, no quiet bowel sounds. GU: Normal male,
anus patent. Extremities: No edema. Skin: Warm, pink, and
well perfused. Neurologic: Appropriate tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **] was
intubated in the delivery room at about five minutes of age.
He was admitted to the [**Known lastname **] Intensive Care Unit and
received two doses of Survanta. He was on conventional
ventilation until day of life six at which time he was
switched to high-frequency oscillatory ventilation for
escalating respiratory support and pulmonary interstitial
emphysema on chest x-ray. He was on high-frequency
oscillatory ventilation until day of life 12 at which time he
was placed back on conventional ventilation. He was weaned to
continuous positive airway pressure on day of life 38, then
to nasal cannula oxygen on day of life 46 and finally weaned
to room air on day of life 78.
[**Known lastname **] was receiving Combivent while on the ventilator.
Caffeine citrate was started on day of life 20 for apnea of
prematurity and discontinued on day of life 51. He has had no
recent episodes of apnea or bradycardia. Diuril was started
on day of life 51 for persistent oxygen requirement. It was
subsequently discontinued on day of life 77. He received
multiple doses of sodium bicarbonate in the first week of
life for persistent metabolic acidosis.
Cardiovascular: [**Known lastname **] received one normal saline bolus shortly
after admission to the NICU for hypotension. No vasopressors
were needed. A murmur was noted on day of life one. He
received two courses of indomethacin for persistent patent
ductus arteriosus. Follow-up echocardiogram on [**12-19**]
showed a moderate PDA with continuous left-to-right flow
prompting transfer to [**Hospital3 1810**] on [**12-20**] for
a PDA ligation. [**Known lastname **] blood pressure has been normal for the
remainder of his hospitalization.
Fluid, electrolytes, and nutrition: IV fluids of D10W were
started at 100 cc/kg/day upon admission to the [**Known lastname **]
Intensive Care Unit. Umbilical arterial and umbilical venous
catheters were placed upon admission. A PICC line was placed
on day of life seven. Trophic feeds were started on day of
life nine, but interrupted for persistent metabolic acidosis,
abdominal distention, and bilious aspirates. Feeds were
restarted on day of life 18 and advanced to full volume by
day of life 25. Maximum volume 150 cc/kg/day. Maximum caloric
density: Breast milk 32 calories with ProMod. Electrolytes
have been stable throughout his hospitalization. Last
electrolytes on [**3-2**]: Sodium of 137, potassium of 5.2,
chloride of 103, and total CO2 of 27.
GI: Phototherapy was started on day of life one for a
bilirubin of 4.3. Phototherapy was finally discontinued on
day of life 17 for a bilirubin of 2.4 with a rebound
bilirubin of 3.5 on day of life 18.
Heme: [**Known lastname **] received four packed red blood cell transfusions
during his hospitalization. Last hematocrit on [**3-2**] was
31.4 with a reticulocyte count of 5.7.
Infectious disease: A CBC with differential and blood culture
was drawn upon admission to the [**Month (only) **] Intensive Care Unit.
White cell count of 3,000, hematocrit of 48, platelet count
of 183 with 8 percent polys and 0 percent bands. A followup
CBC on day of life one showed a white blood cell count of
3.7, hematocrit of 45, platelet count of 190 with 34 percent
polys and 0 bands. He was started on ampicillin and
gentamicin upon admission to the [**Month (only) **] Intensive Care Unit
and received 48 hours of antibiotics. A blood culture drawn
at this time was negative.
Ampicillin and gentamicin were restarted on day of life 14
for abdominal distention. The CBC at that time was
unremarkable and the blood culture was negative. The
antibiotics were discontinued after 48 hours. A CBC and blood
culture were sent on day of life 29 for lethargy. White blood
cell count 9.5, hematocrit 34, platelet count 422 with 14
percent polys and 15 percent bands. Blood culture was
negative at this time. He received seven days of vancomycin
and gentamicin. The LP at this time was unremarkable. He also
received five days of erythromycin eye ointment for eye
drainage from day of life 28 to day of life 32.
Neurology: [**Known lastname **] has had three normal head ultrasounds, the
first on [**12-19**], the second on [**12-31**], and the third
on [**1-16**].
Sensory: Hearing screen is pending.
Ophthalmology: [**Known lastname **] eyes were most recently examined on
[**3-9**] revealing stage I, zone 3 ROP in the right eye and
immature to zone 3 in the left eye. A follow-up exam is
suggested for 2 weeks.
Psychosocial: Loving invested single mom. She suffered a
subarachnoid hemorrhage shortly after delivery of the twins
and was in [**Hospital1 69**] Medical
Intensive Care Unit for several days.
CONDITION AT TIME OF TRANSFER: Stable in room air to
[**Hospital3 1810**] for hernia repair.
TRANSFER DISPOSITION: To [**Hospital3 1810**] via ambulance.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 37517**] of [**Hospital 1887**]
Pediatrics. Phone number is [**Telephone/Fax (1) 37518**].
CARE AND RECOMMENDATIONS: Infant has been NPO since 3 a.m.
on [**3-12**].
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Passed.
STATE [**Month (only) **] SCREEN STATUS: Last state [**Month (only) 19402**] screen was
sent on [**3-8**]. No abnormal results have been reported.
IMMUNIZATIONS RECEIVED: [**Known lastname **] received his hepatitis B
vaccine on [**1-24**] and [**2-21**]. His Prevnar on
[**2-21**] and his DTaP, HIB, and IPV on [**2-23**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of the following:
Daycare during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-age
siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSIS LIST: Prematurity at 26-6/7 weeks.
Twin gestation.
Presumed sepsis.
Respiratory distress syndrome.
Status post patent ductus arteriosus ligation.
Hyperbilirubinemia.
Right inguinal hernia.
Mild retinopathy of prematurity. Follow-up exam needed in 2
weeks)
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2201-3-12**] 01:26:52
T: [**2201-3-12**] 04:42:18
Job#: [**Job Number 59785**]
Name: [**Known lastname 11**], BOY II ([**Known firstname 5461**] G) Unit No: [**Numeric Identifier 10947**]
Admission Date: [**2200-12-15**] Discharge Date: [**2201-3-15**]
Date of Birth: [**2200-12-15**] Sex: M
Service: NB
This is a discharge summary addendum to follow the discharge
summary report date of [**2201-3-12**].
[**Known lastname **] [**Known lastname **] is now a 90-day old former 26-5/7-week infant,
twin #2 who is ready for discharge home.
His NICU course since the last discharge summary as follows:
Respiratory status: [**Known lastname **] has remained in room air. He has had
no further episodes of apnea or bradycardia. On exam, his
respirations are comfortable. Lung sounds are clear and
equal.
Cardiovascular status: He has been mildly hypertensive since
his hernia surgery on [**2201-3-12**] with systolics in the
high 90 range and diastolic in the 50-60 range. This was
thought to be due to discomfort that was not adequately
treated. After doses of Tylenol, his blood pressure came down
to 84/42 with a mean of 58. For completeness, he did have a
urinalysis sent that had a bag specimen that had trace blood,
30 mg/dl of protein, [**2-28**] red blood cells, [**2-28**] white blood
cells, and 0-2 epithelial cells, specific gravity 1.010, and
pH 7.5. BUN was 8 and creatinine 0.2. On exam, his heart was
regular rate and rhythm, no murmur. He is pink and well
perfused.
Fluid, electrolytes, and nutrition status: At discharge, his
weight is 2,840 grams, length 48 cm, and head circumference
35 cm. He is taking 26 calories per ounce Enfamil AR on an ad
lib schedule.
Gastrointestinal status: On [**2201-3-12**], he had his
bilateral inguinal hernias repaired and umbilical hernia
repaired and was circumcised. The inguinal-abdominal
incisions remained with mild erythema and edema with well-
approximated edges.
Infectious disease status: On the day after surgery due to
the exam of the incisions, a CBC and blood culture were done.
Blood culture remains negative. CBC had a white count of 10.5
with a differential of 27 polys and 2 bands, hematocrit of
26, and platelets 421,000. He was not started on any further
antibiotics.
Hematology: He has received no further blood product
transfusion.
Sensory: Hearing screening was performed with automated
auditory brain stem responses. The infant passed in both
ears.
Psychosocial: His twin sibling was discharged the day prior
to [**Known lastname **].
CONDITION AT DISCHARGE: He is discharged in good condition.
DISPOSITION: He is discharged home with his family.
PRIMARY PEDIATRICIAN: His primary pediatrician is Dr. [**First Name8 (NamePattern2) 10948**]
[**Last Name (NamePattern1) 10949**], telephone number [**Telephone/Fax (1) 10950**].
FEEDINGS AT DISCHARGE: Enfamil AR 26 calories per ounce, 4
calories per ounce with concentration and 2 calories per
ounce with corn oil on an ad lib schedule.
MEDICATIONS: Ferrous sulfate (25 mg per mL) 0.25 mL p.o.
daily.
Tylenol 40 mg p.o. every 6 hours for 24 hours after
discharge.
CAR SEAT POSITION SCREENING: He passed a car seat position
screening test.
IMMUNIZATIONS RECEIVED: He received his Synagis immunization
on [**2201-3-14**].
FOLLOW-UP APPOINTMENTS: Early Intervention of [**Location (un) 8029**],
Early Intervention Program of [**Location (un) 407**], telephone number [**Telephone/Fax (1) 10951**].
Visiting Nurses Association of the [**Company 720**],
telephone number 1-[**Telephone/Fax (1) 10952**].
Infant Follow-up Program at [**Hospital3 5223**], telephone
number [**Telephone/Fax (1) 10953**].
Ophthalmology appointment for his retinopathy of prematurity
with Dr.[**First Name9 (NamePattern2) 10954**] [**Name (STitle) **] of telephone number [**Telephone/Fax (1) 10955**]. His
appointment is on [**2201-4-1**] at 11 a.m.
ADDITIONAL DISCHARGE DIAGNOSES: Status post bilateral
inguinal hernia repair.
Status post umbilical hernia repair.
Status post circumcision.
Status post transient hypertension.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 10956**]
Dictated By:[**Last Name (NamePattern1) 10957**]
MEDQUIST36
D: [**2201-3-16**] 01:53:50
T: [**2201-3-16**] 04:49:31
Job#: [**Job Number 10958**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
[]
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|
20525, 20943
|
2893, 6309
|
14970, 15407
|
9905, 14943
|
19907, 20503
|
19455, 19882
|
15435, 19144
|
167, 1910
|
9013, 9876
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,800
| 196,611
|
46360
|
Discharge summary
|
report
|
Admission Date: [**2161-10-11**] Discharge Date: [**2161-10-19**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Acute on chronic respiratory distress
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
65M with Severe COPD (FEV1/FVC 23% of predicted) on home 02,
Schizophrenia, Pulmonary HTN (51-66mmHg on TTE)The pt presents
from his group home after he was noted to be lethargic with
oxygen sats in the 70s. History is unable to be obtain from the
patient and no contact information was available for contact.
[**Name (NI) **] EMS report "pt was found lying in bed having difficulty
breathing but stating he didnt want to go." Per report usual O2
sats are in the 80s. Pt was noted there to have bilaterally
upper airway wheezes and decreased breath sounds at the bases.
There the pt was not noted to have JVD.
.
In the ED, initial 96.5 72 124/84 28 97. Initial exam notable
for letharic but speaking and audible wheezing. Labs notable for
initial ABG 7.19/109/100. WBC 9.7, Na 147 HCO3 36, Trop 0.01.
Patient underwent CXR with question R lower infiltrate. The
patient received Combivent Nebs, Azithromycin 500mg, Ceftriaxone
1gm, Solumedrol 125mg. The patient also underwent a non-contrast
head CT. ECG NSR 74, TWI in II, III, avf, V2-V6. The patient
then underwent repeat ABG in the ED following an hour of BiPap
7.31/64/153. The pt continued to remain lethargic and was
subsequently intubated.
Past Medical History:
1) COPD: FEV1 23% predicted, home 1.5-2L O2 at night only
2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
3) Schizophrenia
4) Hx GI bleeding
5) Mental Retardation
6) Pulmonary Hypertension
7) s/p tonsillectomy
Social History:
Lives in [**Location **] with brother and brother-in-law. On
disability since [**2149**] for mental health issues. Has home nurse
visit every morning and evening. Reports ~50 pack-year smoking
and has now cut down to 3 cigs/day. Denies any ETOH/drug use.
Family History:
Patient unable to provide.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Intubated Sedated, Moving all extremities
[**Year (4 digits) 4459**]: PERRLA, 1mm
Neck: JVP to ear on right elevated, no LAD
Lungs: Mild bilateral wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley
Ext: Cool lower extremities, 1+ DP
Pertinent Results:
LABS at admission:
[**2161-10-11**] 09:38AM BLOOD WBC-9.7 RBC-4.73 Hgb-14.4 Hct-44.9 MCV-95
MCH-30.4 MCHC-32.1 RDW-14.0 Plt Ct-239
[**2161-10-11**] 09:38AM BLOOD Neuts-76.9* Lymphs-16.8* Monos-3.9
Eos-1.7 Baso-0.7
[**2161-10-11**] 09:38AM BLOOD PT-13.2 PTT-33.4 INR(PT)-1.1
[**2161-10-11**] 09:38AM BLOOD Plt Ct-239
[**2161-10-11**] 09:38AM BLOOD Glucose-137* UreaN-26* Creat-1.0 Na-147*
K-4.5 Cl-105 HCO3-36* AnGap-11
[**2161-10-11**] 01:15PM BLOOD Glucose-151* UreaN-27* Creat-1.2 Na-143
K-4.7 Cl-103 HCO3-35* AnGap-10
[**2161-10-11**] 09:38AM BLOOD ALT-18 AST-23 AlkPhos-57 TotBili-0.4
[**2161-10-11**] 01:15PM BLOOD CK(CPK)-45*
[**2161-10-11**] 09:38AM BLOOD cTropnT-0.01
[**2161-10-11**] 01:15PM BLOOD CK-MB-4 cTropnT-<0.01
[**2161-10-11**] 09:38AM BLOOD Albumin-4.3
[**2161-10-11**] 01:15PM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
[**2161-10-11**] 09:50AM BLOOD Lactate-0.8 K-4.3
[**2161-10-11**] 09:50AM BLOOD Lactate-0.8 K-4.3
___________________________________________________
IMAGING:
CTA [**10-11**]
IMPRESSION:
1. No pulmonary embolism or aortic dissection.
2. Persistent severe emphysema with mild ground-glass opacities
and
interstitial septal thickening involving the posterior right
upper lobe
segment and apical posterior left upper lobe segment abutting
the major
fissures. This is nonspecific and may represent underlying
aspiration
pneumonitis/pneumonia.
3. Near two-year stability to multiple pulmonary nodules which
do not warrant
further followup. Stable mediastinal and hilar lymph nodes.
4. Mosaic attenuation of the lung parenchyma likely related to
severe
underlying emphysema as well as air trapping from unchanged
tracheobronchomalacia, most severely involving the bronchus
intermedius.
5. Mild dilatation to the main right and left pulmonary arteries
well as
right atrium/ventricle, which may reflect underlying pulmonary
arterial
hypertension.
ECHO [**10-13**]
IMPRESSION:
The left atrium is normal in size. 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>55%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated and the free wall may be hypokinetic (not fully
viusalized). The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no pericardial effusion.
CXR [**10-18**]
IMPRESSION:
The cardiac silhouette and mediastinum is within normal limits.
There has
been improved aeration at the streaky opacities at the lung
bases. No
pulmonary edema or pleural effusions are identified. There are
no
pneumothoraces.
___________________________________________________
BLOOD GASes:
[**2161-10-18**] 01:14PM BLOOD Type-ART pO2-56* pCO2-63* pH-7.46*
calTCO2-46* Base XS-17 Comment-NASAL [**Last Name (un) 154**]
[**2161-10-18**] 01:14PM BLOOD Type-ART pO2-56* pCO2-63* pH-7.46*
calTCO2-46* Base XS-17 Comment-NASAL [**Last Name (un) 154**]
[**2161-10-16**] 11:44PM BLOOD Type-[**Last Name (un) **] pO2-80* pCO2-90* pH-7.37
calTCO2-54* Base XS-21
[**2161-10-13**] 03:45PM BLOOD Type-ART Temp-35.6 pO2-146* pCO2-55*
pH-7.25* calTCO2-25 Base XS--3 Intubat-NOT INTUBA Comment-SIMPLE
FAC
[**2161-10-11**] 09:05PM TYPE-ART TEMP-36.7 RATES-12/ TIDAL VOL-550
PEEP-5 O2-40 PO2-117* PCO2-53* PH-7.41 TOTAL CO2-35* BASE XS-7
-ASSIST/CON INTUBATED-INTUBATED
___________________________________________________
LABS at Discharge:
[**2161-10-19**] 04:04AM BLOOD WBC-10.1 RBC-4.58* Hgb-13.7* Hct-43.1
MCV-94 MCH-30.0 MCHC-31.9 RDW-13.6 Plt Ct-257
[**2161-10-18**] 04:05AM BLOOD Neuts-92.0* Lymphs-4.5* Monos-2.5 Eos-0.7
Baso-0.3
[**2161-10-19**] 04:04AM BLOOD Glucose-112* UreaN-27* Creat-0.6 Na-142
K-3.7 Cl-97 HCO3-40* AnGap-9
[**2161-10-19**] 04:24AM BLOOD Type-[**Last Name (un) **] Temp-36.1 Rates-/30 Tidal V-200
PEEP-5 FiO2-24 pO2-44* pCO2-73* pH-7.41 calTCO2-48* Base XS-16
Intubat-NOT INTUBA Vent-SPONTANEOU
[**2161-10-18**] 01:14PM BLOOD Type-ART pO2-56* pCO2-63* pH-7.46*
calTCO2-46* Base XS-17 Comment-NASAL [**Last Name (un) 154**]
[**2161-10-19**] 04:24AM BLOOD Lactate-0.9
Brief Hospital Course:
65M with COPD exacerbation and acute on chronic hypercarbic
respiratory failure
.
# Acute on Chronic Hypercarbic Hypoxemic Respiratory Failure :
Pt with known severe COPD, pC02>100 on arrival which initially
improved on bipap. Pt was afebrile without leukocytosis.
Precipitating factors may have included CAP, viral URI. Patients
with large A-a gradient on arrival. Lethargy prompted intubation
in the ED after he was given ativan for agitation. He was then
extubated on [**10-12**] to BIPAP. He received IV diuretics, IV steroids
which were transitioned to PO prednisone on [**2161-10-18**] and
completed 5 day course of Azithromycin for COPD exacerbation. He
was initially treated with Ceftriaxone as well for 3 days but
this was discontinued when there was no clear evidence of
pneumonia. He continued to have waxing course requiring long
duration of BIPAP especially at night, frequent nebs, suctioning
as well as morphine IV for agitated respiratory distress. DNI
status was confirmed with pt and family several times. BIPAP was
then weaned over the course of next several days and daily
steroid dose was decreased. On day of discharge, he was sating
in low-mid 90s on 1L NC. He had only required 2 hours of BiPap
the day prior for increased work of breathing which was much
decreased from prior requirements. He may still require Bipap at
night for fatigue. At time of discharge, he demonstrates
abdominal breathing and tachypnea with RR high 20s but he states
breathing is much improved and is alert and awake and his pCO2
is at his baseline in the mid 60s. Home tiotropium and advair
held while he is receiving albuterol and ipratropium nebs and PO
prednisone. Plan is for 7 more days of prednisone which could be
adjusted based on pulmonary status.
.
# Acute Change in MS: Patient noted to be lethargic on arrival.
This was initially in the setting of pCO2>100. Unclear from ED
course whether patients MS improved following BiPap. CT Head
without acute ICH. Pt subsequently became more alert and
oriented as his respiratory status improved. On day of discharge
he was somnolent but able to converse appropriately when
aroused.
.
# Hypotension: Patient initially with SBP 124 on arrival to the
ED. Following intubation and sedation with propofol,his SBP has
dropped to 90s. Pt with questionable PNA on CXR but without
fever, tachycardia or leukocytosis, and thus did not meet SIRS
criteria. His BP remained stable during the MICU course. Blood
and sputum cx were negative.
.
# TWIs: ECGs with TWIs inferolaterally. Troponins negative. Echo
LVEF>55% with thickened LV and dilated, possibly hypokinetic RV.
Stable during MICU course.
# Schizophrenia: He was continued on his home medication
zyprexa.
Medications on Admission:
Albuterol MDI
Famotidine 20mg [**Hospital1 **]
Advair 500-50
Zyprexa 7.5mg
Tiotropium 18mcg
ASA 81mg
Tylenol 325
Colace
MVI
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
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).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Olanzapine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 7 days.
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Morphine 5 mg/mL Solution Sig: 1-2 mg Injection Q4H (every 4
hours) as needed for anxiety/agitation.
12. Insulin Lispro 100 unit/mL Solution Sig: [**3-20**] units
Subcutaneous ASDIR (AS DIRECTED): See attached. Only needed
while patient continues on prednisone.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Hemodynamically Stable, on Nasal cannula with intermittent
BIPAP, O2 in low-mid 90s on nasal cannula at rest. He does
exhibit slightly labored breathing with the use of accessory
muscles.
Alert and oriented, able to converse appropriately,
He is able to take PO medication and meals.
He is not currently ambulating.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing from
your COPD. You did not have any evidence of infection or
pneumonia. You were initially on a breathign machine for
approximately 2 days but we took you off the breathing machine
and your breathing slowly improved with steroids and breathign
treatments. You intermittently required a mask to help you with
your breathing but the time you required the mask improved
greatly over the course of your stay in the ICU.
Please follow up with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Please take all of your medications as prescribed and please do
not resume smoking cigarettes. This is extremely important for
your health, especially while you are on oxygen.
We made the following changes to your medications:
1. We added albuterol nebs q6hours and q2 hours as needed
2. We added ipratropium nebs q6 hours and stopped your
tiotropium while you are receiving nebs
3. We added prednisone 60mg PO daily x 7 more days
4. We added morphine as needed for SOB
5. We added insulin for hyperglycemia to 200s while you were on
prednisone
6. We added a nicotine patch to help you with quitting smoking
7. We added a bowel regimen for constipation
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] when you leave the rehab
facility.
Name: [**Last Name (LF) 1022**], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 4004**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2161-10-21**]
|
[
"319",
"491.21",
"300.00",
"518.84",
"305.1",
"295.90",
"416.8",
"458.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10941, 11012
|
6915, 9625
|
354, 366
|
11073, 11390
|
2628, 6215
|
12676, 13326
|
2142, 2170
|
9799, 10918
|
11033, 11052
|
9651, 9776
|
11414, 12197
|
2185, 2609
|
12226, 12653
|
277, 316
|
6235, 6892
|
394, 1592
|
1614, 1852
|
1868, 2126
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,228
| 197,239
|
54408
|
Discharge summary
|
report
|
Admission Date: [**2185-5-1**] Discharge Date: [**2185-5-4**]
Date of Birth: [**2124-6-6**] Sex: M
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Requesting detox
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 yo male with history of EtOH abuse presents to the ED
requesting detox after initially presenting to [**Hospital1 112**] but the wait
was too long. He reports his last drink was yesterday morning
and he drank a pint and [**12-26**] of vodka and [**12-26**] pint of wine. He
was just discharged from the ED on [**2185-4-29**] for ETOH intoxication.
He has had multiple hospitalizations for ETOH intoxication over
the last month.
.
In the ED initial VS were 98.4 105 152/129 22 100% RA.
According to the ED staff who knows him well, he appears very
different, appears sober. Given hypertension, "shaky" and
tachycardia, treating empirically for withdrawal despite pending
ETOH level. Labs were significant for mag 0.9, ast 80, alt 52,
serum tox pending. He has received a total of 10mg PO and 40mg
IV valium, MVI, thiamine, folate, and will receive 4gm of mag
prior to transfer. Because of the suspicion of active
withdrawal, he was transferred to the MICU. No CIWA scores were
obtained. VS on transfer were 98.5 93 180/114 20 98%RA.
.
On the floor, the patient is requesting "meds" because he is so
shaky. He reports ears ringing, seeing "bubbles." He also
reports mild Abd pain and headache. He is concerned "ETOH
WITHDRAWAL" will appear on his discharge paperwork and will
effect his probation.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies 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, or changes in bowel habits.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
ETOH abuse w/ reported history of seizures and DTs
Polysubstance abuse (heroin remotely, and cocaine more recently)
Chronic HCV infection
Remote history of vertebral osteomyelitis
Low Back Pain / Degenerative disease / Vertebral compression
fractures
Diabetes mellitus type II
Pseudo-seizures
Hypertension
Depression
Left parietal bone lesion NOS - ?atypical hemangioma
Calf injury [**2175**] with left gluteal transplant to left calf
Social History:
Reports at least 1 [**12-26**] pints of vodka plus wine per day. He
drinks because he is "depressed." Smokes 1 cigar per day. Used
heroin >3 years ago and cocain >1 year ago. Emigrated from
[**Male First Name (un) 1056**] in [**2132**]. Patient has been homeless for 2 weeks.
Family History:
DM in mother, brother. Father died of throat cancer. No FH of
drug or alcohol abuse.
Physical Exam:
On admission:
General: Alert, oriented, no acute distress, mildly anxious,
resting tremor worse with intention
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
On discharge:
Patient was alert and oriented x3. He had no nystagmus, slurred
speech, coarse tremors, or tactile or visual hallucinations. The
rest of his exam including his HEENT, pulmonary, cardiac, and
abdominal exam was at baseline.
Pertinent Results:
Admission labs:
[**2185-5-1**] 09:16AM BLOOD WBC-7.7 RBC-4.17* Hgb-13.3* Hct-37.3*
MCV-90 MCH-31.8 MCHC-35.5* RDW-14.4 Plt Ct-297
[**2185-5-1**] 09:16AM BLOOD Neuts-73.4* Lymphs-18.8 Monos-6.0 Eos-0.9
Baso-1.0
[**2185-5-1**] 08:35AM BLOOD Glucose-117* UreaN-6 Creat-0.9 Na-141
K-3.8 Cl-99 HCO3-25 AnGap-21*
[**2185-5-1**] 08:35AM BLOOD Calcium-9.2 Phos-3.4 Mg-0.9*
Discharge labs:
[**2185-5-4**] 06:31AM BLOOD WBC-6.7 RBC-3.86* Hgb-12.1* Hct-35.6*
MCV-92 MCH-31.4 MCHC-34.0 RDW-14.5 Plt Ct-242
[**2185-5-2**] 05:55AM BLOOD Neuts-70.1* Lymphs-19.6 Monos-4.3
Eos-5.0* Baso-1.0
[**2185-5-4**] 06:31AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-135 K-3.9
Cl-101 HCO3-27 AnGap-11
[**2185-5-3**] 06:33AM BLOOD ALT-77* AST-129* AlkPhos-87 TotBili-0.3
[**2185-5-2**] 05:55AM BLOOD calTIBC-330 VitB12-685 Folate-17.6
Ferritn-119 TRF-254
Brief Hospital Course:
60 yo male with history of ETOH abuse, history of polysubstance
abuse, HTN, admitted to the MICU for treatment of alcohol
withdrawal, stabilized and then transferred to the inpatient
floor
.
# ETOH withdrawal: Patient has extensive history of ETOH
dependence requiring multiple admissions for alcohol
intoxication and detox. In the ED, Mr. [**Known lastname 30258**] received large
quantities of valium and then was admitted to the MICU for ETOH
withdrawal. In the MICU, he was put on the CIWA score with
valium and stabilized. He also received multivitamins, thiamine
and folate. On [**5-1**] the patient was transferred to the inpatient
unit on [**5-1**] where he was continued on the CIWA score and
required valium for coarse tremors. Additionally the patient
endorsed nausea, vomiting, and he was tachycardic and
hypertensive to the 180s systolic. However throughout the
hospital stay, the patient denied any auditory, visual or
tactile hallucations. He was afebrile, and his detox was not
complicated by seizures. On discharge the patient reported
symptomatic improvement and was without any valium requirement.
CIWA score was [**6-1**] but was mostly related to mild coarse tremor
and anxiety which was improved.
.
# Diarrhea: Patient reports a 3 week history of diarrhea and
was on ciprofloxacin in the past. Mr. [**Known lastname 30258**] also endorses
bloating and intermittent abdominal cramping. He believes his
diarrhea has worsened recently and was incontient in the MICU
and on the inpatient floor. Stool samples including a
clostridium difficile screen were ordered but diarrhea resolved
prior to dsicharge so they were nto sent.
.
# Hypertension: Patient's systolic blood pressure was elevated
to the 180s and diastolic blood pressure to the 110s. This was
most likely related to ETOH withdrawal in addition to baseline
HTN. Notably at no point during this hospital course did the
patient experience any signs of hypertensive emergency such as
visual changes, headache, etc. Per the patient he was on
verapamil in the past for HTN, and therefore he was re-started
on verapamil 180 mg daily but with minimal effect. He also had
occasional low heart rate at night in 60s, and therefore the
patient was changed to amlodipine on [**5-2**] for improved blood
pressure control which can be uptitrated to 10mg as an
outpatient. He was not started on ACE or diuretic due to unclear
follow-up and need for closer follow up.
.
# Depression: Patient reports history of depression and at this
time endorses anhedonia. However he is not acutely at risk for
self-harm and denies suicidal ideations and homicidal ideations.
Patient was on citalopram in the past and requested that he
re-start on his medication. We re-started him on citalopram 20
mg daily.
.
# Anemia: Normocytic anemia with normal Fe, B12 and folate.
This is most likely secondary to his alcoholism. Alcohol has a
direct toxic effect on red blood cell production. Also bleeding
can occur from alcoholic gastritis although patient currently
does not report any coffee-ground emesis, melena or bright red
bleeding per rectum at this point. Given that he is
nutritionally replete without evidence of bleeding, no acute
intervention is indicated at this point.
Transitional Issues
On discharge, patient was afebrile with stable vital signs. He
reported symptomatic improvement and expressed a desire to
attend an inpatient substance abuse facility. He will need
follow-up in terms of formulating an adequate blood pressure and
depression medication regimen. Lastly he will need follow-up for
the work-up of his diarrhea including his stool studies. Finally
patient is homeless and will need social work and case
management services.
Medications on Admission:
Thiamine HCl 100 mg PO DAILY
Folic Acid 1 mg PO DAILY
Verapamil 180 mg PO Q24H
Citalopram 20 mg PO DAILY
Multivitamin PO DAILY (Daily)
Trazodone prn
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary diagnosis: ETOH withdrawal, hypertension
Secondary diagnosis: Polysubstance abuse, low back pain, DM-II,
depression, chronic HCV infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for alcohol withdrawal. You received valium to
control your symptoms such as anxiety and tremors. Additionally
you were also given thiamine, multivitamins and folate.
You also had high blood pressure in the hospital. This may be
related to your alcohol withdrawal. Verapamil the medication you
were on was not helping us control your blood pressure
adequately, so we switched to another medication amlodipine.
We made the following changes to your medication:
- We stopped Verapamil 180 mg daily
- We started Amlodipine 5 mg daily
We are discharging to an inpatient facility where they will
continue to help manage your alcohol dependence, high blood
pressure, and depression.
Followup Instructions:
Patient will need follow-up with his PCP after he is discharged
from the inpatient facility
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"285.9",
"787.91",
"275.2",
"291.81",
"311",
"724.2",
"303.91",
"070.54",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
9114, 9157
|
4579, 8286
|
283, 289
|
9348, 9348
|
3731, 3731
|
10221, 10409
|
2839, 2926
|
8486, 9091
|
9178, 9178
|
8312, 8463
|
9499, 10198
|
4113, 4556
|
2941, 2941
|
3488, 3712
|
1650, 2071
|
227, 245
|
317, 1631
|
9248, 9327
|
3747, 4097
|
9197, 9227
|
2955, 3474
|
9363, 9475
|
2093, 2530
|
2546, 2823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,657
| 122,125
|
23708
|
Discharge summary
|
report
|
Admission Date: [**2184-10-6**] Discharge Date: [**2184-10-8**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Ativan
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
[**Age over 90 **] year old male with stroke [**2175**], PVD, CAD s/p CABG [**2172**],and
CKD who presents with chief complaint of fatigue and 1 episode
of BRBPR 1 week ago with black stools since then. Routine
screening labs done at his [**Hospital3 **] facilty detected a
hgb of 5.6for which his PCP referred him to the ED.
.
In the ED, initial vitals were 98.3 103/53 96 16 100%RA. Initial
HCT was 18.5. The patient was guaiac positive. He was also noted
to have a positive troponin and lateral ST depressions which
were attributed to demand ischemia. The patient was transfused 1
units of packed RBCs, a second was ordered and started on a PPI.
GI was consulted. His mentation was noted to be slow and off his
baseline.
.
On arrival to the floor, vitals 88 143/70 16 100% 2L. Pt reports
that he has been feeling fatigued with minimal chest pain. He
does endorse worsening shortness of breath and dyspnea on
exertion. He notes that his appetite has been decreased for the
last several days. he endorses minimal nausea and diarrhea but
no vomiting. He states that his legs have been bothering when he
stands or walks. He also reports that he has fallen in the past,
most recently about 2 weeks ago. He denies headache and dysuria.
Past Medical History:
- Peripheral vascular disease - s/p left common femoral to
anterior tibial angioplasty ([**3-/2180**]) now has Significant
stenosis in the left common femoral artery, moderate stenosis in
the popliteal artery.
- CAD s/p CABG [**2172**]
- Hypertension - off BP meds since [**11-23**]
- Hyperlipidemia
- Hypothyroidism
- "h/o bradycardia"
- h/o diverticulitis
- Irritable bowel syndrome
- Hiatal hernia with GE reflux and a lower esophageal ring
- Chronic kidney disease (baseline Cr 2.0 per daughter)
Social History:
Lives in [**Hospital3 **] in [**Location (un) 1887**], MA. Retired accountant.
Widowed. Has 2 children. A son lives in , [**Name (NI) 60583**], PA. A
daughter lives in MA. He eats his breakfasts and dinners in
dining [**Doctor Last Name **]. Drinks 1 glass of Scotch per day. Non-smoker.
Family History:
NC
Physical Exam:
PHYSICAL EXAM
Vital signs: T- 97.0, HR- 83, BP- 136/65, RR- 18, SaO2- 98% on
RA
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. Conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. Neck Supple, No LAD
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= not elevated
LUNGS: Clear to ausculatation bilaterally. Good air movement
biaterally.
ABDOMEN: Positive bowel sounds. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-19**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2184-10-6**] 11:25AM WBC-9.7 RBC-1.92*# HGB-5.6*# HCT-18.5*#
MCV-96 MCH-29.1 MCHC-30.3* RDW-15.5
[**2184-10-6**] 11:25AM NEUTS-67.5 LYMPHS-21.8 MONOS-8.1 EOS-2.2
BASOS-0.4
[**2184-10-6**] 11:25AM PLT COUNT-401#
[**2184-10-6**] 11:25AM PT-12.9 PTT-22.8 INR(PT)-1.1
[**2184-10-6**] 11:25AM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-2.4
[**2184-10-6**] 11:25AM CK-MB-11* MB INDX-8.7*
[**2184-10-6**] 11:25AM cTropnT-0.36*
[**2184-10-6**] 11:25AM GLUCOSE-108* UREA N-39* CREAT-1.7* SODIUM-143
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-26 ANION GAP-12
[**2184-10-6**] 11:37AM HGB-5.7* calcHCT-17
[**2184-10-6**] 09:09PM HCT-25.7*#
[**2184-10-6**] 09:09PM CK(CPK)-98
[**2184-10-7**] 05:11AM BLOOD WBC-9.9 RBC-3.75*# Hgb-11.0*# Hct-33.2*#
MCV-89# MCH-29.4 MCHC-33.2 RDW-16.4* Plt Ct-243
[**2184-10-7**] 12:02PM BLOOD Hct-32.1*
[**2184-10-7**] 08:13PM BLOOD Hct-32.6*
[**2184-10-8**] 06:00AM BLOOD WBC-9.3 RBC-3.64* Hgb-10.9* Hct-32.4*
MCV-89 MCH-29.9 MCHC-33.6 RDW-16.3* Plt Ct-244
[**2184-10-6**] 11:25AM BLOOD PT-12.9 PTT-22.8 INR(PT)-1.1
[**2184-10-7**] 05:11AM BLOOD PT-13.7* PTT-26.5 INR(PT)-1.2*
[**2184-10-8**] 06:00AM BLOOD Plt Ct-244
[**2184-10-6**] 11:25AM BLOOD Glucose-108* UreaN-39* Creat-1.7* Na-143
K-4.4 Cl-109* HCO3-26 AnGap-12
[**2184-10-7**] 05:11AM BLOOD Glucose-96 UreaN-32* Creat-1.6* Na-141
K-4.5 Cl-110* HCO3-22 AnGap-14
[**2184-10-8**] 06:00AM BLOOD Glucose-78 UreaN-25* Creat-1.5* Na-139
K-4.0 Cl-106 HCO3-23 AnGap-14
[**2184-10-6**] 11:25AM BLOOD CK(CPK)-127
[**2184-10-6**] 09:09PM BLOOD CK(CPK)-98
[**2184-10-7**] 05:11AM BLOOD CK(CPK)-96
[**2184-10-6**] 11:25AM BLOOD cTropnT-0.36*
[**2184-10-6**] 09:09PM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2184-10-6**] 11:25AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.4
[**2184-10-7**] 05:11AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3
EKG ([**10-6**])- Sinus arrhythmia with frequent ventricular
premature beats. Left axis deviation with left anterior
fascicular block. Right bundle-branch block. Inferolateral ST-T
wave changes that are non-specific. Compared to the previous
tracing of [**2183-1-8**] ventricular premature beats are new
EGD ([**10-7**])-
Impression: Hiatal hernia
Erythema in the gastroesophageal junction compatible with
Barrett's esophagus
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Acute blood loss anemia - Remained hemodynamically stable.
Transfused 4 U PRBC with appropriate increase in Hct. Treated
with IV PPI [**Hospital1 **]. EGD [**10-7**] showed hiatal hernia and possible
Barrett's esophagus but no active source of bleeding. Colonscopy
planned for [**10-8**] however patient determined that he did not
want to undergo a colonoscopy. Patient's last colonoscopy at
least 6 years ago in New Jersdy, reportedly negative. Dr.
[**Last Name (STitle) 24692**] had long discussion with daughter [**Name (NI) **] [**Last Name (NamePattern1) 410**] who is
HCP and overall decision was not to pursue colonoscopy. There is
clear understanding that this could be colon pathology including
malignancy. Patient would not want anything done even if
malignancy. Patient will not pursue colonoscopy at any point and
prefers to be transfused as needed should hematocrit decrease as
an outpatient. He ambulated well (without any dizziness or
difficulties) and tolerated his diet. Upon discharge, he had no
more BRBPR and his hematocrit was stable at ~33 (18.5 on
admission). His aspirin and plavix were held on discharge with
plans for primary care physician to decide on resuming them when
he sees the patient next week ([**Date range (1) 60584**]) at his nursing home.
Troponin Leak - Seen in consultation by cardiology who felt more
consistent with subendocardial/demand ischemia in the setting of
obstructive CAD and acute blood loss anemia. EKG not
significantly changed from prior. Continued crestor. Aspirin,
plavix, metoprolol held. Patient denied any chest pain,
shortness of breath, headache, dizziness, or syncope. He was
monitored on telemetry and no ischemic events were noted. Upon
discharge, he was stable and asymptomatic.
Hypothyroidism - Continued levothyroxine
Medications on Admission:
Plavix 75mg daily
Crestor 20mg daily
Prilosec 20mg daily
Ocuvite 2 tablets [**Hospital1 **]
Levothyroxine 88mcg daily
MVI 1 tablet daily
Aspirin 81mg daily
Discharge Medications:
1. FiberCon 625 mg Tablet Sig: One (1) Tablet PO once a day.
2. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Medication
Please continue your home dose of Ocuvite- 2 tablets by mouth
twice daily
7. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Caretenders VNA
Discharge Diagnosis:
Primary: GI bleed
Secondary: Peripheral vascular disease, coronary artery
disease, hypertension, hyperlipidemia, hypothyroidism
Discharge Condition:
Good. Vital signs stable. Ambulated well.
Discharge Instructions:
You were admitted to the hospital for a GI bleed. While here
you had a low blood count so you were transfused some blood.
You underwent a scope which showed no signs of an upper GI
bleed. You decided that you did not want a colonoscopy
performed. Your blood counts remained stable for multiple days
while here. You did not have a bloody bowel movement while
here. Upon discharge, you were stable and comfortable.
The following changes were made to your medications:
1. Please discontinue your aspirin until you see your primary
care physician next week.
2. Please discontinue your plavix until you see your primary
care physician next week.
If you experience another GI bleed, fevers, chills, vomiting,
chest pain, shortness of breath or any other medically
concerning symptoms, please contact your primary care physician
or go to the emergency department immediately.
Followup Instructions:
Your primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 60585**]) is aware that
you were admitted to the hospital and will come see you at your
home within the next week. If you have any questions, please
call him at [**Telephone/Fax (1) 60586**].
Please discuss restarting aspirin and plavix with him at this
appointment
Completed by:[**2184-10-10**]
|
[
"403.90",
"530.85",
"553.3",
"414.00",
"443.9",
"285.1",
"244.9",
"585.9",
"272.4",
"578.1",
"530.81",
"564.1",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8133, 8179
|
5579, 7380
|
254, 259
|
8354, 8399
|
3265, 3265
|
9325, 9720
|
2370, 2374
|
7586, 8110
|
8200, 8333
|
7406, 7563
|
8423, 9302
|
2389, 3246
|
208, 216
|
287, 1523
|
3281, 5556
|
1545, 2048
|
2064, 2354
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,564
| 112,044
|
1524
|
Discharge summary
|
report
|
Admission Date: [**2122-12-23**] Discharge Date: [**2123-1-28**]
Date of Birth: [**2068-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Mr. [**Known lastname **] is a 54-year-old gentleman with
biopsy-proven locally advanced T3N1M1A carcinoma of the mid
esophagus. He continues to have intense pain with increased
PET activity at the superior and inferior aspect of the stent.
Major Surgical or Invasive Procedure:
thoraco-abdominal esophagectomy, esophagogastroduodenoscopy,
J-tube revision [**2122-12-23**]
Port-O-Cath removal [**2123-1-22**]
EGD w/ pylorus dilitation
History of Present Illness:
54 yr old man cervical esophageal cancer requiring
Mr. [**Known lastname **] is a 54-year-old gentleman with
biopsy-proven locally advanced T3N1M1A carcinoma of the mid
esophagus. He has recently completed chemoradiotherapy on an
induction protocol. He has had a remarkable reduction in his
documented nodal disease as well as in the T stage. He
continues to have intense pain with increased PET activity at
the superior and inferior aspect of the stent.
Past Medical History:
Hepatitis C Virus
Hypertension
Prostate Cancer s/p brachytherapy.
Poorly differentiated squamous esophageal CA (stage III)
-dx'ed [**2122-7-20**] on multiple biopsies with EGD
-PET found supraclavicular nodes that appeared positive.
-s/p esophageal stent
-planned for surgery in 6 weeks
Gastric esophogeal reflux disease
Social History:
Previously worked at Digital and Polaroid. Lives with his
daughter. [**Name (NI) **] ?girlfriend. Used to smoke, quit after cancer
diagnosis. No EtOH currently, never heavy drinker. No IVDU.
Family History:
both brothers have prostate cancer, one passed away 2 month ago
from this
Physical Exam:
General: cachetic appearing African American male w/ c/o
epigastric pain on -chronic sq dilaudid PTA
chest: lungs CTA bilat. POC
Cor: RRR S1, S2
Abd: flat, soft, NT, J-tube in place.
Extrem: no LE edema.
Neuro: A+OX3 w/no focal neuro deficits
Pertinent Results:
[**2122-12-23**] 05:57PM GLUCOSE-147* UREA N-17 CREAT-0.7 SODIUM-134
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17
[**2122-12-23**] 05:57PM WBC-17.2*# RBC-3.98* HGB-12.0* HCT-34.1*
MCV-86 MCH-30.1 MCHC-35.2* RDW-14.4
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-1-27**] 06:25AM 6.5 2.91* 8.2* 25.6* 88 28.2 32.2 14.5
391
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2123-1-27**] 06:25AM 391
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2123-1-26**] 11:00AM 144* 11 0.6 139 3.9 104 261 13
1 NOTE UPDATED REFERENCE RANGE AS OF [**2122-8-14**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2122-12-27**] 03:09AM 742* 160* 190 108 0.9
Source: Line-arterial
OTHER ENZYMES & BILIRUBINS Lipase
[**2122-12-26**] 03:33AM 8
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2123-1-26**] 11:00AM 8.3* 4.0 1.5*
HEMATOLOGIC calTIBC Ferritn TRF
[**2123-1-4**] 06:10AM 160* 859* 123*
LIPID/CHOLESTEROL Cholest Triglyc
[**2123-1-4**] 06:10AM 109 851
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
ANTIBIOTICS Vanco
[**2123-1-27**] 06:25AM 14.4*
LAB USE ONLY GreenHd EDTA Ho
CHEST (PA & LAT) [**2123-1-26**] 10:23 AM
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with esoph ca now s/p thoraco-abd esophagectomy.
REASON FOR THIS EXAMINATION:
?interval change
TWO VIEW CHEST X-RAY [**2123-1-26**]:
COMPARISON: Deceember 11, [**2122**].
INDICATION: Status post esophagectomy.
IMPRESSION: Stable postoperative appearance of mediastinum.
Improving multifocal pulmonary opacities.
BAS/UGI AIR/SBFT
Reason: please evaluate follow-through of barium from
oral-pharynx t
COMPARISON: Upper GI study of [**2122-8-31**].
LIMITED SINGLE CONTRAST UPPER GI STUDY: Contrast passes freely
down the remaining esophagus and gastric pull-up. Trace
aspiration was noted. Adjacent to the site of the drain, there
is appears to be a focal area of contrast extravasation. There
is delayed and slow emptying of contrast from the stomach.
Barium was administered through the J- tube which demonstrated
filling of the jejunal loops. The patient vomited approximately
150 cc of barium and the study was terminated due to patient
intolerance.
IMPRESSION:
1. Mild aspiration.
2. Focal contrast extravasation at the site of the leftsided
drain.
The study and the report were reviewed by the staff radiologist.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2123-1-27**] 2:47 PM
Reason: Please obtain UPRIGHT CXR to assess for pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with esoph ca now s/p thoraco-abd esophagectomy
now s/p EGD w/ balloon dilation of stricture
REASON FOR THIS EXAMINATION:
Please obtain UPRIGHT CXR to assess for pneumothorax
PORTABLE CHEST, [**2123-1-27**]
COMPARISON: [**2123-1-26**].
INDICATION: Status post EGD procedure. Evaluate for
pneumothorax.
There is no evidence of pneumothorax or pneumomediastinum.
Postoperative changes are noted in the mediastinum following
esophagectomy and pull-up procedure. There remains asymmetrical
perihilar haziness on the right as well as a moderate-sized
right pleural effusion. Minor atelectatic changes are seen
within the left lung base, also without interval change.
IMPRESSION: No evidence of pneumothorax or pneumomediastinum.
CXRY - protable [**2123-1-28**]
s/p PICC line placement
Placement of PICC line tip in distal SVC. Confirmed by
visualization of film by NP and IVRN.
MICROBIOLOGY DATA
[**2123-1-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {STAPH AUREUS COAG +} INPATIENT
[**2123-1-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2123-1-24**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2123-1-24**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2123-1-22**] CATHETER TIP-IV WOUND CULTURE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}
INPATIENT
[**2123-1-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT
[**2123-1-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT
[**2123-1-21**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE} INPATIENT
[**2123-1-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
LIMITED SINGLE CONTRAST UPPER GI STUDY: Contrast passes freely
down the remaining esophagus and gastric pull-up. Trace
aspiration was noted. Adjacent to the site of the drain, there
is appears to be a focal area of contrast extravasation. There
is delayed and slow emptying of contrast from the stomach.
Barium was administered through the J- tube which demonstrated
filling of the jejunal loops. The patient vomited approximately
150 cc of barium and the study was terminated due to patient
intolerance.
IMPRESSION:
1. Mild aspiration.
2. Focal contrast extravasation at the site of the leftsided
drain.
The study and the report were reviewed by the staff radiologist.
Weight [**2123-1-28**] 51.5kg
Brief Hospital Course:
54-year-old gentleman with biopsy-proven locally advanced
T3N1M1A carcinoma of the mid-esophagus
esophagoscopy,bronchoscopy, transthoracic near total
esophagectomy with rightthoracotomy, laparotomy and left
cervicotomy, left cervical esophagogastrostomy and left tube
thoracostomy. Patient tolerated procedure well. Transferred to
ICU for observation, intubated, sedated, neo gtt, IVF, NPO, CT
to sx- no leak,. Pain control w/ fentanyl gtt iv due to
non-effective epidural. ICU course significant for:
POD#2 pt was extubated and new epidural placed, w/ dilaudid
PCA,+ BS, + flatus; IVF, NPO.Abd JP drains intact and draining.
Inc- C/D/I.
POD#3- tube feedings started- probalance at 10/hr. O2 wean trial
- 90% on 4Lnc.
POD#5-Tube feedings held for residual >200cc overnight, IVF. CT
to waterseal; ambulation- physical therapy, lytes repleated.
Patient transferred out of ICU to floor. Pain control w/ PCA,
epidural d/c.
On Floor:
REsp- pod#6 O2 sat 94% on RA, improving to 98-99% RA pod#33 at
time of discharge. CT d/c pod#7 w/o complication. Periodic
CXRY-wnl, w/ some atelectasis improving over hospital course.
GI- POD#6-+ flatus, + BM; j-tube accidently d/c'd and replaced
w/o complication. Tube feeding resumed @30-40cc/hr w/ c/o
nausea, therefore held. Patient developed prolonged ileus
(bloating, nausea, distention) w/ multiple unsuccessful tube
feeding restarts until [**2123-1-17**]-(pod#24). J-tube placed to
gravity during this time. TPN started as below. Tube feedings
tolerated w/ slow advancement to max rate of 50/hr w/ goal as
stated. Patient has persistant c/o nausea and therefore
[**2123-1-27**]- EGD w/ pyloric dilitation. Pylorus patent on
visualization, dilitation done to affirm continued patency. Diet
advanced to clear, then full liquids post-op, then to mechanical
soft [**2123-1-28**]. See below and page 1 for specific tube
feeding/nutrition instructions.
Nutrition/ electrolytes-IVF w/ electrolyte replacement until TPN
started pod#21- [**2123-1-4**] and cont until [**2123-1-18**] when tube
feedings at 2/3 goal rate on pod#25([**2123-1-20**]). Lytes routinely
monitored and repleated. Diet advanced to clear, then full
liquids post-op, then to mechanical soft [**2123-1-28**]. See below and
page 1 for specific tube feeding/nutrition instructions. Weight
[**2123-1-28**] 51.5kg
RAD- UGI- SBFT pod#8- + ileus.
Incisions and Drains- Chest tube d/c pod# 7; JP drain d/c pod#8;
Incisions - thorocotomy, abdominal and cervical all healed,
staples removed, steri-strips off. Port-o-cath removal site-
left upper chest- C/D/I, change dsd qd. Sutures remain, to be
assessed and removed at follow-up appointment [**2123-2-4**].
Infectious Disease- Course of zosyn(prophylaxis) and fluconazole
(?esophogeal candidiasis). POD#27([**2123-1-21**]) patient developed
fever to 102, elevated WBC- cx results- [**5-18**] + BC, staph- MRSA,
Vancomycin started and cont per therapeutic levels for 14 day
course, levofloxacin- 10 day course. Source- infected port site-
removed in OR [**2123-1-22**]. Peripheral line placed. PICC line placed
[**2123-1-28**], confirmed placement in distal SVC by CXRAY [**2123-1-28**].
Pain control- Transitioned to percocet elixer and MSO4iv prn
pod#6. Slowly weaned to off over next 3-4 weeks.Pain med
restarted post-op [**2123-1-22**] for port removal. At discharge pt
receiving minimal pain med on prn basis.
Activity-Physical therapy, ambulation with encouragement. Pt
gradually independent w/ ambulation with encouragement.
Consistant encouragement w/ activity necessary.
Medications on Admission:
MS contin, Roxanol, magic mouthwash
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
give via j-tube.
6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 12H (Every 12 Hours) for 11 days.
7. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for nausea.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day: give via j-Tube.
10. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H
(every 6 hours) as needed for Breakthrough pain.
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
esophageal CA
prolonged post op ileus
POC bacteremia resulting in removal
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 1504**] if you have
fever, nausea/vomiting, inability to take in your feeds, or
dizziness/weakness, aor any other post surgical issues.
Followup Instructions:
Follow up appointment with Dr. [**Last Name (STitle) **] in Thoracic Surgery Clinic
[**2123-2-4**] at 3pm. [**Hospital1 18**], [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 8939**]. Please call [**Telephone/Fax (1) 170**] for any questions.
Completed by:[**2123-1-28**]
|
[
"458.29",
"112.84",
"996.69",
"070.70",
"560.1",
"996.62",
"V15.3",
"427.31",
"V10.46",
"790.7",
"150.4",
"V09.0",
"401.9",
"196.2",
"041.11",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"99.15",
"42.52",
"03.90",
"40.29",
"42.23",
"38.93",
"96.6",
"44.22",
"42.42",
"86.05",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
12223, 12377
|
7443, 10973
|
564, 722
|
12495, 12504
|
2132, 3445
|
12753, 13041
|
1778, 1854
|
11059, 12200
|
4782, 4891
|
12398, 12474
|
10999, 11036
|
12528, 12730
|
1869, 2113
|
282, 526
|
4920, 7420
|
750, 1208
|
1230, 1553
|
1569, 1762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,490
| 109,948
|
51146
|
Discharge summary
|
report
|
Admission Date: [**2162-8-26**] Discharge Date: [**2162-9-9**]
Date of Birth: [**2093-4-1**] Sex: M
Service: SURGERY
Allergies:
Indocin / Clinoril / naproxyn / allopurinol / sodium thiosulfate
/ probenecide / suldinac / indomethacine / Heparin Agents /
Sulfa(Sulfonamide Antibiotics) / furosemide / sulfonamides /
Tylenol
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2162-8-28**]:
Right hip hemiarthroplasty
[**2162-8-31**]:
Exploratory laparotomy with sigmoid colon
resection and Hartmann pouch
[**2162-9-3**]:
Reopening of recent laparotomy.
Resection and revision of colostomy.
Mesh repair of incisional hernia.
V.A.C. closure midline wound 60 cm square.
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old man with severe psoraitic
arthritis, Crohn's disease (on prednisone) and recent bilateral
DVT (on coumadin) presents with atraumatic right femoral neck
fracture. He was exercising Sunday, 6 days prior to admission
and felt a [**Doctor Last Name **] in his left hip and noticed a burning pain and
required a crutch to help him walk afterwards. Pain increased
throughout the week and eventually left him bedbound. One day
prior to admission, he stepped out of bed and felt severe pain
in his right anterior hip area and fell to the ground. He
continued to have full range of motion of his ankle and did not
have any numbness or tingling. He was on the ground for about 4
hours before he was brought into the ED by ambulance.
In the ED, he was afebrile with stable vitals, labs revealed INR
of 4.5. CT head was normal, CT pelvis/hip/femur were notable for
diffuse osteopenia and acute femoral neck fracture. He was seen
by ortho who planned on admission to medicine and surgery in the
morning.
Of note, patient has had multiple admissions in the past several
months. He was admitted from [**2162-4-23**] - [**2162-5-7**] for diarrhea
likely from Crohn's flare and was started on 40 mg prednisone at
that time. His platelets fell during that admission, which was
thought to be due to heparin induced thrombocytopenia from SQH,
so he was switched to fondaparinux, which resulted in rectal
bleeding, likely complication of Crohn's. His PF4 Ab came back
positive during that admission, so he was continued on
fondaparinux for prophylaxis. He was discharged to rehab, where
he developed large volume rectal bleeding and was readmitted on
[**2162-5-11**] requiring transfusion. A seratonin release assay was
negative during that admission, so it was felt that he did not,
in fact, have HIT. He was discharged on continued prednisone and
mesalamine.
He was admitted again on [**2162-7-20**] - [**2162-8-2**] for bilateral leg
swelling and redness and found to have bilateral posterior
tibial DVTs. He was started on IV heparin and bridged to
coumadin. Labs were notable for a pancytopenia, though it is
unclear if that was due to heparin. He has been on coumadin 4
mg daily since that time and LENIs in the ED on [**8-26**] were
negative for DVTs.
Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough. Denied chest pain or tightness, palpitations.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Past Medical History:
- Crohn's disease
- Psoriasis
- Psoriatic arthritis
- Hypertension
- Obesity
- GERD
- Hyperuricemia
- Anxiety
- Cholelithiasis
- Multiple liver hypodensities seen on CT, most likely cysts
- Left renal cyst
- Impaired glucose tolerance
- Ascending colon adenoma, removed ([**2161-2-5**])
- Long history of liver problems since [**2131**] in Atrius records-
has had 2 liver biopsies at [**Location (un) 2274**] (In [**2137**] and [**2144**]) that showed
? methotrexate induced toxicity or ? gold reaction.
- Gastrointestinal bleed
- h/o DVT in upper extremity after PICC line insertion
- h/o bilateral LE DVTs ([**7-/2162**])
- s/p right hip arthroplasty ([**8-/2162**])
Social History:
Lives by himself in [**Location (un) **]. Ambulates with crutch. Worked for
Department of Defense. Quit drinking 15 years ago, used to drink
[**7-16**] drinks/weekend. Denies hx of tobacco smoking or any other
drug use. Has son in [**Name (NI) **] who helps him out.
Family History:
Dad [**Name (NI) **]-Arthritis, CHF
Mom [**Name (NI) **]-HTN, brain aneurysms
Sister-CLL, [**Name (NI) **] disease
Physical Exam:
Admission physical exam:
Vitals: 98.4 125/76 82 20 93-100%RA FSBG: 172
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
Skin: Diffuse erythematous patches appox 0.5-1cm with scale
distributed over his back, chest, abdomen, upper arms, and legs.
Lesions on legs appear to be coalescing and with more scale.
Ext: Warm, well perfused, 1+ pulses, pitting edema bilaterally
with chronic venous changes. Hands with shortened digits,
especially thumbs.
Neuro: CNII-XII intact, moving right extremity distally, but
deferred proximal exam given recent fx. Otherwise moving all
extremities equally with good strength.
Physical examination upon discharge: [**2162-9-9**]:
Vital signs: t=98.8, hr=74, rr=20, oxygen sat=97% room air,
bp=98/60- 110/68
General: Resting comfortable, conversant
HEENT: scleral anicteric
CV: ns1, s2, -s3, -s4, no murmurs
LUNGS: Clear
ABDOMEN: soft, mild tenderness, mid-line wound open, edges pink,
pink granuation tissue, no exudate, ostomy left side abdomen,
stoma red, marroon liquid in bag, stoma slightly retracted
EXT: hyperpigmentation lower ext. bil., feet cool, + dp bil.,
contracture hands bil.
SKIN: fine macular rash back, upper thigh, abdomen, macular
hemorrhagic area both arms, skin abrasion dorsal surface of
right hand ( DSD), stage 2 abrasion coccyx
MENTATION: alert, oriented x3, speech clear, no tremors
Pertinent Results:
[**2162-9-9**] 05:02AM BLOOD WBC-9.3 RBC-2.52* Hgb-7.5* Hct-24.7*
MCV-98 MCH-29.6 MCHC-30.3* RDW-16.6* Plt Ct-372
[**2162-9-8**] 02:33PM BLOOD WBC-14.5* RBC-2.96* Hgb-8.8* Hct-28.9*
MCV-98 MCH-29.9 MCHC-30.5* RDW-16.3* Plt Ct-519*
[**2162-9-8**] 04:50AM BLOOD WBC-11.9* RBC-2.59* Hgb-7.8* Hct-25.2*
MCV-97 MCH-30.1 MCHC-31.0 RDW-16.3* Plt Ct-444*
[**2162-8-26**] 04:45PM BLOOD WBC-8.9 RBC-4.07* Hgb-12.7* Hct-38.5*
MCV-95 MCH-31.1 MCHC-32.9 RDW-16.4* Plt Ct-175
[**2162-8-30**] 08:00AM BLOOD Neuts-84.8* Lymphs-11.1* Monos-3.8
Eos-0.2 Baso-0.1
[**2162-9-9**] 05:02AM BLOOD Plt Ct-372
[**2162-9-9**] 05:02AM BLOOD PT-13.4* INR(PT)-1.2*
[**2162-9-8**] 02:33PM BLOOD Plt Ct-519*
[**2162-9-8**] 04:50AM BLOOD Plt Ct-444*
[**2162-9-8**] 04:50AM BLOOD PT-14.8* INR(PT)-1.4*
[**2162-9-8**] 04:50AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-140
K-4.1 Cl-104 HCO3-30 AnGap-10
[**2162-9-7**] 04:54AM BLOOD Glucose-80 UreaN-6 Creat-0.4* Na-139
K-3.8 Cl-103 HCO3-30 AnGap-10
[**2162-9-3**] 01:44AM BLOOD ALT-7 AST-16 CK(CPK)-26* AlkPhos-65
Amylase-10 TotBili-0.8
[**2162-8-26**] 04:45PM BLOOD CK(CPK)-41*
[**2162-9-3**] 01:44AM BLOOD CK-MB-1 cTropnT-<0.01
[**2162-9-3**] 03:39AM BLOOD freeCa-1.14
[**2162-8-31**] 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
[**2162-9-3**] 05:33PM BLOOD Lactate-1.0
[**2162-9-3**] 03:39AM BLOOD Hgb-8.3* calcHCT-25 O2 Sat-96
[**2162-9-3**] 03:39AM BLOOD freeCa-1.14
[**2162-8-26**]: ct of the head:
IMPRESSION: No intracranial hemorrhage or fracture; sinus
disease as
described above.
[**2162-8-26**]: bil. lower ext. veins:
IMPRESSION: No bilateral deep vein thrombosis evident.
Specifically, the posterior tibial vein thrombosis identified on
prior study are not seen today. Left peroneal vein is not
visualized.
[**2162-8-26**]: pelvis:
Transcervical right femoral neck fracture.
[**2162-8-31**]: cat scan of abdomen and pelvis:
IMPRESSION: Large amount of free intraperitoneal air with
stranding adjacent to the sigmoid colon in the right lower
quadrant, suggesting sigmoid colon perforation. Urgent surgical
consultation is recommended.
[**2162-9-3**]: CTA of head and neck:
1. Questionable area of decreased blood flow with normal blood
volume, and mildly increased mean transit time in the left
frontal lobe, which are nonspecific and may represent an
artifact. No acute territorial infarct or intracranial
hemorrhage.
2. Unremarkable MRA of the head and neck
[**2162-9-3**]: chest x-ray:
Moderate cardiomegaly is stable. There are low lung volumes.
Increasing opacities in the left lower lobe could be due to
increasing atelectasis but aspiration could also be present.
There is a small left pleural effusion.
The right IJ catheter tip is in the lower SVC. NG tube tip is
out of view below the diaphragm. Widened mediastinum is stable.
Brief Hospital Course:
The patient was admitted to the hospital after a fall. Upon
admission, he was made NPO, given intravenous fluids, and
underwent imaging. An x-ray of the pelvis showed a
transcervical right femoral neck fracture.
The patient had supratherapeutic INR on admission from
anticoagulation for DVT which was diagnosed on [**2162-7-21**], so
arthroplasy was delayed one day while the patient was reversed
with IV vitamin K 5 mg x 2. On [**8-28**], the patient underwent
uncomplicated right hip surgical fixation with orthopedics. No
blood was required peri-operatively. Post-operative pain was
controlled with oxycodone and home oxycontin. The patient
remained hemodynamically stable on the floor. Because of the
patient's history of DVT the patient was given IV heparin to
bridge to coumadin. A pantocytopenia was noted, and it was
unclear if it was related to heparin use, but possibly related
to ? HIT. PF4 antibodies were positive, but serotonin release
assy was negative. The patient was started on fondaparinux on
POD #1 in order to bridge to coumadin. On POD #1, 5 mg of
coumadin was started. Physical therapy was ordered and began
evaluating the patient in preparation for discharge.
Over the course of the next 3 days, the patient began to notice
a dull progressing to sharp and extreme pain in his right lower
quadrant. A cat scan of the abdomen was performed on [**2162-8-31**],
which showed free intraperitoneal air. He was evaluated by the
acute care service and based on the ct findings, the patient was
emergently taken to the operating room for exploratory
laparotomy, sigmoidectomy and [**Doctor Last Name **] pouch. During the
operative course, there was a 50cc blood loss and a 2 liter
fluid requirement. He did not require any vasopressor infusions
and was actually hypertensive requiring treatment with
labetalol. He was successfully extubated and then transferred to
the intensive care unit for monitoring.
Upon arrival to the intensive care unit, the patient complained
of incisional pain but was otherwise well. He was alert,
oriented and conversant. He was able to move all extremities
with good peripheral pulses and no evidence of shock/sepsis.
His pain was controlled with a dilaudid PCA and he remained NPO
with intravenous hydration. There were no acute events
overnight, and on [**9-1**] he was deemed stable for transfer to the
surgical floor for additional recovery.
After arrival to the surgical floor the patient was reported to
have an episode of unresponsiveness. The Neurology service was
consulted and a cat scan of the head was ordered which showed no
evidence of acute ischemia or vessel occlusion. [**Last Name (un) **] this
imaging, he had continuous EEG monitoring to look for evidence
of seizure activity after an apparent significant effect of
lorazepam to his mental status. In 24 hours, he returned to his
baseline mental status. He was however found on the morning
after the episode to have a necrotic, ischemic colostomy and
went to the operating room on [**2162-9-3**] for reopening of recent
laparotomy, resection and revision of colostomy and mesh repair
of incisional hernia A vac dressing was placed on the wound.
The patient returned to the surgical floor in stable condition
with an intact neurological status. The patient receive
intravenous analgesia after the surgery. Once tolerating clear
liquids, the patient was transitioned to oral analgesia.
The GI service was consulted regarding tapering of his
prednisone dose. On HD # 14, his prednisone taper was started.
He will be tapered 2.5 mg weekly. The patient was maintained on
arixtra with a bridge to coumadin. He has received coumadin x 3
days, current INR is 1.2. He has received arixtra 2.5, but was
increased to 7.5mg daily to provide him with the treatment dose
for DVT. His INR was closely monitored. Once he attains INR of
2.0, arixtra can be discontinued. On POD #6 from the ostomy
revision, the patient was noted to have frank blood from the
ostomy. He remained hemodynamically stable with a stable
hematocrit.
During the hospitalization, the ostomy nurse provided
instruction to the patient in caring for the ostomy. Physical
therapy evaluated the patient's mobility status and his
capability of caring for himself at discharge. He was reported
to have a skin breakdown on his coccyx for which mepilex has
been applied. Recommendations were made for discharge to a
rehabilitation facility.
On HD #15 , the patient was discharged to a rehabilitation
facility with stable vital signs. Appointments for follow-up
were made with the acute care service, orthopedics, and his GI
provider.
*********
VAC dressing removed prior to discharge and moist to dry
dressing applied: needs reapplication of VAC dressing
Providers: GI Dr. [**Last Name (STitle) **] at [**Location (un) 2274**] ([**Telephone/Fax (1) 106179**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Repaglinide 1 mg PO WITH LUNCH
2. Warfarin 4 mg PO/NG DAILY16
3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
4. Ascorbic Acid 500 mg PO BID
5. Atenolol 25 mg PO DAILY
Hold for SBP<100 or HR<60
6. Ferrous Sulfate 325 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Hold for oversedation
11. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
12. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
13. DiCYCLOmine 40 mg PO TID
14. Calcium Carbonate 1500 mg PO BID
15. Colchicine 0.6 mg PO DAILY
16. Atovaquone Suspension 1500 mg PO DAILY
17. Apriso *NF* (mesalamine) 1.5g Oral daily
18. Calcipotriene 0.005% Cream 1 Appl TP [**Hospital1 **]
Apply to psoriatic areas twice daily. Do not apply below mid
thighs.
19. Coal Tar 3% Shampoo 1 Appl TP DAILY
20. Ethacrynic Acid 50 mg PO BID
Hold for SBP<100
21. Lidocaine 5% Patch 1 PTCH TD DAILY
22. Loperamide 2-4 mg PO QID:PRN Diarhhea
4mg following first loose stool of day, 2mg afterwards
23. Thiamine 100 mg PO DAILY
24. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Hold for oversedation or RR<10
Discharge Medications:
1. Atenolol 25 mg PO DAILY
Hold for SBP<100 or HR<60
2. Calcipotriene 0.005% Cream 1 Appl TP [**Hospital1 **]
Apply to psoriatic areas twice daily. Do not apply below mid
thighs.
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Hold for oversedation
4. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Hold for oversedation or RR<10
5. PredniSONE 17.5 mg PO DAILY Duration: 1 Weeks
last dose 10/8
6. Pantoprazole 40 mg PO Q24H
7. Sarna Lotion 1 Appl TP QID:PRN pruritis
8. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
9. Colchicine 0.6 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
hold for diarrhea
11. Fondaparinux Sodium 7.5 mg SC DAILY
please start [**9-10**]
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Ascorbic Acid 500 mg PO BID
14. Calcium Carbonate 1500 mg PO BID
15. FoLIC Acid 1 mg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. Multivitamins 1 TAB PO DAILY
18. Thiamine 100 mg PO DAILY
19. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
20. PredniSONE 15 mg PO DAILY
start [**9-14**], last dose 10/15
21. PredniSONE 12.5 mg PO DAILY
start [**9-21**], last dose 10/22
22. PredniSONE 10 mg PO DAILY
start [**9-28**], last dose 10/29
23. PredniSONE 7.5 mg PO DAILY
start [**10-5**], last dose [**10-11**]
24. PredniSONE 5 mg PO DAILY
start [**10-12**], last dose 11/12
25. PredniSONE 2.5 mg PO DAILY
start [**10-19**], last dose 11/19
26. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
27. Coal Tar 3% Shampoo 1 Appl TP DAILY
28. Ferrous Sulfate 325 mg PO DAILY
29. DiCYCLOmine 40 mg PO TID
30. Repaglinide 1 mg PO WITH LUNCH
31. Ethacrynic Acid 50 mg PO BID
Hold for SBP<100
32. Warfarin 7.5 mg PO ONCE Duration: 1 Doses
please give 4pm [**9-9**]...daily coumadin as per INR monitoring
33. Atovaquone Suspension 1500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnoses:
- Atraumatic right hip fracture
- Prior bilateral DVT
- Perforated colon
- Ischemic ostomy
Secondary diagnoses:
- Severe psoriatic arthritis
- Crohn's disease on prednisone
- Heparin induced thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Right leg anterior weight bearing precautions.
Discharge Instructions:
You were admitted to hospital after you fell and fractured your
hip. You had your hip repaired. Three days after the surgery,
you had abdominal pain. You underwent a cat scan and you were
found to have a perforation in your colon. You were taken to
the operating room where you had a portion of your colon removed
and a colostomy. You returned to the operating room because the
color of your ostomy had change and underwent an exploratory
laparotomy. You were monitored in the intensive care unit, and
were transferred to the surgical floor. While on the surgical
floor, you had a change in your mental status and there was a
concern for a stroke. A cat scan was done which was normal. You
gradually improved and returned to the surgical floor. You are
now slowly getting better and you are preparing for dishcarge to
a rehabilitation facility where you can further regain your
strength and mobility.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2162-9-14**] at 9:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2162-9-14**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD
Specialty: Endocrinology
[**Location (un) 2274**] [**Location (un) **]
[**Location (un) 2129**]
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 89288**]
When: [**9-16**] at 3:30pm
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], MD
Specialty: Gastroenterology
[**Hospital1 **]
[**Location (un) 4363**]
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 89288**]
When: We are working on a follow up appointment. You will be
contact[**Name (NI) **] with an appointment. If you have not heard in two
business days, please call above number for status
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2162-9-23**] at 2:15 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] in the ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2162-9-10**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,853
| 119,383
|
4772
|
Discharge summary
|
report
|
Admission Date: [**2113-5-16**] Discharge Date: [**2113-5-25**]
Date of Birth: [**2062-6-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ibuprofen / Terbinafine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
sternal dehiscence
Major Surgical or Invasive Procedure:
sternal rewiring/plating/bilateral pectoralis advancement flaps
History of Present Illness:
This 50 year old white male underwent coronary artery bypass
grafting 6 months ago. He continues to smoke despite multiple
admonishments to stop. He felt a popping 48 hours prior to
presenting and he presented with an unstable sternum. A CT scan
revealed fractured wires and sternal separtion.
Past Medical History:
Coronary artery disease
Hypertension
insulin dependent diabetes mellitus
Polysubstance abuse
Hypercholesterolemia
Gastroesophageal Reflux Disease
h/o pancreatitis secondary to ETOH abuse
s/p C4/5 fusion
s/p rotator cuff surgery
Social History:
Reports that he lives in [**Hospital1 8**] in a boarding house. Is
single and has no children. Smokes 0.5-1ppd X 40+ yrs. Denies
current alcohol use - reports he has not had anything to drink
in 5 months, admits to crack use 5 months ago. Denies IVDU. Of
note, patient uses different names in hospitals around [**Location (un) 86**]
and has a history of leaving AMA.
Family History:
non-contributory
Physical Exam:
Admission:
T 97.7F Pulse: 76SR B/P: 122/86 Resp: 18 SaO2: 97/RA
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Sternum: incision well-healed without erythema, drainage or
fluctuance; (-)click, but obvious (+)sternal instability
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft, non-distended, non-tender [x]
Ext: Warm, well-perfused [x] Edema Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: nd Left: nd
Radial Right: 2+ Left: 2+
Carotid Bruit Right: (-) Left: (-)
Pertinent Results:
[**2113-5-22**] 05:31AM BLOOD WBC-8.7# RBC-3.73* Hgb-10.9* Hct-33.3*
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.9* Plt Ct-324
[**2113-5-15**] 11:45PM BLOOD WBC-5.1 RBC-4.31* Hgb-12.9* Hct-39.2*
MCV-91 MCH-30.0 MCHC-32.9 RDW-15.5 Plt Ct-331
[**2113-5-15**] 11:45PM BLOOD Neuts-60.4 Lymphs-29.3 Monos-6.4 Eos-3.0
Baso-0.9
[**2113-5-23**] 04:45AM BLOOD Glucose-130* UreaN-17 Creat-1.1 Na-141
K-4.6 Cl-105 HCO3-28 AnGap-13
[**2113-5-15**] 11:45PM BLOOD Glucose-184* UreaN-25* Creat-1.6* Na-141
K-5.3* Cl-108 HCO3-23 AnGap-15
[**2113-5-16**] 04:15PM BLOOD ALT-19 AST-21 LD(LDH)-165 AlkPhos-60
Amylase-40 TotBili-0.3
Brief Hospital Course:
Following admission Mr.[**Known lastname 1968**] was taken to the Operating Room on
[**5-17**] where sternal debridement, Synthes plating and myocutaneous
flap advancement was performed by the Plastic Surgical service.
There was no evidence of infection.
He tolerated the procedure well and was transferred to the CVICU
for further monitoring. He remained hemodynamically stable
postoperatively, however he had a prolonged stay in the CVICU
due to acidosis and visual/auditory hallucinations secondary to
narcotics and withdrawal. A narcan drip was utilized and
Mr.[**Known lastname 10881**] acidosis cleared.
POD# 5 he was transferred to the floor for further recovery. The
plastics surgery service followed the JP drain/drainage. POD# 8
after several episodes of Mr.[**Known lastname 1968**] wanting to leave AMA,
Dr.[**First Name (STitle) **] and Dr.[**First Name (STitle) **] cleared Mr.[**Known lastname 1968**] for discharge to home
with the JP drain in place. Antibiotics (Keflex po)are to
continue until the JP drain is removed by Dr.[**First Name (STitle) **]. The PICC
line was removed prior to discharge. VNA arrangements were made
with the first visit on [**5-26**]. Mr.[**Known lastname 1968**] was instructed on caring
for the JP drain. A follow up appointment with Dr.[**First Name (STitle) **] has
been arranged for [**6-1**] at 3:45 pm and no further follow up with
[**Last Name (NamePattern4) 20022**] is required.
Medications on Admission:
Plavix 75mg daily
Toprol XL 100 mg daily
Lisinopril 10mg daily
Simvastatin 40mg daily
Actos 30mg daily
Humalog 75/25 20units am, 28units pm,
Gabapentin 800mg [**Hospital1 **]
Tramadol 150mg [**Hospital1 **]
Diclofenac 100mg [**Hospital1 **]
Zantac 150mg [**Hospital1 **]
amitriptyline 100hs
ASA 81
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
3. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*120 Capsule(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
10. Insulin Aspart 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: resume home dosing: 20 units Q AM/
28units QPM.
Disp:*qs * Refills:*0*
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
sternal dehiscence
s/p sternal rewiring/plating
s/p coronary artery bypass grafts
hypercholesterolemia
hypertension
insulin dependent diabetes mellitus
gastroesophageal reflux
polysubstance abuse
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with ****
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
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**]).
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments:
Plastic Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Thursday [**2113-6-1**] at 3:45pm
Dr[**Location (un) 20023**] office:[**Telephone/Fax (1) 1416**]
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-5-25**]
|
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|
966, 1335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,338
| 108,248
|
5771
|
Discharge summary
|
report
|
[** **] Date: [**2151-11-9**] Discharge Date: [**2151-11-12**]
Service: MEDICINE
Allergies:
Protonix
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Black Stools
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
[**Age over 90 **] yo M h/o gastric bleeding from Dieulafoy lesion in [**2148**] p/w 5
days black stools. He has been having 1 BM per day for the last
5 days which has been black. He reports dizziness on standing up
and walking associated with fatigue. He denied any CP, SOB,
nausea, vomiting, diarrhea, abdominal pain.
.
ED: His vitals were stable. He was frank guiac pos. His HCT was
down to 26.2 from 34.7 in [**December 2150**]. He refused NG lavage. GI
consulted who decided to scope him in the ICU.
.
*EGD [**12-12**]: Polyp in the fundus, Mild gastritis
*EGD [**7-11**]: An oozing gastric Dieulafoy lesion was seen in the
fundus. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis
successfully.
Past Medical History:
1. HTN
2. CV ***Echo- [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. Nl LVSF. Mild dilated
ascending
aorta. [**12-8**]+ AR. mod-sever MR.
3. Flailed of a posterior mitral valve leaflet
4. PVD with critical carotid stenosis on Left side
5. glaucoma
6. macular degeneartion
7. hyperlipidemia
8. BPH
9. h/o TIA in [**7-11**]
10. GIB-[**1-11**], [**7-11**] with Dielafoy's lesion and blood in the
antrum
11. Sleep apnea
12. h/o epistaxis
13. GERD in remission
14. Claustrophobia
Social History:
Social History: Pt is retired from the textile industry. He
lives at home with his wife. Quit smoking in [**2106**]. Smoked 1.5
ppd x 20 years. Drinks 4 oz bourbon per day.
Family History:
Non contributory
Physical Exam:
97.9, 70, 145/53, 17, 100%/2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RRR, S1, no S2 heard, [**3-12**] holosystolic murmur at apex and
LSB
ABD: distended, tympanic, non-tender, no HSM
EXT: no c/c/e, warm, good pulses
SKIN: xerosis
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: guaiac positive
Pertinent Results:
[**2151-11-9**] 01:05PM BLOOD WBC-3.9* RBC-2.85*# Hgb-8.5*# Hct-26.2*
MCV-92# MCH-29.7 MCHC-32.4 RDW-13.1 Plt Ct-264
[**2151-11-9**] 02:35PM BLOOD WBC-4.0 RBC-2.89*# Hgb-8.6* Hct-26.4*
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.9 Plt Ct-307
[**2151-11-10**] 02:22AM BLOOD WBC-3.9* RBC-3.19* Hgb-9.8* Hct-28.5*
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.2 Plt Ct-231
[**2151-11-9**] 02:35PM BLOOD Neuts-58.7 Lymphs-31.8 Monos-5.8 Eos-3.6
Baso-0.1
[**2151-11-9**] 01:05PM BLOOD Plt Ct-264
[**2151-11-9**] 02:35PM BLOOD PT-13.3 PTT-37.8* INR(PT)-1.1
[**2151-11-9**] 02:35PM BLOOD Glucose-104 UreaN-58* Creat-1.8* Na-139
K-4.6 Cl-108 HCO3-21* AnGap-15
[**2151-11-9**] 01:05PM BLOOD ALT-10 AST-11 AlkPhos-100
[**2151-11-9**] 02:35PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.6
.
EGD:
Esophagus:
Lumen: A small size hiatal hernia was seen.
Stomach:
Contents: Red blood was seen in the fundus.
Flat Lesions A large clot and pool of blood was seen in fundus.
After extensive suctioning and rolling of patient to other side,
an oozing Dieulafoy lesion was seen. 10 1 cc.Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis with success.
Duodenum: Normal duodenum.
Impression: Small hiatal hernia
Dieulafoy lesion in the fundus (injection)
Blood in the fundus
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
[**Age over 90 **] yo M h/o gastric bleeding from Dieulafoy lesion in [**2148**] p/w 5
days black stools due to upper GIB. An EGD was performed in the
ICU on [**11-10**]; an oozing Dieulafoy lesion was identified and
injected with epinephrine until hemostasis was achieved. He
received 2 units of PRBCs. His hematocrit remained stable for
36 hours following the procedure. H Pylori serologies were
negative. He resumed a normal diet without complication. He
will follow up with his PCP on discharge, he will hold his
aspirin until he follows up with his PCP.
.
Code Status: DNR/DNI. Communication: Patient and Son [**Name (NI) 382**]-
[**Telephone/Fax (1) 22948**].
.
Medications on [**Telephone/Fax (1) **]:
Diovan 40 mg QD
Aspirin 40 mg QD
Lasix 20 mg QD
Metoprolol 50 mg QD
Terazosin 10 mg QD
Finasteride 5 mg QD
Timolol eye drops
Tobradex
Fish oil
Ambien 10 mg QHS
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic [**Hospital1 **] (2 times a day).
3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. 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*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
8. Terazosin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed due to Dieulafoy lesion
Discharge Condition:
Hemodynamically stable, stable hematocrit, tolerating POs.
Discharge Instructions:
During this [**Hospital1 **] you were treated for bleeding in your
stomach.
Please continue to take all medications as precribed; call your
primary care doctor with any questions regarding your
medications.
Please come to the ED immediately if you experience recurrent
black or bloody stools, or vomiting blood or black liquid; if
you experience chest pain or shortness of breath, or of you
develop any other concerning symptoms.
We have started a new medication called omeprazole. We have
stopped your aspirin--please DO NOT restart your aspirin until
you see you PCP [**Last Name (NamePattern4) **] [**11-22**].
Followup Instructions:
You have the following appointment with your PCP: [**Name Initial (NameIs) 2169**]:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2151-11-22**]
9:30
.
Follow up with GI if you have any recurrent symptoms: black or
bloody stool, black or bloody vomit, or abdominal pain. Call
for an appointment. Your GI doctors [**First Name (Titles) **] [**Last Name (Titles) **] were [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 174**], MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Name8 (MD) **], MD (fellow). The phone number for
the [**Hospital **] clinic is ([**Telephone/Fax (1) 22346**].
|
[
"458.0",
"396.3",
"272.4",
"553.3",
"401.9",
"414.01",
"V12.54",
"790.01",
"433.10",
"600.00",
"537.84",
"786.50",
"443.9",
"285.9",
"578.0",
"365.9",
"780.57",
"362.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5477, 5483
|
3736, 4612
|
228, 239
|
5565, 5625
|
2406, 3713
|
6287, 6977
|
1714, 1732
|
4635, 5454
|
5504, 5544
|
5649, 6264
|
1747, 2387
|
176, 190
|
267, 983
|
1005, 1507
|
1539, 1698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,165
| 191,746
|
28994
|
Discharge summary
|
report
|
Admission Date: [**2180-2-3**] Discharge Date: [**2180-2-24**]
Date of Birth: [**2120-12-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Ms. [**Name (NI) 69876**] was admitted to [**Hospital 1474**] Hospital in [**9-24**] and again
earlier this month with a partial small-bowel obstruction
proximal to the level of the terminal ileum. She was discharged
from [**Hospital 1474**] Hospital on [**2180-1-31**] and presented for an initial
visit with Dr. [**Last Name (STitle) 1120**] yesterday. Since her discharge, her diet
has
consisted entirely of liquid nutritional supplements. Although
this has reduced her diarrhea from 15 episodes per day to 2, her
abdominal distention has returned. She has been admitted for
management of a high grade functional small bowel obstruction.
Major Surgical or Invasive Procedure:
[**2180-2-7**] - laparotomy, lysis of adhesions, small bowel resection
(25cm)
[**2180-2-12**] - Right nephrostomy inserted in interventional radiology
History of Present Illness:
[**Name (NI) **] [**Name (NI) 69876**] is a 59-year-old woman who underwent
sigmoidectomy and total abdominal hysterectomy on [**2179-1-8**] for a
large obstructing mass near the rectosigmoid junction. She had
presented for a colonoscopy after developing small frequent
bowel movements. Pathology revealed T4 colon adenocarcinoma.
Surgical margins and 26 lymph nodes were negative. Ms. [**Name (NI) 69876**]
was subsequently treated with infusional 5-FU and radiation for
5 weeks from [**Month (only) 956**] to [**2179-3-18**]. On [**2179-5-18**] she began FOLFOX
chemotherapy. Treatment was complicated by the development of
diarrhea, abdominal distention, and 25-lb. weight loss starting
in [**7-24**] and requiring chemotherapy to be postponed on multiple
occasions. She last received chemotherapy on [**2179-12-27**].
.
Ms. [**Name (NI) 69876**] was admitted to [**Hospital 1474**] Hospital in [**9-24**] and again
earlier this month with a partial small-bowel obstruction
proximal to the level of the terminal ileum. She was discharged
from [**Hospital 1474**] Hospital on [**2180-1-31**] and presented for an initial
visit with Dr. [**Last Name (STitle) 1120**] [**2180-2-2**]. Since her discharge, her diet has
consisted entirely of liquid nutritional supplements. Although
this has reduced her diarrhea from 15 episodes per day to 2, her
abdominal distention has returned. She has been admitted for
management of a high grade functional small bowel obstruction.
Past Medical History:
PMH:
Colon cancer
Allergic rhinitis
.
PSH:
Tonsillectomy
Segmental colectomy with TAH [**2178**]
Social History:
Married, not working, 2 grown up children
10 pack-year tobacco history, smokes [**1-20**] PPD
Occasional alcohol
no drugs
Denies toxin exposure.
Family History:
Mother died of cervical cancer at age of 80
Father died at age of 94. She believes he may have had colon
cancer in his 60s and underwent resection.
Physical Exam:
Vital signs: T 98.2 BP 120/60, P 58, R 18, O2 sat 100% RA
General: cachectic but in no acute distress.
CV: Regular rate and rhythm. No murmurs, gallops or rubs.
Lungs: Clear to auscultation and percussion bilaterally.
Abdomen: Soft, nontender, minimally distended. Normoactive bowel
sounds present. Liver margin is palpable but non-tender. No
splenomegaly or ascites.
Extremities: No clubbing, cyanosis, or edema.
Pertinent Results:
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2180-2-18**] 4:16 PM
INDICATION: Status post small bowel resection and right ureteral
damage. Please assess fluid collections, urinoma, and damage of
right ureter.
IMPRESSION:
1. Findings consistent with small bowel obstruction with a
transition point at the anastomotic site in the pelvis. New
marked edema within a loop of bowel in the left lower quadrant
is potentially concerning for ischemia.
2. Progression of pneumoperitoneum, both free and loculated in a
lower abdominal/pelvic collection with rim enhancement.
3. Right-sided hydronephrosis and hydroureter with nephrostomy
catheter in place.
4. Anasarca.
5. Bilateral pleural effusions and patchy opacities likely
reflecting infectious or inflammatory process.
6. Probable severe fatty infiltration of the liver.
.
RADIOLOGY Final Report
ABDOMEN (SUPINE ONLY) PORT [**2180-2-3**] 4:23 PM
Reason: 59 yo abd pain r/o obstruccion
IMPRESSION: Probable partial small-bowel obstruction, although
if large-bowel contrast material was introduced from below this
could represent a complete obstruction.
.
RADIOLOGY
PICC LINE PLACMENT SCH [**2180-2-4**] 8:54 AM
Reason: please place DL PICC unsuccessfull bedside placement
IMPRESSION: Ultrasound and fluoroscopically guided left brachial
PICC line placement via the left brachial venous approach. Final
internal length is 39 cm with the tip positioned in the distal
SVC. The line is ready to use.
.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2180-2-5**] 10:04 AM
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with sigmoidectomy for bowel cancer, now with
high grade SBO
IMPRESSION: Persistent features of mechanical small-bowel
obstruction without evidence for free air or pneumatosis.
.
RADIOLOGY Final Report
CHEST (PRE-OP PA & LAT) [**2180-2-6**] 4:50 PM
Reason: BOWEL OBSTRUCTION
FINDINGS:
A Port-A-Cath is seen on the right with the tip in the SVC and
there is a left central venous catheter with the tip at the
distal brachiocephalic vein. No PTX. Left hemidiaphragm is
slightly elevated with an air-filled loop of colon just below
it. There is no focal consolidation and some left basilar
atelectasis is seen on the lateral view. This is accompanied by
posterior effusion likely on the left as well. There is no free
air under the diaphragm.
.
RADIOLOGY Final Report
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with ureteral injury s/p exlap/LOA, now
draining urine into abdomen.
REASON FOR THIS EXAMINATION:
placement of R nephrostomy tube
INDICATION: 59-year-old woman with ureteral injury and
hydronephrosis based on recent CT.
IMPRESSION: Ultrasound and fluoroscopically guided right
nephrostomy tube placement for right-sided urinary obstruction
.
[**2180-2-20**] 06:45AM BLOOD WBC-7.5 RBC-2.87* Hgb-9.5* Hct-26.7*
MCV-93 MCH-33.0* MCHC-35.4* RDW-14.3 Plt Ct-112*
[**2180-2-14**] 02:18AM BLOOD WBC-11.6*# RBC-3.11* Hgb-10.1* Hct-29.2*
MCV-94 MCH-32.5* MCHC-34.6 RDW-14.6 Plt Ct-103*
[**2180-2-3**] 05:30PM BLOOD WBC-3.4* RBC-2.95*# Hgb-10.0*# Hct-28.5*#
MCV-97 MCH-33.9*# MCHC-34.9 RDW-14.1 Plt Ct-101*#
[**2180-2-7**] 04:21AM BLOOD Neuts-72.0* Lymphs-17.1* Monos-8.1
Eos-2.4 Baso-0.4
[**2180-2-20**] 06:45AM BLOOD Plt Ct-112*
[**2180-2-12**] 09:54AM BLOOD PT-14.8* PTT-32.1 INR(PT)-1.3*
[**2180-2-3**] 05:30PM BLOOD PT-13.4 PTT-27.0 INR(PT)-1.2*
[**2180-2-3**] 05:30PM BLOOD Fibrino-255
[**2180-2-4**] 02:19PM BLOOD Ret Aut-1.9
[**2180-2-20**] 06:45AM BLOOD Glucose-105 UreaN-18 Creat-0.4 Na-136
K-4.0 Cl-104 HCO3-23 AnGap-13
[**2180-2-3**] 05:30PM BLOOD Glucose-89 UreaN-17 Creat-0.7 Na-135
K-4.0 Cl-105 HCO3-23 AnGap-11
[**2180-2-21**] 11:00AM BLOOD ALT-149* AST-148* AlkPhos-385*
TotBili-0.9
[**2180-2-3**] 05:30PM BLOOD ALT-66* AST-64* LD(LDH)-259* AlkPhos-139*
Amylase-76 TotBili-0.8
[**2180-2-20**] 06:45AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.4 Mg-1.9
Iron-21*
[**2180-2-3**] 05:30PM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.6
Mg-1.5* Iron-52 Cholest-100
[**2180-2-20**] 06:45AM BLOOD calTIBC-104* Ferritn-849* TRF-80*
[**2180-2-4**] 02:19PM BLOOD VitB12-1199* Folate-17.3 Hapto-136
[**2180-2-20**] 06:45AM BLOOD Triglyc-82
[**2180-2-3**] 05:30PM BLOOD Triglyc-69 HDL-25 CHOL/HD-4.0 LDLcalc-61
[**2180-2-4**] 02:19PM BLOOD TSH-2.8
[**2180-2-4**] 02:19PM BLOOD CEA-1.9
[**2180-2-19**] 06:11AM BLOOD Vanco-15.9
[**2180-2-16**] 06:22PM BLOOD freeCa-1.15
.
GRAM STAIN (Final [**2180-2-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2180-2-10**]):
REPORTED BY PHONE TO DR.[**Last Name (STitle) **] ON [**2180-2-8**] AT 14:30.
PROTEUS VULGARIS. SPARSE GROWTH.
ESCHERICHIA COLI. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2180-2-13**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE. OF TWO COLONIAL MORPHOLOGIES
.
[**2180-2-11**] 6:52 pm URINE Source: Catheter.
**FINAL REPORT [**2180-2-13**]**
URINE CULTURE (Final [**2180-2-13**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
.
[**2180-2-11**] 10:07 pm BLOOD CULTURE Source: Line-pic.
**FINAL REPORT [**2180-2-14**]**
Blood Culture, Routine (Final [**2180-2-14**]):
PROTEUS VULGARIS. FINAL SENSITIVITIES.
PROTEUS VULGARIS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2180-2-12**]):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2180-2-12**]): GRAM NEGATIVE
ROD(S).
.
Brief Hospital Course:
The patient was admitted on [**2-3**]. She was made NPO, a
nasogastric tube was placed for decompression, and IV fluids
were started.
.
[**2180-2-4**]-PICC line placed, TPN started due to profound
malnourishement. Heme/Onco team was consulted, and evaluated
patient on [**2180-2-4**] for pancytopenia.
.
[**Date range (1) 40042**]-continued with TPN, NGT, IVF
.
[**2180-2-7**]-After failing to resolve the obstruction conservatively,
the patient was taken to the operating room where a laparotomy,
lysis of adhesions, and 25 cm small bowel resection were
performed. A nasogastric tube remained, a JP was placed
intraoperatively, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pain pump subcutaneously for pain
relief, dilaudid PCA for pain, and IV fluids for rescucitation
were given.
.
[**2180-2-8**]-POD1-continued TPN and IV fluids, NG tube remained in
place, continued monitoring on the floor. Required 1 liter of
fluid bolus for marginal urine output. Urine output stabilized
in the evening. NGT removed today, but remained NPO.
.
[**2180-2-9**]-POD2-continued TPN and IV fluids. Started with sips of
clears. Foley was removed. She was able to urinate without
difficulty. She ambulates with assist. Feels & appears weak.
SBP-80-90 with some complaints of feeling dizzy. Physical
therapy consulted. Her HCT dropped from 30 to 20%. She was
repleted with 2 units of PRBC.
.
[**2180-2-10**]-POD3-Increased JP bulb drain output- fluid dark red in
color, previously more serosanguinous.
.
[**2-11**]-POD4-Nursing staff reported mental status changes resulting
in a trigger. EKG revealed changes consistent with possible
pulmonary embolism. CTA ordered which ruled out PE, but
considerable for either hemmorhage or pulmonary edema. Due to
patient's change in status, she was transferred to Trauma ICU
for closer monitoring.
.
[**2-11**]-ICU: Intubated due to progressive desaturation and
tachypenia related to pulmonary edema & bilateral pulmonary
infiltrates. Patient aggressively diuresed. Vasopressors
initiated for decrease in blood pressure with adequate response.
Central line inserted at bedside. Respiratory status monitored
.
[**2-12**]-ICU: Continued with respiratory decompensation, remained
intubated. New GNR in blood cx from [**2-11**]-continues with
vancomycin, levofloxacin, flagyl, & fluconazole. Urology
consulted. Surgical intervetion not indicated due to patient's
compromised respiratory status. Right nephrostomy tube inserted
per Urology recommendations due to hydronephrosis, and fluid
volume overload. Vasopressors & sedation weaned as tolerated.
.
[**Date range (1) 69877**]-ICU: [**First Name9 (NamePattern2) 25714**] [**Doctor Last Name **] pain pump site erythematous &
fluctuant. Patient pre-medicated. Site opened at bedside,
pus-like exudate expressed from site. Culture sent. Continued to
wean pressors and sedation as tolerated. Labwork notable for
mild thrombocytopenia-HIT panel sent, and positive. All heparin
products discontinued. Culture data followed. Continued with IV
antibiotics for sepsis and TPN for severe malnutrition.
Nutrition and Physical Therapy consulted. Albumin started for
intravascular depletion. Extubated on [**2-16**]-respiratory status
stablized. Midline abdominal incision opened at bedside due to
erythema. Proximal wound with visible small loop of bowel. Areas
packed with W-D dressing. Vacuum dressing applied on [**2180-2-20**] at
bedside. Patient's general status stabilized.
.
[**2-20**]: Transferred back to [**Wardname 7911**]. Fluconazole discontinued, other
antibiotics & albumin continued. Mental status with mild
confusion-A/Ox2-3. Bed alarm set & other safety precautions
initiated. Started on a Regular diet with supplements. Calorie
counts. Vacuum dressing continued.
.
[**Date range (1) 59473**]: AVSS, afebrile. TPN weaned and discontinued. Tolerating
regular high protein diet with Ensure supplements. Continued
with Vac dressing to abdominal incision, changed every 3 days.
Site improving, CDI. Continues with IV Vancomycin & Zosyn to
treat both bacteremia and enterococcus growth in urine both
cultures from [**2180-2-11**]. Right nephrostomy remains patent with
clear, yellow urine. Right Abdominal JP drain continues to drain
moderate amounts of serous fluid. Check weekly creatinine
levels. [**Month/Day/Year 25714**] old Bupivicaine subcutaneous [**Doctor Last Name 3389**] pump
site-continues with [**Hospital1 **] W-D packings. Site healing with
decreased erythema. Evaluated per Physical & Occupational
therapy. Ambulates with assist. Physical condition decompensated
due to prolonged malnourishment. She will benefit from
aggressive physical therapy, nutrition, and wound assessment &
management.
.
UROLOGY: She will need to make an appointment to have right
nephrosotomy replaced in 1 month, and then follow-up with Dr.
[**First Name (STitle) **] for further management.
Medications on Admission:
Ativan prn
Benadryl prn
Discharge Medications:
1. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for allergy symptoms.
2. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for diarrhea: Do not exceed 16mg/day.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): Discontinue once more
independent.
5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
agitation.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 3 weeks.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 5 days.
10. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 8H (Every 8 Hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Functioning high grade small bowel obstruction
pancytopenia
Malnutrition
Post-op sepsis
Post-op urinay retention
Post-op hypovolemia
Post-op hypoxia
Post-op delirium
.
Secondary diagnosis:
Colon cancer
Allergic rhinitis
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
CRIMSON General d/c instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
*Avoid driving or operating heavy machinery while taking pain
medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness, swelling, tenderness, odorous or purulent
discharge).
*Maintain the bulb deflated to provide adequate suction.
*Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
*Be sure to empty the drain frequently and record the output.
*Maintain the site clean, dry, and intact.
*Keep drain attached safely to body to prevent pulling and
possible dislodgement.
.
Nephrostomy Tube:
*Flush with 10 cc normal saline daily.
Followup Instructions:
1. Please call the office of Dr. [**Last Name (STitle) 1120**] at [**Telephone/Fax (1) 29433**] to make a
follow up appointment within 2-3 weeks.
2. Please call [**Telephone/Fax (1) 69878**] to arrange follow up with Dr. [**First Name (STitle) **]
after having your nephrostomy tube exchanged in 1 month.
3. Follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **],
[**Telephone/Fax (1) **] in 1 week or as needed.
Completed by:[**2180-2-24**]
|
[
"263.9",
"998.59",
"V10.05",
"486",
"293.0",
"560.81",
"995.92",
"998.2",
"998.32",
"V15.3",
"284.1",
"038.8",
"785.52",
"591",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.03",
"86.04",
"99.15",
"54.59",
"99.04",
"45.62",
"99.77",
"96.72",
"96.04",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
15685, 15757
|
9605, 14485
|
957, 1110
|
16030, 16108
|
3520, 5053
|
18012, 18532
|
2916, 3066
|
14560, 15662
|
5919, 6006
|
15778, 15955
|
14511, 14537
|
16132, 17071
|
17086, 17989
|
3081, 3498
|
274, 919
|
6035, 9582
|
1138, 2616
|
15976, 16009
|
2638, 2737
|
2753, 2900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,620
| 188,230
|
49803
|
Discharge summary
|
report
|
Admission Date: [**2164-5-24**] Discharge Date: [**2164-5-29**]
Date of Birth: [**2120-9-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
woman with a history of insulin dependent diabetes mellitus,
end stage renal disease on dialysis who was recently at [**Hospital1 1444**] for high grade fever and malaise
and was treated for three weeks with Vancomycin for suspected
infection of the AV graft, however, no blood cultures were
ever positive. During that admission the patient had a
clotted AV graft that required thrombectomy. She also was
difficult to access. On ultrasound and had a nonpatent
bilateral IJ veins. The patient was discharged to rehab and had
been in her usual state of health denying an fevers or
chills, cough, shortness of breath, abdominal pain,
headaches, change in bowel movements. She does have right
chronic arm pain and bilateral heel ulcers. At [**Hospital **] Rehab
she had persistent low blood pressures with systolic in the
60s, 70s and heart rate in the 80s. She denied any
lightheadedness at that time. She was transferred to [**Hospital1 1444**] and has had persistently low
blood pressures in the Emergency Department with systolics
less then 90s and heart rate 70s and 80s. However, she
remained asymptomatic during this time. The patient was
admitted to the MICU for observation. She received 1.5
liters of normal saline in the Emergency Room with slight
improvement in her blood pressure. Chest x-ray showed signs
of early congestive heart failure. Blood cultures times two
were sent and Vancomycin, Levo and Flagyl were given.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. End stage renal disease on HD.
3. Failed cadaver kidney transplant.
4. Past history of hypertension.
5. Personality disorder.
6. Osteoporosis.
7. Gastroparesis.
8. Right eye blindness.
9. Hyperlipidemia.
10. Chronic pain.
11. Right AV graft thrombectomy.
12. Bilateral nonpatent internal jugulars.
MEDICATIONS ON ADMISSION:
1. Neurontin 300 mg t.i.d.
2. Levoxyl 50 micrograms q.d.
3. Zocor 10 mg q.d.
4. Nephrocaps.
5. Aspirin 81 q.d.
6. Tums [**2160**] t.i.d.
7. Reglan 5 b.i.d.
8. Oxycodone prn.
9. Ativan 0.5 t.i.d.
10. Sodium bicarb 650 b.i.d.
11. Midodrine 2.5 b.i.d.
12. Insulin sliding scale.
13. Glargine 16 units q.h.s.
14. Vancomycin just finished.
ALLERGIES: Sulfa.
SOCIAL HISTORY: At rehab at [**Hospital **] nursing home. Brother
is involved in her care. No tobacco or alcohol use.
FAMILY HISTORY: Father died of hydrocephalus at age 76.
Mother has hypertension. Two brothers are healthy.
PHYSICAL EXAMINATION: Temperature is 98.0. Heart rate 74.
Blood pressure 68/30. Respiratory rate 16. Sating 96% on
room air. The patient is a well appearing middle aged white
female in no acute distress. Sclera clear. Oropharynx is
moist. Neck supple. No lymphadenopathy. Chest clear to
auscultation bilaterally. No crackles or wheezes. Cardiac
examination S1 and S2, 1 out of [**1-26**] early systolic murmur at
the left upper sternal border. Abdomen soft, nontender. No
hepatosplenomegaly. Normoactive bowel sounds. No rebound or
guarding. Extremities no edema. Good bilateral popliteal
pulses. Bilateral heel ulcers, alert and oriented times
three, cranial nerves III through XII intact. Strength 5 out
of 5 throughout. Deep tendon reflexes 1+ bilateral,
symmetric throughout, decreased sensation on both lower
extremities beyond knees. Gait not tested, but the patient
states she ahs difficulty ambulating.
LABORATORIES ON ADMISSION: White blood cell count 15.4,
hematocrit 32.1, platelets 654, MCV 91, 76.8 neutrophils,
18.2 lymphocytes, 6.7 monocytes, 3.4 eosinophils. Chemistry
sodium 138, potassium 5.8, chloride 92, bicarb 22, BUN 52,
creatinine 8.2, glucose 152, PTT 31.0, INR 1.6.
Electrocardiogram normal sinus rhythm at 82 beats per minute,
normal axis, normal intervals. Questionable .[**Street Address(2) 1755**]
elevations in 2, 3 and AVF. Chest x-ray mild upper vascular
redistribution, questionable retrocardiac air bronchogram.
HOSPITAL COURSE: The patient was admitted to the MICU.
1. Hypotension. The patient persisted to have low blood
pressures while in the MICU, however, remained asymptomatic.
The patient had a random Cortisol tested, which was slightly
low at 20.8. Etiology of the hypotension was felt to be
primarily due to autonomic dysfunction, however, the
possibility of adrenal insufficiency was brought up. The
patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] Stim test after being transferred to the
floor, which was negative. Later on in the hospital course a
possible friction rub was noted and the patient had an
echocardiogram performed, which showed mild to moderate
pericardial effusion new from echocardiogram done a month
ago. It is possible that this pericardial effusion may have
contributed to her hypotension, however, while she was on the
floor the patient's blood pressure remained stable above 100
between 120 and 100. The patient had repeat
electrocardiograms done, which showed no significant change
and the echocardiogram showed no signs of tamponade. The
patient was started on Florinef along with the Midodrine,
which was continued at 2.5 mg b.i.d. The patient's blood
cultures remained negative and the patient ruled out for
myocardial infarction by serial cardiac enzymes. The patient
will be scheduled for a repeat echocardiogram in four days in
order to asses interval change in the effusion.
2. End stage renal disease: The patient continued to go to
dialysis Monday, Wednesday and Friday. The patient was
continued on her renal medications. initially Reglan and
sodium bicarb were discontinued due to possible effects on
hypotension, however, they were reinstituted.
3. Gastroparesis: The patient had significant abdominal
distention and pain after being transferred to the floor.
The patient had a KUB, which showed no signs of obstruction.
The patient was given aggressive bowel regimen and Reglan was
restarted at 5 mg q.i.d. with improvement in her abdominal
distention.
4. Diabetes: The patient had elevated blood sugars on
admission with a slight anion gap. This was corrected with
insulin sliding scale. The patient initially had Glargine
held, but this was restarted and the patient was switched to
Humalog sliding scale per endocrine. The patient was noted
to have an elevated TSH, however, in light of her recent
illness and the fact that her TSH was low on prior tests it
was felt that it might be due to a recent infection and will
be rechecked in several weeks. No changes in her Synthroid
regimen were made. It will be deferred to outpatient follow
up.
5. Cardiac: The patient was continued on Zocor and aspirin.
Aspirin was increased to 162 mg q.d. The patient had an
echocardiogram, which showed no significant change except for
the pericardial effusion. In light of the fact that the
patient had a questionable infection three weeks ago and no
bacterial organism was identified it is possible that the
patient had a viral infection and the pericardial effusion
was related to a viral infection. The patient will have a
repeat echocardiogram done on Friday to assess for interval
change. Decisions on whether to tap the effusion can be made
at that point.
6. Heel ulcers: The patient was seen by podiatry who felt
that the heel ulcers were not infected and there was no need
for antibiotics. The patient was continued on wet to dry
changes b.i.d. The patient was started on MultiPodus boots.
It is advised that the patient should avoid heel touch down.
She should limit her weight bearing and only do toe touch
down bilaterally. The patient will have VNA Services for
wound care and to help with ambulation along with medication
administration.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Hypotension.
2. Pericardial effusion.
3. Autonomic dysfunction.
4. Insulin dependent diabetes mellitus.
5. End stage renal disease on hemodialysis.
6. Bilateral heel ulcers.
7. Hypothyroidism.
FOLLOW UP: The patient will have a repeat echocardiogram
Friday [**6-1**] at 1:00 p.m. She has a follow up appointment
scheduled with Dr. [**Last Name (STitle) 19511**] on [**6-4**] at noon time and a
follow up appointment scheduled with podiatry with Dr.
[**Last Name (STitle) 22889**] on Friday [**5-8**] at 10:50 a.m. She should continue
hemodialysis as before and follow up with Dr. [**Last Name (STitle) 1860**].
DISCHARGE MEDICATIONS:
1. Zocor 10 mg q.d.
2. Nephrocaps one tab q.d.
3. Aspirin 162 mg q.d.
4. Tums 1500 mg t.i.d. with meals.
5. Tylenol prn.
6. Levoxyl 50 micrograms q.d.
7. Midodrine 2.5 mg b.i.d.
8. Reglan .5 mg q.i.d.
9. Fludrocortisone 0.1 mg q.d.
10. Sodium bicarb 650 mg b.i.d.
11. Glargine 14 units q.h.s.
12. Humalog sliding scale.
13. Colace 100 mg b.i.d.
14. Senokot one tab b.i.d.
15. Lactulose 30 cc q 4 hours prn for constipation.
16. Protonix 40 mg q.d.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAN
Dictated By:[**Last Name (un) 94046**]
MEDQUIST36
D: [**2164-5-30**] 11:10
T: [**2164-5-30**] 07:36
JOB#: [**Job Number 104085**]
|
[
"423.9",
"458.8",
"996.81",
"272.0",
"250.61",
"250.81",
"707.14",
"250.11",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2543, 2636
|
7913, 8117
|
8562, 9255
|
2034, 2404
|
4129, 7858
|
8129, 8539
|
2659, 3583
|
160, 1632
|
3598, 4111
|
1654, 2008
|
2421, 2526
|
7883, 7892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,100
| 120,285
|
20528
|
Discharge summary
|
report
|
Admission Date: [**2182-4-13**] Discharge Date: [**2182-4-24**]
Date of Birth: [**2142-8-19**] Sex: F
Service: MEDICINE
Allergies:
Apple / Peach / Pear
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 54925**] is a 39yo female with cirrhosis [**1-21**]
schistosomiasis with resultant portal hypertension, esophageal
varices, diuretic-resistant ascites, and lower extremity edema,
admitted today from home for SBP.
.
History is obtained via pt's husband and per [**Name (NI) 3271**] [**Name (NI) 679**]
admission note
.
Pt has been feeling more tired since her recent discharge last
week for throat pain. CT of her neck was unremarkable. This
throat pain has since been evaluated by EGD by GI on [**4-11**], with
finding of mild erythema in the mid-distal esophagus. She has
had poor PO intake, and has had several episodes of nausea with
vomiting over the past few days (non-bloody). Her family also
notes some confusion over the past week. She had chills last
night. Denies fever, abdominal pain, diarrhea, melena,
hematochezia. She underwent therapeutic paracentesis yesterday
at the Liver clinic, with 2900ml removed, received 50g albumin.
She tolerated the procedure, and was sent home. This morning,
she was called to come in after peritoneal fluid culture came
back positive in [**1-21**] bottles for GNR. She was direct admitted to
[**Hospital Ward Name 121**] 10. On arrival to the floor, she was rigoring. Initial BP
was 76/39 (baseline high 90s-100). She was given ~750cc NS
bolus, 70g albumin, with no response in her BP. She also
received midodrine, octreotide, and ceftriaxone. Labs are
notable for WBC 3.1, Hct 26.9 (baseline 28-34), INR 3.6 (from
2.7 on [**4-10**]), Cr 2.5 (from 1.2 [**4-10**]), bicarb 13. She is being
transferred to the MICU for close monitoring and further
evaluation.
.
On ROS, she feels lightheaded when sitting up. She has cold
intolerance at baseline. Otherwise negative in detail.
Past Medical History:
1)ESLD from schistosomiasis; currently on the [**Month/Year (2) **] list.
She is s/p single treatment with Praziquantel and no evidence of
organisms on ERCP evaluations; she has known about her liver
disease for about 8-10 years. She also had episodes of jaundice
and pruritis 10 to 15 years ago in [**Country 4194**], both times when she
was pregnant. Once in her sixth month of pregnancy and once in
her eight month of pregnancy. She was told that she had
hepatitis C. She has hepatitis C antibody, but negative PCR. She
lost her baby both times. Her jaundice and pruritis resolved
after delivery, both episodes. She is immune to hepatitis A. She
is vaccinated for hepatitis B. No prior history of culture
positive SBP, but has received empiric treatment in the past.
2)Grade [**12-21**] varicies and portal gastropathy without bleeding on
endoscopy in [**12-28**]
3)HCV+ but PCR repeatedly negative
4)s/p CCY 15y ago in [**Country 4194**] for which she received blood txf
5)s/p tubal ligation
6)GERD, previously admitted for associated epigastric pain
7)Strongyloides Ab positive in [**12-28**] - treated w/5 days
Ivermectin
Social History:
Married, lives with her husband in [**Name (NI) 15739**] [**Name (NI) **]. Originally from
[**Country 4194**]. She works part time as a housekeeper (private homes). No
tobacco, alcohol, or IVDA.
Family History:
Non-contributory
Physical Exam:
Vitals: T 97.6, BP 82/45 , HR 57, RR 18, SaO2 98% RA
Gen: portuguese-speaking, chronically ill appearing, tired, NAD,
jaundiced
HEENT: Dry mucous membranes, Scleral icterus, Dobhoff tube in
place, no oral thrush, ulcers or any other lesions, good
dentition
Heart: RRR, no m,r,g
Lungs: CTAB, no w/r/r
Abdomen: Soft, mildly distended, non-tender to palpation,
well-healed midline abdominal scar from cholecystectomy
Extremities: trace lower extremity edema, no cyanosis/clubbing,
warm and well perfused, 2+DP pulses bilaterally
Neuro: mild asterixis, A+O x 2 (name, [**Hospital1 18**], did not know year),
CN2-12 intact grossly, strength 5/5 diffusely, sensation intact
grossly
Pertinent Results:
Portable TTE (Complete) Done [**2182-4-15**] at 1:49:17 PM: The left
atrium and right atrium are normal in cavity size. The estimated
right atrial pressure is 0-10mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size. Normal global
and regional biventricular systolic function. Mild mitral and
moderate tricuspid regurgitation.
[**2182-4-12**] 02:10PM ASCITES WBC-120* RBC-2240* POLYS-35*
LYMPHS-11* MONOS-51* MACROPHAG-3*
[**2182-4-13**] 03:00PM PT-34.0* PTT-51.6* INR(PT)-3.6*
Brief Hospital Course:
# Initial Floor Course: Patient presented to clinic for
paracentesis but did not have evidence of SBP on cell count.
However, the culture started to grow E. Coli resistant to Cipro
and Bactrim and she was called and asked to come into the
hospital for IV antibiotics. At the time of admission her MELD
was 43. Once admitted she was started on Ceftriaxone and noted
to have hypotension, acute renal failure, anemia and guaiac
positive stool as well as worsening mental status. Nadolol,
lasix and spironolactone were held. She was given FFP and
started on treatment for hepatorenal syndrome with midodrine,
octreotide and IV albumin. She received IVF but her hypotension
worsened so she was transferred to the MICU for presumed sepsis
[**1-21**] SBP.
.
# MICU Course: Received a total of 4 units FFP, 1 unit pRBC's
and 1 bag platlets. Did not require pressor support.
Antibiotics were also broadened to vancomycin dosed by level and
zosyn. Peritoneal cxs with E. Coli sensitive to zosyn and CTX
and blood cxs with 1/4 bottles positive for coag negative Staph.
Midodrine increased to 7.5 mg PO TID, Crit 25.8-> 25.7-> 24.6,
transfused one unit. Echo: no vegetations, nl LV size and EF.
mild MR, TR, d/c-ed Vanc and redosed, peritoneal fluid growing
Ecoli. Patient also developed hepatic encephalopathy which
improved with increased doses of lactulose and treatment of
infection. In regards to Cr, peaked at 3.5 on [**4-13**] as above and
has since been downtrending with IVFs, midodrine, octreotide,
and albumin with Cr today at 2.0. Transferred to the floor due
to stabilization of blood pressures.
.
# [**Location (un) **] course:
#) SBP: Patient completed a 5 day course of Zosyn, renally
dosed, for SBP. Repeat paracentesis on [**4-19**] did not show any
evidence of SBP. Given patient's E. Coli was resistant to both
Cipro and Bactrim she was started on cefpodoxime for SBP
prophylaxis.
.
# Acute renal failure: Cr baseline 0.5 - 0.8. Differential
diagnosis is HRS vs. ATN from IV contrast and/or hypotension.
Most likely 2/2 HRS. Urine lytes suggestive of prerenal state in
MICU. Creatinine trended down over 6 days after fluid
resuscitation, midodrine, octreotide, and IV albumin.
Octreotide and Albumin were d/c'd once patient's creatine <1.0
however midodrine was continued for blood pressure.
.
# Cirrhosis: Patient has cirrhosis [**1-21**] schistosomiasis. Also has
known grade I and II varices and portal gastropathy. She is
currently on the [**Month/Day (2) **] list. MELD on admission was 43. INR
up from 2.7->3.8, likely in setting of cirrhosis and infection,
now back down then trended back down to 2.6. LFTs elevated but
not significantly changed from baseline with exception of Tbili
which was as high as 40. Patient continued on lactulose but
nadolol and spironolactone were held due to renal failure and
hypotenzion. PAtient became encephalopathic in the ICU.
Rifaximin was started and encephalopathy resolved by the time of
admission to the floor. Nadolol and spironolactone restarted.
Patient required 2 therapeutic paracenetesis, each with 4L
removed and no further sign of SBP.
.
# Acute on chronic anemia: Pt had guaiac postive stools and has
received pRBC transfusion. Has history of varices although none
visualized on recent EGD on [**4-11**]. Patient continued on IV PPI in
the ICU then transitioned to PO PPI on the floor. HCT remained
stable.
.
# Positive Blood Cx: Patient intially given 1g IV Vanco.
However, when speciated was felt likely contaminant as only [**12-23**]
bottles and speciated out to coag neg Staph. Surveillance blood
cx on [**4-15**] NGTD.
.
# Positive UA: In setting of no urinary symptoms. Urine cxs X 2
have been negative. Patient was on Zosyn and cefpodoxime for
SBP which would cover for UTI as well.
.
# Hyponatremia: Improved with albumin, holding spirinolactone.
.
# Depression: continued Celexa
.
Medications on Admission:
CIPROFLOXACIN 250 mg PO daily
CITALOPRAM 20 mg Tablet PO daily
CLOTRIMAZOLE 10 mg PO 5x/day
LACTULOSE 15 ml-30 PO three times daily
NADOLOL 20 mg PO daily
PANTOPRAZOLE 40mg PO daily
SPIRONOLACTONE 50 mg Tablet PO daily
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Midodrine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): take in conjuction with 2.5 mg tablet for total of 12.5 mg
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
8. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO three times a
day: take in conjunction with 10 mg tablet for total of 12.5 mg
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X/DAY (5 Times a Day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
AST/ALT/Alk Phos., T.[**Name (NI) **], Albumin, PT/PTT/INR, Chem 7 drawn
every Wednesday
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Spontaneous Bacterial Peritonitis
Sepsis [**1-21**] Spontaneous Bacterial Peritonitis
Acute renal failure [**1-21**] sepsis, hepatorenal syndrome
Hepatic encephalopathy
Secondary Diagnosis:
Cirrhosis [**1-21**] schistosomiasis
GERD
Discharge Condition:
Stable, ambulating, tolerating tube feeds at goal. Afebrile.
Discharge Instructions:
You came to the hospital because there was bacteria growing in
your ascites. You became very sick from this and required care
in the ICU. You improved with IV antibiotics and treatment to
help your kidneys. We took fluid off of your abdomen twice and
you felt better and had no more signs of infection.
.
We made the following changes to your medications:
1) We STOPPED ciprofloxacin.
2) We STARTED cefpodoxime for prevention of infection in the
fluid in your abdomen. Please take 200 mg twice daily.
3) We STARTED lasix for prevention of accumulation of fluid in
your abdomen. Please take 20 mg daily.
4) We STARTED rifaximin 400 mg three times a day to prevent
confusion.
5) We STARTED midodrine 12.5 mg three times a day to help your
blood pressure and increase the amount of blood flow to your
kidneys.
.
If you have any fever, chills, abdominal pain, nausea, vomiting,
diarrhea, worsening confusion, or any other worrisome symptoms,
please call your doctor or return to the emergency room.
Followup Instructions:
Please have your AST/ALT/Alk Phos., T.[**Name (NI) **], Albumin, PT/PTT/INR,
Chem 7 drawn every Wednesday
.
You have the following appointments:
You will follow-up with Dr. [**Last Name (STitle) 497**] in the [**Last Name (STitle) **] clinic on
[**2182-5-1**] at 1:40PM. Their office is located in the [**Hospital **] Medical
Office Building, [**Last Name (NamePattern1) 439**]. Please call [**Telephone/Fax (1) 673**] if
you need to reschedule this appointment. You should have your
stiches removed at this appointment.
.
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2182-5-8**] 3:00
.
Please follow-up with your primary care doctor within 1 week.
|
[
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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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246, 259
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331, 2076
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10977, 11021
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10786, 10956
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2098, 3228
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3244, 3443
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,479
| 180,614
|
42109
|
Discharge summary
|
report
|
Admission Date: [**2135-10-18**] Discharge Date: [**2135-10-21**]
Date of Birth: [**2091-1-22**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
TCA overdose (likely flexeril)
Major Surgical or Invasive Procedure:
Intubation
Central Line placement
History of Present Illness:
This is a 45-year-old woman transferred to [**Hospital1 18**] with AMS and
hypotension in the setting of an intentional ingestion.
.
Per report, Ms. [**Known lastname **] was brought in by the police after her
husband called 911 because she was expressing suicidal ideation.
Patient initially triaged at OSH to psychiatry for evaluation,
whereupon she developed altered mental status and hypotension.
Patient was intubated for airway protection with etomidate
followed by succinylcholine and vecurunium. Initial EKG
revealed widenend QRS and RBBB widened so patient treated for
presumed TCA overdose. Patient was placed on bicarb 2gm,
Magnesium 2gm, 2L NS and started on dopa drip. Patient also
received narcan 0.4 and decision made to transferred to [**Hospital1 18**]
for further evaluation.
.
At [**Hospital1 18**], EKG revealed QRS of 150: patient was given 1amp of
bicarb and started on a bicarb drip. Calcium was given as well.
SBPs remained in the 70s on max dopamine and decision was made
to start levophed. Repeat ABG showed a pH 7.51 and bicarb gtt
stopped. Patient was then given intra-lipid 150ml iv x1 and
25ml/min x60minutes. Toxicology was consulted and recommended
continuing supportive care.
.
In the ICU, Ms. [**Known lastname **] continued to improve. Her QRS narrowed
and the bicarb drip was stopped. She was extubated and called
out to the floor. Patient told MICU team that she may have
taken old migraine medication, which likely had TCA-like
properties.
Past Medical History:
Depression with previous suicide attempt
Migraines with aura
Asthma
OA
Social History:
Patient is currently unemployed. She lives with a roommate and
is estranged from her husband. [**Name (NI) **] a history of domestic and
sexual abuse. Has a 22-year-old daughter, 3-year-old grandson,
and daughter is expecting.
Family History:
Noncontributory
Physical Exam:
On Admission:
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
On discharge:
Vitals stable
GENERAL: No acute distress, flat affect, pleasant
HEENT: Moist mucous membranes
NECK: No cervial, submandibular, or supraclavicular LAD
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: No edema bilaterally
SKIN: Warm, slightly diaphoretic
PSYCH: Slightly aloof affect, conversant, tearful but smiling
appropriately
Pertinent Results:
Admission Labs:
[**2135-10-18**] 11:46PM TYPE-ART RATES-18/ TIDAL VOL-500 PEEP-5 O2-50
PO2-180* PCO2-36 PH-7.55* TOTAL CO2-32* BASE XS-9 -ASSIST/CON
INTUBATED-INTUBATED
[**2135-10-18**] 10:20PM TYPE-[**Last Name (un) **] TEMP-36.9 RATES-18/ TIDAL VOL-500
PEEP-5 O2-50 PO2-43* PCO2-42 PH-7.50* TOTAL CO2-34* BASE XS-7
INTUBATED-INTUBATED VENT-CONTROLLED
[**2135-10-18**] 10:20PM GLUCOSE-130* LACTATE-2.1* NA+-136 K+-3.2*
CL--98
[**2135-10-18**] 10:20PM HGB-10.6* calcHCT-32
[**2135-10-18**] 10:20PM freeCa-1.02*
[**2135-10-18**] 04:26PM TYPE-[**Last Name (un) **] PO2-153* PCO2-43 PH-7.48* TOTAL
CO2-33* BASE XS-8 COMMENTS-GREEN TOP
[**2135-10-18**] 04:26PM LACTATE-3.1*
[**2135-10-18**] 04:00PM GLUCOSE-172* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-30 ANION GAP-12
[**2135-10-18**] 04:00PM CALCIUM-8.2* PHOSPHATE-1.4* MAGNESIUM-2.0
[**2135-10-18**] 11:26AM PO2-45* PCO2-45 PH-7.45 TOTAL CO2-32* BASE
XS-6
[**2135-10-18**] 11:26AM LACTATE-3.6*
[**2135-10-18**] 11:12AM GLUCOSE-147* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-3.0* CHLORIDE-97 TOTAL CO2-28 ANION GAP-16
[**2135-10-18**] 11:12AM ALT(SGPT)-20 AST(SGOT)-31 ALK PHOS-66 TOT
BILI-0.1
[**2135-10-18**] 11:12AM CALCIUM-8.6 PHOSPHATE-1.1* MAGNESIUM-2.1
[**2135-10-18**] 11:12AM WBC-12.2* RBC-3.49* HGB-11.1* HCT-29*
MCV-83.5 MCH-31.7 MCHC-38.2* RDW-12.5
[**2135-10-18**] 11:12AM PLT COUNT-350
[**2135-10-18**] 07:54AM TYPE-[**Last Name (un) **] PO2-82* PCO2-51* PH-7.36 TOTAL
CO2-30 BASE XS-1 COMMENTS-GREEN TOP
[**2135-10-18**] 07:54AM LACTATE-4.5*
[**2135-10-18**] 04:47AM TYPE-ART TEMP-37.0 PO2-246* PCO2-47* PH-7.51*
TOTAL CO2-39* BASE XS-13
[**2135-10-18**] 04:40AM GLUCOSE-326* UREA N-19 CREAT-1.1 SODIUM-139
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-18* ANION GAP-24*
[**2135-10-18**] 04:40AM estGFR-Using this
[**2135-10-18**] 04:40AM ALT(SGPT)-24 AST(SGOT)-36 LD(LDH)-392* ALK
PHOS-69 TOT BILI-0.4
[**2135-10-18**] 04:40AM LIPASE-90*
[**2135-10-18**] 04:40AM ALBUMIN-4.2 CALCIUM-7.8* PHOSPHATE-1.6*
[**2135-10-18**] 04:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2135-10-18**] 04:40AM GLUCOSE-294* LACTATE-2.5* NA+-139 K+-3.9
CL--99 TCO2-25
[**2135-10-18**] 04:40AM WBC-14.2* RBC-3.98* HGB-12.2 HCT-33.7* MCV-85
MCH-30.6 MCHC-36.1* RDW-12.6
[**2135-10-18**] 04:40AM PT-10.8 PTT-18.4* INR(PT)-0.9
[**2135-10-18**] 04:40AM PT-10.8 PTT-18.4* INR(PT)-0.9
[**2135-10-18**] 04:40AM FIBRINOGE-197
.
EKG [**2135-10-18**]: Sinus rhythm at the upper limits of normal rate.
Rightward axis. Consider right bundle-branch block. Borderline
prolonged Q-T interval. No previous tracing available for
comparison. Clinical correlation is suggested. QRS 154
.
CXR [**2135-10-18**]:
The right internal jugular line is malpositioned with the tip
coursing towards the right axilla, probably within the right
subclavian vein.
However an inadverant position into the arterial system cannot
be ruled out. Consider repositioning the catheter. Bilateral
lung volumes are low. Right lower paracardiac opacity, left
lower lung and retrocardiac opacities are likely from lung
atelectasis.
.
CXR [**2135-10-19**]:
Lines and tubes remain in place in a standard position. There
are persistent low lung volumes. There is no
pneumothorax/pleural effusion. There are persistent bibasilar
opacities likely atelectasis. Perihilar opacity and the left
suprahilar region is also unchanged. Attention in followup in
this area is recommended. This could be due to atelectasis, but
an underlying lung lesion can be present.
.
CXR [**2135-10-20**]:
As compared to the previous radiograph, the patient has been
extubated. All other monitoring and support devices have also
been removed. Arising from the middle portions of the left
hilus is a band-like opacity that is directed towards the left
lung apex. The appearance of this opacity is resembling
atelectasis. At the bases of both the right and the left lungs,
a subtle parenchymal scarring is seen. Resolution of the
atelectasis should be monitored with chest x-ray. In case of
non-resolution, a CT should be performed. Normal size of the
cardiac silhouette. No pleural effusions. Status post right
shoulder surgery.
.
[**2135-10-21**]
White Blood Cells 5.0 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.55* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 10.7* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 30.5* 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 86 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 30.2 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 35.1* 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 12.9 10.5 - 15.5 %
Glucose 83 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 11 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 1.1 0.4 - 1.1 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 141 133 - 145 mEq/L
PERFORMED AT WEST STAT LAB
Potassium 4.1 3.3 - 5.1 mEq/L
PERFORMED AT WEST STAT LAB
Chloride 108 96 - 108 mEq/L
PERFORMED AT WEST STAT LAB
Bicarbonate 24 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 13 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 8.7 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 3.9 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 2.3 1.6 - 2.6 mg/dL
PERFORMED AT WEST STAT LAB
Glucose 147* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 15 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 0.9 0.4 - 1.1 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 138 133 - 145 mEq/L
VERIFIED BY ALTERNATE METHODOLOGY
PERFORMED AT WEST STAT LAB
Potassium 3.0* 3.3 - 5.1 mEq/L
VERIFIED BY ALTERNATE METHODOLOGY
PERFORMED AT WEST STAT LAB
Chloride 97 96 - 108 mEq/L
VERIFIED BY ALTERNATE METHODOLOGY
PERFORMED AT WEST STAT LAB
Bicarbonate 28 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 16 8 - 20 mEq/L
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 20 0 - 40 IU/L
HEMOLYSIS FALSELY ELEVATES ALT
PERFORMED AT WEST STAT LAB
Asparate Aminotransferase (AST) 31 0 - 40 IU/L
HEMOLYSIS FALSELY ELEVATES AST.
PERFORMED AT WEST STAT LAB
Alkaline Phosphatase 66 35 - 105 IU/L
PERFORMED AT WEST STAT LAB
Bilirubin, Total 0.1 0 - 1.5 mg/dL
PERFORMED AT WEST STAT LAB
CHEMISTRY
Calcium, Total 8.6 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 1.1* 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 2.1 1.6 - 2.6 mg/dL
PERFORMED AT WEST STAT LAB
Brief Hospital Course:
Ms. [**Known lastname **] is a 44-year-old woman with a pmhx. significant for
depression and previous suicide attempts who presents with
intentional ingestion, likely from TCA-like substance.
.
# OVERDOSE: Patient presented with suicidality/intentional
overdose to OSH and soon developed hypotension with obtundation
necessitating intubation for airway protection. She was started
on dopamine and transferred to [**Hospital1 18**] where initial toxicology
screen tested positive for serum TCAs. She had QRS prolongation
to 150s on transfer consisitent with sodium channel blockade.
Toxicology team was consulted and followed closely. She
received bicarb and intralipid in the ED. She was started on a
sodium bicarbonate drip in the ICU over the course of about 24
hours with steady narrowing of her QRS interval, which closed to
a normal 116 by later her first hospital day and remained narrow
after discontinuing her bicarb drip on HD2. She was extubated
on HD2. Upon waking, she struggled to recall the name of the
culprit medication. She did recall an old migraine medication
that sounded like it could have TCA component. Of her listed
meds, both flexeril and seroquel can cause a false TCA serum
test, and the former is structurally similar to TCAs. She met
with the psychiatry team, and noted that she recently separated
from her husband, though has frequent contact with him. She
found him with a new partner the night of the overdose, which
prompted her decompensation.
.
# DEPRESSION: As above, she is depressed with active
suicidality prompted by a negative interaction with her
ex-husband and his partner. A section 12 was placed in the
patient's chart, and she had a 1:1 sitter throughout admission.
Most of Ms. [**Known lastname 91349**] psychiatric medications were stopped
except for her citalopram. These medications can be restarted
at the discretion of her psychiatry team.
.
# LEFT UPPER ARM SWELLING: On the day of discharge from the
medical floor, Ms. [**Known lastname **] was noted to have a swollen,
indurated left upper arm. An ultrasound (wet-read) showed:
"basilic vein superficial thrombophlebitis just above the
antecubital fossa on the left (at the site of the patients skin
changes). No DVT." She was instructed to continue using warm
packs on the arm and keep it elevated.
.
# ABNORMAL CXR: Patient had a CXR on [**10-19**] while she was
intubated that was concerning for atelectasis vs. mass.
Although the image is most consistent with atelectasis,
radiology suggested that Ms. [**Known lastname **] have a repeat CXR in the
next 2-4 weeks, and then CT scan if CXR continues to be
abnormal.
.
# ASTHMA: Fluticasone and albuterol were continued.
.
# ANEMIA: mild anemia during this admission, fluid resuscitation
likely caused a dilutional effect. Hct 30 on discharge. Can be
followed after discharge.
Medications on Admission:
Citalopram 40mg 1.5 tabs QD
Vitamin [**Numeric Identifier 1871**] 1cap weekly
Fluticasone 110 mcg inh [**Hospital1 **]
Gabapentin 300mg 1 tab [**Hospital1 **]
Hydroxyzine 50mg cape 1cap qhs
Pantoprazole 40mg tab QD
Seroquel XR 150mg tab QD
Traimterene/HCTZ 37.5/25 2 caps QD
Fioricet 1tab q8hrs prn headache
albuteral inh 2puffs Q4hrs\Flexeril 10mg 1 tab Q4hr
Benadryl 25mg cap 1 prn itch
Naproxen 500mg tab 1 tab [**Hospital1 **]
Oxazepam 10mg tab [**Hospital1 **]
Zolmitriptan 5mg
Oxycodone 5mg tab Q6hrs as needed for pain (20tabs)
Flexeril 10mg 0.5-1mg TID
Pravochol 40mg QD
MVI
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (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. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: Two
(2) Capsule PO once a day.
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-30**]
Tablets PO every eight (8) hours as needed for headache.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
8. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Overdose (likely from TCA-like substance)
Respiratory compromise
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this admission. You
came to the hospital because of a drug overdose. You were
intubated and on vasopressors (to keep your blood pressure up),
and we carefully monitored your EKGs. Your condition stablized,
and we were able to take you off the breathing machine. Your
EKGs have been normal since that time. We all agree that you
need further psychological treatment, and that would be best
attained at an inpatient psychiatric unit.
.
A chest XRAY on [**2135-10-19**] was normal except for a patchy area that
needs to be further evaluated in order to rule out a mass. The
radiologists recommended getting a repeat chest XRAY in [**3-4**]
weeks (in early [**Month (only) 359**]), and if the concerning area is still
there, go for a CT scan of your chest.
.
Your left arm was swollen, likely because of an infiltrated IV.
We did an ultrasound that was negative for a deep blood clot.
.
We started a medication called Fioricet for your headaches.
.
The following changes were made to your medications:
Please stop taking: hydroxyzine, seroquel, benadryl, naproxen,
oxazepam, zolmitriptan, and oxycodone until intstructed by your
outpatient providers.
Followup Instructions:
You will need to see your primary care physician after you are
discharged from the psychiatric facility.
|
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icd9cm
|
[
[
[]
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] |
[
"96.71",
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icd9pcs
|
[
[
[]
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14106, 14121
|
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1913, 1986
|
2002, 2233
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,518
| 168,133
|
28910
|
Discharge summary
|
report
|
Admission Date: [**2110-7-21**] Discharge Date: [**2110-9-26**]
Date of Birth: [**2067-11-1**] Sex: F
Service: SURGERY
Allergies:
Iodine-Iodine Containing / vancomycin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Diarrhea, hypotension.
Major Surgical or Invasive Procedure:
[**2110-7-21**]: Exploratory laparotomy.
[**2110-7-22**]: CT-guided intra-abdominal abscess drainage.
History of Present Illness:
Pt is a 42F well-known to the service having undergone a
colostomy take-down, left and partial right colectomies with
primary anastmoses, and abdominal wall reconstruction with
component separation on [**2110-7-8**]. She was discharged home on
[**2110-7-19**] doing well. Her post-operative course included
intermittent fevers for which a CT scan of the abdomen was
performed on [**2110-7-15**] without any evidence of leak, free air, or
abscess. Blood cultures were negative on [**7-13**], and she
had been afebrile for > 48 hours at the time of discharge. Of
note, her tunneled HD line was replaced on [**2110-7-11**] as the cuff
was exposed and again on [**2110-7-18**] as the line was not
functioning.
[**Known firstname 69408**] presented to [**Hospital6 **] yesterday with
complaints of diarrhea and small amount of blood per rectum.
She was treated with IV hydration and discharged home. She then
presented to the [**Hospital1 18**] ED this morning with complaints of
diarrhea and intermittent abdominal cramps along with rectal
pain. She denies fever, chills, SOB, N/V, CP/SOB. She reports
she has been eating minimally since discharge.
Past Medical History:
1. Tuberous Sclerosis: S/p bilateral nephrectomy [**2101**] at [**Hospital1 2177**],
c/b bowel perforation requiring end colostomy complicated by
large parastomal hernia
2. [**2110-7-8**] Exploratory laparotomy, repair of peristomal hernia,
colon resection x3, colocolostomy, coloproctostomy, Ventral
hernia repair with component separation and Marlex mesh.
3. ESRD with HD M/W/F via tunneled L IJ HD line
4. Tertiary hyperparathyroidism s/p parathyroidectomy
5. GERD
6. Right hand pain thought to be d/t steal from right AVF, s/p
ligation of AVF
7. PUD
8. Pericarditis [**2107**]
9. Asthma as a child
Social History:
Lives in [**Location 2268**] by herself. Son checks in on her. She likes to
volunteer at shelters to cook food for the homeless. She has
daughters that live in [**Name (NI) **] and [**Name (NI) **]. Denies current
tobacco use although she is a former smoker (1 pack per week,
quit [**2102**]). No ETOH. No history of IVDU. She is on disability.
She has the RIDE and uses a cane for walking.
Family History:
The patient has had four children with one deceased, from
complications of tuberous sclerosis. Father also with tuberous
sclerosis. Two living grandchildren also with tuberous
sclerosis. Mother with history of breast cancer and hypertension
and an MI in her 60s.
Physical Exam:
On admission:
VS 74/54 75 18 99% RA
NAD, sleeping but wakes easily. Alert, oriented.
No jaundice or icterus
CTA B/L
RRR
Abd soft, sl distended. minimal tenderness to deep palpation. no
rebound or guarding. no shake or tap tenderness. L drain in
place draining scant serosangeous output. Central portion of
the midline incision macerated with blood-tinged drainage. No
purulence. Several staples removed, no drainage could be
expressed.
No LE edema
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2110-9-26**] 06:36 5.3 3.05* 8.4* 27.6* 90 27.5 30.4* 20.6*
370
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2110-9-19**] 09:37 80* 5 9* 6 0 0 0 0
0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Target Burr Tear Dr [**Last Name (STitle) **]
[**2110-9-19**] 09:37 OCCASIONAL 1+ 2+ 1+ OCCASIONAL 1+ 1+ 2+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2110-9-26**] 06:36 370
Source: Line-dialysis
[**2110-9-26**] 06:00 20.2* 33.7 1.8*
Source: Line-picc
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2110-8-15**] 02:08 661*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2110-9-26**] 06:36 811 12 6.6* 140 3.9 98 25 21*
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2110-9-21**] 05:53 13 15 131*
1.0
Source: Line-art
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd
Iron
[**2110-9-26**] 06:36 7.5* 3.3 2.2
PITUITARY TSH
[**2110-8-13**] 03:02 2.2
[**2110-9-16**] 8:29 pm BLOOD CULTURE Source: Line-CVL.
**FINAL REPORT [**2110-9-19**]**
Blood Culture, Routine (Final [**2110-9-19**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2110-9-17**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Male First Name (un) **] @ 9:49AM
[**2110-9-17**].
Anaerobic Bottle Gram Stain (Final [**2110-9-17**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
On [**2110-7-21**], the patient was admitted to the transplant surgery
service and started on broad-spectrum antibiotics. That night
she underwent attempted exploratory laparotomy for
intra-abdominal abscess from anastomotic leak. This was
unsuccessful and a wound VAC was placed. She was then admitted
to the SICU. On [**2110-7-22**], she underwent CT-guided drainage of
this abscess. Drain produced succus. There was evidence on CT
abdomen of enteral fistula into the abscess cavity as well. She
remained NPO with TPN for most of hospital course.
She remained in sinus tachycardia with heart rate ranging
100-130s. Cardiology consult was obtained and tachycardia was
attributed to infection, hypovolemia, and anemia. There was no
evidence of myocardial injury. She was hypotensive and
initially required neosynephrine gtt, which was weaned. She was
hemodynamically stable on midodrine. This was subsequently
discontinued.
She was intubated episodically for invasive procedures.
Infectious work-up found enterobacter pneumonia on
broncheoalveolar lavage on [**2110-8-5**], and this was treated with
a two-week course of meropenem.
She had h/o bilateral nephrectomy. She required intermittent
hemodialysis as well as CVVH while hypotensive and requiring
vasopressors in the SICU. Intravenous fluids were given as
needed for maintenance and for hypovolemia. CVVH was switched to
intermittent hemodialysis when she was off pressor support.
Post-operative course was complicated by Candidemia found on
blood cultures on [**2110-7-28**], which was treated with Ambisome ([**8-2**]
thru [**8-15**])then Micafungin [**8-15**] thru [**8-24**]). This was switched to
Fluconazole for 2 weeks (10/3-1016). Ophthalmology was
consulted. Retinal specialist found changes indicating only
tuberous sclerosis. . Hematocrit was checked regularly and she
was transfused with 2 units of PRBC on [**9-21**] and [**9-24**]. She had
no acutely anemic events.
Central venous access was necessary at all times, with temporary
HD catheter and triple-lumen central venous line, as it was not
possible to establish peripheral IV access. Lines were changed
when blood cultures grew [**Female First Name (un) **]. R Temporary HD line was
removed on [**9-2**] when she had head/neck and bilateral arm edema.
CTA venogram on [**9-3**] demonstrated partially occlusive thrombus
within the right subclavian vein near the thoracic inlet with
probable occlusion of the right internal jugular vein. She was
started on a Heparin drip. Coumadin was initiated on [**9-6**].
Heparin was stopped once INR was therapeutic.
She continued to have intermittent fevers for which blood was
cultured. She spiked to 101.4. Abdominal CT with po contrast was
done on [**9-8**] showing decreased size of LUQ collection with
extravasated enteric contrast with pigtail catheter positioned
appropriately. Foci of gas at the base of a vacuum drainage
apparatus in the anterior abdominal wall was noted. Bibasilar
pulmonary consolidation consistent with pneumonia.
A tagged WBC scan was done on [**9-9**] that was negative. The
abdominal drain was injected and abdomen scanned on [**9-16**]. The
pigtail catheter was seen with tip coiled in the left paracolic
gutter, just inferior to the spleen. Contrast was seen entering
the lumen of the colon through a fistula track measuring
approximately 5 mm in width. Contrast then continued to opacify
the descending colon rectum. Post CT, she spike to 103.6 and was
hypotensive to 70s necessitating transfer to SICU for IV fluid
bolus and IV Neo. She was pan-cultured and started on Linezolid
which continued until [**9-18**] when blood cultures from [**9-16**]
isolated pan-sensitive Staph coag positive. Linezolid was
switched to Nafcillin on [**9-18**] per ID recommendations. ID
recommended TTE. This was done,and was negative for vegetations,
but was a sub-optimal study. TEE was planned, but the patient
refused this study. US of the known right SVC/IJ was done to
characterize previously known non-occlusive thrombus to rule out
another source of bacterial seeding. No thrombus was seen in the
SVC/ distal IJ or right upper extremity.
Antibiotic plan was for 4 weeks for question endocarditis given
that TEE was not done in setting of positive blood cultures.
Nafcillin was switched to Cefazolin on [**9-26**]. This should be
given at dialysis 3xweek until [**10-17**].
Left IJ CVL and R tunnelled groin HD line, were changed to L
temporary femoral HD line [**9-16**]. R groin line was removed and a
left arm picc was placed. Daily blood cultures were done and
were negative to date. The left groin HD line was changed to a
tunnelled line in IR on [**9-24**]. The left picc line was placed on
[**9-23**] then needed repositioning on [**9-24**].
Vac dressing was changed on [**9-26**]. Wound bed was ~10cm 5cm x1cm
with granulation tissue. Blue prolene sutures were visible in
wound bed. This will stay in place until f/u with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
on [**10-2**]. Abdominal pigtail output was scant cloudy fluid.
PT evaluated and recommended rehab. She will be transferring to
[**Hospital3 **], in [**Hospital1 8**].
She was ambulating with supervision. Diet with supplements was
well tolerated.
Coumadin was started on [**9-6**] for SVC thrombus then held for
supratherapeutic INR from [**9-15**] thru [**9-22**]. Coumadin was resumed
on [**9-23**] at 2mg. INR was 1.8 at time of discharge. Goal INR was
[**12-26**].
Last HD session was [**9-26**] with 0.5 liter UF.
Medications on Admission:
. acetaminophen 1000 mg q8hr prn
2. docusate sodium 100 mg [**Hospital1 **]
3. calcium carbonate 500 mg calcium (1,250 mg) [**Hospital1 **]
4. aspirin 81 mg DAILY
5. hydromorphone 2-4 mg q3hr prn
6. Nephrocaps 1 mg once a day.
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol: of note, patient off insulin due to hypoglycemia.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Pruritis.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: inr
goal [**12-26**] for R SVC thrombus. .
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q6H (every 6 hours) as needed for nausea.
14. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
15. CefazoLIN 2 g IV 2X/WEEK (MO,WE)
every Monday and Wednesday after hemodialysis
stop date [**2110-10-15**]
16. CefazoLIN 3 g IV 1X/WEEK (FR)
give after HD on Friday
stop date [**2110-10-17**]
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
18. Outpatient [**Month/Day/Year **] Work
Weekly CBC, ast, alt, alk phos, t.bili
fax to [**Hospital1 18**] ID attn: Drs [**Last Name (STitle) 724**] [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Telephone/Fax (1) 1419**]
19. Outpatient [**Name (NI) **] Work
PT/INR 3x/wk, goal INR [**12-26**] for R SVC thrombus
20. Dilaudid
0.5mg ivp prn: prior to Vac change
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
ESRD
Tuberous Sclerosis
Abdominal abscess
Abdominal incision wound
Intestinal leak
Fungemia
Enterobacter Pneumonia
MSSA bacteremia
Partially occlusive thrombus within the right subclavian vein
near the thoracic inlet
Discharge Condition:
Mental Status: Clear and coherent.
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) 670**] office [**Telephone/Fax (1) 673**] if you experience
any of the following:
fever (temperature of 101 or greater), shaking chills, nausea,
vomiting, increased drain output, abdominal wound has increased
drainage/foul odor, malfunctioning of tunnelled HD line,
constipation/diarrhea
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2110-10-2**] 1:10, [**Last Name (NamePattern1) 439**], Transplant
Institute, [**Location (un) **], [**Location (un) 86**]
Provider: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2110-10-10**] 8:00 in [**Hospital **] clinic, [**Last Name (NamePattern1) 439**],
(Basement)[**Location (un) 86**]
Completed by:[**2110-9-26**]
|
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"585.6",
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"530.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
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icd9pcs
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14456, 14456
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2932, 2932
|
257, 281
|
450, 1604
|
2946, 3385
|
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|
1626, 2229
|
2245, 2637
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,603
| 152,839
|
30679
|
Discharge summary
|
report
|
Admission Date: [**2123-5-11**] Discharge Date: [**2123-5-13**]
Date of Birth: [**2058-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
EGD
History of Present Illness:
64M w/ h/o mild CVA w/memory deficits on ASA, anxiety,
depression, hyperlipidemia w/three episodes of BRBPR on evening
prior to admit after finding blood in his underwear. Hct 45 @
NWH; repeat Hct 38 after 1L IVF so transferred to [**Hospital1 18**] for
further evaluation. Per report, he's been taking up to 3 tablets
of advil 2-3 times per week for back pain. He also take 325 mg
of aspirin per day as he's had a CVA.
.
Patient is poor historian, but is very anxious. He is able to
say that he had a normal colonoscopy seven months ago and that
he has never had similar symptoms before. On the floor, he had
two more episodes of BRBPR totaling about 1 L. He was
diaphoretic and dizzy while passing more BRBPR, so [**Hospital Unit Name 153**] consult
was called. His HR was 103, BP 120/78, and 98% on RA at time of
transfer.
.
Upon [**Hospital Unit Name 153**] eval, he was pale and complained of dizzyness. NG
lavage with 500 cc returned 100 cc of clear fluid. He was
transferred for closer monitoring and rescusitation. He was
transfused and Foley placed for urinary retention, also
creatinine 1.7 (suspect prerenal). Colonscopy and EGD was
performed [**5-12**] and only notable for diverticuli with gastritis,
no active bleeding source identified. He is transferred back to
the floor in stable condition. Mild hyperglycemia was also noted
during his stay (130's). His CK has risen to 955.
.
ROS: denies fevers, weight loss, dysuria, hematuria, abd pain,
chest pain, shortness of breath, palpitations, visual changes,
headaches. Admits to thirst, dizzyness, diaphoresis, and chills.
Past Medical History:
Hyperlipidemia
CVA
Heart murmur
Anxiety
Hypothyroidism
Social History:
Married, lives in [**Location 745**], 1 son, denies EtOH, smokes [**5-23**]
cigarettes "a week". Denies recreational drugs. Retired
inventory controller for industrial heating company. He is
estranged from 2 sisters.
Family History:
Brother died of "eating too much chocolate" (eg. MI). Parents
died in their 90's of "old age". Sisters health unknown.
Physical Exam:
98.3 129/83 89 20 96% RA
Obese man, pleasant, A+Ox3, tangential answers
Neck supple, MMM and clear, no LAD, no carotid bruits
CAT B
RRR S1S2 no m/r/g appreciated
Soft, obese, nt, nd, +BS
No c/c/e
Pertinent Results:
[**2123-5-11**] ECG: Sinus tachycardia with atrial premature beats.
Modest non-specific low amplitude T wave changes. No previous
tracing available for comparison.
.
[**2123-5-12**] EGD: Findings: Esophagus: Normal esophagus.
Mucosa: Localized erythema and erosion of the mucosa with no
bleeding were noted in the antrum and fundus. These findings are
compatible with non-steroidal induced gastritis.
Duodenum: Normal duodenum.
Impression: Erythema and erosion in the antrum and fundus
compatible with non-steroidal induced gastritis
Recommendations: Send serologies for H. Pylori
Protonix 40 mg twice daily
.
[**2123-5-12**] COLONOSCOPY: Findings:
Protruding Lesions Two sessile polyps of benign appearance and
ranging in size from 4mm to 5mm were found in the sigmoid colon.
A single sessile 6 mm polyp of benign appearance was found in
the cecum. A single sessile 4 mm polyp of benign appearance was
found in the transverse colon. A small size 10 mm lipoma was
seen in the transverse colon.
Excavated Lesions Multiple non-bleeding diverticula with medium
openings were seen in the sigmoid colon, descending colon and
ascending colon.Diverticulosis appeared to be of moderate
severity.
Impression: Polyps in the sigmoid colon
Polyp in the cecum
Polyp in the transverse colon
Diverticulosis of the sigmoid colon, descending colon and
ascending colon
Lipoma in the transverse colon
.
[**2123-5-11**] 06:58AM BLOOD WBC-10.2 RBC-3.86* Hgb-11.9* Hct-36.9*
MCV-95 MCH-30.9 MCHC-32.3 RDW-14.2 Plt Ct-317
[**2123-5-11**] 08:47AM BLOOD WBC-10.6 RBC-3.31* Hgb-11.1* Hct-32.6*
MCV-98 MCH-33.4* MCHC-33.9 RDW-13.8 Plt Ct-309
[**2123-5-11**] 01:48PM BLOOD Hct-35.2*
[**2123-5-11**] 07:53PM BLOOD Hct-35.0*
[**2123-5-11**] 06:58AM BLOOD Neuts-72.6* Lymphs-21.1 Monos-4.8 Eos-1.3
Baso-0.2
[**2123-5-11**] 06:58AM BLOOD Macrocy-1+
[**2123-5-11**] 08:47AM BLOOD Plt Ct-309
[**2123-5-11**] 08:47AM BLOOD PT-12.5 PTT-23.2 INR(PT)-1.1
[**2123-5-11**] 06:58AM BLOOD Plt Ct-317
[**2123-5-11**] 08:47AM BLOOD Glucose-131* UreaN-19 Creat-1.7* Na-141
K-4.5 Cl-110* HCO3-24 AnGap-12
[**2123-5-11**] 06:58AM BLOOD Glucose-127* UreaN-18 Creat-1.7* Na-144
K-4.6 Cl-110* HCO3-27 AnGap-12
[**2123-5-11**] 01:48PM BLOOD CK(CPK)-88
[**2123-5-11**] 01:48PM BLOOD CK-MB-4 cTropnT-0.02*
[**2123-5-11**] 08:47AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.8
[**2123-5-11**] 06:58AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
.
[**2123-5-12**] 04:08AM BLOOD WBC-11.1* RBC-3.38* Hgb-11.3* Hct-32.3*
MCV-96 MCH-33.4* MCHC-35.0 RDW-14.1 Plt Ct-254
[**2123-5-12**] 03:32PM BLOOD Hct-31.8*
[**2123-5-12**] 04:08AM BLOOD PT-12.5 PTT-24.6 INR(PT)-1.1
[**2123-5-12**] 04:08AM BLOOD Plt Ct-254
[**2123-5-12**] 04:08AM BLOOD Glucose-112* UreaN-19 Creat-1.3* Na-141
K-3.9 Cl-107 HCO3-25 AnGap-13
[**2123-5-12**] 04:08AM BLOOD CK(CPK)-555*
[**2123-5-12**] 03:32PM BLOOD CK(CPK)-935*
[**2123-5-12**] 04:08AM BLOOD CK-MB-7 cTropnT-0.02*
[**2123-5-12**] 03:32PM BLOOD CK-MB-7 cTropnT-0.03*
[**2123-5-12**] 04:08AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.9
[**2123-5-12**] 03:32PM BLOOD TSH-0.29
[**2123-5-12**] 03:32PM BLOOD Free T4-1.5
.
[**2123-5-12**] 03:32PM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.019
[**2123-5-12**] 03:32PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2123-5-12**] 03:32PM URINE RBC-210* WBC-9* Bacteri-NONE Yeast-NONE
Epi-0
[**2123-5-12**] 03:32PM URINE Eos-NEGATIVE
[**2123-5-12**] 03:32PM URINE Hours-RANDOM UreaN-467 Creat-92 Na-217
.
[**5-13**] HCT 33.9, CK 1473
Brief Hospital Course:
GI bleed: Likely diverticular. Had EGD with gastritis; Colon
with polpys/diverticulae. No obvious source of bleeding found;
bleeding stopped spontaneously. Transfused a total of 2U PRBC.
HCT stable on day of discharge. Added PPI, d/c'd ASA on
discharge. Will f/u with outpatient PCP/GI doc for repeat colon
(for polypectomy).
.
ARF: resolved with IVF.
.
Elevated CK: no evidence of Cardiac Ischemia. ?related to
immobility. Pt to hold statin on discharge, will f/u with PCP.
Medications on Admission:
ASA 325mg qd
Paxil 40mg qd
Alprazolam 2mg qAM, 1mg qPM
Lipitor 20mg qd
Pepcid 40mg qd
imipramine 100mg qh
synthroid 200mcg qd
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
3. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
4. Imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
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. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed, likely diverticular
Hypertension
Acute Renal Failure, resolved
Elevated CK, NOS
h/o CVA
Discharge Condition:
stable
Discharge Instructions:
Please be sure to follow up with the gastroenterologists because
you had polyps in your colon that need to be biopsied. Stop
taking advil, motrin, or naproxen since these were causing the
lining of your stomach to become thin and to bleed.
We have started a new medicine to help your stomach called
"Protonix".
Do not take your aspirin until you follow up with Dr. [**Last Name (STitle) 18376**].
Do not take your Lipitor until you see Dr [**Last Name (STitle) 18376**].
Followup Instructions:
1. You have an appointment scheduled with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 18376**] ([**Telephone/Fax (1) 18377**]) on [**2123-5-18**] at 3:00. You will also need
to have a repeat colonoscopy in [**3-21**] months. The doctor who did
your colonoscopy here at [**Hospital1 18**] is Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**]. You can
discuss this with your PCP.
2. Please call your GI doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], to schedule
a follow-up appointment. [**Telephone/Fax (1) 44650**]
|
[
"272.4",
"535.50",
"244.9",
"562.12",
"584.9",
"401.9",
"300.00",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7408, 7414
|
6162, 6648
|
321, 339
|
7556, 7565
|
2638, 6139
|
8086, 8689
|
2286, 2406
|
6825, 7385
|
7435, 7535
|
6674, 6802
|
7589, 8063
|
2421, 2619
|
276, 283
|
367, 1957
|
1979, 2036
|
2052, 2270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,946
| 164,873
|
26273
|
Discharge summary
|
report
|
Admission Date: [**2196-1-14**] Discharge Date: [**2196-1-20**]
Date of Birth: [**2137-8-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional Symptoms
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 4 ([**2196-1-14**])
History of Present Illness:
58 y/o male with exertional symptoms. Cardiac cath revealed 3
vessel disease (LM 50%, LAD 80%, OM 80-90%, RCA 95%) with a
45-50% EF. He was then referred for cardiac surgery.
Past Medical History:
Hypertension
Hyperlipidemia
Arthritis
Kidney Stones
s/p Right hand surgery
s/p ruptured achilles
Social History:
Quit smoking in [**2178**]. Occ. ETOH
Family History:
Mother had MI in 50;s
Physical Exam:
VS: 55 17 110/70 100%on RA
Neuro: NAD, A&O x 3
CV: RRR, +S1S2 -c/r/m/g
Lungs: CTAB -w/r/r
Abd: Obese, spft NT/ND
Ext: Warm, -edema/varicosities
HEENT: EOMI/PERRL
Neck: -Carotid Bruits
Pertinent Results:
CXR [**1-18**]: Decreased size of right pneumothorax following chest
tube
placement.
[**2196-1-16**] 06:00AM BLOOD WBC-12.5* RBC-3.49* Hgb-11.4* Hct-30.6*
MCV-88 MCH-32.6* MCHC-37.2* RDW-13.5 Plt Ct-107*
[**2196-1-15**] 01:47AM BLOOD PT-13.0 PTT-29.7 INR(PT)-1.1
[**2196-1-18**] 07:30AM BLOOD Glucose-115* UreaN-12 Creat-1.0 Na-138
K-3.9 Cl-97 HCO3-33* AnGap-12
[**2196-1-19**] 07:05AM BLOOD UreaN-14 Creat-1.0 K-3.8
Brief Hospital Course:
Patient was a same day admit and brought directly to the
operating room where she underwent a coronary artery bypass
graft x 4. Please see op note for full surgical details. Pt
tolerated the procedure well and was transferred to the CSRU in
stable condition. Later on op day he was weaned from mechanical
ventilation and sedation and extubated. He was neurologically
intact. He was also weaned from all Inotropes by post op day
one. Diuretics and B blockers were started per protocol and he
was transferred to the telemetry floor on post op day one. Chest
tubes were removed on post op day two. Post chest tube pull
chest x-ray revealed a small-to-moderate right pneumothorax.
Epicardial pacing wires were removed on post op day three. On
post op day four he continued to have a persistent pneumothorax
and a right chest tube was reinserted. Following chest tube
placement chest x-ray revealed a decrease in size of his right
pneumothorax. On post op day five his chest tube was removed and
final chest x-ray showed stable-appearing small right apical
pneumothorax. The rest of his hospital course was uneventful. He
remained in a normal sinus rhythm and tolerated beta blockade.
He reponded well to diuresis and continued to make clinical
improvements. He was discharged home with VNA services and the
appropriate follow-up appointments on post op six. At discharge,
his BP was 106/64 with a HR of 84 in sinus. His room air
saturations were 99%. All surgical incisions were clean, dry and
intact without evidence of infection. He had adequate pain
control with Dilaudid.
Medications on Admission:
ASA 325mg qd
Imdur 30mg qd
Lipitor 10mg qd
Metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 5 days.
Disp:*10 Tablet Sustained Release(s)* Refills:*0*
8. 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:
TBA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Hypertension
Hyperlipidemia
Postoperative Pneumothorax - small, stable
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions with water and gentle soap.
Gently pat dry. Do not bath.
Do not apply lotions, creams, ointments, or powders to
incisions.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
Take all medications and make follow-up appointments.
If you notice any redness, drainage from incisions or develop
fever greater than 101, please contact office.
Followup Instructions:
Dr. [**Last Name (STitle) 28946**] in 4 weeks
Dr. [**Last Name (STitle) 1911**] in [**2-12**] weeks
Dr. [**Last Name (STitle) 1159**] in [**1-11**] weeks
Completed by:[**2196-2-10**]
|
[
"414.01",
"274.0",
"401.9",
"512.1",
"272.4",
"427.89",
"E878.2",
"V15.82",
"997.1",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"88.72",
"36.15",
"89.64",
"36.13",
"34.04",
"39.61",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
4185, 4219
|
1473, 3046
|
341, 393
|
4394, 4400
|
1030, 1450
|
4860, 5044
|
788, 811
|
3172, 4162
|
4240, 4373
|
3072, 3149
|
4424, 4837
|
826, 1011
|
282, 303
|
421, 597
|
619, 717
|
733, 772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,172
| 178,792
|
29328
|
Discharge summary
|
report
|
Admission Date: [**2146-12-12**] Discharge Date: [**2146-12-17**]
Date of Birth: [**2061-4-9**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Bactrim DS
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
ANTERIOR fusion T11-L1 with T12 partial corpectomy
History of Present Illness:
Mr. [**Known lastname 6164**] [**Last Name (Titles) 18095**] a T12 burst fracture and underwent
posterior decompression and stabilization T10-L2 on [**2146-11-29**].
He was discharged to rehab with the plan of returning to the OR
for a partial corpectomy T12.
Past Medical History:
PMH: CAD, HTN, HL, BPH, BPPV, spinal stenosis, pacemaker
,tinnitus, renal insufficiency (lasix recently stopped for Cr
2.2, new baseline since [**2145**] 2.1-2.3)
PSH: pacemaker implantation, CABG x 4 [**2145**], AVR with St.[**Male First Name (un) 923**]
Epic Tissue Valve [**2145**], TURP, back surgery for spinal stenosis,
bilateral knee replacement
Social History:
-Tobacco history: never
-ETOH: never
-Illicit drugs: never
Pt is a former [**University/College **] design and land development professor.
Lives in [**Location **] with grandson and a close friend. His friend
helps out with cooking, and he bathes himself. Pt is still
active in planning an intergenerational apartment complex in
[**Hospital1 8**].
Family History:
Father died at [**Age over 90 **] yo of CHF. Mother had a "[**Last Name **] problem" since
her youth but died at [**Age over 90 **] yo of complications after hip fx. Two
sisters both 80 and 82 yo with hx of colon cancer.
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2146-12-16**] 09:00AM BLOOD WBC-7.8 RBC-3.49* Hgb-10.6* Hct-33.0*#
MCV-95 MCH-30.2 MCHC-32.0 RDW-15.2 Plt Ct-206
[**2146-12-15**] 05:00AM BLOOD WBC-11.5* RBC-2.80* Hgb-8.5* Hct-25.5*
MCV-91 MCH-30.2 MCHC-33.3 RDW-17.1* Plt Ct-175
[**2146-12-14**] 03:11PM BLOOD WBC-13.7* RBC-3.05* Hgb-9.3* Hct-27.2*
MCV-89 MCH-30.4 MCHC-34.0 RDW-17.3* Plt Ct-188
[**2146-12-14**] 01:50AM BLOOD WBC-13.1* RBC-3.20* Hgb-9.7* Hct-28.0*
MCV-88 MCH-30.4 MCHC-34.8 RDW-17.4* Plt Ct-199
[**2146-12-12**] 08:30PM BLOOD WBC-9.5 RBC-3.31* Hgb-9.9* Hct-30.3*
MCV-92 MCH-30.1 MCHC-32.8 RDW-17.1* Plt Ct-283#
Brief Hospital Course:
Mr. [**Known lastname 6164**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
T12 corpectomy. He was informed and consented and elected to
proceed. Please see Operative Note for procedure in detail.
Post-operatively he was given antibiotics and pain medication.
He was transfered to the SICU for further evaluation. A hemovac
drain was placed intra-operatively and this was removed POD 2.
His bladder catheter was removed POD 3 and his diet was advanced
without difficulty. He was able to work with physical therapy
for strength and balance. He was discharged in good condition
and will follow up in the Orthopaedic Spine clinic.
Medications on Admission:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection [**Hospital1 **] (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for congestion.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for congestion.
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection [**Hospital1 **] (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for congestion.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for congestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
T12 burst fracture
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR fusion
T11-L1 with T12 partial corpectomy
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 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.
oLimit any kind of lifting.
-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
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2146-12-16**]
|
[
"V54.19",
"403.90",
"E815.0",
"272.4",
"285.1",
"V45.81",
"805.2",
"V42.2",
"511.9",
"585.9",
"V45.01",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"81.04",
"89.45",
"34.09",
"80.99",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
5803, 5873
|
2754, 3453
|
286, 339
|
5968, 5975
|
2147, 2731
|
8130, 8211
|
1390, 1612
|
4640, 5780
|
5894, 5947
|
3479, 4617
|
5999, 6096
|
1627, 2128
|
7946, 8014
|
8036, 8107
|
6132, 6325
|
237, 248
|
6361, 6816
|
6828, 7928
|
367, 628
|
650, 1006
|
1022, 1374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,732
| 182,439
|
21576
|
Discharge summary
|
report
|
Admission Date: [**2119-9-4**] Discharge Date: [**2119-9-7**]
Date of Birth: [**2056-9-23**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Inferior STEMI
Major Surgical or Invasive Procedure:
[**2119-9-4**]: Cardiac catherization with two drug eluting stents
placed in RCA.
[**2119-9-5**]: DC cardioversion at 200 J times one.
History of Present Illness:
62 year-old male with no known coronary artery disease who had
sharp pain between his shoulder blades and anterior chest pain
that radiated down his left arm while doing yardwork. He also
was diaphoretic, nauseated, and had a tingling sensation in both
hands. He called EMS and was transfered to [**Hospital1 34**] where he was
found to have ST elevations in leads II, III, and aVf. He was
started on metoprolol, aspirin, plavix, heparin, and
integrellin. He was transfered to the [**Hospital1 18**] for cardiac
catherization. At catherization, he was found to have RCA
thrombis with no disease in the LMCA, LAD, or LCx. Two cypher
stents were placed in the RCA. During the procedure, he went
into atrial fibrillation and had transient hypotension that
required neosynepherine drip and an IV fluid bolus.
Post-procedure, he did not have chest pain or shortness of
breath.
Past Medical History:
1. h/o chest pain, shortness of breath, diaphoresis 6 years ago
x 2 episodes. He was treated at [**Hospital3 2005**] and had a
negative stress test. There is a question of atrial
fibrillation on that admission.
2. Hypercholesterolemia
3. Asthma requiring Albuteral inhaler daily, advair, and
flovent.
4. Depression
5. s/p removal of benign middle/inner ear tumor 2 years ago
leaving him with about 50% hearing in left ear.
6. h/o colitis.
Social History:
He is married with 6 children. He works as a carpenter. He
does not smoke and drinks occasionally.
Family History:
Family history is significant for his father who had an MI at
age 51.
Physical Exam:
Well appearing gentleman in no acute distress. His vitals are
temperature 95.5, heart rate 127 (105-127), blood pressure
106/66, respiratory rate 18, oxygen saturation 98 % on 2L NC.
His mucous membranes are moist. His cardiac exam is irregular
and tachycardic with a normal S1 and S1, no murmors, rubs, or
gallops. His JVP is at the level of the sternal notch. Femoral
pulses are present with bruit, no evidence of hematoma at the
catherization site. His pulmonary exam is clear to auscultation
anteriorly. His abdomen is soft, nontender, mildly distended,
with bowel sounds present. His extremeties are warm without
cyanosis or edema, distal pulses are 2+ bilaterally.
Pertinent Results:
At [**Hospital1 34**]:
Na: 140 K: 4.2 Cl: 103 Co2: 23 BUN: 21 Cr: 0.9 Glu: 104
WBC: 9 Hct: 45 Pl: 184
CK: 427 CKMB: 4.9 Trop-T: < 0.01
EKG: Sinus rhythm, ST elevation II, III, aVf, ST depressions
V2-3, I, aVl.
[**2119-9-4**] 06:44PM TYPE-ART O2 FLOW-2 PO2-75* PCO2-40 PH-7.39
TOTAL CO2-25 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2119-9-4**] 06:44PM K+-3.4*
[**2119-9-4**] 06:44PM HGB-14.1 calcHCT-42 O2 SAT-95
[**2119-9-4**] 05:35PM POTASSIUM-3.8
Brief Hospital Course:
Briefly, this is a 62 year-old male with no known coronary
artery disease who was transfered from [**Hospital1 34**] for an inferior
STEMI.
1. CAD: At cardiac catherization, he was found to have thrombis
in the RCA. Two cypher stents were placed. During the
procedure, he went into atrial fibrillation and had transient
hypotension that required neosynepherine and IV fluid bolus. He
was started on integrillin for 18 hours, aspirin, plavix,
atorvastatin, and low dose metoprolol. His hypotension was
thought to reflect some RV involvement, but an ECHO showed
normal RV function. The ECHO also showed an EF of 50% and
regional left ventricular basalar hypokinesis. After one day,
his blood pressure was stable, so he was called out to the
floor. He tolerated the low dose metoprolol, so the dose was
increased.
2. Atrial Fibrillation: He went into atrial fibrillation during
catherization. Since he was in normal sinus rhythm earlier, it
was decided to attempt cardioversion. He was started on IV
heparin anticoagulation with a goal PT of 50-70. Chemical
cardioversion was attempted with a 1 mg ibutilide infusion over
10 minutes with no conversion to sinus rhythm. He did not have
a prolongation of the QT interval, so a second 1 mg ibutilide
infusion was attempted that also did not result in conversion.
He was then DC cardioverted with 200 J times one that converted
him to sinus rhythm. He remained in normal sinus rhythm
throughout this hospitalization. Because his atrial
fibrillation was induced in the catherization lab, his
anticoagulation was discontinued.
3. Pump: He has no evidence of heart failure. His ECHO showed
an EF of 50%, which is likely secondary to the acute MI. He
appeared euvolemic with a low JVP throughout his hospital
course.
4. Asthma: He has a history of asthma; however, on admission, he
had no evidence of an acute issue. His albuteral inhaler was
not given because of his tachycardia.
5. PPX: He was kept on colace and senna as a bowel regimen,
pantoprazole for GI ulcers. He was ambulating for DVT
prophylaxis.
6. FEN: He was kept NPO for his cardioversion on [**9-5**];
otherwise, he was kept on a cardiac healthy diet. His potassium
was repleted during this admission. He was given two IV fluid
bolus during the first severall hours post-catherization for
transient hypotension.
7. Dispo: He was discharged to home on the third hospital day.
Medications on Admission:
Albuterol Inhaler
Advair
Flonase
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 90 days.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain: Call a physician
anytime that you use this medication.
Disp:*30 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior ST-elevation MI
Atrial Fibrillation
Discharge Condition:
Stable.
Discharge Instructions:
You were started on 4 new medications for your heart. You
should take the plavix (Clopidogrel Bisulfate) for 90 days. The
rest of the medications should be continued for the rest of your
life.
Do not lift anything over 10 pounds. Only do light exercise
until after cardiology rehab. Refrain from sexual activity
until you see your cardiologist.
Call [**Doctor First Name 17**] at [**Telephone/Fax (1) **] to discuss cardiology follow-up.
Return to the ED or call your PCP if you have recurrent chest
pain, shortness of breath, nausea, or palpitations.
Followup Instructions:
You have the following appointment for follow-up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2119-10-26**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17503**] Follow-up appointment
should be in 2 weeks
Completed by:[**2119-9-7**]
|
[
"458.29",
"427.31",
"272.0",
"997.1",
"414.01",
"410.41",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"99.20",
"37.78",
"36.07",
"88.56",
"37.23",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
6481, 6487
|
3271, 5679
|
328, 466
|
6576, 6585
|
2757, 3248
|
7192, 7600
|
1973, 2044
|
5762, 6458
|
6508, 6555
|
5705, 5739
|
6609, 7169
|
2059, 2738
|
274, 290
|
494, 1374
|
1396, 1839
|
1855, 1957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,307
| 168,261
|
11734+56275+56276
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2147-12-5**] Discharge Date: [**2147-12-21**]
Date of Birth: [**2074-11-18**] Sex: M
Service: Neuro ICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73-year-old man
with past history of hypertension, atrial fibrillation on
Coumadin, coronary artery disease status post MI ten years
ago, and COPD who was transferred to [**Hospital1 190**] from [**Hospital 16843**] Hospital with a large left
thalamic bleed found on head CT at that outside hospital. At
approximately 3:30 a.m. on [**12-5**] he noticed some right sided
weakness. At about 5:30 a.m. he tried to get up from bed but
found he could only sit at the edge of the bed. He woke his
wife and told her that he was unable to get up. She reports
that his right side appeared weak at his leg and his arm and
that he could answer her coherently but could not form his
own sentences, that his words came out gibberish. She gave
him a sublingual Nitroglycerin and called 911. At that time
he slid off his bed but remained alert, responsive and moving
his left side only. He was taken by EMS to [**Hospital 16843**]
Hospital Emergency Room where he was found to be alert,
following commands with slurred speech and not moving his
right arm and leg. He gradually became less verbal, became
agitated, combative and stopped following commands. He
received a small amount of sedation, was intubated for airway
protection and transferred to [**Hospital1 188**]. At [**Hospital 16843**] Hospital he was found to have an INR
of 4.2. On transfer to [**Hospital1 **], the INR was repeated and found to
be elevated at 5. He received Vitamin K and received FFP for
a total of 6 units. His blood pressure initially was found
to be elevated up to 220. He was started on Labetalol drip
and Nipride drip for blood pressure control. He also
received 4 mg of Ativan while in the Emergency Room here. On
head CT he was found to have a large intraparenchymal left
thalamic/basal ganglia hemorrhage with intraventricular
extension, slight subfalcine herniation and 1 to 2 mm midline
shift. The intraventricular blood predominantly involved the
left lateral ventricle with a small amount of blood seen
within the posterior [**Doctor Last Name 534**] of the right lateral ventricle as
well as in the left temporal [**Doctor Last Name 534**] and third ventricle. Also
seen was an area of hypodensity within the right temporal
lobe consistency with an old infarct and a large calcified
right frontal convexity meningioma measuring 2.8 cm.
PHYSICAL EXAMINATION: On exam on admission blood pressure
ranged from 220 down to 132/70's to 80's, heart rate 70's to
80's and atrial fibrillation. The patient was intubated,
breathing at a rate of 10 and he was afebrile. The patient
was intubated and sedated. Head was normocephalic,
atraumatic. Neck was supple without bruits. Cardiovascular,
he had irregularly irregular S1 and S2 with no murmurs.
Lungs clear to auscultation bilaterally on anterior exam with
quiet breath sounds. Abdomen was obese, soft, nontender.
Extremities, no edema. Neurologic exam, patient did not open
his eyes to voice or painful stimuli, he did not follow
commands. He was moving his left face, arm. He did have
spontaneous movements of the left face, arm and leg. There
were no spontaneous movements on the right side with the
right arm and leg flaccid. There was withdrawal to painful
stimuli on the left arm and leg. He grimaced to painful
stimuli on the right lower extremity. There was no response
to pain on the right upper extremity. Cranial nerves, pupils
1.5 mm bilaterally and both sluggishly reactive on the right.
There was spontaneous conjugate gaze to the left with a left
gaze preference but the eyes were able to go to the right
with Doll's eyes. There was positive corneal reflexes
bilaterally, positive cough and the patient was found to be
breathing at a rate over the set rate of the ventilator.
Reflexes, he was hyporeflexic throughout with a right upgoing
toe.
LABORATORY DATA: On admission INR 5, PTT 42, white count
12.0, hematocrit 45, platelet count 147,000. Electrolytes
unremarkable. BUN, creatinine 26/1.2.
PAST MEDICAL HISTORY: Coronary artery disease status post MI
[**56**] years ago, status post angioplasty. Hypertension times 8
years. Atrial fibrillation on Coumadin times 10 years for
psoriasis with bullous pemphigoid. Chronic obstructive
pulmonary disease/emphysema. Colonic polyp removed last
year, regular colonoscopy q year.
MEDICATIONS: Prior to admission, Norvasc 5 mg q day, Lasix
20/40, Atenolol 25 mg q day, Terazosin 2 q day, Coumadin 2 q
day, Atarax 25 mg [**Hospital1 **] and Aspirin 325 mg q day.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: His father died of colon cancer, mother with
CAD, [**Name (NI) 2481**]. Brother with atrial fibrillation, colonic
polyps.
SOCIAL HISTORY: Quit smoking 30 years ago, did smoke 1??????
packs per day times 25 years, drinks one drink of Scotch
every night, lives with his wife. Managed retail store and
now had been working 3 days per week, running a hot dog cart.
PCP is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37133**], [**Name Initial (PRE) **].D. [**Telephone/Fax (1) 37134**].
HOSPITAL COURSE: The patient was admitted to the neuro ICU.
Blood pressure was controlled with Labetalol drip to maintain
systolic blood pressure 140's to 160's. He was given FFP for
a total of 6 units to reverse elevated INR. Head of bed was
kept 30 degrees. Frequent neuro checks were done to watch
for any sign of hydrocephalus. He was placed on gentle
hydration with IV fluids at 50 cc per hour. He was evaluated
by neurosurgery who felt that his intraparenchymal bleed was
not operable. Throughout his hospital course his neurologic
exam did not significantly change. He remained with flaccid
right arm and leg and with good spontaneous movements on his
left arm and leg. He remained intubated and sedated. The
sedation was withdrawn on [**12-7**] with no significant change in
his neurologic status or responsiveness other than opening
his eyes to stimulation. Repeat head CT was done on [**12-6**] to
evaluate for any change in hemorrhage or mass effect or
hydrocephalus. Repeat head CT showed a stable hemorrhage
with no significant change from the prior study. It
continued to require aggressive blood pressure control. He
again had a repeat head CT done on [**2147-12-10**] for question of
decreased responsiveness and again no significant change was
seen in the hemorrhage or small amount of shift. His
ventilatory requirements continued to be weaned. He was
weaned to pressure support and C-pap, though continued to
require intubation for airway protection. After discussion
with the family it was decided to place tracheostomy as well
as PEG tube which was done on [**12-18**]. He did become febrile
over his hospital course with cultures showing an
enterococcus UTI and MSSA in his sputum. He was started on
antibiotics including Levaquin and Oxacillin. He received a
total course of a 7 day course of Levaquin and is to continue
for a total of 7 days of Oxacillin requiring one more day, to
be discontinued after [**12-22**] dose. He did have an episode of
acute respiratory distress on [**12-19**]. At that time the
episode resolved spontaneously. Chest x-ray at that time
showed mild CHF, the episode was felt to possibly be a PE.
Lower extremity dopplers were done which were negative. The
patient had been on boots for DVT prophylaxis and was started
on subcu Heparin. Neurologic exam on discharge remained not
significantly changed. The patient is awake, alert, opens
eyes to verbal stimuli. He does not follow commands. he
does squeeze with his left hand but not consistently to
command. He continues with a left gaze deviation, both eyes
sometimes do cross midline. He does not track with his eyes,
his pupils are equal, round and reactive to light. The left
gaze deviation is able to be overcome by dolls. He continues
with a dense right hemiplegia. He has good spontaneous
movements on the left arm and leg. He withdraws his left arm
and leg to painful stimuli. There is occasionally triple
flexion response to painful stimuli of the right leg. There
is no withdrawal on the right arm.
DISCHARGE MEDICATIONS: Colace elixir 100 mg via PEG [**Hospital1 **],
Norvasc 10 mg via PEG q day, Nitro paste 2 inches to the
chest wall q 6 hours, Lopressor 150 mg via PEG tid, Oxacillin
1 gm IV q 6 hours times one more day to be discontinued after
[**12-22**], Protonix 40 mg via PEG q day, Regular insulin sliding
scale with fingersticks [**Hospital1 **], ProMod with fiber tube feeds at
65 cc per hour, MVI one tablet via PEG q day, Albuterol MDI
6-8 puffs and Atrovent MDI 4-6 puffs q 4 hours, Heparin 5,000
units subcu [**Hospital1 **], Hydralazine 50 mg IV q 6 hours, Lasix 40 mg
via PEG [**Hospital1 **], hold for SVP under 110, KCL 40 mEq via PEG q
day, Clonidine 0.3 mg via PEG [**Hospital1 **].
DISCHARGE DIAGNOSIS:
1. Status post large left thalamic/basal ganglia bleed with
residual right hemiplegia.
ISSUES:
1. CV: The patient is cardiovascularly stable, requiring
blood pressure control for maintenance of systolic blood
pressure around 140-160, continue current blood pressure
medicines for that goal. Atrial fibrillation has been rate
controlled while in the hospital.
2. Pulmonary: The patient is status post trach. Goal at
this time is to wean, ventilate her to pressure support of 5
as tolerated and eventually to trach collar.
3. GI: Continue tube feeds, tolerating well.
4. Endocrine: Continue regular insulin sliding scale
coverage.
5. Renal: Foley in place, continue diuresis with Lasix 40
mg [**Hospital1 **]. BUN and creatinine stable at 43/1.1.
6. ID: White count is decreasing, status post Levaquin
times 7 days, to complete 7 day course of Oxacillin by [**12-22**]
for treatment of enterococcus Urinary tract infection and
MSSA in the sputum. Cath tip culture and blood cultures are
negative.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 28327**]
Dictated By:[**Last Name (NamePattern1) 4823**]
MEDQUIST36
D: [**2147-12-21**] 12:49
T: [**2147-12-21**] 12:51
JOB#: [**Job Number 37135**]
Name: [**Known lastname 6636**], [**Known firstname 77**] Unit No: [**Numeric Identifier 6637**]
Admission Date: [**2147-12-5**] Discharge Date:
Date of Birth: [**2074-11-18**] Sex: M
Service:
This is an addendum to the discharge summary by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6638**]
of [**2147-12-21**].
ADDENDUM: The [**Hospital 1325**] hospital course has remained
essentially unchanged since the discharge summary dictation
from [**2147-12-21**]. The following changes are to be noted:
1. Neurologic - The patient's exam has remained unchanged.
A head CT scan was done on [**2148-1-2**] which in comparison to
prior head CT scan of [**2147-12-10**] shows resolution of blood in
the area of the [**Doctor First Name **] ganglia and no evidence of any further
shift obstruction or areas of new hemorrhage.
2. Respiratory - The patient was weaned off the ventilator
to a humidfied 02 trach collar.
3. Infectious Disease - The patient remains afebrile at
discharge with no active Infectious Disease issues.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 657**] 13-130
Dictated By:[**Doctor Last Name 6639**]
MEDQUIST36
D: [**2148-1-4**] 09:32
T: [**2148-1-8**] 12:47
JOB#: [**Job Number 6640**]
Name: [**Known lastname 6636**], [**Known firstname 77**] Unit No: [**Numeric Identifier 6637**]
Admission Date: Discharge Date: [**2148-1-4**]
Date of Birth: [**2074-11-18**] Sex: M
Service: NEUROLOGY
This is an addendum to the prior discharge summary of
[**2147-12-21**], by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 6641**].
ADDENDUM: Interval events: The patient has remained
essentially without significant change, awaiting
rehabilitation bed in the intervening two weeks. The
following interval events are as follows:
1. Neurologic: The patient had mild improvement on
examination at discharge in that the patient was able to
intermittently mouth single word and nod yes and no,
inconsistently on occasion to the Intensive Care Unit team.
On neurological evaluation the patient was never able to
consistently follow commands. The patient had a head CT scan
performed on [**1-2**] which showed continued improvement
in the patient's hemorrhage as compared to the study from
[**2147-12-10**] with no new areas of hemorrhage or infarct.
2. Respiratory: The patient was weaned off the ventilator
to humidified O2 tracheostomy collar and remained at 50% O2
on tracheostomy collar. At discharge, the patient had been
weaned off four days prior to transfer.
3. Cardiovascular: The patient remained in atrial
fibrillation and had blood pressure controlled with regimen
at discharge.
4. Gastrointestinal: The patient was receiving tube feeds
at goal via Percutaneous endoscopic gastrostomy.
5. Endocrine: The patient was receiving NPH q PM.
6. Renal: No active issues. The patient has a condom
catheter on at discharge.
7. Hematology / Infectious Disease: The patient remained
afebrile for the remainder of his hospital stay with no
active issues.
DISPOSITION: The patient is to be transferred to
rehabilitation on [**2148-1-4**].
DISCHARGE MEDICATIONS: Tube feeds via percutaneous
endoscopic gastrostomy at 120 cc/hr over sixteen hours from
04:00 PM to 08:00 AM, hydralazine 50 mg per PEG q six hours,
Protonix 40 mg per PEG q day, clonidine patch 0.3 mg q week,
Lopressor 150 mg per PEG tid - hold for systolic blood
pressure less than 100 or for heart rate less than 60, Zoloft
25 mg via PEG q day, Colace elixir 100 mg via PEG [**Hospital1 **],
Norvasc 10 mg via PEG q day, heparin 5,000 units subcutaneous
[**Hospital1 **], Lasix 20 mg per PEG [**Hospital1 **], insulin sliding scale, NPH
insulin 5 units subcutaneous q evening at 06:00 PM,
multi-vitamin one tablet per PEG q day, free water boluses
via PEG 150 cc tid, Albuterol and Atrovent metered dose
inhalers q four hours prn wheezing.
DISCHARGE CONDITION: The patient was discharged in good
condition from the Intensive Care Unit team with Neurology
consult.
[**First Name8 (NamePattern2) 657**] [**First Name8 (NamePattern2) 33**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1736**]
Dictated By:[**Last Name (NamePattern1) 6642**]
MEDQUIST36
D: [**2148-1-5**] 13:38
T: [**2148-1-8**] 13:23
JOB#: [**Job Number 6643**]
|
[
"342.90",
"482.41",
"428.0",
"250.00",
"518.82",
"599.0",
"401.9",
"427.31",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"31.1",
"43.11",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14401, 14812
|
4751, 4875
|
13635, 14379
|
9033, 13611
|
5274, 8303
|
2561, 4177
|
173, 2538
|
4200, 4734
|
4892, 5256
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,482
| 106,664
|
45695
|
Discharge summary
|
report
|
Admission Date: [**2183-10-12**] Discharge Date: [**2183-10-13**]
Date of Birth: [**2129-1-14**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atazanavir / fresh fruit / Cephalosporins /
raltegravir / maraviroc / Hydralazine
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 yo F with h/o HIV on HAART (CD4=437 [**8-3**]), DM2 (diet
controlled), CKD, R-sided CHF w/severe pulm HTN, with two recent
admissions to [**Hospital1 112**] for hypersensitivity reaction c/b
polymicrobial bacteremia (including VRE/MRSA), iatrogenic
[**Location (un) 3484**], recent C. diff colitis s/p recent hospitalization at
[**Hospital1 18**] from [**9-10**] to [**10-10**] for fluid overload (treated with lasix
gtt and metolazone), MRSA septicemia (requiring MICU stay, IVF,
CVL, and treated with IV vancomycin), skin breakdown (bactroban
cream TID), and hyponatremia. The patient was discharged to
rehab off of diuretics, which were stopped as it was felt she
was intravascularly volume depleted. The patient had just
finished her course of PO vancomycin for C. diff on Friday (two
days before admission).
Earlier today, the patient was found to be acting out and
yelling in pain at her nursing facility. On the ambulance ride
to [**Hospital1 **], the patient's blood glucose was found to be
"low." At [**Hospital1 **], CXR negative. The patient was given
1 amp of D50 and 500mL [**Hospital1 1868**] of saline, after which she stopped
complaining of discomfort. The patient was requiring increasing
oxygen, but otherwise her vital signs were stable. Her blood
pressures were never below 110 systolic, and pulse was generally
in 60s-70s. The patient was hypothermic to 95.8 there. After
discussion with her son [**Name (NI) 2855**], it was decided to bring her to
[**Hospital1 **], where she has received most of her care.
Here she was also found to have a wide-complex, sinusoidal EKG.
Due to concern for hyperkalemia (hemolyzed blood sample),
patient was given 6g calcium gluconate, nebulizer, 10 units of
insulin and an amp of bicarb. She did not receive kayexelate.
She was found to have hypothermia here as well and placed in a
Beir Hugger. She was breathing rapidly and deeply and appeared
to have increasing oxygenation requirement. The patient was
eventually transferred to the ICU on CPAP 10/5 with 50% FiO2.
On my interview, the patient reported that she was much more
comfortable with the CPAP. She confirmed the history above and
reported that she continued to have pain, especially in her
shoulders and legs. When specifically asked, she also endorsed
chest pain.
Past Medical History:
- HIV, diagnosed in [**2158**], on HAART (CD4=437 [**8-3**]),
-Patient recently presented to [**Hospital1 18**] ED on [**7-11**] with severe
desquamating rash and transferred to [**Hospital1 112**] burn unit. Rash was
determined to desquamating lichenoid hypersensitivity reaction
which was treated by stopping ART, avoidance of cephalosporins
and drugs of abuse such as cocaine. Dermatology was consulted on
admission and recommended wrapping patient in saran wrap and
using Vaseline for skin care. No mucosal involvement was noted
on admission. She was given copious IVF, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Hugger was
utilized given insensible losses and impaired thermoregulation.
Dermatology re-evaluation on [**2183-8-11**] revealed worsening mucosal
involvement and new erythroderma. This raised concern for
progression of her severe drug hypersensitivity eruption. This
was felt to be secondary to ART, specifically abacavir and
lamuvidine, and potentially ceftriaxone to her recent admission
to [**Hospital1 112**]. She is not currently on any related medications. Of
note, her last attempted ART was on [**7-29**] resulting in
maculo-papular rash. s/p Transfer to [**Hospital1 756**] Burn Unit [**8-11**]
- Hepatitis C - no response to PEG-IFN/Ribavirin
- Shingles
- Migraines
- HTN
- DM II
- History of MRSA
- Recurrent UTI
- Recurrent nephrolithiasis
- HSV
- Pancytopenia [**1-23**] HAART medications
- CKD baseline creatinine 2.85-3.0, followed by Dr. [**Last Name (STitle) 118**]
(nephrolithiasis, pyelonephritis & perinephric abscess c/b
perinephric hematoma during stenting [**8-/2182**])
Social History:
Lives at home in [**Location (un) 745**]. Has 3 children: one son [**Name (NI) 2855**] is her
HCP, one daughter with hydrocephalus/seizure disorder is in a
nursing home ([**Location (un) 511**] Pediatric Care), 3rd child (female)
died in childhood from complications of HIV.
- Worked as a counselor (no longer working)
- Former heavy smoker, currently 1 pack q2 weeks.
- Former ETOH abuse, none since [**2174**]
- Former IVDU, none since [**2174**]
- Recent cocaine use ([**2182**])
Family History:
- Father died of MI
- Mother with diabetes
- Sister with lung cancer at age 38 and was a heavy smoker.
- Brother with diabetes
Physical Exam:
Admission physical exam:
Vitals: T: 96.6, BP: 125/66, P: 74, R: 26 on CPAP
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, BiPAP mask in place, MMM, oropharynx
clear, EOMI, PERRL
Neck: supple, no meningismus
CV: S1, S2, systolic mumur heard best at lower sternal border
Lungs: Clear to anterior auscultation only
Abdomen: Soft, non-tender, bowel sounds present, readily
palpable enlarged liver
Ext: Warm, well perfused, 1+/2+ pulses, skin on hands and feet
rough/lichenified, edematous
Neuro: CN III-XII intact, 5/5 strength grip and lower
extremities, grossly normal sensation
Pertinent Results:
[**2183-10-12**] 09:30PM WBC-6.7 RBC-2.66* HGB-7.8* HCT-26.2* MCV-98
MCH-29.2 MCHC-29.8* RDW-17.7*
[**2183-10-12**] 09:30PM HGB-8.1* calcHCT-24
[**2183-10-12**] 09:30PM NEUTS-58 BANDS-0 LYMPHS-31 MONOS-8 EOS-2
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2183-10-12**] 09:30PM PT-17.9* PTT-50.7* INR(PT)-1.6*
[**2183-10-12**] 09:30PM GLUCOSE-95 LACTATE-8.8* NA+-129* K+-5.7*
CL--108
[**2183-10-12**] 09:30PM TYPE-[**Last Name (un) **] PO2-41* PCO2-30* PH-7.15* TOTAL
CO2-11* BASE XS--18 COMMENTS-GREEN TOP
[**2183-10-12**] 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-10-12**] 09:30PM CORTISOL-19.4
[**2183-10-12**] 09:30PM TSH-95*
[**2183-10-12**] 09:30PM ALBUMIN-2.2* CALCIUM-7.2* PHOSPHATE-7.1*#
MAGNESIUM-2.0
[**2183-10-12**] 09:30PM CK-MB-3 proBNP-5182*
[**2183-10-12**] 09:30PM cTropnT-0.08*
[**2183-10-12**] 09:30PM LIPASE-40
[**2183-10-12**] 09:30PM ALT(SGPT)-39 AST(SGOT)-138* CK(CPK)-52 ALK
PHOS-139* TOT BILI-0.9
[**2183-10-12**] 09:30PM estGFR-Using this
[**2183-10-12**] 09:30PM GLUCOSE-97 UREA N-45* CREAT-3.0* SODIUM-125*
POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-9* ANION GAP-25*
[**2183-10-12**] 09:35PM URINE RBC-1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2183-10-12**] 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2183-10-12**] 09:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2183-10-12**] 10:13PM freeCa-1.29
[**2183-10-12**] 10:13PM GLUCOSE-122* LACTATE-9.9* NA+-129* K+-4.7
CL--108
[**2183-10-12**] 10:13PM TYPE-ART TEMP-35 RATES-/30 PO2-172* PCO2-19*
PH-7.26* TOTAL CO2-9* BASE XS--16 INTUBATED-NOT INTUBA
[**2183-10-12**] 11:50PM O2 SAT-38
[**2183-10-12**] 11:50PM LACTATE-8.7* K+-4.7
[**2183-10-12**] 11:50PM TYPE-[**Last Name (un) **]
Imaging:
[**2183-10-12**] CXR:
IMPRESSION: Possible mild pulmonary vascular congestion. No
significant
change from prior.
[**2183-10-13**] CT abdomen:
1. New, moderate-to-large volume ascites as compared to
[**2182-8-22**] exam, which appears to be simple.
2. Increase in heart size compared to prior, consistent with
worsening right heart failure as documented in previous
cardiology notes. Suspect that the ascites may be related to
the right heart failure.
2. Cholelithiasis.
3. Dysmorphic appearance of the right kidney with some capsular
calcifications likely secondary to prior hematoma.
Brief Hospital Course:
The patient is a 54-year-old woman with a complicated medical
history presenting with altered mental status and lactic
acidosis. It was unclear whether her lactic acidosis is Type A
or Type B. The patient was lethargic and agitated earlier, which
suggests hypoperfusion of brain. Creatinine has slowly been
rising over the last week. The patient does not have an obvious
site of infection. She appears to have some cardiac dysfunction,
but chest X-ray suggestive of only mild interstitial edema.
Cortisol level unknown, but patient thought to have iatrogenic
[**Location (un) **] disease in the past. In addition, patient on two HIV
medications that have been implicated in lactic acidosis
(abacavir and lamivudine). She was started on broad coverage
with vancomycin and meropenem for occult infection. She was
started on IV fluids with bicarbonate. She also received stress
dose steroids since she has history of iatrogenic [**Location (un) **]
disease. Her HIV medications were held due to concern for
causing lactic acidosis. The patient was found to have wide QRS
complex, which Cardiology felt was secondary to toxic-metabolic
derangement. The plan was to perform Echo in the morning and
check MB. Troponin was mildly elevated but patient had kidney
injury. At 5:10am on the morning of admission, patient
complained of chest pain and then has seizure-like activity,
followed by bradycardia and loss of blood pressure. A code was
called, and the patient was fund to be in pulseless electrical
activity. After 15 minutes of the pulseless electrical activity
algorithm, the patient had a return of spontaneous circulation.
Despite the presence of two pressors, however, her blood
pressure and heart rate could not be maintained and she went
into pulseless electrical activity again. Another code
commenced. Despite maximal efforts, spontaneous circulation
could not be achieved, and at 5:50 am, the patient was
pronounced dead. The patient's family was notified and decided
against postmortem examination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 300 mg PO BID Start: In am
2. Fosamprenavir 1400 mg PO Q12H Start: In am
3. LaMIVudine 150 mg PO DAILY Start: In am
4. Aquaphor Ointment 1 Appl TP DAILY
5. Aveeno Bath 1 PKG TP [**Hospital1 **] Start: In am
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Start: In am
Hold for SBP < 100.
8. Metoprolol Succinate XL 50 mg PO DAILY Start: In am
Hold for SBP < 100, HR < 60.
9. Omeprazole 40 mg PO DAILY Start: In am
10. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
|
[
"054.9",
"276.2",
"416.0",
"250.00",
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"427.5",
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"287.5",
"427.1",
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"585.9",
"428.0",
"695.13",
"042",
"695.50",
"403.90",
"584.9",
"410.91",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10824, 10833
|
8114, 10124
|
379, 385
|
10893, 10911
|
5645, 8091
|
10976, 10995
|
4882, 5010
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10783, 10801
|
10854, 10872
|
10150, 10760
|
10935, 10953
|
5050, 5626
|
318, 341
|
413, 2703
|
2725, 4363
|
4379, 4866
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,158
| 190,543
|
52627
|
Discharge summary
|
report
|
Admission Date: [**2172-3-6**] Discharge Date: [**2172-3-13**]
Date of Birth: [**2113-8-16**] Sex: M
Service:
ADMITTING DIAGNOSIS:
Small bowel obstruction.
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
male with a history of gastric bypass for morbid obesity and
He presented complaining of acute onset of abdominal pain for
several hours. This pain was crampy in nature and was
associated with nausea. The patient denied any fevers,
chills or emesis. He also claimed he was passing flatus. He
did not complain of any significant distention at the time of
admission. The patient had a normal bowel movement on the day of
admission.
PAST MEDICAL HISTORY: Hypertension, high cholesterol,
arthritis, nephrolithiasis. Status post gastric bypass in
8/99 by Dr. [**Last Name (STitle) **]. Status post exploratory laparotomy for
small bowel obstruction secondary to internal hernia in 9/99
by Dr. [**Last Name (STitle) **]. Status post appendectomy.
MEDICATIONS:
Atorvistatin 20 mg p.o. q. day.
Zestril 5 mg p.o. q. day.
Prilosec 20 mg p.o. q. day.
Multi-vitamins.
Allopurinol 100 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is neither a smoker or a
drinker.
PHYSICAL EXAMINATION: Vital signs revealed temperature of
96.5; heart rate of 58; respiratory rate 20; blood pressure
142/81. Oxygen saturation of 100% on room air. The patient
was an obese, pleasant gentleman, who appeared to be slightly
uncomfortable on admission. His heart was regular. His
lungs were clear. His abdomen was noted to be somewhat
distended and tender in the upper quadrants. He had no
hernias on examination, either ventral or inguinal. His
rectal examination was heme negative and did not have any
masses.
LABORATORY DATA: White count was 8.3; hematocrit 41;
platelets 294. Chemistries were unremarkable.
X-ray: KUB showed some dilated air filled small bowel loops.
HOSPITAL COURSE: Due to the patient's prior history of
surgery, he was admitted to the surgical service for
observation. A nasogastric tube was placed and Foley
catheter was placed to monitor the patient's intake and
output. The patient was resuscitated with intravenous fluids
and plan was made to perform a CAT scan the same evening. The
patient was placed on H2 blockers and was managed with
serial observation.
The CAT scan that was obtained later the same evening and
revealed some dilated small bowel loops, with no evidence of
intestinal ischemia. There was some ascites present in the
abdomen.
Over the course of the evening, the patient continued to
complain of pain; however, he was passing flatus. His
abdominal examination narrowed to just upper quadrant
tenderness. He was making urine on the floor and never had a
temperature.
Over the course of the next morning, the patient's examination
evolved with progressive tenderness. He was evaluated and felt to
have a complete small bowel obstruction. He was taken to the
operating room urgently for an exploratory laparotomy.
At that time, he was noted to have an infarcted segment of
distal ileum secondary to intestinal volvulus around an adhesion
at the root of the mesentery. This bowel was resected and the
patient was taken to the Intensive Care Unit intubated.
He recovered well in the Intensive Care Unit. He was
extubated the same evening and sent to the floor the
following day. His postoperative course was unremarkable.
A gastrostomy tube, that was placed in the operating room,
for drainage of the excluded stomach was clamped. By [**2172-3-13**], the
patient was tolerating p.o. He was therefore discharged home.
DISCHARGE DIAGNOSES:
Small bowel obstruction with intestinal infarction.
Status post exploratory laparotomy and small bowel resection.
Morbid obesity, status post gastric bypass.
High cholesterol.
DISCHARGE CONDITION: Good, discharged to home.
DISCHARGE MEDICATIONS: The patient will resume all of his
preoperative medications as well as Percocet prn for pain.
DISCHARGE INSTRUCTIONS: The patient is instructed to
follow-up with Dr. [**Last Name (STitle) **] in the office for follow-up and
eventual management of his gastrostomy tube.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 13187**]
Dictated By:[**Last Name (NamePattern4) 108612**]
MEDQUIST36
D:
T: [**2172-4-1**] 05:05
JOB#: [**Job Number **]
|
[
"557.9",
"560.2",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"54.59",
"45.93"
] |
icd9pcs
|
[
[
[]
]
] |
3850, 3877
|
3651, 3828
|
3901, 3996
|
1946, 3630
|
4021, 4423
|
1252, 1928
|
201, 663
|
146, 172
|
686, 1165
|
1182, 1229
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,900
| 144,934
|
6807
|
Discharge summary
|
report
|
Admission Date: [**2200-12-31**] Discharge Date: [**2201-1-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Central line placement
Temporary Hemodyalysis Catheter placement
Permanent Hemodyalsysis Catheter placement
History of Present Illness:
82 y/o retired pathologist w/ hx of heart mumur and lack of
medical care x 20 years with recent [**Hospital1 18**] admission [**6-5**] for
syncope now c/o confusion and slurred speech x 1 month. The
daughter indicated that the pt would say he was about to go to
work, though he has been retired for some time. His speech has
also become progressively more slurred. The past week has been
particularly bad, especially today. His daughter reports
worsening bipedal edema over 1 month.
.
ED course: Pt received lopressor iv 5mg x 4 and hydralazine 10mg
iv x 1 to control BP down to 130-150. The ER staff d/w neurosurg
attending who happened to be there to look at the CT head. The
neurosurgeon did not feel that the basal ganglion lesion merited
neurosurgical intervention. Neurology then saw the pt, with
their recs as below. A renal consult was obtained for creatinine
of 9 up from 4. The patient was admitted to the ICU for close BP
monitoring and electrolyte monitoring in the setting of uremic
metabolic acidosis and intraparenchymal hemorrhage in the basal
ganglia.
.
ROS: The pt had cough, sore throat, and airway congestion one
month ago, which resolved two weeks ago without treatment. He
denies those symptoms currently.
He denies focal neurologic deficit, visual or hearing changes,
numbness, tingling, weakness, fall, LOC, lightheadedness, CP,
SOB, dyspnea, difficulty with stooling or urinating, bloody or
tarry stools or bloody urine.
Past Medical History:
1. Critical Aortic Stenosis, [**Location (un) 109**]=0.6cm2
2. Moderate-Severe Mitral Regurgitation.
3. Systolic Heart Failure.
4. 6cm Ascending Thoracic Aortic Aneurysm.
5. End Stage Renal Disease likely [**3-5**] HTN, with atrophic Right
Kidney.
6. 2 cm Left Adrenal Mass.
7. Nephrotic Range Proteinuria.
8. Anemia of ESRD and Chronic Inflammation.
9. Hypertension.
10. Depression.
11. Right Auricular Basal Cell Carcinoma, s/p resection 25 yrs
ago with recurrence
12. Benign Prostate Hypertrophy.
13. Secondary Hyperparathyroidism.
14. Recent GI bleed with worsened anemia
15. h/o kidney stones
16. Right inguinal hernia
.
PSH:
Kidney stone removal over 20 years ago
Hemorrhoid "operation" over 20 years ago
Social History:
-retired pathologist at [**Hospital1 18**]
-married, wife is chronically ill
-no hx of alcohol or tobacco
Family History:
-mother died at age 79
-uncle died at age 50 of an MI
-father died of lung cancer
Physical Exam:
VS- 95.1F - 97 - 178/83 - 21 - 100% on NC
Gen- Frail male in his 80s with notable confusion.
HEENT- nc/at. sclera anicteric. Marked conjunctival pallor. eomi
except OS CN VI. PERRL. Nares patent w/o drainage. Oropharynx
dry; no erythema noted. No LAD.
[**Name (NI) 298**] Pt intermittently able to follow commands. Unable to
comply w/ MMSE. Mild asterixis. Motor: moves all extr
symmetrically. Sensory: intact to light touch bilaterally. DTRs
[**3-7**] bilaterally at knee. Downgoing babinski. CNs intact except
CN VI on OS.
CV- RRR, 4/6 systolic mumur heard best at base. Pulses [**3-7**]
radial and 1-/4 bilateral DP.
Pulm- bilateral crackles throughout. moves air well.
Abd- BS+, flat, nt/nd. Enlarged liver span noted. Abd firm.
Extr- Bipedal edema.
Skin- mottled at bilateral feet. no rash.
Access: 2 PIVs (forearms); 1 A-line right radial artery
Pertinent Results:
On Admission:
[**2200-12-31**] 08:08PM LACTATE-0.7
[**2200-12-31**] 04:53PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2200-12-31**] 04:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2200-12-31**] 04:53PM URINE RBC-[**4-5**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2200-12-31**] 04:40PM GLUCOSE-117* UREA N-134* CREAT-9.2*#
SODIUM-128* POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-10* ANION
GAP-27*
[**2200-12-31**] 04:40PM CK(CPK)-935*
[**2200-12-31**] 04:40PM CK-MB-42* MB INDX-4.5 cTropnT-0.25*
[**2200-12-31**] 04:40PM CK-MB-42*
[**2200-12-31**] 04:40PM IRON-153
[**2200-12-31**] 04:40PM calTIBC-228* FERRITIN-GREATER TH TRF-175*
[**2200-12-31**] 04:40PM WBC-6.2 RBC-2.58* HGB-8.2* HCT-22.7* MCV-88
MCH-31.7 MCHC-35.9* RDW-17.1*
[**2200-12-31**] 04:40PM NEUTS-79* BANDS-0 LYMPHS-6* MONOS-9 EOS-4
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2200-12-31**] 04:40PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL OVALOCYT-2+ SCHISTOCY-OCCASIONAL BURR-1+
ACANTHOCY-OCCASIONAL
[**2200-12-31**] 04:40PM PLT SMR-LOW PLT COUNT-128*
[**2200-12-31**] 04:40PM PT-12.8 PTT-32.4 INR(PT)-1.1
[**2200-12-31**] 04:40PM RET MAN-1.8*
.
[**2200-12-31**] CT head non-contrast:
IMPRESSION: Small 5-mm focus of intraparenchymal hemorrhage in
the right basal ganglia. New since the prior exam.
.
[**2200-12-31**] CXR:
IMPRESSION: Left pleural effusion with associated retrocardiac
opacity, which
may represent atelectasis versus infiltrate. Clinical
correlation is
requested.
.
[**2200-12-31**] EKG (my read): NSR, LAD, 1st degree AV block,
incompletely widened QRS comlex, ST elevation in V3; ST segment
w/ abnl morphology in V2 and V3 w/o elevation. Overall this EKG
shows interval reducation of the ST elevations of the V2-V4
leads.
.
Renal/Abdominal Ultrasound:
1. Echogenic kidneys in keeping with chronic renal failure. No
hydronephrosis.
2. Small bibasilar pleural effusions and partial left lower lobe
atelectasis.
.
[**2201-1-1**] 9:15 AM Successful placement of right IJ triple-lumen
VIP catheter which can be used for dialysis and IV access with
tip at the cavoatrial junction. The line is ready for use.
.
[**2201-1-2**] ECHO: Conclusions:
1. The left atrium is mildly dilated. The right atrium is
moderately dilated.
2. There is moderate symmetric left ventricular hypertrophy. The
left
ventricular cavity size is normal. There is mild global left
ventricular
hypokinesis. Overall left ventricular systolic function is
mildly depressed.
3. The ascending aorta is markedly dilated
4. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis. Mild to moderate ([**2-2**]+)
aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary
artery systolic hypertension.
7. There is a small pericardial effusion.
8. Compared with the findings of the prior study of [**2200-6-19**],
there has been no significant change.
.
[**1-5**] EKG: Sinus rhythm. First degree A-V heart block. Probable
left atrial abnormality. Left anterior fascicular block.
Probably old inferior wall myocardial infarction. Probable old
anterior myocardial infarction. Probable left ventricular
hypertrophy. Compared to the previous tracing no significant
change.
.
CENTRAL TUNNELED W/O PORT [**2201-1-6**]:
INDICATION: Chronic renal insufficiency requiring dialysis. The
patient presents for conversion of a temporary hemodialysis
catheter to a tunneled hemodialysis catheter. Successful
conversion of a temporary double-lumen VIP dialysis catheter to
a tunneled 14.5 French, 19 cm tip-to-cuff dual-lumen dialysis
catheter via the right internal jugular vein, with tip at the
junction of the superior vena cava and the right atrium. The
catheter is ready for use.
.
CXR [**1-6**]:COMPARISON: Chest radiograph dated [**2201-1-4**].
FINDINGS: Again note is made of central venous catheter
terminating at the junction of SVC and right atrium. Again note
is made of cardiomegaly and tortuous aorta, overall unchanged
compared to the prior study. Note is made of bibasilar opacity
associated with effusion, probably representing atelectasis;
however, pneumonia, pneumonia cannot be excluded. The bibasilar
opacities are slightly decreased compared to the chest x-ray
dated [**2201-1-4**]. No pneumothorax. The osseous structures
are unremarkable.
.
IMPRESSION: Central venous catheter terminating in the junction
of SVC and right atrium. Persistent cardiomegaly, tortuous
aorta, slightly decreased bilateral lower lobe opacity with
effusion.
.
Upon Discharge/Interval Data:
WBC 6.9 Hb 11.6 Hct 31.6 Plts 92
Ca: 7.9 Mg: 1.7 P: 3.0
Brief Hospital Course:
Dr. [**Known lastname **] is an 82 yo gentleman with critical aortic stenosis,
chronic renal failure admitted with mental status changes in the
setting of uremia and hypertensive emergency.
.
ED course: Patient received Lopressor IV 5mg x 4 and Hydralazine
10mg IV x 1 to control BP down to 130-150. CT head showed a
bleed in the basal ganglia. Neurosurgery did not feel that this
required intervention. Neurology therefore recommended BP
monitoring in ICU. A renal consult was obtained for creatinine
of 9, increased from 4. The patient was admitted to the ICU for
close BP monitoring and electrolyte monitoring in the setting of
uremic metabolic acidosis and intracranial hemorrhage.
.
In the MICU: Patient was admitted to MICU with neurology consult
recommendations to keep MAPS <130 with SBP <140, goal achieved
with IV hydralazine which was then changed to Metoprolol IV.
Intracranial bleed thought to be [**3-5**]/ to poorly controlled
hypertension. Renal was consulted, patient was started on HD
with HD catheter placed by IR, DDAVP was given for uremic
coagulopathy, and bicarb drip started for acidosis. Patient was
started on Levofloxacin for concern of PNA on CXR. Patient also
required total of 4 units of pRBCs for anemia. In addition,
Cardiology was consulted for troponin leak, thought to be [**3-5**] to
demand ischemia, treated with beta blocker, Statin. Repeat echo
showed no significant change from prior. Patient's BP stabilized
with HD and he is not off antihypertensives. Nutrition eval
recommended Dobhoff tube feedings.
.
Upon transfer to the regular medical floor: Patient was drowsy
but arousable, responding to questions, denied pain. Patient's
daughter was at the bedside. In terms of the patient's
individual medical problems, hospital course is described below:
.
Altered mental status: Likely multifactorial given CNS bleed,
uremic symptoms, PNA, electrolyte abnormalities. Improving
gradually, patient having coherent conversation with Daughter,
more easily arousable, answers questions appropriately. Patient
also evaluated by speech and swallow, cleared to eat regular
diet with assistance. Patient received Dobhoff tube feedings for
less than 48 hrs then started on regular diet with aspiration
precautions which he tolerated very well. Patient continued to
have transiently elevated blood pressures prior to hemodialysis
and therefore required ongoing dialysis for fluid management. On
[**2201-1-6**] patient had a permanent HD catheter placed. Repeat CXR
on [**2201-1-6**] showed partial resolution of PNA and therefore the
patient was continued on Levofloxacin to complete a 10 days
course.
In terms of other work up for the patient's altered mental
status, B12 and TSH were measured which showed elevated B12 and
TSH/T4 wnl. The patient hyponatremia resolved promptly with
normal saline IVF and he no longer requires ongoing IVF given
good PO intake.
.
Bleeding. Patient oozing from line sites and ear (basal cell CA
on right ear) likely secondary to uremic coagulopathy. Patient
was initially managed with pressure dressings and thrombin
applied to the catheter site. Patient then had a Hct drop from
32->27 and required 2 units pRBC with improvement to 34. Patient
also received a one time dose of DDAVP per renal recommendations
which also assisted in diminishing his oozing. His Hct is
currently stable at 31.6 and there is minimal oozing from line
sites. Patient also noted to have an elevated PTT to a max of
150 thought to be potentially secondary to heparin given with
hemodialysis. Patient was not given any heparin products on the
floor given his bleeding tendency. This lab value was repeated
and found to be wnl at 27, therefore this was likely a spurious
lab value. Patient also maintained a stable Hct with decreased
oozing from his line. Of not a DIC workup was negative and there
was no evidence of hemolysis.
.
Hypertension. Elevated BP on admission, likely lead to
intracranial bleeding. Initially required IV Hydralazine,
Lopressor IV and Labetalol gtt with poor control. HD required
for fluid management and BP control. Patient's daughter gives
history of long standing hypertension >200 at times without
seeking medical attention. Blood pressure came under good
control with HD and all antihypertensive medications where
discontinued. Patient is currently off ALL antihypertensive meds
which should be avoided given his severe aortic stenosis. Blood
pressure should be managed with dialysis alone. Patient having
elevated BP prior to HD up to 180s, otherwise well controlled to
120-130s after dialysis, now stable at 140-150s.
.
Renal Failure. Patient with worsening renal failure over several
months, now presenting with uremic symptoms, started on
hemodialysis during this admission with improvement in blood
pressure and Bun/Cr. On admission Bun/Cr 134/9.2 which improved
to 25/3.0 upon discharge. Mental status improved with ongoing
HD, likely secondary to treatment of uremia. Patient initially
had a temporary HD catheter placed which was then changed for a
permanent line. He is discharged with a right subclavian
tunnelled catheter for permanent HD. His blood pressures have
been controlled with HD since patient has tight aortic stenosis
(as above). Renal service followed the patient throughout this
admission and their recommendations were followed. Patient is to
continue with permanent HD in rehab.
.
Right basal ganglia intraparenchymal hemorrhage. Found on CT
head upon admission when patient presented with elevated blood
pressure. CT showed a 5mm area w/ surrounding edema w/o shift or
hydrocephalus. Repeat CT was consistent with evolution without
any further extension of bleeding. This is a potential cause for
his change in mental status although malignant hypertension
alone with uremia is a more likely explanation. Neurosurgical
evaluation did not feel that the patient required any operative
intervention. Neurology was consulted and recommended blood
pressure control in an ICU setting. Patient was later
transferred to the floor in stable condition. Blood pressure was
managed with HD as mentioned above.
.
Metabolic Acidosis. Initial chem 7 showed an AG of 22, without
compensation. Initial lactate 0.7. Uremia being the leading
etiology, patient had no evidence of sepsis. Anion gap closed
with hemodialysis and ultrafiltration x 2.
.
Anemia. Normocytic anemia. Hct 22 on presentation requiring one
unit of pRBCs initially. Likely secondary to renal failure. Iron
studies consistent with anemia of chronic disease with normal
Iron level. B12 elevated. Of note, patient had trace guaiac
positive stool with no history of colonoscopy. Last EGD was
negative in [**6-5**]. This should likely be followed up as an
outpatient and the patient has an appointment to follow up with
his PCP in the near future. Patient also had ongoing bleeding
while in hospital likely secondary to uremic coagulopathy
requiring another 2 units of pRBCs. This Hct is stable upon
discharge at greater than 30.
.
Pneumonia. Questionable retrocardiac opacity on CXR prior to
admission, also with history of upper respiratory symptoms that
resolved prior to admission. Patient was started on Levaquin
however, given that the patient was very ill on presentation and
the underlying cause of his change in mental status was not
clear. Patient completed a 10 day course of Levaquin (started
[**12-31**]). Repeat CXR showed partial resolution of this opacity and
as such he was continued on this 10 day course of antibiotics.
Patient remains without any symptoms of cough, shortness of
breath or sputum production.
.
Apnea. Patient noted to have several episodes of transient apnea
at night during sleep. Patient as maintained on telemetry
throughout admission. No further episodes after arrival to the
regular medical flood. Likely secondary to intracranial bleed,
uremia, toxic metabolic disturbance. This has resolved with
treatment of the underlying cause, primary with HD. No specific
treatment as provided other than treatment of his underlying
medical problems.
.
Electrolyte abnormalities. Patient with hyponatremia Na 128 on
admission. Possibly secondary to intracranial event, also
possibly due to dehydration with hypovolemic hyponatremia.
Patient responded well to IV NS with improvement to 137. Patient
has maintained a normal sodium level for several days without
intervention. He is discharged with a sodium of 142.
.
Cardiac ischemia. Initial concern for demand ischemia in setting
of hypertensive emergency. EKG consistent with old MI, age
indeterminate though at least as old as [**2200-9-1**]. Cardiology
consult was placed who did not feel this was an acute coronary
syndrome. Cardiac enzymes were as follows: CK 933->910->922;
CK-MB 42->39->35; MB Index 4.5->4.3->3.8; TnT 0.25->0.24->0.24.
Troponins on prior admission were 0.27 in [**9-5**].10 in [**6-5**]
likely secondary to CRI, ?demand ischemia. Repeat EKGs showed no
change. Patient was initially given a beta blocker and statin
currently off all antihypertensive medications. ASA was held in
setting of bleeding which can be restarted as needed after
evaluation by his PCP.
.
History of aortic aneurysmal dilation of ascending aorta.
Discovered during syncope workup in [**6-5**]. No active issues
during this admission. Patient without symptoms of dissection,
denied CP, SOB, dizziness, lightheadedness. Repeat EKG was
unchanged.
.
Basal cell carcinoma right ear. Patient had appointment as
outpatient with dermatology surgery. Patient missed this
appointment as he was in hospital. This appointment has been
rescheduled. Patient was bleeding from this site due to his
coagulopathy. This was treated with pressure dressings and
thrombin. Currently his is oozing minimally from this site.
Patient should assure that he follows up with Dermatology since
likely surgical excision will be warranted.
.
Left cranial nerve VI palsy. Initially noted as an outpatient.
Trace left sided CN 6 palsy on examination in hospital. Stable
throughout admission. No intervention needed.
.
FEN: Fluids managed with HD. Patient required a Dobhoff feeding
tube temporary and then advanced to regular diet after speech
and swallow evaluation. Patient is currently eating a regular
diet. Electrolytes were monitored and replaced as needed.
.
Prophylaxis. Venodynes, aspirin and heparin held given bleeding,
PPI, bowel regimen.
.
Communication: Daughter [**First Name4 (NamePattern1) **] [**Known lastname **] [**Telephone/Fax (1) 25779**]
.
Code status: Family meeting indicated her patient would want
Full Code. PCP ([**Doctor Last Name **]), Nephrologist ([**Location (un) 805**]) were present
during this meeting along with ICU housestaff and attending.
Medications on Admission:
- Metoprolol 25 m [**Hospital1 **]
- ASA 325 mg daily (d/c'd [**6-5**])
- Finasteride 5 mg daily
- Atorvostatin 10 mg daily
- Sevelamer 400 mg TID
- Aranesp
Discharge Medications:
1. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*qs 1* Refills:*2*
6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs 1* Refills:*2*
7. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
8. Silver Nitrate 10 % Ointment Sig: One (1) units Topical ONCE
(once): please apply topically to ear as needed.
Disp:*qs units* Refills:*2*
9. Finasteride 5 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
1. Hypertensive Emergency
2. Uremia
3. Coagulopathy
4. Intracranial bleed
Secondary:
- Aortic Stenosis
- Basal Cell CA of right ear
Discharge Condition:
Good - patient's mental status is significantly improved, blood
pressure under much better control with hemodyalysis, eating
regular diet
Discharge Instructions:
Please take all of your medications as directed
Please follow up as listed below
Please return to the hospital if there is any significant change
in mental status, persistently elevated blood pressure or low
blood pressure, excessive bleeding from catheter sites, chest
pain, shortness of breath or any other complaints
Followup Instructions:
Please follow up with DERMATOLOGY SURGERY - your appointment is
below on the [**Hospital Ward Name **] Saprio building [**Location (un) 1773**]:
Provider: [**First Name11 (Name Pattern1) 8122**] [**Last Name (NamePattern4) 8123**], M.D. Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2201-1-21**] 2:00
.
Please follow up with your PCP, [**Name10 (NameIs) **] have an appointment below,
on Sapiro [**Location (un) **]:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-2-4**] 3:00
Completed by:[**2201-1-9**]
|
[
"276.51",
"441.2",
"584.9",
"403.91",
"276.2",
"585.6",
"431",
"173.2",
"285.21",
"287.4",
"276.1",
"588.81",
"396.2",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
20452, 20525
|
8576, 10379
|
284, 394
|
20702, 20842
|
3717, 3717
|
21212, 21805
|
2745, 2829
|
19457, 20429
|
20546, 20681
|
19275, 19434
|
20866, 21189
|
2844, 3698
|
223, 246
|
422, 1870
|
3731, 8553
|
10394, 19249
|
1892, 2605
|
2621, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,329
| 184,532
|
5459
|
Discharge summary
|
report
|
Admission Date: [**2154-8-21**] Discharge Date: [**2154-8-25**]
Date of Birth: [**2098-4-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
right carotid body tumor
Major Surgical or Invasive Procedure:
[**2154-8-21**] - coil embolization of right carotid body tumor
[**2154-8-22**] - resection of right carotid body tumor
History of Present Illness:
56F with a known right carotid body tumor. This was first
identified back in [**2149**] when she saw Dr. [**First Name (STitle) **] [**Name (STitle) 2719**] for a
right-sided shoulder and neck pain and he identified a mass in
her carotid which proved to be a carotid body tumor. She was
subsequently seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] in [**2152**] and he
advised resection of the tumor as it had been enlarging but she
had deferred. She has recently developed increasing pain in the
side and difficulty lying on that side of her neck with some
discomfort, although no dysphagia and has finally agreed to have
surgery.
Past Medical History:
hypothyroidism, anxiety
Social History:
Nonsmoker, lives with husband, no IVDU, no heavy EtOH use.
Family History:
Noncontributory
Physical Exam:
Discharge day:
97.5 70 134/76 16 98RA
Gen NAD
HEENT R neck incision site clean/dry/intact; CN 2-12 intact
CV RRR
Chest CTAB
Abd soft, nontender, nondistended
Ext WWP; 2+ pulses at DP/PT b/l; strength/sensation equal and
intact bilaterally with the exception of mild R hand grip
weakness, stable since previous rotator cuff surgery
Brief Hospital Course:
Ms. [**Known lastname 22107**] was admitted to the vascular surgery service on
[**2154-8-21**] following embolization of her known right carotid body
tumor by the interventional radiology department. She was
monitored in the CVICU overnight and found to be neurologically
intact and stable. In the morning of [**2154-8-22**] she underwent an
uncomplicated resection of the right carotid body tumor.
Postoperatively she complained of chest pain which appeared to
be reproducible on palpation; an EKG and cardiac enzymes were
negative and the chest pain was self-limited. On the evening of
POD #0 she did demonstrate a mild right mouth droop. In
addition her right hand grip was slightly weak, however the
patient reported this was her baseline since having had right
rotator cuff surgery in [**2150**]. She remained otherwise
neurologically intact and her pain was well-controlled with
tylenol.
On POD# [**1-23**] she did complain of intermittent mild frontal
headaches which were alleviated with tylenol. The ENT service
followed the patient throughout her admission and did a
postoperative laryngoscopy (see OMR for full report). She
underwent a speech and swallow evaluation and was delared safe
for pureed solids and thin liquids.
On POD #3 the JP drain in her neck was removed. She was able to
tolerate a diet and swallow her pills without difficulty. She
denied pain and she was able to ambulate without difficulty.
She was discharged to home in good condition with scheduled
follow-up with [**Hospital **] clinic, vascular surgery clinic, and
speech/swallow clinic.
Medications on Admission:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Trazodone Oral
3. Cetirizine 5 mg Tablet Oral
4. Omeprazole (patient reports not taking)
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Trazodone Oral
3. Cetirizine 5 mg Tablet Oral
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: Use while taking
percocet for pain.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right carotid body tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 5695**] office or Dr.[**Name (NI) 20390**]
office if you experience fevers, chills, nausea, vomiting, chest
pain, shortness of breath, weakness in face or arms, difficulty
speaking, hoarseness, or increasing redness or drainage from the
incision site.
You may remove bandages or dressings in 24 hours. You may
shower and bathe as desired. You may resume your normal
activities, however it is normal to feel somewhat tired for the
first several days after surgery.
Do not drive while you are taking percocet (narcotic pain
medication).
Continue a pureed solids / thin liquids diet until your
follow-up speech and swallow appointment.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2154-8-30**] 3:20
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2154-9-9**] 2:30
Speech/swallow eval: call [**Telephone/Fax (1) 3731**] to schedule appointment
|
[
"244.9",
"194.5",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.8",
"39.75"
] |
icd9pcs
|
[
[
[]
]
] |
3925, 3931
|
1689, 3273
|
338, 460
|
4000, 4000
|
4841, 5227
|
1297, 1314
|
3485, 3902
|
3952, 3979
|
3299, 3462
|
4151, 4818
|
1329, 1666
|
274, 300
|
488, 1158
|
4015, 4127
|
1180, 1205
|
1221, 1281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,153
| 198,945
|
45443
|
Discharge summary
|
report
|
Admission Date: [**2160-12-2**] Discharge Date: [**2160-12-11**]
Service:
HISTORY OF THE PRESENT ILLNESS: This 81-year-old
African-American female has a history of hypertension and
coronary artery disease. She had a positive stress test in
[**2140**] and had cardiac catheterization in [**2155**] which revealed
two vessel disease and had PCI. She also had a
catheterization in [**2158**] with repeat PCI. She also has a
history of renal artery stenosis, hypercholesterolemia, and
diabetes. She had back pain a few days prior to admission.
She also had chest pain and jaw pain the next day. The
symptoms recurred for several hours and increased in severity
so she came to the hospital.
In the ER, she had EKG changes and had a CT which revealed a
2 cm descending abdominal aortic dissection at the celiac.
She was admitted to the CCU and started on a nitroglycerin
drip and Nipride.
PAST MEDICAL HISTORY:
1. History of coronary artery disease, status post PCI in
[**2155**] and [**2158**].
2. History of hypertension.
3. History of diabetes.
4. History of CHF.
5. History of hyperlipidemia.
6. History of DJD.
7. History of depression.
8. History of diverticulosis.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Amlodipine 10 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Atenolol 100 mg p.o. q.d.
5. Glucophage 500 mg p.o. q.d.
6. Hydrochlorothiazide 25 mg p.o. q.d.
7. Isordil 40 mg p.o. t.i.d.
8. Zestril 40 mg p.o. q.d.
9. Potassium 20 mEq p.o. q.d.
10. NPH insulin 54 units subcutaneously q.a.m.
11. Prozac 10 mg p.o. q.d.
SOCIAL HISTORY: She does not smoke cigarettes. She drinks
one drink per month.
FAMILY HISTORY: Significant for coronary artery disease.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION ON ADMISSION: General: She is an
elderly African-American female in no apparent distress.
Vital signs: Stable. Afebrile. HEENT: Normocephalic,
atraumatic. The extraocular movements were intact. The
oropharynx was benign. The neck was supple, full range of
motion. No lymphadenopathy or thyromegaly. The carotids
were 2+ and equal bilaterally without bruits. Lungs: Clear
to auscultation and percussion. Cardiovascular: Regular
rate and rhythm with a II/VI crescendo/decrescendo murmur
heard best at the left lower sternal border. Abdomen: Soft,
nontender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities: Without clubbing, cyanosis
or edema.
HOSPITAL COURSE: She underwent cardiac catheterization on
the day of admission which revealed that she had a proximal
95% LAD lesion, 75% diagonal I lesion, 100% OM1 lesion, and a
60% mid RCA lesion. Her left ventricle had a 70% ejection
fraction with apical inferior hypokinesis. Dr. [**Last Name (STitle) 1537**] was
consulted and Vascular was consulted as well and they did not
see a contraindication for heparinization in the OR and felt
that she did not need intervention on her aortic aneurysm.
On [**2160-12-3**], she underwent a CABG times four with LIMA to the
LAD, reverse saphenous vein graft to the OM with sequential
to the diagonal and reverse saphenous vein graft to the RCA.
The cross-clamp time was 93 minutes, total bypass time 107
minutes.
She was transferred to the CSRU on dobutamine, nitroglycerin,
and propofol. She was slightly acidotic postoperatively and
required volume and bicarbonate and remained intubated
overnight. She recovered overnight.
On postoperative day number one, she was extubated. On
postoperative day number two, she had her chest tubes
discontinued. She continued to require aggressive diuresis
and respiratory therapy. She remained in the CSRU. She did
have an echocardiogram on [**2160-12-7**] which revealed an EF of
45-50 with no pericardial effusion. She was aggressively
diuresed.
On postoperative day number six, she was transferred to the
floor in stable condition. She continued to have a stable
postoperative course. On postoperative day number eight, she
had her epicardial pacing wires discontinued. She was
discharged to rehabilitation in stable condition.
DISCHARGE MEDICATIONS:
1. Lopressor 100 mg p.o. b.i.d.
2. Albuterol nebulizers p.r.n.
3. Glucophage 500 mg p.o. q.d.
4. Potassium 40 mEq p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Ecotrin 325 mg p.o. q.d.
7. Percocet one to two p.o. q. four to six hours p.r.n.
pain.
8. Lisinopril 40 mg p.o. q.d.
9. NPH insulin 15 units subcutaneously q.h.s.
10. Norvasc 10 mg p.o. q.d.
11. Lipitor 10 mg p.o. q.d.
12. Prozac 10 mg p.o. q.d.
13. Lasix 40 mg p.o. q.d. times seven days.
14. Hydrochlorothiazide 25 mg p.o. q.d. when the Lasix is
discontinued.
15. Hydralazine 25 mg p.o. q. six hours p.r.n. for
hypertension.
LABORATORY DATA ON DISCHARGE: Hematocrit 29.7, white count
9,200, platelets 405,000. Sodium 141, potassium 4.4,
chloride 102, C02 30, BUN 25, creatinine 1.5, blood sugar 73.
FOLLOW-UP: The patient will be followed by Dr. [**Last Name (STitle) 2450**] in one
to two weeks and Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2160-12-11**] 01:01
T: [**2160-12-11**] 13:45
JOB#: [**Job Number 96985**]
|
[
"997.3",
"414.01",
"272.0",
"518.0",
"441.02",
"E879.0",
"V45.82",
"410.71",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"89.68",
"36.13",
"88.53",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
1723, 1765
|
4160, 4769
|
2522, 4137
|
1269, 1623
|
4784, 5366
|
1785, 1817
|
1832, 2504
|
922, 1246
|
1640, 1705
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,451
| 168,026
|
53481
|
Discharge summary
|
report
|
Admission Date: [**2144-3-7**] Discharge Date: [**2144-3-18**]
Date of Birth: [**2103-11-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy with [**Location (un) **] patch of the duodenal
ulcer.
2. Repair of internal hernia at the jejunojejunostomy.
3. Upper endoscopy.
4. Gastrostomy tube.
History of Present Illness:
Patient is a 40 yo female transferred from [**Hospital3 **] with past medical history gastric bypass who presented
with diffuse abdominal pain. Patient with complaints of
intermittent pain and constipation for over a week. Her pain
has become gradually worse and constant she rates her pain as a
[**10-26**] diffuse pain with associated nausea. She denies any
vomiting. Patient is passing flatus and is tolerating a regular
diet. She denies any diarrhea, any BRBPR. Patient seen at OSH
with NGT placed. She was transferred to [**Hospital1 18**] for further
evaluation and management.
Past Medical History:
PMH: Anxiety
PSH: Lap gastric bypass [**2133**]
Social History:
Lives with boyfriend, 2 cats. Not working. Smokes 1-1.5 packs
of cigarettes per day. Heavy alcohol use history, less
recently. Denies drug use. No recent travel. History of
Domestic Violence including current relationship.
Family History:
obesity
Physical Exam:
Vital signs: T 99.2, HR 82, BP 104/61, RR 18, O2 96% RA
Constitutional: No acute distress
Neuro: Alert and oriented to person, place and time
Cardiac: RRR
Lungs: No acute respiratory distress
Abdomen: soft, non-tender. no active bleeding
Wounds: open midline abdominal wound 80% granular, 20% fibrotic,
no active drainage. wound edges are clean. There is one proximal
and one distal simple interrupted 2-0 prolene suture
Extremities: symmetric 2+ LE edema, pulses palpable, no calf
pain b/l
Pertinent Results:
Admission Labs [**2144-3-7**]:
WBC-4.3 RBC-4.60 Hgb-9.3 Hct-34.6 Plt Ct-307 PT-11.9 PTT-19.5
INR(PT)-1.0
Neuts-83 Bands-9 Lymphs-3 Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-0
Hypochr-2+ Anisocy-2+ Poiklo-3+ Macrocy-1+ Microcy-1+
Polychr-OCCASIONAL Ovalocy-1+ Tear Dr[**Last Name (STitle) 833**]
[**Name (STitle) 15924**]
Glucose-123 UreaN-14 Creat-0.9 Na-135 K-3.9 Cl-106 HCO3-15
ALT-9 AST-18 TotBili-0.2
TotProt-6.3 Albumin-3.4 Globuln-2.9 Calcium-8.1 Phos-4.2 Mg-2.0
Hgb-9.6 calcHCT-29 freeCa-1.12
.
WBC trend: K+ trend
[**3-7**]: 8.6 3.9
[**3-8**]: 7.2 3.6
[**3-9**]: 7.8 3.3
[**3-10**]: 7.4 3.7
[**3-11**]: 7.5 2.8
[**3-12**]: 9.3 3.3
[**3-13**]: 9.7 3.3
[**3-15**]: 10.6 2.8
[**3-16**]: 4.3 3.8
[**3-17**]: 3.4
[**3-18**]: 4.1
.
Urine:
Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-150
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
.
Blood Cx negative x 3, H.Pylori Abx negative, MRSA screen:
negative
.
Abdominal wound swab:
GRAM STAIN (Final [**2144-3-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2144-3-18**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
FULL WORK UP PER DR.[**First Name (STitle) **],D [**2144-3-16**].
FULL WORK UP CANCELLED PER DR.[**Last Name (STitle) **] [**2144-3-17**].
ANAEROBIC CULTURE (Final [**2144-3-18**]): NO ANAEROBES ISOLATED.
.
G-tube wound swab:
GRAM STAIN (Final [**2144-3-16**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2144-3-18**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
.
Cardiology Report ECG Study Date of [**2144-3-7**]:
Sinus tachycardia. Baseline artifact makes evaluation of ST-T
waves in limb leads difficult. No previous tracing available for
comparison. Suggest repeat tracing if clinically indicated.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2144-3-8**]:
ET tube is in standard placement at the thoracic inlet, right
jugular line
ends in the upper SVC. Moderately severe left lower lobe
atelectasis, small left pleural effusion, and moderate right
pleural effusion are all new. The heart is not enlarged. Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **] paged.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2144-3-11**]:
No consolidations suggestive of pneumonia, but persistent
right-sided effusion and mild interstitial edema.
.
Radiology Report CHEST (PA & LAT) Study Date of [**2144-3-13**]
There are low lung volumes. Cardiomediastinal contours are
unchanged. A
small right pleural effusion has decreased in amount. Right
lower lobe
opacity is a combination of pleural effusion and consolidation,
given the
clinical suspicion of pneumonia, these area could correspond to
a focus of
pneumonia. Mild vascular congestion is stable. Left lower lobe
atelectasis
has improved.
.
Radiology Report SMALL BOWEL ONLY (GASTROGRAF) Study Date of
[**2144-3-13**]
No evidence of duodenal leak status post duodenal ulcer repair.
.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2144-3-17**]
No evidence of deep vein thrombosis in either leg.
.
Brief Hospital Course:
Ms. [**Known lastname 84323**] was transferred from an outside hospital on [**3-7**], [**2144**] for further management based upon CT scan results
suggestive of fluid in the abdomen and extravasation of
contrast. As she appeared to decompensate clinically, she
required an emergent exploratory laparotomy due to concerns of a
perforated duodenal ulcer. Pre-operative consent was obtained
and the patient was taken to the operating room for exploratory
laparotomy with [**Location (un) **] patch of the duodenal ulcer, repair of
internal hernia at the jejunojejunostomy, upper endoscopy and
gastrostomy tube placement. There were no adverse events in the
operating room; please see the operative note for details. The
patient remained intubated was taken to the PACU until stable,
then transferred to the surgical intensive care and finally the
general surgical [**Hospital1 **] for further observation.
Neuro: The patient was alert and oriented throughout her
hospitalization; pain was initially managed with a PCA and then
transitioned to oral dilaudid once tolerating a stage 2 diet.
Her pain was well controlled with oral dilaudid, however, she
did occassionally require intravenous breakthrough medication
with good effect.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The pt was weaned from the ventilator and extubated
shortly after arriving in the SICU. She remained stable from a
pulmonary standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. It was initially believed
that the pt may have developed hospital acquired pneumonia - she
was impirically started on v/az/f. Her temperature came down.
(Subsequently, her abdominal incisional wound dehisced &
drained, so it was then believed that this wound infection
resulted in her temperature spikes, not pneumonia. She was
switched to PO antibiotics - levo & flagyl)
GI/GU/FEN: She was kept NPO post-operatively with maintenance
intravenous fluids. A gastrograffin study via her g-tube was
performed on post-operative 5, this study negative for any type
of leak or obstruction. On post-operative day 7, her diet was
advanced to a bariatric stage 5 diet, which was well tolerated.
On post-operative day 9, the g-tube was clamped and JP #2 was
removed. There was no bilious drainage present in the remaining
JP drain, therefore, the g-tube remained clamped. On
post-opertive day 10, this drain was also removed.
Additionally, the patient required frequent potassium repletion
due to persistent hypokalemia, which had resovled prior to
discharge. She did not experience any adverse effects from the
hypokalemia.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. As mentioned above, it was
initially believed that the pt may have developed HA PNA,
however, it was later found out that her temp spikes likely are
related to the wound infection.
Electrolytes: the pt was found to have hypokalemia +
hypocalcemia while in house. Her potassium & calcium were
repleted accordingly.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The pt will be sent home
with oral iron due to iron deficiency anemia (dosage recommended
by Bariatric dietitian) and she was encouraged to follow-up with
the hematologist and bariatric dietitian.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she was encouraged to get
up and ambulate as early as possible.
Social: The pt was initially placed on a CIWA scale due to a
history of etoh abuse. She did not exhibit any signs or
symptoms of withrdrawal, therefore, the CIWA monitoring was
discontinued. Additionally, a history of past domestic violence
was identified during the initial nursing assessement, including
a history with her current boyfriend who was released from jail
recently. She was seen by the Social Worker and reported
feeling safe at home and that her boyfriend has not either
physically or emotionally abused her since being released from
jail. Please defer to Social Work notes for further details.
Of note, a representative from the Domestic Violence Prevention
and Treatment team provided resources to the patient.
Dispo:
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 5
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:
None (advil in excessive amounts)
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever: Do not exceed 4000 mg in a 24
hour period. Tablet(s)
2. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 10 days.
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain: Please do not drive or operative heavy
machinery while taking this medication.
4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for
Congestion, wheezing, shortness of breath.
6. senna 8.8 mg/5 mL Syrup Sig: Five (5) ml PO twice a day as
needed for constipation.
7. Vitron C Sig: One (1) Tablet PO three times a day.
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: Open capsule; do
not chew beads.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
1. Perforated duodenal ulcer.
2. Internal hernia.
3. Anterior GJ ulcer, not perforated.
4. Peritonitis.
5. Hypokalemia + Hypocalcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a perforated duodenal
ulcer, and an internal hernia, which were repaired during your
surgery. Also, an ulcer at the gastrojejunal anastamosis was
noted. You will be going home with a gastrostomy tube in place.
Please see instructions below for the care of this drain. Also,
it has been discussed with you that you must not ever take
NSAIDS (including but not limited to ibuprofen, Motrin, Advil,
Naproxen, aspirin). If you are unsure if a medication is
considered an NSAID you must ask your primary care provider or [**Name Initial (PRE) **]
[**Name9 (PRE) 109961**] pharmacist before taking the medication. Also, you
must not smoke or drink alcohol.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 18462**] to make a follow-up
appointment. This physician will be your new primary care
provider as discussed with his office, which is the same office
as your previous physician who is no longer at this site.
Please note he will not be seeing patients until [**2144-4-20**]. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will be the covering physician if needed.
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3201**] to make an appointment
within 2 weeks.
Please contact the Hematology Department at [**Telephone/Fax (1) 39833**] for
further management of your iron status.
Please contact the Bariatric Dietitian at [**Telephone/Fax (1) 305**]
Completed by:[**2144-3-19**]
|
[
"276.8",
"534.90",
"998.59",
"E878.8",
"998.32",
"519.11",
"305.1",
"275.41",
"300.00",
"303.91",
"280.9",
"567.9",
"724.5",
"V58.64",
"V45.86",
"532.50",
"E849.7",
"785.0",
"682.2",
"553.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"44.43",
"53.9"
] |
icd9pcs
|
[
[
[]
]
] |
11380, 11438
|
5505, 10238
|
286, 465
|
11616, 11616
|
1958, 3912
|
15109, 15921
|
1421, 1430
|
10322, 11357
|
11459, 11595
|
10264, 10299
|
11767, 13908
|
13923, 15086
|
1445, 1939
|
232, 248
|
493, 1086
|
3948, 5482
|
11631, 11743
|
1108, 1159
|
1175, 1405
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,996
| 100,242
|
17327
|
Discharge summary
|
report
|
Admission Date: [**2161-8-30**] Discharge Date: [**2161-10-7**]
Date of Birth: [**2130-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
fever to 103
Major Surgical or Invasive Procedure:
IR removal of Tunnelled HD line [**8-30**]
tissue AVR [**2161-9-18**]
redo homograft aortic root replacement [**2161-9-29**]
PICC line placement
History of Present Illness:
31M with h/o ESRD on HD, HTN, went to HD yesterday. At HD found
to have Temp 103, pt w/persistent fevers and chills for 1 day
prior to admission. Pt did notice a couple of days ago some
minor purulence around tunnelled HD line. Pt with similar
admission in [**5-/2161**] with fevers and CONS, tunnelled HD line was
removed and replaced on [**2161-5-29**]. He completed a 2 week course of
vanco.
TEE in [**Month (only) 116**] apparently showed mitral valve vegetation.
Past Medical History:
1. ESRD- membranous glomerulonephritis, dx in childhood, renal
biopsy [**2158**], HD x 5 yr, on Renal Transplant list
2. HTN
3. Hyperlipidemia
4. Chronic fatigue syndrome
5. H/o pyloric stenosis in childhood - surgically repaired
Social History:
Originally from [**Male First Name (un) 1056**]. Now lives by himself in Mission
[**Doctor Last Name **]. ETOH [**2-20**] drinks/month. Tobacco - smokes 1/2ppd x10 years.
Denies other drug use, no IVDU. Works in the electrical
engineering dept. at [**Hospital1 112**].
Family History:
mother - breast ca at 45, survivor, aunt - died of MI at 50, no
other family hx of renal disease, no DM or other CA in the
family
Physical Exam:
Vitals- 103.9 154/80 120 18 98%RA wt 66.1kg
General- NAD, speaking in full sentences
HEENT- dry MM, OP Clear, no exudates, PERRL, EOMI, no Cervical
LAD
Pulm- CTA b/l, no crackles, no wheezing
CV- Reg Sinus Tach, Nml S1,S2, No M/R/G
Abd- Soft ND/NT +BS
Extrem- No C/C/E, Warm, 2+DP pulses B/L
Neuro-A&OX3, no focal deficits,
Pertinent Results:
TEE [**2161-9-3**]: Aortic valve endocarditis with associated severe
aortic regurgitation. Large aortic paravalvular abscess.
Micro: [**2161-8-30**] = 4/4 bottles MSSA, line tip with MSSA, urine
ngtd. Since [**2161-8-31**], 18/18 bottles ngtd (last on [**2161-9-9**]).
[**2161-9-30**] Upper Extremity U/S
Extensive thrombus in the right subclavian vein with thrombus in
the left subclavian vein at its junction with the internal
jugular.
[**2161-9-29**] ECHO
PRE-BYPASS:
1. The left atrium is normal in size. A patent foramen ovale is
present. A
left-to-right shunt across the interatrial septum is seen at
rest.
2. Regional left ventricular wall motion is normal.
3. Overall left ventricular systolic function is mildly
depressed. There is mild global right ventricular free wall
hypokinesis.
4. A bioprosthetic aortic valve prosthesis is present. The
aortic prosthesis leaflets appear to move normally and the
annulus appears to be well seated. Trace central AI is seen. A
paravalvular aortic valve leak is seen, directed eccentrically.
An abscess cavity is noted in the perimembranous portion of the
interventricular septum, with color flow noted through the
cavity.. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen.
5. The mitral valve leaflets are structurally normal. Trivial
mitral
regurgitation is seen.
POST-BYPASS: Pt is in sinus tachycardia and is on dobutamine,
phenylephrine and epinephrine.
1. A aortic homograft is seen in the aortic position. No AI is
seen. Leaflets open well.
2. No flow is detected across the septum to suggest a VSD.
3. Inferior, inferolateral walls are mild- moderately depressed,
global
function is mildly depressed
4. Aorta is intact
Brief Hospital Course:
Mr. [**Known lastname 11041**] was admitted to the [**Hospital1 18**] on [**2161-8-30**] for further
work-up of his fever. Blood cultures revealed MSSA bacteremia
and an infectious disease consult was obatined. Vancomycin and
gentamicin were started and an echo was performed. This revealed
acute endocarditis with new aortic regurgitation and a
paravalvular abscess. The cardiac surgery service was consulted
for surgical evaluation and Mr. [**Known lastname 11041**] was worked-up in the
usual preoperative manner. It was preferred to wait 4-6 weeks
prior to surgery given his active endocarditis. Given the length
of stay and his multiple medical issues, the remainder of the
discharge summary will be broken down into systems.
Renal:
The renal service continued to follow Mr. [**Known lastname 11041**] and manage his
hemodialysis. His electrolytes were repleted as needed.
Transplant:
Given his positive blood cultures and his history of multiple
line infections, the transplant service was consulted. His old
tunneled catheter was removed and a temporary internal jugular
line was placed. The transplant service decided that he would
be best served with a more permenant catheter for upcoming
dialysis. On [**2161-9-9**], Mr. [**Known lastname 11041**] [**Last Name (Titles) 1834**] removal of his right
internal jugular line and placement of a left internal jugular
PermaCath. He remained on the transplant surgery list. [**2161-9-30**]
an ultrasound was obtained as his lines were not flushing
easily. This revealed extensive thrombus in the right subclavian
vein with thrombus in the left subclavian vein at its junction
with the internal jugular. His lines were left in place with as
access was needed and some of the clot was extracted.
Dental:
A dental consult was obtained who recommended he have his wisdom
teeth removed prior to his valve surgery based on a physical
exam and x-rays. Clindamycin was prophylactically dosed for his
extraction. On [**2161-9-14**], Mr. [**Known lastname 11041**] [**Last Name (Titles) 1834**] extraction of
three impacted third molar teeth and 3 impacted supernumerary
teeth without complication. He tolerated the procedure well
without complications. He had a slight fever two days following
his teeth extraction which delayed his surgery however his
fevers were not related to his extractions.
Infectious Disease:
Given his admission for endocarditis, the infectious disease
service was consulted for assistance in Mr. [**Known lastname 48504**]
management. Based on cultures and the patients allergy to
penicillin, vancomycin was used. As beta lactam therapy was the
choice therapy, the allergy service was asked to comment on his
penicillin allergy. Penicillin desensitization was recommended
which was commenced without complication. Mr. [**Known lastname 11041**] was then
transitioned to nafcillin. Surveillance cultures remained
negative. It was recommended to continue nafcillin until
[**2161-10-28**]. Mr. [**Known lastname 11041**] continued to have periodic fever spikes in
the presence of a normal white cell count and normal healing
wounds. Pan-cultures continued to remain negative.
Cardiac:
The cardiac surgical service and cardiology service followed Mr.
[**Known lastname 11041**] closely. It was planned that his surgery may be
performed when surveillance blood cultures were negative. His
volume status and hemodynamics were optimized. A nicotine patch
was used to help with smoking cessation.
He was taken to the OR on [**9-18**], [**Month/Day (4) 1834**] tissue AVR (please see
operative note for details of surgical procedure). He was weaned
off pressors, continued on hemodialysis treatments, and was
extubated over the next 48 hours, and transfeerred to the
telemetry floor on POD # 2. He was followed closely by the ID
service. OR cultures revealed MSSA, and penicilln was felt to
be the best treatment. As the patient had an allergy to
penicillin, he was brought back to the ICU for desensitization
which he tolerated well.
On [**9-24**], he had an echocardiogram which revealed dehiscence of
his prosthetic aortic valve with abscess. On [**2161-9-29**], he was
taken to the OR for a re-do AVR/homograft. Please see operative
report for details of procedure. On postoperative day one, he
self extubated himself without any complication. An ultrasound
of the upper extremities was obtained due to a question of clot
in the SVC in the OR. This revealed bilateral subclavian vein
thrombus, and anticoagulation was initiated. His drains and
pacing wires were rmeoved per protocol. His volume overload was
removed by hemodialysis. Heparin was continued until his INR
became therapeutic on coumadin. On postoperative day three, he
was transferred back to the step down unit for further recovery.
The physical therapy service worked with him to help increase
his strength and mobility.
Mr. [**Known lastname 11041**] continued to make steady progress and was discharged
home on [**2161-10-7**]. He will resume his regular hemodialysis
schedule. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist,
the infectious disease service, his primary care physician and
the renal service as an outpatient.
Medications on Admission:
Pt not compliant with meds, only taking Renagel and renal caps.
The other indicated meds not taken.
Atorvastatin Calcium 20mg qd
Furosemide 80mg qam, 40mg qpm
Epoetin Alfa 4,000U QMOWEFR
Atorvastatin 20mg qd
Sevelamer 2400mg Tablet TID w/meals
Labetalol 200mg TID
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Aortic valve endocarditis
ESRD/HD
HTN
elev. chol.
chronic fatigue
DVT
repair of pyloric stenosis as a child
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# for 10 weeks
may shower, no bathing or swimming for 1 month
no creams, lotions, or powders to any incisions
call for fever greater than 100, redness or drainage
no driving for one month
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**1-19**] weeks
with Dr. [**Last Name (STitle) 914**] in [**3-21**] weeks [**Telephone/Fax (1) 170**]
with Dr. [**Last Name (STitle) **] ([**Hospital **] clinic) [**10-23**] at 11:30 AM
with Dr. [**First Name (STitle) 437**] (card)in [**2-20**] weeks
HD Tues-Thurs-Sat
Completed by:[**2161-10-13**]
|
[
"585.6",
"305.1",
"272.4",
"522.4",
"996.1",
"041.11",
"520.6",
"403.91",
"790.7",
"996.73",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"35.21",
"88.72",
"99.04",
"35.39",
"38.95",
"23.19",
"39.95",
"36.99",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9234, 9295
|
3721, 8920
|
301, 448
|
9447, 9454
|
1992, 3698
|
9705, 10045
|
1501, 1632
|
9316, 9426
|
8946, 9211
|
9478, 9682
|
1647, 1972
|
249, 263
|
476, 946
|
968, 1199
|
1215, 1485
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,907
| 152,136
|
35266
|
Discharge summary
|
report
|
Admission Date: [**2145-10-3**] Discharge Date: [**2145-10-14**]
Date of Birth: [**2115-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Cardiac arrest s/p suspected heroin overdose
Major Surgical or Invasive Procedure:
Intracranial bolt placed for ICP monitoring [**2145-10-7**]
Bronchoscopy [**2145-10-10**]
History of Present Illness:
Mr. [**Name14 (STitle) 80449**] is a 30 yo male with past medical history of
hemochromatosis and hepatitis C found down after reported heroin
use, found to be in cardiac arrest in the field. Per report EMS
was called by a friend who reported the patient became
unresponsive after heroin and alcohol use. Down time prior to
EMS arrival was approximately 10 minutes per report. He was
intubated in the field, and received 30 minutes of CPR with
initial rhythm of asystole followed by PEA. He received epi X2,
atropine X2, HCO3 X2 and narcan 6 mg. Pt initially taken to
[**Hospital 8125**] Hospital where intial BP 58/22. Pt treated with IV fluid
bolus with improvement in his BP and 2amp of bicarb. Pupils were
fixed and dilated. Initial EtOH level was 265. Initial ABG
6.94/77/66/16. CT Head negative for acute bleed. He was
transferred to [**Hospital1 18**] for ongoing care.
On arrival to the [**Hospital1 18**] ED, vitals: HR 130, 150/100. Neurologic
exam on arrival included pupils fixed and non-reactive at 6mm.
No withdrawal of extremities to pain. CXR showed ET in place. He
was started on the Artic Sun post-arrest hypothermia protocol. 2
PIVs were placed and he was started on propofol for sedation.
ABG on arrival: 7.41/24/172/16. Labs showed serum EtOH of 198.
Serum benzo screen positive.
Past Medical History:
Psoriasis
Hemochromatosis
Hepatitis C
Hx substance abuse, EtOH/IVDU (Heroin)
Social History:
Hx of heroin and ethanol abuse. Mother, father, and sister live
in the area and were at patient's bedside.
Family History:
Noncontributory.
Physical Exam:
PE on admission:
Gen: intubated and sedated
HEENT - Pupils 4mm - L pupil surgical, R pupil non-reactive
CV: RRR, no MRG
Resp: CTAB
ABd: soft, NT/ND, NABS
Ext: no edema
Skin: diffuse psoriatic lesions over elbows, abd, kness and
entire bilateral lower extremities
Neuro: pt on propofol - no gag, no corneal reflexes, no response
to threat, no withdrawal of extremities to pain/pressure
Pertinent Results:
[**2145-10-3**] 06:50PM BLOOD WBC-4.9 RBC-3.95* Hgb-13.5* Hct-38.4*
MCV-97 MCH-34.2* MCHC-35.3* RDW-14.9 Plt Ct-165
[**2145-10-3**] 06:50PM BLOOD PT-12.2 PTT-23.1 INR(PT)-1.0
[**2145-10-3**] 10:06PM BLOOD Glucose-194* UreaN-8 Creat-1.1 Na-145
K-3.4 Cl-107 HCO3-19* AnGap-22*
[**2145-10-3**] 10:06PM BLOOD ALT-184* AST-317* CK(CPK)-2060*
AlkPhos-141* Amylase-55
[**2145-10-3**] 10:06PM BLOOD CK-MB-7 cTropnT-<0.01
[**2145-10-3**] 06:50PM BLOOD ASA-NEG Ethanol-198* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2145-10-5**] 10:18AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
Pt is a 30 yo male s/p cardiac arrest in the setting of
suspected heroin overdose. Reported downtime of ~10min in the
field f/b 30min of CPR before restoration of vital signs.
Admitted to the Medical ICU for Artic Sun post-arrest induced
mild hypothermia protocol.
#Anoxic brain injury - Minimal neurologic response prior to
initiation of cooling protocol. 24hr protocol completed and
rewarming initiated. During rewarming, he developed profound
rigors and subsequently became febrile to 104. The rigors were
not responsive to increasing sedation or demerol, thus he was
re-paralyzed. The following morning, the paralytic was
discontinued, and he developed movements more consistent with
seizure activity most prominent in the R arm and R leg. He was
loaded with phenytoin with some improvement in seizure activity
and neurology was consulted. He developed persistent
breakthrough seizure-like movements requiring boluses of
phenytoin and initiation of Keppra. A video EEG was performed
and results showed diffuse encephalopathic changes without
evidence of electrographic seizures. An MRI was performed on
[**2145-10-6**] which revealed findings c/w global infaraction,
anoxic brain injury, and diffuse cerebal edema. On the morning
of [**2145-10-7**], pt was noted to have a change in his pupillary exam
and papilledema. A STAT head CT revealed complete loss of
grey-white matter differentiation c/w diffuse cerebral edema. Pt
was started on mannitol infusion, HOB to 30 degrees, and
hyperventilated to a PCO2 of 28. Neurosurgery was consulted,
placed a bolt, found the initial ICP to be 24. Pt was continued
on mannitol q6h, Keppra, and continous ICP monitoring (ICPs
ranged from 20s-60s). Neurologic exams off-sedation revealed
absent corneal reflexes, absent cold calorics, and no response
to painful stimuli. Apnea tests x 2 ([**10-11**], [**10-13**]) revealed that
patient continued to demonstrate respiratory effort, and thus
did not meet criteria for brain death. After ongoing discussions
with the family regarding his poor prognosis, and based on
previously expressed wishes of the patient, the family decided
to shift goals of care to CMO on the morning of [**2145-10-14**]. He was
extubated, made comfortable with morphine, and declared dead at
1:39pm on [**2145-10-14**]. NEOB had been contact[**Name (NI) **] and pt was ruled out
for donation after cardiac death.
# S/p Cardiopulmonary Arrest: Pt received the 24hr post-arrest
hypothermia protocol. Cardiac enzymes were cycled and were
negative for any significant ischemia. A transthoracic ECHO done
on [**2145-10-5**] revelead normal structure and function. Pt remained
hemodynamically stable without need for vasopressor support.
#Fever: Pt became febrile in the midst of diffuse rigors. Blood,
urine, and sputum cultures were sent. A CXR on [**2145-10-6**] revealed
a new LLL opacity, consistent with atelectasis vs. infiltrate.
He was started on Levofloxacin and Flagyl to cover for possible
aspiration. He was switched to Ceftriaxone and Flagyl the
following morning (concern for lowering the seizure threshold on
flouroquinolones). Blood and urine cultures were negative but
sputum cultures were positive for Klebsiella, Enterobacter, and
Staph Aureus. Bronchoscopy on [**2145-10-20**] revealed copious purulent
secretions. Pt was treated with appropriate IV antibiotics until
the decision made made to focus on CMO.
The family was provided with support from social work and the
hospital priest & chaplaincy services. They were at the bedside
when he expired.
Medications on Admission:
Seroquel
Librium
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to severe anoxic brain injury s/p cardio-respiratory
arrest due to suspected heroin and alcohol overdose
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"041.3",
"486",
"348.1",
"E980.9",
"980.0",
"E980.0",
"070.70",
"305.51",
"305.01",
"696.1",
"518.81",
"965.01",
"275.0",
"427.5",
"V66.7",
"780.01",
"780.39",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.10",
"38.91",
"33.24",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6744, 6753
|
3107, 6648
|
361, 452
|
6911, 7048
|
2469, 3084
|
2030, 2048
|
6715, 6721
|
6774, 6890
|
6674, 6692
|
2063, 2066
|
277, 323
|
480, 1785
|
2080, 2450
|
1807, 1889
|
1905, 2014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,123
| 127,919
|
7928
|
Discharge summary
|
report
|
Admission Date: [**2181-1-31**] Discharge Date: [**2181-2-12**]
Date of Birth: [**2118-11-28**] Sex: M
Service: Transplant
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 62-year-old male
with a past medical history significant for end stage renal
disease secondary to diabetes mellitus who presents today for
a cadaveric renal transplantation. The patient's past
medical history is notable for coronary artery disease with
placement of a sirolimus coated stent in [**2180-6-13**]. His past
medical history is also notable for hypertension and
neuropathy along with gastroesophageal reflux disease.
REVIEW OF SYSTEMS: He denies chest pain, shortness of
breath, fevers, chills, vomiting, nausea, or diarrhea.
Underwent a successful cardiac workup including a stress test
in [**2180-10-14**] which demonstrated no reversible
profusion defects.
PAST MEDICAL HISTORY:
1. End stage renal disease.
2. Type 2 diabetes.
3. Diabetic neuropathy.
4. Hypertension.
5. Coronary artery disease, status post myocardial
infarction and stent placement.
MEDICATIONS:
1. Aspirin 325 mg p.o. once daily.
2. Atenolol 25 mg p.o. once daily.
3. Neurontin 200 mg p.o. three times a day.
4. Renagel 800 mg p.o. three times a day.
5. Nephrocaps one tablet p.o. once daily.
6. TUMS two tablets p.o. three times a day.
7. Erythropoietin q. hemodialysis.
ALLERGIES: The patient has allergies to penicillin and
intravenous contrast.
PHYSICAL EXAMINATION: Vital signs; temperature 98.2 F, blood
pressure 132/64, heart rate 78, respiratory rate 16. Oxygen
saturation 100% on room air. In general, the patient is a
pleasant gentleman who is in no apparent distress. Head,
eyes, ears, nose and throat, clear oropharynx. Moist mucous
membranes. Neck supple, nontender without lymphadenopathy.
Heart regular rate and rhythm. Lungs clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended with no
palpable masses. Extremities, trace pedal edema.
HOSPITAL COURSE: The patient underwent a cadaveric renal
transplantation on the day of admission. The operation was
complicated by postoperative hypotension requiring a two day
stay in the Surgical Intensive Care Unit with the use of a
Neo-Synephrine drip to maintain a systolic blood pressure
greater than 110, and elevated potassium at 6.7, and a low
urinary output. The patient was weaned off of the
Neo-Synephrine overnight, was dialyzed and was treated with
Kayexalate. His pain was well controlled in the
postoperative state using a morphine PCA pump. He was
treated with six doses of ATG along with a Solu-Medrol taper,
CellCept, and eventually Imuran and Prograf for
immunosuppression. The patient had a duplex ultrasound of
the transplanted kidney on postoperative day number one which
demonstrated normal indices without obstruction. The patient
was dialyzed on postoperative day number two, number three,
and number eight. His urine output improved from 130 cc the
day following his surgery to 1700 cc daily at the time of
discharge. The postoperative creatinine was 10.4 but
subsequently decreased to 3.5 at the time of discharge. He
remained afebrile with adequate blood pressure and blood
sugar control throughout his stay and was discharged to home
on postoperative day number 12 with a visiting nurse [**First Name (Titles) **]
[**Last Name (Titles) **] with blood draws, and JP drain care. The [**Last Name (un) **]
service helped control the patient's blood glucose levels
while he was in the hospital and he will be following up with
them in the postoperative period. Of note, the patient did
develop some abdominal discomfort on postoperative day seven
and had not had a bowel movement since his surgery. An
nasogastric tube was placed at this time but was subsequently
removed the following day after a successful bowel movement.
DISCHARGE DIAGNOSIS:
1. End stage renal disease status post cadaveric renal
transplantation.
2. Coronary artery disease status post myocardial infarction
with stent.
3. Hypertension.
4. Insulin dependent diabetes mellitus.
5. Postoperative ileus.
6. Postoperative hypotension.
7. Diabetic neuropathy.
DISCHARGE MEDICATIONS:
1. Bactrim single strength one tablet p.o. once daily.
2. Protonix 40 mg p.o. once daily.
3. Colace 100 mg p.o. twice a day.
4. Regular insulin sliding scale as directed.
5. Percocet 5/325 one to two tablets p.o. q.4-6h. p.r.n.
pain.
6. Prednisone 20 mg p.o. once daily.
7. Valganciclovir 450 mg p.o. q.other day.
8. Nystatin 5 cc p.o. four times a day.
9. Imuran 100 mg p.o. once daily.
10. Prograf 3 mg p.o. twice a day.
11. Neurontin 300 mg p.o. three times a day.
12. Ativan 0.5 mg p.o. q.h.s. p.r.n.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: The patient was discharged to home
with visiting nurse services to [**Last Name (un) **] with blood draws and
blood sugar monitoring along with wound care injection by
drain care.
FOLLOW-UP PLANS: The patient was instructed to follow-up
with Dr. [**Last Name (STitle) **] on [**2181-2-19**]. He was instructed to
follow-up with the [**Hospital **] [**Hospital 982**] Clinic in the outpatient
setting. He was instructed to follow-up sooner if he
developed fevers greater than 101.5?????? F, severe abdominal
pain, vomiting or if he had any other questions or concerns.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2181-3-3**] 15:59
T: [**2181-3-5**] 08:11
JOB#: [**Job Number 28472**]
|
[
"357.2",
"997.4",
"560.1",
"458.29",
"403.91",
"250.40",
"250.60",
"530.81",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
4750, 4931
|
4719, 4726
|
4182, 4697
|
3871, 4159
|
2003, 3850
|
1476, 1985
|
4949, 5576
|
651, 876
|
169, 631
|
898, 1453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,728
| 120,815
|
25252
|
Discharge summary
|
report
|
Admission Date: [**2175-10-23**] Discharge Date: [**2175-10-29**]
Date of Birth: [**2117-10-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Had exertional symptoms of SOB and malaise prior to being
diagnosed with MI in [**Month (only) 216**]. She had no prior history of CAD.
Major Surgical or Invasive Procedure:
[**10-23**] CABG x 2
History of Present Illness:
58 yo female with no previous history of CAD, who suffered an MI
in [**9-1**]. A stent was placed in the RCA at that time, and
follow-up ETT showed fixed defects. Repeat cath showed a patent
RCA stent, and 80% LM lesion. Her exertional sx have decreased,
and she denies rest pain. Referred to [**Hospital1 18**] for CABG with Dr.
[**Last Name (STitle) 1290**].
Past Medical History:
inferior myocardial infarction (IABP)
RCA stent [**9-1**]
elev. chol.
HTN
colon CA/colectomy [**2168**]
appy [**2141**]
ovarian cyst [**2148**]
Social History:
lives with husband and a daughter
office worker
smoked [**1-29**] ppd for 40 years, quit 9 months ago
has an occasional drink
Family History:
father died of MI at 66
Physical Exam:
HR 60 120/80 62 kg
NAD, somewhat anxious
SKIN/ HEENT unremarkable, neck supple without bruits
lungs CTAB
RRR without murmur or rub
abd has well-healed scar, soft, NT, ND
no apparent varicosities, 2+ fem, DP pulses bilat, 1+ PT pulses
bilat.
neurologically grossly intact
Pertinent Results:
[**2175-10-25**] 07:10AM BLOOD WBC-6.9 RBC-3.59* Hgb-11.3* Hct-31.9*
MCV-89 MCH-31.5 MCHC-35.6* RDW-14.9 Plt Ct-125*
[**2175-10-25**] 07:10AM BLOOD Plt Ct-125*
[**2175-10-25**] 07:10AM BLOOD Glucose-119* UreaN-17 Creat-0.8 Na-135
K-4.9 Cl-102 HCO3-28 AnGap-10
[**2175-10-26**] 07:10AM BLOOD UreaN-18 Creat-0.8 K-5.5*
[**2175-10-24**] 01:24AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.9
pre-op CXR [**10-4**]: no significant abnormalities
Brief Hospital Course:
59 yo female admitted [**10-23**] and underwent CABG x2 by Dr.
[**Last Name (STitle) 1290**] on the same day (LIMA to LAD, SVG to OM). Transferred
to CSRU in stable condition on titrated neosynephrine and
propofol drips. Extubated later that day, on insulin, nipride
and nitroglycerin drips. Beta blockade and diuresis were begun
on POD #1, as well as lisinopril for BP management. Plavix was
also restarted for coverage of the RCA stent.Transferred to the
floor also on POD #1. CTs were removed on POD #3 after some
continued drainage on POD #2. Pacing wires were also removed on
POD #3. Pt did very well and was discharged home on POD 6.
Medications on Admission:
lipitor 80 mg qd
ASA 81 mg qd
lisinopril 5 mg qd
plavix 75 mg qd
lopressor 75 mg qd
citalopram 20 mg qd
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Ranitidine 150 mg PO BID
4. Aspirin 81 mg Tablet Daily
5. Citalopram 20 mg PO DAILY
6. Atorvastatin 80 mg Tablet PO DAILY
7. Dilaudid
8. Lasix 40 mg PO BID
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD s/p RCA stent ([**9-1**])
HTN
s/p CABG x2
elev. chol.
myocardial infarction [**9-1**]
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, wash incision with soap and water and pat dry.
No driving until follow up with surgeon at 4 weeks.
No lifting greater than 10 pounds for 10 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 10755**] 2 weeks
Dr. [**Last Name (STitle) 32255**]/ Dr. [**Last Name (STitle) 1295**] in 2 weeks
|
[
"V10.05",
"427.31",
"272.0",
"424.0",
"412",
"V17.3",
"997.1",
"414.01",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"99.04",
"89.60",
"39.61",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
2996, 3045
|
1953, 2594
|
427, 450
|
3179, 3187
|
1499, 1930
|
1167, 1192
|
2749, 2973
|
3066, 3158
|
2620, 2726
|
3211, 3485
|
3536, 3703
|
1207, 1480
|
252, 389
|
478, 840
|
862, 1008
|
1024, 1151
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,282
| 133,025
|
44561+58728
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-10-12**] Discharge Date: [**2161-10-23**]
Date of Birth: [**2105-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2162-10-19**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM,
SVG to PDA)
[**2161-10-13**] Cardiac Catheterization
History of Present Illness:
56yo gentleman with h/o HTN, dyslipidemia, and DM who presents
with chest pain. He has been having intermittent pain for the
last couple of weeks. Pain occurs mostly at rest when he is
watching the baseball games. He describes it as being shaped
like an H across the center of his chest and being "tight" in
character. Non-radiating. +Associated with nausea today but
otherwise not usually. No shortness of breath or diaphoresis.
.
Today, he dropped his son off to start college and felt very
emotional about it. Shortly after, he admitted to his wife that
he was having chest pain and she brought him to the ED.
.
Of note, he admits that he has been poorly compliant with his
medications and has not taken them for several days. He has been
out of a job and has had difficulty finding ways to pay for his
medications.
.
At [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], VS were: 97.1 BP 182/108 75 20 99%. He was given
ASA 324mg, dilaudid 2mg IV, insulin 6 units for BS 400, and
started on heparin and nitro gtt. He was given a SL NTG that
took away the sensation of "tightness," he has had [**2163-2-12**] chest
pain since but without the sensation of tightness. He was
transferred to [**Hospital1 18**] for care of unstable angina.
Past Medical History:
Diabetes Mellitus, Hypertension, Hypercholesterolemia,
Hypothyroidism, Arthritis, s/p Bilat. knee surgery, s/p Bilat.
rotator cuff repair, s/p right carpal
tunnel release, s/p lumbar fusion
Social History:
Former heavy smoker, quit 20-25 years ago; rare cigar use; no
ETOH; distant MJ/cocaine use, no IVDU
Family History:
Father (42) & multiple paternal family members w/ premature CAD;
Mother w/ CAD @ 85.
Physical Exam:
ADMISSION PE:
V/S: BP 157/82 HR 77 RR 20 O2sat 95% 3L
GENERAL: Obese man appears comfortable lying in bed, NAD
HEENT: NC/AT, OP clear w/ dry MM
NECK: Supple, JVD difficult to assess [**3-14**] habitus
CV: distant heart sounds RRR nl S1S2 no m/r/g
LUNGS: CTAB no w/r/r
ABD: soft NTND normoactive BS no abd bruit
EXTREMITIES: warm, dry no c/c/e 2+ fem pulses no bruit 2+ PT/DP
Pertinent Results:
[**10-13**] Cardiac cath: 1. Selective coronary angiography in this
right dominant system demonstrated 3 vessel disease. The LMCA
had mild disease. The LAD had an 80% lesion at D2 bifurcation,
and D2 had an 80% stenosis. The LCx had a 60% lesion at OM1.
The RCA was totally occluded with left to right collaterals. 2.
Limited resting hemodynamics revealed systemic arterial pressure
of 133/81 while the patient was on IV nitroglycerine.
[**10-19**] Echo: PREBYPASS: 1. The left atrium is normal in size. 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. 2. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of
inferior and inferoseptal walls, EF 40%. The remaining left
ventricular segments contract normally. 3. Right ventricular
chamber size and free wall motion are normal. 4. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. There are simple atheroma in
the descending thoracic aorta. 5. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. The
aortic valve leaflets are mildly thickened. 6. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. 7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) **] was
notified in person of the results. POST-CPB: On phenylephrine,
atrial pacing. Improved systolic function post bypass. LVEF is
now 45-55%. The inferoseptal hypokinesis is improved. MR is 1+.
Aortic contour is normal post decannulation.
[**2161-10-12**] 04:45AM BLOOD WBC-10.9 RBC-4.42* Hgb-12.5* Hct-36.3*
MCV-82 MCH-28.3 MCHC-34.5 RDW-13.2 Plt Ct-261
[**2161-10-21**] 05:38AM BLOOD WBC-12.8* RBC-3.25* Hgb-9.1* Hct-26.8*
MCV-82 MCH-28.0 MCHC-34.0 RDW-13.4 Plt Ct-238
[**2161-10-12**] 04:45AM BLOOD PT-13.9* PTT-73.2* INR(PT)-1.2*
[**2161-10-19**] 12:43PM BLOOD PT-13.5* PTT-35.3* INR(PT)-1.2*
[**2161-10-12**] 04:45AM BLOOD Glucose-339* UreaN-19 Creat-1.3* Na-135
K-4.5 Cl-97 HCO3-27 AnGap-16
[**2161-10-21**] 05:38AM BLOOD Glucose-188* UreaN-18 Creat-1.2 Na-133
K-4.5 Cl-95* HCO3-27 AnGap-16
[**2161-10-14**] 05:25AM BLOOD ALT-22 AST-41* LD(LDH)-373* TotBili-0.6
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 1726**] was transferred from [**Hospital1 **] after being ruled in for a Myocardial Infarction. Upon
admission he was appropriately medically managed and then
underwent a cardiac cath on [**10-13**]. Cath revealed severe three
vessel disease. Over the next several days patient was worked-up
for upcoming surgery. Surgery was waited upon until Plavix
washout. During this time he was medically managed. On [**10-19**] he
was brought to the operating room where he underwent a coronary
artery bypass graft x 3. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. Chest tubes were removed on post-op day one and
he was transferred to the telemetry floor for further care.
There he was seen in consultation by the [**Last Name (un) **] Diabetes service
for his elevated blood sugars and pre-op Hgb A1C of 10.2. His
insulin was increased accordingly. He was also seen by social
work to help manage finances and obtain the medicines he needs
to control his diabetes. His beta blockade was increased as
tolerated. He was placed on [**First Name8 (NamePattern2) **] [**Last Name (un) **] rather than an ACE for his
ejection fraction of 46% because he was on this medication
pre-operatively. He was discharged to home on post-operative
day 4.
Medications on Admission:
ASA 81mg daily, Lopressor 100 mg daily, Norvasc 10 mg daily,
Lantus 40 units QAM and 40 units QPM, Humalog SS (usually takes
22 U w/ meals), Levoxyl 200 mcg daily, Lipitor, Vicodin 5/500
Discharge Medications:
1. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
2. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days: sternal erythema.
Disp:*28 Capsule(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO Q 8H
(Every 8 Hours).
Disp:*3 Tablet(s)* Refills:*2*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*1*
11. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 packets* Refills:*1*
12. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous twice a day: take at breakfast and dinner.
Disp:*qs units* Refills:*2*
13. Insulin Aspart 100 unit/mL Solution Sig: qs units
Subcutaneous four times a day: per sliding scale.
Disp:*qs bottles* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Hospice Program
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Myocardial Infarction
PMH: Diabetes Mellitus, Hypertension, Hypercholesterolemia,
Hypothyroidism, Arthritis, s/p Bilat. knee surgery, s/p Bilat.
rotator cuff repair, s/p right carpal tunnel release, s/p lumbar
fusion
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
Report any fever greater then 100.5. Report any weight gain of 2
pounds in 24 hours or 5 pounds in 1 week.
No lotions, creams or powders to incision until it has healed.
Shower daily. No baths or swimming.Gently pat the wound dry.
o lifting greater then 10 pounds for 10 weeks.
No driving for 1 month
Take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Cardiologist in [**3-15**] weeks
Dr. [**Last Name (STitle) 1407**] in [**2-11**] weeks
Completed by:[**2161-10-23**] Name: [**Known lastname **],[**Known firstname 133**] E Unit No: [**Numeric Identifier 15113**]
Admission Date: [**2161-10-12**] Discharge Date: [**2161-10-23**]
Date of Birth: [**2105-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Lantus was increased to 48 units two times per day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 13985**] Hospice Program
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2161-10-23**]
|
[
"401.9",
"414.01",
"428.0",
"410.71",
"715.90",
"584.9",
"272.0",
"428.42",
"724.5",
"244.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"99.20",
"88.72",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
9816, 10008
|
4940, 6410
|
334, 463
|
8574, 8580
|
2589, 4917
|
9188, 9793
|
2093, 2179
|
6647, 8163
|
8274, 8553
|
6436, 6624
|
8604, 9165
|
2194, 2570
|
284, 296
|
491, 1747
|
1769, 1960
|
1976, 2077
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,507
| 133,165
|
37020
|
Discharge summary
|
report
|
Admission Date: [**2142-2-9**] Discharge Date: [**2142-2-18**]
Date of Birth: [**2077-9-24**] Sex: F
Service: MEDICINE
Allergies:
Aleve / Erythromycin Base / Simvastatin / Boniva / Augmentin
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
tachycardia
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
Reason for MICU Admission: a-flutter w/ RVR
.
Primary Care Physician: [**Name10 (NameIs) 1112**],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 3070**]
.
CC:[**CC Contact Info 83473**].
HPI: This is a 64 year-old female with a history of diffuse
B-cell Lymphoma s/p 6 cycles of R-[**Hospital1 **] ([**Date range (2) 83474**]), Stage
III NSCLC (dx on [**11-5**] apical posterior segment of the left
upper lobe mass) s/p chemoradiation with [**Doctor Last Name **]/taxol on
[**2141-12-14**], CAD s/p 3 stents [**2138**], PE x2 s/p IVC filter
(not on coumadin [**2-28**] hemoptysis), HTN who presents with
pnuemonia. The patient reports coughing and increased sputum
over the last week. She was treated with a 5 day course of
azithromycin as an outpatient for "bronchitis" that she finished
on Monday. The patient reports development of fatigue and and
pleuritic left sided chest pain that started last night. She
denied fevers, chills, or SOB. She went to her outpatient
transfusion clinic for planned pRBC transfusion. At clinic
today she was noted to be tachycardic to the 140's and BP was
75/50. She was referred to the ED for further management.
.
In the ED, 99.2 130 108/85 18 85%RA. She had a CXR that showed
a new left upper lobe opacity concerning for pneumonia. She
also underwent a CTA that was negative for PE, but confirmed the
left upper lobe consolidation. The patient's labs were
signficant for a leukocytosis of 13.8 and lacate of 0.7. She
was empirically covered with Levofloxacin/Vancomycin. Her Hct
was 25.7 and received 2U pRBC. She was also given 1.5L IVF.
She continued to be in a-flutter with RVR. Her CE were negative
x1 and BNP 3351. She was given tylenol and no rate controlling
agents were given. On transfer her vitals were 99.8 132 101/70
19 100% RA
.
In the [**Hospital Unit Name 153**] the patient reported feeling well without chest
pain. She did endorse continued cough that had not resolved
after antibiotics.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity edema, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
.
Past Medical History:
ONCOLOGIC HISTORY:
-Presented in Spring [**2141**] to cardiologist with dyspnea and
lightheadedness. CXR prior to catherization showed a possible
pneumonia. CT then showed evidence of mediastinal
lymphadenopathy, as well as a splenic abnormality. Underwent a
CT
guided core biopsy of the spleen on [**2141-5-25**] consistent
with
diffuse large B-cell lymphoma. Bone marrow biopsy on [**2141-6-12**]
without disease. [**Date range (2) 83474**] 6 cycles of R-[**Hospital1 **].
.
-Stage III NSCLC (dx on [**11-5**] apical posterior segment of the
left upper lobe mass). Treated chemoradiation with [**Doctor Last Name **]/taxol
on [**12-4**]
.
- Coronary artery disease with history of myocardial infarction
in [**2126**], s/p 3 stents w/ last one in [**2138**]
- Osteoarthritis.
- Polymyalgia rheumatica
- Hypertension.
- Steroid-induced hyperglycemia.
- Status post bilateral oophorectomy for ovarian cyst ([**2125**]).
- Status post bilateral cataract surgeries
- Status post cholecystectomy.
- Status post R hip replacement in [**2140-6-27**]. Post-op, the
patient developed bilateral pulmonary emboli, IVC placed
- She underwent a left hip replacement in [**2140-10-27**].
- GERD.
- Obesity.
- Depression.
- "Clot" involving left kidney.
- Hypercholesterolemia
- PE in [**2141-7-27**], lovenox-->coumadin bridge
- COPD
Social History:
- Married
- Lives in [**Location 1411**] with her husband, 2 of her daughters and a son
who has special needs
- 6 children in total and 3 grandchildren
- Does not work outside the home
- Former smoker for 40 years, quit 3 years ago
- Rare alcohol
- Denies use of illicit drugs.
Family History:
- Father died of unknown malignancy
- Mother died from complications secondary to hip surgery
Physical Exam:
On Admission:
GEN: Well-appearing, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: tachy, no M/G/R, normal S1 S2, radial pulses +2
PULM: rhonchi in the left upper lobe, otherwise no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
.
Pertinent Results:
Studies:
ECG: poor baseline, a-flutter with rapid ventricular rate at
130.
Imaging:
CXR:
IMPRESSION: Unchanged left hilar mass. New left upper lobe
opacity,
concerning for post obstructive pneumonia. Followup radiograph
is
recommended after completion of treatment to ensure resolution.
.
CTA:
No evidence for pulmonary embolism. New left upper lobe
consolidation,
concerning for pneumonia, but new or underlying mass cannot be
excluded. If
treated for pneumonia, follow-up chest imaging is recommended to
ensure
resolution and exclude new mass.
[**2142-2-8**] 01:48PM WBC-14.2*# RBC-2.84* HGB-9.1* HCT-26.6*
MCV-94 MCH-32.1* MCHC-34.3 RDW-20.2*
[**2142-2-8**] 01:48PM PLT COUNT-405#
[**2142-2-9**] 11:13AM PLT SMR-NORMAL PLT COUNT-383
[**2142-2-9**] 11:13AM PT-13.2 PTT-24.0 INR(PT)-1.1
[**2142-2-8**] 01:48PM UREA N-12 CREAT-0.8 SODIUM-136 POTASSIUM-4.1
CHLORIDE-92* TOTAL CO2-34* ANION GAP-14
[**2142-2-9**] 11:13AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2142-2-9**] 11:13AM WBC-13.8* RBC-2.81* HGB-8.8* HCT-25.7* MCV-91
MCH-31.3 MCHC-34.2 RDW-20.6*
[**2142-2-9**] 11:13AM NEUTS-80* BANDS-0 LYMPHS-10* MONOS-8 EOS-0
BASOS-1 ATYPS-0 METAS-1* MYELOS-0
[**2142-2-9**] 11:13AM GLUCOSE-144* UREA N-10 CREAT-0.8 SODIUM-138
POTASSIUM-3.3 CHLORIDE-95* TOTAL CO2-33* ANION GAP-13
[**2142-2-9**] 11:13AM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2142-2-9**] 11:13AM cTropnT-<0.01
[**2142-2-9**] 11:13AM proBNP-3351*
[**2142-2-9**] 07:26PM FIBRINOGE-694*#
[**2142-2-9**] 07:26PM PT-15.1* PTT-26.2 INR(PT)-1.3*
[**2142-2-9**] 07:26PM HAPTOGLOB-435*
[**2142-2-9**] 07:26PM CK-MB-2 cTropnT-<0.01
[**2142-2-9**] 07:26PM LD(LDH)-153 CK(CPK)-37 TOT BILI-1.4
[**2142-2-9**] 11:30AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-[**7-6**]
[**2142-2-9**] 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2142-2-9**] 11:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.003
Brief Hospital Course:
64 year-old female with a history of diffuse B-cell Lymphoma s/p
6 cycles of R-[**Hospital1 **] ([**Date range (2) 83474**]), Stage III NSCLC (dx on
[**11-5**] apical posterior segment of the left upper lobe mass) s/p
chemoradiation with [**Doctor Last Name **]/taxol on [**12-4**], a-fib, CAD
s/p 3 stents [**2138**], PE x2 s/p IVC filter (not on coumadin [**2-28**]
hemoptysis), HTN who presents with pnuemonia and a-flutter with
RVR.
.
# HCAP/Post Obstructive Pneumonia: Pt with h/o Stage III NSCLC
with a left upper lobe mass. She had CXR and CTA evidence of a
consolidation in the left upper lobe. She has a leukocytosis,
but otherwise afebrile and without cough, sputum or SOB.
represents a post-obstructive pneumonia. She received
Vanco/Levofloxacin in the ED. Urine legionella negative. Patient
initially treated with Zosyn and Levofloxacin. On [**2-12**] patient
had temp to 101 - levofloxacin was changed to cipro and
vancomycin was added. Vanco d/c'ed on [**2-14**]. Plan for 10 day
treatment course for post-obstructive PNA with Zosyn and cipro.
PICC placed on [**2-13**] and VNA arranged. Blood cx with NGTD. Unable
to obtain sputum cultures as patient without productive cough.
Plan for antibiotics through [**2-19**]. She has a persistant
leukocytosis (WBC 15 at discharge); blood cultures negative, UA
negative and repeat CXR stable. Recommend repeat CBC at PCP f/u
appointment later this week. Will need to consider XRT,
bronch/stenting if symptoms return or do not resolve with full
course of antibiotics.
.
# A-flutter w/ RVR: Rate control difficult in the ICU, likely
precipitated by volume depletion and infection. Cardiology was
consulted. Required intermittent dilt gtt; however eventually
achieved rate control with dilt 90mg QID, metoprolol 100mg QID
and digoxin. Blood pressures stable. Pt is not on coumadin given
history of hemoptysis. ASA 81 mg was started. She was
discharged on digoxin, Metoprolol 100mg QID and diltiazem 360
daily with heartrates of 60-70s x 24 hours. She has close
follow up with Dr. [**Last Name (STitle) **] on Monday (the day after discharge).
.
# CAD, native: Her chest pain is likely related to her
post-obstructive pna. No evidence of ischemia and CP free. CTA
was negative for PE. Restarted BB and CCB. Holding [**Last Name (un) **] at
discharge; consider restart as an outpatient. Aspirin 81 mg
daily started.
.
# HTN, benign: On admission relative hypotension and initially
held home medications. As BP permitted and rate necessitated
beta-blocker and calcium channel restarted. Home lasix restarted
on [**2-13**]. Held [**Last Name (un) **] held as above.
.
# COPD: Patient peristently wheezey on exam; treated with
Xopenex and ipratropium Neb treatments as well as Prednisone
40mg pulse x 5 days with improvement of respiratory status.
.
# Diabetes: home oral medication held initially, covered with
sliding scale, restarted prior to discharge.
# Comm: [**Name (NI) **] (Husband)- [**Telephone/Fax (1) 83475**]
.
# Code: The patient was FULL code during this admission.
Medications on Admission:
Albuterol 2 puffs:prn wheeze
Codeine-Guaifenesin 5-10ml
Advair 250/50 [**Hospital1 **]
Lasix 40-60mg daily
Glipizide 2,5mg ER daily
Halobetasol propionate 0,05% cream
Hydrocortisone 1% cream [**Hospital1 **]:prn
Levothyroxine 175mcg daily
Lorazepam 1mg:prn
Losartan 50mg daily
Metoprolol 50mg qAM and 25mg qPM
Zofran prn
Paroxetine 20mg daily
KCl 20mEq SR
Pravastatin 20mg daily
Prochlorperazine 10 q8:prn
Tylenol
Probiotic
Calcium & Vit D
Folic Acid 0.4mg daily
MV
Discharge Medications:
1. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 grams Intravenous Q8H (every 8 hours) for 2 days.
Disp:*6 vials* Refills:*0*
2. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
3. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for insomnia/anxiety.
10. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
15. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*120 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Please ask Dr [**First Name (STitle) **] to check a Chem 10 and CBC at your
appointment later this week.
18. diltiazem HCl 360 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
19. 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.
20. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
21. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
22. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
23. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-28**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*2 inhalers* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Post obstructive pneumonia/Healthcare associated pneumonia
Rapid atrial fibrillation/flutter
NSCLC
Coronary artery disease
Chronic diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and high heart rate.
You were diagnosed with a post obstructive pneumonia as the
cause of your symptoms. With antibiotics your symptoms have
improved. You will need to continue these medications to
complete a full course.
**Please have Dr [**First Name (STitle) **] check a CBC (blood count) and Chem 10
(chemistries) at your visit with her this week.**
In addition, you were found to have a very high heart rate
called Atrial Fibrillation/Atrial Flutter. Even with high dose
medication your heart rate remained high. Cardiology
recommended changes to your medications which resulted in
improved heart rate.
Medication Changes:
CONTINUE Ciprofloxacin and Zosyn to complete a course through
[**2-19**]
START Diltiazem and Metoprolol for heart rate control. We have
also treated you with a medication called digoxin for your heart
rate; ask Dr [**Last Name (STitle) **] at your appointment tomorrow whether you
should continue this medication or whether you may discontinue
it now.
START Aspirin 81mg daily
Your other blood pressure medications (losartan) have been held.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Department: Cardiology- [**Hospital1 18**] [**Location (un) 620**]
Address: [**Street Address(2) 3001**] [**Location (un) 620**], MA
Phone: [**Telephone/Fax (1) 4105**]
Appointment: Monday [**2142-2-19**] 2:00pm
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: THURSDAY [**2142-2-22**] at 11:40 AM
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
|
[
"428.0",
"202.80",
"272.4",
"285.9",
"276.2",
"414.01",
"V43.64",
"427.31",
"311",
"428.32",
"162.3",
"715.90",
"E932.0",
"486",
"V15.82",
"V12.51",
"401.1",
"725",
"412",
"496",
"530.81",
"249.00",
"V45.82",
"427.32",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13231, 13276
|
7157, 10199
|
332, 349
|
13464, 13464
|
5089, 7134
|
14848, 15539
|
4349, 4444
|
10716, 13208
|
13297, 13443
|
10225, 10693
|
13614, 14271
|
4459, 4459
|
14291, 14825
|
281, 294
|
377, 2691
|
4473, 5070
|
13479, 13590
|
2713, 4037
|
4053, 4333
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,445
| 142,347
|
45252
|
Discharge summary
|
report
|
Admission Date: [**2143-3-6**] Discharge Date: [**2143-3-9**]
Service: MEDICINE
Allergies:
Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation and mechanical ventilation
Arterial Line placement
History of Present Illness:
* Pt intubated and with no accompanying family so below
information obtained from ED report and OMR review*
86 yr/o F with Hx of metastatic breast CA (lungs, skull bones),
DVT (on Fragmin via study protocol), HTN (on nifedipine) who
presented to clinic today for an appointment feeling acutely
SOB.
.
O2 sat found to be 60% on RA when EMS arrived. She was placed on
a NRB and found to be 77% with this on arrival to [**Hospital1 18**] ED.
Initial vitals showed HR 138 and SBP > 200. Pt found to have
bilateral rales, perioral cyanosis, 2+ pittle LE edema, and very
poor mental status unable to answer questions or discuss code
status. EKG was reported to have peaked T waves V1-V4 as well as
? j point elevationand LBBB (known LBBB in past). Cards fellow
thought T waves rate related and did bedside ECHO with normal EF
but hypokinesis in LAD distribution. Pt was given 40mg IV lasix,
750mg IV levofloxacin, and Nitro paste, and transiently put on
BiPAP but was believed to be fatiguing within 5 min so was
intubated with propofol in the ED. SBP fell to 80s with propofol
and intubation so pt received a 600cc bolus. ETT pulled back
from 25 to 23 in ED.
.
At time of transfer to CCU pt had put out 150cc urine and had
vitals showing HR 77, BP 125/73, O2 Sat 100% on CMV TV 500, RR
20, PEEP 5, FiO2 100%. Gas showed 7.32 / 52 / 100 / 28 with
PaO2/FiO2 100 but question that this gas was drawn at same time
as being intubated and without full effect of vent as repeat gas
on vent settings CMV TV 500, PEEP 5, RR 14, FiO2 100% showed
7.42 / 44 / 392 / 30.
.
LE swelling first noted by PCP [**Last Name (NamePattern4) **] [**1-25**] both by pt report that
Heme/Onc doctor told her she needed lasix and by exam in PCP
[**Name Initial (PRE) 3726**]. Started on 20mg PO lasix in Feburary. Heme/Onc note
reports leg swelling last year found to be DVT in [**2142-2-12**] and
has been on Dalteparin via [**Company 2860**] protocol since. This new
swelling is apparently different than past DVT swelling and had
raised question of cardiac congestive cause in ambulatory
setting.
.
Per brief discussion with HCP [**Name (NI) 4457**], pt is an avid musician and
plays the trumpet. Roughly 1 week ago patient started
complaining of trouble holding her air playing the trumpet which
had never been a problem before.
Past Medical History:
per OMR review
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])
PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]
Social History:
She lives alone in [**Location (un) 96700**] and is very active at
baseline. Ambulates independently. Spends Mon/Fri at the
cultural center, Tues playing trumpet in a band, and Weds/Thurs
running erands. Has 3 cars at home and drives. Retired
teacher. Never married and without children. Smoked 2ppd x
10-15 years until [**2094**], glass of wine <1x/week. No other drug
use.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None
Family History:
Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **].
Father died at 49 from coronary thrombosis.
Sister with [**Name2 (NI) 499**] cancer.
Another sister with pancreatic cancer.
Niece and nephew (in same family) both with [**Name (NI) 4278**].
She is last surviving relative.
Physical Exam:
Admission:
VS: T=afebrile BP=153/75 HR=76 RR=16 O2 sat=100% on 60% FiO2
GENERAL: Intubated and sedated. Opens eyes to command.
HEENT: NCAT. Sclera anicteric. PERRL, no pallor or cyanosis of
the oral mucosa.
NECK: Supple with mild JVP elevation roughly 10mmHg
CARDIAC: normal S1, S2. ? murmurs/extra heart sounds but
difficult to ascertain underneath ventilator sounds. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Crackles at lateral bases, course breath sounds anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive bowel
sounds
EXTREMITIES: 1+ LE edema, some redness in pre-tibial areas
bilaterally. Extremities warm and well perfused.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Discharge Exam:
Gen: alert, oriented, energetic, talkative
HEENT: supple, JVD at 12 cm
CV: RRR, no M/R/G
RESP:crackles bibasilar
ABD: soft, NT, ND
EXTR: 2+ pitting peripheral edema
NEURO: A/O
Extremeties: warm
Pulses:
Right: DP 1+ PT 1+
Left: DP 2+ PT 1+
Skin: intact
Pertinent Results:
Admission Labs:
[**2143-3-6**] 11:18AM BLOOD WBC-10.7 RBC-5.20 Hgb-14.2 Hct-44.9
MCV-86 MCH-27.2 MCHC-31.6 RDW-16.0* Plt Ct-543*
[**2143-3-6**] 11:18AM BLOOD Neuts-76.1* Lymphs-16.9* Monos-5.6
Eos-0.6 Baso-0.7
[**2143-3-7**] 03:32AM BLOOD PT-13.2 PTT-21.2* INR(PT)-1.1
[**2143-3-6**] 09:48PM BLOOD Glucose-113* UreaN-25* Creat-1.0 Na-139
K-3.5 Cl-97 HCO3-31 AnGap-15
[**2143-3-6**] 11:18AM BLOOD Glucose-173* UreaN-24* Creat-1.1 Na-139
K-5.5* Cl-98 HCO3-30 AnGap-17
[**2143-3-7**] 03:32AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.0
Cardiac:
[**2143-3-7**] 03:32AM BLOOD CK-MB-4 cTropnT-0.06*
[**2143-3-6**] 09:48PM BLOOD CK-MB-7 cTropnT-0.06*
[**2143-3-6**] 11:18AM BLOOD cTropnT-0.02*
[**2143-3-6**] 11:18AM BLOOD CK-MB-6 proBNP-1216*
ABGs:
[**2143-3-6**] 10:06PM BLOOD Type-ART pO2-124* pCO2-37 pH-7.51*
calTCO2-31* Base XS-6
[**2143-3-6**] 02:28PM BLOOD Type-ART Tidal V-400 PEEP-5 FiO2-100
pO2-392* pCO2-44 pH-7.42 calTCO2-30 Base XS-4 AADO2-292 REQ
O2-54 -ASSIST/CON Intubat-INTUBATED
[**2143-3-6**] 12:17PM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100
pO2-100 pCO2-52* pH-7.32* calTCO2-28 Base XS-0 AADO2-576 REQ
O2-93 -ASSIST/CON Intubat-INTUBATED
[**2143-3-6**] 10:06PM BLOOD Lactate-1.1
ECHO [**2143-3-6**]:
The left atrium is mildly dilated. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
distal septum and apex. The remaining segments contract normally
(LVEF = 50-55 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. No aortic regurgitation is seen. Cannot exclude
aortic stenosis. The mitral valve leaflets are moderately
thickened. There is severe mitral annular calcification. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Mild mitral regurgitation.
CTA Chest [**2143-3-6**]:
1. No evidence of pulmonary embolism.
2. Severe pulmonary edema, scattered subsegmental atelectasis,
and moderate bilateral pleural effusions, right greater than
left. It should be noted that processes such as pulmonary
hemorrhage can have a similar appearance. Given substantial
parenchymal abnormality, supervening consolidation or focal
lesion cannot be excluded.
CXR [**2143-3-7**]:
IMPRESSION: Interval redistribution of bilateral opacities from
upper to
lower zones. Overall mild improvement of now mild-to-moderate
pulmonary
edema. Endotracheal tube now in standard position.
Discharge Exam:
[**2143-3-9**] 08:55AM BLOOD WBC-9.0 RBC-4.30 Hgb-11.6* Hct-36.7
MCV-85 MCH-26.9* MCHC-31.6 RDW-16.0* Plt Ct-348
[**2143-3-9**] 08:55AM BLOOD Glucose-106* UreaN-29* Creat-0.9 Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
Brief Hospital Course:
Patient is an 86 yr old F with Hx of metastatic breast CA
(lungs, skull), DVT (completed course of Dalteparin (Fragmin)
via study protocol), HTN (on nifedipine) who presented to clinic
with acute SOB with CXR findings concerning for flash pulmonary
edema requring brief intubation with resolution of pulmonary
edema with diuresis.
# Pulmonary Edema: Patient had severe hypoxia at rest in clinic
and only mild improvement to high 70s with NRB. Initial ABG in
ED was likely falsely hypoxic as obtained at parallel time with
intubation and repeat gas 90min later with no sig change in vent
settings much improved an no longer with PaO2/FiO2 consistent
with ARDS. Presumed cause of hypoxia was flash pulm edema
although unclear what baseline lung function is with prior
documentation of lung mets. Patient received 1 dose of
levofloxacin in the ED. CT read confirms that lung findings most
likely due to severe pulmonary edema. She was intubated in the
ED and was extubated the next morning after she was net negative
2.5 L with diuresis with iv lasix. Pt given additional doses of
IV diuresis for further diuresis on [**3-7**] and [**3-8**] and then
discharged on 20mg of PO lasix to be uptitrated as needed as an
outpatient. At time of discharge pt was able to ambulate without
RA oxygenation falling to less than 92% on RA.
# CORONARIES: No history of coronary disease. Only has HTN
documented as RF although no recent lipid panels/A1C and last
A1C in [**2140**] was mildly elevated at 6.4. There is evidence of
coronary disease on chest CTA. Bedside ECHO in ER showed some
question of hypokinesis in LAD distribution consistent with CAD
but EKG without signs of active ischemia and biomarkers negative
x 2. Initially was started on a heparin gtt as thought that pt
still therapeutically anticoagulated as an outpatient. After pt
extubated the next day and able to report that no longer taking
therapeutic anticoagulation she was switched to sub-Q heparin.
No need for cardiac catheterization as did not appear that
presentation due to acute ischemic event.
# PUMP: Preserved LVEF ECHO with some mild regional dysfunction
with hypokinesis of distal septum and apex. CXR showed signs of
acute pulm edema likely related to hypertension.
# RHYTHM: Was initially in sinus tach in 130s but after initial
interventions in ER her HR decreased down into 70s.
# HTN: BPs in last few months have been documented in 130-140s
systolic with diastolics in 60-70s. Pt had significantly
elevated pressures on presentation with Sys BP >200 but came
down to 130s with lasix, nitro paste, and intubation/sedation.
She is only on nifedipine at home for BP control and was
recently placed on low-dose lasix for LE edema more than BP. In
the CCU her blood pressure was well controlled. Her nifedipine
was intitially held and the next day she was started on
lisinopril and carvedilol and nifedipine stopped. She was
discharged home on carvedilol uptitrated to 6.25mg [**Hospital1 **] and
lisinopril uptitrated to 10mg daily at time of discharge.
# Breast Ca: Patient has known mets to both skull bones and
lungs although documentation of lung mets not noted in our
imaging as no chest imaging present. She is on Tamoxifen and
Fluoxymesterone as outpt through [**Company 2860**] and seems to be fairly
stable per PCP [**Name Initial (PRE) 12883**]. Unclear if has home O2 reqirement with
lung mets. Head CT showed no evidence of intra-cranial bleed or
intra-cranial mets. Her outpatient Fluoxymesterone was
non-formulary and unavailable and was not given this
hospitalization.
# DVT Hx: Hx DVT last year in setting of known malignancy and
multiple past ortho proceedures. Was on Fragmin as outpt via
study protocol at [**Company 2860**] and has completed a 12 month course. She
was initially on heparin drip which was stopped when CTA showed
no evidence of PE. She was then maintained on heparin subQ for
DVT prophylaxis.
Medications on Admission:
- Dalteparin (Fragmin) (dosed at [**Company 2860**] as part of study protocol)
- Fluoxymesterone [Androxy] 10mg [**Hospital1 **]
- Furosemide 20mg daily ([**2143-2-1**])
- Nifedipine ER 60mg daily
- Omperazole 20mg daily
- Oxycodone-Acetaminophen 5mg-325mg QID PRN
- ASA 325mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. fluoxymesterone 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
8. Roxicet 5-325 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Hypertension
Metastatic Breat Cancer
Osteoarthritis
Left Shoulder pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your blood pressure was very high and you developed acute
diastolic congestive heart failure with fluid in your lungs. You
will need to change your blood pressure medicines to prevent
this from happening again. We increased your blood pressure
medications to bring your blood pressure into a good range. We
gave you diuretics to get rid of the extra fluid and your dose
of this diuretic (lasix) may need to be increased by your
outpatient doctors if [**Name5 (PTitle) **] continue to retain extra fluid. Please
weigh yourself every morning, call Dr. [**Last Name (STitle) 2204**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the follwoing changes in your medicines:
1. Stop taking nifedipine
2. Decrease aspirin to 81 mg daily
3. Start taking Lisinopril 10mg by mouth at bedtime to lower
your blood pressure
4. Start taking Carvedilol 6.25mg twice a day to lower your
blood pressure and heart rate
5. Continue taking Lasix 20mg by mouth daily. This dose may need
to be increased to 40mg daily if your doctors [**Name5 (PTitle) **] that [**Name5 (PTitle) **]
are still retaining fluid.
6. Continue taking your other home medications
Followup Instructions:
If you continue to retain extra fluid, you may need to have your
dose of lasix increased by one of your outpatient doctors.
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: You will be called by the office regarding your
appointment for 1-2 weeks after your discharge. If you have not
heard from the office in 2 business days, please call the number
listed below.
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**]
When: Wednesday [**2143-3-13**] at 10 AM
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 2205**]
|
[
"197.0",
"428.0",
"428.33",
"V10.05",
"V16.0",
"V10.3",
"401.9",
"719.41",
"V43.65",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
13427, 13485
|
8440, 12345
|
311, 388
|
13652, 13652
|
5638, 5638
|
14990, 16031
|
4292, 4588
|
12678, 13404
|
13506, 13631
|
12371, 12655
|
13803, 14967
|
4603, 5349
|
2844, 2917
|
8204, 8417
|
252, 273
|
416, 2719
|
5654, 8188
|
13667, 13779
|
2948, 3790
|
2741, 2824
|
3806, 4276
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,759
| 111,657
|
22344
|
Discharge summary
|
report
|
Admission Date: [**2193-8-10**] Discharge Date: [**2193-8-21**]
Date of Birth: [**2114-12-22**] Sex: M
Service: NMED
Allergies:
Azithromycin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
tx from outside hospital with right frontal lobe hemmorhage
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 78 year old man with a history of CAD s/p MI in
[**2168**], ?seizure in [**2181**], and depression now presenting from an
outside hospital with a large right frontal hemorrhage. As per
the patient's daughter, the patient had a sudden drooping of the
left side of his face and difficulty speaking (she was on the
phone with her mother, who was telling her of these symptoms).
He
was taken to an outside hospital, where a large right frontal
hemorrhage was uncovered on CT scan and was transferred to [**Hospital1 18**]
for further management. In the ED, the patient was evaluated
and
admitted to the NICU service. While on this service the patient
had his blood pressure kept below 140 systolic with largely po
metoprolol. He was started on seizure prophylaxis with
phenytoin.
He currently denies any headache, chest pain, shortness of
breath, or dizziness.
Past Medical History:
-CAD s/p MI in [**2168**]
-emphysema
-major depression
-? of seizure in [**2181**]
-s/p left leg dermatofibrosarcoma resection plus radiation in
[**2176**]
-cholecystectomy in [**2180**]
-s/p pacer
-s/p cystourethotomy
Social History:
-Lives with wife
-Former [**Name2 (NI) 1818**]
-No recent ETOH use
Family History:
Non-contributory
Physical Exam:
Vitals: 98.4 130/45 60 25 98% room air
General: elderly man in no acute distress
Neck: supple, no carotid bruits
Lungs: wheezing heard anteriorly
CV: Regular rate and rhythm, faint s1, s2
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema, faint dp pulses
Neurologic Examination:
Mental Status: lethargic but arousable with loud voice, will
answer questions when pressed, will not open eyes
Oriented to person, but not place, month or president (thought
it
was [**2173**] and he was at home)
Attention: Can spell "world" forward but only 2 letters backward
Language: not fluent Fund of knowledge normal
[**Location (un) **] and writing deferred due to inattention
Cranial Nerves: unable to test visual fields. Pupils equally
round and reactive to light, 5 to 2 mm bilaterally. Extraocular
movements not assessable; prominent left sided facial droop
Hearing intact to finger rub bilaterally. Tongue midline, no
fasciculations
Motor:
decreased bulk noted in calves; tone increased on right
No tremor; unable to asses power, secondary to inattentiveness
Sensory exam not reliable; withdraws all extremities to pain
Reflexes: B T Br Pa Pl
Right 1 1 0 1 0
Left 1 1 0 1 0
Grasp reflex absent
Toe upgoing on left; down on right
Coordination not tested due to inattentiveness
Gait not tested
Pertinent Results:
Cbc: 15.4/34.9/147
Chem: 143/3.6 108/27 27/1.1 102
LFTs: AST:24 ALT:29 AP:127 TB: 0.8
CK: 185
C/M/P: 8.9/2.0/1.5
Cxr: no evidence of pna
Head Ct: large right frontal parenchymal hemmorhage
Brief Hospital Course:
Mr. [**Known lastname 30476**] is a 78 year-old man with a history significant for
CAD, s/p pacer, depression, baseline dementia, and skin cancer
of nose who presented on [**2193-8-10**] with a left facial droop,
drooling, and left sided weakness. Subsequent CT scan at
[**Hospital3 **] showed right frontal lobe hemorrhage. He
was transferred to [**Hospital1 18**] ED, then admitted to the NICU service.
On presentation, he denied headache, nausea, vomiting, visual
changes, numbness, dizziness, shortness of breath, chest pain,
abdominal pain. Wife noted no changes in balance, gait, tremor,
shaking, or seizure. He has had a 50lb. weight loss over a year
and has is on pureed diet at baseline. On [**8-10**], patient ruled
out for MI. Repeat CT confirmed presence of 4.5 x 3.5 x 8.0 cm
right frontal intraparenchymal hemorrhage. CTA showed no
evidence of abnormal vascular structures to indicate AVM. EKG
demonstrated A- and V- paced 60bpm, TWI avL, LAD. Repeat CT on
[**8-12**] no change in hemorrhage or edema and no mass effect.
Management has included BP control with metoprolol, seizure
prophylaxis with phenytoin, and treatment for suspected UTI with
SMX-TMP. UA/urine culture was negative for bacteria and yeast.
Blood cultures drawn on [**8-11**] are still pending. Sputum from
[**8-11**] was positive for coag+ staph. aureus. Pulmonary status
was initially managed with albulterol, fluticasone, and
ipratropium. Psych status was managed with olanzapine,
citalopram, and mirtazapine. During hospital course, patient
developed lethargy, fluctuant delirium, and mild dysarthria,
concurrent with pulmonary congestion suspicious for pneumonia.
CXR on [**8-13**] confirmed the presence of left lower lobe
infiltrate, and patient was treated with levofloxacin and
metronidazole with clinical improvement -- decreased lethargy,
improved mental status, and improved pulmonary exam with, at
present, mild rhonchi bilaterally. Repeat CXR on [**8-14**] showed
apparent interval improvement in LLL consolidation. Due to
nutritional concerns, patient was fed via NG tube plus
supplemental phosphate,
with multiple swallow studies before switching to PO diet.
While on NG tube, patient was on level II restraints to maintain
tube placement. Presently, neurologic exam has improved
slightly, with decreased lethargy and improved mental status
when awake. Mild left facial droop and left-sided weakness
persist. With improved mental status, stable neuro exam,
resolving pneumonia with antibiotics. He failed a swallow exam
on [**8-19**] for the 3rd time so the decision was made to place a GJ
tube for continued nutrition. He is now calm, not on
restraints, alert and ready for rehab.
Medications on Admission:
-mvi
-baby asa
-zocor 40 qd
-metoprolol 75/25
-vit. e and d
-albuterol
-atrovent
-celexa
-azmacort inh
-remeron 7.5 qhs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO QD
(once a day).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
7. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Phenytoin 100 mg/4 mL Suspension Sig: Three Hundred (300) mg
PO Q24H (every 24 hours).
13. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) grams
Injection Q6H (every 6 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. hemorrhagic stroke
2. pna
Discharge Condition:
Stable, alert, following simple commands
Discharge Instructions:
Please cont. oxacillin for 10 more days.
Patient will need physical and occupational rehab
Patient will need tube feedings
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 4 weeks or
as needed.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2193-8-21**]
|
[
"780.39",
"496",
"401.9",
"599.0",
"296.20",
"V45.02",
"431",
"482.49",
"V10.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"46.32"
] |
icd9pcs
|
[
[
[]
]
] |
7305, 7385
|
3208, 5911
|
329, 336
|
7457, 7499
|
2985, 3131
|
7670, 7896
|
1589, 1608
|
6082, 7282
|
7406, 7436
|
5937, 6059
|
7523, 7647
|
1623, 1913
|
230, 291
|
364, 1245
|
2339, 2966
|
3140, 3185
|
1952, 2323
|
1937, 1937
|
1267, 1488
|
1504, 1573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,677
| 185,866
|
3063
|
Discharge summary
|
report
|
Admission Date: [**2142-7-16**] Discharge Date: [**2142-7-27**]
Date of Birth: [**2080-12-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
s/p fall and right knee pain.
Major Surgical or Invasive Procedure:
Right above-knee amputation
History of Present Illness:
61 yo russian man s/p R BKA [**2142-6-27**], IDDM with complications,
PVD, and recent right CFA-AKpop bpg w/arm vein p/w mechanical
fall from side of bed in setting of bed not being locked and
sensation of vertigo which the patient gets after each meal.
Patient reports 10 seconds of either LOC or confusion as to what
occurred which quickly resolved. Patient states occasional when
sitting or standing very fast he will get dizzy, but this is not
a common occurance. Patient noted s/p fall to have increased
stump pain, bloody drainage from lateral aspect of the stump.
Patient transferred to [**Hospital1 18**] ED due to concern for trauma to
recent R BKA. Of note, patient started on Bactrim for increased
erythema at site of R BKA [**7-11**] with good effect per [**Hospital 8220**] Center notes. Patient states since stitch removal 5 days
ago he has had pain right lateral side of the R BKA.
.
Patient states that for the past 5 days he has experinces
transient vertigo (room is spinning horizontally) after his
meals. He reports that this sensation resolves with rest or with
passing gas. He reports no other associated deficits.
.
In ED, vitals 98.2, HR 66, BP 120/59, RR 16, 99% RA. Patient
found to have tender R BKA site. Patient given 1 percocet, 1L
NS. Vascular sugery was consulted and given WBC with left shift
recommended falgyl 500 mg IV, cipro 400 mg IV and vancomycin 1
gm IV which were given in ED. Right lower extremtity films
demonstration no trauma at site of BKA. Neurology evaluated the
patient for "syncope" and felt it was not consistent with a
vascular event. Suggested investigation for infection, careful
BG monitoring. Patient admitted to medicine for syncopy work-up
with vascular surgery following regarding R BKA.
.
ROS: patient denies chest pain, shortness of breath, fevers,
chills, nausea, vomiting, dysuria, difficultly with urination,
increased frequency of urination, constipation,
numbness/tingling in arms/legs. + dry non-productive cough * 1
week. + belching, denies otehr reflux sxs including epigastric
pain or burning.
Past Medical History:
DMI x 50 yrs (retinopathy, neuropathy) [**12-7**] HgBA1C 5.7%
PVD see surgeries below
Hypertension
Hypercholesterolemia
PUD
CKD Cr 1.5-1.8
BPH
.
PSH: s/p R Fem-[**Doctor Last Name **] with svg (in LA [**2126**]), S/p left fem-[**Doctor Last Name **] with
[**Doctor Last Name 4726**]-TEX 97, re do left profunda-PT with in situ vein by Dr.
[**Last Name (STitle) 1391**] [**2133**]. s/p RLE angiography [**2142-6-18**], right CFA-AKpop bpg
with arm vein [**2142-6-21**], Right BKA [**2142-6-27**]
Social History:
Pt. has been in the US for 12 years, worked in computer industry
before becoming disabled. Pt. lives alone but has son and son's
family very nearby. Patient does not smoke, drink alcohol, or
use illicits
Family History:
Significant for DM
Physical Exam:
General: NAD
HEENT: PERRL, EOMI, OP clear, MMdry
Neck: no LAD, supple, JVP of 7cm
Heart: RRR II/VI SEM to carotids
Lungs: CTAB no wheezes, crackles, rhochi
Abd: +BS, NTND, soft
Ext: right extremity AKA with staples in place. left leg 2+ DP,
callouses left heel and great toe pad, but no lesions.
Pertinent Results:
[**2142-7-26**] 05:50AM BLOOD WBC-7.2 RBC-3.00* Hgb-9.1* Hct-27.1*
MCV-91 MCH-30.5 MCHC-33.7 RDW-13.4 Plt Ct-430
[**2142-7-25**] 05:40AM BLOOD WBC-11.0 RBC-3.22* Hgb-9.6* Hct-29.5*
MCV-92 MCH-29.8 MCHC-32.6 RDW-13.5 Plt Ct-435
[**2142-7-24**] 12:18PM BLOOD WBC-8.7 RBC-3.05* Hgb-9.1* Hct-27.8*
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.3 Plt Ct-340
[**2142-7-24**] 05:50AM BLOOD WBC-8.4 RBC-2.68* Hgb-8.1* Hct-24.7*
MCV-92 MCH-30.3 MCHC-32.9 RDW-13.2 Plt Ct-402
[**2142-7-23**] 06:40AM BLOOD WBC-7.6 RBC-2.75* Hgb-8.0* Hct-25.1*
MCV-91 MCH-29.1 MCHC-31.8 RDW-13.2 Plt Ct-381
[**2142-7-24**] 05:50AM BLOOD Neuts-85.4* Lymphs-9.9* Monos-3.1 Eos-1.5
Baso-0.2
[**2142-7-19**] 06:55AM BLOOD Neuts-89.7* Bands-0 Lymphs-5.8* Monos-4.1
Eos-0.4 Baso-0.1
[**2142-7-26**] 05:50AM BLOOD Plt Ct-430
[**2142-7-25**] 05:40AM BLOOD Plt Ct-435
[**2142-7-24**] 12:18PM BLOOD Plt Ct-340
[**2142-7-24**] 05:50AM BLOOD Plt Ct-402
[**2142-7-24**] 05:50AM BLOOD PT-13.8* PTT-32.9 INR(PT)-1.2*
[**2142-7-23**] 11:05AM BLOOD PT-13.8* PTT-27.2 INR(PT)-1.2*
[**2142-7-23**] 06:40AM BLOOD Plt Ct-381
[**2142-7-26**] 05:50AM BLOOD Glucose-171* UreaN-30* Creat-1.3* Na-130*
K-3.9 Cl-98 HCO3-22 AnGap-14
[**2142-7-25**] 05:40AM BLOOD Glucose-176* UreaN-30* Creat-1.2 Na-135
K-4.3 Cl-100 HCO3-20* AnGap-19
[**2142-7-24**] 12:18PM BLOOD Glucose-322* UreaN-34* Creat-1.4* Na-130*
K-3.9 Cl-97 HCO3-17* AnGap-20
[**2142-7-24**] 05:50AM BLOOD Glucose-227* UreaN-31* Creat-1.4* Na-132*
K-4.2 Cl-97 HCO3-21* AnGap-18
[**2142-7-23**] 06:40AM BLOOD Glucose-162* UreaN-32* Creat-1.5* Na-135
K-3.8 Cl-100 HCO3-25 AnGap-14
[**2142-7-26**] 05:50AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
[**2142-7-25**] 05:40AM BLOOD Calcium-7.7* Phos-2.7 Mg-2.0
[**2142-7-24**] 12:18PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.0
[**2142-7-24**] 05:50AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
[**2142-7-23**] 06:40AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.4
Brief Hospital Course:
61 y/o vasculopath with recent R BKA, mechanical fall p/w
?syncope and increased R BKA pain. He is now s/p R AKA.
.
# R BKA: The patient is s/p recent trauma from fall with lateral
wound. WBC [**12-12**] since [**Month (only) 116**]. No fever. He had infection of the
stump site requiring IV antibiotics with vancomycin and zosyn.
His wound culture grew proteus mirabilis sensitive to zosyn. He
continued to spike fevers through this regimen and eventually
required a revision of his BKA to AKA by vascular surgery which
was performed on [**7-24**].
.
# Syncope: It is unclear whether or not the patient had syncope.
He had no ECG changes. Symptoms limited to post-prandial, ?
cerebellar-basilar insufficiency with blood shunt to gut s/p
meals, hyper/hypoglycemia, arrythmia. ECHO was normal. Per
neuro, likely peripheral vestibulopathy. He should be referred
for outpatient vestibular physical therapy at discharge.
.
# DMI x 50 yrs (retinopathy, neuropathy) [**12-7**] HgBA1C 5.7%. His
BG was poorly controlled in the setting of stump infection, and
he required a short ICU stay for DKA. His AG peaked at 18 and
stabilized around 12 to 13. [**Last Name (un) **] followed during his stay and
titrated his standing and sliding scale insulin prn.
.
# [**Last Name (un) **] on CKD: Patient admitted with increase in creatinine to
2.4 on [**7-16**] with unclear precipitate. He was slightly dry on
exam with a gap acidosis which may be due to [**Last Name (un) **]. His HCTZ and
enalapril were initially held. His enalapril was added back in
on [**2142-7-22**] as his creatinine improved. His HCTZ was held at
time of transfer to vascular surgery.
.
# PVD: We continued his aspirin. Amputation managed per vascular
surgery as above.
.
# Hypertension: We continued atenolol. Enalapril originally held
due to increase in creatinine but restarted when creatinine
returned to baseline.
.
# Hypercholesterolemia: Continued simvastatin.
.
# PUD: Continued PPI.
.
# Anemia: His baseline HCT is 25-30, likely a combination anemia
of chronic disease and blood loss with recent BKA. Iron studies
unclear as iron low but ferritin not low. Likely some iron
deficiency and anemia of chronic inflammation. Stable.
.
# BPH: Continued tamzulosin nightly.
.
# FEN/GI - diabetic, cardiac diet, electrolyte repletion prn
# PPx - hep sc, ppi, bowel regimen
# Code - full
# Dispo - pending work-up
# Communication - with patient
Medications on Admission:
Atenolol 50 mg [**Hospital1 **]
Enalapril 10 mg daily ([**Hospital1 **] on outpatient medications)
HCTZ 25 mg daily
Insulin -- Glargine 30 units 5pm, HISS
Simvastatin 20 mg daily
Cyanocobalamin 1,000 mcg daily
Folic Acid 1 mg daily
Vit D3 400 units daily
Tamsulosin 0.4 mg qhs
Aspirin 325 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Heparin 5000 units TID sc
.
Lactobacillus 2 tabs po daily * 14 days, started [**7-11**]
Bactrim DS [**Hospital1 **] * 14 days, started [**7-11**]
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
14. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) Units
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: One (1) U Subcutaneous
QIDACHS: as per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center-[**Location (un) **]
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis, resolved
Right below-knee amputation stump infection, s/p right
above-knee amputation
Acute on chronic renal insufficiency, resolved
.
Secondary:
DMI x 50 yrs (retinopathy, neuropathy) [**12-7**] HgBA1C 5.7%
PVD see surgeries below
Hypertension
Hypercholesterolemia
PUD
CKD Cr 1.5-1.8
BPH
Discharge Condition:
Good
Discharge Instructions:
You were seen at [**Hospital1 18**] for an infection at your amputation site.
You suffered a diabetic complication of this infection, for
which you needed a short stay in an ICU. You underwent a
revision of your amputation on [**2142-7-24**].
It is not clear that you passed out but you might have a problem
with equilibrium that can be addressed by vestibular physical
therapy.
.
Please follow-up as below.
.
Please take your medications as prescribed.
.
You should call your primary care provider or return to the
emergency department if you experience worsening pain at your
amputation site, fevers/chills greater than 101.4 degrees F,
fatigue, lightheadedness, increased urination, increased thirst,
or any other symptoms that concern you.
Followup Instructions:
Please follow up with your primary physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **],
within 2 weeks of discharge. Call [**Telephone/Fax (1) 9347**] to make an
appointment.
Please follow up with Dr. [**Last Name (STitle) 1391**] in 3 weeks. Call his office
at ([**Telephone/Fax (1) 14585**] to make an appointment
Completed by:[**2142-7-27**]
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40,033
| 136,285
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53879
|
Discharge summary
|
report
|
Admission Date: [**2143-5-15**] Discharge Date: [**2143-6-5**]
Date of Birth: [**2103-2-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
abdominal pain/distension
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
40M w/PMHx EtOH cirrhosis who was admitted to [**Hospital1 2025**] from [**4-21**] to
[**5-6**] for abdominal discomfort & found to have peritoneal TB, now
presents w/abdominal pain ongoing since [**Hospital1 2025**] discharge,
increasing jaundice, and TB-med noncompliance.
Pt unable to provide much medical history to the ED or to [**Hospital **]
medical staff. Does report ongoing diffuse abdominal pain,
bloating and poor appetitite since going home from [**Hospital1 2025**] last
week. Unsure why he was admitted to [**Hospital1 2025**] and doesn't think they
helping him. He was discharged with some medications he can't
remember (later found to be INH, ethambutol, moxifloxacin per
[**Hospital1 2025**] records) which he took for 3-4 days, then stopped taking
them 4 days ago because a family member who works in healthcare
felt he didn't need them because he doesn't have TB. There was
concern at home that the meds might be worsening his jaundice.
Denies jaundice before the past month. Unaware of liver disease
previously, unaware of cause of liver disease at this time. Had
not previously seen a PCP. [**Name10 (NameIs) **] drinking alcohol completely
at time of [**Hospital1 2025**] admission, but previously drank 8-10 beers/day
for at least 10 years and was binging immediately prior to that
admission.
In the ED today, initial VS 99.8 110 97/56 16 100%. Exam
revealed jaundice with distended, tender abdomen. Labs revealed
hyponatremia to 122, hyperkalemia to 6.1 (nonhemolyzed), WBC
23.5, Hct 30, lactate 2.2, and Cr 2.5. LFTs showed Tbili of 13.
(No prior labs in our system.) Diagnostic paracentesis in the ED
was cloudy & blood, w/400 WBC (29%neutrophils 36%lymphocytes
35%macrophages). Given 1 L NS, ceftriaxone 2gm for suspected SBP
(before peritoneal fluid diff returned) and kayexelate for K
6.9. Urine cultures sent but no blood cultures. Did receive an
amp calcium gluconate, dextrose, and insulin for hyperkalemia.
Hepatology was consulted & recommended albumin 100gm and
admission to [**Hospital Ward Name 121**] 10; however the ED felt he was more
appropriate for an ICU bed. On transfer, vitals were T99 HR103
113/55 20 98%RA.
.
After interviewing the pt we were contact[**Name (NI) **] by the [**State 350**]
DPH who alerted us to his active TB and provided contact info
for [**Name (NI) 2025**] ID specialist [**Name (NI) 794**] [**Last Name (NamePattern1) 110525**] who has been caring for him
over the past week.
Additional from Dr. [**Last Name (STitle) 110525**] and faxed [**Hospital1 2025**] records show he was
admitted there in early [**2143-4-14**] for abdominal discomfort,
increasing girth, pain. Found to have advanced EtOH cirrhosis
w/admission tbili 5.8. Extensive workup showed abdominal
discomfort likely a result of previously-undiagnosed tuberculous
peritonitis. Peritoneal fluid showed lymphocytic peritonitis,
bacterial and AFB cultures negative. CT Abd/Pelvis findings
raised concern for peritoneal TB, so he had surgical laparotomy
for omental and peritoneal biopsies which showed granulomatous
infiltration, giant cells concerning for TB. No cough, and chest
imaging not suggestive of pulmonary TB so [**Hospital1 2025**] did not get
induced sputums. Since clinical concern was very high for
peritoneal TB, they initiated TB treatment
w/INH-rifampin-ethambutol for planned 6 month course. LFTs rose
further, to tbili max 10.8, so rifampin was exchanged for
moxifloxacin.
In addition, all abdominal imaging at [**Hospital1 2025**] (MR, CT, US) showed
nodular cirrhotic liver and ascites. Abdominal CT also showed
3.7 cm lesion in liver concerning for cholangiocarcinoma (CA19-9
66 (normal 0-36)) but IR-guided biopsy was nondiagnostic. GI
consult performed an EGD which showed grade I varices and
gastritis, no active bleeding.
Pt was discharged home the same day antibiotics were changed as
pt was desperate to leave hospital & agreed to DOT at home.
Daily labs by DOT VNA on [**5-7**] showed mildly increasing
LFTs, tbili 10.1->10.8 alkphos 173 ALT 29 AST 78. Plan was to
continue current regimen (INH, moxifloxacin, ethambutol) until
clear evidence of worsening LFTs. DPH DOT nurses stopped
following over weekend and when they were able to contact him
again yesterday, were told by patient/family that they did *not*
want to take TB meds and did not believe he had a TB infection
because they heard his CXR was clear.
Past Medical History:
Alcoholic Liver Disease (diagnosed [**2143-4-14**])
Tuberculous Peritonitis (diagnosed [**2143-4-14**])
Social History:
Drinks 8-10 beers/day for years, stopped 3-4 years ago. Never a
smoker. Originally from [**Location (un) **], emigrated to the US ~10y ago. No
hx blood transfusions, IVDU or incarceration. Currently
unemployed, previously worked in kitchen at [**Last Name (un) **] Hotel. Office
worker in [**Location (un) **] before emigration.
Family History:
Mother HL, HTN
Father DM
One sister w/liver disease, etiology unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T 98.1 HR 114 BP 105/55 RR 95%/RA
GEN: thin, fatigued, jaundiced young man lying in bed NAD,
speaks softly with brevity
HEENT: NCAT sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1/S2, no mrg
Lungs: clear no r/r/w
ABD: soft, distended, diffusely tender to focal palpation
throughout abdominal. shifting dullness without bulging flanks.
liver edge nonpalpable, no abdominal bruits. dry blood-soaked
dressing over umbilicus removed, horizontal 2 cm peri-umbilical
laparotomy scar visible, not healed but nonerythematous, no
exudate or active bleeding visualized
Ext: WWP, 2+ pulses, trace edema
Neuro: CNII-XII intact, 4/5 strength all extremities, gait
deferred, no asterixis
.
DISCHARGE PHYSICAL EXAM:
GEN: thin, jaundice, in no distress
HEENT:, +scleral and subungual icterus, OP otherwise clear, EOMI
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased breath sounds at bases bilaterally
CV: Tachycardic, regular rhythm, normal S1/S2, no MRG
ABD: distended but still soft, normoactive bowel sounds.
Dullness to percussion at flanks, + horizontal 2 cm
peri-umbilical laparotomy scar visible, no exudate or active
bleeding visualized
GU: no foley
EXTR: WWP, 2+ pulses, 3+ LE edema b/l up to prox thigh
NEURO: CNII-XII intact, 4/5 strength all extremities, gait
deferred, no asterixis
SKIN- non palpable elongated red rash following a blood vessel
appearance
Pertinent Results:
ADMISSION LABS:
[**2143-5-15**] 11:50AM BLOOD WBC-23.5* RBC-3.06* Hgb-10.1* Hct-30.6*
MCV-100* MCH-33.0* MCHC-33.0 RDW-15.8* Plt Ct-410
[**2143-5-15**] 11:50AM BLOOD Neuts-86* Bands-0 Lymphs-2* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2143-5-15**] 11:50AM BLOOD PT-24.4* PTT-46.9* INR(PT)-2.3*
[**2143-5-15**] 11:50AM BLOOD Glucose-85 UreaN-51* Creat-2.5* Na-122*
K-6.1* Cl-89* HCO3-21* AnGap-18
[**2143-5-15**] 11:50AM BLOOD ALT-32 AST-69* AlkPhos-139* TotBili-13.1*
[**2143-5-15**] 11:50AM BLOOD Lipase-76*
[**2143-5-15**] 11:50AM BLOOD Albumin-2.5* Calcium-7.7* Phos-6.5*
Mg-2.6
[**2143-5-15**] 12:08PM BLOOD Lactate-2.2*
[**2143-5-15**] 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
URINALYSIS
[**2143-5-15**] 01:00PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2143-5-15**] 01:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-5.0 Leuks-NEG
[**2143-5-15**] 01:00PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
[**2143-5-15**] 01:00PM URINE CastHy-10*
[**2143-5-15**] 01:00PM URINE Hours-RANDOM Creat-137 Na-<10 K-57 Cl-<10
[**2143-5-15**] 06:00PM URINE Osmolal-400
.
PARACENTESIS
[**2143-5-15**] 12:29PM ASCITES WBC-400* RBC-[**Numeric Identifier 79389**]* Polys-29*
Lymphs-36* Monos-0 Macroph-35*
[**2143-5-15**] 12:29PM ASCITES TotPro-3.0 Glucose-69 Albumin-1.2
[**2143-5-22**] 04:30PM ASCITES WBC-1500* RBC-[**Numeric Identifier 27589**]* Polys-57*
Lymphs-0 Monos-42* Eos-1*
[**2143-5-22**] 04:30PM ASCITES TotPro-4.5 Glucose-4 LD(LDH)-1581
Albumin-2.0
.
DISCHARGE LABS:
[**2143-6-5**] 05:50AM BLOOD WBC-13.9* RBC-2.19* Hgb-7.1* Hct-22.7*
MCV-104* MCH-32.7* MCHC-31.5 RDW-20.1* Plt Ct-221
[**2143-6-5**] 05:50AM BLOOD PT-21.2* INR(PT)-2.0*
[**2143-6-5**] 05:50AM BLOOD Glucose-90 UreaN-67* Creat-1.5* Na-139
K-4.3 Cl-101 HCO3-23 AnGap-19
[**2143-6-5**] 05:50AM BLOOD ALT-24 AST-78* AlkPhos-96 TotBili-7.0*
[**2143-6-2**] 07:50AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9
[**2143-5-15**] 10:41PM BLOOD Hapto-107
[**2143-6-5**] 06:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2143-6-5**] 06:56AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2143-6-5**] 06:56AM URINE RBC-6* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
[**2143-5-18**] 03:49PM URINE CastHy-30*
MICRO
GRAM STAIN (Final [**2143-5-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2143-5-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2143-5-21**]): NO GROWTH.
URINE CULTURE (Final [**2143-5-17**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
MRSA SCREEN (Final [**2143-5-18**]): No MRSA isolated.
**FINAL REPORT [**2143-5-21**]**
Blood Culture, Routine (Final [**2143-5-21**]): NO GROWTH
**FINAL REPORT [**2143-5-21**]**
Blood Culture, Routine (Final [**2143-5-21**]): NO GROWTH.
[**2143-5-16**] 8:30 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2143-5-17**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
RAPID PLASMA REAGIN TEST (Final [**2143-5-17**]):
NONREACTIVE.
**FINAL REPORT [**2143-5-17**]**
CMV IgG ANTIBODY (Final [**2143-5-17**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
56 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2143-5-17**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
[**2143-5-16**] 6:41 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2143-5-17**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
URINE CULTURE (Final [**2143-5-20**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2143-5-21**] 2:10 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2143-5-22**]**
C. difficile DNA amplification assay (Final [**2143-5-22**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
[**2143-5-22**] 12:40 pm BLOOD CULTURE
**FINAL REPORT [**2143-5-28**]**
Blood Culture, Routine (Final [**2143-5-28**]): NO GROWTH.
[**2143-5-22**] 4:30 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2143-5-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2143-5-25**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2143-5-28**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2143-5-23**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2143-5-22**] 4:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2143-5-22**] 4:45 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT [**2143-5-28**]**
Blood Culture, Routine (Final [**2143-5-28**]): NO GROWTH.
URINE CULTURE (Final [**2143-5-23**]): NO GROWTH.
URINE CULTURE (Final [**2143-5-24**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
.
IMAGING
[**5-15**] RUQ US
FINDINGS: The liver is heterogeneous and nodular consistent with
cirrhosis.
No focal liver lesions are identified. The portal vein is patent
with
reversal of flow, suggesting portal hypertension. There is trace
perihepatic ascites. The gallbladder is nondistended. The wall
is mildly thickened, likely due to abdominal ascites. There is
sludge within the gallbladder.
There is no evidence of cholecystitis. The pancreas is not well
evaluated due to overlying bowel gas. The spleen is borderline
enlarged and measures 12.4 cm.
There are small bilateral pleural effusions.
The kidneys are unremarkable without renal stones, masses, or
hydronephrosis.
The left kidney measures 12.7 cm. The right kidney measures 13.2
cm.
There is a large amount of hypoechoic complex fluid within the
mid abdomen
extending into the bilateral lower quadrants, more so on the
left than the
right. There is also complex hypoechoic fluid in [**Location (un) 6813**]
pouch. There is no increased vascularity. These findings are
most consistent with hemorrhagic or infected ascites.
IMPRESSION:
1. Cirrhotic liver without focal masses.
2. Patent portal vein with reversal of flow, suggesting portal
hypertension.
3. Complex fluid within the abdomen may be hemorrhagic or
infected ascites.
4. Sludge within the gallbladder, but no evidence of acute
cholecystitis.
.
[**5-15**] CXR
FINDINGS: Frontal and lateral views of the chest were obtained.
There are
relatively low lung volumes. Bibasilar opacities are seen which
in
combination with recent ultrasound are likely due to bilateral
pleural
effusions with overlying atelectasis, underlying consolidation
not excluded. There is no pneumothorax. The cardiac silhouette
is not enlarged.
Mediastinum is unremarkable.
IMPRESSION: Bilateral pleural effusions with overlying
atelectasis;
underlying consolidation not excluded.
.
[**2143-5-17**] Abdominal U/S Ascites search: Limited four quadrant
ultrasound was performed to assess for ascites. Limited
ultrasound demonstrates the presence of loculated ascites
bilaterally. There was no large pocket of fluid visualized
within all four quadrants to target for paracentesis.
IMPRESSION: Extensive loculated ascites with no large pocket of
fluid identified to target for paracentesis. Findings were
discussed with ICU team at the time of procedure in person.
.
[**2143-5-17**] CXR (portable): There is a Dobbhoff tube within the
stomach. There are bilateral pleural effusions with bibasilar
opacities which may represent atelectasis. The upper lung zones
are clear. Mediastinal silhouette is stable.
IMPRESSION: Dobbhoff tube within the stomach. Bilateral pleural
effusions and bibasilar opacities, which may represent
atelectasis. Cannot exclude underlying pneumonia.
CHEST (PORTABLE AP) Study Date of [**2143-5-19**] 2:24 PM
FINDINGS: The Dobbhoff tube is in the mid stomach. Bilateral
pleural
effusions and volume loss/consolidation in the lower lobes are
again
visualized.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2143-5-21**] 11:29 AM
IMPRESSION:
1. Patent main portal vein with reversal of flow, consistent
with cirrhosis.
2. Extensively loculated ascites is not amenable for
therapeutic
paracentesis.
3. Small right pleural effusion.
CHEST (PORTABLE AP) Study Date of [**2143-5-22**] 5:17 PM
FINDINGS: The Dobbhoff tip projects over the right upper
quadrant, and is
likely located in the distal stomach or proximal duodenum.
Known bilateral pleural effusions from the previous radiograph.
Unchanged
subsequent bibasilar consolidations. No evidence of
complications, unchanged
size of the cardiac silhouette.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 110526**],[**Known firstname 26540**] [**2103-2-9**] 40 Male [**-1/2113**]
CONSULT
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
SPECIMEN SUBMITTED: Slides referred for consultation.
Procedure date Tissue received Report Date Diagnosed
by
[**2143-5-23**] [**2143-5-23**] [**2143-5-24**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
************This report contains an addendum***********
DIAGNOSIS:
Consult slides labeled N12-4044, dated [**2143-4-29**], [**Hospital3 **], [**Location (un) 86**], MA:
I. Liver, FNA (7 slides sublabeled A1-7):
1. Benign hepatocytes and bile ducts seen on direct smears.
2. Numerous neutrophils seen on liquid based preparations. See
note #1.
II. Liver, targeted needle core biopsy (2 slides sublabeled
B1-1 and [**1-17**]):
1. Established cirrhosis (Stage 4 fibrosis). See note # 2.
2. Mild predominantly macrovesicular steatosis with rare
ballooning degeneration and abundant intracytoplasmic hyalin
identified.
3. Moderate septal, mild periseptal and lobular mixed
inflammation consisting of lymphocytes, neutrophils, and rare
plasma cells.
Note #1: The neutrophils seen on the liquid based preparation
are not seen on the duct smears. This can be attributed to
sampling. If the neutrophils are representative of the lesion,
then an inflammatory/abscess process should be considered.
Radiologic and clinical correlation, as to the site of sampling,
is recommended. The case findings were discussed with Dr. [**Last Name (STitle) **].
Yashuk by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10940**] on [**2143-5-24**].
Note #2: The findings are that of an end stage cirrhotic liver
with features consistent with toxic/ metabolic injury. There is
no explanation for a mass lesion in this biopsy. No granulomas
are seen.
ADDENDUM: On [**2143-5-29**], received from [**Hospital3 104358**], [**Street Address(2) 38740**], [**Location (un) 86**], [**Numeric Identifier 18228**] are three (3)
unstained slides labeled "N12-4044" and all sub labeled B 1 from
procedure date [**2143-4-29**]. The patient's name on the
corresponding report is "[**Known lastname 97865**], [**Known firstname **] C."
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mavf
Date: [**2143-5-31**]
Clinical: Liver mass; Question cholangiocarcinoma vs abscess
vs TB.
Gross: Received from [**Hospital6 1129**], [**Street Address(2) 110527**], [**Location (un) 86**], [**Numeric Identifier 18228**] are two (2) H&E stained slides labeled
"N12-4044 [**Known lastname 97865**],[**Known firstname **]" and sub labeled B [**1-13**] and B [**1-17**] from
procedure date [**2143-4-29**]. Also included are three (3) cytology
slides sub labeled A-2 Liver FNAB, A-3 Liver FNAB and A-7 Liver
FNAB. Also included are four (4) smears sub labeled A-1, A-4,
A-5 and A-6. The patient's name on the corresponding report is
"[**Known lastname 97865**], [**Known firstname **] C."
CHEST (PORTABLE AP) Study Date of [**2143-5-27**] 9:03 PM
The NG tube tip terminates in the stomach. Bilateral large
pleural effusions
appear to be increased since the prior study. They obscure the
cardiac border
that the assessment of the cardiac size cannot be done. Bibasal
areas of
atelectasis are unchanged.
CHEST (PORTABLE AP) Study Date of [**2143-5-28**] 4:27 PM
FINDINGS: Scattered radiation related to the size of the
patient greatly
obscures detail. However, the intestinal tube does appear to
extend to the
mid body of the stomach.
****************
[**Hospital1 2025**] RECORDS
[**Hospital1 2025**] labs
Admission LFTs ([**2143-4-22**]) ALT 52 AST 123 AlkP 276 tbili 5.8 dbili
2.4
Discharge LFTs ([**2143-5-10**]) ALT 29 AST 78 Alkp 173 tbili 10.8 dbili
6.6
HIV negative
Hepatitis A Ab positive
Hep B serologies/VL all negative
Hep C Ab negative
Quantiferon Gold positive
T-spot TB positive
AFP 4.4
Fe 49 TIBC 135 Ferritin 826 B12 1815 Folate 7.6
TSH [**7-/2129**] fT4 1.2
aldosterone 97 renin 37
cortisol 23.4 (5:30 pm)
CBC [**5-10**]: WBC 18.4 HCT 31.4 Plt 399
Chem7 [**5-10**]: Na 124 K 4.3 Cl 90 Co2 24.2 BUN 22 Cr 0.9 Glu 92
[**Hospital1 2025**] micro
[**2143-4-22**] peritoneal fluid - culture negative for mycobacteria
after 15 days. No AFB observed. Abundant mononuclear cells.
[**5-2**] surgical specimen (unspecified - peritoneal and omental
samples sent) - bacterial cx no growth, AFB smear negative,
mycobacterial culture - negative after 5 days, fungal prep - no
fungi seen, fungal culture - negative after 5 days
[**2143-4-24**] Ascites Fluid - culture no growth, AFB prelim negative,
myobacterial culture negative after 13 days.
[**Hospital1 2025**] imaging
[**2143-4-28**] CT CHEST
2 upper lobe pulmonary nodules 4-5 mm indeterminate etiology.
[**2143-4-26**] MRI LIVER
1. 3.6x2.8 cm well-circumscribed lesions within segment 5 of the
liver has no engancement material phase and subsequent
hyperenhancement on delayed images, with the appearance of a
focal mass rather than focal infection. This lesion does not
have an appearance typical for metastatic carcinoma. Enhancement
pattern raises the suspicion for cholangiocarcinoma, although
less likely may represent a secondary primary of unknown
etiology. Consider further evaluation with image guided biopsy
of the focal lesion.
2. Heterogeneous perfusion of the liver predominant central
portion around the oprta hepatis likely perfusion anomaly due to
underlying cirrhosis.
3. Nodular hepatic contour, suggesting cirrhosis.
4. Omental and peritoneal increased vascularity and hyperemia.
Thin peritoneal enhancement, unchanged and likely relating to
peritonitis.
[**2143-4-25**] CT ABD/PELVIS WITH CONTRAST
1. Enhancing peritoneal lining and mesenteric stranging
suggestive of peritonitis. Differential considerations include
tuberculous peritonitis.
2. Cirrhotic liver morphology w/ascites, multiple varices,
mesenteric congestion.
3. 3.7 cm hypodense lesion in segment 4 of the liver,
indeterminate. Findings could represent malignant or infectious
etiologies.
[**2143-4-23**] RUQ US
Ascites and Cirrhosis. Gallbladder sludge.
[**Hospital1 2025**] PATHOLOGY
[**2143-5-2**] peritoneum biopsy
Diffuse granulomatous inflammation. Multinucleated giant cells
and central degeneration are noted. No necrosis is observed. The
findings are consistent with the clinical diagnosis of
peritoneal tuberculosis. A special stain for AFB is pending.
[**2143-5-2**] Omentum biopsy
(result identical to peritoneum biopsy): Diffuse granulomatous
inflammation. Multinucleated giant cells and central
degeneration are noted. No necrosis is observed. The findings
are consistent with the clinical diagnosis of peritoneal
tuberculosis. A special stain for AFB is pending.
[**2143-4-30**] Stomach biopsy
Gastric transition zone mucose with chronic inactive gastritis
and multifocal intestinal metaplasia. Immunostain for H pylori
is negative.
[**2143-4-29**] Liver FNA biopsy
Nondiagnostic specimen. Benign hepatocytes and ductal cells.
Acute inflammatory cells on the Surepath slide only. Cirrhotic
liver.
[**4-24**] ASCITES CYTOLOGY
No malignant cells identified.
EGD [**2143-4-30**]
Grade B esophagitis.
Grade 1 varices lower esiphagus, no stigmata of bleeding or red
[**Last Name (un) 23199**] sign. No banding performed. Diffuse moderate gastric
inflammation/erythema c/w chronic gastritis. Multiple very small
celean-based superficial ulders (biopsied). Normal duodenum.
H pylori samples sent (pending)
Brief Hospital Course:
Mr. [**Known lastname 97865**] is a 40 year old Peruvian gentleman with recent
diagnoses of alcoholic hepatitis and TB peritonitis,
hospitalized at [**Hospital1 2025**] [**Date range (1) 110528**] for these problems, admitted with
increasing abdominal pain and distention after not taking his
medications for several days, now being treated for TB
peritonitis, with MICU course c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] concerning for HRS and
decompensated liver cirrhosis.
.
.
ACTIVE ISSUES:
# TB PERITONITIS:
Diagnosed at [**Hospital1 2025**] a few weeks prior to this admission, when he
was admitted for abdominal discomfort. Diagnosis initially
suspected due to pt's when CT scan was suggestive of peritoneal
TB, TB-spot and quantiferon gold positive and
peritoneal/omental biopsies demonstrated granulomatous
inflammation. Being from [**Location (un) **] is his primary risk factor; no
IVDU or prison/homeless exposures. CT chest at [**Hospital1 2025**] showed "upper
lobe pulmonary nodules" not further evaluated. Sputum AFBs were
sent x 3 and were negative for TB. ID was consulted and felt
that triple therapy with INH w/B12 supplementation, moxifloxacin
and ethambutol as prescribed by [**Hospital1 2025**] was appropriate. Attempted
to obtain IR paracentesis, but ultrasound showed loculated fluid
collections not amenable to drainage. We discussed his treatment
plan with Department of health who requested he stay on
treatment for TB until his cultures from [**Hospital1 2025**] return negative
which may take many months. He remained on the three antibiotics
mentioned above for the duration of his hospital stay. Upon
discharge from [**Hospital1 **] he should follow up with Dr. [**First Name4 (NamePattern1) 794**]
[**Last Name (NamePattern1) 110525**] - [**Telephone/Fax (1) 110529**] (cell phone), [**E-mail address 110530**] at
[**Hospital1 2025**] infectious disease.
.
# ETOH CIRRHOSIS
Pt w/jaundice elevated DF on admission. Disease likely
longstanding as pt has cirrhosis/nodular liver demonstrated on
all imaging studies at [**Hospital1 2025**] (MRI,CT,US). Not a candidate for
steroids. Na 124, consistent w/recent labs at [**Hospital1 2025**]. Hct stable,
~30. Hepatology was consulted and recommended albumin for fluid
resuscitation. Patient subsequently had BRBPR with
approximately 100cc of gross blood in stool. Started on
octreotide and PPI drip, octreotide was stopped after one day
and was transitioned to PPI [**Hospital1 **]. Patient had Dobbhoff placed and
was started on TFs as per nutrition recommendations. Large
volume paracentesis by IR was not able to be obtained as above.
He also was started on Lactulose daily to achieve [**3-17**] bowel
movements per day. He showed no signs of hepatic encephalopathy
during his course. Tube feeds were continued for 2 weeks and his
liver function significantly improved from admission.
# Anemia
Pt reported small volume BRB in toilet bowl on day PTA. EGD last
week showed only 1 cord grade 1 varices. No prior hx GIB
symptoms. Pt could have rectal varices, or hemorrhoids. Had
repeat gross blood in stool on HD 2 and was started on
octreotide and pantoprazole gtt. Also received vitamin K and 4
of FFP. After transfer out of the MICU, patient continued to
experience Guaiac positive stool, with occasional small amount
of bright red blood at the end of his bowel movement. It was
determined that he had hemorrhoids. Per GI recommendations, no
endoscopy was performed. His HCT trended down slowly over the
course of his hospitalization which most likely was attributed
to continued phlebotomy more than GI blood loss. He was
transfused on two occasions for Hct < 21.
#Acute Kidney Injury
Pt Cr up to 2.5 on admission. This was believed to be due to
HRS. Nephrology was consulted and recommended fluid
resuscitation with albumin and initiation of midodrine and
octreotide. He completed a two week course of this regimen and
his creatine slowly trended down to 1.3-1.5.
#Spontaneous Bacterial Peritonitis- During this hospitalization
the pt was complaining of increasing abdominal pain. A
diagnostic paracentesis was obtained and was concerning for SBP.
He was started on ceftriaxone and metronidazole for therapy for
which he completed a 7 day course. His abdominal pain resolved
with this regimen.
# Abdominal Cellulitis- During this hospitalization the pt
developed a cellulitic rash on his abdominal wall that was
spreading outside outlined boarders. Vancomycin was added to his
daily antibiotic regimen as well which resolved the cellulitis.
He completed a 7 day course of Vancomycin.
#[**Name (NI) 110531**] Pt developed significant LE edema during this
hospitalization. This was related to his underlying liver
cirrhosis and initial discontinuation of diuretics due to [**Last Name (un) **].
Once his kidney failure was improving with treatment for HRS,
torsemide was initiated and the pt's urine out and kidney
function improved further. He was encouraged to continue to
elevate his legs while seated and to limit is salt intake to 2g
daily and his water intake to 1.5L daily. After discontinuation
of tube feedings his LE edema began to slowly improve as well.
# HYPERKALEMIA
Pt dehydrated with hx poor PO intake over the past week. EKG
without peaked t-waves. Received 1L fluid and Kayexalate in ED,
albumin resuscitation. K down with albumin and was 4.0 on call
out from MICU. On the floor his potassium remained in the normal
range.
# HYPONATREMIA
Often corresponds w/liver failure. Stable at 124 initially per
OSH records. Improved with albumin resuscitation to 130s-140s
and remained stable in that range.
# ASCITES
Paracentesis in ED not c/w SBP. Received 1 dose Ceftriaxone in
the ED. Therapeutic paracentesis was not obtainable due to
significant loculations of the ascitic fluid. His abdominal
ascites improved with initiation of Torsemide.
# Transitional:
1. pt is discharged to [**Hospital **] hospital for further antibiotic
treatment
2. F/u with Health Department case manager [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**]
[**Telephone/Fax (1) 110532**] at time of discharge for assistance with his
discharge plan
3. Continue to trend his HCT daily, our transfusion goal was Hct
< 21
4. Please continue to trend kidney function and INR daily
Medications on Admission:
Current Medications: none
[**Hospital1 2025**] Discharge Medications [**2143-5-7**]
Isoniazid 300 QD
Moxifloxacin 400 QD
Ethambutol 1200 QD
Omeprazole 40 mg [**Hospital1 **]
Folate 1 mg QD
MV 1 tab QD
Pyridoxine 50 mg QD
Thiamine 100 mg QD
Oxycodone 5-10 mg q4h PRN
Colace 100 QD PRN
Discharge Medications:
1. isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO daily ().
3. ethambutol 400 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): to achieve [**3-17**] bowel movements per day.
11. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Liver Cirrhosis
TB Peritonitis
Acute on Chronic Kidney Injury
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 97865**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with acute
liver failure, acute kidney failure and concern for an abdominal
infection with TB. We treated you antibiotics and tube feeds.
Your liver and kidney function have improved since your
admission. You are being sent to another acute care facility for
further treatment.
The following changes have been made to your medications:
START:
Oxycodone as needed for pain
Torsemide for excess fluid removal
Lactulose to soften your stool and prevent complications from
liver failure
Followup Instructions:
After Discharge from [**Hospital **] Hospital it is recommeneded that
you makde a follow up appointment at [**Hospital3 104358**] Infectious Disease Department with Dr. [**First Name4 (NamePattern1) 794**] [**Last Name (NamePattern1) 110525**] -
[**Telephone/Fax (1) 110529**] (cell phone), [**E-mail address 110530**]
Department: LIVER CENTER
When: MONDAY [**2143-7-1**] at 11:10 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please discuss with the staff at the facility about establishing
PCP when you are ready for discharge.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,083
| 158,951
|
5840
|
Discharge summary
|
report
|
Admission Date: [**2111-4-21**] Discharge Date: [**2111-5-13**]
Date of Birth: [**2036-8-31**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Iodine / Iron
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Central Line
PICC
Trach
PEG placement
History of Present Illness:
74y/o F NH resident w/ h/o COPD, CHF, DM2, CRI, was in USOH 2
days PTA when she began to develop fever, productive
cough-yellow sputum, increasing shortness of breath with
decreased sats (85% on 2L increased to 93% on 4L). She was seen
by her PCP who started her on steroids (prednisone 60mg),
levofloxacin 500mg, and nebs for treatemtent of a COPD
exacerbation. Pt was then sent to ED at [**Hospital1 18**]. Here she was
given further nebs in addition to antibiotics/steroids and
admitted to the medicine service. The CXR at time showed
pneumonia and heart failure. On [**2111-4-22**], ICU was called for
worsening shortness of breath despite increasing oxygenation.
*
On arrival to the ICU, the patient was noted to be tachypneic,
with no accessory muscle use. She was lethargic and disoriented
with HR 116, BP 122/60, R 24, T 101. ABG at time was
7.22/91/201 on high flow mask. Patient was then placed on BIPAP,
and within minutes patient became more awake. Repeat ABG after
10min on NIV was 7.23/86/102.
Past Medical History:
COPD- reported history, unkown PFT's
CHF- diastolic dysfunction
Dibetes type II- Insulin requiring
Chronic Renal Insufficiency
s/p CVA w/ minimal residual L hemiparesis
Hypertension
Hypercholesterolemia
Social History:
Nursing home resident at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. code status= full code.
Family History:
non-contributory
Physical Exam:
On Admission [**4-21**]:
Vitals- T 101, HR 96, BP 162/56, RR 29, O2 93% 4L
gen- mild respiratory distress, speaks in full sentences
heent- MMM. JVP at 14cm
CV- RRR. no murmurs,rubs, gallops
PULM- difffuse scattered rhonchi, increased expiratory phase.
cough w/o sputum production. no wheezes.
ABD- obese, soft, NT/ND. +BS
EXT- trace edema, cool R foot
*
On Transfer to ICU [**4-22**]:
Vitals- T 97.2, BP 122/60, HR 116, RR 24, 90% on High Flow FM
Gen- moderate respiratory distress, sleepy, disoriented female
HEENT- EOMI, PERRLA. MM dry
Neck- B/L supraclavicular fat pads. JVP 13 cms
CV- Tachy, RRR. distant heart sounds
PULM- bilateral crackles at bases to mid-lung fields; mild
bilateral insp/exp wheezes. Poor inspiratory effort
ABD- obese, active bowel sounds. NT/ND
EXT- no clubbing, cyanosis, edema. minimal DP/PT pulses.
reflexes 2+ b/l.
Neuro- Decreased strength over L arm/leg, but not cooperative w/
full neuro exam. CN II-XII intact.
Pertinent Results:
Admission Labs:
*
CBC: WBC-24.1 HGB-11.7 HCT-36.7 MCV-92 PLT 200
*
DIFF: NEUTS-86* BANDS-10* LYMPHS-2* MONOS-1* EOS-0 BASOS-0
ATYPS-0 METAS-1
*
Coags: PTT 31.7, INR 1.4
*
CHEM: GLUCOSE-172* UREA N-49* CREAT-1.8* SODIUM-145
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-36* ANION GAP-15
*
Random Cortisol (9pm): 56.9
*
LACTATE-2.1
*
Radiologic Studies:
*
CXR [**4-21**]: Findings consistent with failure which may be slightly
asymmetric. Patchy basilar and retrocardiac opacities making
difficult to exclude superimposed pneumonia.
*
LENI [**4-23**]: Negative for DVT
*
ECHO [**4-22**]:
There is moderate symmetric LVH. The LV cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. LV systolic function
appears hyperdynamic (EF>75%). The RV cavity is dilated. RV
systolic function appears depressed. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The MV leaflets are mildly
thickened. There is no MV prolapse. MR is present but cannot be
quantified. TR is present but cannot be quantified. There is a
trivial/physiologic pericardial effusion
*
Renal Doppler U/S [**4-23**]:
1) No evidence of hydronephrosis.
2) Technically suboptimal Doppler examination of the kidneys.
Renal artery stenosis cannot be excluded on the basis of this
exam
*
Bronchial Washings [**4-24**]: Negative for malignant cells.
*
CHEST/ABD/PELVIS CT [**4-27**]:
1) Congestive heart failure with likely underlying multifocal
pneumonia; correlate clinically.
2) Cardiomegaly and marked prominence of the main pulmonary
artery, likely consistent with pulmonary artery hypertension.
3) Aortic and coronary artery calcification.
4) Cholelithiasis. Possible gallbladder wall edema, though this
may be artifactual second to non-contrast low-dose technique.
5) No other identifiable cause to explain the patient's severe
abdominal pain and distention.
6) Thoracic kyphosis and degenerative disease of the spine.
*
[**4-28**] RUQ U/S:
1. Cholelithiasis and gallbladder wall edema in a nondistended
gallbladder. This finding is nonspecific in nature and could
represent chronic cholecystitis. Alternatively, this could
represent sequela of hepatitis, pancreatitis, or a low protein
state.
*
[**5-6**] Chest/Abd CT:
1) Unchanged bilateral pleural effusions, increased
consolidation within the left lower lobe as well as improved
opacity within both upper lobes. These findings are suggestive
of aspiration pneumonia.
2) Cholelithiasis with no pericholecystic inflammatory change.
No cause for the patient's abdominal pain is identified.
3) Enlargement of the pulmonary artery indicating probable
pulmonary artery hypertension.
4) Collapse of the airways in this patient status post
tracheostomy, a finding raising the question of tracheomalacia.
*
Micro Data:
[**4-21**]- Blood Cx: Negative
[**5-9**]- Blood Cx: NGTD
[**5-12**]- Blood Cx: NGTD
[**4-22**]- Urine Cx: Negative
[**5-12**]- Urine Cx: Negative
[**4-22**]- Sputum Cx: Negative
[**4-22**]- Urine Legionella: Negative
*
[**4-24**]- BAL: Negative
[**4-24**]- Influenza A/B: Negative
*
5/4,5/5,[**5-9**]- Cdiff: Negative
Brief Hospital Course:
This is a 74 y/o F with PMH of COPD, diastolic CHF, DM2, CRI,
who initially presented with hypoxia secondary to CHF/COPD flare
and likely LLL pneumonia. Her respiratory status worsened and
she was admitted to the ICU on hospital day 2 for hypercarbic
respiratory failure. A brief [**Hospital 11822**] hospital course is
outlined below.
1. Respiratory Failure: She developed worsening dyspnea and was
admitted to the ICU for hypercarbic respiratory failure on
hospital day 2. Her intial ABG was 7.22/91/201 and was not
responsive to BiPap, so she was emergently intubated. Her
respiratory failure was felt multi-factorial from COPD/CHF and
underlying LLL pneumonia (with leukocytosis). While intubated
she was treated with a steroid taper for COPD exacerbation,
diuresed aggressively for CHF, and was treated with a 14 day
course of Zosyn for suspected pneumonia. She had initially
recieved 4 days of Levofloxacin and Vancomycin, but this was
changed to Zosyn on HD 5 for broader coverage of suspected
nosocomial pneumonia (and no history of MRSA). She was extubated
on HD 11. However, she subsequently developed increasing work of
breathing off of the ventilator, and was therefore re-intubated
on HD 14 with plan for trach. Trach was placed on HD 15.
However, she was unable to be weaned from the ventilator despite
continued diuresis and completion of her antibiotic course. She
has a noted history of COPD, but her lung volumes were not felt
to be consistent with this diagnosis, and she did not have PFTs
on record here for further evaluation. Chest CT was also
performed to evaluate for interstitial process and was negative.
NIF was performed and was borderline (-25). Of note, following
completion of her 14 day course of Zosyn, she was also treated
empirically with a 7 day course of vancomycin for empiric
treatment of gram positive cocci in her sputum culture (from
4/31), although final sputum culture showed only oropharyngeal
flora. She did gradually begin to have improved respiratory
status (unclear if related to vancomycin antibiotics or other
un-related factors) with decreasing need for pressure support.
RSBI was noted to be <100 and she was given a trial on trach
collar, which she tolerated very well. On 70% FiO2 through trach
collar, oxygen saturation was maintained at >93% and so she was
titrated down to 50% FiO2 prior to discharge to rehab. She may
be able to tolerate a passy-muir valve, which may be attempted
at rehab.
2. COPD: Uncertain diagnosis. Per PCP notes, the patient has a
history of severe COPD and is treated with standing flovent and
atrovent nebs. She was noted to have diffuse wheezes on initial
exam and was therefore treated with steroid taper for likely
COPD flare. However, she did not have great improvement of
symptoms with this, and her lung volumes on CXR and chest CT did
not appear consistent with severe COPD. She was continued on
albuterol and atrovent nebulizers in addition to flovent. PFT's
were not performed on this admission, but may be of benefit to
re-do in the outpatient setting for diagnostic purposes.
3. CHF: Initial CXR showed evidence of mild CHF. An ECHO was
performed which showed hyperdynamic LV systolic function at 75%.
She likely has component of diastolic dysfunction and is on
standing lasix as outpatient. She was treated with beta blocker,
ace-I, and lasix prn. She was initially diuresed aggressively to
try and improve her respiratory status, however this did not
have a dramatic effect. Upon discharge she is felt to be
euvolemic and is not on standing lasix. She is off her
lisinopril due to concern of exacerbating pancreatitis. She
responds well to 40mg IV lasix as needed to match ins and outs
daily.
4. CAD: She remained chest pain free through her hospital course
without ischemic EKG changes. She was continued on lipitor 10mg
daily and aspirin 81mg per day in addition to b-blocker.
5. Acute renal failure: Initially presented with elevated
creatinine to 2.6, which was above her baseline chronic renal
insufficiency of 1.0. This was felt to be secondary to pre-renal
state and exacerbated by right sided failure w/ cor-pulmone.
Renal function improved with treatment of her underlying lung
disease as outlined above and improved back to baseline. Of
note, evaluation at that time including renal ultrasound and
urinalysis was negative for other etiology. Urine eosinophils
were negative and urine sediment was bland. She subsequently
maintained good urine output with creatinine at 0.8-1.0 upon
discharge.
6. DM2: Insulin dependent diabetes, requiring large amounts of
NPH as an outpatient. Her outpatient regimen included 56 units
qam and 18 units qpm. Her blood sugars proved difficult to
control given her changing nutrition status and episodic NPO
states. While NPO she was maintained on insulin sliding scale.
Subsequently tube feeds were initiated and she was re-started on
NPH. However, tube feeds were stopped due to the development of
pancreatitis (see below) and NPH was again tapered down.
Now that her pancreatic enzymes are elevated she is on TPN for
nutritional support, currently with 15 Units of Insulin mixed in
her TPN. In addition she is on a standing NPH regimen of 36
Units qam and 17 units qpm. Her fingersticks will continue to be
monitored at rehab with insulin regimen adjusted as needed.
7. Pancreatitis: Developed abdominal pain with elevated lipase,
suggestive of pancreatitis. RUQ ultrasound on HD 7 showed no
extrahepatic biliary ductal dilatation. A 1 cm gallstone was
present within the neck of the gallbladder with marked
gallbladder wall edema, however the gallbladder was not
distended and no pericholecystic fluid was seen. This was felt
to be consistent with chronic cholecystitis or possibly
pancreatitis. Follow-up non-contrast abdominal CT on [**5-6**] showed
no evidence of acute or complicated pancreatitis. Given her
elevated lipase and concurrent abdominal pain, tube feeds were
held and she was kept NPO. Her triglycerides were checked and
were within normal limits. Ace-I was discontinued since this was
felt to possibly be a medication-related cause of her
pancreatitis. Subsequently, her clinical exam improved with
resolution of her abdominal pain. In addition her pancreatic
enzymes trended down off tube feeds. She developed low-grade
fever on [**5-11**] so a repeat CT scan was performed which again
showed no evidence of acute pancreatitis. Further imaging and
evaluation was deferred given her clinical improvement.
8. Psych: She was continued on her outpatient regimen of zoloft
at 100mg daily. Benzodiazepenes and sedatives should be avoided
given her complicated respiratory status. Prn olanzapine at 5mg
or haldol at 2.5mg (with monitoring of QT interval) have been
given for agitation or anxiety with good effect.
Medications on Admission:
zoloft 100mg daily
aricept
atrovent
ASA 81mg daily
isosorbide dinitrate 30 mg daily
lisinopril 20mg daily
lasix 40mg daily
zaroxyln 2.5mg QOD
NPH 56 U SC qam, 18 U SC qpm
naproxen
flovent
MVI
sliding scale insulin
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
mL Injection TID (3 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours).
12. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Six (36) Subcutaneous qam.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Seventeen (17) Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
1. hypercarbic respiratory failure
Secondary Diagnosis:
1. diastolic heart failure
2. diabetes II- insulin requiring
3. COPD
4. chronic renal insufficiency
5. pancreatitis
6. anemia of chronic disease
7. deconditioning
8. pneumonia- nosocomial
Discharge Condition:
Stable. On Trach Collar.
Discharge Instructions:
You are being discharged to rehab. Please follow-up with your
primary physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] following completion of your stay.
Followup Instructions:
Please follow-up with your primary physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. Call to
make an appointment at [**Telephone/Fax (1) 608**]
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6,884
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1849
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Discharge summary
|
report
|
Admission Date: [**2118-11-26**] Discharge Date: [**2118-12-14**]
Date of Birth: [**2075-4-14**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
difficulty breathing, R eyelid heaviness/double vision
Major Surgical or Invasive Procedure:
Plasmapheresis catheter placement
History of Present Illness:
The pt is a 43 yo female w/ [**First Name9 (NamePattern2) 10332**] [**Last Name (un) 2902**], s/p thymectomy
for thymoma in [**2115**] which was found to be metastatic to lung and
abdomen. The pt now presents w/ several weeks of tiredness,
several days of dyspnea on exertion, and 1 day of diplopia. The
pt first started feeling tired several wks ago after undergoing
2 biopsies for staging of her thymoma metastes ([**9-18**]). The
tiredness progressed over the next few wks. Several days ago,
the pt then noticed that she became short of breath after
walking quickly. She describes her sensation of dyspnea as "not
having enough air" and feeling tired. Yesterday, she became
increasingly short of breath w/ less exertion, e.g. going up
stairs, cleaning the kitchen, and talking; she also required 2
pillows to go to sleep last night due to orthopnea. Yesterday,
she also noted that her R eye felt "heavy", i.e. was difficult
to open, and that she was seeing double, ie.. 2 objects
side-by-side. The double vision occurred at various times
during
the day, corresponding to when the pt felt tired, and was worse
w/ horizontal gaze and looking at far versus near objects. The
pt denied any associated eye pain and said her L eye felt
normal. This morning, the pt's diplopia had resolved, but she
continued to be short of breath w/ minimal exertion, e.g.
talking in short sentences, so she came to the [**Hospital1 18**] ED.
.
The pt had similar sx of tiredness and diplopia 3y ago (but
never dyspnea) and was subsequently diagnosed w/ MG. At the
time of dx, the pt was found to have a thymoma, so per Dr. [**First Name4 (NamePattern1) 951**]
[**Last Name (NamePattern1) 952**], the pt underwent induction of chemoradiotherapy followed
by median sternotomy and anterior thymic resection; she was also
found at that time to have metastases to the L pleura.
Following the initial surgery in [**2115**], the pt remained
asymptomatic. However, despite subsequent trials of
chemotherapy, her metastatic disease continued to progress,
spreading to the L lung and possibly L retroperitoneum. In
[**9-18**], the pt underwent several staging biopsies of the
metastases in the L lung and a suspicious L suprarenal mass
(pathology pending). Given the extent of the pt's disease, the
pt discussed her treatment options w/ Dr. [**Last Name (STitle) 952**] and her
oncologist, Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], and she has decided to undergo
surgery (L extrapleural pneumonectomy w/ additional resection of
L suprarenal mass). Her surgery is scheduled for this Weds,
[**2118-11-30**]. Given her current sx, the pt is concerned about how
she will be able to handle the surgery, but she and her husband
express a strong desire to go ahead with the surgery, either on
the scheduled day or as soon as her health would allow.
.
ROS:
Pt noted intermittent palpitations w/ fast walking associated w/
the recent SOB described above. Pt also notes mild abdominal
pain since her bx in [**9-18**]; immediately after the procedure, the
pt says she developed an "infection" involving fever and
"yellowish stuff" draining from her umbilicus; the fever and
discharge have since resolved, but mild pain persists,
intermittent and sharp in the epigastric/LLQ area "right under
the skin." Additionally, the pt denies recent depression or
anxiety but says that she feels "very sad" whenever she thinks
about her children (9y, 11y), because "they are so young and
they need me still."
.
Aside from the sx above, the pt says her health has been good.
The pt denies fever (except as above), chills, sick contacts,
recent URI, HA, dizziness, difficulty chewing or swallowing,
dysarthria, neck pain/stiffness, cough, chest pain, abdominal
pain (except as above), nausea, vomiting, diarrhea, dysuria,
difficulty voiding, extremity pain/focal
weakness/numbness/tingling.
Past Medical History:
PMH:
1. MG, as above.
2. Metastatic thymoma, as above.
.
PSH:
1. Thymectomy, [**2115**], as above.
2. Lung bx, [**9-18**], as above.
3. Retroperitoneal bx, [**9-18**], as above..
.
Onc History:
MG; taken off mestinon and prednisone (per taper) in [**Month (only) 216**]; has
been symptomatic since [**2115**]
- Metastatic thymoma. Diagnosed with thymoma when she
presented with myasthenia [**Last Name (un) 2902**], [**8-15**]. Prior treatment: Three
cycles of preoperative cisplatin, Adriamycin and Cytoxan.
Surgical resection of both the large mediastinal mass and left
pleural stripping. External beam radiation to the postsurgical
mediastinal bed. One cycle of postoperative carboplatin and
Taxol, but carboplatin was discontinued due to infusional
reaction. Eight weeks of weekly Taxol completed, [**1-15**].
Documented to have recurrent disease with small pulmonary
nodules, [**2-17**]. Initiated Tarceva [**4-17**].
Social History:
Pt lives w/ her husband, mother, and two children, 9y and 11y.
She and her husband moved here from [**Name (NI) 651**] 15y ago and speak both
English and Cantonese. The pt used to work as a cashier at a
Japanese restaurant but was recently laid off ([**3-21**]) and is now
experiencing financial difficulties. She receives health
insurance through MassHealth. She denies use of tobacco,
ethanol, or other drugs.
Family History:
Non-contributory, no h/o MG, diabetes, MS, SLE, or other
autoimmune diseases
Physical Exam:
T-98.6 BP-123/90 HR-104 RR-16 O2Sat (RA)-98%
Gen: Sitting up in bed, some use of accessory respiratory
muscles in neck, appears SOB w/long sentences.
HEENT: NC/AT, moist oral mucosa.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruit.
Back: No point tenderness or erythema. No CVA tenderness.
CV: RRR, III/VI systolic murmur heard at LSB. Radial, DP pulses
2+ bilaterally. Cap refill 2 sec bilaterally.
Lung: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi.
Abd: +BS soft, nontender.
Ext: No edema.
.
Neurologic examination:
Mental status:
Awake and alert, cooperative with exam, becomes teary-eyed when
talking about her two children but o/w normal affect. Oriented
to person, place, and date. Attentive, able to give thorough
history of present illness. Speech is fluent with normal
comprehension and repetition; naming intact. No dysarthria.
Registers [**4-15**], recalls [**4-15**] in 5 minutes. No evidence of neglect.
.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Diplopia noted on upward gaze x 10sec, o/w no diplopia w/
unsustained extraocular movements. Sensation intact V1-V3.
Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation
symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact.
.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Neck extension and flexion full strength against
resistance.
.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF [**Last Name (un) 938**] TF
L 5* 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5* 5 5 5 5 5 5 5 5 5 5 5 5 5
.
*Deltoids w/ slight decreased strength (i.e. just breakable
against resistance) following 50 arm raises at shoulders
bilaterally.
.
Sensation:
Intact to light touch, pinprick, vibration and proprioception
throughout. Romberg deferred.
.
Reflexes :
1+ throughout bilaterally. Toes mute.
.
Coordination:
Finger-nose-finger normal, heel-to-shin normal, RAMs normal.
.
Gait :
Deferred.
Brief Hospital Course:
Patient is a 43 year old R-handed woman with a history of
myasthenia [**Last Name (un) 2902**] status post thymoma resection in [**2115**], now
with recent metastases of malignant thymoma to her lungs and
retroperitoneal space, who comes to the ED for increased
shortness of breath and episodes of double vision. On exam, she
reports double vision upon sustained upgaze after 12 secs, she's
able to count to 19 in one breath, weakness of her neck
extensors (5-/5), and fatigue on repetitive motion of the right
deltoid (5-/5).
.
1. NEURO:
Patient usually has double vision with worsening of her
myasthenia. However, her shortness of breath was a new symptom
and it was unclear whether it related worsening of her
myasthenia or tumor infiltration into her mediastinum or
pericardium. Since she did complain of double vision since
being weaned off mestinon and prednisone, Mestinon was restarted
on [**11-26**] and settled on a dose of 60mg Q4H on [**12-12**] given
sweating and chest pressure with the higher doses. She also
received plasmapheresis for a total 5 cycles between [**11-29**] to
[**12-6**] as she remained tachypneic and had an O2 requirement a few
days into her admission. Prednisone was restarted at 60 mg QD,
which lead to some improvement in her breathing after several
days. She was kept on close monitoring including telemetry,
continuous O2 sats and q4 hour neuro and vitals checks. Her
double vision gradually improved with the therapies and her
fatigue, which was mild, also resolved. Her NIFs and VCs were
stable for several days prior to discharge.
.
2. RESP:
In the ED, patient had a chest CT with contrast which was
negative for pulmonary embolism. NIFs and VC were checked every
8 hours. On admission, her NIF -40 and VC 2.4L. Throughout the
hospital course she ranged NIFs -30-50, VC 1.0-1.5L and was
admitted to the intensive care unit for close monitoring
overnight on [**11-29**] due persistent tachypnea, a slightly
increased A-a gradient and dramatic decrease in VC 2.4 to 1.3.
Pulmonology was consulted and recommended checking an ambulatory
sat which was 94-97%; otherwise, followed her course with the
primary team. She may also need formal pulmonary function tests
as an outpatient if she decides to proceed with a surgical
procedure in the future. Chest x-ray showed a paralyzed lateral
left hemidiaphragm which was felt to also be contributing to her
shortness of breath. Appeared that her breathing did not
improve dramatically after the 5 cycles of plasmapheresis.
.
3. [**Last Name (un) **]/ONC:
Thoracic surgery and hematology/oncology were consulted
regarding the plan for left extrapleural pneumonectomy w/
additional resection of L suprarenal mass given her worsening
myasthenia and shortness of breath. Thoracics recommended an
abdominal CT with IV and PO contrast which was negative for new
metastases; however, the risk of complication with patient's
current breathing problems outweighed the benefit of any
imminent surgical procedure. Plan which was discussed with
patient, her family and primary team would be to re-evaluate her
after treatment of her myasthenic crisis and stabilization after
discharge. At that point, de-bulking surgery could be
reconsidered. Oncology recommended Alimta chemotherapy which
they will set up as an outpatient with Dr. [**Last Name (STitle) **] who is
covering for patient's primary oncologist, Dr. [**Last Name (STitle) 10333**].
4. CV:
Patient's EKG showed PR depression in inferior leads and slight
ST depression in lead II concerning for her cardiac process.
Initially there was concern for a possible pericarditis +/-
pericardial effusion, myocardial ischemia or most likely
infiltrating tumor into the pericardium. Cardiology was
consulted due to sustained elevation of cardiac enzymes from
[**Date range (1) 10334**] (CK 221, 176, 158, 170; CKMB 23, 19, 20, 22; CKMBI
10.4, 10.8, 12.7, 12.9; TnT 0.10 x 4). Per cardiology, patient
had no signs, symptoms or risk factors for acute coronary
syndrome but CT showed metastasis near the pericardium and so
recommended a 2D echo which showed 2+ mitral regurgiation
(incr'd from prior), normal ejection fraciton >55% and no
pericardial effusion. BNP was 70, not suggestive of CHF. She
was continued on aspirin only.
.
5. PROPHYLAXIS:
-VD boots and heparin sc
-OOB with assistance
.
6. SW:
-Palliative care SW consulted by Dr. [**Last Name (STitle) **] re: end of life
issues w/ young children -> met w/ pt [**11-30**]
-SW contact[**Name (NI) **] re: pt's question about [**Social Security Number 10335**]social security
.
Medications on Admission:
No medications currently. Was on prednisone [**Date range (1) 10335**] but then
tapered off at end of [**Month (only) 216**] (also was on ranitidine for
duration of steroid tx). Was also on Mestinon but d/c'ed at end
of [**Month (only) 216**].
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours).
Disp:*180 Tablet(s)* Refills:*2*
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
8. Home Oxygen
[**Known firstname 17**] [**Known lastname 10336**] [**First Name8 (NamePattern2) 10337**] [**Hospital1 392**] [**Telephone/Fax (5) 10338**]
Malignant thymoma Home O2 2-3LPM cont, Liq Res - Liq Port
RA sat 88% [**2118-12-14**]. Pt leaves home 4-6hrs/day for appts errands
visits etc. Times 1 year
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia [**Last Name (un) **]
Malignant Thymoma
Discharge Condition:
Stable, still some mild shortness of breath but O2 sat stable
95-100% on room air, cleared by PT for discharge
Discharge Instructions:
Please call your doctor or go to the ER if you have any
worsening trouble breathing, shortness of breath, chest pain,
heart racing, weakness, double vision, blurry vision, or any
other symptoms that concern you.
Please take all medications as prescribed.
Please call the hospital [**Telephone/Fax (1) 10339**] and ask the operator to
page Dr. [**Last Name (STitle) 10340**] if you have any questions or concerns prior to
your appointment on [**2118-12-28**].
Followup Instructions:
Hematology-Oncology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2118-12-15**] 9:30
Provider: [**Name11 (NameIs) 5558**],[**Name12 (NameIs) 5557**] HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-12-15**] 9:30
Provider: [**Name10 (NameIs) 10341**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2118-12-15**] 2:30
Primary Care: Please call Dr.[**Name (NI) 10342**] office at [**Telephone/Fax (1) 8236**] to
set up a follow up appointment in the next 1-2 weeks.
Neurology: You have an appointment scheduled with Drs. [**Last Name (STitle) **]
and [**Name5 (PTitle) 10340**] on [**2118-12-28**] at 12:30 on [**Hospital Ward Name 23**] 8. Please call
[**Telephone/Fax (1) 541**] with any questions.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
Completed by:[**2118-12-29**]
|
[
"197.8",
"V10.29",
"197.0",
"358.01",
"198.89",
"V58.65",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.71"
] |
icd9pcs
|
[
[
[]
]
] |
14021, 14027
|
8023, 12605
|
331, 367
|
14122, 14235
|
14744, 15711
|
5684, 5762
|
12902, 13998
|
14048, 14101
|
12631, 12879
|
14259, 14721
|
5777, 6328
|
236, 293
|
395, 4283
|
6769, 8000
|
6367, 6753
|
6352, 6352
|
4305, 5236
|
5252, 5668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,460
| 170,006
|
31953
|
Discharge summary
|
report
|
Admission Date: [**2155-8-10**] Discharge Date: [**2155-8-14**]
Date of Birth: [**2092-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Thoracentesis x 2
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname 74901**] is a 63 year old male with a history of poorly
differentiated non-small cell lung cancer with known metastases
to brain and liver, polycythemia [**Doctor First Name **], and RUE DVT on lovenox
who presents with worsening dyspnea.
.
He was diagnosed with stage IV non-small cell lung cancer in
[**2153-10-11**] and has received cyberknife for brain lesions,
carboplatin, pemetrexed, and PF-[**Telephone/Fax (3) 74902**] as part of a
clinical trial. He discontinued this trial [**Doctor Last Name 360**] on [**2155-8-6**]
because of clinical (worsening dyspena) and radiolographic
evidence of cancer progression. He then started a new [**Doctor Last Name 360**],
Alimta, on [**2155-8-7**].
.
His recent history is notable for dsypnea over the last four
weeks that has worsened over the past four days. He underwent
right thoracentesis on [**2155-8-1**] with removal of 800cc of cloudy
yellow fluid found to be a malignant effusion. He had some
improvement in his dyspnea as a response but notes worsening
over the past few days, even after starting home O2 (2-4L) on
[**2155-8-7**]. He also notes having subjective fevers and chills and
a nonproductive cough since starting Alimta. He presented to
the ED because of worsening symptoms.
.
VS on presentation were 97.9 128/60 97 28 94%ra. He had a CXR
and a chest CTA that was neg for PE but concerning for worsened
pleural effusions bilaterally, lymphangetic spread of tumor, and
a possible post-obstructive pneumonia. He was given vanc/zosyn
and bronchodilators. He became increasingly dyspneic and
hypoxic in the ED, satting 87% on ra, and was placed on a NRB
(satting in the 90s and then bipap with significant improvement.
He was then admitted to the MICU for further management.
.
On arrival, he is with his family and appears comfortable on
bipap. He has no complaints.
.
Review of sytems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
1. Stage IV EML4-ALK (E13A20 ?????? variant 1) nonsmall cell lung
cancer diagnosed in [**2153-10-11**], with known metastases to
brain and liver
2. Brain metastases diagnosed in [**2153-10-11**].
3. Deep vein thrombosis of the upper extremity diagnosed in
[**2153-10-11**] (likely related to his stage IV nonsmall cell lung
cancer). Recurrence of thrombosis with portal vein thrombosis in
[**2155-1-12**] and SVC syndrome. Now on low molecular weight
heparin.
4. Radiation necrosis of the right frontal lobe lesion in
[**Month (only) 359**]
[**2153**], status post surgical resection.
5. GERD
Past Oncologic History:
1. Status post stereotatic radiosurgery (Cyberknife) to 2 brain
lesions in [**2153-10-26**].
2. Status post 2 cycles of 1st line systemic chemotherapy with
Carboplatin 6 AUC D1 and Gemcitabine 1000 mg/m2 D1,8 of 3 week
cycle in [**2152**] (had progressive disease).
3. Status post 12 cycles of pemetrexed 500 mg/m2 D1 of 3 week
cycle. Started in [**2154-1-8**] (attained partial response). Last
dose
of pemetrexed [**2154-9-10**].
4. Status post 9 cycles of PF-[**Telephone/Fax (3) 74902**] mg [**Hospital1 **] as part of
clinical trial DFHCC 06-068. Started in [**2154-11-29**] (attained
partial response) and had RECIST-based progression in
[**2155-6-5**].
Continues to take study drug.
Social History:
He has an eight pack year smoking history and stopped in [**2133**].
He does report significant second hand smoke exposure as a
child. He is a retired vice-president of operations at a telecom
company. He lives with his wife. [**Name (NI) **] does not currently drink
alcohol or use illicit drug.
.
Family History:
Mother had arthritis, osteoporosis, and aortic insufficiency.
Father had COPD, bronchitis, enlarged prostate, and malaria. He
has two healthy daughters.
Physical Exam:
Vitals: 97.9 128/60 97 28 100% on bipap
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased bs on left, scattered rhonchi, wheezing at LUL
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 lesions, no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
LABS:
Admission:
PT-14.9* PTT-27.6 INR(PT)-1.3*
.
WBC-12.6* HCT-41.5 MCV-70*
NEUTS-91.6* LYMPHS-4.7* MONOS-1.8* EOS-1.6 BASOS-0.2
.
ALT(SGPT)-246* AST(SGOT)-81* LD(LDH)-355* CK(CPK)-94 ALK
PHOS-141* TOT BILI-1.5 ALBUMIN-2.5*
.
GLUCOSE-111* UREA N-21* CREAT-1.0 SODIUM-134 POTASSIUM-4.3
CHLORIDE-100 TOTAL CO2-27
.
LACTATE-2.5*
.
Discharge:
WBC-8.3 Hct-33.4* MCV-69* Plt Ct-87*
.
Glucose-108* UreaN-17 Creat-0.8 Na-138 K-3.8 Cl-103 HCO3-29
.
ALT-80* AST-32 LD(LDH)-243 AlkPhos-148* TotBili-1.3
.
Type-ART pO2-219* pCO2-37 pH-7.46* calTCO2-27 Base XS-3
.
.
IMAGING:
.
CTA [**2155-8-10**]:
1. No evidence of PE.
2. Bilateral pleural effusions, right greater than left,
slightly increased in size since the prior study.
3. Increase in encasement of the right-sided airways by soft
tissue density, likely representing tumor, with areas of
increased consolidation in the inferior aspect of the right
upper lobe and right middle lobe likely due to post-obstructive
pneumonia, although increased tumor burden cannot be excluded.
4. Diffuse bronchovascular and septal thickening consistent with
lymphangitic spread of tumor.
5. Stable left lower lobe lung mass.
6. Stable diffuse bony metastases and hepatic metastases.
.
ECHO [**2155-8-11**]:
The left atrium is normal in size. 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%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CXR [**2155-8-13**]:
IMPRESSION: Relatively stable radiographic examination with
slight
accentuation of the interstitial markings most notably on the
right. There is suspected mild volume overload on the background
of lymphangitic
carcinomatosis. At least partially loculated left pleural
effusion again
re-demonstrated.
.
Brief Hospital Course:
63 year old man with metastatic non-small cell lung cancer
admitted with dyspnea 1 week following right sided thoracentesis
for pleural effusion, found to have reaccumulated pleural
effusion on x-ray.
.
Hypoxia: The pt was initially on non-rebreather in the ED, and
was weaned to BiPap in the ICU. On [**8-12**] am the pt was noted to be
stable on 4L nasal cannula oxygen, and he did not have to go on
bipap again. Dyspnea was most likely due to fluid reaccumulation
and progression of cancer, however vanc/zosyn was started for a
7 day course for possible post-obstructive pneumonia. On [**8-12**] pt
had a right thoracentesis with 1200 ml serous fluid removed. On
[**8-13**] pt had a left thoracentesis with 500 ml removed. Pt will
likely need pleurex catheter on the right if fluid reaccumulates
again. Pt tolerated both procedures well, and was transfered to
OMED on [**8-13**] with interventional pulmonary planning to follow him
on the floor. On the floor, patient looked well and was satting
in the mid 90s at 4LNC. He felt well and was ready to go home.
It was thought that even though he was above his baseline for
O2, that because his prognosis was only weeks remaining that it
would be best for him to go home to be with his family for his
remaining days. He was to follow up with IP within 1 week for
evaluation for pleurodesis and to see his oncologist on [**2155-8-28**].
.
# Non-small cell lung cancer: has known metastases to brain and
liver, recent drainage of a malignant right pleural effusion,
?worsening lymphangitic spread on chest CT, and initiation of
new chemotherapeutic [**Doctor Last Name 360**] in the setting of progression.
Unfortunately, his disease has progressed despite chemotherapy
and his prognosis is quite poor with only weeks to live.
.
# Right upper extremity DVT: Has been on lovenox at home. We
continued Lovenox.
.
# Polycythemia [**Doctor First Name **]: stable, no active issues.
.
Medications on Admission:
Albuterol MDI
Lovenox 60 q12h
Keppra 500 [**Hospital1 **]
Ativan prn
Naratriptan prn
Omeprazole 20 daily
Ambien prn
Folic acid 0.4
MVI
.
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleeplessness.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take for 3 days, last dose [**2155-8-17**].
Disp:*3 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H PRN () as needed for shortness of
breath or wheezing.
8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Ambien 5 mg Tablet Sig: One (1) Tablet PO QHS as needed for
insomnia.
10. Naratriptan 1 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for headache: Do not exceed 5mg in 24 hours.
11. Home O2 Cannister
12. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
twice a day.
.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] oxygen company
Discharge Diagnosis:
1) Pleural effusion
2) NSCLC
3) Community acquired pneumonia
.
Discharge Condition:
Stable, afebrile
.
Discharge Instructions:
You were admitted to the hospital for shortness of breath. Your
symptoms were thought to be related to worsening of your lung
cancer as well as a pneumonia. You were started on antibiotics
for your pneumonia. We also drained fluid from the pleural space
around your lungs. Both of these interventions improved your
symptoms and your fevers resolved. You will be discharged on a 3
day course of Levofloxacin antibiotic to finish treating your
pneumonia. You will also be sent home on supplemental oxygen to
help your breathing.
.
We have made a change to your medications:
START Levofloxacin 750mg by mouth daily
.
Please note your follow up appointments listed below.
.
Please return to the emergency room if you experience worsening
shortness of breath, chest pain, high fevers, or any other
symptoms that are concerning to you.
Followup Instructions:
Appointment with Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL
PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2155-8-19**] 10:00
.
Appointment with Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**]
Date/Time:[**2155-8-28**] 10:00
.
Appointment with Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2155-8-28**] 10:00
.
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2155-8-14**]
|
[
"198.3",
"V12.51",
"511.81",
"238.4",
"197.7",
"284.89",
"V58.61",
"E933.1",
"162.8",
"485",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10577, 10643
|
7294, 9224
|
334, 366
|
10749, 10769
|
4979, 7271
|
11647, 12219
|
4275, 4429
|
9411, 10554
|
10664, 10728
|
9250, 9388
|
10793, 11624
|
4444, 4960
|
275, 296
|
2280, 2610
|
394, 2262
|
2632, 3942
|
3958, 4259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,421
| 116,230
|
11117
|
Discharge summary
|
report
|
Admission Date: [**2136-8-6**] Discharge Date: [**2136-8-29**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Aortic valve replacement (25-mm [**Doctor Last Name **] Magna E
pericardial),aortic endarterectomy7/19/10
emergency re-exploration [**2136-8-8**]
sternal washout/advance pectoralis flaps and closure [**2136-8-10**]
PICC line placement [**8-23**]
History of Present Illness:
This 87 year old male with severe aortic stenosis and recent
admission for congestive heart failure exacerbation was admitted
with worsening renal failure and hyponatremia. Cardiac surgical
consultation was obtained to evaluate for aortic valve
replacement. he was admitted now for elective surgery.
Past Medical History:
Aortic Stenosis
chronic atrial fibrillation
h/o gastrointestinal bleed
Hypertension
Systolic and diastolic congestive heart failure
Hyperlipidemia
chronic Anemia
Benign Prostatic Hypertrophy
Moderate pulmonary Hypertension
Chronic Kidney Disease
s/p cataract surgery
s/p basal cell CA excision from face
s/p Tonsillectomy
Social History:
Race:Caucasian, primarily Italian speaking
Last Dental Exam:many years, poor dentition
Lives with:wife and daughter
Occupation:previous factory worker
Tobacco:40 pack year history
ETOH:2 glasses wine/day
Family History:
Sister on dialysis, hypertension. Mother died suddenly at 65
years old, also with hypertension. Father died at 89yo of old
age. There is no family history of premature coronary artery
disease or sudden death.
Physical Exam:
admission:
Pulse: Resp: O2 sat:
B/P Right: Left:
Height:5'3" Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema +2 Varicosities:
0
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: Left:
Pertinent Results:
[**2136-8-6**] Echo: PRE BYPASS The left atrium is markedly dilated.
The left atrium is elongated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricle displays normal free wall
contractility. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area = 0.6cm2). Mild to moderate ([**1-21**]+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results in the
operating room at the time of the study.
POST BYPASS The patient is being v-paced. There is normal
biventricular systolic function. The interventricular septum
shows dyssynchronous motion consistent with pacing. There is a
bioprosthesis located in the aortic position. It is well seated
and displays normal leaflet motion. No significant aortic
regurgitation is appreciated. The maximum gradient across the
aortic valve is 14 mmHg with a mean of 7 mmHg at a cardiac
output of 4.2 liters/minute. The effective orifice area of the
valve is 1.4 cm2. The mitral regurgitation is somewhat improved
- now moderate in severity. The tricuspid regurgitation is
somewhat improved - now mild. The thoracic aorta appears intact
after decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**8-6**] was taken to the
Operating Room where he underwent aortic valve replacement and
ascending aortic endarterectomy. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in unstable condition on Neo
Synephrine. he subsequently stabilized and was weaned from
sedation, awoke neurologically intact and extubated.
On [**8-8**] he underwent a right thoracentesis for 1200cc of straw
colored fluid. He later that day was found to have a
significant hematocrit drop. A chest tube was placed for about
2 liters of dark blood and he suffered a cardiac arrest.
Closed, then open massage were performed and he returned to the
Operating Room. He was returned to the ICU on Epinephrine, Neo
Synephrine and Nitroglycerin infusions with an open chest. He
stabilized, and on [**8-10**] returned to the operating Room for chest
washout and closure. He remained on multiple pressors. He
became severely oliguric and CVVH was instituted with renal
consultation. Fluid was removed gradualy and he weaned from
pressors. Tube feeding was instituted and he gradually awoke.
He was transitioned to hemodialysis and as renal function
stabilized he was given a holiday from dialysis and remained
stable. He was extubated with some stridor which responded to
racemic Epinephrine. he improved, was able to swallow and tube
feeds were discontinued. He should have nectar-thick foods with
ground solids for dysphagia. He become progressively more alert
and was intact. Physical Therapy worked with him for
strengthening and he was screened for transfer to a
rehabilitation facility. He completed abx therapy today. Sternal
wound should be washed with hydrogen peroxide when showered. He
is to return to [**Hospital Ward Name 121**] 6 in 7 days for wound check and removal of
remaining sutures. Foley may be removed tomorrow [**8-30**]. Cleared
for discharge to [**Hospital1 **] at [**Hospital1 **] on [**8-29**]. Follow up appts
were advised.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
2. Doxazosin 1 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS (at bedtime).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Year (2) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [**Month/Year (2) **]: One (1)
Tablet PO DAILY (Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
[**Month/Year (2) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold for sbp<100, hr<50.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) neb Inhalation Q6H (every 6 hours).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units SC Injection TID (3 times a day).
6. Simvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): hold for HR <55 or SBP <90 and call provider.
8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
10. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Aortic Stenosis
chronic atrial fibrillation
Hypertension
Systolic and diastolic congestive heart failure
Hyperlipidemia
anemia-chronic
Benign Prostatic Hypertrophy
Moderate pulmonary Hypertension
s/p Aortic Valve Replacement
s/p ascending aortic endarterectomy
s/p postop cardiac arrest with mediastinal exploration
chest reclosure
coronary artery disease
Chronic Kidney Disease
s/p cataract surgery
s/p basal cell carcinoma excision from face
s/p Tonsillectomy
post operative acute renal failure
dysphagia
Discharge Condition:
Alert and oriented x3 nonfocal
uses lift; does not ambulate
Incisional pain with tylenol prn
mild BLE edema
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Please shower daily including washing incisions gently with mild
soap,STERNAL INCISION TO ALSO BE WASHED WITH HYDROGEN PEROXIDE;
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage
FOLEY [**Month (only) **] BE REMOVED TOMORROW [**8-30**]
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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound check and suture removal [**Hospital Ward Name 121**] 6 Wed [**9-5**] @ 10:30 AM
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]),on Tuesday, [**9-18**] at
1:00 PM
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 2205**]in [**1-21**] weeks
Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in [**1-21**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2136-8-29**]
|
[
"807.09",
"584.5",
"585.9",
"428.43",
"287.5",
"511.89",
"482.83",
"998.11",
"518.5",
"285.1",
"E870.5",
"807.2",
"427.5",
"414.01",
"428.0",
"427.31",
"998.0",
"403.90",
"600.00",
"997.31",
"440.0",
"424.0",
"998.2",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.14",
"34.79",
"34.03",
"39.95",
"39.61",
"96.72",
"35.21",
"38.93",
"78.41",
"37.91",
"00.40",
"96.04",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
8574, 8649
|
4419, 6475
|
286, 534
|
9200, 9370
|
2296, 4396
|
10403, 11161
|
1445, 1655
|
7290, 8551
|
8670, 9179
|
6501, 7267
|
9394, 10380
|
1670, 2277
|
227, 248
|
562, 863
|
885, 1208
|
1224, 1429
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,606
| 164,751
|
49617
|
Discharge summary
|
report
|
Admission Date: [**2135-2-20**] Discharge Date: [**2135-2-24**]
Date of Birth: [**2061-9-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fever, tachypnea
Major Surgical or Invasive Procedure:
Thoracentesis [**2-21**]
History of Present Illness:
73yo M w/ long hx of CLL on chronic steroids and c/b AIHA,
hypogammaglobinemia, recent R hip fx ([**1-6**]) s/p R hip nail and
ORIF and recurrent pna's, who now presents with fever and pna.
Since [**October 2134**] pt has had off and oncough w/ sputum. In [**Month (only) **] tx w/
outpt levaquin. Then admitted multiple times:
[**11-16**]- chest CT neg, AFB negc3, pertusis neg, 1 cx G(-)rods - tx
w/ cefepime
[**11-25**]-worsening SOB, CT neg, improved w/ lasix
[**12-8**]- RSV infection (no lower respir infxn) s/p IVIG and
levaquin x5d
[**12-27**]- multilobar pna + persistent RSV infxn, blood cx + for
Strep pneumo, tx w/ cefpodxime
[**1-6**]- R femur fx, difficulty extubating, tx w/ Meropenem + Vori
and bronc on [**1-12**] showed [**Female First Name (un) **] (contaminant), but w/ elev
B-glucan tought to be fungal PNA (from other than [**Female First Name (un) **]), and
has remained on fluconazole since then. Also tx w/ rituxand and
IT mtx. D/c on [**2135-2-10**] to [**Hospital1 **] for rehab.
At [**Hospital1 **] he was initially doing well, and started walking
again. He has had persistent intermittent cough that has
unchanged in frequency or severity over the last 1.5 wks. It
occasionally productive w/ clear sputum. [**Name (NI) **] AM pt had a fever
100.1 and went away on its own, but Dr. [**First Name (STitle) **] from [**Hospital1 **]
reported the pt was more lethargic and started Vanc/Ceftaz and
wanted to see how he does. The next morning (today) pt had a
fever 100.8 and was significantly more weak, and had tachypnea,
and was brought in.
In [**Hospital1 18**] ED, 99.8, hr 98, 141/85, rr40, NRB 98% on ?o2. Exam
demonstrated bil rhonchi. Labs notable for hct drop from
baseline, no clinical signs of bleed. given vancomycin and
zosyn for presumed pna. But due to tachypnea out of proportion
to cxr for pna, CTA ordered to rule out pe. Placed on bipap for
tachypnea, with clinical improvement. Vital signs in ED prior
to transfer: 129/76, hr 87, rr 28, 100%, fio2 100%. Access 18,
picc, full code.
Past Medical History:
-CLL/SLL, on Rituxan/Bedamustine
-Recurrent pleural effusions, status post right pleurodesis on
[**2131-10-1**]. He has continued with loculated effusion on the
right, although currently improved
-Hypogammaglobulinemia, receiving IVIG q. monthly during winter
months in particular, most recently [**2134-11-17**]
-Recurrent pneumonias, requiring admissions periodically
-Peptic ulcer disease
-Status post right inguinal hernia repair
-Status post skin biopsies of the left neck, left shoulder, left
ear biopsy consistent with hypertrophic actinic keratoses
-Basal cell carcinoma with Mohs procedures of the left chest,
left scalp area, area of squamous cell carcinoma noted on the
right forehead with Mohs procedure
-Status post left hip femoral head stress fracture [**2131-2-14**].
-Status post T5 and T12 vertebral fractures on [**2131-10-23**].
-RSV
-IVC compression by RP LAD causing lower extremity edema
-Autoimmune hemolytic anemia related to CLL, on prednisone x10
years
Social History:
Mr. [**Known lastname 103757**] lives with his wife in [**Name (NI) **]. He is retired
and previously worked doing maintenance. Prior to this he was a
soccer coach in his home country of [**Location (un) 3156**]. He moved from the
[**Location (un) 3156**] before Chernobyl. He is a prior smoker, previously
smoked 10 cigarettes for 10 years but quit approximately 25
years ago. He denies any alcohol or IVDU.
Family History:
Notable for his son who has AML in remission.
Physical Exam:
On admission:
GENERAL: Pleasant, mild resp distress
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=9cm
LUNGS: bibasilar rales, and rales throughout R lung
ABDOMEN: +BS, soft, LUQ firm mass (likely stool), No HSM
EXTREMITIES: 2+ LE edema R>L, RLE improved from previous per
wife
SKIN: [**Name2 (NI) 103759**] at abdomen
NEURO: A&Ox3
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
CXR: Bilateral pleural effusions, left greater than right
CTA: IMPRESSION:
1. No evidence of PE, dissection or pneumothorax.
2. Slight increase in large left and moderate right pleural
effusion.
3. Interval decrease in size of right upper lobe pulmonary
nodule, evaluation
of lung parenchyma is limited by motion artifact.
Pleural fluid:
Many lymphocytes, mesothelial cells and blood.
Repeat CXR:
Moderate bilateral pleural effusion, right greater than left,
increased
bilaterally since [**2-22**]. No pneumothorax. Lungs grossly
clear. Heart
size normal. Ascending thoracic aorta tortuous or dilated but
not acutely
changed. No pneumothorax.
LABS:
[**2135-2-20**] 10:50AM BLOOD WBC-5.4 RBC-2.24*# Hgb-7.9*# Hct-23.0*#
MCV-103* MCH-35.2* MCHC-34.3 RDW-21.5* Plt Ct-32*#
[**2135-2-23**] 04:01AM BLOOD WBC-6.1 RBC-2.73* Hgb-9.6* Hct-27.1*
MCV-99* MCH-35.3* MCHC-35.6* RDW-22.2* Plt Ct-26*
[**2135-2-21**] 03:42AM BLOOD Neuts-17* Bands-0 Lymphs-76* Monos-1*
Eos-0 Baso-0 Atyps-6* Metas-0 Myelos-0
[**2135-2-21**] 03:42AM BLOOD PT-16.9* PTT-26.2 INR(PT)-1.5*
[**2135-2-20**] 10:50AM BLOOD Glucose-92 UreaN-15 Creat-0.5 Na-133
K-4.2 Cl-95* HCO3-30 AnGap-12
[**2135-2-23**] 04:01AM BLOOD Glucose-71 UreaN-25* Creat-0.7 Na-135
K-4.3 Cl-102 HCO3-23 AnGap-14
[**2135-2-21**] 03:42AM BLOOD LD(LDH)-348* TotBili-2.4*
[**2135-2-20**] 10:50AM BLOOD CK(CPK)-4*
[**2135-2-20**] 10:50AM BLOOD cTropnT-<0.01
[**2135-2-23**] 04:01AM BLOOD Calcium-11.1* Phos-2.1* Mg-2.2
[**2135-2-23**] 06:21AM BLOOD Type-ART Temp-36.7 O2 Flow-3 pO2-85
pCO2-35 pH-7.50* calTCO2-28 Base XS-3 Intubat-NOT INTUBA
[**2135-2-20**] 11:15AM BLOOD Lactate-2.7*
Glucan positive, galactomannan negative.
Brief Hospital Course:
73yo M w/ long hx of CLL on chronic steroids and c/b AIHA,
hypogammaglobinemia, recent R hip fx ([**1-6**]) s/p R hip nail and
ORIF and recurrent pna's, returns with presents with PNA (cough,
tachycardia, hypoxia) and after treatment with antibiotics and
therapeutic thoracentesis without improvement, family discussion
reached conclusion of making pt [**Name (NI) 3225**].
#. [**Name (NI) 103760**] Pt was brought to the ICU w/ his tachypnea, and
placed on bipap. Once he reached the ICU pt was taken off the
bipap and was found the was 97-100% on RA. His RR was still in
the 40-50s. This was attributed to his pleural effusions. He
also has a h/o Recurrent pleural effusions, status post right
pleurodesis on [**2131-10-1**]. A left thoracentesis was performed w/
1100cc of bloody fluid removed, sent for cytology, cell count
and diff, hct, and was c/w malignant effusion. Pt had tachypnea
that improved post-thoracentesis w/ RR in 20s increasing to 30s
the following day. Central hyperventilation was considered from
a CNS infection but thought low likelihood and LP was not
pursued after discussion w/ Hem/Onc. CXR on [**2-23**] showed
significant reaccumulation of the fluid. Pleurodesis was
discussed, but w/ such rapid reaccumilation and pt being near
end of life, decision was made to focus on comfort and pt was
made [**Month/Year (2) 3225**]. He was transferred out of the ICU, where he became
lethargic and minimally aroused. Nasal cannulla supplementary
oxygen was continued for comfort breathing, and morphine ordered
for liberal use if breathing appeared labored or pt in pain.
Vital signs checks were discontinued. Pt passed away on [**2-24**]
from cardiopulmonary arrest, with family by the bedside.
#. Fever - pt has had chronic cough since [**Month (only) **], and reccurent
PNA. No focal infiltrate on CT. Pt may have pnau Pt may be
immunocompromised from CLL and will tx. Pt received Vanc/Zosn in
ED. Pt may have developed a PNA vs. pneumonitis, but was placed
on Vanco/Zosyn and Fluconazole prophylactically. Pt's glucan was
still elevated at 219 (previous admission [**1-26**]- 411, [**2-6**]- 330).
Also pt's PICC was removed as from OSH, and was d/c'd. Pt's
fever's resolved after PICC was removed. Abx were stopped once
pt made [**Month/Year (2) 3225**].
#. Volume status- initially it was thought pt may be
hypervolemic, but no h/o heart failure - previously fluid
overloaded on previous admission, currently 2+ LE edema,
bibasilar rales. Pt does have a h/o IVC compression by RP LAD
causing lower extremity edema No significant cardiomegaly, and
very mild blunting of costophrenic angle. Lasix 40 IV x1 was
given, and pt became tachycardic to 130s. Pt's MM dry and pt
recieved fluid boluses. All volume status management was stopped
once code status was changed to [**Month/Year (2) 3225**].
#. Hypogammaglobinemia- IVIG was on [**2135-1-4**], planned to get
monthly in winter months. Gave IVIG on night of admission, but
pt developed rigors, temp to 100, and hypertension to 180s. IVIG
was stopped, pt was given IV benadryl and tylenol. Restarted
next day w/ premedication and pt tolerated well.
#. CLL - per outpt onc, on Rituxan/Bedamustine. All bloodwork
and transfusion parameters discontinued once made NPO. For
secondary autoimmune hemolytic anemia, pt was continued on his
chronic steroids, also until made NPO.
#. S/p femur fx - Pain was well controlled
# FEN: Swallow study passed, but recommendation remained NPO,
crush meds, and can give occasional soft diet given pt's poor
mental status
#PPX: Pt was prophylaxed with pentamidine, Acycolovir, IVIG, and
pneumoboots until made [**Year (4 digits) 3225**].
Medications on Admission:
- acyclovir 400mg TID
- albuterol neb q6 prn
- ipratrop neb
- benzonatate 100mg TID
- codeine-guaifenisn 100/10
- fentanyl 25mcg/h q72
- fluconazole 400mg QD
- advair 250/50
- folic acid 1mg QD
- lidocaine patch q12
- protonix 40mg QD
- pentamidine 300mg qmo
- prednisone 10mg QD
- vit b12 1000mcg QD
- delsym q12 prn cough
- colce
- senna
- MVI
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia, pleural effusions, CLL
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2135-6-28**]
|
[
"584.9",
"533.90",
"287.4",
"414.01",
"493.90",
"E878.1",
"279.00",
"V58.65",
"486",
"283.9",
"204.10",
"799.4",
"999.31",
"799.02",
"288.00",
"707.03",
"511.9",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10346, 10355
|
6248, 9903
|
339, 365
|
10432, 10441
|
4560, 6225
|
10494, 10665
|
3879, 3926
|
10317, 10323
|
10376, 10411
|
9929, 10294
|
10465, 10471
|
3941, 3941
|
283, 301
|
393, 2432
|
3955, 4541
|
2454, 3436
|
3452, 3863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,823
| 165,135
|
36532
|
Discharge summary
|
report
|
Admission Date: [**2101-4-11**] Discharge Date: [**2101-4-25**]
Date of Birth: [**2061-5-4**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Erythromycin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 13013**] is a 39 yo female with h/o Bipolar and
Schizoaffective disorder who presents from [**Hospital3 **]
with hypoxia. Per report, pt had been having mild respiratory
complaints recently. Mother notes that the patient complained of
lip and eye swelling on Friday and was seen at [**Hospital **]
hospital. She was cleared medically and then admitted to
[**Hospital3 **] for benzo detox. At [**Hospital1 **], she was
noted to have LE edema and hypoxia and so was transferred to the
[**Hospital1 18**] ED. In the ED, her O2 sat was normal, workup was only
notable for 3+ LE edema and elevated bicarb. When her mother saw
her on the following day, she noted that the pt's "body looked
swollen". On routine vitals earlier today she was found to have
a RA sat in the mid-80s. On repeat check, her sat was 94%, but
then dropped to the mid-80s again. EMS was called. On their
arrival, once again her sat was in the mid 80s with a good
tracing. She was placed on a non-rebreather mask and brought to
[**Hospital1 18**].
.
In the ED, initial vitals were: T 97.2, BP 117/74, HR 101, R 32,
O2 sat 89% on supplemental O2 (unclear how much). Exam was only
notable for intermittent agitation, no respiratory distress,
lungs clear, mild LE swelling. Pt was noted to desat to 70-80s
on RA with purplish tint to lips and requiring 10L supplemental
O2. ABG was 7.37/70/48 on RA with lactate 0.8. No leukocytosis.
Negative serum tox. CXR was clear. CTA chest negative for PE.
Patient was given neb with minimal effect. Also received
solumedrol, ceftriaxone, motrin, risperdal and ativan. She was
admitted to the MICU for further evaluation.
.
On the floor, she has no complaints. She denies SOB, chest pain,
chest tightness, cough. Repeat ABG on NRB was 7.31/75/126. When
taken off of NRB, her O2 sats drifted to the low 80s and pt did
complain of some SOB.
Past Medical History:
-Hepatitis C- dx one year ago, felt to be contracted sexually,
untreated, liver bx 1 month ago reportedly negative
-Bipolar Disorder
-Schizoaffective disorder
-Raynaud's
Social History:
Lives in a group home for the past 1.5 years. Formerly lived in
the downstairs apartment of her mother's house. Smokes [**12-10**] pack
per day, pt does not know for how many years. Denies EtOH or
illicit drug use.
Family History:
Father with bipolar disorder.
Physical Exam:
Vitals: T 95.5 (ax), BP 137/77, HR 89, RR 14, SaO2 98% on NRB-->
low 80s on RA
General: appears fatigued, laughing inappropriately, no acute
distress
HEENT: Sclera anicteric, MMM, poor dentition, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diminished breath sounds bilaterally, no wheezes or rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, diffuse mild tenderness to
palpation without rebound or guarding, bowel sounds present, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, trace bilateral LE edema
Neuro: A+O x 2 (name, [**Hospital1 18**]), CNII-XII intact, motor [**4-12**]
throughout, difficulty with finger-to-nose and rapid alternating
hand movements with the left arm, no difficulty on right
Pertinent Results:
[**2101-4-11**] 11:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR
[**2101-4-11**] 11:52PM URINE RBC-0-2 WBC-[**2-10**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2101-4-11**] 08:42PM TYPE-ART PO2-48* PCO2-70* PH-7.37 TOTAL
CO2-42* BASE XS-11
[**2101-4-11**] 08:42PM LACTATE-0.8
[**2101-4-11**] 06:40PM GLUCOSE-112* UREA N-13 CREAT-0.7 SODIUM-142
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-39* ANION GAP-9
[**2101-4-11**] 06:40PM ALT(SGPT)-16 AST(SGOT)-24 CK(CPK)-43 ALK
PHOS-72 TOT BILI-0.2
[**2101-4-11**] 06:40PM cTropnT-<0.01
[**2101-4-11**] 06:40PM CK-MB-NotDone proBNP-69
[**2101-4-11**] 06:40PM ALBUMIN-3.8
[**2101-4-11**] 06:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-4-11**] 06:40PM WBC-7.3 RBC-4.23 HGB-13.0 HCT-39.8 MCV-94
MCH-30.6 MCHC-32.5 RDW-14.9
[**2101-4-11**] 06:40PM NEUTS-51.5 LYMPHS-35.6 MONOS-7.7 EOS-4.7*
BASOS-0.5
[**2101-4-11**] 06:40PM PLT COUNT-162
[**2101-4-11**] 06:40PM PT-12.8 PTT-25.5 INR(PT)-1.1
Lung Scan ([**2101-4-14**]): Prelim read - no evidence of shunt
Brief Hospital Course:
This is a 39 year old female with schizoaffective and bipolar
disorder who presents with hypoxia and hypercarbia.
# Hypoxia: Patient presented with significant hypoxia with
oxygen saturations occasionally falling into the 60s on room
air. Etiology of hypoxia appeared to be multifactorial. On
presentation patient was severely sedated. This hypoventilation
with subsequent atelectasis was a significant contributor.
After sedating psychiatric medications were held her hypoxia and
hypercarbia mildly improved and her symptoms resolved. Echo
with bubble study was performed that ruled out any septal
defects or cardiac malformations that could be causing a shunt.
CTA showed no evidence of PE. EKG was without ischemic changes,
cardiac enzymes were negative and telemetry was without events.
Echo and chest x-ray showed no evidence of pulmonary effusion or
CHF. PFTs supported significant underlying COPD--degree of which
was surpising for patient's 25 year smoking history. She also
had diminished diffusion capacity on PFTs but without clear
evidence of interstitial edema or fibrosis on imaging. She had
no fever or leukocytosis during admission but infiltrate on CT
chest suggested infectious etiology so patient was treated with
a 5 day course of levaquin. The Pulmonary team followed this
patient throughout her admission. They determined that the
patient likely has a chronic hypoventilation syndrome. This
hypoventilation in setting of underlying COPD, sedation,
obesity, and pneumonia is likely responsible for this patient's
hypoxia and hypercarbia on admission. During her admission
patient's saturations improved. At time of discharge she was
maintaining saturations greater than 90% on room air while
awake. With ambulation she would occasionally fall to 88%. At
night, however, patient's oxygen saturations would fall to
80-85%. Would strongly consider outpatient sleep study to
evaluate for obstructive sleep apnea. Patient has a BMI of 30
but would likely benefit from weight loss. Sedating meds such as
Depakote were held and benzos were minimized as much as
possible. Patient will require night-time oxygen therapy via
nasal cannula when discharged. She was counseled at length about
the risks of smoking to her lungs and in the setting of
supplemental oxygen. She did not smoke during her admission and
was continued on nicotine patches after discharge. Patient will
be followed by Dr. [**First Name (STitle) 437**] in Pulmonary Clinic.
# Hypercarbia: Patient presented with diminished breath sounds
and rapid respiratory rate exacerbating likely chronic
hypoventilation. With smoking history, paraseptal emphysema on
CT, and PFTs support diagnosis of COPD. Patient did not appear
to have contributory muscular weakness on exam. She was started
on spiriva and advair with albuterol prn.
# Bipolar/Schizoaffective Disorder: Known history of bipolar and
schizoaffective disorder would give patient limited reserve in
the setting of hypoxia, hypercarbia, and hospitalization in an
unfamiliar setting. No other electrolyte abnormalities, no
underlying infectious process. Restarted outpatient psychiatric
medications with exception of depakote and clonazepam and
minimized sedating medications. Patient was followed by the
Psychiatry team throughout admission. They agreed with the
medication changes. Patient did well throughout
hospitalization. She was very cooperative with limited evidence
of psychosis.
# Pediculosis: Dermatology consulted. Recommended medicated
shampoo and oral ivermectin x 2 separated by one week. Lice and
viable nits were absent on day of discharge. There remained
evidence of old, dead nits which would require intensive
fine-tooth combing and likely further oil therapies to have them
removed. Patient requires no further treatments unless lice
return. Group home was notified of patient's lice and
instructed to screen other residents of the group home.
Medications on Admission:
Augmentin 1 tab PO BID x 14 days
Claritin 10mg PO daily
Flonase 2 sprays to each nostril daily
Ativan 0.5mg PO TID prn
Depakote ER 2000mg PO qHS
Risterdal 3mg PO BID
Trilafon 16mg PO BID
Clonazepam 1mg PO BID
Vistaril 25mg PO TID
Lasix 20mg PO daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation every four (4) hours as needed for wheezing.
Disp:*1 inhaler* Refills:*1*
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal QAM.
Disp:*30 Patch 24 hr(s)* Refills:*2*
3. Perphenazine 8 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for agitation.
Disp:*120 Tablet(s)* Refills:*0*
4. Risperidone 3 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Supplemental Oxygen
For treatment of chronic hypoxia please continue to use
supplemental oxygen at night via face mask or nasal cannula.
Self administer QHS.
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation QAM.
Disp:*30 Cap(s)* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) INH Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO TIDprn as needed
for anxiety, agitation.
Disp:*90 Tablet(s)* Refills:*0*
9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] health systems
Discharge Diagnosis:
Primary Diagnosis
1. Hypoxia
2. Pediculosis
Secondary Diagnosis
Schizoaffective disorder
Chronic obstructive pulmonary disease
Discharge Condition:
Hemodynamically stable, afebrile, oxygen saturations greater
than 90% on room air when awake.
Discharge Instructions:
You were admitted to the hospital with low oxygen levels. This
was most likely from a variety of causes, including side effects
from your medications which were making you sleep a lot, from
changes to your lungs because of your smoking history, from not
taking deep breaths, and from a lung infection called pneumonia.
We made the following changes to your medications:
1. We STOPPED your Depakote, Clonazepam, Lasix, Augmentin,
Flonase, and Vestaril.
2. We STARTED albuterol inhaler, tiopropium (spiriva), and
fluticasone-salmetrol (advair).
It will also be important for you to wear your oxygen mask at
night to help your lungs.
Please return to the ER or call your primary care doctor if you
develop shortness of breath, chest pain, increased leg swelling,
lightheadedness, dizziness, fever, chills, or any other
concerning symptoms.
Followup Instructions:
Please follow up with Pulmonary (Lung) doctor Dr. [**First Name (STitle) 437**]
[**Telephone/Fax (1) 612**] on [**2101-5-13**] at 11:00am at [**Hospital1 18**] [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Building [**Location (un) **] Medical Specialities.
Please follow up with your Primary Care Doctor Dr. [**Last Name (STitle) 4020**]
[**Telephone/Fax (1) 82715**] on Monday [**5-9**] at 12:45 pm.
Please follow up with your Psychiatrist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 82716**].
His will be calling your group home to notify you of the time
and date of this appointment.
|
[
"305.1",
"295.70",
"278.00",
"E939.4",
"293.0",
"296.80",
"486",
"E936.3",
"V85.30",
"276.2",
"518.81",
"780.57",
"496",
"518.0",
"132.0",
"443.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10004, 10065
|
4626, 8552
|
295, 301
|
10237, 10333
|
3490, 4603
|
11221, 11833
|
2636, 2667
|
8852, 9981
|
10086, 10216
|
8578, 8829
|
10357, 10699
|
2682, 3471
|
10728, 11198
|
248, 257
|
329, 2194
|
2216, 2388
|
2404, 2620
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,540
| 115,742
|
29940
|
Discharge summary
|
report
|
Admission Date: [**2177-12-20**] Discharge Date: [**2178-1-13**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Esophageal food impaction and esophageal perforation.
Major Surgical or Invasive Procedure:
Rigid and flexible esophagoscopy and retrieval of esophageal
foreign body, right thoracotomy and repair of distal esophageal
perforation, intercostal muscle pedicle flap.
History of Present Illness:
88 y F h/o dementia and AF who presents upon transfer from
[**Hospital3 **] with a esophageal food impaction. She presents
today with a copied chart but no formal discharge summary.
History is as best obtained with these sources and the help of
her son. Pt originally presented [**12-18**] with a chocking episode
and hypoxia. Family noticed some worsening shortness of breath
on the day the patient had a episode of choking on her meal.
During this episode she appeared to choke, then coughed up some
food and developed some respiratory distress. In the ED, she
was found to be hypoxic with sat 75%. Pt was w/o symptomatic
complaint at that time. Pt admitted to ICU with diagnosis of
aspiration pnuemonitis and possible CHF. Treated with
ABx(levofloxacin/clinda) and diuresis. Diuresis complicated by
episodes of hypotension. AFib management unclear. Underwent 2
subsequent EGDs both of which unsuccessful in clearing a large
food bolus impacted in her esophagus. Pt transferred to [**Hospital1 18**]
for further management. Upon arrival, pt confused and
tachycardic, hemodynamically stable. Pt unable to give history
and denies any symptomatic complaints.
Past Medical History:
osteoporosis
afib
dementia
Social History:
Pt lives alone. No alcohol or tobacco use.
Family History:
Non-contributory.
Physical Exam:
T 98.4 P 121 BP 131/78 R 28 SaO2 95% FM
gen- agitated, tachypneic but comfortable appearing
heent- perrl, op wnl, mmm
neck- supple, JVP not visible at 45 deg
cvs- tachycardic and [**Last Name (un) 3526**], no murmurs obvious
pulm- decreased BS right base with bibasilar rales
abd- soft, ND, no apparent tenderness, +BS
ext- WWP, no edema
neuro- alert and oriented times self, moving all extremities, no
obvious motor deficit, answers questions but not appropriately,
not following commands
Pertinent Results:
[**2177-12-20**] 10:12PM BLOOD WBC-10.6 RBC-3.65* Hgb-11.3* Hct-33.8*
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.9 Plt Ct-170
[**2177-12-20**] 10:12PM BLOOD PT-16.1* PTT-34.1 INR(PT)-1.5*
[**2177-12-20**] 10:12PM BLOOD Glucose-105 UreaN-31* Creat-1.0 Na-144
K-3.2* Cl-106 HCO3-29 AnGap-12
[**2177-12-21**] 8:31 am SPUTUM
**FINAL REPORT [**2177-12-23**]**
GRAM STAIN (Final [**2177-12-21**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2177-12-23**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Patient was admitted to the ICU and was intubated for her
respiratory distress which was thought to be due to either
aspiration pneumonia or pneumonitis. The patient's DNR/DNI
status was reversed. She had an EGD on the evening of admission
and found to have broccoli impaction. Large amounts of food was
able to be extracted. An attempt was made to wean the sedation
and extubate the patient the following day. As the propofol
sedation was weaned off, the patient became increasingly
agitated and self extubated herself. She had an adequate oxygen
saturation on 100% face tent and did not require intubation.
The patient was made strict NPO and the plan was to have a
second EGD to reassess for retained food. On [**2177-12-23**], the
patient had another EGD which demonstrated food in the middle
and lower third of the esophagus. The scope was able to be
passed through the site of retained food to the stomach with
moderate difficulty. An attempt was made to push the retained
food particles into the stomach, however this was done without
success. The following day, the decision was made to electively
intubate the patient and re-attempt EGD to try to remove the
food particles with an overtube. However, this attempt was
again unsuccessful and the procedure was aborted.
Thoracic surgery was consulted and the patient went to the OR on
[**2177-12-25**] for a rigid and flexible esophagoscopy in an attempt to
clear the food. During the rigid esophagoscopy, a full
thickness tear was noted in the esophagus at approximatedly 30cm
from the incisors. Informed consent was obtained from the
patient's son for an open repair of her esophageal perforation
which the patient tolerated well and was transferred to the ICU
in stable condition. Post-operatively, the patient was placed
on broad spectrum empiric antibiotics. She was started on TPN
for nutrition.
The patient was able to be extubated on post-op day 1. However,
she required reintubation for repiratory decompensation and
hypotension on post-op day 2. The patient received frequent
bronchoscopies to suction her copious airway secretions and was
started on stress dose steroids for her hypotension. To evaluate
for possible pulmonary embolism, the patient had a CT scan which
showed a 8 x 12 mm thrombus in the left atrial appendage. The
patient was started on a heparin drip for this.
On [**2177-12-30**], the patient was taken to the OR for a tracheostomy
and G tube and J tube placement which she tolerated well. The G
tube was left to gravity and tube feeds via the J tube were
slowly advanced to goal and the TPN was discontinued. The
patient was able to be weaned off the vent and was able to
tolerating breathing via trach collar. Frequent suctionings of
the patient's tracheostomy were done to clear her airway
secretions. The patient finished a 2 week course of ceftriaxone
for Klebsiella that grew from her sputum. The patient also
developed a MRSA pneumonia and was started on Vancomycin for
this.
From a neurologic standpoint, the patient continued to have
delirium throughout her hospital course, being unresponsive to
commands and minimally active. Neurology was consulted to
provide recommendations. EEG showed encephalopathy and MRI/MRA
of the head was essentially normal with no infarctions shown.
If there is improvement in the patient's decreased mental
status, progression would likely be very slow and the hope is
having the patient placed in a rehab facility would help with
her mental status.
The patient's chronic atrial fibrillation was managed with beta
blockers and anticoagulation. She was transitioned to coumadin
from her heparin drip and her INR was monitored closely. From a
fluid/electrolyte standpoint, the patient was diuresed
aggressively for fluid overload and she developed hyponatremia.
Her tube feeds were switched to full strength and her sodium
trended up into the normal range. The patient was discharged on
[**2178-1-13**] in stable condition.
This d/c summary was completed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] and signed by
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP
Medications on Admission:
1. risperidal 0.25 [**Hospital1 **]
2. cardia 120
3. benadryl qhs
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 3 weeks.
2. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
3. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) nebule
Inhalation Q6H (every 6 hours) as needed.
4. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO Q4-6H (every 4 to 6 hours) as needed.
7. Haloperidol Lactate 5 mg/mL Solution [**Age over 90 **]: 0.5 mg Injection
[**Hospital1 **] (2 times a day) as needed.
8. Insulin per sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Northeast-[**Location (un) 38**]
Discharge Diagnosis:
Esophageal food impaction
Esophageal perforation
Atrial fibrillation
Atrial thrombus
Pneumonia
Delirium
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor or seek immediate medical attention if you
experience fever, chills, lightheadedness, dizziness, cough
productive of increased amount of sputum, chest pain, shortness
of breath, palpitations, severe abdominal pain, nausea/vomiting,
or increased drainage, redness, or bleeding from surgical wound.
Let the steri-strips fall off on their own. You may pat the
wound dry and cover with dry dressing.
Activity as tolerated.
Nothing by mouth.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] after you leave your rehab
facility. Please call [**Telephone/Fax (1) 170**] for appointment.
Completed by:[**2178-1-13**]
|
[
"429.89",
"935.1",
"E911",
"998.2",
"530.4",
"427.31",
"518.81",
"482.41",
"349.82",
"733.00",
"276.0",
"482.0",
"294.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"98.02",
"38.93",
"34.04",
"45.13",
"33.22",
"96.71",
"42.89",
"99.07",
"99.15",
"33.21",
"43.19",
"96.04",
"96.6",
"31.1",
"96.72",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
8874, 8950
|
3709, 7890
|
281, 454
|
9098, 9107
|
2326, 3686
|
9611, 9789
|
1778, 1797
|
8006, 8851
|
8971, 9077
|
7916, 7983
|
9131, 9588
|
1812, 2307
|
187, 243
|
482, 1650
|
1672, 1701
|
1717, 1762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,052
| 162,646
|
8930
|
Discharge summary
|
report
|
Admission Date: [**2187-12-13**] Discharge Date: [**2187-12-18**]
Date of Birth: [**2114-4-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Lactose
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB/DOE
Major Surgical or Invasive Procedure:
[**2187-12-13**] Aortic valve replacement with a 27-mm [**Company 1543**]
Mosaic aortic valve bioprosthesis. Replacement of ascending
aorta using a 28-mm Vascutek Dacron tube graft using deep
hypothermic circulatory arrest. Epiaortic duplex scanning.
History of Present Illness:
73 year old male with a history of
lymphoma treated with radiation and chemotherapy and Aortic
Aneurysm followed with serial CT scans. He reported to
DR.[**Last Name (STitle) 6512**]
that he's noticed increasing shortness of breath and dyspnea on
exertion over a week ago. CTA [**12-3**] revealed increasing Thoracic
aortic aneurysm and coronary and aortic valve calcifications.
[**2187-11-14**] TTE revealed severe Aortic stenosis/Ascending aorta and
transverse aorta are dilated measuring 4.9-5.1 cm and 3.3cm/
LVEF=50%. Cath did not reveal significant CAD. Referred
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Lymphoma
Aortic aneurysm
Hypertension
Dyslipidemia
Social History:
Lives with wife. Retired social worker.
-Tobacco history: remote history, occasional cigar
-ETOH: occasional
-Illicit drugs: denies
Family History:
Mother: CAD,
Father: [**Name (NI) **] cancer
Physical Exam:
Pulse:72 Resp:18 O2 sat: 94%
B/P Right: 131/88 Left: 126/91
Height: Weight:
General:A&Ox 3, NAD
Skin: Warm[x] Dry [x] intact x[]
HEENT: NCAT[x] PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [ x]
Heart: RRR [] Irregular [] Murmur [x] SEM IV/V loudest along
LSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Carotid Bruit none pulses Right: 2+ Left:2+
Pertinent Results:
POST BYPASS There is low normal right ventricular systolic
function. The left ventricle displays mild global hypokinesis
with an ejection fraction of about 40 to 45%. There is a
bioprosthesis in the aortic position. It appears well seated.
The leaflets can not be seen very well. There are two trace jets
of aortic regurgitation that are likely perivalvular but image
quality makes definitive diagnosis extremely difficult. The
maximum gradient through the valve is 12 mm Hg with a mean
gradient of 7 mm Hg at a cardiac output of about 4
liters/minute. The effective orifice area of the valve is about
1.7 cm2. There is trace mitral regurgitation. The ascending
aortic gradft can not be well seen. The rest of the thoracic
aorta appears intact after decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2187-12-13**] 14:50
[**2187-12-18**] 03:50AM BLOOD WBC-7.2 RBC-3.25* Hgb-9.4* Hct-27.6*
MCV-85 MCH-28.9 MCHC-34.1 RDW-16.3* Plt Ct-171
[**2187-12-18**] 03:50AM BLOOD Plt Ct-171
[**2187-12-18**] 03:50AM BLOOD PT-13.9* INR(PT)-1.2*
[**2187-12-13**] 11:10AM BLOOD Fibrino-302
[**2187-12-18**] 03:50AM BLOOD Glucose-114* UreaN-37* Creat-1.4* Na-135
K-4.1 Cl-99 HCO3-28 AnGap-12
[**2187-12-13**] 11:22PM BLOOD ALT-16 AST-45* AlkPhos-43 Amylase-72
TotBili-0.6
[**2187-12-18**] 03:50AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.3
Brief Hospital Course:
Admitted [**12-13**] and underwent surgery with Dr. [**Last Name (STitle) 914**].
Transferred to the CVICU in stable condition on titrated
phenylephrine and propofol drips. Extubated the next morning.
PICC placed for access on POD #2.Transferred to the floor on POD
#3 to begin increasing his activity level. Gently diuresed
toward his preop weight. Chest tubes and pacing wires removed
per protocol.Loaded with amiodarone for A fib.He continued to
make good progress and was cleared for discharge to home with
VNA on POD #5.All f/u appts were advised.
Medications on Admission:
allopurinol 100 mg Tablet 2 Tablet(s) by
mouth once a day,enalapril maleate 20 mg Tablet1 Tablet(s) by
mouth once a day ,omeprazole 20 mg Capsule, Delayed
Release(E.C.)
1 Capsule(s) by mouth once a day,pravastatin 20 mg Tablet
1 Tablet(s) by mouth once a day
* OTCs *
aspirin 81 mg Tablet, Delayed Release (E.C.)
1 Tablet(s) by mouth once a day ,calcium carbonate-vitamin D3
500 mg (1,250 mg)-400 unit Tablet 1 Tablet(s) by mouth twice a
day multivitamin Tablet 1 Tablet(s) by mouth once a day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*qs qs* Refills:*0*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400 mg twice a day for 7 days then decrease
to 400 mg once a day for 7 days then decrease to 200 mg until
seen by Dr [**Last Name (STitle) **] .
Disp:*63 Tablet(s)* Refills:*0*
8. warfarin 2 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a
day: dose to be adjusted based on INR with goal 2.0-2.5 - being
followed by [**Hospital3 **] [**Hospital1 **] .
Disp:*60 Tablet(s)* Refills:*0*
9. warfarin 5 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a
day: dose to be adjusted based on INR .
Disp:*60 Tablet(s)* Refills:*0*
10. Coumadin
You have received two different doses of coumadin/warfarin - 5
mg tablets and 2 mg tablets to allow adjust of your dose of
coumadin with goal INR 2.0-2.5 for atrial fibrillation
[**Hospital3 271**] will be following your INR and speaking
with you in relation to what dose to take
You have received 2.5 mg today at the hospital - the VNA will
see you [**12-19**] and draw your lab - from there the [**Hospital 3052**] will tell you how much coumadin/warfarin to take
11. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
13. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic stenosis s/p AVR
Dilated ascending aorta s/p Ascending Aorta Replacement
Postoperative atrial fibrillation
Asthma
Gout
Arthritis
Diverticulosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1 bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2188-1-1**] 2:30 pm
Cardiologist: Dr [**Last Name (STitle) **] [**1-11**] at 9:50 am
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**5-7**] weeks [**Telephone/Fax (1) 31019**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**2187-12-19**]
Results to Anticoagulation management services
phone [**Telephone/Fax (1) 31020**] fax [**Telephone/Fax (1) 31021**]
Please draw INR monday, wednesday, and friday for minimum of 2
weeks
Completed by:[**2187-12-21**]
|
[
"585.9",
"493.90",
"401.9",
"414.00",
"424.1",
"202.80",
"441.2",
"276.2",
"274.9",
"272.4",
"427.31",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"38.45",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7327, 7402
|
3863, 4417
|
292, 549
|
7597, 7792
|
2314, 3840
|
8633, 9471
|
1566, 1613
|
4966, 7304
|
7423, 7576
|
4443, 4943
|
7816, 8610
|
1628, 2295
|
1243, 1316
|
245, 254
|
577, 1149
|
1347, 1400
|
1171, 1223
|
1416, 1550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,270
| 164,108
|
22399
|
Discharge summary
|
report
|
Admission Date: [**2158-11-1**] Discharge Date: [**2158-11-29**]
Service: SURGERY
Allergies:
Demerol
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
External fixation, R femur
ORIF R femur
PEG tube insertion
Tracheostomy
Bronchoscopy
History of Present Illness:
82 year old female presents from OSH s/p fall down a 30 foot
staircase. No LOC, single episode bloody emesis en route to
[**Hospital1 18**]. Pt HD stable during transfer. Pt c/o pain in L hip, R
eye, L leg.
Past Medical History:
Seizure d/o
Htn
CAD
L hemiperesis
s/p craniotomy in [**2124**] for tumor resection
Social History:
Noncontributory
Family History:
Noncontributory
Physical Exam:
R periorbital eccymosis
Blood from b/l nares
C-collar in place
CTA
RRR
soft, NT, ND
Good rectal tone, guaic neg
2+ radial, DP pulses
RLE shortened, externally rotated
No spinal step off or tenderness
Pertinent Results:
[**2158-11-1**] 09:51PM HCT-28.5*
[**2158-11-1**] 04:57PM TYPE-ART PO2-206* PCO2-36 PH-7.37 TOTAL
CO2-22 BASE XS--3
[**2158-11-1**] 04:57PM GLUCOSE-139*
[**2158-11-1**] 10:28AM UREA N-14 CREAT-0.4 SODIUM-144 POTASSIUM-3.6
CHLORIDE-115* TOTAL CO2-23 ANION GAP-10
[**2158-11-1**] 06:56AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
STUDIES:
On admission:
CXR: neg
PXR: neg
Bilateral Hip films: neg
Right Femur films: distal femur fx Knee neg
CT Head: R Meningioma w/small ICH bleed, repeat no change
CT face: nasal fx, R max sinus fx/orbital floor fx
CT Cspine: neg
CT Chest: old L clavicle fx, old L rib fx
CT Abdomen/Pelvis: old R pubic ramus fx, 4cm gallstone
[**11-1**] s/p angio R LE: occluded SFA, recon DP, no PT
[**11-1**] s/p ex fix R femur fx
[**11-2**] Head CT w/ contrast: no bleed, has possible recurr tumor
[**11-2**] TLS XR: T11, L3, L5 compression fx OLD
[**11-6**] Head CT- No interval change
[**11-8**] CXR- worse CHF & worse LLL consolid / effus
[**11-8**] Head CT- No interval change
[**11-13**] CXR- decr LLL consolidation / effusion [**11-14**] CXR- no
change
[**11-14**] Echo- LV nl size/[**Last Name (LF) **], [**First Name3 (LF) **] 75%, tr MR
[**11-15**] LENI's- neg
[**11-16**] trach/PEG
[**11-17**] CXR-slight improvement l. base consolid
[**11-20**] flex ex neg c collar cleared
[**11-21**] CXR: no pna
[**11-23**] CXR: PICC line plcmt
Brief Hospital Course:
Pt presented to the trauma bay on [**2158-11-1**]. The pt was intubated
on arrival due to agitation. Studies on admission were as above,
showing R small ICH into Meningioma; R femur Fx, R max
sinus/orbital floor & nasal Fx, R femur fx, occluded SFA. Pt
was admitted to the Trauama SICU. 2 units PRBCs were given.
Orthopedics, Plastic surgery (covering face), Neurosurgery, and
vascular surgery were consulted. In [**11-2**] the pt had open
reduction of her femur fracture with external fixation. Per
Vascular recs, angiography of the lower extremities was
performed to evaluate for decreased pulses and ABI of 0.2.
Angio was unremarkable. Opthalmology was consulted and found no
evidence of entrapment or globe injury. A head CT was repeated,
showed no change from admission. A left axillary a-line was
placed and a R subclavian central line was attempted
unsuccessfully. The pt was started on prophylactic Unasyn for
her facial fx. On [**11-3**] a spinal CT was obtained, showing T11,
L1,L3 compression fx. On [**11-4**] 2 more units PRBC were given for
persistently low hct (23-25). On [**11-6**] the pt had a right IJ
line placed successfully. The pt was taken to the OR by
orthopedics for internal fixation of the right femur. On [**11-7**]
the pt was started on Lovenox. Neurosurgery stated the small
ICH into her meningioma was nonoperative in nature and signed
off. On [**11-9**] the pts persisten anemia was evaluated by
hematology, who determined the pt has Anti-E and Anti-Jkb
antibodies causing a persistent low-grade hemolysis and mild
transfusion reactions. On [**11-10**] the pt recieved 2 more units
PRBCs. The pt remained stable until [**11-14**] when weaning from the
vent was attempted unsuccessfully. 1 additional unit PRBC was
given. Unasyn was stopped (day 13). On [**11-15**] an echocardiogram
was obtained showing EF >75%, thickened MV, dilated LA. On
[**11-16**] the pt was taken to the OR for tracheostomy and PEG tube
insertion. Optho signed off the pt, diagnosing a traumatic
right 6th nerve palsy that can be followed as an outpt. On
[**11-17**] the pt was started on tube feedings. On [**11-20**] the pt was
noted to be febrile with infiltrates on CXR. A bronchoscopy was
performed with BAL. BAL gram stain showed gram neg rods and the
pt was started on Levofloxacin. The following day the bacteria
was identified as Pseudamonas and ceftazidime was added. Also
on [**11-21**] flex/ex films of the c-spine showed no ligamentous
injury. On that day Heme/Onc left formal recommendations
stating that the pt has what is likely a chronic though
non-classic hemolytic anemia with poor marrow response of
unknown origin. They due to the presence of alloantibodies,
they reccommended transfusing crossmatched blood only when
needed. The also recommended maintaining Hct in the 25-26
range. On [**11-22**] sensitivities showed the pseudamonas showing her
pneumonia to be sensitive to imipenem, which was started. A
Passey-mask was placed. On [**11-23**] a swallow eval showed the pt
to be cleared to take soft solids and advance slowly. On the
same day a psych consult was called for agitation and auditory
and visual hallucinations. Psychiatry made a diagnosis of
multifactorual delerium and recommended standin orders for IV
Haldol. On [**11-24**] the pt had a PICC line placed and her central
line was removed. On [**11-26**] the pt was transferred to the floor.
She remained stable on the floor until [**2158-11-29**] when she was
discharged to an acute rehab facility.
Medications on Admission:
Norvasc 10mg po qd
Provachol 20mg po qhs
ASA
Dilantin 30mg po bid
Keppra 750mg po bid
Vioxx 25mg po qd
Tylenol
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
7. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-26**]
Puffs Inhalation Q6H (every 6 hours).
18. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Haloperidol 1 mg Tablet Sig: 0.5-1 Tablet PO TID (3 times a
day) as needed for agitation.
20. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: as
directed. Subcutaneous twice a day: 16U NPH [**Hospital1 **]. check
fingersticks qid, RISS coverage.
21. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon
Soln Intravenous Q6H (every 6 hours) for 5 days: continue until
[**12-4**].
Disp:*20 Recon Soln(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
R small intracranial hemorrhage
R femur fx
R maxillary sinus, orbital floor, and nasal fx.
occluded SFA
PNA
delirium
allogenic hemolytic anemia
T11, L1,L3 compression fx
6th cranial nerve palsy
Discharge Condition:
stable
Discharge Instructions:
touchdown weight-bearing for RLE x 8wks total.
continue tube feeds: Probalance Full Strength, rate 60ml/hr,
cycle from 7pm-7am.
Heart-healthy diet, encourage POs, perform calorie counts.
Continue antibiotics until [**12-4**].
Followup Instructions:
Please arrange to follow up with Dr. [**Last Name (STitle) 1005**] from orthopedics
in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment.
Call [**Telephone/Fax (1) 1669**] to arrange an appointment with Dr.
[**Last Name (STitle) 58237**] from Neurosurgery any time within the next 4
weeks.
Call ([**Telephone/Fax (1) 376**] to arrange an appointment in trauma clinic
in 2 weeks.
Call [**Telephone/Fax (1) 274**] to arrange to be seen in plastic surgery
clinic for follow up for your facial fractures within 2 weeks.
|
[
"E880.9",
"225.2",
"518.5",
"293.0",
"378.54",
"805.4",
"283.9",
"821.29",
"802.6",
"440.20",
"805.2",
"378.00",
"780.39",
"801.31",
"482.1",
"802.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"79.35",
"88.48",
"31.1",
"43.11",
"78.65",
"96.6",
"96.04",
"78.15",
"79.05",
"99.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8010, 8082
|
2378, 5911
|
224, 310
|
8319, 8327
|
955, 1326
|
8601, 9135
|
703, 720
|
6072, 7987
|
8103, 8298
|
5937, 6049
|
8351, 8578
|
735, 936
|
176, 186
|
338, 548
|
1439, 2355
|
1340, 1430
|
570, 654
|
670, 687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,231
| 152,678
|
49253
|
Discharge summary
|
report
|
Admission Date: [**2118-1-30**] Discharge Date: [**2118-2-4**]
Date of Birth: [**2043-2-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Heparin Agents
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Central line placement
PICC line placement by interventional radiology
History of Present Illness:
74 yo F with CAD s/p CABG, DM, HTN, known AVM of stomach, small
bowel and colon presents with bright red blood per rectum x 1
day. Last admitted in [**12-2**] and had bleeding scan demonstrating
no active bleeding. In the ED, the patient was noted to have
maroon stools, hct 23. EGD in ED revealed nl esophagus,
gastritis in stomach, normal duodenum. The patient denies any
chest pain, SOB, lightheadedness or dizzyness, N/V, abdominal
pain. In the ED, she received 1 unit PRBCs and 1 L of NS.
Past Medical History:
Lower GI bleeds: scopes w/AVMs, diverticulosis
Throbocytopenia (HIT)
MRSA endocardiitis ([**12-31**])
CRI, baseline creat [**4-1**]
CAD s/p MI & CABG '[**15**]
CHF EF >=55% (diastolic)
DM2 on insulin
HTN, hyperlipid
Paroxysmal atrial fibrillation (no anticoagulation)
PUD, Barrett's esoph
Asthma
Hypothyroidism
Osteoarthritis
s/p CCY
Social History:
NO EtOH, tobacco, and drugs. Lives alone at home.
Family History:
Significant for CAD and DM
Physical Exam:
96.8 lying: 62 137/63 sitting: 64 142/52 12 100% (3L)
Gen: pleasant, comfortable, NAD
HEENT: pale conjunctiva, OP clear
neck: supple, large, no appreciable JVD
CV: Reg, distant HS
lungs: CTA bilaterally
Abd: NABS, soft, obese, NT
Ext: 1+ edema on left, trace on R, warm, pink, 1+ DP/PT
bilaterally
Neuro: A&O x 3, CN 2-12 intact, 5/5 strength
Pertinent Results:
[**2118-1-30**] 11:45PM HCT-26.2*
[**2118-1-30**] 12:13PM GLUCOSE-201* UREA N-79* CREAT-4.4* SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-28 ANION GAP-12
[**2118-1-30**] 12:13PM WBC-4.2 RBC-2.37* HGB-7.4* HCT-22.9* MCV-96
MCH-31.1 MCHC-32.3 RDW-16.2*
[**2118-1-30**] 12:13PM NEUTS-74.9* LYMPHS-15.9* MONOS-5.1 EOS-3.7
BASOS-0.4
[**2118-1-30**] 12:13PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+
[**2118-1-30**] 12:13PM PLT SMR-LOW PLT COUNT-97*
[**2118-1-30**] 12:13PM PT-14.2* PTT-26.5 INR(PT)-1.3
Brief Hospital Course:
Hospital course was significant for the following issues:
* GIB: The patient was initially started on [**Hospital1 **] PPI. The patient
underwent EGD which revealed gastritis but no evidence of an
acute bleed. She was admitted to the MICU and transfused a
total of 4 units of PRBCs and serial hematocrits stabilized.
The patient initially had 2 peripheral iv, but subsequently
required R IJ central line placement. She underwent colonoscopy
on [**2118-2-1**] which revealed few angioectasias in the cecum and near
the ileocecal valve, with friable mucosa. No active bleeding
was noted. [**Hospital1 **]-Cap electrocautery was applied for hemostasis.
There were multiple non-bleeding diverticula in the sigmoid
colon and cecum. The patient's hematocrit remained stable and
her diet was advanced.
*CAD: The patient's beta-blocker was initially held in order to
allow accurate hemodynamic monitoring. The patient was
re-started on her beta-blocker prior to discharge. She was
maintained on statin. Aspirin was held given her significant GI
bleeding history.
*CRI: The patient's creatinine was slightly above baseline upon
admission at 4.4. This trended down to her baseline ([**4-1**]) prior
to discharge and she maintained good urine output.
*DM: The patient was maintained on 70/30 and RISS. While NPO,
she received half of her 70/30 dose. Her blood sugars were
somewhat low while in house on her [**Doctor First Name **] diet, so her NPH dose was
reduced.
*Hypothyroid: Patient was continued on synthroid.
*UTI: The patient had a urinalysis consistent with a UTI upon
admission. Though she did not have symptoms, she did have some
fevers while in the ICU. She was initially treated with
levofloxacin; however, her urine culture grew Klebsiella that
was resistant to levofloxacin and to bactrim. Given the
patient's history of penicillin allergy, cephalosporin's were
avoided and she was treated with aztreonam. She received a PICC
line and should continue aztreonam 1g q 12 hours for 5 more
days.
*The patient's code status remained DNR/DNI per her wishes. She
was evaluated by physical therapy and found to be able to make
safe transfers and to be safe for home if she uses her
wheelchair.
Medications on Admission:
[**Doctor First Name **] 60 [**Hospital1 **]
levothyroxine 175 mcg qd
Atorvastatin 10 qd
Flovent 2 puffs [**Hospital1 **]
Atrovent 2 puffs qid
toprol 25 qd
pantoprazole 40 qd
lasix 40 qd
folate
Insulin 70/30 (30 units qAM, 10 units qPM)
Discharge Medications:
1. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Insulin 70/30 70-30 unit/mL Suspension Sig: Thirty (30) units
Subcutaneous qAM.
9. Insulin 70/30 70-30 unit/mL Suspension Sig: Ten (10) units
Subcutaneous qPM.
10. [**Doctor First Name **] 60 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Aztreonam 1 g Recon Soln Sig: One (1) gram Injection twice a
day for 5 days.
Disp:*10 doses* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
The Bostonian - [**Location (un) 86**]
Discharge Diagnosis:
Lower gastrointestinal bleed
Blood loss anemia
chronic renal insufficiency
Coronary Artery Disease
Heparin induced thrombocytopenia
Insulin dependent diabetes
Thrombocytopenia
Discharge Condition:
good, stable hct, tolerating po, ambulating with walker
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2118-2-7**] 4:00
Follow up with Dr. [**Last Name (STitle) 1789**] within 2 weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2118-2-4**]
|
[
"244.9",
"599.0",
"414.01",
"428.30",
"999.9",
"287.5",
"428.0",
"535.40",
"562.10",
"041.3",
"280.0",
"569.85",
"E876.1",
"455.0",
"V45.81",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.43",
"45.13",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5872, 5937
|
2328, 4537
|
324, 412
|
6157, 6214
|
1793, 2305
|
6363, 6783
|
1380, 1408
|
4824, 5849
|
5958, 6136
|
4563, 4801
|
6238, 6340
|
1423, 1774
|
257, 286
|
440, 939
|
961, 1297
|
1313, 1364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,549
| 170,762
|
40971
|
Discharge summary
|
report
|
Admission Date: [**2178-10-9**] Discharge Date: [**2178-10-23**]
Date of Birth: [**2137-2-10**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
retroperitoneal liposarcoma
Major Surgical or Invasive Procedure:
[**2178-10-9**]: retroperitoneal exploration for recurrent high grade
liposarcoma
[**2178-10-20**]: paracentesis
History of Present Illness:
41 year old male with a history of left retropertioneal sarcoma
s/p resection in [**2177-10-2**], insulin - dependent diabetes
who now presents s/p resection of recurrence of his sarcoma. He
initially presented in [**2177-9-1**] wo an OSH with fevers,
leukocytosis, and anemia with a CT scan showing a large psoas
lesion extending into the left kidney. The lesion was resected
one year ago with acute blood loss anemia as the major
complication post op. He was supposed to undergo subsequent
radiation therapy, however, he was lost to follow up because of
an incaceration until he represented in [**Month (only) 205**] of this year to Dr. [**Name (NI) 19165**] clinic. It had become evident that the sarcoma recurred,
thus he went to the OR earlier today for resection. On [**10-9**], he
had resection of the sarcoma, along with psoas resection and a
left nephrectomy. EBL was 5 L. He was transfused a total 6 units
PRBCs, 500cc 5% albumin, and 10 L fluid over the 7 hour surgery.
Hct increased from 31 to 40 post op and pt was admitted to the
[**Hospital Unit Name 153**]. Pt was transferred to the floor on [**10-11**] and underwent
paracentesis on [**10-20**] that returned 4+ PMNs, no microorganisms
identified. JP drain remained in place until discharge with
small amount of chylous fluid collected.
Past Medical History:
asthma
diabetes
left retroperitoneal sarcoma
PSH
Thoracoabdominal resection of left retroperitoneal sarcoma.
Social History:
nonsmoker, moderate EtOH intake
Family History:
No cancer, sister decreased (lupus?) Father with diabetes and
h/o CVA
Physical Exam:
Vitals: 98.9, 93, 116/79, 20, 99%RA
General: AA, Ox3
HEENT: PERRLA, no scleral icterus
PUML: No resp distress
ABD: Soft, Distended, Mid abdominal incision c/d/i, mild pain on
palpation on the L
EXTREM: WWP
NEURO: No focal deficits
Pertinent Results:
Admission labs:
[**2178-10-9**] 05:25PM BLOOD WBC-9.6 RBC-3.47*# Hgb-10.6*# Hct-31.0*#
MCV-90 MCH-30.5 MCHC-34.1 RDW-14.7 Plt Ct-160#
[**2178-10-10**] 09:09AM BLOOD Neuts-83* Bands-7* Lymphs-2* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2178-10-9**] 05:25PM BLOOD PT-16.0* PTT-37.5* INR(PT)-1.5*
[**2178-10-9**] 05:25PM BLOOD Fibrino-143*#
[**2178-10-9**] 07:19PM BLOOD Glucose-168* UreaN-16 Creat-1.1 Na-136
K-5.7* Cl-105 HCO3-22 AnGap-15
[**2178-10-10**] 09:09AM BLOOD ALT-22 AST-31 CK(CPK)-955* AlkPhos-38*
TotBili-0.8
[**2178-10-10**] 02:57AM BLOOD Lipase-45
[**2178-10-9**] 07:19PM BLOOD Calcium-8.2* Phos-5.0* Mg-1.2*
[**2178-10-9**] 01:39PM BLOOD Type-ART pO2-202* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Intubat-INTUBATED
[**2178-10-9**] 01:39PM BLOOD Glucose-126* Lactate-2.6* Na-135 K-4.6
[**2178-10-9**] 01:39PM BLOOD Hgb-12.5* calcHCT-38
[**2178-10-9**] 02:44PM BLOOD freeCa-1.03*
Discharge labs:
[**2178-10-22**] 03:30AM BLOOD WBC-12.7* RBC-2.98* Hgb-8.7* Hct-27.0*
MCV-91 MCH-29.2 MCHC-32.3 RDW-14.0 Plt Ct-828*
[**2178-10-23**] 05:50AM BLOOD Glucose-126* UreaN-15 Creat-1.2 Na-138
K-5.3* Cl-103 HCO3-28 AnGap-12
[**2178-10-23**] 05:50AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.8
Other pertinent results:
[**2178-10-20**] 10:12AM ASCITES WBC-1775* RBC-[**Numeric Identifier 89397**]* Polys-45*
Lymphs-34* Monos-0 Eos-3* Mesothe-2* Macroph-16*
[**2178-10-20**] 10:12AM ASCITES TotPro-2.8 Glucose-119 Creat-1.1
LD(LDH)-261 Amylase-19 Triglyc-334 Misc-LIPASE= 34
Imaging:
CXR [**2178-10-9**]: In comparison with the study of [**10-5**], there is now an
endotracheal tube in place with its tip about 3.6 cm above the
carina. Nasogastric tube appears to extend to the upper
stomach, though the side port cannot be definitely identified as
being below the esophagogastric junction. Very low lung volumes
may account for some of the prominence of the transverse
diameter of the heart. No definite vascular congestion.
Specifically, there is no evidence of pneumothorax. Mild
atelectatic changes are seen at the left base.
CXR [**2178-10-10**]: No previous images. Left subclavian pacer has been
placed, with the leads in the general area of the apex of the
right ventricle and the right atrium. Cardiac silhouette is
within normal limits without definite vascular congestion or
pleural effusion. No evidence of post-procedure pneumothorax.
There is evidence of coronary artery calcification as well as
previous CABG procedure with intact midline sternal wires.
Micro:
[**2178-10-20**] 10:12 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2178-10-20**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
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.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2178-10-21**]): NO ACID FAST BACILLI SEEN
ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Brief Hospital Course:
41 yo M with history of highly undifferentiated retroperitoneal
sarcoma s/p resection in [**2177**], now with recurrence of tumor s/p
resection and left nephrectomy, complicated by an EBL of roughly
5 Liters who was admitted to the [**Hospital Unit Name 153**] and stabilized and sent to
the surgical floor. While on the floor, pt developed abdominal
distension and approximately 3L fluid was drained through
paracentesis. JP drain was then inserted, which produced milky
fluid likely to be chyle. Pt discharged on low-fat diet.
# Acute blood loss anemia: Patient had significant EBL during
his surgery. He was transfused 6u of blood and 2 of FFP. He
was originally requiring pressors and these were weaned down. He
was monitored in the [**Hospital Unit Name 153**] and when he was no longer bleeding was
transferred to the floor. At the time of transfer his HCT was
stable x24 hours. Patient remained HDS on floor with no further
blood loss.
# RP Sarcoma: Now s/p resection and left nephrectomy. Per
surgery. Patient on ancef for post op prohylacis x 3 doses.
Patient will follow up with surgery and rad onc recs on
discharge.
# Pain and epidural catheter: Epidural catheter in, pain
following and recommended adjusting the rate rather than adding
on a pca. Hispain was well controlled at the time of transfer to
the floor. Pain managed with IV pain meds on floor and
transitioned to PO pain meds at time of discharge
# Respiratory failure: Intubated for procedure and remained
intubated overnight on HD!1, he was extubated without problem
and with increased IS and getting OOB his ABG improved and his
respiratory acidosis improved. Saturating >94% on room air at
time of discharge
# Diabetes: Patient's insulin regimen unknown, currently on a
sliding scale. Blood sugars were regularly checked and within
normal limits throuhgout stay on floor.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Glargine 55 Units Bedtime
2. MetFORMIN (Glucophage) 800 mg PO BID
Discharge Medications:
1. HYDROmorphone (Dilaudid) 1-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**2-2**] tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
2. MetFORMIN (Glucophage) 850 mg PO BID
3. Acetaminophen 1000 mg PO Q4H:PRN pain, fever, HA
4. Aspirin 325 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
retroperitoneal liposarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1005**],
It was a pleasure caring for you during your stay at [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. You underwent a re-excision of a left
retroperitoneal mass. You have been recovering well, have
adequate pain control and may return home for your recovery. The
following is a summary of discharge instructions.
MEDICATIONS
1. Please resume all home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
2. Please take all pain medications as prescribed, as needed.
You may not drive or operate heavy machinery while taking
Oxycodone narcotic pain medication. You may also take ibuprofen
800 mg three times a day as needed.
3.We recommended that you take an over-the-counter stool
softener such as Colace and a laxative such as Senna to prevent
constipation while on narcotic pain medication.
4. Please continue to monitor your blood sugars closely. Your
home dose Metformin and Lantus insulin were restarted.
WOUND CARE
1. Monitor your abdominal incision for signs of infection,
including redness that is spreading or increased drainge from
wounds. Please call Dr.[**Name (NI) 1745**] office if you experience any of
these symptoms.
2. Your abdominal staples will be removed at your follow-up
apointment next week.
ACTIVITY
1. No strenuous activity until cleared by Dr. [**Last Name (STitle) 519**]. Otherwise no
strict activity restrictions related to wounds.
2. You may shower and pat your incision dry, do not rub
incision.
Please call Dr.[**Name (NI) 1745**] office or go to the nearest Emergency
Department if you experience any of the danger signs listed
under the heading below.
Followup Instructions:
Please schedule a follow up appointment with Dr. [**Last Name (STitle) 519**] for next
week [**Telephone/Fax (1) 6554**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2178-10-23**]
|
[
"E878.8",
"276.7",
"278.00",
"V58.67",
"158.0",
"493.90",
"250.00",
"997.09",
"953.5",
"V85.25",
"355.8",
"285.1",
"786.2",
"458.29",
"997.49",
"560.1",
"276.2",
"457.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51",
"03.90",
"54.4",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
7869, 7919
|
5436, 7293
|
332, 448
|
7991, 7991
|
3537, 5139
|
9907, 10189
|
1981, 2054
|
7535, 7846
|
7940, 7970
|
7319, 7512
|
8142, 9884
|
3233, 3518
|
2069, 2301
|
5413, 5413
|
5268, 5379
|
265, 294
|
476, 1782
|
2336, 3217
|
5221, 5235
|
8006, 8118
|
1804, 1915
|
1931, 1965
|
5171, 5185
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,172
| 149,793
|
50741
|
Discharge summary
|
report
|
Admission Date: [**2144-12-8**] Discharge Date: [**2144-12-17**]
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
admitted after a fall in the nursing home
Major Surgical or Invasive Procedure:
intubation/mechanical ventilation
History of Present Illness:
[**Age over 90 **] yr old female, NH resident, with PMH significant for HTN,
depression, ?PMR, dementia w/psychotic features who was
transfered from OSH with the question of basilar skull fx. The
patient was found fallen out of wheelchair on her face in pool
of blood. Taken to OSH where then transferred to the [**Hospital1 18**] for
further evaluation of basilar skull fracture. CT head was
negative for fracture. MRI cleared c-spine. In ED, patient
developed respiratory distress and was intubated.
Past Medical History:
1. HTN
2. Dementia with psychotic features
3. Depression
4. ? Polymyalgia rheumatica
Social History:
NH resident
Family History:
Non-contributory
Physical Exam:
General: elderly female, intubated and sedated, + periocular
ecchymoses
HEENT: NC, AT, intubated, MM dry, pupils are pinpoint
Neck: no LAD
CV: regular, nl S1, S2, no m/g/r
Pulm: CTA bilaterally
Abd: + BS, soft, NT, ND
Extr: no c/c/e
Pertinent Results:
[**2144-12-8**] 06:35PM BLOOD WBC-15.7* RBC-4.34 Hgb-13.1 Hct-39.9
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.0 Plt Ct-224
[**2144-12-8**] 06:35PM BLOOD Neuts-84* Bands-8* Lymphs-5* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2144-12-8**] 06:35PM BLOOD PT-12.8 PTT-30.4 INR(PT)-1.0
[**2144-12-8**] 06:35PM BLOOD Glucose-156* UreaN-29* Creat-0.8 Na-144
K-4.2 Cl-109* HCO3-27 AnGap-12
[**2144-12-9**] 08:10AM BLOOD ALT-10 AST-32 CK(CPK)-310* AlkPhos-57
TotBili-0.5
[**2144-12-10**] 03:04AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.2 Cholest-174
[**2144-12-10**] 03:04AM BLOOD Triglyc-659* HDL-39 CHOL/HD-4.5
LDLmeas-88
[**2144-12-15**] 01:55PM BLOOD Vanco-10.7*
[**2144-12-9**] 05:06AM BLOOD Type-ART pO2-335* pCO2-33* pH-7.49*
calHCO3-26 Base XS-3 Intubat-INTUBATED
[**2144-12-8**] 06:44PM BLOOD Lactate-1.8
[**2144-12-9**] 01:55PM BLOOD freeCa-1.14
Micro:
Influenza A positive (confirmed by culture).
Radiology:
CT head neg
CT cspine neg
CTA chest neg
CXR PNA
CT abd/pelvis neg for bleed; old rib fx and L pelvic fx
MRI no acute fx (old compression fx)
ECHO [**2144-12-10**]: EF 25-30%. Anteroseptal and apical AK/HK and
inferior akinesis with hypokinesis elsewhere. The left
ventricular inflow pattern suggests impaired relaxation. 1+ AR,
2+ MR
Brief Hospital Course:
The patient was admitted in respiratory failure secondary to
influenza A infection. The patient was intubated in the
emergency room. She had troponin leak with normal CKMB, MB index
attributed to demand ischemia. She was continued on Plavix,
Valsartan. Aspirin was not given because of history of allergies
and beta-blocker was held secondary to hypotension. She then
developed dense retrocardiac opacity on CXR on [**12-13**] and
was started on empiric treatment with Vancomycin and Levaquin
for ventilator associated pneumonia. She has been receiving
fludrocortisone and hydrocotisone given chronic steroid use.
Patient was very sensitive to sedation and her sedation was
difficult to titrate due to either over sedation or agitation.
During one of the attempts to decrease sedation in order to
prepare the patient for extubation she developed a wide complex
tachycardia lasting several minutes that resolved spontaneously.
The rhythm was most likely a SVT with LBBB pattern. Cardiology
was consulted. Per discussion with son who is a health care
proxy, the decision was made to proceed with an attempt to
extubate the patient but he did not want the patient to be re
intubated if the attempt at extubation fails. The patient was
extubated on [**2144-12-16**]. She failed the extubation and was
made comfort measures only per family wishes shortly thereafter.
The patient expired on [**2144-12-17**].
Medications on Admission:
Zyprexa 5 mg qhs, senna, colace, lactulose, MOM on Tuesdays and
Fridays, Calcium carbonate, Vit D, Tylnol prn, Lorazepam 0.5 mg
q8 hrs prn for agitation, Actonel, Diovan 160 mg qd, prednisone
10 mg po qd.
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2144-12-19**]
|
[
"921.0",
"599.0",
"295.30",
"518.5",
"401.9",
"E884.3",
"802.0",
"427.89",
"487.0",
"428.0",
"251.8",
"E932.0",
"414.8",
"725",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"96.34",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4238, 4247
|
2537, 3943
|
272, 307
|
4306, 4479
|
1277, 2514
|
991, 1009
|
4198, 4215
|
4268, 4285
|
3969, 4175
|
1024, 1258
|
191, 234
|
335, 838
|
860, 946
|
962, 975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,353
| 100,373
|
24361
|
Discharge summary
|
report
|
Admission Date: [**2136-8-19**] Discharge Date: [**2136-8-23**]
Date of Birth: [**2101-10-31**] Sex: F
Service: MEDICINE
Allergies:
Ambien
Attending:[**Last Name (NamePattern1) 13159**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
34F with history of insulin-dependent diabetes, cardiomyopathy,
hypomagnesemia and blindness secondary to mitrochondrial
myopathy presents with tachycardia and full body pain. Patient
states she has not been taking her insulin for 2 weeks because
she was visiting a friend. She refuses to explain further, just
saying that she "didn't feel like taking it," despite having
been admitted for DKA in the past. She has chronic issues with
hypomagesemia which results in muscle pains, she reports taht
she was having severe muscle pains and thought she likely had
low magnesium, so she came to the ER. She also was having
tachycardia over the past few days, especially with ambulation,
and began to feel progressively weak and tired, which was
another cause of her to seek care.
She complains of pain in her entire body her arms. Denies
fevers, chills, chest pain, palpitations, abdominal pain,
nausea, vomiting. She has been urinating more frequently.
In the ED, initial VS were: 173 169/105
04:40 162 153/103 28 100%
05:14 130 135/77 32 100%
05:20 8 109 129/75 28 100%
06:21 108 124/75 18 99%
06:57 98.3
07:37 131 121/72 25 99%
08:30 7 108 122/72 18 98%
09:45 3 98.4 83 120/71 13 98%
Rec'd 3050 (incl IL NS w 40 kcl) last K 2.8
Up now D5NS at 125/ hr; Insulin drip
Drips: Insulin drip 100units/100cc at 7 units per hour
Rec'd Dilaudid 0.5mg IV x 3 last dose at 0930 w good effect
Initial Glu 400s- rec'd 16 Units Humalog. Fsbs prior to drip 78.
Given 1 amp Dextrose
Has voided several times large amounts
#18 Rac/ # 20 R ac outer aspect
On arrival to the MICU, the patient says that she feels
nauseous. She says that she has muscle pain in her arms, legs
and some rib pain, which she describes as bone pain. She cannot
pin down whether she has abdominal pain alone. She has not had
any vomiting, but she says that she began to feel nauseous after
she began to drink soda [**Doctor Last Name **] in the ER.
Past Medical History:
Diabetes mellitus, type I
Hypertension
Hypomagnesemia
blindness
Gait disorder
Mitochondrial myopathy
Insomnia
Obstructive sleep apnea- on CPAP
Social History:
Lives alone, enjoys [**Location (un) 1131**] books and listening to TV shows,
sister is in apartment in same building (also blind with same
mitochondrial disorder). Sister's husband recently passed away.
She is independent in ADLs, does not require walking assistance
despite myopathy/vision deficit. Uses walking stick.
Tobacco- denies
Alcohol- denies
Illicits- denies
Family History:
Father- unknown
[**Name (NI) 12237**] [**Name (NI) 2320**]
[**Name (NI) 12408**] mitochondrial myopathy
[**Name (NI) 61697**] colon cancer
Grandmother- breast cancer
Father- unknown
[**Name (NI) 12237**] [**Name (NI) 2320**]
[**Name (NI) 12408**] mitochondrial myopathy
[**Name (NI) 61697**] colon cancer
Grandmother- breast cancer
Physical Exam:
ON ADMISSION [**2136-8-19**]
Vitals: T: 98.2 BP: 129/68 P: 106 R: 18 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
edentulous. Eyes with dilated pupils, not focusing, often with
eyes closed.
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, mild diffuse tenderness, obese, bowel sounds
present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation,
ON DISCHARGE [**2136-8-22**]
PHYSICAL EXAM:
VS - Temp 97.9F, BP 104/67, HR 66, RR 18, O2-sat 99% RA FSBG 105
General: Alert, awake, oriented, no acute distress, flat affect,
laying in bed, pleasant, cooperative, having breakfast
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear, edentulous. Eyes with dilated pupils, not focusing, often
with eyes closed, there is mild horizonatal nystagmus noted,
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, obese, bowel sounds
present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation to light touch and proprioception
bilaterally, no sensation to light touch at right heel
Pertinent Results:
ADMISSION LABS:
[**2136-8-19**] 04:40AM WBC-5.1 RBC-5.47* HGB-15.9 HCT-46.1 MCV-84
MCH-29.1 MCHC-34.6 RDW-15.5
[**2136-8-19**] 04:40AM GLUCOSE-406* UREA N-11 CREAT-1.1 SODIUM-137
POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-13* ANION GAP-26*
[**2136-8-19**] 07:03AM TYPE-[**Last Name (un) **] PO2-150* PCO2-24* PH-7.26* TOTAL
CO2-11* BASE XS--14
[**2136-8-19**] 01:13PM LACTATE-2.8*
[**2136-8-19**] 12:06PM BLOOD Osmolal-292
[**2136-8-19**] 05:52PM BLOOD Glucose-125* UreaN-5* Creat-0.7 Na-138
K-3.5 Cl-110* HCO3-18* AnGap-14
[**2136-8-19**] 07:45PM BLOOD Glucose-84 UreaN-5* Creat-0.7 Na-138
K-3.7 Cl-109* HCO3-20* AnGap-13
MICROBIOLOGY
URINE CULTURE (Final [**2136-8-20**]):MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKINAND/OR GENITAL CONTAMINATION
BLOOD CULTURES [**2136-8-19**]: PENDING
MRSA SCREEN (Final [**2136-8-21**]): No MRSA isolated.
IMAGING [**2136-8-19**]:
PORTABLE AP CHEST RADIOGRAPH: The lungs are clear. No
confluent opacity is identified. There is no pulmonary edema or
pleural effusions. Cardiomediastinal and hilar contours are
within normal limits.
IMPRESSION: No acute cardiopulmonary process
EKG [**2136-8-19**]:
Sinus tachycardia at 160 beats per minute. Low voltage in the
limb leads with much baseline artifact. There appears to be
leftward axis. R wave progression is abnormal consistent with
prior anterolateral myocardial infarction or lead placement.
Clinical correlation is suggested. Compared to the previous
tracing of [**2136-7-28**] sinus tachycardia is new and the abnormal R
wave progression persists.
DISCHARGE LABS:
[**2136-8-23**] 09:05AM BLOOD WBC-2.8* RBC-4.71 Hgb-13.8 Hct-39.3
MCV-83 MCH-29.2 MCHC-35.1* RDW-16.2* Plt Ct-196
[**2136-8-23**] 09:05AM BLOOD PT-11.6 PTT-29.7 INR(PT)-1.1
[**2136-8-23**] 09:05AM BLOOD Plt Ct-196
[**2136-8-23**] 09:05AM BLOOD Glucose-102* UreaN-7 Creat-0.9 Na-139
K-3.3 Cl-105 HCO3-21* AnGap-16
[**2136-8-23**] 09:05AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.2*
Brief Hospital Course:
34 year old female with a significant PMH for insulin-dependent
diabetes, cardiomyopathy, hypomagnesemia and blindness secondary
to mitochondrial myopathy presenting with hypomagnesemia and DKA
likely secondary to noncompliance.
# DKA: Patient was started on an insulin drip in the ED anion
gap and blood sugar had resolved on arrival to the MICU.
Patient tolerated a PO diet and was transitioned to subq
insulin. There were no localizing symptoms concerning for
infectious or ischemic causes of DKA. Given patient's history of
poor control, DKA most likely secondary to non-compliance.
Electrolytes were monitored every 2 hours and repleted. [**Last Name (un) **]
was consulted and saw patient in MICU. Psychiatry was consulted
and medication non-compliance likely [**12-29**] to severe depression.
# respiratory acidosis: was most likely secondary to
hyperventilation in the setting of anxiety. Patient's CO2
resolved on subsequent ABGs.
# Whole Body Pain: the patient reported that she was at
baseline mitrochondrial myopathy pain except that it is
worsened, which may be related to dehydration and concomitant
illness. There are no localizing sx on exam and her pain is
diffuse. She was given minimal doses of PO dilaudid and kept on
on home doses of NSAIDS and tylenol. Her home carisprodol 350 mg
was continued. Her pain improved with correction of magnesium.
# Depression/anxiety: Patient reporting intention of self-harm
by not taking insulin. She was maintained on her home dose of
fluoxetine and lorazepam. She was refusing oral medication and
food intake [**12-29**] to depression. Psychiatry was consulted and
recomended inpatient psychiatric admission. She was agreeable to
this on discharge.
# Lactic Acidosis: likely type A acidosis related to
hypovolemia. Was 3.7 on admission to MICU and normalized on
repeat labs after fluid hydration.
# Hypomagnesemia: Patient on aggressive home repletion with
magnesium gluconate 27mg (500mg) 4 tablets [**Hospital1 **] at home. She was
closely monitored and repleted during admission. We did not
carry this on formulary and she was treated with Magnesium oxide
400mg daily as home equivalent. She continued to have muscle
pains which improved with IV Mg.
# Type I Diabetes: Her HgA1c was 8.1 at PCP's office on [**7-10**],
was previously 6.4 on [**2136-3-1**]. Pt reports HgA1C ranges of [**4-1**].
Patient's home regimen is insulin [**Date Range **] 37u qHS with Humalog
sliding scale. [**Last Name (un) **] was consulted and gap closed she was
maintained on [**Last Name (un) **] 20 units and humalog 5 units before each
meal with correction 1 unit for every 50 above 150 with sugars
in 120s-150s.
# OSA/insomnia: patient continued on CPAP @ 9 PEEP.
# Code: Full (confirmed)
TRANSITIONAL ISSUES:
[ ] Please attempt to keep patient on home magnesium gluconate
27mg (500mg) 4 tablets [**Hospital1 **]. If not on formulary consider giving
400mg of Magnesium oxide [**Hospital1 **].
[ ] Trend magnesium levels
[ ] Insulin sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations: [**Last Name (un) **] 20
units and humalog 5 units before each meal with correction 1
unit for every 50 above 150.
[ ] Encourage CPAP at 9 PEEP
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Atenolol 50 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fluoxetine 60 mg PO DAILY
4. Glargine 37 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
5. Lorazepam 1 mg PO BID:PRN anxiety
6. Pregabalin 200 mg PO TID
7. traZODONE 25 mg PO HS:PRN insomnia
8. magnesium gluconate *NF* [**2123**] mg Oral [**Hospital1 **]
9. carisoprodol *NF* 350 mg Oral QHS
10. Lovaza *NF* (omega-3 acid ethyl esters) 1 gram Oral [**Hospital1 **]
11. Acetaminophen 650 mg PO Q6H:PRN pain
not to exceed 3000 mg in 24 hours
12. Ibuprofen 400 mg PO Q8H:PRN pain
do not exceed 1200 mg in 24 hours
13. Amiloride HCl 5 mg PO DAILY
hold for SBP < 90
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
not to exceed 3000 mg in 24 hours
2. Amiloride HCl 5 mg PO DAILY
hold for SBP < 90
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. carisoprodol *NF* 350 mg Oral QHS
6. Fluoxetine 60 mg PO DAILY
7. Ibuprofen 400 mg PO Q8H:PRN pain
do not exceed 1200 mg in 24 hours
8. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
9. Lorazepam 1 mg PO BID:PRN anxiety
10. Pregabalin 200 mg PO TID
11. magnesium gluconate *NF* [**2123**] mg Oral [**Hospital1 **]
12. Lovaza *NF* (omega-3 acid ethyl esters) 1 gram Oral [**Hospital1 **]
13. Senna 1 TAB PO BID:PRN Constipation
14. Docusate Sodium 100 mg PO BID
15. traZODONE 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Diabetic ketoacidosis
Severe Depression
Hypomagnesemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent but visually impaired
and requiring guidance.
Discharge Instructions:
Dear Ms. [**Known lastname 29571**]:
It was a pleasure taking care of you at [**Hospital1 18**]. You had come into
the ED because you had severe muscle pain and an increased heart
rate. In the ED your sugar was found to be high and you were
diagnosed diabetic ketoacidosis. You were transfered to the MICU
were you were given a large amount of IV fluids and your
electrolytes were repleted. Your diabetic ketoacidosis improved.
You were also seen by psychiatry which felt that you were
depressed and this was the reason you had stopped taking your
medications. Your apetite, sugars, and pain improved throughout
your stay. Your magnesium was low during your stay and we gave
you oral and IV medications to make this better. Your pain also
improved with administration of magnesium.
We made the following changes to your medications.
Please CONTINUE taking your home medications as prescribed.
Please START humalog and [**Hospital1 **] as directed.
Please START taking docusate sodium 100mg twice daily and Senna
twice daily for constipation.
Please follow-up with the appointments as outlined below.
Thank you,
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2136-9-11**] at 8:40 AM
With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: [**Hospital Ward Name **] [**2136-9-28**] at 7:40 AM
With: DR. [**First Name (STitle) **]/DR. [**First 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
Department: ORTHOPEDICS
When: MONDAY [**2136-9-10**] at 8:30 AM
With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V58.67",
"401.9",
"V15.81",
"300.00",
"250.13",
"785.0",
"327.23",
"369.4",
"780.52",
"277.87",
"311",
"564.00",
"275.2",
"425.4",
"276.8",
"729.1",
"359.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11507, 11552
|
6773, 9517
|
281, 287
|
11651, 11651
|
4788, 4788
|
12986, 13945
|
2830, 3163
|
10777, 11484
|
11573, 11630
|
10018, 10754
|
11847, 12963
|
6375, 6750
|
3904, 4769
|
9538, 9992
|
238, 243
|
343, 2261
|
4804, 6359
|
11666, 11823
|
2283, 2427
|
2443, 2814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,087
| 113,345
|
22806
|
Discharge summary
|
report
|
Admission Date: [**2109-3-20**] Discharge Date: [**2109-3-29**]
Date of Birth: [**2051-5-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion.
Major Surgical or Invasive Procedure:
Mitral valve repair with resection of posterior leaflet [**2109-3-20**].
History of Present Illness:
This is a 57 year old male patient with known heart murmurs who
has been followed by serial echos since [**2093**]. In [**8-27**] he saw
his primary care physician with the complaint of progressive
dyspnea. A Cardiac catheterization in [**11-28**] showed severe mitral
regurgitation, an ejection fraction of 66% and a right coronary
artery with a 70% lesion which was stented. He was subsequently
referred for a minimally invasive mitral valve repair
Past Medical History:
Hypertension.
Addison's disease.
Hypothyroidism.
Melanoma.
BPH.
Social History:
Works as mechanical engineer. Lives with wife. [**Name (NI) 58972**] tobacco
use, reports [**12-27**] drinks of alcohol per week.
Family History:
Noncontributory
Physical Exam:
BP: (R) 135/76 (L) 149/79 HR 68 Weight 225
Gen: Tall young lad in no acute distress
Skin: well healed right shoulder incision
HEENT: EOMI intact, nl buccal mucosa, anicteric, oropharynx
benign.
Neck: supple, murmur transmitted, No JVD
Chest: Clear
Heart: RRR, III/VI systolic murmur.
Abdomen: Soft, Nontender, nondistended
Ext: warm and well perfused
Neuro: grossly intact
Pertinent Results:
[**2109-3-26**] 08:50AM BLOOD WBC-10.8 RBC-2.60* Hgb-8.0* Hct-23.3*
MCV-90 MCH-30.9 MCHC-34.5 RDW-15.0 Plt Ct-203
[**2109-3-26**] 08:50AM BLOOD Plt Ct-203
[**2109-3-21**] 03:04AM BLOOD PT-12.9 PTT-30.5 INR(PT)-1.1
[**2109-3-26**] 08:50AM BLOOD Glucose-81 UreaN-15 Creat-0.9 Na-133
K-3.7 Cl-95* HCO3-28 AnGap-14
[**2109-3-25**] 04:46AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9
[**2109-3-28**] 11:30AM BLOOD WBC-9.8 RBC-4.04* Hgb-12.1* Hct-36.4*
MCV-90 MCH-30.0 MCHC-33.3 RDW-15.3 Plt Ct-407#
[**2109-3-28**] 11:30AM BLOOD Plt Ct-407#
[**2109-3-28**] 11:30AM BLOOD Glucose-102 UreaN-19 Creat-1.0 Na-136
K-4.6 Cl-96 HCO3-27 AnGap-18
[**2109-3-25**] 04:46AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9
[**2109-3-22**] CXR
No evidence of pneumothorax, no significant CHF but bilateral
moderate amount of pleural effusions as seen on single view
chest examination.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 58973**] was admitted the morning of [**3-20**] and proceeded
directly to the operating room. He underwent a mitral valve
repair with resection of the posterior leaflet with a 28 mm
[**Doctor Last Name 405**] band with Dr. [**Last Name (Prefixes) **]. Please see OP note for full
details.
He was successfully weened and extubated on his operative
evening and was placed on a steroid taper with the help of
endocrinology given his addisons disease.
On postoperative day two he was transferred to the inpatient
telemetry floor for ongoing management and rehabilitation.
On postoperative day four he had a burst of atrial fibrillation
-- converted spontaneously and was noted to have a first degree
AV-block. Due to this AV block, his beta blockade was held.
On postoperative day five, with no furtehr episodes of afib but
with elevated BP and HR, a low dose beta-blocker was added with
no change in his AV block. He also continued to be
significantly edamatous, nearly 14 kg up from his pre-op weight
and he was actively diureses with lasix.
On postoperative days six and seven, we continued to diurese him
heavily. Endocrine also continued to follow with regards for
his steroid taper.
On postoperative eight, he cleared physical therapy and was
discahrged home with a visiting nurse to follow.
Medications on Admission:
Plavix 75 daily.
Prednisone 12.5 mg daily.
Flurinef 0.1 mg daily.
Levoxyl 0.025 mg daily.
Enalapril 10 mh [**Hospital1 **].
Lipitor 20 mg daily.
Aspirin 325 mg daily.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
11. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every [**2-27**]
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*56 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
14. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)): 5 mg on the PM.
Disp:*45 Tablet(s)* Refills:*2*
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral regurgitation.
Hypertension.
Addison's disease.
Hypothyroidism.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily with soap and water. Rinse well. [**Male First Name (un) **] not apply
any creams, lotions, powders, or ointments.
Take all new medications as prescribed.
Make follow-up appointments as directed.
No heavy lifting, greater than 10 pounds.
No driving x 6 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call to schedule appointment with Dr. [**Last Name (Prefixes) **].
Call to schedule appointment with Dr. [**Last Name (STitle) **].
Completed by:[**2109-3-29**]
|
[
"424.0",
"255.4",
"427.31",
"V45.82",
"401.9",
"244.9",
"426.11",
"997.1",
"414.00",
"280.0",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"99.04",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5808, 5863
|
298, 373
|
5978, 5987
|
1534, 2381
|
1107, 1124
|
3972, 5785
|
5884, 5957
|
3781, 3949
|
6011, 6287
|
6338, 6501
|
1139, 1515
|
2432, 3755
|
238, 260
|
401, 854
|
876, 942
|
958, 1091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,858
| 118,091
|
7790
|
Discharge summary
|
report
|
Admission Date: [**2149-1-7**] Discharge Date: [**2149-1-16**]
Date of Birth: [**2076-10-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
weight loss
Major Surgical or Invasive Procedure:
liver biopsy
ETT placement
EGD x2
History of Present Illness:
72yo M no significant PMH presents with elevated WBC and history
of 30lb weight loss since [**Month (only) 205**]. Pt presented to PCP for these
complaints on [**1-6**]. Endorsed abdominal pain, loss of appetite,
shortness of breath on exertion and weakness. He has occasional
nausea but no vomiting. Has been able to eat only chicken soup
and occasional rice. Also endorses some swelling in his upper
abdomen. Denies black stool, BRBPR, no dysuira or hematuria, no
fevers/chills, cough. Pt has had very thin stools over the last
3 months, normal in color and much less than usual. Has never
had a colonoscopy. Was scheduled for endoscopy this Thursday but
after labs checked at PCP appt and found to have WBC 18.6,
elevated LFTs so was sent to ED.
In the ED initial VS were 99.4 100 127/93 14 97%. Exam
concerning for crackles in L lung base, abd with firm, nontender
epigastric mass palpated subcostally and firm palpable liver
edge, no abd distension, no rebound/guarding. CT A/P done,
prelim with Diffuse liver and lung metastases, with mild
abdominal ascites, of unknown primary. No biliary dilatation.
CXR with multiple lesions concernign for metastatic disease. VS
on transfer 97.1, 91, 145/100, 16, 100% RA.
Currently, pt denies any complaints other than stress about
possible diagnosis of cancer.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
none
Social History:
Immigrant from [**Country 10181**], 30 years ago. Denies smoking, EtOH, drug
use. Married and lives with wife.
Family History:
denies any family history of malignancy, heart disease, diabetes
or other conditions
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 120/78 72 16 96% RA
GENERAL - thin, age-appropriate male; NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - crackles at bases bilaterally
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, palpable 4 cm diameter mass in
epigastric area, palpable liver edge no rebound/guarding
Rectal: prostate smooth w/o nodularity, no mass. Guiac neg
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-6**] throughout, cerebellar exam intact per FNF
.
DISCHARGE PHYSICAL EXAM:
expired
Pertinent Results:
Labs on admission:
[**2149-1-6**] 02:53PM WBC-18.6*# RBC-5.66 HGB-16.9 HCT-53.7*
MCV-95# MCH-29.9 MCHC-31.5 RDW-14.9
[**2149-1-6**] 02:53PM UREA N-17 CREAT-1.4* SODIUM-137 POTASSIUM-4.5
CHLORIDE-93*
[**2149-1-6**] 02:53PM ALT(SGPT)-106* AST(SGOT)-182* ALK PHOS-551*
AMYLASE-43
[**2149-1-6**] 02:53PM LIPASE-86*
[**2149-1-6**] 02:53PM ALBUMIN-3.6 CALCIUM-9.7
[**2149-1-6**] 02:53PM TSH-8.9*
[**2149-1-7**] 08:00PM GLUCOSE-106* UREA N-19 CREAT-1.4* SODIUM-135
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-25 ANION GAP-22*
[**2149-1-7**] 08:10PM LACTATE-6.0*
Images:
CT Abdoman/ pelvis:
1. Widespread metastases to the lung and liver of unclear
primary. Tubular
hypodense structures in the left lobe of the liver could
represent either
possible left portal vein thrombosis or mild intrahepatic
biliary dilatation and may be better assessed with ultrasound if
indicated.
2. Sclerotic foci within the pelvis are noted. While these may
represent bone islands, given the concern for metastatic
disease, a bone scan could be used to further evaluate these
findings.
3. Moderate ascites.
RUQ U/S:
Thrombosed left portal vein. Bidirectional flow is seen within
the main portal vein in the porta hepatis. Reverse flow is seen
in the anterior right portal vein.
CT chest:
The airways are patent to the subsegmental level. Mediastinal
lymph nodes measure up to 8 mm in the perivascular station, 11
mm right lower paratracheal station, in the left hilum up to 8
mm, in the right hilum up to 5 mm, lower paraesophageal lymph
node measures 11 mm. The ascending aorta is at upper normal
limits, measures 4 cm in AP diameter. There are mild
calcifications in the LAD. There is mild cardiomegaly. There is
no pleural effusion. There is trace of pericardial effusion.
There are innumerable lung nodules and masses, consistent with
metastases. Some of them are cavitated. The largest one in the
right upper lobe measures 17 x 16 mm. The largest in the left
upper lobe/lingula measures 4.2 x 2 cm. In the left lower lobe,
the largest measures 2.1 x 2.6 cm and lies against the pleural
surface. In the right middle lobe, the largest one measures 2.5
x 2.2 cm. In the right lower lobe, measures 3.8 x 3.3 cm. This
also lies against the fissure. More distally, a conglomerate of
lung nodules in the right lower lobe measures 4.7 x 4 cm.
This examination is not tailored for subdiaphragmatic
evaluation. Please
refer for more detailed description of abdominal findings in
prior abdomen CT from [**1-7**].
There are no bone findings of malignancy.
IMPRESSION: Extensive metastatic disease in the chest and
visualized upper
abdomen.
MRI head: [**2149-1-10**]
1. Two enhancing lesions, one each in the right cerebellum and
left frontal lobe which are suggestive of metastases.
2. Generalized cerebral atrophy with changes of chronic small
vessel ischemic disease.
3. No acute infarct or intracranial hemorrhage.
MRCP: [**2149-1-11**]
1. Pulmonary metastatic disease is seen with large masses
identified in the lower lobes bilaterally.
2. Diffuse replacement of the liver with metastatic disease with
most notable disease burden noted within segment V of the liver
surrounding the gallbladder, where there is a mass arising from
the its medial wall. This may be the primary site of
adenocarcinoma.
3. Multifocal narrowing of the intrahepatic biliary tree, most
notably the first and second order branches of the left
intrahepatic biliary system, most likely caused by extrinsic
compression of these bile ducts due to the large masses within
the liver, rather than from a lesion arising from the bile ducts
itself. The right intra-hepatic biliary tree is decompressed and
the CBD is normal in caliber. A plastic stent is noted in situ.
4. Attenuated intra-hepatic portion of the IVC and right and
left hepatic veins. The middle hepatic vein is not definitively
seen. The right and main portal vein are attenuated but patent.
The left portal vein is thrombosed.
5. Pancreas divisum.
.
EGD [**1-14**]: Findings: Esophagus:
Excavated Lesions A single clean-based but somewhat atypical
appearing non-bleeding 15 mm ulcer was found at the
gastroesophageal junction. Overlying the ulcer was a white
plaque.
Stomach:
Contents: Old blood was seen throughout the stomach. In
addition, there were multiple large clots in the fundus. These
clots were aggressively suctioned and the patient was
repositioned in order to maximize views of the area. No source
of active bleeding was identified, although views were somewhat
obscured.
Duodenum:
Protruding Lesions A non-bleeding 12 mm polypoid mass was found
at the second part of the duodenum just proximal to the ampulla.
Other The known bilary stent was seen in the ampulla (which
otherwise appeared normal). During the course of the procedure,
a large clot (at least the length of the stent) was extruded
through the stent. Once the entire clot had passed through the
stent, no additional clot or fresh blood was noted to exit the
stent. Overall, the amount of blood in the duodenal was far less
than in the stomach.
Other
findings: Fresh blood was noted to be oozing from an area of
mildly nodular mucosa in the duodenal bulb. Two endoclips were
successfully applied for the purpose of hemostasis.
Impression: Ulcer in the gastroesophageal junction
Blood in the whole stomach
Clot was seen extruding from the known biliary stent
Mass in the second part of the duodenum
Fresh blood was noted to be oozing from an area of mildly
nodular mucosa in the duodenal bulb. (endoclip)
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue to follow HCT and clinical status
If the patient shows signs of active bleeding, would consult IR
as the source of bleeding remains unclear but may be the biliary
tree. There is no role for repeat ERCP as a sphincterotomy was
not performed and bleeding would be from tumor eroding into a
vessel.
If the patient remains stable overnight, suggest repeat EGD
tomorrow after reglan/erythromycin.
Additional notes: The estimated blood loss from the procedure is
5cc. The post-procedure diagnosis is as noted above under
"impressions". No specimens were collected during this
procedure. The patient's reconciled home medication list is
appended to this report. The procedure was done by the Attending
and GI Fellow. There was no source of active bleeding identified
on this study to the third portion of the duodenum.
.
EGD [**1-16**]:Esophagus:
Mucosa: Clean based 8mm erosion/ulceration seen at GE junction
without evidence of bleeding.
Stomach:
Mucosa: The mucosa of the stomach was abnormal with nodularity.
Old blood mixed with mucous was found in the fundus which was
suctioned away to reveal the mildly nodular mucosa. No ulcers or
other sites of bleeding could be found.
Protruding Lesions Many small gastric polyps were found in the
body of the stomach.
Duodenum:
Other The two doudenal bulb clips were in place without
evidence of bleeding. The stent was found in the second part of
the duodenum without evidence of active bleeding, old blood or
clot.
Impression: Abnormal mucosa in the esophagus
Polyps in the stomach
Abnormal mucosa in the stomach
The two doudenal bulb clips were in place without evidence of
bleeding.
The stent was found in the second part of the duodenum without
evidence of active bleeding, old blood or clot.
Otherwise normal EGD to third part of the duodenum
Recommendations: Protonix 40mg IV BID
Unclear source of bleeding. Patient may have bled from biliary
system or bleeding may have been from duodenal bulb lesion. No
active bleeding was seen.
There was no mass or tumor seen in the stomach. The small
nodules are likely benign fundic gland polyps.
If there is further bleeding would consider IR for potential
hemobilia.
Further recs per inpatient GI team
Additional notes: The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss = zero. No specimens were taken for
pathology
Brief Hospital Course:
Mr. [**Known lastname 1022**] is a 72 year old male with no significant history who
presented with weight loss, leukocytosis and diffuse liver
lesions and was found to have widely metastatic adenocarcinoma
from unknown primary. Hospital course was complicated by
cholangitis with subsequent biliary stent placement and profuse
GI hemorrhage.
.
# Gastrointestinal (GI) bleed: He developed a large volume GI
bleed while on the floor. He had both bright red blood per
rectum and hematemesis. He was intubated for airway protection
given his hematemesis. The cause for the bleed was not
definitively identified after 2 endoscopies, however, large clot
burden was found in the biliary stent placed for cholangitis.
It was thought that he was bleeding from his biliary system [**3-6**]
necrosis of his large tumor burden. He was treated with IV
proton-pump inhibitors and octreotide. He also received several
units of packed RBCs, however, he continued to pass blood per
rectum and had increasing IV fluid and vasopressor requirements
to maintain his blood pressure. Because of his worsening
clinical status and subsequent decompensation, a goals of care
discussion was had with the family and he was ultimately made
DNR/DNI with comfort measures only. A CTA was not pursued in
this setting.
.
# Metastatic adenocarcinoma: The patient was initially admitted
to floor for work up of his weight loss and imaging showed
diffuse liver lesions, with liver biopsy confirming
adenocarcinoma. Primary unknown but possiblities were
cholangiocarcinoma and gastric carcinoma. Cancer screening was
not up to date. The patient was being seen by palliative care
inpatient. After being transferred to the MICU for GIB (see
above), the patient's clinical status continued to deteriorate,
and after discussion with the family, he was ultimately made
DNR/DNI and then CMO.
.
# Cholangitis/sepsis: During admission, he developed fevers and
right upper quadrant pain. His liver enzymes were found to be
elevated so he underwent an MRCP. This found extrinsic
compression of the biliary tree by tumor burden and a plastic
stent was placed to open the drainage. He was also started on
ciprofloxacin and metronidazole and later broadened to
Vanc/Zosyn. Once he developed bleeding from the stent (as
above) his leukocytosis worsened and it was thought likely that
he had re-obstruction of the biliary tree either by clot or
tumor progression. During this time, his lactate also increased
to 14 and his pressor requirment increased.
.
# Tumor lysis syndrome (TLS): After an episode of hypotension
he developed laboratory abnormalities which were consistent with
TLS. We suspected that his hypotension had caused tumor
necrosis given his extensive tumor burden. He was treated with
IV fluids with bicarbonate and allopurinol. Unfortunately, his
TLS labs continued to trend upwards and he developed renal
failure from TLS.
.
# Acute renal failure: Secondary to TLS as above. Also likely
that periods of hypotension led to acute tubular necrosis,
accounting for his decreasing urine output, as well as
increasing creatinine.
Medications on Admission:
no home medications
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2149-1-17**]
|
[
"584.5",
"V49.86",
"576.1",
"785.52",
"452",
"576.2",
"197.7",
"285.1",
"277.88",
"038.9",
"199.1",
"789.59",
"531.90",
"V66.7",
"995.92",
"537.89",
"518.81",
"197.0",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"50.11",
"51.87",
"44.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14246, 14255
|
11031, 14144
|
316, 351
|
14307, 14317
|
3028, 3033
|
14373, 14412
|
2127, 2213
|
14214, 14223
|
14276, 14286
|
14170, 14191
|
14341, 14350
|
2253, 2974
|
1707, 1955
|
265, 278
|
379, 1688
|
3047, 11008
|
1977, 1983
|
1999, 2111
|
2999, 3009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,651
| 164,221
|
28367
|
Discharge summary
|
report
|
Admission Date: [**2108-11-21**] Discharge Date: [**2108-12-19**]
Date of Birth: [**2048-7-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
B/L lower extremity weakness, inability to ambulate
Major Surgical or Invasive Procedure:
T5/6 Decompression with T5 Mass Resection
T4-T7 Posterior Fusion with Instrumentation
PMMA insertion into T5/6 Defect
History of Present Illness:
60 y.o. male PMH significant only for cirrhosis p/w back pain X
6
months worsening in last 3 weeks, with increasing difficulty
ambulating for the last several days. Patient recalls episode
of
trauma where he fell while working - since this epidsode has had
chronic pain in the middle of his back. Denies any other recent
injuries/falls. Onset of lower extremity weakness has been
insidious over last three weeks with no precipitating event. No
bowel/bladder incontinece - some constipation/urinary retention.
Denies F/C/N/V/CP/SOB.
Past Medical History:
Cirrhosis
HCV
Social History:
+Tobacco 50 pack year hx, +EtOH (12 pack/day)
Family History:
Non contributory
Physical Exam:
On Admission:
T: 97.9 BP: 171/75 HR: 61 R 17 O2Sats 97
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 3-2mm b/l EOMs intact; no nystagmus
Neck: Supple.
Back: Minimal pain with palpation
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Distended, protuberant
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 4 4+ 4+ 4+
L 5 5 5 5 5 5 4 4+ 4+ 4+
Sensation: Intact to light touch with decreased sensation
inferior to nipple line
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
Pertinent Results:
[**2108-11-21**] 06:30AM GLUCOSE-165* UREA N-13 CREAT-1.0 SODIUM-138
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2108-11-21**] 06:30AM CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-1.6
[**2108-11-21**] 06:30AM WBC-4.5 RBC-4.33* HGB-13.9* HCT-40.7 MCV-94
MCH-32.1* MCHC-34.2 RDW-15.0
[**2108-11-21**] 06:30AM PLT COUNT-168
[**2108-11-21**] 12:45AM GLUCOSE-135* UREA N-10 CREAT-1.0 SODIUM-138
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2108-11-21**] 12:45AM WBC-7.1 RBC-4.84 HGB-15.5 HCT-45.1 MCV-93
MCH-32.1* MCHC-34.4 RDW-15.1
[**2108-11-21**] 12:45AM NEUTS-79.6* LYMPHS-17.5* MONOS-1.0* EOS-1.4
BASOS-0.5
[**2108-11-21**] 12:45AM PLT COUNT-171
[**2108-11-21**] 12:45AM PT-15.6* PTT-43.3* INR(PT)-1.4*
MRI/MRA T Spine [**2108-11-22**]:
1. Osseous metastasis to the T5 vertebra and its posterior
element, with
resultant approximately 30% compression of the vertebral body
height and
significant spinal canal stenosis at this level without signal
abnormality
within the spinal cord.
2. Additional osseous metastasis as above.
3. Grossly unremarkable thoracic/abdominal aorta and its major
tributaries.
4. Bilateral small pleural effusions.
Pathology
T5 vertebral lesion (C):
Metastatic poorly differentiated carcinoma
[**2108-12-1**] 03:29AM BLOOD WBC-25.2*# RBC-3.28* Hgb-10.6* Hct-30.8*
MCV-94 MCH-32.4* MCHC-34.6 RDW-15.8* Plt Ct-162
[**2108-12-11**] 06:39AM BLOOD WBC-16.2* RBC-3.72* Hgb-12.1* Hct-36.5*
MCV-98 MCH-32.5* MCHC-33.1 RDW-16.4* Plt Ct-134*
Brief Hospital Course:
Patient was admitted from ED to the Neurosurgical [**Hospital1 **]. After
obtaining appropriate imaging modalities, patient was taken to
the operating room for T4/T5 decompression with T5 mass removal
and T4-T7 fusion with posterior instrumentation on [**2108-11-23**].
Post-operatively the patient was admitted to the SICU. He was
extubated the following AM from surgery at which time his MS was
not at baseline. Over the following days, and after starting on
a lactulose regimen, his MS improved to baseline. He was seen
and evaluated by PT OT and their recommendations followed.
[**11-30**] his CT was stable. [**12-1**] he was started on Zosyn for gram
(+) cocci in blood cultures as well as high WBC. [**12-3**] he had
MRSA in [**3-3**] blood culture bottles and vanco was started/ PICC
requested. [**12-6**] the pt went back to the OR for formal wound
irrigation. There was a small (approx 4mm opening) that was
irrigated and closed (located approx 2 inches from superior
aspect of incision. Final results on blood cultures from [**12-5**]
showed no growth on [**12-11**].
The patient's mental status has continued to improve while on
the floor and his lower extremities have gained some motor
strength. He has had increased ascites as well as increased
lower extremity edema. The physical therapists and occupational
therapists have cleared him to go to rehab. He will be continued
on the Vancomycin until Sunday [**2108-11-22**].
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
6. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
7. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*2*
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 5 days: Through Sun,
[**2108-12-23**].
Disp:*QS mg* Refills:*0*
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Discharge Disposition:
Extended Care
Facility:
Greycliff - [**Location (un) 14663**]
Discharge Diagnosis:
Metastatic carcinoma T5
Discharge Condition:
Stable
Discharge Instructions:
Please call physician or return to ED if any of the following:
Fever (>101.5), Redness/Drainage/Pain at incision site,
increased pain, intolerable nausea/vomiting, or any other
disturbing symptoms.
Followup Instructions:
Please f/u in 4 weeks from discharge date with Dr. [**Last Name (STitle) 548**]. Call
[**Telephone/Fax (1) 1669**] for appt.
Completed by:[**2108-12-19**]
|
[
"996.62",
"198.89",
"305.1",
"336.3",
"571.2",
"789.5",
"790.7",
"733.13",
"293.0",
"286.7",
"998.32",
"344.1",
"199.1",
"197.7",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.6",
"84.52",
"86.59",
"83.39",
"39.79",
"81.05",
"99.05",
"99.07",
"99.06",
"03.53",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
6551, 6615
|
3631, 5074
|
373, 493
|
6683, 6692
|
2112, 3608
|
6938, 7095
|
1174, 1192
|
5129, 6528
|
6636, 6662
|
5100, 5106
|
6716, 6915
|
1207, 1207
|
282, 335
|
521, 1058
|
1222, 1538
|
1553, 2093
|
1080, 1095
|
1111, 1158
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
353
| 112,976
|
9274
|
Discharge summary
|
report
|
Admission Date: [**2151-6-23**] Discharge Date: [**2151-7-4**]
Date of Birth: [**2089-7-23**] Sex: M
Service: MEDICINE
Allergies:
Ativan / Tetracycline
Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
1. Tunnelled catheter placement
2. [**First Name3 (LF) **]
History of Present Illness:
61Yo End Stage Renal Disease on HemoDialysis, CAD s/p CABG, PVD
s/p bilateral BKAs, recents MRSA line sepsis who presents from
HD with fever and suspected recurrent line sepsis.
.
Patient reports on Wednesday having stomach discomfort. He
states he felt like he did with previous line infections.
Patiends tunneled line was placed on [**4-7**]. He checked his
temperature which was 101.3. On Thursday he had partial [**Month/Year (2) 2286**]
session (2hours) but was ended early due to his
fever/lightheadedness/nausea. His temperature was noted to be
103. In Hemodialysis he recieved Vancomycin was given at HD and
he then transfered to [**Hospital1 18**] ED.
.
In [**Name (NI) **], pt recieved 2 liters IV fluids and was started on
gentamycin. His SBP went to 60's so periheral dopa was started
with improvement of pressures. Multiple attempts at central
access were made but without success. Renal consultation was
done with no indication for emergent HD. Renal approved use of
HD catheter for temporary access.
.
In MICU, patient had aggressive fluid, continued on vanco and
gent, renal consulted. Heparin started
Past Medical History:
- ESRD on HD MWF
- DM 1 or 2 c/b PVD, CAD, ESRD
- bilateral BKAs
- CAD s/p CABG
- clot in L arm AV graft - no longer functioning
- R SC tunnel cath placed
- s/p MSSA bacteremia [**12-2**]
- HTN
- h/o VRE, MRSA
Social History:
Lives in [**Location 5110**] with his mother. A retired pharmacist. Never
smoked, rare etoh use.
Family History:
Mother and father with DM, father with PVD. No h/o CAD.
Physical Exam:
PE: Temp 98.2 BP 118/62 84
Gen: NAD, obese man, flushed face
lungs: CTA no w/r/r
chest: Right Subclavian line without evidence of infection
heart: RRR no m/r/g
abd; soft nontender
ext: s/p bilat BKA
neuro: CN II-XII intact, Cerbellar function intact
Pertinent Results:
[**2151-6-23**] 10:30PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2151-6-23**] 10:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2151-6-23**] 10:30PM URINE SPERM-MOD
[**2151-6-23**] 10:00PM TYPE-ART PO2-187* PCO2-41 PH-7.48* TOTAL
CO2-31* BASE XS-7 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2151-6-23**] 09:50PM GLUCOSE-249* UREA N-48* CREAT-7.2*#
SODIUM-137 POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-26 ANION
GAP-22*
[**2151-6-23**] 09:50PM ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-198
CK(CPK)-164 ALK PHOS-70 TOT BILI-0.8
[**2151-6-23**] 09:50PM CK-MB-2 cTropnT-0.10*
[**2151-6-23**] 09:50PM CALCIUM-8.6 PHOSPHATE-4.6* MAGNESIUM-1.6
[**2151-6-23**] 09:50PM WBC-14.5*# RBC-3.93* HGB-13.1* HCT-36.3*
MCV-92 MCH-33.2* MCHC-36.0* RDW-14.6
[**2151-6-23**] 09:50PM NEUTS-93* BANDS-3 LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-6-23**] 09:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2151-6-23**] 09:50PM PLT SMR-NORMAL PLT COUNT-125*
[**2151-6-23**] 09:50PM PT-22.8* PTT-31.1 INR(PT)-3.4
[**2151-6-23**] 06:25PM LACTATE-4.9* K+-6.8*
Brief Hospital Course:
61YO male with ESRD on HD, bilateral IJ clots on coumadin, CAD
s/p CABG, MRSA sepsis [**4-1**] who presents with sepsis.
Transferred from MICU to floor on [**2151-6-27**]
.
1) Sepsis- SIRS (initial lactate of 4.9), in MICU pt give IV
fluids. Recieved Depo in ED. Switched to Levofed in MICU. Off
pressors as of [**6-24**]. [**Date Range **] line resited to right subclavian
w/ central access available [**6-24**]. Gent was D/C on [**2151-6-27**]. MRSA
+ in blood cx [**6-23**], now on vanc and gent for synergy. Dosed gent
after HD. HD catheter re-sited on R side. Spiked [**6-25**] and has
GPC's from [**6-25**] also, most likely [**12-30**] transient bacteremia
during line change. TEE done [**2151-6-29**] showed no evidence of
endocarditi. CT Abodmen Showed Hypo attenuating lesion in the
head of pancreas with possible dilatation of the pancreatic
duct. This can be further evaluated with MRCP as it could
represent IPMT or a cyst. MRCP was ordered, however patient
refused study. HE will be scheduled for outpatient MRCP with
ourpatient GI follow up.
Patient will continue Vanco (level dosed) per ID Rec for 6 wks,
2) Renal - Renal Consulted in ED. Pt got new tempory R SC line
[**6-25**]. Recieved UF on ([**6-26**]). Perma cath placed Monday [**6-28**].
Patient continued sevelamer, ca carbonate, nephrocaps. In future
plan for Transplant surgery to evaluate pt for possible kidney
transplant
.
3)FEN- Metabolic alkalosis on admission, recieved over 7L in
MICU. Patient was continued cardiac diabetic diet
.
4)CAD-Enzymes negative.Continue aspirin, statin. Patient
restarted on Metroprolol and Lisinopril with holding parameters
systolic <90
.
6)GI- Patient continued anti-emetics for nausea. Patient also
recieved PPI.
.
7)Hem -Thrombocytopenia-may be due to sepsis. Daily CBC were
checked to monitor Platlets.
.
9) Bilateral IJ clots- Hep gtt. Patient continued on Heparin. He
started coumadin on [**2151-6-28**]. He remained hospitalized until his
Coumadin became theurpetic (INR 2.0-3.0)
.
10) Respiratory- In ICU patient has desaturated less than 90 on
room air. On floor patient longer required oxygen
.
11) DM II- Patient restarted Glipizide on the floor with Sliding
Scale
.
12) Access: [**Date Range 2286**] line resited to R subclav [**6-24**] and replaced
over wire [**6-25**], CXR on [**6-27**] to check placement of subclavian.
Subclavian line to be replaced IR [**2151-6-28**]. Patient also has
peripherial line.
.
Medications on Admission:
1. Warfarin Sodium 1 mg qd
2. Simvastatin 40 mg qd
3. Insulin Regular Human 100 unit/mL .
4. B Complex-Vitamin C-Folic Acid 1 mg qd
5. Metoprolol Tartrate 25 mg [**Hospital1 **]
6. Lisinopril 5 mg qd
7. Glipizide 5 mg [**Hospital1 **]
8. Calcium Acetate 667 mg tid with meals
9. Sevelamer HCl 800 mg po tid
Discharge Medications:
1. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
3. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in
the morning)).
4. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
at Hemodialysis for 6 weeks: Have Vancomycin level checked and
if level <15 give 1g Vancomycin.
Disp:*qs * Refills:*0*
11. Outpatient Lab Work
Have PT, PTT levels checked. Your doctors [**First Name (Titles) **] [**Last Name (Titles) 2286**] [**Name5 (PTitle) **] be
adjusting your coumadin based on this.
12. Outpatient Lab Work
Have Vancomycin level drawn at HD sessions and if level <15
administer 1 gram Vanco.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Line infection
2. Tunnelled catheter placement
Discharge Condition:
Stable
Discharge Instructions:
Continue taking all medications as prescribed.
Return to the hospitals if you have any further fevers, nausea,
vomiting, shortness of breath or other concerning symptoms.
Have your Vanco level checked and dosed at hemodialysis.
Have your INR checked each week and called to Dr. [**Last Name (STitle) **] to
adjust your coumadin dosage.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]
COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2151-7-20**] 10:00
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Where: GI ROOMS
Date/Time:[**2151-7-20**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2151-8-3**] 9:00
Completed by:[**2151-7-19**]
|
[
"357.2",
"362.01",
"403.91",
"038.11",
"790.92",
"E879.8",
"250.40",
"996.62",
"287.5",
"250.50",
"276.3",
"583.81",
"E849.0",
"V45.81",
"995.92",
"250.60",
"V09.0",
"518.0",
"414.00",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"88.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7512, 7518
|
3449, 5890
|
287, 348
|
7612, 7620
|
2207, 3426
|
8004, 8565
|
1863, 1920
|
6249, 7489
|
7539, 7591
|
5916, 6226
|
7644, 7981
|
1935, 2188
|
242, 249
|
376, 1498
|
1520, 1732
|
1748, 1847
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,545
| 119,898
|
4596
|
Discharge summary
|
report
|
Admission Date: [**2147-10-8**] Discharge Date: [**2147-10-25**]
Date of Birth: [**2070-7-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Interstitial Pulmonary Fibrosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yr old hx of CRI, RUL NSLCA s/p cyberknife treatment [**9-26**],
UIP, emphysema on 4L liquid o2 baseline doe presenting with
worsening DOE, SOB x 3 days.
.
At home, noted sneezing, cough with blood tinged sputum and
increasing sob. Usually can walk several feet w/o acute
worsening of SOB as per patient, but reports dyspnea and acute
sob when walking 30 feet. At baseline patient >90 % on 4L liquid
oxygen recently but to 86% with ambulation. today 73% 4L with
ambulation. No pleuritic chest pain, fever, chills, nausea,
vomiting, diarrhea, abdominal pain, or myalgias. Patient noted
mild LE edema over several days right mildly greater than left.
Given symptoms to ED.
.
Recent admission [**Date range (1) 19503**] with respiratory distress.
Transferred to the ICU, BAL performed with blood in airway. CT
scan demonstrated new, diffuse ground-glass opacity with
intralobular reticulation in the left lung and right upper lobe,
less in the right lower lobe. These findings were thought to be
due to [**Date range (1) **], diffuse
infection, or acute exacerbation of interstitial lung disease.
Levofloxacin and cefepime for eight day course treatment.He was
covered for PCP with treatment dose bactrim and 1mg/kg IV
steroids. Bactrim changed to prophylaxis dose on [**9-5**] based on
negative beta-glucan/galactomannan and smere. On discharge
improved 91% on 6L on prednisone taper for which patient is
currently on 25 mg.
.
In ED, Vitals 96.6, 110, 142/66, 18, 85%4L. 91% to 95% on 6L.
Exam decreased breath sounds right lower lobe CXR unremarkable.
EKG sinus tach no ST changes. Standard labs at baseline. Lactate
1.3. 1L fluid given. CT chest for PE negative. NAC and bicarb
prior to CT scan. Levo 750 IV x 1 given. Patient admitted for
further work up.
Past Medical History:
RUL NSLC s/p cyberknife treatment [**9-26**]
interstitial lung disease
emphysema
CKD, baseline Cr. 1.7-2
GOUT
hypertension
GERD
esophageal stricture s/p dilatation
Social History:
He lives with his wife in [**Name2 (NI) **] [**Name (NI) 19501**]. No children. He is
retired factory worker from a rubber factory. Was in the navy.
He has a 50-pack-year history of smoking and quit 8 years ago.
He has significant asbestos exposure due to his factory work
with rubber. Previously in the Navy. Drinks 4-5 beers per day.
No illicits. No children.
Family History:
Mother with cancer (unknown type). Brother with leukemia
Physical Exam:
Admission Physical Exam
Vital signs: T 96.4, HR 112, BP 135/70, RR 22, Sat 93% Face mask
Gen: Average stature, elderly white male, NAD, Pleasant and
cooperative. AOx3.
HEENT: PERRLA, EOMI, OP pink w/o ulcers injection or exudates,
dry MM
Neck: Supple. No cervical LAP.
Chest: Broad excursion with good air movement. Crackles at bases
bilaterally, ?rub at posterior lung fields bilaterally
Cor: RRR, S1S2, No MRG.
Abd: S/ND/NT, no HSM.
Extrem: Warm, 2+ radial and pedal pulses, no C/C/E.
Neuro: Good comprehension/cognition. CN 2-12 intact. Muscle
strength 5/5 in all extremities. No sensory deficits. Reflexes
intact.
Comprehensive Musc Skel:
?????? Jaw, neck without limited ROM.
?????? Shoulders, elbows, wrists, hands, fingers: no deformity,
erythema, warmth, swelling, effusion, tenderness, limited ROM.
?????? Lumbosacral spine and hips without limited ROM.
?????? Knee, ankles, feet, toes: no deformity, erythema, warmth,
swelling, effusion, tenderness, limited ROM.
Skin: 3-5mm scattered hemorrhagic lesions on dorsal surface of
fingers and forearms. bruising along forearms
Pertinent Results:
=======
Labs
=======
=======
Radiology
=======
CTA Chest [**10-8**] -
1. Emphysema with interval progression of interstitial lung
disease with
ground- glass opacity, reticulation and honeycombing, most
prominent in the
lower lobes. Given the calcification in the pleura, patient has
likely had
prior asbentos exposure and diffuse lung disease may be due to
asbestosis.
2. No evidence of pulmonary embolus.
3. Calcified granulomas in the lover, spleen, and lungs, likely
sequelae of
prior granulomatous lung disease.
CXR [**10-8**] -
here has been no interval change allowing for differences in
technique. Mid and lower lung opacities are again noted
corresponding to
ground glass and reticular opacities seen on CT. The wedge-
shaped peripheral opacity of the right lung is unchanged. There
is no evidence of superimposed pneumonia. No pleural effusion or
pneumothorax. Cardiac and mediastinal contours are unchanged.
Calcified pleural plaques are compatible with prior asbestos
exposure.
=======
Cardiology
=======
TTE - [**10-11**]
Conclusions
The left atrium is normal in size. 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>55%). The
ascending aorta is mildly dilated. The aortic valve is not well
seen. There is no aortic valve stenosis. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, 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.
Brief Hospital Course:
77yoM with NSCLCA s/p cyberknife, Radiation Pneumonitis presents
with worsening hypoxia.
# SOB/Acute on chronic hypoxemic respiratory failure: Patient
likely had exacerbation if ILD [**1-21**] steroid taper as outpatient.
Completed Bronscopsopy with BAL performed day of admission was
negative for PCP, [**Name10 (NameIs) 11381**] or other infection. Per report, there were
no endobronchial lesions and no purulent secretions seen. CTA
negative for PE, but demonstrates evidence of worsening ground
glass opacities. Blood cxs NGTD. Patient was empirically treated
with Levaquin for CAP. Patient triggered for hypoxia on [**10-10**]
and was transferred to the ICU. Antibiotics were intially
broadened to Vanco/Cefepime given poor reserve function and
worsening CT but pt did not exhibit s/s infection without fever
and all cultures were no growth, including BAL so these were
stopped. There was also concern for antibiotics causing
myelosuppression. He was continued on NAC for IPF. Respiratory
status improved on [**10-15**] and pt weaned to O2 4L via nasal
cannula from ventimask. Symptoms including SPB and tachypnea
also improved. Beta agonists avoided given tahcycardia.
Rheumatology and IP were following and recommended starting
Cellcept for steroid responsive pulmonary disease, ? vasculitis.
This was deferred over the weekend due to improvement in
clinical status. He completed a 3 day course of Solumedrol 1g IV
daily and was transitioned on [**10-14**] to PO prednisone 70mg PO
daily with intended slow taper. The pt was discharged on
Prednisone 60mg, and was given scripts to hold him through his
one week tapers to 50mg.
.
Please note, the patient recieved Inhaled Pentamadine while in
the ICU. He was discharged with follow-up appointment for his
next dose.
# ARF: Pt Cr had been elevated to 2.2 in setting of lasix
administration. Baseline around 1.8. Diuresis and HCTZ were held
given patient clinically euvolemic and creatinine imporved to
1.4 [**10-15**]. His Creatinine was 1.2 on the day of discharge.
.
# tachycardia: patient experienced episodes of MAT vs. sinus
tach with PACs. No evidence of PE on exam, and CT negative.
Monitored on telemetry. Controlled with Diltiazam 30mg QID.
# Anemia/Thrombocytopenia: Patient has had progressive
hematocrit and platelet drop. He was guaiac negative.
Normocytic, low retics, Total Bili WNL. Pt with known AOCD. It
was thought anemia may be [**1-21**] med effect so
Vanc/Cefepime/Bactrim DCd given low likelihood of infection.
Coomb??????s negative. Heme/Onc consulted and felt anemia most likely
related to chronic disease, plus chronic kidney disease and low
level hemolysis given low haptoglobin, together with medication
effect. Recommended following LDH, FDP, fibrinogen, INR,
haptoglobin daily earlier in hospitalization. HIT antibody
negative but platelts trended down after started on Heparin so
are avoiding heparin products given possible HIT Type 1. Patient
required transfusion mid-way through course, to which he
responded appropriately. At time of discahrge, it was agreed
that no bone marrow biopsy was now warrented, but outpatient
follow-up of platlets, RBC and HCT were necessary to ensure
resolving trend continues. If it does not at outpatient
follow-up, the heme service recommneded re-consultation.
# FEN: Regular Renal Diet was provided throughout the hospital
stay.
# PPx: Pneumoboots and PPI were provided throughout the hospital
stay.
# CODE: Patient maintained full code status througout the
hospital stay.
Medications on Admission:
-Prednsione 25 mg tab daily
-Azathioprine 50 mg Tablet PRN
-Polyethylene Glycol 3350 100 % Powder one po daily
-Folic Acid 1 mg Tablet daily
-Docusate Sodium 100 mg Capsule [**Hospital1 **]
-Thiamine HCl 100 mg daily
-Omeprazole 20 mg
-Calcium-Cholecalciferol (D3) 500 (1,250)-400 mg-unit daily
-Trimethoprim-Sulfamethoxazole 80-400 mg daily
-Spiriva once daily
-Advair discus
-Ipratropium Bromide 0.02 % Solution Sig: 0.2mg/ml
Inhalation Q6H (every 6 hours).
-Lorazepam 0.5 mg Tablet PO QHS PRN
-Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day
for 7 days: Take from [**10-26**] until [**11-1**]. .
Disp:*35 Tablet(s)* Refills:*0*
3. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 7 days: Take from [**11-2**] to [**11-8**].
Disp:*28 Tablet(s)* Refills:*0*
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*0 Tablet(s)* Refills:*0*
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3)
Miscellaneous TID (3 times a day).
Disp:*90 containers* Refills:*0*
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*3 bottles* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*5 Cap(s)* Refills:*0*
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*0*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Please hold for SBP under 100 or HR under 60.
.
Disp:*120 Tablet(s)* Refills:*0*
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
17. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: [**12-21**] Inhalation once a day.
Disp:*4 inhalers* Refills:*2*
18. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation once a day.
Disp:*4 inhalers* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH
Discharge Diagnosis:
Interstitial Pulmonary Fibrosis
Discharge Condition:
Good
Discharge Instructions:
Please return to the hospital for shortness of breath, new
difficutly breathing, light-headedness, dizziness, chest pain,
arm or shoulder pain, fevers, chills, night sweats or any other
concerning symptom.
.
Please follow-up with your providors below. You have five (5)
follow-up appointments.
.
Please be sure to take your medications as written below.
Followup Instructions:
-Please see (1) Dr. [**Last Name (STitle) **] and (2) Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 11710**] on
[**11-10**] at 10AM. At this time, you will also get your inhaled
Pentamadine medication. It is very important that you keep this
appointment.
.
-Please see (3) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] on Tuesday [**10-31**] at 10:15AM.
Phone: [**Telephone/Fax (1) 2205**]. Please ask him if your hematologic profile
is improving and if referral to Hematology will be required. The
heme consult service expects your counts to improve, but you may
need to see a Hematologist if they do not. Please ask Dr. [**Last Name (STitle) 2903**]
to advise you on how to proceed.
.
-(4)Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-11-23**]
9:30
.
-(5)Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**0-0-**]
Date/Time:[**2147-11-23**] 11:30
.
Completed by:[**2147-10-23**]
|
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"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
12169, 12276
|
5775, 9283
|
347, 353
|
12352, 12359
|
3902, 5752
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|
276, 309
|
382, 2143
|
2165, 2331
|
2347, 2710
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,947
| 186,122
|
27361
|
Discharge summary
|
report
|
Admission Date: [**2115-11-13**] Discharge Date: [**2115-11-29**]
Date of Birth: [**2051-11-28**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD [**2115-11-13**], diagnostic paracentesis [**2115-11-20**], EGD [**2115-11-28**]
History of Present Illness:
63 y/o with NASH, on transplant list, recently discharged for
worsening LE edema. During his last admission he had two large
volume taps, EGD revealed large (grade II) esophageal varices,
one with a cherry red spot, that were banded. He also had ARF -
his diuresis was restarted after initially being held (until his
Cr recovered), and he was sent to rehab. There he apparently
was not receiving his lactulose, and became encephalopathic. He
then experienced black stools with red clots, and was sent to
[**Hospital3 13313**] where he was apparently scoped without
evidence of ongoing bleeding. He is being transfered here for
eval by the liver service, including repeat EGD, eval for
[**Last Name (un) 10045**] +/- TIPS.
.
On arrival he was found to be intubated, off sedation,
unresponsive to voice or examination. He was immediately
prepped for upper endoscopy. This was performed by the Liver
team, and he was found to have alot of blood in the stomach and
duodenum. This was suctioned out, but no source of active
bleeding was found. He is admitted to the ICU for further
management and evaluation.
Past Medical History:
1. Liver cirrhosis secondary to NASH, complicated by multiple
variceal bleeds, ascites, splenomegaly and portal hypertension.
No recent EGD or C-scope on file in OMR. Listed for transplant,
work-up to date with echo in [**8-/2115**] with preserved systolic
function, PFTs also done though records not available.
2. DM type 2, last HbA1c 6.5% on [**2115-9-16**].
3. Hypertension
4. Gout
5. Osteoarthritis
6. Glaucoma and macular degeneration
7. Status post right first digit amputation [**2115-4-29**] for
osteomyelitis and nonhealing ulcer.
Social History:
He lives with his wife at home. He does no smoke, rare EtOH in
the past.
Family History:
Not reviewed with patient.
Physical Exam:
98 81 120/71 16 100%
Intubated, sedate, unresponsive
Pale
PERRL
No LAD or JVP
RRR no MRG
CTA anteriorly
Abd Distended, + fluid wave, not tense, BS+
No edema
Pertinent Results:
EGD [**2115-11-14**]: Grade 2 esophagitis with contact bleeding was seen
in the lower third of the esophagus, compatible with
esophagitis. Other Banded Varix was seen at 32 cm. There was no
evidence of active bleeding.
Stomach: Contents: Clotted blood was seen in the whole stomach.
Duodenum: Contents: Clotted blood was seen in the whole
duodenum. Impression: Banded Varix was seen at 32 cm. There was
no evidence of active bleeding.Grade 2 esophagitis in the lower
third of the esophagus compatible with esophagitis. Blood in the
whole stomach, but not obvious source of bleeding.Blood in the
whole duodenum
.
EGD [**2115-11-28**]:
Blood in the lower third of the esophagus. Blood in the whole
stomach
1.Clotted blood in duodenum with no active bleeding.there was a
feeding tube noticed going into second part of duodenum.It was
coiled in fundus.
Otherwise normal EGD to second part of the duodenum
.
CT ab/pelvic [**2115-11-22**]:
IMPRESSION:
1. Large amount of ascites. No evidence of retroperitoneal
hemorrhage.
2. Bilateral small pleural effusions and associated compressive
atelectasis.
3. Radiopaque cholelithiasis in shrunken and nodular liver.
4. Similar appearance of right adrenal adenoma.
.
[**2115-11-13**] 11:50PM HCT-28.8*
[**2115-11-13**] 10:51PM TYPE-ART PO2-214* PCO2-27* PH-7.53* TOTAL
CO2-23 BASE XS-1
[**2115-11-13**] 08:17PM ASCITES WBC-200* RBC-330* POLYS-12* LYMPHS-21*
MONOS-0 EOS-1* MESOTHELI-7* MACROPHAG-59*
[**2115-11-13**] 07:56PM HCT-27.5*
[**2115-11-13**] 04:47PM GLUCOSE-242* UREA N-101* CREAT-1.8*
SODIUM-140 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-22 ANION GAP-20
[**2115-11-13**] 04:47PM ALT(SGPT)-109* AST(SGOT)-115* LD(LDH)-231 ALK
PHOS-106 AMYLASE-48 TOT BILI-1.8*
[**2115-11-13**] 04:47PM LIPASE-46
[**2115-11-13**] 04:47PM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-2.0
[**2115-11-13**] 04:47PM WBC-4.6 RBC-3.39* HGB-10.5* HCT-28.4* MCV-84
MCH-31.0 MCHC-37.1* RDW-16.7*
[**2115-11-13**] 04:47PM NEUTS-88* BANDS-1 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2115-11-13**] 04:47PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2115-11-13**] 04:47PM PLT SMR-VERY LOW PLT COUNT-53*
[**2115-11-13**] 04:47PM PT-15.6* PTT-27.8 INR(PT)-1.4*
Brief Hospital Course:
Briefly, this is a 63 year old with NASH who was transfered from
OSH for UGIB and encephalopathy. He expired on [**2115-11-29**] in the
setting of massive GI bleeding. The following is a brief
hospital course by problem.
.
#Chronic Resp failure: The patient was extubated and reintubated
three times for failure to clear secretions and poor cough
reflex. He was presumed to have a tracheobronchitis with MRSA
in sputum from [**11-16**], [**11-20**], and [**11-21**]. He was maintained on
primarily pressure support and MMV during times of apnea. He
was treated with a 7 day course of ceftazadime and a 10 day
course of vancomycin starting [**11-16**] for
tracheobronchitis/ventilator associated pneumonia. The
patient's ABGs revealed a respiratory alkalosis with a PCO2 of
22-23. His resp alkalosis is likely partially as compensation
for met acidosis and due to primary process. On [**11-23**] the
patient had increasing respiratory distress with hypoxemia, felt
to be c/w mucus plugging on CXR. His CXR had improved by [**11-24**],
as had his oxygenation. The pt was satting well on PS of [**5-3**]% Fio2 on [**11-27**], but he had another GIB with suspected
aspiration. Again, his PO2 dropped to 59 on the same vent
settings, so he was placed back on AC.
.
#UGIB/Anemia: EGD revealed blood in the stomach with no active
bleeding source. He has evidence of grade II esophagitis and
gastritis. He had a recurrent bleed on [**11-19**] with 400 cc of
bloody return from his OGT, requiring reintubation. He received
2 units of PRBC on [**11-19**] after his hct dropped from 44 to 30. He
was maintained on an octreotide gtt for 2 days. His hematocrit
wavered between 30 to 40 thereafter and seemed to be dependent
on fluid shifts. CT of the abdomen on [**11-22**] revealed no
retroperitoneal bleed. He remained guaiac positive through his
stay though to be due to the initial GI bleed. On [**11-27**] the pts
hct dropped from 35 to 25 with red clots noted in his stool. He
was transfused 2 units of PRBC, 4 units of FFP, and 1 unit of
plt. Octreotide gtt was again restarted. Repeat EGD on [**11-28**]
revealed massive amounts of blood in the stomach. There was so
much bleeding that a source was not identified. He was
continued on [**Hospital1 **] PPI, sucralfate, and rifaximine 400 tid. His
nadolol was decreased from 40 mg/d to 20 mg/d due to low BP. On
[**11-28**] the pt [**Doctor First Name **] made CMO due to uncontrollable bleeding.
.
# NASH with hepatic encephalopathy: The patient's encephalopathy
resolved with lactulose, rifaximin, and pentoxyfilline.
Diagnostic paracentesis on [**11-20**] revealed no evidence of
infection. The patient was continued on nadolol 20 mg/d. As
per below, he developed hepatorenal syndrome and was maintained
on daily midodrine/octreotide and albumin.
.
#ARF/Hepatorenal syndrome: The pts Cr on admission was 1.8.
This slowly improved to 1.1, but on [**11-20**] it slowly began to
rise, and was up to 1.7 on [**11-25**] despite albumin and fluid
boluses. His UNa was less than 10 was UO of [**5-8**] cc/hr, so his
symptoms were felt to be c/w hepatorenal syndrome. The patient
was started on daily midodrine/octreotide and albumin. As his
creatinine increased to 2.4 by [**11-28**], his albumin was increased
to 25 gm [**Hospital1 **] and midodrine was increased to 15 mg tid.
.
# Pancytopenia: The patient developed pancytopenia on [**11-21**] with
platelet dropping to the 30s, hematocrit dropping to 30, and WBC
dropping from 24 to 4 in 24 hrs. His Vancomycin level was found
to be in the 70s and thought to be the likely source. All cell
lines gradually rose with cessation of further Vancomycin
dosing.
.
#Chest Pain: The patient developed chest pain on the night of
[**11-23**]. EKG revealed poor R wave progression and loss of
anterior forces. Cardiac enzymes revealed no elevation in CK,
but Troponin elevated at 0.11 to 0.19 (likely due to renal
failure). TTE on [**11-25**] to eval for pericardial effusion was
negative for effusion.
.
#UTI: The pt completed a 10 d course of Vanc for enterococcus
growing in urine on [**11-14**].
Medications on Admission:
1. Liver cirrhosis secondary to NASH, complicated by multiple
variceal bleeds, ascites, splenomegaly and portal hypertension.
No recent EGD or C-scope on file in OMR. Listed for transplant,
work-up to date with echo in [**8-/2115**] with preserved systolic
function, PFTs also done though records not available.
2. DM type 2, last HbA1c 6.5% on [**2115-9-16**].
3. Hypertension
4. Gout
5. Osteoarthritis
6. Glaucoma and macular degeneration
7. Status post right first digit amputation [**2115-4-29**] for
osteomyelitis and nonhealing ulcer.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
NASH cirrhosis
upper GI bleed
hepatorenal syndrome
respiratory failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"276.0",
"456.20",
"584.5",
"250.00",
"E930.8",
"599.0",
"799.02",
"401.9",
"284.8",
"482.41",
"535.51",
"707.03",
"786.59",
"E912",
"572.4",
"276.4",
"518.84",
"572.3",
"570",
"934.1",
"572.2",
"571.5",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.6",
"96.72",
"54.91",
"99.04",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9472, 9481
|
4737, 8851
|
287, 373
|
9595, 9604
|
2415, 4714
|
9657, 9664
|
2189, 2218
|
9443, 9449
|
9502, 9574
|
8877, 9420
|
9628, 9634
|
2233, 2396
|
244, 249
|
401, 1517
|
1539, 2082
|
2098, 2173
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,976
| 173,269
|
35271
|
Discharge summary
|
report
|
Admission Date: [**2199-1-13**] Discharge Date: [**2199-1-16**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
Intubation
Central line line placement
Arterial line placement
History of Present Illness:
62 yo Spanish speaking M with PMH of HTN, DM, embolic and
hemorrhagic CVA, aphasia, DVT who presents with lethargy. Per
the ED call-in and family, he was very somnolent this am at NH
but then as the day progressed became more alert. However when
his family came to visit they wanted him to be evaluated in the
ER. His baseline mental status is aphasic but interactive, but
today he is not interactive. The patient is unable to provide a
history.
.
In the ED, initial vs were: 100.0 83 80/67 18 100% NRB. His GCS
was [**3-24**] (with opening his eyes spontaneously). He was found to
have very foul smelling brown guaiac negative stool, however the
family did not report any recent antibiotics. He was intubated
for airway protection. A right IJ was placed, and carotid stuck
initially. U/A unremarkable, cultures were sent, head CT was
done which showed no interval change. A CXR showed hilar
fullness and questionable retrocardiac opacity and he was found
to purulent sputum from the ET tube. The patient was given 5L of
NS, with no response, then started on peripheral dopamine for
pressure support. He was also given vancomycin, levofloxacin
and metronidazole empirically and 15mg of midazolam. After
dopamine was started his blood pressure improved to 111/52.
Past Medical History:
-Hypertension
-CVA: bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**]
-Type II Diabetes mellitus
-Peripheral neuropathy
-Constipation
-Dysphagia
-Depression
-Hypothyroidism
-h/o DVT
Social History:
Resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Family very involved in patient's
care. Patient does not take anything by mouth due to history of
aspiration. Spanish-speaking. tobacco: quit [**2183**]. 30+ yrs,
2ppd. alcohol: denies drugs: denies
Family History:
mother - died, DM
father - died, Pneumonia
other - brother - heart disease
No family history of cancer.
Physical Exam:
General: intubated, sedated, nonresponsive
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA
Neck: supple, JVP not elevated, no LAD, RIJ in place
Lungs: Clear to auscultation bilaterally, bronchial breath
sounds at the bases, rhonchi BL, no crackles or wheezes
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
at the apex, no rubs or gallops
Abdomen: J tube in place, no erythema, soft, non-tender,
non-distended, hypoactive bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: cold, mottled appearance of extremities, 2+ pulses, no
edema,
Neuro: sedated, intubated, contractures present BL UE and LE,
worse on the right
Pertinent Results:
[**2199-1-13**] 11:15PM URINE HOURS-RANDOM CREAT-42 SODIUM-66
[**2199-1-13**] 11:15PM URINE OSMOLAL-429
[**2199-1-13**] 10:38PM TYPE-ART TEMP-36.9 PO2-203* PCO2-41 PH-7.31*
TOTAL CO2-22 BASE XS--5
[**2199-1-13**] 10:38PM K+-2.6*
[**2199-1-13**] 09:06PM TYPE-ART TEMP-37.0 PO2-374* PCO2-43 PH-7.33*
TOTAL CO2-24 BASE XS--3
[**2199-1-13**] 09:06PM LACTATE-1.3 K+-2.4*
[**2199-1-13**] 09:06PM freeCa-1.05*
[**2199-1-13**] 03:50PM URINE HOURS-RANDOM
[**2199-1-13**] 03:50PM URINE UHOLD-HOLD
[**2199-1-13**] 03:50PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2199-1-13**] 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2199-1-13**] 03:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2199-1-13**] 03:18PM LACTATE-2.2*
[**2199-1-13**] 03:10PM GLUCOSE-216* UREA N-33* CREAT-1.2 SODIUM-140
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
[**2199-1-13**] 03:10PM estGFR-Using this
[**2199-1-13**] 03:10PM ALT(SGPT)-29 AST(SGOT)-19 ALK PHOS-52 TOT
BILI-0.3
[**2199-1-13**] 03:10PM LIPASE-34
[**2199-1-13**] 03:10PM cTropnT-0.04*
[**2199-1-13**] 03:10PM CK-MB-2
[**2199-1-13**] 03:10PM ALBUMIN-3.3* CALCIUM-8.0* PHOSPHATE-2.8
MAGNESIUM-2.8*
[**2199-1-13**] 03:10PM TSH-1.9
[**2199-1-13**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2199-1-13**] 03:10PM WBC-23.6*# RBC-5.01 HGB-12.3* HCT-36.3*
MCV-72* MCH-24.5* MCHC-33.8 RDW-15.0
[**2199-1-13**] 03:10PM NEUTS-89.1* LYMPHS-5.4* MONOS-5.4 EOS-0
BASOS-0.1
[**2199-1-13**] 03:10PM PLT COUNT-272
[**2199-1-13**] 03:10PM PT-23.0* PTT-35.5* INR(PT)-2.2*
EKG: Leftward axis, right bundle branch block stable from
prior, sinus
Brief Hospital Course:
# Septic Shock: Initially patient has leukocytosis, tachypnea,
elevated lactate, hypotension however not tachycardic, but
suggestive of septic shock. Source likely pneumonia given chest
x-ray and purulent sputum. Other possible source could be C
diff given foul smelling stool, however no recent antibiotic
use. Cultures sent in ED, which grew out MRSA from sputum and
was found to be C diff Positive. Antibiotics were started on
admission [**1-13**] and were narrowed from Vanc/zosyn/flagyl to PO/IV
Vanc. He was found to be legionella and influenza negative. He
was started on Levophed intermittently overnight on the day of
admission, subsequently weaned off and then started again
overnight. The patient was intubated in the ED for airway
protection and extubated the next morning. Patient did have
some ectopy on telemetry which resolved with electrolyte
administration.
.
# AMS: Likely secondary to infection, however given history of
CVA's could be seizure activity. Will monitor for signs of
seizure activity, will get EEG if evidence of seizures. No sign
of acute hemorrhage or stroke by head CT. All sedating
medications were held and restarted again after extubation 24
hours later, where patient was found to be at his baseline
mental status per family-interactive, follows commands, but has
garbled speech from prior CVA.
.
# Acute renal failure: Likely secondary to hypotension/septic
shock, creatinine normalized with fluid administration.
.
# Hypertension: Remained normotensive through hospital stay,
lisinopril held and not restarted prior to transfer
.
# History of CVAs: bilateral embolic cerebellar [**2188**],
hemorrhagic left thalamic [**2190**]. Continue simvastatin,
anticoagulated with plavix. Continue baclofen for contractures.
.
# Type II Diabetes mellitus: Monitor blood sugars QID, insulin
sliding scale. Blood sugars remained well controlled during
hospital stay.
.
# Chronic Constipation: Aggressive bowel regimen including
colace, miralax, reglan, lactulose, biscodyl, fleet enemas, and
golytely PRN on admission, discontinued the miralax and the
lactulose and monitored stool output, which was elevated likely
due to C diff infection. Patient did not complain of abdominal
pain at any point during stay.
.
# Dysphagia: PEG in place, tube feeds reinitiated.
.
# Depression: Changed duloxetine to paxil given that duloxetine
cannot be crushed. Hold mirtazapine given possible sedation.
.
# Hypothyroidism: Continue levothyroxine.
.
# h/o DVT: Restarted coumadin, INR down to 1.9 and increased
dose from 3 mg to 4 mg [**Last Name (LF) 244**], [**First Name3 (LF) **] need to be followed as an
outpatient.
.
# FEN: No IVF, replete electrolytes, tubefeeds
.
# Prophylaxis: Coumadin now, but will hold for now, lovenox as
needed, PPI
.
# Access: R IJ and left A line-removed [**1-16**], PICC placement
.
# Code: Full code confirmed with HCP
.
# Communication: Sons and daughter in law
.
# Disposition: D/C from ICU to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Medications on Admission:
1. Simvastatin 20 mg Two PO DAILY
2. Duloxetine 60 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Baclofen 20 mg PO QID
5. Mirtazapine 7.5 mg PO HS
6. Levothyroxine 25 mcg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Lidocaine 5 %(700 mg/patch) QDAY
10. PEG-Electrolyte Soln 1 gallon PO q day
11. Enoxaparin 60 mg/0.6 mL Subcutaneous Q DAY
12. Morphine 15 mg PO four times a day.
13. Warfarin 3 mg PO q day
14. Fleet Enema 19-7 gram/118 mL Enema [**Last Name (NamePattern1) **]: Rectal once a day as
needed for constipation.
15. Biscolax 10 mg Rectal once a day as needed for constipation.
16. Plavix 75 mg Tablet PO once a day.
17. Lactulose 10 gram/15 mL Solution [**Last Name (NamePattern1) **]: Thirty (30) gm PO
twice a day.
18. Multivitamin
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (NamePattern1) **]: One (1) PO BID (2
times a day).
2. Metoclopramide 10 mg Tablet [**Last Name (NamePattern1) **]: 0.5 Tablet PO HS (at
bedtime).
3. Simvastatin 10 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO DAILY
(Daily).
4. Baclofen 10 mg Tablet [**Last Name (NamePattern1) **]: Two (2) Tablet PO QID (4 times a
day).
5. Levothyroxine 25 mcg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO DAILY
(Daily).
7. Multivitamin Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO DAILY (Daily).
8. Insulin Lispro 100 unit/mL Solution [**Last Name (NamePattern1) **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Gabapentin 300 mg Capsule [**Last Name (NamePattern1) **]: Two (2) Capsule PO Q8H (every
8 hours).
10. Mirtazapine 15 mg Tablet [**Last Name (NamePattern1) **]: 0.5 Tablet PO HS (at bedtime).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (NamePattern1) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. Morphine 15 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours): Please administer oral liquid via NG.
15. Warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM.
16. Paroxetine HCl 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
MRSA and C difficile sepsis
Hypotension
Previous diagnosis-
-Hypertension
-CVA: bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**]
-Type II Diabetes mellitus
-Peripheral neuropathy
-Constipation
-Dysphagia
-Depression
-Hypothyroidism
-h/o DVT
Discharge Condition:
Hemodynamically stable, tolerating tube feeds, nonambulatory
from contractures secondary to CVA, garbled speech
Discharge Instructions:
Patient will need to continue IV and PO vancomycin for C diff
and MRSA + pneumonia. Day one is [**1-13**].
Followup Instructions:
Please follow up with your primary care doctor in [**12-21**] weeks.
Completed by:[**2199-3-8**]
|
[
"038.12",
"250.60",
"785.52",
"357.2",
"401.9",
"584.9",
"995.92",
"038.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10569, 10665
|
4840, 7884
|
324, 388
|
10980, 11094
|
3057, 4817
|
11250, 11349
|
2246, 2352
|
8705, 10546
|
10686, 10959
|
7910, 8682
|
11118, 11227
|
2367, 3038
|
276, 286
|
416, 1693
|
1715, 1927
|
1943, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,141
| 181,263
|
24981
|
Discharge summary
|
report
|
Admission Date: [**2188-2-27**] Discharge Date: [**2188-3-2**]
Date of Birth: [**2143-11-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
SOB / DOE
Major Surgical or Invasive Procedure:
Mitral valve repair
History of Present Illness:
The patient is a 44-year-old woman who was referred for severe
mitral regurgitation and possible repair or replacement of her
valve.
Past Medical History:
1. Bilateral PEs, on coumadin, last CTA on [**9-11**] showed
nonocclusive LLL subsegmental pulmonary embolus. Probable small
eccentric
subsegmental PEs within the right lower lobe and right upper
lobe.
2. Valvular disease, with severe TR and severe MR
3. Biventricular Congestive heart failure, EF 25%, likely [**1-12**]
valvular disease
4. Hx of cocaine use, +tox screen on last admission, last use
one month ago
5. Hypertension
6. Cervical cancer
7. S/P Cholecystectomy
Social History:
Tobacco - denies
Alcohol - 4 drinks on fridays and saturdays
Drug use - sporadic cocaine use; most recently on Saturday
Family History:
Mother: diabetes, [**Month/Day (2) **], renal disease
Father: unknown
Physical Exam:
spanish speaking
a/o
nad
grossly in tact
cta
rrr
obese / pos bs
distal pulses
Pertinent Results:
[**2188-3-1**] 07:15AM BLOOD
WBC-10.3 RBC-3.23* Hgb-8.6* Hct-27.2* MCV-84 MCH-26.6* MCHC-31.6
RDW-14.0 Plt Ct-191
[**2188-3-1**] 07:15AM BLOOD
PT-17.4* INR(PT)-1.6*
[**2188-3-1**] 07:15AM BLOOD
Glucose-112* UreaN-17 Creat-1.1 Na-136 K-4.2 Cl-101 HCO3-27
AnGap-12
[**2188-2-29**] 1:16 PM
CHEST (PORTABLE AP)
FINDINGS: In comparison with study of [**2-27**], the various tubes
have been removed. No evidence of pneumothorax. Some continued
prominence of the cardiac silhouette with mild atelectatic
changes at the left base.
Brief Hospital Course:
pt admitted
underwent uneventfull valve repair, transfered to the CVICU in
stable condition
Extubated with out difficulty
Chest tubes out pod # 1
Pacing Wires / foley out POD # 2
Coumadin started POD # 2 for previous PE / INR followed / Pt to
have coumadin monitered as a outpt in the usual manner
Diuresed throughout the hospital course / lytes replenished
PT consult
Pt stable for home with VNA
Medications on Admission:
[**Last Name (un) 1724**]: lisinopril 20', lasix 40", toprol xl 50', percocet"/prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 * Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. 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*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Have
you INR checked in the usual fashion.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] vna
Discharge Diagnosis:
MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
lumbar disc disease
Discharge Condition:
good
Discharge Instructions:
No lifting > 10 # for 10 weeks
may shower, no creams, lotions or powders to any incisions
no driving for 1 month
Will need coumadin for 3 months for history of pulmonary
embolism
have you inr followed in the usual manner
Followup Instructions:
with Dr. [**Last Name (STitle) 2427**] in [**1-13**] weeks
with Dr. [**Last Name (STitle) **] in [**1-13**] weeks
with Dr. [**Last Name (STitle) 914**] in [**3-15**] weeks
Completed by:[**2188-3-2**]
|
[
"305.1",
"428.0",
"724.5",
"V12.51",
"401.9",
"424.0",
"V10.41",
"309.81",
"V58.61",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"35.33",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
3534, 3585
|
1902, 2309
|
329, 351
|
3705, 3712
|
1347, 1879
|
3983, 4185
|
1163, 1234
|
2442, 3511
|
3606, 3684
|
2335, 2419
|
3736, 3960
|
1249, 1328
|
280, 291
|
379, 513
|
535, 1009
|
1025, 1147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,891
| 109,421
|
23676+57367
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-10-14**] Discharge Date: [**2192-11-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p fall at the nursing home
Major Surgical or Invasive Procedure:
Placement of right A-line
Placement of left Internal Jugular central line
History of Present Illness:
[**Age over 90 **] yo female, resident at [**Hospital 100**] Rehab with h/o dementia, PE and
DVT in [**5-20**] for which she has been on coumadin (INR 4.7 on
admission), CHF who was found on the floor at [**Hospital 100**] Rehab. Head
CT showed small right temporal intraparenchymal hemorrhage, 2x2
cm., which was unchanged on repeat head CT. INR was 4.7 and
platelets of 93 at the time of presentation. C-spine was cleared
by CT. In the ED, the patient was evaluated by NS and Trauma and
was felt not to be a candidate for intervention. She was
intubated for airway protection. Prior to being transferred to
MICU, the patient was loaded with Dilantin 1 gm IV once, INR
reversed with Vitamin K 10 units SC, 4units of FFP, 6 pack of
platelets. She was given Lasix 40 IV and received 1L NS for
hypernatremia.
Past Medical History:
1. osteoporosis
2. diverticulosis and h/o lower GI bleed secondary to
diverticulitis requiring subtotal colectomy
3. SSS s/p PPM
4. urosepsis
5. dry eyes
6. mild AI
7. CHF EF 20-30%
8. dementia
9. anxiety
10. hypercalcemia (?primary hyperparathyroidism)
11. blindness
12. anxiety
Social History:
Lives at [**Hospital 100**] Rehab. Rest of Social history is unknown. Son
[**Name (NI) **] is HCP. [**Telephone/Fax (1) 60538**]
Family History:
non-contributory.
Physical Exam:
afebrile HR 97 BP 116/71 RR 15 86% on vent (puls ox [**Location (un) 1131**] is
not reliable)
AC 400 x 16; PEEP 5; FiO2 100%
GEN: thin elderly lady, intubated and sedated
HEENT: large left fontal hematoma; eyes with clouded cornea;
small pupils; no obvious reaction to light
NECK: supple no LAD
CV: tachy, irreg irreg, no m/r/g
LUNG: crackles b/l bases
ABD: + BS, soft, nt, midline scar, LLQ hematoma
EXT: 2+ edema b/l ext
NEURO: unable to assess as patient is intubated/sedated
Rectal: guaiac + per ED note
Pertinent Results:
Admission Labs:
.
[**2192-10-14**] 11:45AM PT-25.3* PTT-35.0 INR(PT)-4.7
[**2192-10-14**] 11:45AM PLT SMR-LOW PLT COUNT-93* LPLT-2+
[**2192-10-14**] 11:45AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+
[**2192-10-14**] 11:45AM NEUTS-67.2 LYMPHS-26.8 MONOS-4.0 EOS-1.6
BASOS-0.3
[**2192-10-14**] 11:45AM WBC-7.0 RBC-4.79 HGB-13.0 HCT-43.9 MCV-92
MCH-27.2 MCHC-29.7* RDW-18.9*
[**2192-10-14**] 12:13PM GLUCOSE-124* NA+-157* K+-7.4* CL--114*
[**2192-10-14**] 02:45PM CALCIUM-11.7* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2192-10-14**] 02:45PM GLUCOSE-129* UREA N-38* CREAT-0.8 SODIUM-157*
POTASSIUM-4.4 CHLORIDE-121* TOTAL CO2-26 ANION GAP-14
[**2192-10-14**] 05:00PM PT-17.0* PTT-112.9* INR(PT)-2.0
[**2192-10-14**] 05:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+
[**2192-10-14**] 05:00PM NEUTS-61.6 LYMPHS-33.5 MONOS-2.8 EOS-1.5
BASOS-0.6
[**2192-10-14**] 05:00PM WBC-5.5 RBC-3.56*# HGB-10.0* HCT-33.7*#
MCV-95 MCH-28.2 MCHC-29.8* RDW-19.3*
[**2192-10-14**] 05:00PM CALCIUM-11.9* PHOSPHATE-2.3* MAGNESIUM-2.3
[**2192-10-14**] 05:00PM GLUCOSE-196* UREA N-36* CREAT-0.9 SODIUM-158*
POTASSIUM-4.5 CHLORIDE-116* TOTAL CO2-25 ANION GAP-22*
[**2192-10-14**] 05:17PM LACTATE-5.0*
[**2192-10-14**] 05:17PM TYPE-[**Last Name (un) **] TEMP-36.7 RATES-/18 PO2-19* PCO2-51*
PH-7.38 TOTAL CO2-31* BASE XS-2 INTUBATED-INTUBATED
[**2192-10-14**] 07:07PM LACTATE-2.8*
[**2192-10-14**] 07:07PM TYPE-ART PO2-423* PCO2-31* PH-7.60* TOTAL
CO2-32* BASE XS-9 INTUBATED-INTUBATED
[**2192-10-14**] 10:34PM URINE MUCOUS-MOD
[**2192-10-14**] 10:34PM URINE HYALINE-10*
[**2192-10-14**] 10:34PM URINE RBC-115* WBC-11* BACTERIA-MANY
YEAST-NONE EPI-4
[**2192-10-14**] 10:34PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-TR
[**2192-10-14**] 10:34PM URINE COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.020
[**2192-10-14**] 10:34PM PT-14.8* PTT-29.5 INR(PT)-1.5
[**2192-10-14**] 10:34PM PLT COUNT-96*
[**2192-10-14**] 10:34PM WBC-5.9 RBC-3.81* HGB-10.4* HCT-34.3* MCV-90
MCH-27.3 MCHC-30.2* RDW-18.9*
[**2192-10-14**] 10:34PM CALCIUM-11.5* PHOSPHATE-1.5* MAGNESIUM-2.1
[**2192-10-14**] 10:34PM CK-MB-3 cTropnT-0.02*
[**2192-10-14**] 10:34PM CK(CPK)-70
[**2192-10-14**] 10:34PM GLUCOSE-123* UREA N-36* CREAT-0.8 SODIUM-158*
POTASSIUM-3.3 CHLORIDE-118* TOTAL CO2-31 ANION GAP-12
Pertinent Labs/Studies:
.
[**2192-10-14**] 10:34PM BLOOD CK-MB-3 cTropnT-0.02*
[**2192-10-15**] 06:07AM BLOOD CK-MB-NotDone cTropnT-0.03*
.
Imaging:
[**2192-10-14**]: CT Head: IMPRESSION: Temporal intracerebral
hemorrhage and subcutaneous hematoma in the left frontal region.
.
[**2192-10-15**]: CT Head: IMPRESSION: Stable appearance of right
temporal intraparenchymal hemorrhage.
.
[**2192-10-19**]: Portable Chest: IMPRESSION: Congestive heart failure
with slight improvement in degree of pulmonary edema.
.
[**2192-11-1**]: Portable Chest: Portable supine AP radiograph of the
chest is reviewed, and compared with the previous study of
[**2192-10-29**]. There is marked increase in severe pulmonary
edema probably due to congestive heart failure associated with
cardiomegaly and bilateral pleural effusion. There is increased
atelectasis in both lower lobes. The possibility of
superimposed pneumonia cannot be excluded. Pacemaker leads and
nasogastric tube remain in place. No pneumothorax is
identified. The radiograph is suboptimal in technique.
.
.
Microbiology:
Blood cultures:
[**10-18**]: No growth to date
[**10-19**]: No growth to date
Urine:
[**10-15**]: 2 colonies, both E. Coli, pan-sensitive
[**2192-10-25**]: Yeast > 100K CFU
Stool:
[**10-14**]: Cultures negative
C. Diff negative x 4
.
Sputum:
[**10-15**]: > 25pmns, < 10epi. Gram Positive cocci in pairs and
clusters
- moderate growth of MRSA
Discharge Labs: Patient deceased [**2192-11-2**]
.
[**2192-11-1**] 03:46AM BLOOD WBC-6.9 RBC-2.95* Hgb-8.3* Hct-26.7*
MCV-91 MCH-28.2 MCHC-31.2 RDW-20.1* Plt Ct-210
[**2192-11-1**] 03:46AM BLOOD Glucose-144* UreaN-21* Creat-0.5 Na-143
K-3.8 Cl-102 HCO3-34* AnGap-11
[**2192-11-1**] 03:46AM BLOOD Calcium-10.8* Phos-2.0* Mg-1.7
[**2192-10-21**] 03:41AM BLOOD calTIBC-194* Ferritn-174* TRF-149*
[**2192-10-30**] 07:09AM BLOOD Type-ART pO2-96 pCO2-48* pH-7.37
calHCO3-29 Base XS-1
Brief Hospital Course:
A [**Age over 90 **] year-old female with a history of dementia, CHF, DVT and PE
([**5-20**]), Afib, previously on anticoagulation therapy admitted
s/p fall with intraparenchymal hemorrhage on admission.
.
#. Right Temporal Lobe Cerebral Hemorrhage: The patient was
transferred to [**Hospital1 18**] s/p fall at [**Hospital 100**] Rehab. Patient was found
to have a 2x2 intraparenchymal bleed on CT with noted decline in
mental status while in the ED. This bleed occurred in the
setting of a supertherapautic INR from coumadin. The patient had
immediate reversal of her anticoagulation with 4 units of FFP
and received 6 units of platelets for thrombocytopenia with
platelet count of 93 and was loaded on dilantin for seizure
prophylaxis and started on Keppra as well. The patient was
evaluated by neurosurgery who did not feel there was an
indication for surgery, but did recommend reversal of
anticoagulation with goal of INR < 1.3 and platelets > 1000. The
patient was transferred to the ICU and intubated for airway
protection. The patient had a sodium of 158 on admission and was
given NS for hypovolemia followed by free water repletion to a
normal sodium which was discontinued after normalization and
also upon recommendation from neurosurg given concern for
increasing edema in setting of intracranial bleed. With regards
to her bleed, the patient had two repeat Head CTs which
demonstrated stable bleed without expansion or midline shift.
Given that the hematoma was stable, neurosurgery signed off
recommending repeat Head CT in approximately 4 weeks time. Upon
further discussion, they reported to the treating team that the
patient's prognosis with regards to her mental status changes
would be expected that she should return to her previous
baseline prior to this accident. However, the treating team and
geriatrics team following the patient felt that given her
baseline mental status and the multiorgan damage ensuing from
this accident, that it was probable the patient would not fully
recover from this accident. Given her stable lesion and no
evidence of ongoing bleed, patient's platelet transfusion
threshold lowered to 50K in attempt to decrease fluids as
patient has been developing body volume overload and anasarca in
setting of volume resuscitation for hypotension. The patient
demonstrated very slow to no improvement in neurologic status.
She demonstrated some increasing amounts of spontaneous
movements and was able to open eyes to commands, but performed
very few other commands. When not stimulated, despite being off
all sedatives, the patient remained relatively obtunded. The
patient was maintained on Dilantin and Keppra. After detailed
discussion re: prognosis and potential for recovery with [**Name (NI) 1094**]
son [**Doctor First Name **], HCP), the [**Name (NI) 1094**] code status was changed to
DNR/DNI/CMO, and the Pt. passed away comfortably from
cardiorespiratory arrest/failure shortly after.
.
#. Hypotension: Upon transfer to the MICU the patient had been
requiring volume support and pressors to maintain a MAP > 60. On
admission patient was initially receiving fluid boluses and
started on levophed for hypotension and decreased urine output.
Given the patient was developing total body fluid overload,
including moderate to severe pulmonary edema, levophed was
increased in an attempt to limit fluid support, with goal of
fluid boluses for CVP < 14. In setting of increased levophed the
patient's blood pressure did indeed respond, but she also
developed rapid ventricular response to her Afib. Therefore,
levophed was weaned and the patient was switched to
neosynephrine for pressure support. The patient's CVP goals were
additionally decreased with fluid boluses for CVP < 8, again
given worsening fluid overload. The etiology of the patient's
hypotension is unclear, but likely related to her poor cardiac
function and possibly infection, although the patient never
developed a leukocytosis or fever. The patient had a sputum
culture with moderate growth of MRSA and a urine culture growing
E. Coli (see ID) for which the patient has been treated. Over
the course of time, the patient has been weaned off
neosynephrine and has been maintaining a MAP > 60 without any
fluid or pressor support. She had been diuresed with a net
negative fluid balance of 500 to 1000cc each day and was
tolerating diuresis well without any associated hypotension.
.
#. Respiratory: The patient was initially intubated for airway
protection in the setting of intraparenchymal hemorrhage, with
propofol sedation. The patient was initially placed on AC with
blood gases revealing adequate oxygentation without hypercarbia.
She was switched to pressure support 15/5, with blood gases that
indicated again appropriate ventilation and oxygenation, but the
patient was noted to have intermittent episodes of apnea. The
patient was therefore changed to MMV setting on the vent, again
noted still to trigger vent-initiated breaths for periods of
apnea. On physical exam, the patient was additionally noted
periodically to have periods of rapid ventilation alternating
with periods of apnea, concerning for dysregulation of centrally
mediated respiratory drive. Throughout the hospital course this
respiratory pattern seemed to resolve and the patient had a more
regular pattern of breathing. Of note however, the patient
occasionally had periods of apnea. In attempt to help avoid
respiratory suppression, the patient was started on diamox and
potassium chloride to reduce metabolic alkalosis as an
inhibitory respiratory signal. The patient had a RSBI of 109
with intentions to continue to attempt to wean the patient from
ventilatory support. As above, the patient was noted during her
hospital course to have suctioned sputum with moderate growth of
MRSA. Although unclear if this growth represented pure
colonization, tracheobronchitis or true vent assoicated
pneumonia, the patient was initiated on vancomycin therapy in
attempt to correct any reversible cause constributing to ongoing
respiratory distress and inability to wean from the ventilator.
The patient additionally suffered from moderate to severe CHF
with pulmonary edema and effusions. The patient had been
undergoing successful diuresis with net negative 1500cc over
last 72 hours although over the course of her admission she
still remains 15L positive.
.
#. Afib - The patient had a DDD pacer that was placed for an
indication of sick sinus syndrome. Cardiology consult was
requested as the pacer was noted to be inappropriately firing
despite ventricular beats on admission. The patient's rhythm on
admission and throughout her stay had been Afib. Indeed,
interrogation of the pacer revealed that her atrial lead
detected properly and revealed Afib. Her ventricular lead
detected native ventricular beats as well. However it was found
that the sensitivity of the lead was too low and was adjusted so
that the ventricular lead would not inappropriately fire any
longer. With inappropriate firing the patient was at risk for Q
on T and subsequent V-fib, but her pacing dysfunction likely was
thought to have no relationship to her fall as it would not
cause a bradycardia or asystole. Given the patient's bleed, all
anticoagulation was held. As above, her anticoagulation was
reversed. The patient has known Afib as well as known DVT and
PE previously placing her again for increased risk of clot and
embolus, but necessarily so given her bleed. The patient's
metoprolol has additionally been held given her hypotension. The
patient was noted to have RVR in setting of levophed drip, but
since discontinuing, had ventricular reponse rate in the 80-110
range not requiring any further intervention.
.
#. CHF EF 20-30% - On admission, patient known to have CHF with
reported ejection fraction of 20-30%. The patient required
holding her metoprolol and lisinopril as above given her
persistent hypotension and additionally required large amounts
of fluid bolusing. The patient's obligate fluid load during her
MICU admission had resulted in moderate to severe pulmonary
edema. This degree of edema may have additionally been limiting
patient's ability to wean from vent. Initially, effective
diuresis was limited by the patient's persistent hypotension.
However, since resolution of her hypotension, the patient has
been diuresing well to very small doses of lasix, 10 to 20mg a
day with net negative fluid balance of 500cc to 1000cc per day.
.
#. ID: Since admission, the patient was afebrile without
leukocytosis. The patient had sputum cultures from [**2192-10-15**] with
moderate growth of MRSA. Although the patient had not had fever
or leukocytosis or radiographic evidence of pneumonia, therapy
was initiated with vancomycin in an attempt to treat any
reversible causes underlying patient's ongoing clinical picture
including hypotension and failure to wean form vent. Urine
cultures from [**2192-10-15**] were additionally found to be growing >
100K E. Coli (pan-sensitive) as well as GPC, likely alpha strep
or lactobacillus. The patient was initially started on Zosyn
when only gram negative rods were known, which has since been
changed to Bactrim given pan-sensitive E. Coli. The patient
completed a 7 day course for this infection. All blood cultures
since admission demonstrated no growth.
.
#. Recent PE and DVT - As above all anticoagulation was held
given recent intracranial bleed.
.
#. Hypercalcemia: Patient's hypercalcemia was thought to be
chronic and likely secondary to primary hyperparathyroidism as
she has an elevated PTH in setting of mild hypercalcemia.
Patient's hypercalcemia was stable throughout the hospital
course, not requiring any additional treatment.
.
#. Dementia: Patient has baseline dementia, by report at
baseline she was able to interact and communicate. Patient's
Donepezil and all other non-essential medications were held
during her MICU course in setting of altered mental status and
hypotension with need to minimize all but essential meds.
.
#. FEN: Patient was started on tube feeds for nutrition after
intubation.
Medications on Admission:
Tylenol
MVI
Tobramycin/Dexamethasone OP 1 appl qhs to right eye
Coumadin
Artificial tears
Aspirin 81 mg po daily
Bacitracin/Polymixin 1 appl [**Hospital1 **] to left eye
Calcium/Vit D 500 mg po tid
Cyanocobolamine 259 mcg po daily
Cyclosporine 1 ggt [**Hospital1 **] to right eye
Donepezil 10 mg po daily
Furosemide 20 mg po daily
Lisinopril 5 mg po daily
Metoprolol 50 mg po bid
Discharge Medications:
not applicable.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial Hemorrhage.
Respiratory failure.
Discharge Condition:
Expired.
Discharge Instructions:
not applicable.
Followup Instructions:
not applicable.
Completed by:[**2192-12-5**] Name: [**Known lastname 6672**],[**Known firstname 3485**] Unit No: [**Numeric Identifier 11041**]
Admission Date: [**2192-10-14**] Discharge Date: [**2192-11-2**]
Date of Birth: [**2101-11-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5448**]
Addendum:
The primary reason for this Pt's admission to the MICU was
respiratory failure, which occurred in the setting of an
intraparenchymal hemorrhage following a fall.
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**]
Completed by:[**2192-12-5**]
|
[
"428.0",
"424.0",
"252.01",
"276.51",
"E884.4",
"482.41",
"920",
"853.00",
"518.84",
"286.7",
"427.31",
"038.9",
"V53.31",
"287.5",
"276.0",
"995.94",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"99.05",
"96.6",
"96.04",
"96.72",
"99.07",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
17888, 18054
|
6553, 16622
|
292, 367
|
17190, 17200
|
2234, 2234
|
17264, 17865
|
1669, 1688
|
17052, 17069
|
17122, 17169
|
16648, 17029
|
17224, 17241
|
6066, 6530
|
1703, 2215
|
224, 254
|
395, 1203
|
4938, 6050
|
2250, 4798
|
1225, 1506
|
1522, 1653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,156
| 119,541
|
3796
|
Discharge summary
|
report
|
Admission Date: [**2115-1-4**] Discharge Date: [**2115-1-8**]
Date of Birth: [**2076-1-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: Shortness of breath/Anasarca/acute renal failure
Reason for MICU transfer: Hypercarbia, Somnolence
Major Surgical or Invasive Procedure:
PICC line
History of Present Illness:
Mr [**Known lastname 17028**] is a 38 year old man with poorly controlled type 1
diabetes (c/b nephropathy, neuropathy and retinopathy),
hypertension, hyperlipidemia, question of coronary artery
disease and prior polysubstance abuse, presenting from [**Hospital **]
clinic for dyspnea and weight gain, being transferred from the
floor for hypercapnea and somnolence.
.
Briefly, patient has been residing at [**Hospital1 **] for treatment of
osteomyelitis. He was seen at [**Hospital **] [**Hospital 2793**] clinic earlier on the
day of admission for worsening weight gain, renal failure and
shortness of breath. He was found to have increased creatinine
from baseline and was sent to ED for further evaluation.
.
In the ED, vital signs were initially: 98% RA, 63, 12, 141/88.
Patient was admitted to the medical service where he was noted
to be very somnolent and witnessed to have acute desaturation
event to 70's on supplemental oxygen. Episode is described by
team as "excessive sleepiness" at time of interview, where he
was falling asleep in mid sentence while aswering questions.
Patient had no complaints at the time of desaturation, no
convulsions or apneic episodes were witnessed.
.
Given concern for hypercapnea and somnolence, patient had
arterial blood gas which revealed pH 7.42 pCO2 58 pO2 177.
Overall assessment is that he needed BiPAP for apneic episodes
while remainder of workup was performed.
.
Review of [**Hospital1 **] progress notes reveals patient completed 8
weeks of Vancomycin and Ciprofloxacin on [**2114-12-17**] for R toe
osetomyelitis. He is now on suppression dose doxycycline. He
developed anasarca and was treated with escalating doses of
diuretics including 120mg PO Lasix + Metolazone resulting in
worsening renal function.
Past Medical History:
#. Healing osteomylitis (Coagulase negative staph and
pseudomonas)
- arthroplasty R hallux [**2114-7-12**]
- s/p 8 weeks IV vancomycin, followed ciprofloxacin
#. Diabetes Mellitus
- diagnosed at age 2, poorly controlled
- Last A1C = 9.4 ([**2115-1-4**])
- complicated by neuropathy, nephropathy, and blindness
#. Polysubstance Abuse
- previous use of heroine, cocaine
#. Hypertension
#. history of coronary artery disease
- He reports three MIs in the past: the first at age 20yo
associated with steroids and BDP abuse, the second at age 28
associated with anxiety, and a third at age 34 associated with
cocaine use.
- Per OSH records, he had a cath at a different hospital that
demonstrated clean coronary arteries.
#. Venous Stasis Dermatitis
#. Legally Blind - s/p Vitreoectomies [**2101**]
#. Chronic Renal Insufficiency, stage 3
- proteinuria
- follows with Dr. [**Last Name (STitle) 4090**]
- baseline creatinine 2.3-2.8
#. Bipolar Disorder
- follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **]
#. Anxiety Disorder, NOS
#. Hypercholesterolemia
#. Hyperparathyroidism, secondary (Renal disease)
Social History:
The patient lives with his mother and brother. His mother is his
healthcare proxy and administers all of his medications. The pt
admits to using heroin and cocaine in the past, but states he
currently does not use either. He does currently smoke marijauna
frequently. He denies alcohol. Smoked 1 ppd x 4 months, but quit
smoking. Pt is on methadone 150 mg a day which he gets from
Habbitt Opco.
Family History:
No history of kidney disease, DM or gout. No history of CAD in
parents. Brother with substance abuse; Maternal Grandmother with
hypertension, Lung ca, cardiovascular dz
Physical Exam:
VS: AF, 138/87, 61, 20, 97 RA
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: difficult to assess JVD, neck supple, No lymphadenopathy
in cervical, posterior, or supraclavicular chains noted.
CHEST: Lungs remarkably clear to auscultation.
CARDIAC: Regular rhythm; nl S1, loud P2.
ABDOMEN: No apparent scars. Distended, and soft without
tenderness
EXTREMITIES: marked 3+ edema to thighs, warm without cyanosis. R
index toe with skin breakdown, blister, negative bone probe.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-3**], and BLE [**4-3**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
Pertinent Results:
LABS ON ADMISSION:
[**2115-1-4**] 12:50PM BLOOD WBC-8.2 RBC-3.62* Hgb-9.8* Hct-29.6*
MCV-82 MCH-27.2 MCHC-33.2 RDW-15.0 Plt Ct-327
[**2115-1-4**] 12:50PM BLOOD Neuts-82.3* Lymphs-10.8* Monos-4.0
Eos-2.5 Baso-0.4
[**2115-1-4**] 12:50PM BLOOD PT-11.4 PTT-31.7 INR(PT)-0.9
[**2115-1-4**] 12:50PM BLOOD Glucose-73 UreaN-95* Creat-4.1*# Na-128*
K-4.1 Cl-85* HCO3-34* AnGap-13
[**2115-1-4**] 12:50PM BLOOD CK(CPK)-417*
[**2115-1-4**] 12:50PM BLOOD Calcium-9.0 Phos-5.2* Mg-3.6*
[**2115-1-5**] 07:13PM BLOOD TSH-4.0
[**2115-1-7**] 07:10AM BLOOD ANCA-NEGATIVE B
[**2115-1-7**] 07:10AM BLOOD RheuFac-7
[**2115-1-7**] 07:10AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2115-1-7**] 07:10AM BLOOD HIV Ab-NEGATIVE
[**2115-1-4**] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2115-1-4**] 06:36PM BLOOD Type-ART pO2-177* pCO2-58* pH-7.42
calTCO2-39* Base XS-11
.
LABS ON DISCHARGE:
[**2115-1-8**] 06:10AM BLOOD WBC-6.3 RBC-3.70* Hgb-9.8* Hct-31.1*
MCV-84 MCH-26.5* MCHC-31.7 RDW-14.4 Plt Ct-274
[**2115-1-8**] 06:10AM BLOOD Plt Ct-274
[**2115-1-8**] 06:10AM BLOOD Glucose-437* UreaN-64* Creat-2.9* Na-130*
K-4.2 Cl-86* HCO3-34* AnGap-14
[**2115-1-6**] 06:25AM BLOOD CK(CPK)-113
[**2115-1-8**] 06:10AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
.
CXR: [**1-4**]
IMPRESSION: No acute cardiopulmonary abnormality.
.
ECHO [**2115-1-7**]:
The left and right atria are moderately dilated. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery systolic hypertension. Biatrial enlargement.
.
Compared with the prior study (images reviewed) of [**2114-5-14**],
the findings are similar.
.
RENAL ULTRASOUND [**2115-1-5**]:
IMPRESSION: Unremarkable renal ultrasound.
Brief Hospital Course:
38 year old man with poorly controlled diabetes, hypertension,
chronic renal failure, presenting with worsening edema/anasarca,
shortness of breath, found to be in acute renal failure and
severe somnolence on arrival.
.
# ALTERED MENTAL STATUS: Patient was admitted to the medical
service where he was noted to be very somnolent and witnessed to
have acute desaturation event to 70's on supplemental oxygen.
The episode was described by team as "excessive sleepiness" at
time of interview, where he was falling asleep in mid sentence
while aswering questions. Patient had no complaints at the time
of desaturation, no convulsions or apneic episodes were
witnessed. Given concern for hypercapnea and somnolence, patient
had arterial blood gas which revealed pH 7.42 pCO2 58 pO2 177.
Overall assessment involved BiPAP for apneic episodes while
remainder of workup was performed. His medications were adjusted
with a decrease in pregabalin from 75mg TID to 25mg TID and
decrease in methadone to 100mg. His mental status improved back
to baseline by the AM. He was continued on CPAP at night daily.
.
# ANASARCA/VOLUME OVERLOAD: DDx included proteinuria vs. liver
disease vs. [**Last Name (un) **] on [**Last Name (un) 2091**] vs. cardiac disease, specifically from
pulmonary hypertension, as there was evidence from prior TTE
that patient had mild-moderate pulmonary artery hypertension.
Unlikely to be liver disease, given only minimal evidence of
synthetic dysfunction. In addition, degree of proteinuria was
only minimal to explain 20-40 lb weight gain. Patient was also
on a calcium channel blocker previously, which may have been a
slight contributor. However, suspect primary etiology to be
cardiac disease, or right heart failure, given elevated RV
pressures and elevated pulmonary artery pressures. Patient
underwent TTE at [**Hospital1 **] on [**2114-12-7**] showing estimated end
systolic RV pressure > 35mmHg. DDx for right sided heart
failure included HIV, OSA, polysubstance abuse, and
rheumatologic causes. Workup included negative HIV testing,
negative ANCA, negative rheumatoid factor, and negative [**Doctor First Name **].
Patient did have evidence of prior polysubstance absuse,
including cocaine and methamphetamine, which can contribute to R
heart failure. He was also noted to have an episode of
somnolence with an acute desaturation event, which may be
related to apnea. He was set up with a sleep clinic appointment
for OSA evaluation as an outpatient. He was informed to
eliminate any drug use, which may be contributing. He was
decreased on his lyrica from 75 mg tid to 25 mg tid, since it
may have contributed to his presentation as well. After IV lasix
diuresis for three days, patient had returned to his dry weight
and had lost approximately 15 liters of fluid. His BUN/Cr also
returned to [**Location 213**]. Repeat TTE here showed slightly improved
PA/RV pressures. Patient was discharged on home regimen of 80 mg
PO lasix.
.
# ACUTE RENAL FAILURE ON STAGE IV [**Location 2091**]: Patient with chronic
diabetic nephropathy, however with acute decompensation. It is
possible that OSA is causing severe increase in pulmonary
pressures leading to decreased forward flow, however other
causes of renal failure were considered. DDx included
obstruction (however renal ultrasound was negative), intrinsic
renal failure (although AIN and/or ATN were unlikely given bland
urine sediment). Of note, after aggressive IV diuresis,
patient's BUN and Cr returned to [**Location 213**] (discharge values 64 and
2.9, respectively).
.
# DIABETES TYPE 1: known to be poorly controlled. Insulin dose
adjusted in setting of ARF and hypoglycemic episode on one
morning. Patient continued on SSI. Have arranged for close
follow-up with PCP to adjust BG regimen as needed.
.
# BIPOLAR DISORDER: Continued home regimen of Lamictal and
Abilify
.
# H/O POLYSUBSTANCE ABUSE: Continued methadone.
.
# HYPERTENSION: patient was continued on prior medications, as
[**First Name8 (NamePattern2) **] [**Hospital1 **] notes. His blood pressure was well controlled on
discharge.
.
# OSTEOMYELITIS: s/p 8 week treatment with vancomycin and
ciprofloxacin for osteomyelitis. Continued home regimen of
doxycycline for suppressive therapy. Patient was seen by
[**Hospital1 **], and they noted healing heel ulcers as well as healing
right 5th digit blister. They recommended wet to dry dressings
on discharge. Of note, patient has follow-up arranged with Dr.
[**Last Name (STitle) **].
.
# ANEMIA OF IRON DEFICIENCY AND [**Last Name (STitle) 2091**]: Hct remainded at baseline.
Patient continued his home iron regimen.
.
# CARDIAC: Pt reported MI, normal angiogram [**Location (un) 7349**], subsequent
ETT-MIBI OSH which showed a small anterior mixed defect.
.
# DISPO: discharge to home with PCP, [**Name10 (NameIs) **], sleep clinic
follow-up. He is to obtain chemistry 10 panel and fax results to
Dr. [**Last Name (STitle) 4090**].
Medications on Admission:
Lyrica 75 Mg PO TID
Clonidine 0.1 mg QID
methadone 150 mg PO Q daily
Amlodipine 10 mg PO Q daily
Lamictal 100 mg PO BID
Furosemide 80 mg Q day
Clonazepam 1 mg PO TID
Calcitrol 0.25 mg PO Q Day
Saline nasal spray
Simvastatin 40 mg PO Q day
Carvedilol 25 mg PO BID
Aspirin 81 mg PO Q day
Docusate 100 mg PO BID
Vit D 400 U PO BID
Abilify 20 mg PO Q day
Mag [**Doctor Last Name **] plus 15 ml PO Q4 PRN indegestion
Chloride hydrate 1000 mg PRN insomnia
saline nasal spray
Glargine 30 U Q HS
doxycycline 100 mg PO Q day
Ascorbic acid 5-00 mg PO TID
Discharge Medications:
1. Outpatient Lab Work
Please obtain chemistry 10 panel on [**2115-1-10**] and have results
faxed to [**Telephone/Fax (1) 12142**]. Dr. [**Last Name (STitle) 4090**] will review these results.
2. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*30 Capsule(s)* Refills:*2*
3. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. Methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO DAILY
(Daily): prescribed by alternate provider at methadone clinic.
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
16. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
17. Humalog 100 unit/mL Solution Sig: as per sliding scale sheet
units Subcutaneous before breakfast, lunch, and dinner as per
sliding scale.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Acute right heart failure.
- Pulmonary artery hypertension.
- Anasarca.
.
Secondary:
- Diabetes mellitus type I.
- [**Last Name (STitle) 2091**] stage IV
- Neuropathy, retinopathy, and blindness
- Substance Abuse
- Bipolar disorder type I
- Hypertension
- Osteomyelitis right big toe.
- Anemia of iron deficiency and [**Name (NI) 2091**]
- Pt reported MI, normal angiogram [**Location (un) 7349**], subsequent ETT-MIBI OSH
which showed a small anterior mixed defect.
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
worsening weight gain and shortness of breath. You were noted to
have some acute kidney injury and your total body volume
overload was felt to be from high blood pressure in your lungs
(pulmonary hypertension). This is likely from multiple causes
including obstructive sleep apnea, prior drug use, and
potentially high dose lyrica. You were given IV lasix and you
were discharged when your weight had returned to baseline. You
will likely require a sleep study on discharge. It will be
critical for you to continue CPAP to keep the fluid from
re-accumulating. The sleep study should be arranged by your
primary care doctor, and can be discussed at next visit. In
addition, you were seen by the [**Hospital1 **] team for your heel
ulcers and your right 5th digit ulceration. They recommended wet
to dry dressings on discharge, and have arranged for a follow-up
appointment, as noted below.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- DECREASE lyrica to 25 mg three times a day
- continue CPAP at night
- wet to dry dressing changes to right 5th digit
.
Please seek medical attention for worsening volume overload,
progressive shortness of breath, fevers, worsening drainage from
your heel/toe ulcer, chest pain, abdominal pain or distension,
or any other concerns. Please discuss outpatient sleep study
with your primary care doctor.
Followup Instructions:
We have made an appointment with your primary care doctor, Dr.
[**Last Name (STitle) 17029**], on [**2115-1-15**] at 11:45 AM. Please call [**Telephone/Fax (1) 17030**] if
you need to re-schedule.
.
We have made an appointment for you at sleep clinic on [**2115-1-17**]
at 1 pm with Dr. [**First Name (STitle) **]. It will be at [**Hospital Ward Name 23**] [**Location (un) 436**]. Please
call [**Telephone/Fax (1) 612**] if you need to reschedule.
.
Provider [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2115-1-15**] 10:10 ([**Month/Day/Year **])
.
You will obtain a chemistry 10 laboratory blood draw and have
these results faxed to Dr. [**Last Name (STitle) 4090**] as noted below.
Completed by:[**2115-1-8**]
|
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icd9cm
|
[
[
[]
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[
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] |
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[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,636
| 155,423
|
45841
|
Discharge summary
|
report
|
Admission Date: [**2100-10-29**] Discharge Date: [**2100-11-3**]
Service: MEDICINE
Allergies:
Morphine Sulfate / Aspirin / Metoprolol / Levaquin
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
Upper endoscopy with biopsy on [**2100-11-1**]
History of Present Illness:
[**Age over 90 **] yo M retired internal medicine physician, w/Hx of GIB while
on ASA X2, history of coronary artery disease s/p stent 9 wks
ago, abdominal aortic aneurysm repair and paroxysmal atrial
fibrillation, who presents with a 1d H/o melena. Pt has been on
Plavix and ASA since recent stent ([**7-27**]). Pt reports that 1d
PTA he had one mahogany colored stool, (guiaic pos per pt) early
in the day, and then after having lunch and juice had a dark,
tarry stool, also guiaic pos per pt report. No abdominal pain.
No nausea/vomiting. No lightheadedness/dizziness. Reports he
had continued to take his plavix, but his last dose of ASA was
[**10-29**].
In the ED, hct 34-->26.7 (recent baseline was 30-32). He was
given 2L NS and protonix IV. NGL was positive and cleared after
250cc NS. GI was consulted. Pt was originally observed O/N and
now transferred to the ICU for an EGD, when hct drop was noted.
Vital signs have remained stable.
.
ROS: Neg for CP/SOB. Stable 2 pillow orthopnea. No PND. Able
to walk 10 min before developing his angina, which he states is
much less since he has had his stent placement. No
palpitations. Reports recent [**8-31**] lb weight loss, stating that
his "clothes are falling off of (him)."
Past Medical History:
1. First, UGI bleed [**2-24**] ASA use, erosive gastritis, H pylori
positive, no treatment. Second UGIB [**2-24**] ASA use after his CABG
placement 15 years ago.
2. Lower GI bleed 2 years ago- Found to have an AVM in the
terminal ileum
3. AAA repair, [**2085**]
4. Thyroid dysfunction
5. pacemaker implantation [**2099-10-20**]
6. paroxysmal atrial fibrillation for 15 years, s/p several
cardioversions, complicated by amiodarone induced thyrotoxicosis
tx with tapazole ([**2098-10-22**]), continues to take amiodarone,
stable on 100mg po qd
7. PUD
8. CAD s/p CABG in [**2080**], status post cardiac cath with stent
placement in [**2100-7-23**], on ASA and plavix with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] following as his cardiologist.
9. valvular heart disease, mitral and aortic regurgitation
10. pacemaker placement in [**9-26**]
11. CHF with last Echo [**2100-10-28**] EF 25%, severe regional left
ventricular systolic dysfunction with severe
hypokinesis/akinesis of the distal anterior septum, apex, and
distal anterior wall, [**1-24**]+AR, 2+MR, 2+TR, significant pulmonic
regurgitation
12. TURP
13. Right renal artery stenosis
14. chronic renal insufficiency, with baseline Cr 1.6
15. gun shot wound to right chest [**2039**]
16. fractured metatarsal
17. fractured wrist
18. Hyperuricemia
19. Hiatal hernia
20. Positive Coombs test
21. Constipation
22. Multinodular goiter
23. Anemia
24. Secondary hyperparathyroidism
Social History:
Smoker from the age of 17-27, quit. No alcohol or IVDA. Worked
as an Internist for several years here at [**Hospital1 18**], then worked for
BU in Occupational Medicine. Retired several years ago.
Family History:
Mother died at age [**Age over 90 **]. Father died PAF. Sister died,
[**Name (NI) 5895**] ds. Son died [**Name2 (NI) **] climbing- Mt. [**Doctor Last Name **] in
[**Location (un) 24402**], Or. One living son.
Physical Exam:
Temp: BP: 123/52 P: 65 RR: 14 Oxygen sat: 100% on RA
General: [**Age over 90 **] y/o Caucasian man in NAD. Breathing comfortably on
room air. Pleasant, cooperative. Well-spoken. WNWD.
HEENT: PERRL, EOMI. Sclerae anicteric. MMM. Neck supple, no
LAD.
JVP to mid-jaw.
Lungs: With bibasilar crackles. Scar midline over sternum.
CV: RRR With a diastolic murmur at the RUSB, loud holosystolic
murmur at LLSB, rad to apex. Pacer in place.
Abd: Soft, ND, NT. Normoactive bowel sounds. no masses felt.
With midline abdominal scar. No HSM.
Peripheral ext: 2+ DP pulses bilaterally. Ext warm and
well-perfused. No edema BLE.
Neuro: No focal deficits. Appropriate.
Pertinent Results:
[**2100-10-28**] 04:17PM BLOOD WBC-5.7 RBC-3.44* Hgb-10.4* Hct-32.0*
MCV-93 MCH-30.2 MCHC-32.4 RDW-15.5 Plt Ct-202
[**2100-10-29**] 07:30PM BLOOD PT-13.2 PTT-24.3 INR(PT)-1.2
[**2100-10-29**] 07:30PM BLOOD Glucose-98 UreaN-51* Creat-2.3* Na-140
K-4.3 Cl-101 HCO3-27 AnGap-16
[**2100-10-30**] 03:41PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0
[**2100-10-30**] 03:41PM BLOOD TSH-2.5
[**2100-10-31**] 02:56AM URINE Hours-RANDOM Creat-79 Na-84
ECHO [**2100-10-28**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is severe regional left
ventricular systolic dysfunction with severe
hypokinesis/akinesis of the distal anterior septum, apex and
distal anterior wall. Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated.
The ascending aorta is moderately dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic valve stenosis.
Mild to moderate ([**1-24**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2100-2-5**], left ventricular function has
deteriorated
CHEST (PORTABLE AP) [**2100-10-30**] 1:45 PM
There is slight prominence of the pulmonary vasculature with
cardiomegaly, indicating mild congestive heart failure. The
patient has prior CABG and median sternotomy. Pacemaker leads
remain in place. No pneumothorax is seen. A nasogastric tube
terminates in the gastric antrum.
[**2100-11-1**] report date [**2100-11-3**] "Esophageal" polyp, biopsy:
Gastric-type hyperplastic polyp with focal ulceration.
Brief Hospital Course:
This is a [**Age over 90 **] year old male physician with past medical history
significant for two upper gastrointestinal bleeds in past
secondary to aspirin use presents after two dark stools, both
guiaic positive, hemodynamically stable, repeat hematocrit near
baseline. Currently on ASA and Plavix.
.
1. Gastrointestinal bleed- In the ED, hct 34-->26.7 (recent
baseline was 30-32). Pt was transferred to the ICU, when
hematocrit drop was noted. INR, platelets appropriate. He was
given 2L NS and protonix IV. NGL was positive and cleared after
250cc NS. GI was consulted. Vital signs remained stable so
patient was transferred to floor. On [**11-1**], GI performed an EGD
showing gastritis, large gastric polyp s/p bx. Bleeding was
thought to be most likely from gastritis and/or polyps. Probably
exacerbated by recent anticoagulation with ASA and plavix.
Serial hematocrits were fairly stable within range. Pt was
restarted on the plavix following his EGD. After discussion with
attending, patient was also started back on ASA 81 mg daily as
pt had stent in left main only nine weeks ago. Continued on
protonix [**Hospital1 **].
.
2. [**Name (NI) 4964**] Pt's last echo was significant for a LVEF of 25%.
Monitored closely for fluid overload. Euvolemic on exam with no
evidence of symptomatic HF. Lungs clear and no edma. Admission
CXR clear.
.
3. [**Name (NI) **] Pt is s/p LM stent nine weeks ago. Doing well since that
time in sense that he has not had any more angina. Patient was
restarted on plavix after EGD and restarted on ASA prior to
discharge. While on the floor, patient was on tele and continued
on beta blocker and ACEi as he was well compensated and not
actively bleeding.
.
4. Acute on chronic renal insufficiency. Baseline creatinine per
pt between 1.6 and 2.9. Was elevated to 2.3 on admission most
likely from prerenal state. Down to 2.0 prior to discharge.
.
5. Paroxysmal atrial fib- Stable with good rate control.
Continued on amiodarone and on tele. Pt with pacemaker.
.
6. FEN- Heart healthy. Electrolyte replacement as needed.
.
7. Proph- Pneumoboots; PPI
.
8. Access- Two large bore peripheral IVs.
.
9. Code status: Full
.
10. Communication: With the pt.
Medications on Admission:
1. Amiodarone 100mg po qd
2. ASA
3. Plavix 75mg po qd
4. Captopril 12.5mg po qd
5. CoReg 12.5mg po qAM and qPM
6. Lipitor 20mg po qd
7. Omeprazole 20mg po qPM
8. Bumex 100mg po qAM
9. Vit B12 1000mcg po qd
10. Vit B6 100mg po qd
11. Ferrous gluconate
12. Ambien 5mg po prn
13. Folic acid 1mg po qd
14. Vit D
15. Aranesp
16. Tapazole 5mg po qMon, Wed, Fri
.
Allergies: Sensitive to asa-GI bleed
morphine-vomiting
Levaquin muscle pain, bleeding into muscle
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
11. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Ambien 5 mg Tablet Sig: One (1) Tablet PO QHS PRN.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
15. Tapazole 5 mg Tablet Sig: One (1) Tablet PO Every Mon, Wed,
and Fri.
16. Aranesp 40 mcg/mL Solution Sig: Forty (40) mcg Injection As
previously prescribed.
17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QAM.
18. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
GI bleed
Polyps in cardia and stomach body
Gastritis
Small Hiatal Hernia
Secondary Diagnosis:
Coronary Artery Disease s/p stent [**7-/2100**]
Chronic Renal Insufficiency
Discharge Condition:
Stable. Pt's last stool was guiac negative and his Hct was
stable.
Discharge Instructions:
1. Please take medications as prescribed.
2. Please call your PCP or return to the emergency room if you
have any chest pain, bright blood per rectum, melena, shortness
of breath or any other concerning symptoms.
3. Please keep all follow up appointments.
4. You had a biopsy of a polyp during your EGD. The GI doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) 138**] [**Name5 (PTitle) **] at home with the results of this biopsy as they
are not yet available.
5. Please resume your aranesp as you were taking it at home.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 10012**] Call to schedule
appointment within one week of discharge. The office will be
expecting your call.
2. Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2101-1-6**] 2:30
3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2101-1-6**] 3:30
Completed by:[**2101-2-7**]
|
[
"427.31",
"280.9",
"414.01",
"593.9",
"276.50",
"584.9",
"211.1",
"553.3",
"428.0",
"535.51",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
10313, 10319
|
6258, 8446
|
265, 314
|
10553, 10622
|
4228, 6235
|
11194, 11737
|
3304, 3519
|
8960, 10290
|
10340, 10340
|
8472, 8937
|
10646, 11171
|
3534, 4209
|
219, 227
|
342, 1589
|
10454, 10532
|
10359, 10433
|
1611, 3070
|
3086, 3288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,422
| 165,552
|
47604
|
Discharge summary
|
report
|
Admission Date: [**2176-1-15**] Discharge Date: [**2176-1-22**]
Date of Birth: [**2106-6-28**] Sex: F
Service: SURGERY
Allergies:
Prochlorperazine / Marinol
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Locally invasive Colon Cancer
Major Surgical or Invasive Procedure:
Subtotal colectomy, end ileostomy, excision of abdominal wall,
abdominal wall reconstruction with component separation.
History of Present Illness:
69F who was recently admitted with abdominal pain and a left
sided abdominal mass. Colonoscopy on [**2175-12-28**] revealed a large
fungating ulcerated mass in the descending colon. Biopsies were
taken and show adenoma with high grade dysplasia. She was
discharged to rehab on TPN to enhance her nutritional status. A
staging chest CT was obtained and this revealed a pulmonary
embolus. An IVC filter was placed and she was discharged on
Lovenox. She has been doing well in rehab, tolerating her TPN.
She states she does get nausea whenever she tries to drink
liquids. Her pain comes and goes, but is manageable. She
states
the pain is rather diffuse than focal. She denies fever,
chills,
emesis, melena, diarrhea, constipation, dysuria, chest pain,
dyspnea, lower leg edema.
.
Past Medical History:
Past Medical History: Denies
Pas Surgical History: Denies
Medications at Home: None
Social History:
As documented in Social Work Note: Full-time volunteer at
synagogue and this congregation has "taken pt. under their
[**Doctor First Name 362**]". Rabbi describes pt. as "emotionally fragile" as well as
very private.
Family History:
noncontributory
Physical Exam:
Gen - A&O x 3, NAD
Pulm - CTAB
CV - rrr no m/g/r
Abd - soft, +BS, MD, ttp near midline incision, incision CDI, JP
x 2 draining ss fluid
Extrem - no c/c/e
Pertinent Results:
[**2176-1-15**] WBC-11.0 Hct-31.2
[**2176-1-17**] WBC-10.0 Hct-27.4*
[**2176-1-16**] 1:15 pm SWAB Site: ABDOMEN ABDOMINAL WALL
ABSCESS.
GRAM STAIN (Final [**2176-1-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
The patient was admitted to the Colorectal surgery service on
[**2176-1-15**] and had a subtotal colectomy, end ileostomy, and
abdominal wall reconstruction for locally invasive cancer on HD
2. The procedure was complicated by aspiration of enteric
contents and the patient was extubated in the ICU on POD 0 due
to concern for aspiration. She tolerated the extubation well and
was comfortable on 4LNC on POD 1. An NG tube was placed
intraoperatively and was started on NGT clamping trial on
[**2176-1-17**], the NGT was discontinued on [**2176-1-20**], the diet was
advanced to clears and TPN was started.
Neuro: Post-operatively, the patient received Dilaudid
intravenously with good effect and had adequate pain control.
She was weaned off and was started on oral analgesia with
adequate effect.
Heme: On [**1-16**] she was bolused with intravenous fluids due to
low urine output. She was hydrated conservatively due to
concerns of risk for fluid volume overload and disturbing
abdominal wall reconstruction. She was noted to have a drop in
hematocrit and was transfused with 1 unit red blood cell, and
was diuresed with Lasix post transfusion.
CV: The patient had a couple episodes of paroxysms of
supraventricular tachycardia high 160 and received adenosine
while in the intensive care unit. She was placed on a cardiac
rule out and cardiac enzymes were cycled which were negative. A
echocardiogram was obtained and she had a (LVEF >55%) suggestive
of borderline pulmonary hypertension. While on the inpatient
Unit she had several episodes of hypertension requiring
additional doses of Metoprolol.She was subsequently weaned off
Metoprolol IV and started on Metoprolol PO which has been
titrated to 50 mg TID. She denies any chest pain.
Pulmonary: The patient was stable from a pulmonary standpoint
after the aspiration; vital signs and chest xray were routinely
monitored. [**2176-1-17**] Chest Xray showed worsening left upper lobe
aspiration pneumonia and small to moderate bilateral pleural
effusions. On [**2176-1-18**] she had a repeat chest xray which was
suggestive of worsening pneumonia vs pulmonary edema. The
patient was stable with no respiratory distress.
GI/GU: Post-operatively, the patient was given intravenous
fluids until tolerating oral intake. Her diet was advanced to
sips and then advanced to regular accordingly. She had high
ostomy output and was also started on Metamucil and Imodium to
slow down ostomy output. The foley catheter was removed on POD
on [**1-21**] /11 and has been voiding without difficulty. The ostomy
is functioning with adequate brown liquid stool. The stoma is
pink and protruding.
ID: Pre-operatively, the patient was started on IV Cipro and
Flagyl and Vancomycin was started. The antibiotics were
discontinued prior to transfer from the ICU to the inpatient
floor. OR culture and urine culture were negative.
PE/ DVT Prophylaxis: The patient received subcutaneous heparin
during this stay, and was encouraged to get up and ambulate as
early as possible. She was started on Lovenox on [**2176-1-17**] and
bridged to Coumadin 5 mg by POD. By the time of discharge on POD
6, the patient was doing well, afebrile with stable vital signs,
tolerating a regular diet. She requires encouragement and
assistance to get out of bed and to ambulate.
Incision/Drains: She has a transvere incision with dressing in
place and an abdominal binder that she is to wear at all times.
She also has two JP drains in place to abdomen.
Dispo: She is stable for transfer to rehabilitation facility.
Medications on Admission:
lovenox 60mg [**Hospital1 **] for PE, insulin sliding scale, famotidine 20mg
daily, calcium carbonate 1000mg [**Hospital1 **], TPN
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours).
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Local invasive colon cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You underwent a resection of your colon and the creation of a
an end ileostomy. Your surgery went very well with no
complications and can now continue your recovery at home. We
were pleased with your ostomy output and your ability to
tolerate a regular diet, and you were deemed safe for discharge
home.
Please make sure to care for your ostomy as you were instructed
by the ostomy nurse, and a visiting nurse will also come by to
help you. Keep track of your ostomy output, and make sure to
drink enough fluids to keep up.
Take all medications as prescribed, and do not drive while on
pain medication.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-28**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] in [**11-1**] days. Please call [**Telephone/Fax (1) 73531**] to make that appointment.
Completed by:[**2176-1-23**]
|
[
"V85.1",
"427.89",
"276.50",
"567.22",
"560.89",
"997.39",
"997.1",
"507.0",
"V12.51",
"427.1",
"799.4",
"198.89",
"788.5",
"153.2",
"783.21",
"790.01",
"E849.7",
"E878.3",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.20",
"54.3",
"45.73",
"54.72",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6836, 6902
|
2280, 5825
|
315, 437
|
6975, 6975
|
1819, 2189
|
9384, 9554
|
1612, 1629
|
6007, 6813
|
6923, 6954
|
5851, 5984
|
7158, 8748
|
1355, 1362
|
1644, 1800
|
8780, 9361
|
246, 277
|
2222, 2222
|
465, 1254
|
2257, 2257
|
6990, 7134
|
1298, 1334
|
1378, 1596
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,544
| 192,803
|
18077
|
Discharge summary
|
report
|
Admission Date: [**2147-11-4**] Discharge Date: [**2147-11-8**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
gentleman with a history of atrial fibrillation who was on
[**Hospital 28492**] transferred from an outside hospital with an eight
day history of neck pain. The patient was mowing his lawn
and reported the onset of pain with four day history of
moderate difficulty raising his arm and was walking fine.
The family reports doing well until yesterday. He could not
move his right arm. He was only able to wiggle his finger
slightly. This has since progressed to include lower
extremity. He reports decreased sensation from the chest
down. No bowel movement in three days. Foley catheter was
placed for 1100 cc. No history of incontinence.
PAST MEDICAL HISTORY: Congestive heart failure and atrial
fibrillation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Coumadin, Dyazide and Tiazac.
PHYSICAL EXAMINATION: On physical examination his
temperature was 96.7, blood pressure 122/77, pulse 77,
respiratory rate 17, saturation 97% on room air. He is awake
and alert with a neck brace in place. Cranial nerves II
through XII were grossly intact. No diplopia. Biceps on the
left were 4 and triceps were 2, grasp was 0. He was flaccid
in the right upper extremity with no strength and no tone.
He voluntarily moves the lower extremity to stimulation. His
sensation is decreased from the right elbow, T1 to T2 and on
the left below T6. Reflexes are 3+ at the knees on the left,
1 on the right. Ankles were 2+ on the left, 1 on the right.
Biceps were 2+ on the left, absent on the right. No clonus
and no [**Doctor Last Name **] bilaterally.
LABORATORY DATA: His laboratory data on admission 12.7 white
count, 35.6 hematocrit, 322 platelet count, 135/3.8, 99/22,
43, 1.6 and 107. His creatinine kinase was 2154. His
troponin was negative, MB was negative. PT was 28.1, PTT
51.4, INR 5.2. The patient was admitted to the Neurosurgical
Service and underwent emergent decompressive cervical
laminectomy for a epidural hematoma in the cervical spine.
Magnetic resonance imaging scan demonstrates an intraspinal
focal area of hemorrhage at C5 vertebrolateral in the spinal
canal. This is likely representative of epidural hematoma,
or possibly subdural hematoma.
HOSPITAL COURSE: He was taken to the Operating Room for
emergent evacuation without intraoperative complications.
Postoperatively he was awake, alert and following commands.
Biceps were 2 on the right, 2 on the left, triceps 4- on the
left, 1 on the right, grasp was 0 on the right, 1 to 2 on the
left, AT flicker on the left, absent on the right. His chest
was clear to auscultation. He had a second set of CPKs which
were 1288, MB 44, troponin was less than .01. He had
coagulation screens checked q. 2 hours. Postoperatively he
was monitored for neurological status in the Neurological
Intensive Care Unit where he remained neurologically stable.
He was transferred to the regular floor on [**11-5**]. He has
remained neurologically stable. His strength is improved on
the left side and on the left he is 4- in the biceps, 4 in
the triceps, 4- in grasp, IPs 5, quadriceps 5, AT 5, extensor
hallucis longus 4+, gastrocnemius is 5 on the left, on the
right he is 0 in biceps, 4- in the triceps, 0 grasp, 1 IP, 2
AT, 1 extensor hallucis longus and 3 gastrocnemius. He was
seen by physical therapy and occupational therapy and found
to acquire acute spinal cord injury rehabilitation. His
drain was removed on postoperative day #2 and there was a
stitch in place that should be removed on postoperative day
#5. The dressing is clean, dry and intact. He will return
to Dr.[**Name (NI) 1334**] office in two weeks for staple removal.
MEDICATIONS ON DISCHARGE:
Artificial tears one to two drops both eyes prn
Lacrilube prn
Percocet 1 to 2 tablets p.o. q. 4 hours prn
Protonix 40 mg p.o. q. day
Colace 100 mg p.o. b.i.d.
Heparin 5000 units subcutaneously q. 12 hours
Tylenol 650 p.o. q. 4 hours prn
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 1327**] in two weeks for staple
removal.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2147-11-8**] 09:49
T: [**2147-11-8**] 10:16
JOB#: [**Job Number 50021**]
|
[
"V58.61",
"336.1",
"432.1",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
3809, 4047
|
928, 959
|
2358, 3783
|
4146, 4493
|
982, 2340
|
113, 789
|
812, 901
|
4072, 4134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,561
| 157,906
|
49350
|
Discharge summary
|
report
|
Admission Date: [**2143-10-28**] Discharge Date:
Date of Birth: [**2097-5-26**] Sex: M
Service: [**Doctor Last Name 1181**]/MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old
male with a history of alcoholic and hepatitis C cirrhosis
that has been complicated in the past by a variceal bleed
last year, status post TIPS procedure, who was transferred
from [**Hospital6 **] where he was initially admitted on
[**2143-10-17**], after being found down at home by his mother. At
that time, the patient was found to have a hematocrit of 23.0
with platelet count of 69,000 and a creatinine of 4.3, well
above his baseline thought to be secondary to acute tubular
necrosis. He was started on Dopamine and Octreotide. He had
an initial esophagogastroduodenoscopy that did not show an
active bleed, but follow-up endoscopy showed grade II varices
and oozing portal hypertensive gastropathy. He ultimately
received a total of eight units of packed red blood cells,
twelve units of platelets and four units of fresh frozen
plasma. He was intubated for airway protection at his second
scope and transferred intubated on [**2143-10-28**], in part out of
the possibility for liver transplant candidacy. He was
initially transferred to the [**Hospital Ward Name 332**] Intensive Care Unit.
While he was there, he spiked a fever to 101.6. Of note, he
had been on Gatifloxacin at the outside hospital for about
ten days for pneumonia that was found on chest film on
[**2143-10-19**]. He had a repeat AP film here on [**2143-10-28**], that
showed a left lower lobe collapse and consolidation. He was
initially started on Levaquin but soon changed to Ceftazidime
and Vancomycin and the respiratory culture soon grew out
Staphylococcus aureus with sensitivities pending. Of note,
the patient had a liver ultrasound with Doppler that showed a
patent TIPS with normal flow direction and increase in
ascites. He had a paracentesis while in the [**Hospital Unit Name 153**] with a
total of 40cc of fluid for diagnosis that was not suggestive
of spontaneous bacterial peritonitis. The patient self
extubated on the day of transfer from the Intensive Care Unit
without any further complications. The patient was unable to
provide any further history of the initial events but was
able to whisper yes or no to basic questions. He denies pain
and dyspnea.
PAST MEDICAL HISTORY:
1. Cirrhosis secondary to alcohol and hepatitis C diagnosed
four years ago with cirrhosis. He had been held off the
transplant list in the past secondary to ongoing alcohol use
though he has been sober for several months.
2. Variceal and gastrointestinal bleed, status post banding
and TIPS in [**2141-10-30**].
3. Duodenal ulcer bleed, status post H. pylori treatment in
[**2142**].
4. Lumbar vertebral compression fracture, status post motor
vehicle accident two years ago.
5. Hypothyroidism.
6. Head injury, status post motor vehicle accident in [**2124**].
ALLERGIES: Penicillin and Robaxin.
MEDICATIONS ON ADMISSION:
1. Levoxyl 50 once daily.
2. Multivitamins.
3. Nadolol 80 mg once daily.
4. Protonix 40 mg once daily.
5. Flonase one q.p.m.
6. Iron Sulfate 325 mg twice a day.
7. Lasix 80 mg once daily.
8. Spironolactone 200 mg once daily.
MEDICATIONS ON TRANSFER:
1. Gatifloxacin 200 mg once daily.
2. Octreotide 25 per hour.
3. Lasix 20 mg twice a day.
4. Aldactone 100 mg twice a day.
5. Propranolol 10 mg three times a day.
6. Lactulose 30 four times a day.
7. Neomycin 500 mg four times a day.
8. Protonix 40 mg once daily.
9. Synthroid 50 once daily.
10. Albuterol and Atrovent p.r.n.
11. Haldol 1 to 2 mg p.r.n.
12. Ativan 1 to 2 mg p.r.n.
SOCIAL HISTORY: The patient is a former marketing consultant
for a designing firm. He has been unemployed for several
years. He has a history of alcohol abuse. He lives at home
by himself. His primary social supports are his mother who
lives several miles away.
PHYSICAL EXAMINATION: On initial examination in the [**Hospital Ward Name 332**]
Intensive Care Unit, temperature was 97.9, heart rate 82,
blood pressure 124/60, oxygen saturation 100% on AC with a
tidal volume of 700, PEEP 5, FIO2 100%. In general, he was
comfortable without jaundice. His pupils are equal, round,
and reactive to light and accommodation. Oropharynx
examination, he had moist mucous membranes with dried blood
around his mouth. Nasogastric tube in place. He had
inspiratory wheezes, left greater than right with decreased
breath sounds at the bases. Cardiac examination - He had
regular rate and rhythm, without murmurs, rubs or gallops.
The abdomen was distended and protuberant, nontender to
palpation with active bowel sounds. On extremity
examination, he had 3+ pitting edema with significant scrotal
edema. Skin examination had no petechiae although he had a
superficial erosion on his back.
LABORATORY DATA: On admission, white blood cell count was
9.1, hematocrit 31.7, platelet count 253,000. His Chem7 was
notable for blood urea nitrogen of 23 and creatinine of 1.3.
His AST was 79, ALT was 58, his bilirubin was 8.0. Albumin
was 2.2 with an alkaline phosphatase of 128. He had a
urinalysis that showed [**4-4**] red blood cells, 5 white blood
cells, occasional bacteria. Urine lytes had less than 10
sodium with a few osoms of 543. He had a partial
thromboplastin time of 45.4, INR 2.7. Ascites analysis
included a white blood cell count of 275 with 82% polys, 45%
lymphocytes with 450 red cells, albumin less than 1.0, total
protein 0.3. The microscopic of that peritoneal fluid on
transfer from the [**Hospital Ward Name 332**] Intensive Care Unit was negative for
bacteria or fungi.
He had a chest film that showed as mentioned above with
marked elevation of the right hemidiaphragm and left lobar
collapse and consolidation of the left lower lobe and small
left pleural effusion. He had a liver ultrasound that showed
patent TIPS and appropriate hepatopetal flow.
HOSPITAL COURSE: He had liver ultrasound that did not
indicate TIPS stenosis that could explain worsening hepatic
failure which would have been a more simple explanation for
his decompensation. He had Chem10, coagulation studies
monitored throughout his hospital course. He was seen by the
liver transplant team in preparation to liver transplant. He
was seen by the Social Worker and team who worked with him
during his hospitalization. He was initially treated with
lactulose, Neomycin and Propranolol and the diuretics were
soon held when his creatinine continued to rise during his
hospitalization here. His Lactulose was titrated to three to
four bowel movements a day. His encephalopathy was slow to
improve but ultimately did improve. The patient became quite
clear during the latter part of his hospitalization. His
Neomycin which was initially as part of his encephalopathy
regimen was discontinued with no adverse effect on his mental
status. His Propranolol was kept throughout his
hospitalization. The patient was kept off his diuretics
until his renal function returned to baseline at which point
they were slowly reinitiated. Unfortunately, his renal
function continued to decline afterwards at which point they
were taken off once again. His volume status continued to
worsen over the duration of his hospitalization when his
diuretics were removed and he gained well over fifteen pounds
in fluid. The patient became clear enough that the
nasogastric tube was able to be removed and he was able to
take his p.o. Lactulose and other oral medications. The
patient had low grade fevers and occasional abdominal pain.
This led to several attempts at tapping him. One attempt was
successful under ultrasound guidance that showed perineal
fluid that was not consistent with peritonitis. Once the
patient cleared, started diuretics only to have them stopped
soon after due to renal failure. He was started on 25 grams
of Albumin twice a day in an effort to increase his
intravascular volume and improve his urine output. At the
time of this dictation, his current regimen includes
Lactulose, Propranolol and the 25 grams of Albumin twice a
day. He has been relisted on the Liver Transplant Program
and has a score of about 33 to 34 at the time of this
dictation.
2. Fever/infectious disease - The patient had a fever of
101.6 while in the [**Hospital Ward Name 332**] Intensive Care Unit. This was not
felt to be due to peritonitis due to the normal paracentesis.
It was felt that his source was more likely due to the
pneumonia. He ended up growing out Methicillin resistant
Staphylococcus aureus pneumonia which was initially treated
with Ceptaz and Vancomycin prior to the sensitivities being
available. Once they did become available, the Ceptaz was
removed and he was continued on a fourteen day course of
Vancomycin. Towards the end of this course, the patient
continued to have low grade fevers of unclear etiology.
Fever workup at the time was undertaken but was essentially
negative including a negative paracentesis as noted above,
negative blood and urine cultures including fungal isolates.
Vancomycin was finished after fourteen days at which point
the patient actually was afebrile and so further fever workup
as not performed. However, at the time of this dictation
over the previous three days, the patient was complaining of
severe diarrhea, however, on further questioning of hospital
nursing staff, the patient having increased stools over the
past three days only had three to five stools over most of
this time per day. His Lactulose was initially held and
reinstituted. At the time of this dictation, the patient was
not felt to have an active infection.
3. Renal - The patient had significant renal failure at the
outside hospital likely acute tubular necrosis but was
notable for having almost complete improvement but his
creatinine rose again while in the [**Hospital Ward Name 332**] Intensive Care Unit
and was transferred back to the floor. Urine lytes were
consistent with prerenal azotemia although acute tubular
necrosis certainly could not be excluded based upon hepatic
etiology. His diuretics were held and he had a near
normalization of his renal function. At this point, the
diuretics were restarted with 100 mg of Spironolactone and 40
mg of Lasix only to have his creatinine rise since that time.
Despite the cessation of his diuretics, his creatinine rose
from 1.3 up to 2.4 at the time of this dictation. Albumin
was added to improve his intravascular volume with a
steadying of the creatinine but not an improvement at this
time. For the short term, the diuretics would not be a part
of his regimen based upon his acute renal failure.
4. Upper gastrointestinal bleed - The patient was kept on
twice a day intravenous Protonix and had serial hematocrit
levels in the unit and on the floor. He was transfused for
hematocrit less than 30.0. He was guaiac positive for the
first seven to ten days of his hospitalization requiring
several units of blood, however, then became guaiac negative.
His hematocrit remained stable around 28.0 to 30.0. He was
not rescoped during this hospitalization.
5. Hematology/coagulopathy - The patient had coagulation
studies monitored daily. He was given Vitamin K throughout
his hospitalization with a minimal effect on his INR which
was not surprising. The patient was transfused for platelet
count less than 50,000 if bleeding and less than 10,000 if
not bleeding. He did not receive any platelet products
during this hospitalization at the time of this dictation.
6. Fluid, electrolytes and nutrition - The patient was
initially kept on tube feeds and had aggressive electrolyte
repletion, however, once his mental status cleared and the
tube feeds were stopped, he had a swallowing study which had
initially indicated aspiration and then later actually
revealed no aspiration. So he was started on an oral diet
which he tolerated well.
7. Endocrine - thyroid - The patient had no evidence of
worsening thyroid disease during this hospitalization. He
was covered with four times a day fingerstick and insulin
during the time he was on tube feeds. However, once he was
off the tube feeds, he did not require further coverage with
insulin.
8. Hoarseness - The patient was noted to be significantly
hoarse during his [**Hospital 46355**] hospital course. A ENT
consultation was obtained and they performed a fiberoptic
laryngoscopy which showed vocal cords that were mobile
bilaterally, but poor adductor with phonation as well as mild
edema of the bilateral vocal cords. No other lesions were
noted. The arytenoids ere mildly erythematous. They
recommended keeping the head of the bed at 30 degrees and
continue with speech therapy per speech pathology as well as
to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**] as an outpatient.
CONDITION ON DISCHARGE: Not verifiable. The patient is
currently verifiable.
DISCHARGE STATUS: Not verifiable. The patient is currently
inpatient.
MEDICATIONS AT TIME OF DICTATION:
1. Albumin 25 intravenously twice a day.
2. Protonix 40 mg once daily.
3. Albuterol and Atrovent p.r.n.
4. Propranolol 20 mg three times a day.
5. Vitamin K 5 mg once daily.
6. Tylenol less than two grams per day.
7. Synthroid 50 once daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2143-11-16**] 21:23
T: [**2143-11-17**] 12:15
JOB#: [**Job Number 103378**]
|
[
"572.3",
"571.2",
"276.0",
"572.2",
"482.41",
"038.9",
"287.5",
"584.9",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3033, 3267
|
5987, 12882
|
3975, 5969
|
182, 2379
|
3292, 3684
|
2401, 3007
|
3701, 3952
|
12907, 13602
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,290
| 176,151
|
29836
|
Discharge summary
|
report
|
Admission Date: [**2153-12-18**] Discharge Date: [**2153-12-21**]
Date of Birth: [**2118-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
V fib arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization with drug eluting stent placement.
History of Present Illness:
35yo man with history of htn and tobacco who presented to [**Hospital **] after collapsing at a friend's house. CPR
initiated by friend/nurse. [**First Name (Titles) **] [**Last Name (Titles) 71342**] and found to be in VF,
then shocked out of VF. At [**Hospital3 15402**], found to have anterior
STE-MI. Given 1/2 dose reteplase, eptifibitide, plavix load and
transferred to [**Hospital1 18**]. EKG in-transit showed resolution of STE.
Cath at [**Hospital1 18**] showed lesion at mid-LAD and prior to D1, DES
placed to LAD. On arrival to the CCU, he was confused,
repeatedly asking what had happened and to call his workplace.
Pt c/o mild chest pain at sternum otherwise had no complaints.
Patient has limited memory of event, but denies preceding
illness, chest pain, diaphoresis, SOB.
Past Medical History:
PMH:
Anxiety
panic attacks
ptsd
?htn
Social History:
2 drinks the night of arrest, 1ppd smoker (now 1/3ppd). Denies
illicits but tox at OSH showed cannabis. Works at transitional
house as cook. Reportedly lives in an apartment that he rents.
Per friends' report pt does binge drink at least once per week,
usually on weekends. Has a h/o crack/cocaine abuse, now clean x
1yr. No history of IVDU (per pt's psychiatrtist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3517**] [**Telephone/Fax (1) 71343**] at [**Location (un) 22870**] Mental Health. on SSDI [**1-25**]
psych issues.
.
Pt was born in [**Country 6257**]. Lived in the US in [**Location (un) **]. Goes to
[**Country **] often. MSM. unknown HIV status. Former user of cocaine
and heroin.
.
Patient has no family here. Has 1 aunt that he doesn't really
talk to. Is closest to his friends:
[**Name (NI) **] [**Last Name (NamePattern1) **] ([**Hospital1 112**] Cardiac nurse)
H: [**Numeric Identifier 71344**]
C: [**Telephone/Fax (1) 71345**]
Family History:
Unknown
Physical Exam:
PE:
VS: BP 149/98 HR 71 RR 18
Gen: Pleasant wn/wd young man, anxious
HEENT: pupils dilated, MMM
CV: Nl s1/s2, rrr, no m/r/g
Pul: CTA b/l
Abd: Soft,NT
Ext: DP 2+ b/l sheath in place
Pertinent Results:
Please call [**Telephone/Fax (1) 2756**] for cath report (not available at
discharge).
.
Admission Labs: [**2153-12-18**] 03:51AM
GLUCOSE-110* UREA N-14 CREAT-0.9 SODIUM-137 POTASSIUM-4.2
CHLORIDE-103 TOTAL CO2-26 ANION GAP-12 ALT(SGPT)-63*
AST(SGOT)-98* LD(LDH)-283* CK(CPK)-475* CK-MB-36* MB INDX-7.6*
cTropnT-1.32* MAGNESIUM-2.2
.
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
WBC-22.8* RBC-4.14* HGB-13.4* HCT-38.4* MCV-93 MCH-32.4*
MCHC-34.9 RDW-13.8
Plts 429 NEUTS-90.9* LYMPHS-6.0* MONOS-2.8 EOS-0.3 BASOS-0.1
.
PT-12.0 PTT-68.8* INR(PT)-1.0
.
URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
.
[**2153-12-20**]: TSH 1.8, VitB12 230, Folate 5.9, RPR negative
.
[**2153-12-19**] Head CT: IMPRESSIONS:
1. No acute intracranial abnormality.
2. No specific evidence of anoxic brain injury, with normal
appearance of the deep [**Doctor Last Name 352**] matter structures. If clinical
suspicion persists, MR imaging would be more sensitive in this
regard.
.
ECHO REPORT [**2153-12-18**]:
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Myocardial infarction.
Height: (in) 70
Weight (lb): 150
BSA (m2): 1.85 m2
BP (mm Hg): 129/82
HR (bpm): 80
Status: Inpatient
Date/Time: [**2153-12-18**] at 10:52
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W050-0:32
Test Location: West CCU
Technical Quality: Adequate
.
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 2.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 3.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.2 cm (nl <= 3.0 cm)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.14
Mitral Valve - E Wave Deceleration Time: 154 msec
TR Gradient (+ RA = PASP): 8 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter with <50% decrease during respiration
(estimated RAP 11-15mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Cannot
exclude LV mass/thrombus. Moderately depressed LVEF. No resting
LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Focal
apical hypokinesis of RV free wall.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta. Normal
aortic arch diameter. No 2D or Doppler evidence of distal arch
coarctation.
AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal
mitral valve supporting structures. Normal LV inflow pattern for
age.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures. Normal PA systolic
pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
.
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. An apical left
ventricular mass/thrombus cannot be excluded with certainty.
Overall left ventricular systolic function is
moderately-to-severely depressed (ejection fraction 30 percent)
secondary to severe hypokinesis of the anterior septum and
anterior free wall (with basal segment function relatively
preserved) and extensive apical akinesis with focal dyskinesis.
There is no ventricular septal defect. Right ventricular chamber
size is normal. There is focal hypokinesis of the apical free
wall of the right ventricle. The aortic root is mildly dilated
at the sinus level. 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. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
A/P: 35M with h/o HTN, tobacco, admitted s/p VF arrest with
anterior STEMI s/p PCI.
.
# STEMI: Patient had PCI with DES to mid LAD lesion. peak CK at
[**Hospital1 18**] 509, peak MB 7.6. Patient was treated with Integrillin x
18hrs peri placement of the stent. We began medical management
with Aspirin 325mg, Plavix 75, Toprolol XL 50mgQD, atorvastatin
80mg QD, Lisinopril 10mgQD.
.
#Cardiomyopathy/Pump: His post MI echo shows EF < 30% with
akinetic apex and could not rule out LV thrombis. He was
started on lisinopril and toprolol. He was started IV heparin
and coumadin for ?LV thrombus and apical akinesis. He will be
discharged on coumadin with lovenox bridge and scheduled
INR/PTT/PT checks. He will need MRI, TWA, and signal avg EKGs in
4-6wks post dc for risk stratification and ICD implantation
consideration.
.
#Rhythm: Normal sinus with rate of 60-70 with very rare PVCs.
He will be discharged with a holter monitor and the results will
be faxed to his cardiologist, Dr. [**First Name (STitle) 1169**].
.
#Risk factors: Patient is a smoker, +etoh, +h/o crack/cocaine
use. Lipids profile:
Triglyc: 156 HDL: 36 CHOL/HD: 2.9 LDLcalc: 39. These can be
falsely lowered in setting of acute event and patient will need
retested as outpatient. He will continue atorvastatin 80mg for
cardiac protection. We have given him a prescription for
nicotine patches and have encouraged him to stop.
.
#Aspiration PNA/leukocytosis/fever: wbc of 22 on admission, no
bands, likely in a setting of AMI. But wbc count bumped from 11
to 12 on hospital day 3, with low grade fever and with mild
peribronchovascular opacity suggestive of early infiltrate. In
the setting of v fib arrest and time down we will treat with
Clindamycin x 7 days (last day [**2152-12-26**]) for aspiration pna (no
levoflox b/c of long QT). After one day of treatment his WBC
decreased, he defervesced and His urine cultures were negative
.
#Groin hematoma: This was likely from movement of leg. Initially
treated with compression dressing. His hematoma is resolving
and his hct was stable throughout.
.
#ST memory loss: Slowly improving. Per converstaion with the
patient's psychiatrist, the patient has a h/o depressive sx, ?
ptsd, panic attacks, [**1-25**] h/o of prior abusive relationships. CT
head with no evidence of anoxic brain injury. No focal
neurological symptoms. Improving memory and insight. Psychiatry
was consulted. We tested for causes of early dementia
(syphilis, folate, b12 and tsh), which was negative except a
slightly low B12, for which he was started on supplements.
.
#psych: h/o depression, anxiety, panic attacks. on xanax,
doxepin. sees oupt psych. has substance abuse issues with active
etoh use and crack/cocaine use. Patient reports to be clean for
1yr. Initially on CIWA scale with valium, he was switched to
xanax at home dose.
.
#Hematuria: Patient self reported small amounts of gross blood
in urine, which was confirmed by dipstick. This was in setting
of foley placement and discontinuation and heparin. We would
recommend outpatient pcp/urology follow-up.
.
#FEN: cardiac diet
.
#FULL CODE
.
#Follow up plans: will need MRI, signal avg ekg, t-wave alterans
upon discharge (4-6wks after)
.
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71346**]/[**Last Name (un) **] ([**Telephone/Fax (1) 71347**]
.
Contacts: [**Name2 (NI) **] has no family here. Has 1 aunt that he doesn't
really talk to. Is closest to his friends:
[**Name (NI) **] [**Last Name (NamePattern1) **] ([**Hospital1 112**] Cardiac nurse)
H: [**Numeric Identifier 71344**]
C: [**Telephone/Fax (1) 71345**]/1
.
Psych: Dr. [**Last Name (STitle) 3517**], [**Location (un) 22870**] health
[**Telephone/Fax (1) 71343**]
Medications on Admission:
Doxepin 300qhs
Xanax 2mg TID:PRN
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for a minimum duration of 1 year.
Disp:*30 Tablet(s)* Refills:*12*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 6 days.
Disp:*72 Capsule(s)* Refills:*0*
9. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for anxiety.
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) 60mg
Subcutaneous twice a day for 7 days: Until coumadin/INR is
therapeutic.
Disp:*14 syringes* Refills:*0*
12. Lab work Sig: One (1) ONCE for 1 doses: Please draw
PT/INR, ALT, AST, BUN and Cr on Sunday [**2153-12-23**] and have the
results faxed to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1169**] [**Last Name (NamePattern1) 71348**]fax
[**Telephone/Fax (1) 71349**], phone [**Telephone/Fax (1) 40420**]. .
Disp:*1 1* Refills:*0*
13. Doxepin 25 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime): Please only take 150mg QD until instructed otherwise.
.
Disp:*QS Capsule(s)* Refills:*2*
14. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily): Please readdress with your PCP at the
next visit. .
Disp:*QS Patch 24HR(s)* Refills:*2*
15. Xanax 2 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA [**Location (un) 5503**]
Discharge Diagnosis:
Primary
ST elevation MI
s/p ventricular fib arrest and defibrillation
CHF with EF of <30%
suspicion of LV thrombis
apical akenesis
h/o ?HTN
Secondary
hematuria
.
Discharge Condition:
Stable
Discharge Instructions:
It is very important that you take your medications.
.
The most important medications are aspirin and plavix (also
called clopidigrel). If you were to stop taking these you would
have a high likelihood of having another major heart attack and
possibly dying.
.
We have started you on several other medications that are
important for your heart. They are all listed below.
.
You are on antibiotics for pneumonia. You will need to complete
a seven day course.
.
Your dose of doxepin was decreased by half. Please take this
until you see your psychiatrist and cardiologist. It was
decreased for possible effects on your heart.
.
Please call your doctor or seek medical attention if you have
increasing chest pain, palpitations, lightheadedness, difficulty
breathing, weight gain, feet swelling. You will need to weigh
yourself daily. Please contact your doctor if you gain more
than 3 pounds a day. Please limit your sodium intake to 2 grams
daily.
.
We have made you an appointment with a cardiologist. It is very
important that you keep this appointment as you will need
closely followed by a cardiologist from now on.
Followup Instructions:
You need to have VNA follow up for the next few weeks with
medication checks, INR checks, weight checks. Please talk to
your PCP about cardiac rehab.
.
You need to return your holter monitor to the [**Hospital1 18**] for
analysis.
.
Please see your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71346**]/[**Last Name (un) **] ([**Telephone/Fax (1) 58547**]), in
the next 7-10 days. Have her follow up on medications,
anticoagulation and hematuria.
.
You have an appointment with a cardiologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1169**], on [**2153-12-26**] at 3:30. The office is at [**Last Name (NamePattern1) **].
The phone number is [**Telephone/Fax (1) 40420**] ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]).
[Patient prefers to follow up at [**Hospital6 302**]. The
cardiologists all have private offices.]
.
Patient will need risk stratification including Signal Average
EKG, cardiac MRI, TWA in 6 weeks and follow up with EP.
.
Please follow-up with your psychiatrist. This was a major event
and your life will change. You will also need to address your
medications.
|
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"300.00",
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"414.01",
"401.9",
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"410.01",
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icd9cm
|
[
[
[]
]
] |
[
"00.45",
"00.66",
"00.44",
"00.40",
"37.23",
"88.56",
"36.07",
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] |
icd9pcs
|
[
[
[]
]
] |
12924, 13000
|
6991, 10707
|
331, 392
|
13206, 13215
|
2497, 2586
|
14387, 15576
|
2271, 2280
|
10791, 12901
|
13021, 13185
|
10733, 10768
|
13239, 14364
|
3578, 6968
|
2295, 2478
|
279, 293
|
420, 1209
|
3254, 3552
|
2602, 3245
|
1231, 1270
|
1286, 2255
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,352
| 125,829
|
10689
|
Discharge summary
|
report
|
Admission Date: [**2123-1-16**] Discharge Date: [**2123-1-27**]
Date of Birth: [**2068-11-4**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
EGD scope
History of Present Illness:
This is a 54 year old female with h/o Fe def anemia (for which
she was admitted in [**5-28**] with Hct 14) who now presents with
palpitations, hemetamesis and early satiety x 1 day. Denies
CP/SOB. Has no h/o liver disease. Not on anticoagulation. States
she did take 2 pills of Motrin 4 days ago for a HA. Had 2
episodes of n/v with coffee ground emesis since last night.
Endorses some LLQ discomfort but denies epigastric pain.
Complains of belching. Denies diarrhea, melena, BPRPR, or
fevers.
.
In the ED, initial VS were T 99.1 HR 117 BP 125/92 RR 16 O2 sat
100% on RA. Pt was guaiac pos with brown/black stool. NG lavage
showed large amt of coffee grounds which cleared with 500cc
water. GI eval pt and has plan to perform EGD tomorrow AM. Has 2
large bore PIVs for access. Was T&C for 4U. CXR was
unremarklable. Was given GI cocktail and Zofran which relieved
her abdominal discomfort. Pt was also given Pantoprazole 80mg
then started on a gtt. Labs were notable for WBC of 12.0, Hct of
30.7 and plts of 636. Lactate was wnl as were LFTs, lipase and
d-dimer. On transfer, VS were HR 90 BP 145/91 RR 20 O2 sat 100%
on RA.
.
Upon arrival to the ICU, pt is comfortable. Denies abd pain, any
new episodes of emesis. Denies any pain.
Past Medical History:
iron deficiency anemia
Anxiety
Social History:
Very anxious female, denies tobacco, quit 12 years ago. Admits
to drinking about a glass of wine per night. denies drugs.
currently lives with father; mother passed away last year with
alot of depression and anxiety on the patients part after this.
Has a brother in the area.Her husband passed away 10 years ago.
Family History:
No known history of anemia or blood disorders. Mother passed
away at age 82 (two months ago) from pneumonia. Grandmother with
diabetes. No family history of colon cancer.
Physical Exam:
Admission:
VS: Temp: BP: 120/70 HR: 79 RR: 16 O2sat: 99% on RA
GEN: pleasant, comfortable, NAD, thin female
HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions
Neck: no LAD, no JVD, no masses
RESP: CTAB
CV: RRR no murmurs noted
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: - edema, - rash
Rectal- no skin tags or fissures noted. Dark brown stool, guaiac
+
Pertinent Results:
[**2123-1-16**] 08:49PM WBC-9.0 RBC-3.10* HGB-8.6* HCT-25.3* MCV-82
MCH-27.8 MCHC-34.0 RDW-12.6
[**2123-1-16**] 02:00PM GLUCOSE-109* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-30 ANION GAP-15
[**2123-1-16**] 02:00PM ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-92 TOT
BILI-0.3
.
EGD: [**2123-1-17**]
A single cratered non-bleeding 4 cm ulcer was found in the
incisura of the stomach. The ulcer was deep and large.
.
CT abdomen: [**2123-1-17**]
1. Large gastric ulcer with focal mass of the lesser curvature
of the stomach. There are concerning lymph nodes along the
gastrohepatic ligmament and an omental deposit in the left upper
abdomen.
2. Cholelithiasis.
Brief Hospital Course:
She was initially admitted to the Medicine service.
Medicine [**Hospital **] Hospital Course as follows per dictation of
medical resident:
54 year old female with PMH of iron deficiency anemia who
presented with hematemesis and UGIB, initially admitted to ICU
for careful monitoring, transferred to medicine when
hemodynamically stable and with stable Hct then found to have
large gastric ulcer on EGD and gastric mass on CT abdomen and
transferred to surgery for further management of her gastric
mass.
.
#. UGIB: Initially presented with hematemesis and required 1
unit PRBC in the unit. She was treated with pantoprazole drip.
She was then transferred to the medicine when was
hemodynamically stable. Upper endoscopy showed non-bleeding
large gastric ulcer. Biopsy not obtained in setting of upper GI
bleed. Pantoprazole drip was changed to omeprazole 40 mg po bid.
CT abdomen obtained showed large gastric ulcer with focal mass,
lymph node deposits concerning for gastric cancer. Surgery was
consulted she was transferred to their service. -appreciate GI
recs
.
#. Iron deficiency anemia: Hematocrit at 30.7 on admission then
trended down to 24.3 and she received 1 unit PRBCs. Her
hematocrit then came back to around 30 and was stable. Her home
iron supplementation was held in the setting of a GI bleed as to
not cause confusion with possible melena.
.
3. Thrombocytosis: likely reactive, stable
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Her course following transfer to Acute Care Surgery Service on
[**2123-1-19**]:
She was taken to the operating room on [**1-20**] for exploratory
laparotomy, truncal vagotomy, partial distal gastrectomy,
Bilroth I Reconstruction and open cholecystectomy. There were no
complications. Findings during her operation reveled that the
gastric mass was likely not a malignancy, rather a giant, benign
gastric ulcer. Postoperatively she recovered in the PACU and was
transferred to the regular nursing unit once stabilized. She was
placed on gastrectomy pathway.
Over the course of the next several days her diet was advanced
for which she was able to tolerate. On HD# 11 she was noted with
fevers >101 and was cultured, chest xray was done showing a
consolidation in her right lung base. She was started on
Levofloxacin which will continue for 7 days.
Her abdominal staples will be removed when she has follow up in
[**Hospital 2536**] clinic next week She will also need to follow up with her
PCP next week for general care.
Medications on Admission:
1. Ferrous Sulfate 300 mg DAILY
2. fish oil suppl daily
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Giant gastric ulcer, probably benign secondary to Type III
peptic ulcer disease.
2. Cholelithiasis with chronic cholecystitis.
3. Iron deficiency anemia
4. Pneumonia
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 and found to have a large
gastric ulcer and gallstones. You were taken to the operating
room for repair of the ulcer and removal of your gallbladder.
You are also being treated for a pneumonia for 7 days. Please be
sure to complete your entire course of antibiotics as
prescribed.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Post Gastrectomy diet:
1. Eat six small meals daily to avoid overloading the stomach.
Limit fluids to 4 oz ([**12-20**] cup) during mealtimes. This prevents
the rapid movement of food through the upper gastrointestinal
tract and allows adequate absorption of nutrients.
2. Drink liquids 30 to 45 minutes before eating and 1 hour after
eating, rather than with meals.
3. Rest or lie down for 15 minutes after a meal to decrease
movement of food from the stomach to the small intestine. This
decreases the severity of symptoms.
4. Avoid sweets and sugars. They aggravate the dumping syndrome.
5. Avoid very hot or cold foods or liquids, which may increase
symptoms in some patients.
6. Stomach surgery is performed for different reasons, so
calorie requirements may vary from patient to patient. For
example, a patient who has had surgery for severe obesity will
need to be on a weight reduction program. A very thin patient
who has had ulcer or cancer surgery will need extra calories.
7. You may have problems with Vitamin B12 absorbtion. This needs
to be followed with lab studies and possibly injections on a
monthly basis. Dr. [**Last Name (STitle) **] has been notified of that.
AVOID Aspirin, Ibuprofen, Motrin, Naprosyn or other NSAIDS
(non-steroidal anti-inflammatory drugs).
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-2**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Follow up with [**Hospital 2536**] clinic in [**12-20**] weeks for removal of your
staples, call [**Telephone/Fax (1) 600**] for an appointment.
Follow up with your primary care physician next week ([**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and [**Telephone/Fax (1) 7477**]). You will need to call for an
appointment.
Follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] office (Gastroenterology) as
directed; please call [**Telephone/Fax (1) 682**] to set up an appointment.
You also have an appointment with the following doctor that was
scheduled prior to your hospital stay:
Provider: [**Name10 (NameIs) 3150**],[**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 11133**]
Date/Time:[**2123-2-4**] 11:00
Completed by:[**2123-1-27**]
|
[
"997.39",
"486",
"238.71",
"531.40",
"280.0",
"288.60",
"574.10",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"45.13",
"44.01",
"43.6"
] |
icd9pcs
|
[
[
[]
]
] |
6661, 6667
|
3290, 5825
|
324, 336
|
6884, 6884
|
2586, 3267
|
10212, 11015
|
2002, 2174
|
5932, 6638
|
6688, 6863
|
5851, 5909
|
7035, 9842
|
2189, 2567
|
264, 286
|
9854, 10189
|
364, 1600
|
6899, 7011
|
1622, 1654
|
1670, 1986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,584
| 161,973
|
19010
|
Discharge summary
|
report
|
Admission Date: [**2143-8-24**] Discharge Date: [**2143-9-13**]
Date of Birth: [**2084-4-26**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
gentleman with uncorrected critical aortic insufficiency who
presented with syncope, systolic congestive heart failure,
and hypoxia.
The patient reported increasing shortness of breath with
chest discomfort, weakness, and daily nausea and vomiting
over the past month prior to admission. During this period,
he had discontinued all of his cardiac medications.
Over the two days prior to admission, the patient noted
increasing lower extremity edema greater on the left than the
right. On the day prior to admission, he was very short of
breath with positive orthopnea, diaphoresis, and tachycardia.
He subsequently presented to [**Hospital3 15174**] where
he was given 60 mg of intravenous Lasix, morphine, started on
a nitroglycerin drip, and aspirin.
He was then transferred to [**Hospital1 188**] for further management and possible valve repair. The
patient was admitted to the Coronary Care Unit for
management.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Alcoholic cardiomyopathy.
3. Systolic congestive heart failure.
4. Aortic insufficiency.
5. Gastroesophageal reflux disease.
6. Hypertension.
7. Chronic back pain.
8. Insomnia.
9. History of bleeding ulcerations.
10. Status post cardiac catheterization in [**2143-2-9**]
and in [**2141**].
MEDICATIONS ON ADMISSION: (Home medications included)
1. Atacand 15 mg by mouth once per day.
2. Digoxin 0.125 mg by mouth every day.
3. Lasix 20 mg by mouth twice per day.
4. Prevacid.
Please note, the patient had taken none of these medications
during the past month.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 24013**] with his
mentally disabled son. The patient also has a daughter with
whom he has a relationship. The patient reports drinking
three to four beers per day. He denies any tobacco use or
illicit drugs.
FAMILY HISTORY: The patient's father had a myocardial
infarction at the age of 55. No family history of diabetes.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed his temperature was 95.5 degrees
Fahrenheit, his heart rate was 101, his blood pressure was
129/82, his respiratory rate was 35, and his oxygen
saturation was 97% nonrebreather. In general, the patient
was sitting upright. He was diaphoretic and appeared
uncomfortable. Head, eyes, ears, nose, and throat
examination revealed sclerae were anicteric. Pupils were
equal, round, and reactive to light. Positive jugular venous
distention and jugular venous pulsation to 5 cm.
Cardiovascular examination revealed a regular rate and
rhythm. Could not appreciate any murmurs, rubs, or gallops.
Respiratory examination revealed crackles throughout with
coarse breath sounds three-fourths of the way up. Occasional
wheezing. The abdomen was obese, distended, without tympany.
Could not appreciate hepatosplenomegaly. Extremity
examination revealed the extremities were cool. Pulses were
regular with low amplitude. Lines: Peripherally inserted
central catheter bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed his sodium was 133, potassium was 3.2,
chloride was 96, bicarbonate was 21, blood urea nitrogen was
10, creatinine was 1, and blood glucose was 136. His white
blood cell count was 11.8, his hematocrit was 45.6, and his
platelets were 300. INR was 2.1. Calcium was 9.1, magnesium
was 1.5, and phosphorous was 4.5. Urinalysis showed moderate
blood with 100 protein and occasional bacteria. Creatine
kinase was 350. CK/MB was 9. Troponin T was 0.05.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray on admission
revealed bilateral pulmonary infiltrates associated with a
large heart consistent with worsening congestive heart
failure.
Electrocardiogram on admission showed tachycardia at 120
beats per minute. Normal axis. Intraventricular conduction
delay with left bundle-branch morphology. Poor R wave
progression.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Coronary Care Unit.
During the first 24 hours of admission, the patient was
electively intubated secondary to a respiratory rate of
greater than 35 and persistent respiratory distress. A
Swan-Ganz catheter and arterial line were placed.
Initial numbers on telemetry showed a right atrial pressure
of 22, right ventricle of 70/22, a wedge pressure of
approximately 45, and a pulmonary artery pressure of 70/50.
The patient had a calculated cardiac index of 1.
An echocardiogram was obtained which showed an left
ventricular ejection fraction of 15%. It was consistent with
aortic insufficiency of greater than 2+ and mitral
regurgitation of 2+. There was no effusion.
The patient was stated on milrinone and a Lasix drip. He had
a temperature spike to temperature maximum of 102.6 degrees
Fahrenheit during the first 24 hours of admission. Cultures
were sent.
1. CARDIOVASCULAR ISSUES: (a) Coronary: The patient with
clean coronary arteries by outside hospital catheterization
from [**2143-2-9**]. The patient was continued on aspirin
and Lipitor throughout the admission. His cardiac enzymes
were cycled on admission, and the patient ruled out for a
myocardial infarction.
The patient was started on captopril on [**2143-8-29**].
This dose was titrated to control the patient's blood
pressure. However, by [**2143-9-11**], orthostatic
hypotension was an issue. In addition, the patient had a
increase in from his baseline creatinine. At that time, the
ACE inhibitor was discontinued. The patient was not to be
discharged on an ACE inhibitor as he continued to have low
blood pressures with systolic blood pressures around 100. He
has no history of coronary artery disease, so this should not
affect his long-term mortality.
(b) Rhythm: The patient had pulseless polymorphic
ventricular tachycardia on admission with a magnesium of 1.5.
He required cardioversion for this episode.
Following cardioversion, the patient continued to be
tachycardia with cardiac output and cardiogenic shock. The
tachycardia slowly resolved beginning on [**2143-8-27**] as
the patient's temperature and white blood cell count
decreased. On [**2143-8-28**], the patient had an episode of
rapid atrial fibrillation on dobutamine. He received digoxin
loading at that time.
Over the next few days, the patient continued to have
occasional tachycardia which was attributed to his low
cardiac output and infection.
Electrophysiology was consulted during this admission to
place an implantable cardioverter-defibrillator in the
patient given his history of pulseless ventricular
tachycardia. However, the patient adamantly refused to have
an implantable cardioverter-defibrillator placed after
discussing this with multiple health care workers including
the primary team, the electrophysiologist, and Psychiatry.
The patient understood that without an implantable
cardioverter-defibrillator he could revert into ventricular
tachycardia and possible die.
The patient was started on amiodarone for his arrhythmia on
[**2143-9-10**]. He was to be loaded with amiodarone 400
mg twice per day times one week. Following this, he was to
receive amiodarone 400 mg by mouth once per day times two
week and then continue on a standing dose of amiodarone 200
mg by mouth once per day indefinitely. He was encouraged to
follow up with Electrophysiology in the future if he decided
to have an implantable cardioverter-defibrillator placed.
(c) Pump: The patient has a history of systolic congestive
heart failure and alcoholic cardiomyopathy. On admission, he
had an ejection fraction of 15% with 2+ aortic insufficiency
and 2+ mitral regurgitation.
On admission, the patient was started on milrinone and
Neo-Synephrine to increase his cardiac output. He was fluid
restricted at 1.5 liters on admission. On [**2143-8-26**]
the patient was started on hydralazine for afterload
reduction. On [**2143-8-27**], the milrinone was
discontinued, and the patient was started on dobutamine.
Over the next few days, the patient was aggressively diuresed
with a daily diuresis goal of 1 liter to 1.5 liters. The
patient was started on captopril for afterload reduction on
[**2143-8-29**].
By [**2143-8-30**], the patient had been weaned off standing
diuretics and received as needed Lasix to maintain his volume
status.
An echocardiogram was repeated on [**2143-8-26**]. This
showed the left atrium to be moderately dilated. The left
ventricular wall thickness was normal with moderate
dilatation of the cavity. There was severe global left
ventricular hypokinesis; 2+ aortic regurgitation, and trivial
tricuspid regurgitation were seen. Compared to previous
studies, mitral regurgitation was not seen. The left
ventricular ejection fraction had increased to 25% from
earlier estimates of 20%.
The patient's creatinine began trending up on [**2143-9-11**] which was attributed to overly aggressive diuresis. His
diuretics were stopped at that time as the patient was
believed to be dry. The patient was not to be discharged on
diuretics as he will follow up with his cardiologist shortly
after discharge. He may need to be restarted on a low dose
of diuretics to control his congestive heart failure at that
time. It was likely that his cardiac function will continue
to improve slightly if the patient does not resume alcohol
use.
2. PULMONARY ISSUES: On admission, the patient was in
respiratory distress. This was most likely secondary to
pulmonary edema. He was electively intubated on admission.
Attempts were made to wean the patient off the ventilator
during the early days of his admission, but these were
unsuccessful.
On [**2143-8-30**], the patient was found to most likely have
a methicillin-resistant Staphylococcus aureus pneumonia. At
this time, he was started on vancomycin and Zosyn. However,
during this same period, the patient had increasing liver
function tests consistent with pancreatitis. Therefore, on
[**2143-9-1**], the Zosyn was discontinued.
Throughout the remainder of his admission, he had good oxygen
saturation was in the mid to high 90s on room air. He
completed a 14-day course of vancomycin for the
methicillin-resistant Staphylococcus aureus pneumonia.
3. HEMATOLOGIC ISSUES: The patient had an elevated INR of
2.1 on admission of unknown etiology. It was thought this
may be due to his alcohol use. In addition, the patient had
a history of bleeding ulcerations so stools were guaiaced,
all these laboratories were negative.
The patient's hypercoagulability resolved spontaneously. He
required no blood transfusions and had a stable hematocrit
throughout his admission.
4. GASTROINTESTINAL ISSUES: The patient's liver function
tests were rechecked on [**2143-8-31**] due to persistent
fevers. At that time, these were found to be consistent with
pancreatitis. The patient eventually had a peak amylase of
536 on [**2143-9-2**] and a peak lipase of 713 on [**2143-9-4**].
A right upper quadrant ultrasound was obtained on [**2143-9-2**] to evaluate for possible causes of the pancreatitis.
This found the gallbladder to be distended with a trace
amount of pericholecystic fluid. There was sludge in the
gallbladder; however, there were no stones. It was decided
that the patient's pancreatitis was most likely related to
Zosyn. The Zosyn was then discontinued.
Over the next few days, the patient's pancreatic enzymes
began to trend down. He was asymptomatic on extubation and
was started on a liquid diet; which he tolerated well. His
diet was gradually advanced without occurrence of any
symptoms of pancreatitis.
The patient also has a history of gastroesophageal reflux
disease. He was continued on a proton pump inhibitor
throughout this admission.
5. INFECTIOUS DISEASE ISSUES: The patient was found to
have methicillin-resistant Staphylococcus aureus pneumonia;
as described earlier in the Pulmonary section. He was
treated for this with a 14-day course of vancomycin.
During the early part of the patient's admission, he
continued to be febrile on a daily basis. Multiple cultures
were checked. No bacteria was ever isolated from the
patient's blood. However, he was found to have Serratia
growing in his sputum, so levofloxacin was added on [**2143-9-4**].
On [**2143-9-4**], the patient right internal jugular was
pulled. The tip of the catheter subsequently grew
coagulase-negative Staphylococcus aureus. The patient was
afebrile throughout the remainder of his admission following
removal of this line. He completed a 14-day course of
vancomycin prior to discharge. The patient was to complete a
14-day course of levofloxacin.
6. PSYCHIATRIC AND ETHANOL WITHDRAWAL ISSUES: The patient
was maintained on benzodiazepines as needed on the Unit
during the first two weeks of admission for alcohol
withdrawal. On extubation, the patient alert and oriented
after reorientation to his situation and did not appear to be
experiencing any withdrawal.
However, on the evening of [**2143-9-8**] after transfer to
the floor, the patient became delirious. This delirium was
most likely secondary to withdrawal from benzodiazepines
versus infection. The patient received Ativan for the
delirium and was much improved by the next day. The Ativan
was discontinued following the onset of delirium, and the
patient's symptoms resolved.
Folic acid, vitamin B12, and rapid plasma reagin levels were
checked and were all normal. The patient was continued on
folic acid, thiamine, and multivitamins. By discharge, the
patient's delirium had completely resolved. He was alert and
oriented. He had good understanding of his situation and was
competent to make decisions regarding his medical care.
Psychiatry followed the patient throughout this admission
following the episode of delirium.
7. RENAL ISSUES: The patient with no history of underlying
ramus intermedius. On [**2143-9-11**], the patient had an
increase in his creatinine from baseline to 2.2. This was
most likely due to overly aggressive diuresis. Diuresis was
stopped at that time, as was the patient's ACE inhibitor. He
received multiple normal saline boluses, and the patient's
creatinine trended down over the next two days.
8. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient's
electrolytes were aggressively repleted during this
admission.
While intubated, he initially received tube feeds for
nutrition. However, the increase in his pancreatic enzymes
consistent with pancreatitis, the patient was started on
total parenteral nutrition. Following extubation, the total
parenteral nutrition was discontinued, and the patient did
well; tolerating a heart-healthy diet.
9. REHABILITATION ISSUES: The patient met with Physical
Therapy daily following his extubation. He was doing well by
discharge and was felt that he would be safe at home. He was
to have [**Hospital6 407**] and visiting physical
therapy at home.
10. PROPHYLAXIS ISSUES: The patient was on pneumo boots for
deep venous thrombosis prophylaxis and proton pump inhibitor
for gastrointestinal prophylaxis throughout his admission.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be discharged to home
with [**Hospital6 407**].
DISCHARGE DIAGNOSES:
1. Ventricular tachycardia arrest.
2. Methicillin-resistant Staphylococcus aureus pneumonia.
3. Systolic congestive heart failure.
4. Alcoholic cardiomyopathy.
5. Delirium; now resolved.
6. Syncope.
7. Aortic regurgitation of 2+.
8. Propensity for ventricular tachycardia; refused
implantable cardioverter-defibrillator placement.
9. Gastroesophageal reflux disease.
10. Hypertension.
11. Chronic back injury.
12. History of bleeding ulcers.
MEDICATIONS ON DISCHARGE:
1. Atorvastatin 20 mg by mouth once per day.
2. Pantoprazole 40 mg by mouth once per day.
3. Folic acid 1 mg by mouth once per day.
4. Multivitamin one tablet by mouth every day.
5. Levofloxacin 500 mg by mouth once per day (times six
days; to complete a 14-day course).
6. Aspirin 325 mg by mouth once per day.
7. Thiamine 100 mg by mouth once per day.
8. Amiodarone 400 mg by mouth twice per day for three more
days (to complete a 7-day loading cycle); following this, the
patient was to take amiodarone 400 mg by mouth once per day
times two weeks, and then decrease to his standing dose of
amiodarone 200 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with his
cardiologist/primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2143-9-17**] at 1:30 p.m.
2. The patient may need to be restarted on a small dose of
diuretics at that time.
3. The patient was to discuss the possibility of a future
implantable cardioverter-defibrillator placement with his
cardiologist. If he desires this in the future, he was
encouraged to contact the Electrophysiology Clinic for an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2143-9-13**] 12:29
T: [**2143-9-14**] 08:40
JOB#: [**Job Number 51929**]
|
[
"577.0",
"427.5",
"785.51",
"482.41",
"518.82",
"424.1",
"427.1",
"286.7",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"89.64",
"38.93",
"99.62",
"99.60",
"96.04",
"88.72",
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2071, 4154
|
15476, 15939
|
15965, 16609
|
1504, 1792
|
16642, 17405
|
4188, 15316
|
15331, 15454
|
161, 1114
|
1137, 1477
|
1809, 2054
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,583
| 155,983
|
22168
|
Discharge summary
|
report
|
Admission Date: [**2124-5-24**] Discharge Date: [**2124-6-10**]
Date of Birth: [**2051-4-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
AVR/ CABG x 3/ removal thyroid goiter [**2124-6-1**] (LIMA to LAD, SVG
to OM, SVG to PDA, 27 mm CE pericardial valve)
History of Present Illness:
The patient is a 73M w/ h/o MIx2, critical aortic stenosis, HTN,
CRI, h/o TIAs who presents with several weeks of chest
burning/discomfort. His aortic stenosis was diagnosed 5-6 years
ago and has been followed by serial TTEs by his cardiologist Dr.
[**Last Name (STitle) **]. He has been having several weeks of chest pain that he
describes as a burning sensation across his entire chest and
radiating down both arms. It does not radiate to the neck. He
specifically denies a feeling of pressure. He does not have
presyncopal symptoms or syncopal episodes. These symptoms happen
almost exclusively with exertion. He reports one episde over the
weekend where he felt some discomfort sitting on his bed, and he
took 2 SL NTG with some relief. He reports some DOE but it has
been ongoing for several years. He went to [**Hospital 1474**] Hospital
about 2 weeks ago for these symptoms and was diagnosed with
bronchitis. He saw Dr. [**Last Name (STitle) **] last week who told him his
symptoms were due to his AS and that he would have to have his
surgery soon. He was told this could not wait until he went back
to [**State 108**] in four months. Because his symptoms have not gotten
any better, his wife drove him to the [**Name (NI) **] today.
Past Medical History:
-- MI x 2: [**2080**], late [**2087**] (no intervention)
-- critical AS
-- h/o TIAs/CVA 5-6 years ago, had a catheterization that showed
carotid stenosis but no cardiac disease per pt
-- left CEA [**7-/2117**]
-- borderline diabetic
-- gout x 8 months
-- CRI after catheterization (unsure if pre-existing)
-- diverticulitis [**9-7**]
Social History:
Lives with his wife in [**Name (NI) 108**] for 8 months of the year and in
[**Location (un) 86**] [**Month (only) **] through [**Month (only) **]. He has eight children, 6 from a
prior marriage and 2 from his current wife. [**Name (NI) **] has smoked [**12-6**]
ppd for 60 years. He drinks alcohol rarely and does not use
illicit substances
Family History:
Unremarkable
Physical Exam:
PE:
VS: 97.2, 66, 102/43, 19, 95% RA
Gen: awake, alert, interactive, pleasant elderly man lying
comfortably on stretcher in NAD
HEENT: PERRL, EOMI, anicteric, OP clear, MMM
Neck: supple, no LAD, no JVD, no thyroid mases palpated
CV: RRR, soft S1S2, III/VI cresc-decresc systolic murmur LUSB
Lungs: diffuse exp wheezes b/l
Abd: +BS, S/NT/ND, obese
Ext: no c/c/e, DP pulses [**12-6**]+ b/l
Pertinent Results:
Cardiac cath:
1. Selective coronary angiography demonstrated three vessel
coronary artery disease in a right dominant circulation. The
LMCA had mild diffuse disease. The LAD had a proximal focal 70%
stenosis immediately after the D1 branch. The LCX had an origin
70% stenosis. The remainder of the LCX and OM branches were
without flow limiting disease. The RCA had a mid 80% stenosis.
2. Resting hemodynamics from right and left heart
catheterization reveal elevated right sided filling pressures
RVEDP=11mmHg and normal left sided filling pressures
LVEDP=11mmHg and mean PCWP=11mmHg. Cardiac output and index were
4.5 L/min and 2.2 L/min/m2 respectively.
3. Severe aortic stenois was present with peak-to-peak gradient
of 55mmHg and mean gradient of 44 mmHg. [**Location (un) 109**] was 0.75 cm2.
4. Left ventriculogram not performed due to elevated creatinine.
[**2124-6-9**] 06:30AM BLOOD WBC-12.5* RBC-4.28* Hgb-13.1* Hct-37.6*
MCV-88 MCH-30.7 MCHC-34.9 RDW-14.6 Plt Ct-238
[**2124-6-8**] 02:14AM BLOOD Neuts-70.6* Lymphs-12.3* Monos-5.4
Eos-11.1* Baso-0.6
[**2124-6-9**] 06:30AM BLOOD Plt Ct-238
[**2124-6-9**] 06:30AM BLOOD Glucose-89 UreaN-67* Creat-3.5* Na-137
K-4.6 Cl-102 HCO3-21* AnGap-19
[**2124-5-26**] 01:30PM BLOOD ALT-14 AST-17 AlkPhos-66 TotBili-0.4
[**2124-5-24**] 12:30PM BLOOD cTropnT-<0.01
[**2124-6-8**] 02:14AM BLOOD Calcium-8.3* Phos-3.7# Mg-2.1
[**2124-5-27**] 06:05AM BLOOD calTIBC-228* Ferritn-731* TRF-175*
[**2124-5-26**] 05:49PM BLOOD Triglyc-172* HDL-21 CHOL/HD-5.3
LDLcalc-56
[**2124-6-8**] 02:14AM BLOOD TSH-3.3
[**2124-6-8**] 02:14AM BLOOD Free T4-0.9*
[**2124-5-28**] 06:10AM BLOOD PEP-NO SPECIFI
[**2124-5-29**] 06:40AM BLOOD C3-117 C4-29
[**2124-6-5**] 02:29AM BLOOD Vanco-13.8*
[**2124-6-6**] 12:22PM BLOOD freeCa-1.23
CT Scan Date:[**2124-6-6**]
1. Small bilateral pleural effusions layer posteriorly.
Questioned right
upper pleural or extrapleural loculation is right upper lobe
collapse,
probably related to retained secretions.
2. Essentially normal postoperative appearance following median
sternotomy,
aortic valve replacement, CABG, and thyroidectomy.
[**2124-6-2**] ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
Right
ventricular chamber size and free wall motion are normal. There
are complex(mobile) atheroma in the descending aorta. A
bioprosthetic aortic valve prosthesis is present. The aortic
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion. Transgastric mid-papillary view shows
evidence of hypovolemia. All the four pulmonary veins were
visualized with no increase in velocities.
Brief Hospital Course:
Mr. [**Known lastname 29571**] was admitted to the [**Hospital1 18**] on [**2124-5-24**] for further
evaluation of his chest discomfort. An echocardiogram was
performed which revealed severe aortic stenosis with an aortic
valve area of 0.5cm2. A cardiac catheterization was performed
which revealed severe three vessel disease in addition to the
known severe aortic stenosis. As he had a large hematoma and a
new femoral bruit post catheterization, a femoral ultrasound was
obtained which showed no evidence of pseudoaneurysm or AV
fistula. Given the severity of his disease, the cardiac surgery
service was consulted for surgical management. Mr. [**Known lastname 29571**] was
worked-up in the usual preoperative manner including a carotid
duplex ultrasound which revealed moderate plaque on the right
with a 40-59% carotid stenosis and the left had less than a 40%
stenosis status post endarterectomy. Mr. [**Known lastname 46217**]
preoperative chest x-ray revealed a fullness which was likely a
goiter. A CT scan was performed which showed a multinodular
goiter, a trachea which was narrowed to two thirds of its normal
diameter at the level of the thyroid, moderate-to-severe
emphysema, small hiatal hernia and a probable liver cyst which
incompletely assessed. The enodocrinology service was consulted
who recommended a thyroidectomy given that he was hyperthyroid,
there was tracheal compression and the elevated risk of cancer.
Given the finding of his goiter, the thoracic surgery service
was consulted for assistance in his care. It was decided that a
concommittant thyroidectomy would be peformed with his cardiac
surgery. As Mr. [**Known lastname 29571**] had some renal failure post
catheterization, the renal service was consulted and a renal
ultrasound was performed. This showed multiple right renal cysts
and a nonobstructing kidney stone on the left. Slowly his
creatine normalized. As Mr. [**Known lastname 29571**] had a history of heavy
smoking and chronic obstuctive pulmonary disease, the pulmonary
service was consulted. Atrovent and albuterol were prescribed
and pulmonary function testing was planned. On [**2124-6-1**], Mr.
[**Known lastname 29571**] was taken to the operating room where he underwent
coronary artery bypass grafting to three [**Last Name (LF) 56207**], [**First Name3 (LF) **] aortic
valve replacement using a 27mm pericardial valve and a total
thyroidectomy. Postoperatively he was taken to the cardiac
intensive care unit for monitoring. Synthroid and calcium
supplementation was started. He underwent a bronchoscopy for
thickened secretions and a collapsed right upper lobe with good
success. He was transfused with red blood cells, platelets and
plasma. On postoperative day one, Mr. [**Known lastname 29571**] developed rapid
atrial fibrillation requiring cardioversion and amiodarone. On
postoperative day three, Mr. [**Known lastname 29571**] [**Last Name (Titles) 5058**] neurologically
intact and was extubated. As his voice was slightly hoarse, a
speech and swallow consult was obtained. As he was able to take
foods of all consistencies, he was cleared for a regular diet.
Mr. [**Known lastname 29571**] was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. Mr.
[**Known lastname 29571**] continued to require chest physiotherapy and pulmonary
toilet. The renal service continued to follow him for mild
postoperative renal failure. On postoperative day seven, mr.
[**Known lastname 29571**] was transferred to the step down unit for further
recovery. Thyroid studies were repeated and his synthorid was
adjusted appropriately.
Mr. [**Known lastname 29571**] continued to make steady progress and was
discharged to his home on postoperative day #9 in stable
condition. He will follow-up with Dr. [**Last Name (STitle) 914**], Dr. [**Last Name (STitle) 57869**],
his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Plavix 75 qd
Avaproi 150mg qd
Lipitor 40 qd
HCTZ 25 qd
Toprol XL 50 qd
Pepcid
Claritin
B12 1500 mEq qd
Salmon oil
colchicine 0.6mg qd
trazadone 50 qhs
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day for 1 months.
Disp:*30 Capsule(s)* Refills:*0*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) for 1 months.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 2 days: for 2 days until [**6-11**],then 200 mg daily
ongoing starting [**6-12**].
Disp:*50 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
s/p AVR/CABG x 3/ removal thyroid goiter (total thyroidectomy)
MIs x 2
TIA/CVA
s/p left CEA
borderline NIDDM
gout
CRI
diverticulitis
HTN
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions and pat dry
no lotions, creams or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, or drainage
Followup Instructions:
1) Follow up with Dr. [**Last Name (STitle) **] in [**12-6**] weeks and have calcium level
checked then; after completing one month of calcitriol and
calcium carbonate, please recheck calcium 2 days later. If
calcium normal, may stop both drugs. Please recheck TFT's in one
month.
2) Follow up with Dr. [**Last Name (STitle) **] on Thursday [**7-6**] at 10:30 AM at
[**Hospital Ward Name 23**] 9, [**Hospital Ward Name **] [**Telephone/Fax (1) 170**]
3) Follow up with Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
4) Follow-up with primary care physician in [**Name9 (PRE) 108**] as soon as
your return. Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 57870**]
Completed by:[**2124-6-10**]
|
[
"585.9",
"519.1",
"274.9",
"424.1",
"401.9",
"414.01",
"584.9",
"998.12",
"305.1",
"518.0",
"496",
"250.00",
"427.31",
"412",
"242.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"35.21",
"99.04",
"39.61",
"88.56",
"06.4",
"33.23",
"36.15",
"36.12",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
11314, 11388
|
5646, 9636
|
330, 450
|
11570, 11579
|
2892, 5623
|
11837, 12583
|
2454, 2468
|
9838, 11291
|
11409, 11549
|
9662, 9815
|
11603, 11814
|
2483, 2873
|
280, 292
|
478, 1721
|
1743, 2079
|
2096, 2438
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,492
| 184,035
|
49221
|
Discharge summary
|
report
|
Admission Date: [**2128-2-24**] Discharge Date: [**2128-2-28**]
Date of Birth: [**2072-11-27**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 55 year old woman with
a past medical history significant for severe multiple
sclerosis times twenty-five years resulting in chronic
debilitation and a recent left lower lobe community acquired
pneumonia versus aspiration pneumonia, which required
intubation, who was transferred from [**Hospital **] Rehabilitation
secondary to acute respiratory distress. The patient was
recently admitted to [**Hospital1 69**]
[**2128-1-19**], with community acquired pneumonia versus aspiration
pneumonia. She was started on empiric Levofloxacin and
Flagyl but her pneumonia worsened, leading to eventual
intubation [**2128-1-23**], to [**2128-1-24**]. Antibiotics were changed
to Vancomycin/Zosyn 0/15/04, but unfortunately she was
reintubated [**2128-1-27**], to [**2128-2-1**], secondary to mucous
plugging. Intensive Care Unit course was notable for
ischemic acute tubular necrosis, fluid response of
hypotension, culture negative, guaiac positive stools
requiring two units packed red blood cells and PEJ placement
[**2128-2-4**]. She was discharged to [**Hospital **] Rehabilitation on
[**2128-2-6**], in good condition without any antibiotics. The
morning of admission the patient was noted to be acutely
"cyanotic", "diaphoretic" with increased heart rate to the
130s, increased respiratory rate to the 40s, blood pressure
126/76, oxygen saturation of 81% on three liters, improved to
95% on nonrebreather. For unclear reasons, the patient was
emergently intubated by EMS in the field and brought to [**Hospital1 1444**] Emergency Department for
further evaluation. Chest x-ray in the Emergency Department
was negative for acute infiltrate. CT angiogram was negative
for pulmonary embolus. Her oxygen saturation was excellent
on AC vent settings of 450 by 14, PEEP of 5, 50% FIO2. Blood
pressure was 90s to 110s over 50 to 80, heart rate 90s to
110s. The patient was given 0.5 mg Ativan and 1.5 liters of
normal saline. She was also transiently bradycardic to the
30s in the Emergency Department with drop in blood pressure
and this occurred while bucking the vent, was attributed to a
vasovagal episode.
PAST MEDICAL HISTORY:
1. Multiple sclerosis times twenty-five years.
2. Gastric ulcer.
3. Status post cesarean section.
4. Status post recent left lower lobe pneumonia requiring
two intubations.
MEDICATIONS ON ADMISSION:
1. Beconase Nasal Spray two sprays twice a day.
2. Colace 100 mg twice a day.
3. Lasix 20 mg once daily.
4. Prevacid 30 mg twice a day.
5. Zantac 150 mg twice a day.
6. Atrovent/Albuterol nebulizers twice a day.
7. Reglan 5 mg q.h.s.
8. Zinc 220 once daily.
9. Zoloft 25 mg once daily.
10. Vitamin C 500 mg once daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married, is currently at
[**Hospital **] Rehabilitation, previously was living at home. She
is married and lives with her husband. She has a chronic
Foley. She is dependent on all her activities of daily
living. She has a greater than 20 pack year history of
tobacco and quit in [**2127**]. Husband, [**Name (NI) **], is her health
care proxy.
PHYSICAL EXAMINATION: On admission, temperature 97.7, blood
pressure 96/52 with a MAP of 67, heart rate 92, range 90s to
110s. Vent settings were 450 by 14, PEEP of 5, 50% FIO2,
respiratory rate 14 to 17 with a PIP of 24 and a plateau of
16. She was saturating 100%. In general on examination, she
is intubated, wide awake, following commands in no acute
distress. Head, eyes, ears, nose and throat examination -
The pupils are equal, round, and reactive to light and
accommodation, 3.0 millimeters to 2.0 millimeters, anicteric.
Mucous membranes are moist. Neck - no lymphadenopathy, no
carotid bruit, no jugular venous distention, no thyromegaly.
Lungs - Slightly decreased left base and otherwise clear.
Cardiovascular is regular rate and rhythm, no murmurs, rubs
or gallops. The abdomen is soft, nontender, nondistended
with normoactive bowel sounds, no masses. PEJ site clean,
dry and intact. Extremities - Boots bilaterally lower
extremity, trace to 1+ pitting edema in bilateral lower
extremities, warm, good capillary refill. Fingernails
possible fungal infection.
LABORATORY DATA: The patient's admission data was
significant for white blood cell count of 11.9 which was
decreased from her previous discharge when it was 15.9.
Hematocrit was 32.0, platelet count 496,000. Differential on
her white blood cell count was 88% neutrophils, 2% bands, 2%
lymphocytes, and 8% monocytes. Her chemistries were
significant for potassium of 3.2 and a glucose of 245.
Urinalysis was significant for a specific gravity of 1.013,
protein 30, occasional bacteria, [**3-12**] white blood cells.
Chest x-ray showed a left sided effusion, left lower lobe
atelectasis, and endotracheal tube in place. CTA showed no
pulmonary embolus, left effusion with left lower lobe
consolidation/atelectasis, multiple nodular opacities of the
periphery with a tree and [**Male First Name (un) 239**] appearance consistent with
aspiration pneumonia or other infectious etiology.
Electrocardiogram showed sinus tachycardia at 150, left axis
deviation, poor R wave progression, T wave inversions in I
and V1, J point elevation in V2 to V4.
HOSPITAL COURSE:
1. Respiratory failure - The patient's respiratory failure
was thought to be secondary to mucous plugging. She did not
have signs of infection and she was not initially started on
antibiotics. The patient was started on pressure support as
soon as she arrived in the Medical Intensive Care Unit on the
day of admission, [**2128-2-24**], and was soon extubated when she
did very well on her pressure support trial. Over the next
two days, the patient required frequent suctioning and chest
physical therapy secondary to lack of a cough due to her
severe multiple sclerosis. Given the patient's recent
aspiration pneumonia, and recurrent mucous plugging after
extubation secondary to thick secretions and her inability to
clear them, the patient was offered a tracheostomy and the
patient and her husband agreed to this. On [**2128-2-26**], a
tracheostomy was placed by the interventional pulmonology
team without complications. A regular size tracheostomy was
put in place. The day following the tracheostomy placement
while the patient was being turned, she desaturated and some
blood clots were suctioned out of the tracheostomy. An
urgent bronchoscopy was done and several old clots were
pulled out the bronchi resulting in improved saturation. The
patient remained on 50% face mask with 99 to 100% saturation
during the rest of her hospitalization. Lidocaine and
Epinephrine was injected around her tracheostomy site where
there was some oozing and this resolved over the course of
the next twelve hours. The patient was also continued on her
nebulizers and Beconase Nasal Spray.
2. Cardiac - After the patient was admitted, a CK and
troponin was sent secondary to her sinus tachycardia. The
patient did not have any previous history of cardiac disease.
Her troponin was elevated at 1.01. Her CKs were not
elevated. Over the rest of her hospital stay, troponin
levels were checked and all these trended down. The patient
was never with chest pain. A Baby Aspirin was started. A
beta blocker was not started secondary to low blood pressure.
However, the troponin leak was thought to be secondary to
demand ischemia. The patient's electrocardiograms had some T
wave inversions in III, aVF and V3, however, looking back on
previous electrocardiograms, these were intermittently also
inverted. The patient should have an echocardiogram to
follow-up as there is no history of cardiac disease for any
new wall motion abnormality.
3. Hypotension - During the course of her stay, the patient
occasionally was hypotensive to the high 70s systolic, low
80s. The patient never had a high fever and her white blood
cell count never rose. This hypotension was not thought to
be secondary to sepsis. A random cortisol was checked and it
was normal. The patient was bolused several times during two
nights secondary to her hypotension. However, the patient
was asymptomatic with this and her urine output remained
steady and greater than 30cc/hour at all times. Therefore,
it was concluded that the patient's blood pressure runs low,
especially when she is asleep and this did not need to be
aggressively treated unless the patient is symptomatic which
she does not appear to be during this hospital stay. In
addition, the patient may have some autonomic insufficiency
related to her neurologic disorder.
4. Neurology - The patient's neurology doctor at the
rehabilitation did stop by and commented that the patient's
multiple sclerosis was atypical. In discussion with the
patient's husband, the patient had never had a magnetic
resonance scan in the past to diagnose her, lumbar puncture,
and had had very little treatment or workup for her disease.
In addition, the patient's daughter had been recently
diagnosed with magnetic resonance scan and it was thought
that this patient's disease was not multiple sclerosis given
it was atypical. It may be helpful to know what it is in
case this could help the patient's daughter. Thus, a
magnetic resonance scan of the head and spine were obtained.
The patient needs to follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], to set up neurological follow-up.
The magnetic resonance scan results should also be followed
up on as they were not completed at the time of discharge.
5. Nutrition - The patient was continued on he PEJ tube
feeds during her hospital course without high residuals or
other problems. These should be continued while the patient
is in house.
6. Infectious disease - The patient had blood cultures
initially on admission on [**2128-2-24**]. One bottle out of four
grew coagulase negative Staphylococcus and this was
attributed to a contaminant. Her sputum culture grew
oropharyngeal flora, gram positive rods and gram positive
cocci. In addition, the patient's urinalysis, which did not
have signs of infection other than [**3-12**] white blood cells, did
grow out Vancomycin resistant Enterococcus. The patient was
not treated for this as her urinalysis did not have evidence
of infection and her white blood cell count was not elevated
and she was afebrile. The patient should be on VRE
precautions on discharge.
DISCHARGE DIAGNOSES:
1. Hypoxic respiratory failure secondary to mucous plugging.
2. Multiple sclerosis.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To [**Hospital **] Rehabilitation.
DISCHARGE FOLLOW-UP:
1. The patient should follow-up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] in one
week to follow-up on the magnetic resonance scan spine and
head results. The patient could also be considered for a
neurologic referral so that she has a primary neurologist.
2. The patient should also be considered for a future
echocardiogram to evaluate for any abnormality given recent
troponin leak attributed during this admission to demand
ischemia.
MEDICATIONS ON DISCHARGE:
1. Lansoprazole oral suspension 30 mg nasogastric twice a
day.
2. Docusate Sodium 100 mg twice a day, hold for loose
stools.
3. Beclomethasone AQ (nasal) two sprays intranasally twice a
day.
4. Metoclopramide 5 mg four times a day, a.c. and h.s.
5. Multivitamin one capsule p.o. once daily.
6. Sertraline 25 mg p.o. once daily.
7. Subcutaneous Heparin 5000 units q12hours.
8. Albuterol nebulizer solution one nebulizer inhaled
q6hours p.r.n.
9. Ipratropium Bromide nebulizer one nebulizer inhaled
q6hours p.r.n.
10. Aspirin 81 mg nasogastric once daily.
11. Tylenol Liquid 325 to 650 mg p.o. q4-6hours p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. [**MD Number(1) 2691**]
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2128-2-28**] 12:09
T: [**2128-2-28**] 12:19
JOB#: [**Job Number 103197**]
cc:[**Hospital6 **]
|
[
"507.0",
"707.0",
"410.71",
"305.1",
"340",
"518.0",
"934.9",
"518.81",
"867.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.71",
"99.04",
"96.04",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
10650, 10737
|
11352, 12271
|
2517, 2884
|
5415, 10629
|
3289, 5398
|
167, 2291
|
2313, 2491
|
2901, 3266
|
10762, 11326
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,185
| 196,084
|
49097
|
Discharge summary
|
report
|
Admission Date: [**2118-3-11**] Discharge Date: [**2118-3-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chest pain, black stools
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Mr. [**Known firstname **] is an 85 yo M with CAD (cath in [**2116**] with 3VD, refused
CABG s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **], PDA), PUD and gait disorder who is brought in
to the ED by his wife for hypotension to the 80's-90's systolic
in the last week after recent changes to his antihypertensive
regimen. He also c/o abdominal tightness for the last 2-3 weeks.
With his history of PUD (prepyloric and antral ulcers) he was
supposed to be taking a ppi at home, which he admits to not
taking. He denies hematemesis, BRBPR or melena. Of note, Dr.
[**Last Name (STitle) **], his gerontologist, explored this recent onset morning
hypotension in some detail at his last visit at the end of
[**Month (only) 956**], and he felt that the divided dosing of his lisinopril
may be the etiology, as the half life of this drug is >24 hours,
and advised switching to AM dosing.
.
In the ED, VS 130s-150s systolic, HR 80s-90s. Exam was notable
for brown guaiac + stool and a Hct of 25. His EKG was initially
unchanged from prior. Because he had abd pain he went for a CT
abd. After his scan he developed SSCP with assoc tachycardia.
EKG demonstrated 1-2mm ST depression inferiolaterally. He was
given ASA, IV protonix, nitro, and metoprolol with resolution of
his pain and changes. GI was consulted and felt anemia was
likely secondary to slow GI bleed from recurrent PUD and
recommended EGD and PRBC transfusion.
.
On the floor, the patient is hemodynamically stable with no
complaints.
Past Medical History:
1) CAD: [**12-10**]: cardiac cath with 3VD, refused CABG, s/p [**Month/Year (2) **] to
RPL and RCA. cardiologist - Dr. [**Last Name (STitle) **].
2) Hypertension
3) h/o H. pylori s/p Rx with Prevpac, PUD with two ulcers on EGD
in [**2117**].
4) h/o bronchiectasis.
5) BPH
6) Grade II int hemorrhoids in [**2115**]
7) Gait Disorder, thought to be Parkinsonian
Social History:
Denies alcohol or tobacco use; lives independently with his
wife; former chief enginering officer for Duracel.
Family History:
NC
Physical Exam:
VS: T 97.9, BP 132/57, HR 94, 91%4L
GEN: NAD, awake and alert
HEENT: AT, NC, PERRLA, conjunctival pallor, anicteric, OP clear,
MM dry, Neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, minimal distention, minimal epigastric tenderness, no
rebound/gaurding or masses.
EXT: no jaudice/rashes/[**Location (un) **]
Pertinent Results:
[**2118-3-11**] ABD CT:
IMPRESSION:
1. No mass lesions are detected within the abdomen or pelvis.
Colonoscopy should be considered to evaluate for intraluminal
colonic lesions resulting in anemia as the negative predictive
value of an abdominal CT for this indication is unknown.
2. Unchanged liver hemangioma and left renal cysts.
3. Dense calcified atherosclerotic plaque within the abdominal
aorta and iliac branches including the ostia of the celiac axis
and SMA.
4. Cholelithiasis.
5. Subpleural cystic change in the anterior middle lobe.
.
[**2118-3-11**] CXR:
IMPRESSION: Stable right mid lung zone scarring and
bronchiectasis. No definite evidence of pneumonia.
.
[**2118-3-14**] ECG:
Sinus rhythm with atrial premature complex, Early R wave
progression
Consider left ventricular hypertrophy, Extensive ST changes are
nonspecific or strain, Clinical correlation is suggested, Since
previous tracing of [**2118-3-12**], no significant change.
.
[**2118-3-13**] EGD:
Findings: Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Excavated Lesions A single cratered oozing ulcer was found in
the incisura of the stomach. [**Hospital1 **]-CAP Electrocautery was applied
for hemostasis successfully.
Duodenum:
Mucosa: Normal mucosa was noted.
.
PERTINENT LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2118-3-16**] 08:10AM 4.7 3.30* 10.0* 29.1* 88 30.3 34.3 17.1*
110*#
[**2118-3-15**] 07:40AM 4.7 3.33* 10.3* 28.8* 87 30.9 35.8* 16.4*
69*
[**2118-3-14**] 10:08PM 28.0*
[**2118-3-14**] 02:02PM 27.5*
[**2118-3-14**] 04:28AM 5.9 3.40* 10.6* 29.1* 86 31.3 36.6* 16.9*
74*
[**2118-3-14**] 01:24AM 28.3*
[**2118-3-13**] 09:24PM 29.4*
[**2118-3-13**] 01:34PM 7.2 3.65* 11.1* 30.5* 84 30.4 36.4* 16.7*
61*
[**2118-3-13**] 05:56AM 7.5 3.77*# 11.6*# 31.8*# 84 30.6 36.4*
16.6* 64*
[**2118-3-13**] 01:05AM 5.7 2.80* 8.8* 24.2* 87 31.3 36.2* 17.4*
68*
[**2118-3-12**] 07:25PM 6.4 3.48*# 10.8*# 30.3*# 87 31.1 35.7*
17.0* 72*
[**2118-3-12**] 03:23PM 5.1 2.25* 6.8*1 20.4*1 91 30.4 33.5 17.2*
69*
[**2118-3-12**] 02:42PM 5.8 2.65* 8.2* 24.8* 94 31.1 33.2 17.7*
77*
[**2118-3-12**] 09:15AM 6.2 3.01* 9.2* 26.9* 89 30.5 34.1 16.9*
79*1
[**2118-3-11**] 05:35PM 25.0*
[**2118-3-11**] 03:45PM 4.8 2.67*# 8.8*# 25.3*# 95 32.7* 34.6
14.5 117
.
AT DISCHARGE:
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2118-3-15**] 07:40AM 110* 17 0.9 140 3.7 106 31 7*
.
CARDIAC MARKERS:
CK(CPK)
[**2118-3-14**] 02:02PM 69
[**2118-3-14**] 12:55AM 64
[**2118-3-12**] 09:15AM 68
[**2118-3-11**] 11:01PM 73
.
cTropnT
[**2118-3-14**] 02:02PM <0.01
[**2118-3-14**] 12:55AM <0.01
[**2118-3-12**] 09:15AM <0.01
[**2118-3-11**] 11:01PM 0.03*
[**2118-3-11**] 03:45PM <0.01
.
LFTs:
ALT AST LD(LDH) AlkPhos Amylase TotBili DirBili
[**2118-3-11**] 03:45PM 16 19 124 76 45 0.2
.
Brief Hospital Course:
A/P: 85 yo M with history of CAD s/p stents, PUD noncompliant
with ppi therapy, with upper GI bleed and continued HCT drop.
.
#. UGIB: recurrent PUD given his history and noncompliance with
PPI. Pt noted to be hypotensive in ED, initial HCT 25.3 with sx
of unstable angina. Pt received 2U PRBC transfusion [**3-11**], HCT
dropped to 20.5 on [**3-12**] received 4UPRBC, HCT improved to 30.3. On
[**3-13**] pt was transferred to the MICU for EGD and called out once
EGD done, he received additional 2UPRBC for HCT 29, he did not
receive further blodd transfusions thereafter and HCT remained
stable at 29. He is also on chronic aspirin for his known CAD,
but was taken off plavix approximately 1 month ago. EGD on [**3-13**]
showed 1 cm ulcer in the fundus of stomach, biopsy taken and
cautery done. HCT stable. He had no further melena. He was
continued on PPI [**Hospital1 **]. He tolerated 81mg ASA without a problem.
**Patient needs repeat EGD in 8 weeks (was non-compliant with
past follow up).
.
# CAD: with stents in [**2116**], on aspirin, beta blocker and statin
as an outpatient. The chest pain in the ED was associated with
the IV contrast infusion and is not typical of his cardiac
symptoms. He had ECG changes in the ED, but subsequent ECGs
demonstrate improvement. His second troponin was 0.03, but his
third returned to <0.01. It is likely that the second value was
demand in the setting of anemia, UGIB and CAD. Aspirin was held
temporarily, but restarted after EGD. Had episode of chest pain
in MICU, EKG without ST changes, resolved with SLNTG. 2 sets CE
neg. Spoke with Dr. [**Last Name (STitle) **] on [**3-14**]-no need for inpt stress,
will follow as outpt. He was continued on his ASA, BB, Statin.
His BP and HR were well controlled. He was switched to his
outpatient regimen at time of discharge with plan to hold
evening lisinopril due to intial hypotension during admission.
.
#. Hypertension: Pt intially hypotensive found to have UGIB as
noted above, requiring 8UPRBC in total. His BB was resumed and
was put on metoprolol 37.5mg TID and tolerated this well. Per
prior Dr. [**Last Name (STitle) **] notes, pt noted to have higher BPs in the
afternoon, as such his regimen included lisinopril 20am and 10HS
prior to this admission. Given his recent bleed and initial
hypotension he was transitioned to metoprolol 50mg [**Hospital1 **] and added
lisinopril 20mg daily in am at time of discharge with plan to
follow BP and if he remains hypertensive in the afternoons-plan
to add lisinopril at HS. For now will continue metoprolol 50mg
[**Hospital1 **] and lisinopril 20mg daily.
.
#. Thrombocytopenia: Patient with chronic idiopathic
thrombocytopenia and no evidence of cirrhosis on current
imaging. Platelet goal will be >50,000 given active bleed. 117
at admission, down to 62. At time of discharge PLTs 110. No
heparin products. Goal >50,000. He did not require platelet
transfusions during this admission.
.
#. Gait Disorder/Autonomic Instability: new over past several
months and affecting quality of life per patient. Notes suggest
Parkinson's Disease as etiology. Further evaluation once GIB
stabilized. Per notes, gait disorder worse with hypotension. PT
was consulted and recommended rehab for pt. Pt was hypotensive
only during his intial presentation in ED due to UGIB and
transfusion requirement as noted above.
#. BPH: continued finasteride.
.
#. H/o bronchiectasis: not an acute issue on this admission. CXR
shows stable scarring. O2 sats stable on RA.
.
#. CODE: FULL
#. DISPO: REHAB
Medications on Admission:
Aspirin 325 mg daily
Lisinopril 30 mg daily (divided into 20 in the AM and 10 in the
pm)
Metoprolol tartrate 50 mg b.i.d.
Simvastatin 10 mg daily.
Proscar 5mg daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Erythromycin 5 mg/g Ointment Sig: 0.5 in Ophthalmic QID (4
times a day) as needed for conjunctivitis for 5 days.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
indefinately .
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care Center
Discharge Diagnosis:
Primary:
-Bleeding peptic ulcer s/p cuaterization
-Demand ischemia
.
Secondary:
- CAD: MI in [**12-10**]: cardiac cath with 3VD, refused CABG, s/p [**Date Range **]
to
RPL and RCA. cardiologist - Dr. [**Last Name (STitle) **]. OFF plavix [**2-11**] as
stents >1 year old
- Hypertension
- h/o H. pylori s/p Rx with Prevpac, PUD with two ulcers on EGD
in [**2117**].
- h/o bronchiectasis from recurrent pneumonia. [**Doctor First Name **] in sputum
- BPH on Proscar
- Grade II int hemorrhoids in [**2115**]
- Gait Disorder, thought to be Parkinsonian
- Orthostatic hypotension to Flomax
Discharge Condition:
Stable, no melena, tolerating POs, chest pain free, ambulating
with walker with assistance.
Discharge Instructions:
You were admitted for chest pain, and a peptic ulcer bleed. Your
chest pain resolved once your bleeding stopped. You underwent
an endoscopy which showed the cause for your bleeding.
You must take the pantoprazole twice per day most likely
indefinately. You must discuss this with your primary care
doctor.
.
If you have chest pain, difficulty breathing, blood in your
stools or vomiting blood or have other concerning symptoms
please call your physician or go to the emergency room.
.
Please note the changes in your medications:
-Pantoprazole 40mg twice per day
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2118-4-21**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. Phone:[**Telephone/Fax (1) 7612**]
Date/Time:[**2118-4-5**] 2:30
.
Follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-5**] weeks, call
Dr. [**Last Name (STitle) **] clinic at [**Telephone/Fax (1) 4775**] for a follow up appointment.
.
You need a repeat follow up endoscopy in 8 weeks. Please have
your primary care physician arrange this for you.
Completed by:[**2118-3-16**]
|
[
"285.1",
"531.40",
"287.5",
"414.00",
"V45.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10282, 10343
|
5818, 9350
|
286, 291
|
10973, 11067
|
2819, 4071
|
11679, 12358
|
2384, 2388
|
9565, 10259
|
10364, 10952
|
9376, 9542
|
11091, 11656
|
2403, 2800
|
5197, 5795
|
222, 248
|
319, 1856
|
4087, 5183
|
1878, 2239
|
2255, 2368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,717
| 199,895
|
13879
|
Discharge summary
|
report
|
Admission Date: [**2122-4-18**] Discharge Date: [**2122-4-21**]
Date of Birth: [**2040-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2962**]
Chief Complaint:
Dizziness, weakness
Major Surgical or Invasive Procedure:
Transvenous Pacemaker Placement and Removal
ICD Placement
History of Present Illness:
Mr. [**Known lastname **] is an 81 y.o. male with known CAD s/p CABG in [**2109**],
h/o ischemic cardiomyopathy with EF 25% s/p NSTEMI and BMS to
RCA in [**12-11**], DM, and HTN who presents to the ED with dizziness
and weakness beginning this AM. He has been feeling fatigued
for approximately one month, however this AM felt profoundly
weak to the point where he was unable to get up from his chair.
When he was able to get up he experienced dizziness which is
unusual for him. This symptom resolved when he sat back down.
He also experienced shortness of breath with minimal activity,
like taking off his robe. He took 2 SL NTG which did not change
or relieve his symptoms. He did not experience any chest pain,
syncope or presyncope. At baseline he lives alone and ambulates
without difficulty around the house. He has bilateral knee pain
and therefore is not able to walk long distances. Of note, he
did not take his medications this morning.
.
When EMS arrived on the scene he was found to have a HR of 27.
He received [**2-4**] amp of atropine with HR response to the 50s. On
arrival to the ED HR was again in the 20s, BP 152/60, O2 sat
100% on 2L. Electrophysiology was consulted in the ED and found
him to have high grade AV block. Blood pressure remained stable
with systolic BP in the 140s-160s. In the ED, he was given an
additional 1mg of atropine without change in HR. A digoxin
level was checked and was 0.2. First set of cardiac enzymes
were negative. On arrival to the CVICU he is awake, alert and
conversing with his family.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, hemoptysis, black stools or red
stools. He did have the "flu" one week ago. His main symptoms
were fatigue, cough, and occasional chills. No fevers since
that time. He has bilateral knee discomfort which is stable.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for (-) chest pain,
(+)dyspnea on exertion, (-)paroxysmal nocturnal dyspnea, (+) 2
pillow orthopnea, (+) ankle edema, (-) palpitations, (-)syncope
or (-)presyncope.
Past Medical History:
CAD s/p CABG in [**2109**]
Cardiomyopathy with CHF, EF 20%
Hypertension
Diabetes
CRI, baseline 1.1-1.3
BPH
s/p cholecystectomy
Right eye cataract
Bilateral knee arthritis
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Dad died of MI at 85. Mom died of MI at 80.
Physical Exam:
(on admission)
VS: T 96.7 BP 128/47 HR 35 RR 12 O2 sat 99% on 2L NC
GEN: NAD, elderly male sitting up in bed with NC, mentating
well. Alert and oriented x 3. Pleasant.
HEENT: NCAT, anicteric sclera, EOMI, PERLL, neck supple, 10 cm
elevated JVP
CHEST: Bilateral rales at the bases, no wheezes
CV: Bradycardic, nl S1, S2, no m/r/g appreciated
ABD: NABS, soft, NDNT, no HSM appreciated
EXT: 1+ ankle edema L>R; sensation intact in bilateral feet.
SKIN: no rashes, right groin site c/d/i. no bruit appreciated.
.
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
Admission labs: [**2122-4-18**] 08:30AM cTropnT-<0.01, CK(CPK)-23*,
GLUCOSE-189* UREA N-33* CREAT-1.8* SODIUM-141 POTASSIUM-4.4
CHLORIDE-105 TOTAL CO2-23, DIGOXIN-0.2*, WBC-7.7 RBC-4.65
HGB-13.0* HCT-40.2 MCV-86 MCH-27.9 MCHC-32.3 RDW-14.3
.
Admission CXR:
1. Mild central pulmonary vascular prominence without edema.
Globular
cardiomegaly suggesting panchamber enlargement, status post
coronary artery bypass grafting.
2. Tortuous thoracic aorta suggesting longstanding
hypertension.
.
Admission EKG: EKG from ED demonstrated high degree AV block,
ventricular rate of 27, TWI in I, aVL, V5, V6, significantly
changed from prior dated [**2121-12-20**].
.
Discharge CXR: 1) Status post placement of an ICD with 2 leads
in satisfactory location.
2) Mild cardiomegaly.
3) COPD changes.
Brief Hospital Course:
Mr. [**Known lastname **] is an 81 year old male with history of CAD s/p CABG,
CHF (EF 20%), DM, HTN who presented to ED c/o dizziness and was
found to have high degree AV block.
.
# Rhythm: Admitted with high degree AV block, type II, 2nd
degree block. Pt had a history of LBBB and prolonged PR
interval. The etiology of the patient's bradycardia included
medication induced (dig level is 0.2, atenolol is renally
cleared) vs scar (old infarct and LBBB) vs ischemia (baseline
LBBB). The most likely etiology was felt to be a diseased
His-Purkinje for old scar. Ischemia was ruled out with cardiac
enzymes and EKG. Pt was admitted and pacer pads were kept in
place and atropine was kept at the bedside. Pt was monitor on
telemetry. Lytes were checked and repleted aggressively. A RIJ
and transvenous pacer wire was placed after admission. Digoxin
and nodal agents were held, and the folowing day had an escape
nodal rhythm when pacer tunred down to 50 but inconsistently so
(supporting a disease His-P system). The plan was to place a
biv ICD which was attempted on day3 but LV lead was
unsuccessful. EP decided this was sufficinet in this patient.
He was scheduled for an appointment in the device clinic one
week from d/c and was instructed to call Dr. [**Last Name (STitle) **] for an
appointment to be seen within 1 mo.
.
# Ischemia: h/o CAD s/p CABG
Pt had no chest pain on admission or during course. MI ruled out
as above. ASA, statin, plavix were continued and BB, ACEi were
started after ICD placement. Pt was sent out on Toprol XL 25mg
instead of Atenolol 50mg since pt had BP well controlled at this
dose in hospital on that BP regiment and atenolol we wanted to
avoid given renal insufficiency and possible atenolol toxicity.
Lisinopril was started at 5mg daily for post-MI, CHF with EF<40%
and for chronic renal insufficiency. Imdur was kept at half
dose given initial fear of hypotension, then restarted at full
dose after ICD.
.
# Pump: Systolic heart failure with EF 20%
Pt arrived appearing mildly volume overloaded on exam. CXR with
some evidence of mild pulmonary vascular congestion. Initially
continued half dose lasix given initial fear of hypotension
(home on Lasix 80mg daily). After ICD placement started BB and
ACEi as above. Home lasix dose restarted at d/c. he was
instructed to continue to take fluids but avoid salt.
.
# Renal Failure: Cr on admission 1.8, per report baseline Cr
1.1-1.3. Elevation liekly was [**3-7**] poor forward flow from
bradycardia and improved rapidly when transvenous pacer was
placed. Creatinine was monitored daily. Improved cardiac output
as above with pacer. Creatinine on d/c was 1.3. Please recheck
as an outpt to assume stability.
.
# BPH:
- Continued terazosin.
.
# Glaucoma:
- Continued latanoprost ophtho drops.
.
# HTN: Currently well controlled.
- Held beta blocker initially. Then BB, ACEi, CCB, imdur as
above.
.
# DM:
- Insulin sliding scale in hosp with diabetic diet. Metformin
was restarted on d/c (given cr <1.5)
.
# FEN:
- Diabetic/ Heart healthy diet
- Monitored lytes and replete PRN
.
# Prophylaxis:
- PPI, bowel regimen, heparin subq
.
# Code: full
.
# Communication: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Known lastname **] (daughter) [**Telephone/Fax (1) 41609**] cell or
[**Telephone/Fax (1) 41610**] (home); [**Doctor First Name **] (daughter) [**Telephone/Fax (1) 41611**] home or
[**Telephone/Fax (1) 41612**] cell.
Medications on Admission:
Plavix 75mg daily
Aspirin 325mg daily
Digoxin 0.125 every other day
Tylenol PRN pain
Xylatan eyedrops
Metformin 500mg [**Hospital1 **]
Hytrin unknown dose hs
Simvastatin 40mg hs
Lasix 80mg [**Hospital1 **]
Norvasc 10mg daily
Atenolol unknown dose [**Hospital1 **]
Imdur 60mg daily
He had previously been taking Lisinopril but is no longer taking
b/c cardiologist had told him should avoid due to renal
insufficiency
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for prophylaxis for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Type II second degree AV block s/p ICD placement (unsuccessfull
LV lead placement)
Acute on Chronic Renal Failure (baseline renal function 1.1-1.3)
.
Secondary Diagnosis:
CAD s/p CABG in [**2109**]
Cardiomyopathy with CHF EF 25%
Hypertension
Diabetes
BPH s/p TURP
s/p cholecystectomy
Right eye cataract
Bilateral knee arthritis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for Type II second degree AV block
where your heart beats too slow. For this you had a
defibbrilator placed. Please follow-up in device clinic on
[**2122-4-28**] @ 2:30. Please also clal to schedule an appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to be seen in one to three months. You
were also treated for acute on chronic renal failure likely
caused by the low heart rate. Please schedule an appointment
with your PCP to be seen within 2 weeks.
.
If you develop fever greater than 101F, chest pain, shortness of
breath, dizziness, lightheadedness, fatigue, or if you at any
time become concerned about your health please contact your PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] or present to the nearest ED.
.
Please continue to take your medications as previously with the
following changes:
- please take Keflex for a total of 5 days to prevent a
infection of the ICD
- please take Toprol XL 25mg once daily instead of atenolol (for
your heart)
- please start taking Lisinopril 5mg daily to prtoect the
kidneys and for your heart
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Please adhere to a 2 gm sodium diet.
Followup Instructions:
- Please follow-up in device clinic on [**2122-4-28**] @ 2:30.
(Phone:[**Telephone/Fax (1) 59**])
- Please call to sechedule an appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] to be seen in one to three months ([**Telephone/Fax (1) 285**])
- Please schedule an appointment with your PCP to be seen within
2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]
|
[
"V45.81",
"250.00",
"412",
"414.8",
"428.22",
"428.0",
"600.00",
"585.9",
"496",
"584.9",
"426.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
9785, 9791
|
4608, 8061
|
335, 395
|
10182, 10191
|
3793, 3793
|
11520, 12005
|
2989, 3117
|
8527, 9762
|
9812, 9812
|
8087, 8504
|
10215, 11497
|
3132, 3774
|
276, 297
|
423, 2653
|
10002, 10161
|
3809, 4585
|
9831, 9981
|
2675, 2847
|
2863, 2973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,717
| 151,901
|
46244+58888
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-11-18**] Discharge Date: [**2145-12-4**]
Date of Birth: [**2069-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing / Heparin Agents
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Type A dissection
Major Surgical or Invasive Procedure:
ascending aortic/hemiarch graft replacement [**2145-11-18**]
reoperation for bleeding, open chest [**2145-11-18**]
closure of chest [**2145-11-22**]
History of Present Illness:
This 76 year old white female presented to the Emergency Room
having been awakened from sleep with substernal cheat pain
radiating to her back. A noncontrast CT(contrast
allergy)revealed a Type A dissection extendingn into the head
vessels and descending aorta.
Past Medical History:
coronary artery disease
s/p percutaneous coronary intervention
h/o congestive heart failure
hepatic cysts
h/o breast cancer
s/pp pericardiocentesis
s/p left mastectomy
hypertension
thyroglossal duct cyst
osteoporosis
hiatal hernia
Post-op afib
Social History:
- Patient lives alone
- Previously employeed at [**Company 2486**] but has since retired
- Son assists with some iADLs, but patient able to bath, feed, &
toilet herself
- Tobacco:
- EtOH: Occasional
- Illicit drug use: None.
Family History:
Father: CAD, [**Name (NI) **] CA
Mother: PE
Physical Exam:
Physical Exam
Pulse:44 Resp:18 O2 sat:100%
B/P Right:108/56
Height: Weight:151 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Cool bilaterally, [**11-22**]+ edema
Varicosities: bilateral spider veins
Neuro: sedated, UTA
Pulses:
Femoral Right: 1+ Left:-
DP Right: doppler Left:-
PT [**Name (NI) 167**]: doppler Left:-
Radial Right: 1+ Left:1+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**Known lastname **],[**Known firstname **] N [**Medical Record Number 98312**] F 76 [**2069-7-18**]
Radiology Report KNEE (2 VIEWS) LEFT Study Date of [**2145-12-2**] 2:11
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2145-12-2**] 2:11 PM
KNEE (2 VIEWS) LEFT Clip # [**Clip Number (Radiology) 98313**]
Reason: ? septic joint
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with s/p Asc Ao.Dissection
REASON FOR THIS EXAMINATION:
? septic joint
Final Report
LEFT KNEE, TWO VIEWS
HISTORY: 76-year-old female status post ascending aortic
dissection; ? septic
joint.
FINDINGS: Limited study, with frontal and cross-table lateral
views, is
compared with the radiographs of [**2145-8-5**]. There is now a
relatively large
suprapatellar joint effusion, with diffuse, circumferential
swelling of the
overlying soft tissues. However, there is no cortical
discontinuity,
periosteal new bone formation, or medullary lucency to
specifically suggest
osteomyelitis. There is osteoarthritis involving the lateral
compartment with
joint space narrowing, subchondral sclerosis and marginal
osteophyte
formation, as before.
IMPRESSION: Soft tissue swelling and relatively large
suprapatellar joint
effusion, significantly more marked since the [**7-/2145**]
radiographs. In this
clinical context, septic arthritis remains a concern. No frank
bone
destruction is seen.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: [**First Name9 (NamePattern2) **] [**2145-12-3**] 10:06 AM
ECHO
PRE-CPB:
No atrial septal defect is seen by 2D or color Doppler. The left
atrium is moderately enlarged.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is dilated with borderline normal
free wall function.
The ascending aorta is severely dilated. The descending thoracic
aorta is mildly dilated. A mobile density is seen in the
ascending aorta consistent with an intimal flap/aortic
dissection. This flap extends to the abdominal aorta as far is
it can be visualized. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of study.
POST-CPBx1:
The patient is on a norepinephrine infusion. Biventricular
systolic function is preserved. The left ventricle appears
small, consistent with hypovolemic state. There is no residual
dissection in the aortic root. The aortic insufficiency remains
trace.
POST-CPBx2:
The patient is on norepinephrine and low dose epinephrine
infusions. Biventricular function remain unchanged. Estimated
LVEF is 55%. The left ventricle continues to appear small.
There is brightly echogenic material seen in the ascending
aorta, consistent with ascending tube graft. There is trivial
aortic insufficiency. The dissection flap is again visualized in
the distal arch and descending aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2145-11-18**] 18:11
Brief Hospital Course:
Mrs. [**Known lastname 98305**] presented with Ascending aortic dissection. She
was taken to the operating room emergently and underwent
replacement of ascending and hemiarch aorta with a 28 mm
Gelweave graft under hypothermic circulatory arrest with
selective antegrade cerebral perfusion with Dr.[**Last Name (STitle) **]. Cross clamp
time was 101 minutes +54 minutes. Pump time was 145 minutes +73
minutes. Deep hypothermic circulatory arrest time was 32
minutes. Selective antegrade cerebral perfusion was 26 minutes.
Please see operative report for further details. She weaned from
bypass on Epinephrine and Levophed. She was transferred to the
CVICU intubated and sedated in critical condition.
Postoperatively she was coagulopathic and required multiple
blood products. She returned to the Operating Room for
reexploratopn that night where bleeding from the distal
anastamosis was easily controlled. The chest was left open and
she returned to the ICU in stable condition.
She had increased ventilatory requirements initially and
aggressive diuresis was undertaken. She remained stable and
diuresed well. Her renal function remained stable and her
ventilation requirement decreased. She was kept intubated,
sedated and paralyzed.
On [**2145-11-22**] she returned to the Operating Room where the chest was
easily approximated and closed. Paralytics and versed and
Fentanyl were discontinued then and Propofol used for sedtion.
She remained hypertensive and Nicardipine was initiated. She
went into repid atrial fibrillation requiring cardioversion. She
weaned off Nicardipine and was started on
beta-blocker/Statin/Aspirin.
On [**2145-11-24**] Left internal jugular and right cephalic thrombus seen
on ultrasound. Vascular team was consulted and removal of the
left subclavian catheter, anticoagulation with heparin was
recommended along with transition to Coumadin. The length of
Coumadin anticoagulation should be 3 to 6 months.
Postoperatively Mrs.[**Known lastname 98305**] had worsening thrombocytopenia. She
tested positive for Heparin PF4 Antibody Test by [**Doctor First Name **]. Heparin
was discontinued. Argatraban drip was initiated and
anticoagulation with Coumadin continued. Her thrombocytopenia
improved.
She was slow to wean off the ventilator due to her acute on
chronic diastolic heart failure requiring aggressive diuresis
for pulmonary edema. Tube feeding was initiated for nutritional
support. POD#9 she successfully weaned to extubation. She
remains on nebulizers and diuresis. Her feeding tube was d/c'd
and she was able to take nutrition orally with encouragement.
The following day she was transferred to the step down unit for
further monitoring. Physical Therapy was consulted for
evaluation of her strength and mobility.
She had a persistent leukocytosis, remained afebrile and was
fully cultured. She had a positive urinary tract infection and
was placed on 7 day course of po cipro- she has 5 days remaining
at time of this discharge.
The remainder of her hospital course was essentially uneventful
and she remained slow to progress, requiring pulmonary hygiene.
On POD#16 she was cleared for discharge to [**Hospital1 10151**]. All appointments were advised.
At her follow up visit she will need an MRA or her torso to
evaluate her aorta to the level of her iliacs. She has a
questionable allergy to MRI contrast and will need appropraite
premeds prior to scan. The cardaic surgery office will call and
schedule the MRA.
Medications on Admission:
ALENDRONATE 70mg weekly,ALLOPURINOL 400mg daily,AMLODIPINE 5mg
daily,
AMMONIUM LACTATE - 12 % Lotion - apply to arms and legs
[**Hospital1 **],ATORVASTATIN 80mg daily,BUMETANIDE 1mg weekly prn,CITALOPRAM
20mg daily,FUROSEMIDE 40mg [**Hospital1 **],PANTOPRAZOLE40mg daily,POTASSIUM
CHLORIDE - 10 mEq Tablet daily,POTASSIUM CHLORIDE 10mEq 2 Tablet
Daily,ASPIRIN 81 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet 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. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
10. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: UTI.
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
13. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. warfarin 2.5 mg Tablet Sig: dose based on INR Tablet PO once
a day: indication AFIB
Goal INR 2.0-2.5
.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO twice a day.
16. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
17. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing:
when no longer needs nebs.
18. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
19. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Outpatient Lab Work
INR check on [**2145-12-5**] then everyother day until stable
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Type A aortic dissection
coronary artery disease
s/p grafting ascending aorta and hemiarch
s/p reoperation for bleeding
s/p closure of chest
s/p percutaneous coronary intervention
h/o congestive heart failure
hepatic cysts
h/o breat cancer
s/p left mastectomy
hypertension
thyroglossal duct cyst
osteoporosis
hiatal hernia
post-op afib
heparin induced thrombocytopenia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema: bilateral foot and ankle edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**12-30**] at 1:15pm in the [**Hospital **]
Medical office building [**Doctor First Name **] [**Hospital Unit Name **].
a follow up MRA will be ordered at your follow visit with Dr.
[**Last Name (STitle) **]
Cardiologist:Please have your PCP refer you to a Cardiologist
for follow up.
Please call to schedule appointments with:
Primary Care: Dr.[**First Name11 (Name Pattern1) 1169**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]in [**2-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2145-12-5**]
Results to; please arrange upon discharge from rehab.
Completed by:[**2145-12-4**] Name: [**Known lastname 15683**],[**Known firstname 1940**] N Unit No: [**Numeric Identifier 15684**]
Admission Date: [**2145-11-18**] Discharge Date: [**2145-12-4**]
Date of Birth: [**2069-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing / Heparin Agents
Attending:[**First Name3 (LF) 135**]
Addendum:
Mrs [**Known lastname **] was also discharged on 10 units of lantus daily and
sliding scale insulin per fingerstick.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2145-12-4**]
|
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"453.84",
"428.0",
"553.3",
"274.9",
"289.84",
"530.81",
"401.9",
"427.31",
"443.29",
"453.86",
"443.21",
"441.03",
"998.11",
"V45.82",
"287.5",
"599.0",
"715.36",
"428.33",
"E878.2",
"733.00",
"V10.3",
"414.01",
"V45.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.79",
"35.11",
"39.61",
"96.6",
"96.72",
"38.45",
"34.03",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
14361, 14584
|
5495, 8965
|
328, 479
|
11747, 11950
|
2025, 2449
|
12875, 14338
|
1297, 1342
|
9389, 11245
|
2489, 2534
|
11355, 11726
|
8991, 9366
|
11974, 12852
|
1357, 2006
|
271, 290
|
2566, 5472
|
507, 771
|
793, 1038
|
1054, 1281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,761
| 159,216
|
51912
|
Discharge summary
|
report
|
Admission Date: [**2150-7-16**] Discharge Date: [**2150-7-24**]
Date of Birth: [**2089-11-18**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Sulfonamides / Macrodantin / Levofloxacin / Penicillins
/ Clindamycin / Protonix / Cephalosporins / Erythromycin Base /
Biaxin / Ciprofloxacin / Tetracycline / Flagyl / Triple
Antibiotic / Betadine / Ivp Dye, Iodine Containing / Atropine /
Latex / Morphine / Codeine / Imodium A-D / Demerol / Tape /
Linezolid / Percocet
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Tooth pain
Major Surgical or Invasive Procedure:
Multiple teeth extraction.
History of Present Illness:
This is a 60-year-old female with a history of IGG subclass
deficiency, multiple drug allergies who was referred to the ED
with 2 dental abscesses. Patient went to her dentist on [**7-15**] and
via xray was diagnosed with tooth abscesses which require
antibiotics and extraction.
.
In the ED vitals at presentation were: T 98.8, HR 77, BP 122/63,
RR 16, O2Sat 98% RA. Patient received 2 L fluid in preparation
for receiving Vancomycin, which has causing diuresed and renal
failure in the past. Patient was not started on a carbapenem and
Vancomycin in the ED; however, this was communicated to them by
patient's primary care physician as the preferred regimen prior
to her anticipated oral surgery. ED reported that patient's PCP
arranged for oral surgery to be performed on [**7-17**]. Patient
received blood cultures and Panorex dental films in the ED.
Prior to transfer to floor, vitals were: T 97.8, HR 57, BP
122/74, RR 16, 100% RA.
.
Upon arrival to the floor the patient was comfortable and
reported minimal tooth pain.
.
REVIEW OF SYSTEMS:
(+)ve: Tooth pain, chills, loss of appetite, nausea, sore
throat, internal hemorrhoids
(-)ve: fever, blurry vision, headaches, cough, sputum
production, hemoptysis, chest pain, dyspnea, vomiting, diarrhea,
constipation, hematochezia, melena
Past Medical History:
++Hyperfibrinolysis syndrome
++ IgG subclass deficiency
++ MSSA skin abscesses/cellulitis
- buttocks, thighs, labia, arms, x5 at least
- per patient, due to "CVID"
- prior immunodeficiency evaluation (Dr. [**Last Name (STitle) 2603**] et [**Doctor Last Name **])
demonstrated:
* HIV negative
* nitroblue tetrazolium negative
* T cell subsets wnl
* Mild deficiency of IgG 2, IgG 3
- Last visit w/ Dr. [**Last Name (STitle) 2603**] [**2149-8-12**]; planned future food/environ
skin testing
- prior decolonization with bactroban (intense pruritis) +
Hibiclens
- describes prior at-home desensitization with PCN orally,
tolerated desensitization
++ Uterine cancer
- total abdominal hysterectomy [**2124**]
++ Anal squamous cell cancer
- resections [**2133**], [**2135**], [**2137**]
- no chemo/XRT
++ Breast cancer, right breast
- DCIS s/p resection [**11/2147**]; adjuvant radiation
- grade II; T1bN0M0; ER/PR positive, HER2/neu negative
- [**Year (4 digits) 500**] scan [**5-/2149**] negative for disease
- intolerant to Arimidex, Femara, tamoxifen
- has not tried (does not want): Aromasin, Faslodex, raloxifene
++ C. diff in distant past
++ HSV; "cold sores"
++ Irritable bowel syndrome
++ Depression/chronic fatigue/fibromyalgia
++ Bleeding diathesis? Hyperfibrinolysis syndrome?
++ Osteoporosis
++ s/p excision of R-side of thyroid
++ Deviated septum repair
++ Wrist ganglion removal
++ Hemorrhoids
Social History:
Former nurse (worked until [**2134**]). Currently [**Year (4 digits) 107468**] secondary
to chronic fatigue and multiple allergies. No history of tobacco
or IVDA; occasional alcohol use. Lives w/ a roommate. No
children or other family contacts.
Family History:
Father - multiple myeloma, died age 83
Mother - living, age 87; atrial fibrillation
Brother - arthritis
Sister - arthritis
[**Name2 (NI) **] children
No family history of significant allergic or infectious
conditions: according to the patient, IgG subclass deficiency
and hyperfibrionlysis all started 2 years ago.
Physical Exam:
VS: T 98.6, BP 130/74, HR 56, RR 16, O2Sat 99% RA
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa moist, poor dentition, no
visible inflammation of gingiva
NECK: Supple, no [**Doctor First Name **]
PULM: CTAB
CARD: RR, nl S1, nl S2, nl M/R/G
ABD: Obese, BS+, soft, NT, ND
EXT: no c/c/e
SKIN: No rashes
NEURO: Oriented x 3, non-focal
PSYCH: Patient worried about condition; wearing a purple shower
cap.
Pertinent Results:
[**2150-7-16**] 05:55PM GLUCOSE-94 UREA N-20 CREAT-1.2* SODIUM-143
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15
[**2150-7-16**] 05:55PM estGFR-Using this
[**2150-7-16**] 05:55PM WBC-6.5 RBC-4.38 HGB-13.0 HCT-40.5 MCV-93
MCH-29.8 MCHC-32.2 RDW-13.4
[**2150-7-16**] 05:55PM NEUTS-71.3* LYMPHS-24.6 MONOS-3.2 EOS-0.4
BASOS-0.5
[**2150-7-16**] 05:55PM PLT COUNT-176
[**2150-7-16**] 05:55PM PT-11.6 PTT-24.9 INR(PT)-1.0
Panorex:
Single Panorex image obtained. Several teeth are missing. There
is an impacted right molar tooth. No definite evidence of bony
erosion is
seen. The mandible appears intact.
Brief Hospital Course:
Ms. [**Known firstname 11894**] [**Known lastname 10029**] is a 60-year-old woman with a pmhx of breast
cancer, IgG deficiency, and hyperfibrinolysis syndrome who
presented to the [**Hospital1 18**] ED with a tooth abscess. Due to Ms.
[**Known lastname **] numerous allergies to medication, it was necessary for
her to receive IV antibiotics for the abscess; moreover, in
light of her bleeding disorder, it was best that she be
evaluated for oral surgery in an inpatient setting.
.
Tooth abscess/infection: Ms. [**Known lastname **] was discovered to have tooth
abscesses on XRAY at her dentist's office; she has suffered from
poor dentition for a long time. Ms. [**Known lastname **] dentist recommended
that she have her teeth extracted as well as receive antibiotics
for the infection. However, due to Ms. [**Known lastname **] multiple drug
allergies, she was unable to take any appropriate medications by
mouth. (Of note, her allergies are all severe, ranging from
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Syndrome to anaphylaxis). Patient was admitted
to the hospital and started on vanc and gent; she was
pre-medicated with benadryl and hydrated with IVF prior to vanc
administration due to prior minor side effects and a tendency to
self-diureis. Patient had no serious adverse effects from this
regimen and her creatinine remained normal despite gent
administration. ID was consulted early on in hospital admission
and recommended starting flagyl for anearobic coverage.
However, as patient had had reactions to flagyl in the past, she
was transferred to the MICU were she was placed on a special
desensitization protocol for flagyl. She did well and was
transferred back to the floor.
.
Patient eventually had her teeth extracted by oral surgeon Dr.
[**Last Name (STitle) 2866**] on [**7-19**]. She received Amicar during surgery as bleeding
prophylaxis due to hyperfibrinolysis syndrome; however, after
surgery, patient appeared to be bleeding excessively (she kept
complaining of blood dripping down her throat) and she was
transferred to the MICU for observation on the night of [**7-19**].
She was readmitted to the floor on [**7-20**] in stable condition.
She was continued on IV vanc, gent, and flagyl for 5 more days
until [**7-23**]. Again, she had minor side effects wtih these
antibiotics (coughing, itchy eyes, auto-diuresis) but nothing
life-threatening. Patient had some bleeding and bruising but
hct remained stable throughout admission. She was eventually
transitioned to oral amicar; however, she was was not sent home
on this medication. Patient was discharged home in stable
condition; she was exhausted from her lengthy hospital stay and
still recovering from the oral surgery, but Ms. [**Known lastname 10029**] was doing
well overall.
.
Hyperfibrinolysis syndrome: Patient is followed at the heme/onc
clinic at [**Hospital1 18**]. She has been seen in the past by Dr. [**Last Name (STitle) 2805**].
.
IgG: Patient is managed by heme/onc and her PCP for this
condition. Her PCP is considering referring Ms. [**Known lastname 10029**] to an
allergist for allergen testing as an outpatient.
.
Nutrition: Ms. [**Known lastname 10029**] was able to eat a dairy/wheat/soy-free
diet prior to teeth extraction. Afterward, her diet was slowly
advanced from NPO to sips to soft foods. She preferred eating
jars of baby food in the hospital. She was encouraged to
advance her diet at home.
.
Additional information: declined bowel regimen even though one
was ordered for her (she actually had numerous bowel movements
with the oral flagyl). She was allergic to heparin and
eventually agreed to wear pneumatic boots Ms. [**Known lastname 10029**] was
discharged home in stable condition and scheduled for follow-up
appointments. She was instructed to contact her PCP or return
to the [**Name (NI) **] if she started bleeding, continued to feel pain in
mouth or gums, or had signs/symptoms of an allergic reaction.
Patient also states that she has had some "thyroid problems" and
will follow up with her outpatient physicians for this issue.
Medications on Admission:
Clonazepam 1 mg Tablet 1 Tablet(s) by mouth at bedtime
Mupirocin Calcium [Bactroban] 2 % Cream one three times a day 4)
Raloxifene [Evista] 60 mg Tablet 1 Tablet(s) by mouth once a day
Retapamulin [Altabax] 1 % Ointment
Calcium Carbonate 500 mg (1,250 mg) Tablet 1 Tablet(s) by mouth
twice a day (OTC)
Cholecalciferol (Vitamin D3) 400 unit Capsule
Tolnaftate [Tinactin] 1 % Powder apply to feet daily
Vitamin K
Darvocet N-100
Discharge Medications:
1. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**11-28**]
Tablets PO Q6H (every 6 hours) as needed for pain.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
6. Darvocet-N 100 100-650 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for pain for 10 days.
Disp:*1 40* Refills:*0*
7. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea for 5 days.
Disp:*1 20* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Tooth abscess s/p tooth extraction
Discharge Condition:
Stable.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you on this admission. You
were admitted with an abscess in your mouth for which you
required IV antibiotics. You were given vancomycin and
gentamycin without any serious side-effects. You were
subsequently transferred to the intensive care unit so that you
could be de-sensitized to flagyl; you were able to tolerate the
flagyl well.
.
You were taken to the operating room by Dr. [**Last Name (STitle) 2866**] of oral
surgery who removed your teeth. You were given Amicar at that
time to prevent excessive bleeding due to your hyperfibrionlysis
syndrome. After your operation you were observed in the
intensive care unit overnight and then you were transferred to
the floor.
.
You were kept on all three antibiotics for 5 days, including the
day of your sugery. You did experience side-effects from the
medications, but none were severe or life-threatening. A PICC
line was placed so that infusions could be given more easily.
We kept you on the Amicar to prevent excessive bleeding. You
were able to tolerate solid foods on discharge.
.
We gave you ativan 0.5mg every 6 hours for nausea. We also gave
you a prescription for Darvocet that you can take every 6 hours
as needed for pain. Do not drive or use machinery when taking
these medications.
.
Please keep all of your scheduled appointments.
.
Please return to the hospital if you experience any bleeding,
fevers/chills/sweats, profuse diarrhea, pain in your mouth or
gums, chest pain, shortness of breath, or any other pain or
discomfort.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] on [**2150-8-5**] 3:50
Please call your regular dentist to schedule routine followup.
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-9-29**] 3:30
Provider: [**Name Initial (NameIs) 703**] (H3) [**Doctor Last Name 5034**] THYROID [**Doctor Last Name 706**] Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2151-1-12**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2151-1-26**] 4:00
|
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32,193
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9400
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Discharge summary
|
report
|
Admission Date: [**2162-6-13**] Discharge Date: [**2162-6-25**]
Date of Birth: [**2096-5-8**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Atenolol
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
angiography
Colonoscopy with biopsies
History of Present Illness:
Ms. [**Known lastname 32090**] is a 66 yo female with a h/o CAD s/p CABG, PVD,
afib/flutter on coumadin, ASA, plavix who presents with BRBPR
since yesterday afternoon. Patient was transferred from The
[**Hospital3 2558**] following two episodes of bright red blood that
filled the toilet bowl. Per transfer note, BP dropped from
139/69 to 100/65 and patient reported feeling dizzy at time of
transfer.
Of note, patient was recently discharged from [**Hospital1 18**] following
hospitalization for ulcer/cellulitis of the right foot
complicated by atrial flutter. She underwent LE angiography
which revealed total occlusion of the right DP at the site of
the previous PTA. This lesion was not amenable to intervention.
Hospital also started on coumadin for afib/aflutter prior to
discharge.
On arrival to ED, T 98.4, HR 65, BP 105/70. Hematocrit was 29.8,
unchanged from 29.6 on day of discharge [**6-4**]. She received
Vitamin K 5 mg SC x 1. She had an episode of right-side chest
pain and pressure that did not radiate. Chest pain resolved with
Morphine 1 mg IV. She had one episode of maroon stool in the ED.
NG lavage was attempted but was not successful. GI consult was
called and recommended admission to the MICU.
Past Medical History:
4V CABG '[**51**]
C. diff colitis, toxin positive, in the absence of diarrhea
DM with peripheral neuropathy
CKD, stage IV, baseline creatinine 1.8
COPD on 3L home O2 (non compliant)
OSA
Morbid obesity
PVD s/p angioplasty of anterior tibial artery ([**9-12**]), s/p
angioplasty of right dorsal pedis ([**11-12**])
s/p L5 amp & [**4-10**] metatarsal head resections
GIB from PUD
Chronic anemia (baseline ~ 32)
Afib/flutter s/p multiple cardioversions '[**55**]/'[**56**]
Hypothyroidism
Asthmatic bronchitis
Sciatica
Vertigo
MRSA hx
Dyslipidemia
Hypertension
Social History:
Quit smoking 20 years ago; no current alcohol abuse; son died at
[**Hospital1 18**]; patient had been making progress with PT at [**Hospital 7137**]
Family History:
DM, died of breast CA at age 60; sister: died at 60 of
glioblastoma; father: died of lung ca at 73; and sister: died at
60 of heart disease
Physical Exam:
VS: T 98.2, HR 109, BP 134/67, RR, SpO2 98% on RA
Gen: Obese, pale, elderly female, NAD. Oriented x3.
HEENT: MMM, sclera anicteric, clear OP.
Neck: Supple, no JVD.
CV: regular rhythm, no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations unlabored, no accessory muscle use. CTAB but
decreased air movement, no crackles, wheezes or rhonchi.
Abd: Obese, soft, NTND. No HSM or tenderness. Distended abdomen.
Abd
aorta not enlarged by palpation. No abdominial bruits.
Extrem: Edema to BLE, with chronic skin changes. Gangrenous
first toe of right foot.
Pertinent Results:
Labs during hospital course:
[**2162-6-13**] 02:50AM BLOOD WBC-10.2# RBC-3.65* Hgb-9.6* Hct-29.8*
MCV-82 MCH-26.3* MCHC-32.2 RDW-14.6 Plt Ct-222#
[**2162-6-13**] 09:45PM BLOOD WBC-3.1*# RBC-2.04*# Hgb-5.6*# Hct-16.6*
MCV-82 MCH-27.5 MCHC-33.8 RDW-15.0 Plt Ct-133*
[**2162-6-14**] 10:31AM BLOOD Hct-29.7*#
[**2162-6-25**] 04:50AM BLOOD WBC-4.2 RBC-3.73* Hgb-10.5* Hct-31.7*
MCV-85 MCH-28.0 MCHC-33.0 RDW-16.4* Plt Ct-162
[**2162-6-13**] 02:50AM BLOOD PT-29.3* PTT-39.3* INR(PT)-3.0*
[**2162-6-17**] 05:00AM BLOOD PT-15.3* PTT-28.5 INR(PT)-1.3*
[**2162-6-25**] 04:50AM BLOOD PT-14.4* PTT-31.2 INR(PT)-1.3*
[**2162-6-13**] 02:50AM BLOOD Glucose-157* UreaN-57* Creat-2.1* Na-139
K-5.8* Cl-105 HCO3-26 AnGap-14
[**2162-6-18**] 05:00AM BLOOD Glucose-102 UreaN-22* Creat-1.4* Na-142
K-4.3 Cl-104 HCO3-33* AnGap-9
[**2162-6-25**] 04:50AM BLOOD Glucose-125* UreaN-42* Creat-2.4* Na-138
K-4.2 Cl-94* HCO3-33* AnGap-15
[**2162-6-13**] 05:40AM BLOOD CK(CPK)-654*
[**2162-6-13**] 12:57PM BLOOD CK(CPK)-27
[**2162-6-15**] 07:09AM BLOOD CK(CPK)-30
[**2162-6-13**] 05:40AM BLOOD cTropnT-0.03*
[**2162-6-13**] 12:57PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2162-6-15**] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2162-6-14**] 12:33AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.3
[**2162-6-24**] 04:50AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.2
[**2162-6-15**] 07:09AM BLOOD TSH-5.0*
[**2162-6-15**] 07:09AM BLOOD Free T4-1.5
Tagged RBC scan [**2162-6-13**]:
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 45 minutes were obtained. A left anterior oblique
view of the pelvis was also obtained. Blood flow images show no
abnormalities. Dynamic blood pool images show tracer
extravasation in the right lower quadrant with movement both
laterally across the abdomen and superiorly. Bleeding was first
noticed at 2 minutes.
CXR [**2162-6-13**]: The moderate cardiomegaly is unchanged. The multiple
fractures in the post sternotomy wires as well as the severe
displacement is unchanged as well. There is no pleural effusion
or pneumothorax. The lungs are clear.
Angiography [**2162-6-13**]:
1. Normal angiogram of the superior mesenteric artery and
inferior mesenteric artery with no signs of active bleeding,
vascular malformation, or pseudoaneurysm.
2. Atherosclerotic disease within the [**Female First Name (un) 899**].
CXR [**6-15**]:
O2 requirements, evaluation for interval change. Unchanged
aspect of the multiple fractures in the sternotomy wires. There
might be a newly occurred minimal left-sided pleural effusion,
although apparent blunting
of the left costophrenic sinus might also be caused by a
different patient rotation. The right sinus is clear. Despite
moderate enlargement of the cardiac silhouette, no signs
indicative of overhydration is seen. There is no evidence of
focal parenchymal opacity suggestive of pneumonia.
Colonoscopy [**2162-6-16**]:
Diverticulosis of the sigmoid colon
5cm segment of ucleration erythema and friability at the hepatic
flexure with smaller area of ulceration distally (biopsy)
Polyp in the sigmoid colon
Otherwise normal colonoscopy to terminal ileum
Additional notes: Despite the findings on the previous taggged
RBC scan, the bleeding site is clearly the lesion noted at the
hepatic flexure. The cecum and TI were completely normal without
fresh or old blood. The differential for the lesion includes
ischemic colitis and possibly neoplasm. Further management
depends on biopsy findings. If the biopsy does NOT show
neoplasm, recommend repeat colonoscopy in [**3-11**] months to reassess
the area.
Mucosal colon biopsies [**6-16**]:
A. Hepatic flexure:
Fragments of colonic mucosa with ulceration and acute
inflammation.
Note: Some fragments show ulceration with acute
inflammation/granulation tissue. Others are more intact showing
limited abnormality. No dysplasia or granulomas identified;
findings could represent ischemic changes, but inflammatory
bowel disease cannot be ruled out.
B. Transverse:
Colonic mucosa, with chronic changes (crypt branching and
irregularity).
b/l LE Dopplers [**6-20**]: No evidence of DVT.
Brief Hospital Course:
Ms. [**Known lastname 32090**] is a 66-year-old woman with history of coronary
artery disease s/p 4-vessel CABG, peripheral vascular disease,
atrial fibrillation/atrial flutter on warfarin, who presented
with bright red blood per rectum for one day.
# Gastrointestinal bleed:
Patient has chronically guaiac-positive stool and was recently
started on warfarin. She has a history of gastrointestinal
bleeding secondary to peptic ulcer disease. A colonoscopy in
[**2158**] revealed sigmoid diverticulosis and internal hemorrhoids.
Shortly after admission, her hematocrit dropped from 29 to 21;
her Hct nadir was 16. Her aspirin, clopidogrel, and warfarin
were held, as were her anti-hypertensives. In the MICU, she
received 7 units of pRBCs, 7 units of FFP, 2 bags of platelets.
She still had dark red stools. Her hematocrit was stable in the
low 30s on transfer out of the MICU.
A tagged RBC scan revealed terminal ileum bleed, though
angiographic study on [**2162-6-13**] was negative. Colonoscopy on [**6-16**]
revealed a 5cm ulcerated lesion that was biopsied. Biopsy
showed inflammatory changes that could be due to ischemia,
although inflammatory bowel disease could not be ruled out. She
was scheduled for repeat outpatient colonoscopy.
At the time of discharge, her hematocrit had been stable for a
week without evidence of further bleeding. Her aspirin was
restarted. At some point in the future, she will likely benefit
from restarting coumadin given her risk for stroke. It was not
felt to be safe to have her on 3 different blood thinners at
once.
# Acute on Chronic diastolic heart failure:
Patient was noted to have crackles on exam, increased LE edema,
and a new oxygen requirement in setting of holding her diuretics
and receiving transfusions with pRBCs, platelets, and FFP. Once
her GI bleed had stabilized, she was diuresed with IV lasix gtt
with resolution of oxygen requirement. She continued to have LE
edema at the time of discharge; this edema had been present for
years. She was sent home on 120mg of lasix [**Hospital1 **].
# Coronary artery disease:
Patient is status post 4-vessel CABG. Although she reported
chest pain in the ED in the setting of GI bleed, her troponin
was negative x 3. Her initial CK was elevated in the 600s but
quickly trended down to the 20s. Her anticoagulants were held
after discussion with her cardiologist, Dr. [**Last Name (STitle) **]. She was
continued on the home dose of simvastatin. Aspirin was
restarted at discharge.
# Peripheral vascular disease:
Patient is status post left tibial artery and right dorsal pedis
angioplasty in [**2161**], also s/p previous toe amputation. Another
angiography was performed during recent hospitalization, without
intervention. Her anticoagulants were held. Her toe wound was
dressed with xeroform and sterile dry gauze. Although she had
some mild erythema of her left lower extremity, this was not
felt to be cellulitis and antibiotics were not given, especially
in light of her recent treatment for C diff.
# Atrial fibrillation/atrial flutter:
Rate controlled with metoprolol XL and diltiazem at home. She
was also recently started on warfarin on recent admission in [**Month (only) 116**]
[**2162**]. Her anticoagulants, metoprolol, and diltiazem were held
initially. At the time of discharge, her metoprolol had been
restarted. Diltiazem and coumadin were still held, although she
would likely benefit from coumadin in the future given her risk
of stroke.
# Diabetes:
She was continued on her home regimen of 70/30 50 units qAM, 15
units qPM and was given an insulin sliding scale as well.
# Hypertension:
Stable blood pressures despite being off metoprolol, diltiazem,
nitrate, and benicar which were held in the setting of
gastrointestinal bleeding. Her metoprolol had been restarted,
but her other antihypertensives were still held at the time of
discharge.
# Acute renal failure on Chronic renal insufficiency:
Patient has stage-IV chronic kidney disease with baseline
creatinine of 1.4-1.8. Her creatinine was 2.1 on admission then
trended down to 1.4 after fluid and blood infusion. She received
peri-angiography HCO3 infusion and N-acetylcysteine. Her
creatinine remained stable at 1.8 until she was started on IV
lasix for diuresis. When her creatinine increased to 2.4, she
was switched to oral lasix and discharged home. Her creatinine
should be rechecked by her providers as an outpatient. Sometime
in the future, her benicar should be restarted.
# Hypothyroidism: continued on levothyroxine.
# Code status: full code.
Medications on Admission:
Levothyroxine 100 mcg daily
Quinine sulfate 324 mg qHS
Plavix 75 mg daily
Tolterodine 4 mg daily
Simvastatin 40 mg daily
ASA 325 mg daily
Isosorbide SR 90 mg daily
Toprol XL 25 mg daily
Omega-3 fatty acids 1000 mg PO BID
Hexavitamin PO daily
Bupoprion SR 150 mg qAM
Pantoprazole 40 mg daily
Diltiazem SR 180 mg daily
NPH 50 units qAM, 15 units qPM
Lasix 80 mg [**Hospital1 **]
Metolazone 5 mg daily
Benicar 20 mg daily
Tylenol PRN
Flagyl 500 mg TID (end date [**6-13**])
Coumadin 5 mg daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
3. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. 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*
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
10. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Forty Five (45) units Subcutaneous every morning.
Disp:*1 vial* Refills:*2*
11. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Seven (7) units Subcutaneous at bedtime.
12. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
14. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
twice a day.
Discharge Disposition:
Home with Service
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis: Lower GI bleed
Secondary Diagnoses: Peripheral vascular disease, Acute on
chronic diastolic heart failure, Acute on chronic renal
insufficiency, Coronary artery disease, Atrial fibrillation,
Diabetes
Discharge Condition:
No further evidence of GI bleed, hemodynamically stable.
Discharge Instructions:
You were admitted with bleeding from you large intestine. You
were treated in the ICU and your bleed stopped. You were then
given lasix to remove your extra fluid.
1. Please take all medications as prescribed.
Medication changes:
- you can take 81mg of aspirin a day
- increased lasix to 120mg twice a day
- changed your NPH insulin to 45 units in the morning and 7
units in the morning
- increased your toprol XL to 50mg daily
- stopped your coumadin and plavix
- stopped imdur (isosorbide), benicar, and diltiazem
2. Please attend all follow-up appointments listed below.
3. Please call your doctor or return to the hospital if you
develop chest pain, shortness of breath, fevers, palpitations,
bloody or black stools, lightheadedness, or any other concerning
symptom.
4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Monday [**6-28**] at 1:15pm
at [**Location (un) **].
You have an appointment with podiatry:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2162-7-8**] 2:30
You have a colonoscopy scheduled. Please go to the [**Hospital Ward Name **]
of [**Hospital3 **] at [**Location (un) **]. You will get a phone call
at home with instructions as to how to prepare for the
colonoscopy since you will need to drink a fluid that will clean
out your bowels.
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 6044**] (ST-3) GI ROOMS Date/Time:[**2162-7-30**] 10:30
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2162-7-30**] 10:30.
Completed by:[**2162-7-13**]
|
[
"414.00",
"244.9",
"562.10",
"250.60",
"428.33",
"584.9",
"427.32",
"578.9",
"357.2",
"V45.81",
"428.0",
"403.90",
"585.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
14125, 14199
|
7305, 11876
|
312, 352
|
14464, 14523
|
3129, 3141
|
15479, 16394
|
2364, 2507
|
12417, 14102
|
14220, 14220
|
11902, 12394
|
3158, 7282
|
14547, 14761
|
2522, 3110
|
14277, 14443
|
14781, 15456
|
245, 274
|
380, 1603
|
14240, 14255
|
1625, 2182
|
2198, 2348
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,231
| 196,617
|
9015
|
Discharge summary
|
report
|
Admission Date: [**2185-11-15**] Discharge Date: [**2185-11-21**]
Date of Birth: [**2108-3-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
[**2185-11-15**] Coronary Artery Bypass Grafting x4 (left internal
mammary artery to left anterior descending artery with vein
grafts to diagonal, obtuse marginal and PDA)
History of Present Illness:
This 77 year old male presents with approximately 6 months of
recurrent chest pressure. He is very vague with regards to his
symptoms and precipitating factors. He does describe chest
pressure that radiates to his left arm along with some shortness
of breath. He has undergone Coronary angioplasty in the past.
He denies nausea, lightheadedness, and palpitations. He states
these episodes can occur with exertion but also with rest when
he is just watching TV. He is not bothered much by this. He
states it can last for only moments but other times as long as
20-30 minutes. He is unable to quantify the frequency. He does
not use nitroglycerin and the symptoms resolve with time.
Further evaluation prompted a nuclear stress test which was
positive for inferior ischemia. Catheterization showed severe
coronary artery disease and referred for revascularization.
Past Medical History:
Ccoronary artery disease
s/p coronary angioplasty 10 years ago
s/p cataract surgery
s/p detached retina- s/p laser surgery
hypertension
hyperlipidemia
hernia repair
diabetes-diet controlled
s/p carotid endarterectomy
Social History:
wife recently died
Family History:
father died at age 52 of coronary disease
Physical Exam:
Admission:
Pulse: 60 reg Resp: O2 sat:
B/P Right: 155/75 Left: 153/83
Height: 5'6" Weight: 210 #
General:NAD
Skin: Dry [x] intact [x] raised rash on chest, right neck and
some areas of arms and upper abdomen
HEENT: PERRLA [x] EOMI [x]injected conjunctiva; OP
unremarkable;ptosis of both upper lids
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+
[x]; some pinpoint areas of tenderness RUQ, LLQ, and at midline;
obese; no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema - 1+ BLE
Varicosities: None [x]
Neuro: Grossly intact;MAE [**4-19**] strengths, nonfocal exam
Pulses:
Femoral Right: 1+, ecchymotic post cath Left: trace
DP Right: NP Left: NP
PT [**Name (NI) 167**]: 1+ Left: trace
Radial Right: 1+ Left: 1+
Carotid Bruit -none appreciated
Pertinent Results:
[**2185-11-15**] ECHO
Pre-bypass:
The left atrium is elongated. 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. Overall
left ventricular systolic function is mildly depressed (LVEF= 40
%). with borderline normal free wall function. There are complex
(>4mm) atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-17**]+) mitral regurgitation
is seen. There is a trivial/physiologic pericardial effusion.
Post-bypass:
The patient is not receiving inotropic support post-CPB.
Biventricular systolic function is unchanged from pre-bypass
findings. All other findings are consistent with pre-bypass
findings. The aorta is intact post-decannulation. All findings
communicated to the surgeon
[**2185-11-18**] 01:00AM BLOOD WBC-8.8 RBC-2.91* Hgb-9.7* Hct-28.3*
MCV-97 MCH-33.2* MCHC-34.2 RDW-14.6 Plt Ct-167
[**2185-11-17**] 05:14AM BLOOD WBC-9.1 RBC-3.08* Hgb-9.8* Hct-29.3*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.0 Plt Ct-164
[**2185-11-18**] 01:00AM BLOOD Glucose-147* UreaN-17 Creat-0.8 Na-138
K-4.3 Cl-101 HCO3-31 AnGap-10
[**2185-11-17**] 05:14AM BLOOD Glucose-136* UreaN-16 Creat-0.7 Na-138
K-4.4 Cl-103 HCO3-29 AnGap-10
[**2185-11-18**] 01:00AM BLOOD WBC-8.8 RBC-2.91* Hgb-9.7* Hct-28.3*
MCV-97 MCH-33.2* MCHC-34.2 RDW-14.6 Plt Ct-167
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2185-11-15**] for surgical
management of his coronary artery disease. He was taken to the
Operating Room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next 24 hours, he awoke neurologically
intact and was extubated.
Beta blockade, aspirin and a statin were resumed. On
postoperativeday one, he was transferred to the step down unit
for further recovery. Mr. [**Known lastname **] was gently diuresed towards his
preoperative weight and will continue diuresis after discharge
from acute care towards his baseline weight. The Physical
Therapy service was consulted for assistance with his
postoperative strength and mobility.
He developed rapid atrial fibrillation on POD 3 which responded
to IV Amiodarone and converted to sinus rhythm. He was
subsequently changed to oral Amiodarone which will continue for
a month. Arrangements were made for followup after discharge.
He was ambulatory with wheel chair support and very limited
strength. A stay at a rehabilitation facility is necessary pior
to returning home. He was alert and oriented and
hemodynamically stable.
Medications, follow up care and restrictions were discussed
prior to leaving the hospital.
Medications on Admission:
Plavix 75mg tablet daily (last dose [**10-20**])
Aspirin 325mg tablet daily
Multivitamin 1 tablet daily
Nitroglycerin 0.4mg table PRN
Restasis 0.05% Dropperette 1 drop OU [**Hospital1 **]
Metoprolol 50mg tablet [**Hospital1 **]
Omeprazole 20mg capsule daily
Simvastatin 40mg tablet daily
Vitamin C 500 mg daily
Vitamin E 400 units daily
Vitamin D 100 units daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] ().
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 4 weeks.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
13. Amiodarone 200 mg Tablet Sig: as directed Tablet PO twice a
day for 4 weeks: 400mg(2 tabs) twice daily for a week then
200mg(1 tab)for 3 weeks.
Disp:*70 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] rehab and skilled care
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafts
s/p carotid endarterectomy
Hypertension
Hyperlipidemia
Diabetes - diet controlled
Discharge Condition:
Mental Status: Clear and coherent, Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 170**]): [**2185-12-22**] at 1:00 pm
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**1-18**] weeks )[**Telephone/Fax (1) 8725**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks([**Telephone/Fax (1) **]) Your nurse [**First Name (Titles) **] [**Last Name (Titles) 10542**]e the appointment
Completed by:[**2185-11-21**]
|
[
"327.23",
"278.01",
"276.6",
"518.0",
"272.0",
"427.31",
"V12.72",
"V45.82",
"E878.2",
"V85.32",
"250.00",
"411.1",
"414.01",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7461, 7527
|
4275, 5654
|
304, 478
|
7711, 7711
|
2687, 4252
|
8352, 8804
|
1671, 1714
|
6067, 7438
|
7548, 7690
|
5680, 6044
|
7836, 8329
|
1729, 2668
|
241, 266
|
506, 1376
|
7726, 7812
|
1398, 1618
|
1634, 1655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,539
| 103,121
|
878
|
Discharge summary
|
report
|
Admission Date: [**2169-4-5**] Discharge Date: [**2169-4-16**]
Date of Birth: [**2125-10-11**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Penicillins / Codeine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43F H/O IPF, COPD/Asthma (Multiple Intubations), Current
Smoking, Schizoaffective Disorder/Depression with URI symptoms
and dyspnea. Patient was well until about one week ago when she
developed rhinorrhea, productive cough of yellow sputum, chills,
fevers, mild right ear pain, fatigue and then increased dyspnea,
PND, orthopnea and decreased exercise tolerance. There was no
rash, headache, sore throat, nausea, vomiting, diarrhea,
constipation, chest pain, leg pain, but has chronic mild
swelling. She saw her PCP and had mild improvement with
nebulizers. Her symptoms then worsened and she called EMS.
ED Course: Afebrile. OS85%RA. Peak flow at 250 (baseline of
350). CXR showing perihilar haziness with asymmetric hilar
fullness and no definite infiltrate. Started on Levofloxacin,
Nebs and admitted to Medicine.
Past Medical History:
1. IPF: DIP, transthoracic lung bx ([**2166**]) negative
2. COPD/Asthma: Spirometry ([**5-/2164**]) FVC 2.48 (67%), FEV1 1.96
(68%), FEV1/FVC 101%, DLCO ([**4-/2163**]) 51%, Lung vol ([**4-/2163**]): TLC 64%,
FRC 48%, RV 49%, ERV 47%, multiple admissions, intubation x 1
[**2163**]
3. Current Smoking
4. Schizoaffective Disorder (VH/AH/Paranoia/Olfactory
Hallucinations)
5. Depression
6. H/O Heavy ETOH Use and DTs
7. TLE (Most Recent Sz five years ago)
8. H/O VRE/MRSA
9. PPD Positive S/P INH
10. H/O Meningitis
11. S/P Ex Lap
12. Hyperlipidemia
13. DM
Social History:
She lives alone and is a jewlery maker. She currently smokes and
has 30 pack-years. She is detemited to quit smoking today. She
used marijuana, cocaine and LSD as a teenager but has not used
drugs since then. She rarely drinks ETOH.
Family History:
No lung or known autoimmune disease (such as SLE, Rh or
Sjogrens). Her father and mother died from MIs at ages 55 and
63, resp. Her siblings had MIs in their 40s.
Physical Exam:
T100.3 HR115 BP144/69 OS95%2L.
GEN - NAD. SPEAKING IN FULL SENTENCES. EATING.
HEENT - MMM. CLEAR OP. ANICTERIC.
RESP - B/L EXP WHEEZES WITH POOR AIR MOVEMENT. Improving with
peak flows > 300 and minimal wheezes by discharge.
CV - TACHY AND REGULAR. NML S1/S2. NO MGR.
ABD - S/NT/ND. POS BS.
EXT - TRACE PEDAL EDEMA.
NEURO - A&OX3. CNII-XII GROSSLY INTACT. STRENGTH AND [**Last Name (un) **] TO LT
INTACT THROUGHOUT.
Pertinent Results:
[**2169-4-16**] 07:00AM BLOOD WBC-13.0* RBC-4.51 Hgb-12.4 Hct-36.5
MCV-81* MCH-27.4 MCHC-33.9 RDW-14.7 Plt Ct-313
[**2169-4-9**] 05:33AM BLOOD PT-13.4 PTT-22.9 INR(PT)-1.1
[**2169-4-16**] 07:00AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-142
K-4.0 Cl-103 HCO3-33* AnGap-10
[**2169-4-15**] 07:00AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.0
[**2169-4-11**] 04:13PM BLOOD Type-ART O2 Flow-50 pO2-110* pCO2-56*
pH-7.38 calHCO3-34* Base XS-6 Intubat-NOT INTUBA
[**2169-4-9**] 03:12AM BLOOD Glucose-141* Lactate-0.9 Na-138 K-3.6
Cl-99*
[**2169-4-9**] 03:47PM BLOOD O2 Sat-94
Brief Hospital Course:
43F H/O IPF, COPD/Asthma (Multiple Intubations), Current
Smoking, Schizoaffective Disorder/Depression with URI symptoms
and dyspnea - presumed atypical PNA and COPD exacerbation in
setting of poor lung substrate.
1) Dyspnea: Likely multifactorial and includes Atypical PNA,
COPD/Asthma and underlying IPF. Stable on 2L NC. WBC mildly
elevated and afebrile.
- Continue Levofloxacin 500 mg PO Q24H for typical and atypical
coverage.
- Continnue Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **],
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H, Ipratropium
Bromide Neb 1 NEB IH Q6H, Albuterol 0.083% Neb Soln 1 NEB IH
Q3H, and Guaifenesin [**5-23**] ml PO Q6H:PRN.
- Prednisone Taper: Prednisone 60 mg PO DAILY.
- Smoking Cessation; counseled at bediside. Providing Nicotine
14 mg TD DAILY.
2) DMII: Continue SSI/FS QID, Pioglitazone HCl 30 mg PO DAILY
and Glipizide 10 mg PO BID.
3) Psychosis/Depression: Stable now without symptoms or SI/HI.
- Continue Clozapine 100 mg PO QAM and 400 mg PO HS.
- Continue Risperidone 1 mg PO HS and Fluoxetine HCl 40 mg PO
DAILY.
4) TLE: Most recent seizure five years ago.
- Continue Gabapentin 600 mg PO TID.
5) PPx: PPI, Colace/Senna, Heparin SQ.
6) Code: Full.
7) Access: pIV.
8) FEN: Diabetic/Consistent Carbohydrate.
43F with history of IPF, COPD/Asthma (multiple admissions and
intubation x1), current smoking, Schizoaffective Disorder and
Depression who was originally admitted to the general medicine
floor on [**2169-4-5**] with fevers, URI symptoms and dyspnea. She was
started on levofloxacin for atypical pneumonia and nebulizers
(peak flow 250, BL 350). On the floor, the patient was given
corticosteroids, albuterol and atrovent nebs, fluticasone and
continued on levofloxacin (given a penicillin allergy). Her
oxygen saturations ranged 89-98% and it was thought that she was
generally improving. Alas, she took a turn for the worse as she
had desaturation to high 80s thought [**2-15**] mucous plugging. She
was noted to have hypercarbia on ABG (7.40/54/71). [**Hospital Unit Name 153**] team
evaluated the patient and encouraged increased frequency of nebs
with frequent evals by Respiratory Therapy. She did well until
that evening when she was found to be somnolent and difficult
to arouse. Her oxygen saturation was in the high 90s. An ABG
revealed 7.39/58/72. Nursing was concerned and the patient was
transferred to unit for closer monitoring. While in the unit,
she was noted to have a combined respiratory acidosis and
metabolic alkalosis. She was started on BiPAP and gradually
weaned down. She was transferred to the floor for further
management of her pulmonary disease. By [**2169-4-15**] the patient
was feeling much better with stable SpO2 >94% on 2L oxygen, and
dramatically improved peak flow >300 and minimal wheezing on
exam.
The patient was stable for discharge on [**2169-4-16**], with minimal
wheezing. She has home O2 set up from previous use, and will be
discharged with home services.
During [**2169-4-15**] patient had elevated FBS readings 200-300. She
was initiated on a glargine / humalog insulin regimen, with 15
units glargine qPM giving improved control. She will go home
with this regimen (glargine + humalog sliding scale tid), and
understands that this will need to be adjusted as she
discontinues her steroid medication.
Ms. [**Known lastname 5923**] will receive a slow prednisone taper over one week,
and follow up with her primary care physician and pulmonology.
Medications on Admission:
Albuterol / atrovent
Protonix
Risperidone 2 mg qd
Clozapine 100 mg qAM, 400 mg qhs
Fluoxetine 40 mg po qd
Fluticasone
Metformin / Glipizide
NPH 4U [**Hospital1 **]
Home O2
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) Units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Clozapine 100 mg Tablet Sig: One (1) Tablet PO twice a day:
Take ONE tablet (100mg) in morning, and take FOUR tablets
(400mg) in evening.
(100 mg qAM, 400 mg qPM).
Disp:*150 Tablet(s)* Refills:*0*
7. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) inhaled Inhalation Q12H (every 12 hours).
Disp:*2 discs* Refills:*0*
8. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*0*
10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 inhalers* Refills:*0*
11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
14. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for cough.
15. Prednisone 10 mg Tablet Sig: As written Tablet PO once a day
for 8 days: Take 4 tablets for two days (starting and including
[**4-17**]), then 3 tablets for two day, then 2 tablets for two days,
then 1 tablet for two days, then discontinue use.
Disp:*20 Tablet(s)* Refills:*0*
16. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 doses.
Disp:*2 Capsule(s)* Refills:*0*
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*50 nebulizer treatment* Refills:*0*
18. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
20. Fluoxetine HCl 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*0*
21. Humalog 100 unit/mL Solution Sig: As written Subcutaneous
three times a day: Take with meals according to written sliding
scale.
Disp:*2 vials* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6012**]
Discharge Diagnosis:
Pneumonia, asthma, diabetes
Discharge Condition:
Good
Discharge Instructions:
Patient will need home O2, start 2L/min.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**Name (STitle) 1395**], early this week. You will likely have to reduce your
insulin dose as you reduce your steroid medication (prednisone.)
Followup Instructions:
Please follow up with pulmonary service and your primary care
physician. [**Name10 (NameIs) **] is essential that you see your PCP this week.
|
[
"493.22",
"518.81",
"486",
"305.1",
"276.6",
"345.40",
"311",
"295.70",
"276.3",
"278.00",
"515",
"250.00",
"300.00",
"V58.67",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9730, 9781
|
3195, 6677
|
299, 305
|
9853, 9859
|
2611, 3172
|
10205, 10351
|
1995, 2159
|
6899, 9707
|
9802, 9832
|
6703, 6876
|
9883, 10182
|
2174, 2592
|
252, 261
|
333, 1152
|
1174, 1729
|
1745, 1979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,255
| 199,231
|
25629
|
Discharge summary
|
report
|
Admission Date: [**2189-6-28**] Discharge Date: [**2189-7-4**]
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
generalized weakness/sepsis
Major Surgical or Invasive Procedure:
central line
History of Present Illness:
[**Age over 90 **] yo female with history of CHF, CRI, AS presenting from Marine
Bay NH with diffuse weakness. Private aid came in this evening
to give her a bath and the aide noted that she was particularly
weak. Daughter was away for the weekend last saw her mid-week
after work and she appeared fine. According to notes from the
nursing home she had sudden onset this evening of profound
weakness. She was found to have a RR in the 30s, HR 130-140s.
She denied chest pain or cough. O2 sats at the NH were in the
low 80s. She was transfered to [**Hospital1 18**] for further evaluation.
.
In the ED here her vitals were initially temp 99.6 (spike to
102), HR 96, BP 112/60, RR 16, 98% on 2L. There she was found to
have a lactate of 5 and a RLL pneumonia on CXR. She was
initiated on the Sepsis protocol. In the ED she was given
Ceftazidime and Vancomycin. An US guided RIJ was attempted and
there were 3 flashes but they were unable to advance the wire. A
right SC line was attempted with arterial puncture x 2. They
were eventually able to place a right SC line.
.
Of note she had a similar presentation to [**Hospital1 2025**] in [**Month (only) 404**] that
was initially felt to be pneumonia but eventually turned out to
be CHF.
.
At baseline she is oriented to person only according to nursing
home and daughter. On admission to the ICU she denied any chest
pain, abdominal pain, shortness of breath, or other complaints.
Past Medical History:
1. Hypertension.
2. CHF, followed by Dr. [**Last Name (STitle) 73**] of cardiology. [**12-7**] Echo from
[**Location (un) 620**] with 55-60% EF, [**2-3**]+ MR, Moderate AS
3. Osteoporosis.
4. Dementia. A&O X1 at baseline
5. Osteoarthritis.
6. Glaucoma.
7. Chronic renal failure. BL creat 1.4-1.7
8. Carotid bruits.
9. Gait disorder.
10. Aortic stenosis. [**12-7**] Aortic valve area 0.9 cm2
11. Myelodysplastic syndrome
12. Hearing loss.
Social History:
Lives at [**Location 391**] [**Hospital **] nursing home, daughter is HCP and power of
attorney, no EtoH, no tob
Family History:
NC
Physical Exam:
VS: Temp 96.5, Pulse 110 irregular, BP 98/64, RR 26, 100% on
4LNC
Gen: alert, oriented to person only, tachypneic in moderate
respiratory distress
HEENT: MM dry, OP clear, PERRL
Neck: JVD at jaw line, no lymphadenopathy
Lungs: crackles at the bases bilaterally L>R
CV: tachycardic, irregularly irregular, nlS1S2, 2/6 systolic
murmer radiating to carotids (difficult due to rate)
Abd: soft, non-tender, non-distended, positive BS
Ext: 2+ edema bilaterally
Neuro: A&O X1, moving all extremities, sensation grossly intact
(limited exam)
Pertinent Results:
[**2189-6-28**] 09:17PM WBC-10.8# RBC-3.07* HGB-12.2 HCT-37.5
MCV-122*# MCH-39.8*# MCHC-32.6 RDW-18.7*
[**2189-6-28**] 09:17PM NEUTS-58 BANDS-12* LYMPHS-10* MONOS-19* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2189-6-28**] 09:17PM PLT COUNT-100*#
.
[**2189-6-28**] 09:17PM PT-19.5* PTT-28.7 INR(PT)-1.9*
fibrinogen 575, fdp 0-10
.
[**2189-6-28**] 09:17PM GLUCOSE-177* UREA N-74* CREAT-3.4*#
SODIUM-136 POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-24 ANION
GAP-23*
[**2189-6-28**] 11:58PM ALT(SGPT)-31 AST(SGOT)-28 ALK PHOS-87
AMYLASE-112* TOT BILI-0.5
[**2189-6-28**] 11:58PM LIPASE-9
[**2189-6-28**] 11:58PM CALCIUM-9.0 PHOSPHATE-5.2* MAGNESIUM-2.5
.
[**2189-6-28**] 11:58PM CORTISOL-75.4*
.
LACTATE- 5.0 -> 2.1 -> 3.0
.
[**2189-6-28**] 09:17PM CK(CPK)-27
[**2189-6-28**] 09:17PM cTropnT-0.06* -> 0.07
[**2189-6-28**] 09:17PM CK-MB-3 proBNP->[**Numeric Identifier **]
.
spep: negative
.
pleural fluid:
wbc 2500; rbc [**Numeric Identifier 43202**], polys 59, lymphs 8, monos 31, monos 31,
meso 2
TP 2.5, LDH 288, pH 7.44
gram stain:
.
[**2189-6-28**] 09:42PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2189-6-28**] 09:42PM URINE BLOOD-NEG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2189-6-28**] 09:42PM URINE RBC-0-2 WBC-[**4-6**] BACTERIA-MOD YEAST-NONE
EPI-0-2
.
urine cx [**2189-6-29**]: no growth
.
pleural fluid cx [**2189-6-30**]: no growth
.
blood cx [**2189-7-3**]: no growth to date
.
[**2189-6-28**] 9:42 pm BLOOD CULTURE ([**2-5**] with E coli)
**FINAL REPORT [**2189-7-4**]**
AEROBIC BOTTLE (Final [**2189-7-4**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2189-7-1**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **],4I,5/28/07,11:05AM.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity testing available on
request.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 4 R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
ekg [**2189-6-28**]:
Probable atrial flutter with variable conduction. No previous
tracing available for comparison.
.
CXR [**2189-6-28**] A single portable upright chest radiograph is
reviewed and compared to [**2188-4-8**]. There is a new opacity in the
right lower lung which obscures the right hemidiaphragm, and
appears largely due to new right pleural effusion, although
underlying consolidation or pneumonia is difficult to exclude.
Heart is prominent, and there is mild pulmonary vascular
congestion and upper lobe redistribution suggestive of mild
underlying pulmonary edema. The left lung is clear, and there
is no left pleural effusion. There is no pneumothorax. Old
right rib fracture is unchanged.
IMPRESSION: New right lower lung air opacity appears largely
due to right pleural effusion, although underlying consolidation
or pneumonia is difficult to exclude.
.
CHEST CT WITHOUT CONTRAST [**2189-6-30**]: There is a moderate-to-large
right pleural effusion, most of which layers posteriorly,
although it does extend to the lateral aspect of the right
pleural space. A small left pleural effusion is present as
well. Patchy consolidation is present in the right lower lobe.
A smaller zone consolidation is present in the left lower lobe.
Scattered atherosclerotic calcification is present. The mitral
annulus is calcified. There are prominent mediastinal lymph
nodes which are within normal limits by size criteria.
Mediastinal structures are otherwise unremarkable. The chest
wall is intact. Degenerative arthritic changes are present in
the spine. A
central venous catheter is in place ending in the right atrium.
IMPRESSION: Patchy bilateral lower lobe consolidation, greater
on the right, consistent with pneumonia. Moderate right pleural
effusion which may be partially loculated laterally. Small left
pleural effusion. Bilateral lower lobe consolidation, greater
on the right, consistent with pneumonia.
.
RENAL ULTRASOUND [**2189-6-29**]: The right kidney is not definitely
visualized, and may be atrophic or congenitally absent. The
left kidney measures 8.8 cm in length. There is no
hydronephrosis, nephrolithiasis, renal mass, or perirenal fluid
collection. A Doppler exam was attempted but had to be aborted
due to the inability of the patient to tolerate the exam.
The bladder contains a Foley catheter and is collapsed. There
is a moderate amount of free pelvic fluid.
IMPRESSION:
1. Nonvisualization of the right kidney which may be atrophic
or congenitally absent.
2. Normal-appearing left kidney without evidence of
hydronephrosis.
3. Attempted renal Doppler exam had to be aborted due to
patient's inability to tolerate the exam.
4. Moderate amount of free pelvic fluid.
.
ECHO [**2189-6-30**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 11-15mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is dilated. There is mild global right
ventricular free wall hypokinesis. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
moderate to severe global left ventricular systolic and
diastolic dysfunction and dilated, mildly hypokinetic right
ventricle. Severe pulmonary hypertension. Severe aortic
stenosis. Moderate mitral and tricuspid regurgitation.
Brief Hospital Course:
Patient admitted with E coli septicemia due to bilobar pneumonia
complicated by acute on chronic renal failure, worsening aortic
stenosis, and a drop in her EF. Treated aggressively in the ICU
x 4-5 days. On the floor mental status declined and patient
developed agonal breathing pattern. Family notified and given
multiple comorbidities, in addition to patient's complaints of
dyspnea and extreme whole body pain, decision was made to pursue
comfort care. Patient died within 36 hours of this decision.
.
# E coli septicemia due to bilobar pneumonia: Patient admitted
with elevated lactate with low bp in setting of hypoxia and
fever due to a bilobar pneumonia. Patient initially treated
with vanco/ctx in ED and antibiotics were subsequently expanded
to ctx/vanco/levo to cover nursing home aquired pneumonia on
admission to the ICU. On [**2189-6-29**], blood cultures from admission
grew GNR and antibiotics were changed to meropenem. On [**2189-6-30**]
patient underwent ultrasound-guided thoracentesis to assess a
worsening pleural effusion. There was no evidence of empyema
but fluid did appear to be exudative. There was no evidence of
underlying adrenal insufficiency by labs. Patient's blood
pressure remained stable with intermittent IVF boluses. She was
weaned to room air but continued to complain of dyspnea.
.
#. Elevated INR, low platelets - Labs initially appeared
concerning for DIC, however fibrinogen and FDP normal.
Platelets recovered and INR improved some with vitamin K. LFTs
were in normal range.
.
#. CHF: Initially required IVF bolus for sepsis but
subsequently was grossly volume overloaded. ECHO showed
worsening EF and critical AS. Diuresed with high dose lasix and
diuril with a rise in her creatinine. Patient did had a
troponin leak but with negative MB.
.
#. Acute on chronic renal failure: Creatinine 3.4 on admission
and peaked at 3.9, following initial diuresis, from her baseline
1.4-1.7. Renal was consulted and followed along. Limited renal
ultrasound (due to patient's inability to cooperate) was
unrevealing. She received kayexalate to aid with potassium and
was diuresed with high dose lasix + diuril for her volume
overload. Without these, she made relatively little urine
(approx 10-20 cc/hr).
.
# Afib: Was poorly rate controlled despite increase in home dose
of lopressor likely due to underlying infection/volume overload.
.
#. Dementia - Remained at baseline, oriented x 1.
.
# Glucose control - Covered with RISS
.
# Communication: Daughter is health care proxy, [**Name (NI) 63947**] [**Name2 (NI) 63948**]
Home [**Telephone/Fax (1) 63949**] Cell: [**Telephone/Fax (1) 63950**] and was involved throughout
the admission
Medications on Admission:
1. Ferrous Sulfate 325mg dialy
2. Multivitamin
3. ASA 325mg daily
4. Prilosec 20mg daily
5. Azopt eye drops
6. Lasix 20mg/40mg daily
7. Timolol 0.25% daily
8. Calcium Citrate with Vit D TID
9. Xalatan drops
10. Aricept 10mg daily
11. Lopressor 75mg PO
12. Procrit 5,000 units qweeek (Tuesdays)
Discharge Medications:
patient died in house
Discharge Disposition:
Expired
Discharge Diagnosis:
primary:
E coli septicemia due to multilobar pneumonia
acute renal failure
secondary:
critical aortic stenosis
systolic heart failure
Discharge Condition:
deceased
Discharge Instructions:
none - deceased
Followup Instructions:
none - deceased
|
[
"486",
"428.0",
"584.9",
"038.42",
"427.31",
"585.9",
"403.91",
"290.0",
"424.1",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13067, 13076
|
9984, 12677
|
256, 270
|
13254, 13264
|
2909, 9961
|
13328, 13346
|
2336, 2340
|
13021, 13044
|
13097, 13233
|
12703, 12998
|
13288, 13305
|
2355, 2890
|
189, 218
|
298, 1728
|
1750, 2190
|
2206, 2320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,157
| 179,709
|
5434
|
Discharge summary
|
report
|
Admission Date: [**2126-5-3**] Discharge Date: [**2126-5-9**]
Date of Birth: [**2056-3-18**] Sex: F
Service: CSU
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: The patient
is a 70 year old woman who is status post re-do mitral valve
replacement with a #29 pericardial valve and tricuspid valve
repair with a #34 annuloplasty band who had an uneventful
postoperative course and was discharge to [**Hospital3 1761**] Hospital on postoperative day 6. Since being
admitted to rehab, she has gained 20 pounds of fluid,
developed worsening lower extremity ulcers, had elevated
blood sugars which have been in the 400 and 500 range, and
has been disgruntled with the level of care provided,
therefore, signing out AMA from the rehabilitation center.
She presented to the wound clinic at [**Hospital1 18**] for follow up
following which she was admitted.
PAST MEDICAL HISTORY: Patient's past medical history is
significant for insulin dependent diabetes mellitus, CAD
status post MI, CHF, pernicious anemia, pulmonary
hypertension, chronic renal insufficiency, depression, status
post mitral valve replacement with a porcine valve in [**2119**],
right ORIF of the right tibial plateau fracture with
associated cellulitis of the right knee requiring removal of
hardware, multiple toe amputations.
MEDICATIONS ON READMISSION:
1. Multivitamin 1 q. d.
2. Vicodin 5/500 1 to 2 tablets q. 4-6 hours p.r.n.
3. Ultram 50 mg q. 4-6 hours p.r.n.
4. Insulin, had been discharged on Lantus, was converted to
NPH and regular insulin sliding scale at rehabilitation.
5. Colace 100 mg b.i.d.
6. Celexa 20 mg q. d.
7. Synthroid 50 mcg q. d.
8. Keflex 500 mg b.i.d.
9. Lasix 40 mg q. d.
10.Vitamin C 500 mg b.i.d.
11.Aspirin 81 mg q. d.
12.Ferrous sulfate 325 mg q. d.
ALLERGIES: Patient states allergies to epinephrine,
Captopril, Novacaine, Gentamicin, Dilaudid, Flexeril, ACE
inhibitors, Morphine sulfate and Percocet.
SOCIAL HISTORY: Patient lives in [**Year (4 digits) **] [**State 622**] at home
with her husband. She has a son and daughter who look in on
her. She denies tobacco, alcohol, or drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: At time of admission, heart rate 76
sinus rhythm, blood pressure 148/60, weight 150 pounds.
General: Frail, ill-appearing woman, sitting in chair
crying. Skin: Chronic venous stasis changes of bilateral
lower extremities with erythematous lesions, weeping serous
fluid bilaterally. HEENT: OD blindness. OP exam is benign.
Neck is supple with a full range of motion, no
lymphadenopathy. Chest is clear to auscultation. Sternum is
stable and healing well with some small areas of scab noted
Heart: Regular rate and rhythm, S1, S2, with no murmur.
Abdomen is soft, nontender with normoactive bowel sounds.
Extremities with 3+ bilateral edema and multiple toe
amputations as well as erythematous venous stasis changes up
to the knee with weeping wounds of anterior tibial area.
Neuro is alert, somewhat agitated, unable to ambulate.
Pulses: Right femoral 2+, left femoral 2+, right dorsalis
pedis 1+, left dorsalis pedis 1+. Right and left posterior
tibia 1+, right and left radial 2+. Carotids are 2+ with no
bruits.
LABORATORY DATA: Lab data at time of admission: White count
7.6, hematocrit 27.2, platelets 359. Sodium 139, potassium
5.0, chloride 105, CO2 22, BUN 90, creatinine 1.6, glucose
380.
HOSPITAL COURSE: Patient was initially treated with
subcutaneous regular insulin. However, she did not respond
to that and was then brought to the cardiothoracic intensive
care unit for insulin drip to obtain glucose management.
[**Last Name (un) **] was also consulted at that time for glucose
management. She did well and by hospital day 3, she had
maintained adequate glucose control and was transferred to
the floor for continuing postoperative care and cardiac
rehabilitation. At this time, vascular surgery was also
consulted to evaluate the venous stasis ulcers on the
patient's lower extremities.
Patient was gently diuresed over the period of her
hospitalization. However, during much of this period, the
patient refused many of the recommendations that were made by
both the cardiac surgery team, vascular surgery team, and the
nursing staff and the wound care specialists. On hospital
day 5, the patient expressed a desire to stop all care and be
discharged home to [**State 622**]. At that time, her family was
contact[**Name (NI) **] and on postoperative day 6, arrangements were made
to have family member come to [**Name (NI) 86**] to transport the patient
back to [**State 622**] for continuing postoperative care.
At the time of this dictation, the patient's physical
examination is as follows: Temperature 97.9, heart rate 69
sinus rhythm, blood pressure 139/66, respiratory rate 18, O2
saturation 96% on room air. Lab data: Finger stick blood
sugars are 132 to 286. Chem-7: Sodium 139, potassium 5.6,
chloride 104, CO2 23, BUN 98, creatinine 2.1, glucose 166.
Physical examination: Neurologic, alert, oriented, nonfocal.
Patient somewhat angry and at times argumentative.
Pulmonary: Clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm. Sternum is stable. Incision is
clean and dry without drainage or erythema. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm with 3+ edema and somewhat hyperemic up
to the level of two-thirds of the way up to the knee.
Patient's medications include:
1. Levothyroxine 50 mcg q. d.
2. Multivitamin 1 q. d.
3. Vicodin 5/500 1 to 2 tabs q. 4-6 hours p.r.n.
4. Celexa 20 mg q. d.
5. Colace 100 mg b.i.d.
6. Ferrous sulfate 325 mg q. d.
7. Aspirin 81 mg q. d.
8. Lopressor 12.5 mg b.i.d.
9. Levofloxacin 250 mg q. d. x2 weeks.
10.Flagyl 500 mg t.i.d. x2 weeks.
11.Ascorbic acid 500 mg q. d. x1 month.
12.Bumex 1 mg b.i.d. x1 month, then 1 mg q. d.
13.Insulin glargine 22 units q. hs., Humalog sliding scale
q.i.d.
14.Viagra 50 mg t.i.d.
15.Vitamin B complex 1,000 mcg IM 2 times per week.
DISPOSITION: Patient is to be discharged to home where she
has visiting nurse and home care already set up. She is to
have follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 22028**] upon return to [**State 622**],
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7111**], orthopedic surgeon, on [**7-16**],
patient to call to confirm appointment, with the [**Hospital **]
Clinic, Dr. [**First Name (STitle) 3636**], patient to call for appointment, and with
Dr. [**Last Name (STitle) 914**] when she returns to see Dr. [**Last Name (STitle) 7111**] in [**Month (only) 216**].
DISCHARGE DIAGNOSES:
1. Status post mitral valve replacement with a #29
pericardial valve and tricuspid repair with a #34
annuloplasty band.
2. Diabetes mellitus.
3. Coronary artery disease status post stent.
4. Status post multiple toe amputations.
5. Chronic renal insufficiency with a baseline of 1.62.
6. Pulmonary hypertension.
7. Pernicious anemia.
8. Right tibial fracture with open reduction/internal
fixation and subsequent cellulitis requiring hardware
removal.
CONDITION: Patient's condition at time of discharge is
stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10585**], MD [**MD Number(2) 10586**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2126-5-8**] 17:26:30
T: [**2126-5-8**] 18:32:50
Job#: [**Job Number 22029**]
|
[
"593.9",
"250.81",
"412",
"416.8",
"V49.72",
"583.81",
"250.51",
"281.0",
"459.81",
"250.41",
"682.6",
"414.01",
"707.10",
"311",
"428.0",
"V45.82",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2141, 2159
|
6657, 7466
|
3414, 4989
|
5012, 6636
|
183, 872
|
895, 1933
|
1950, 2124
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
502
| 116,367
|
13982
|
Discharge summary
|
report
|
Admission Date: [**2143-10-23**] Discharge Date: [**2143-11-4**]
Date of Birth: [**2093-4-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
CVL insertion
Mechanical Intubation
Bronchoscopy with BAL
OG tube insertion
[**First Name3 (LF) 2793**] replacement therapy
History of Present Illness:
50 yo M with mixed connective tissue/vasculitis with history of
pulmonary hemorrhage and lupus nephritis currently being
treating with prednisone and cytoxan who presented to OSH
complaining of [**3-13**] days of worsening SOB. Per report, the
patient had no recent fevers, wheezing, coughing, chest pain or
nausea but did complain of worsening LE edema. In the ED there
he was hypoxic to 76% on RA, RR37, HR 130s, BP 94/65. He was
placed on NRP and O2 Sat improved to 88% but he continued to
appear cyanotic. He was emergently intubated and intial ABG
following intubation was 7.34/32.6/48.6. He was given 80 IV
lasix, hydrocortisone 100, phenylephrine 50 mg IV push x 2,
ketamine 100 mg IV, Succinylcholine 150 IV, and vecuronium 10 mg
IV. He was transferred to [**Hospital1 18**], where he receives the majority
of his care.
.
On arrival to the [**Hospital1 18**] ED, the patient's intial vitals were HR
132, BP 109/67, RR 22, SaO2 98%. Initial ABG on 100% FiO2 was
7.14/54/85/19. Labs were notable for WBC of 19.9 with a left
shift (11% bands), Hct 31.1 (range in OMR 28-36), Cr of 2.5 from
baseline 1.0, and lactate 1.0. Blood and urine cultures were
sent, and he was given 2L NS, vanco 1 g IV, zosyn 4.5 mg IV. He
was initially started on propofol drip but then changed to
fentanyl/versed drip. CXR showed multifocal bilateral pulmonary
infiltrates, and ventilator settings changed to ardsnet protocol
and admitted to the MICU for further management.
.
On arrival to the MICU, patient was hypotensive to 80s/60s, HR
120-130s, SaO2 92%, and appeared dyssynchronous with the
ventilor. He was started on peripheral neosynephrine and
paralyzed with vecuronium.
.
Notably, patient had a recent [**Hospital1 18**] admission for hemoptysis
([**Date range (1) 41780**]). During that admission, he had a cavitaory LUL
lesion for which extensive testing failed to identify specific
diagnosis. During that admission, he had a CT scan, was ruled
out for TB with multiple sputum tests and serologic sputum
testing for Nocardia histo, coccidioidomycosis, aspergillosis
were all negative. He did have an "indeterminate" quantiferon
test at that time, of unclear [**Name2 (NI) 41781**], and has several AFB
cultures still pending currently (from [**8-27**], [**8-28**], [**8-29**]). ANCA
testing was negative and lung biopsy was considered and
discussed but not done.
Past Medical History:
- Mixed connective tissue//vasculitis: Characterized by
fluctuating
lymph nodes, Raynaud's phenomenon, skin ulcerations, neuropathy,
arthralgias, alopecia, and prior history of thrombocytopenia,
hemolytic anemia
- History of chronic inflammatory demyelinating polyneuropathy,
status post four plasmapheresis sessions in [**2136**].
- Bilateral hip avascular necrosis in the setting of steroid
therapy, status post bilateral hip replacements.
-Hypertension
-Hypogonadism
-IV-G V lupus nephritis and class V membranous nephritis with
[**Year (4 digits) **] impairment, high-grade proteinuria and nephrosis --
currently receiving cytoxan/mesna monthly, has received 5
cycles, last dose 9/3
-cavitary LUL lesion with extensive ID workup neg except for
indeterminate quantiferon test
Social History:
He denies cigarette use and uses alcohol very rarely. He denies
any recent history of cocaine, IV drug, or marijuana use.
Family History:
His sister also has an undiagnosed autoimmune condition,
currently in remission. He denies any history of diabetes,
hypertension, or kidney disease in the family.
Physical Exam:
General Appearance: Pale, ill-appearing
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube, alopecia
Cardiovascular: tachycardic and regular, no murmur appreciated
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Breath Sounds: No(t) Rhonchorous: ),
coarse and rhonchorus lying flat, improved upright
Abdominal: Soft, Distended, hypoactive BS
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, Cyanosis
Skin: Cool, multiple deep, prurlent ulcers on LE b/l
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Paralyzed, Tone: Not assessed
Pertinent Results:
CT head:
1. Hemorrhagic transformation of the previously seen right MCA
and PCA territorial infarct with significant mass effect causing
uncal and subfalcine herniation.
2. New right thalamic infarct.
3. Mass effect effacement of ipsilateral right lateral
ventricles with trapping of the left lateral ventricles.
[**2143-11-1**] 9:52 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2143-11-4**]**
GRAM STAIN (Final [**2143-11-1**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2143-11-4**]):
RARE GROWTH Commensal Respiratory Flora.
ASPERGILLUS FUMIGATUS. RARE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 41782**]
[**2143-10-29**].
YEAST. RARE GROWTH.
CUNNINGHAMELLA SP..
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 41782**]
[**2143-10-29**].
Brief Hospital Course:
50 yo M with history of vasculitis including prior pulmonary
hemorrhage and lupus nephritis being treated with prednisone and
cytoxan who presented to [**Hospital1 18**] on [**2143-10-23**] with hypoxic
respiratory failure and shock.
.
# Hypoxic Respiratory failure: The differential diagnosis for
acute respiratory failure in this significantly
immunocompromised patient included bacterial infection,
fungal/PCP infection, pulmonary hemorrhage, cytoxan-induced
pneumonitis. ID, Rheum, and Nephrology were consulted. The
patient was intubated and had an esophageal balloon for
transplerual pressure monitoring placed. Rheum thought that a
vasculitic process was unlikely given that the patient was on
cytoxan and prednisone as an outpatient and there was no benefit
from plasmapheresis. He was treated with pulse steroids for 4
days, then tapered back to a standing dose of prednisone, which
was later discontinued. [**Date Range 2793**] initiated CVVH given the
[**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] and tenuous clinical picture, and this was later
discontinued as his [**Last Name (NamePattern4) **] function improved. Per ID, the
patient was initially started on vancomycin, meropenem, IV
bactrim, ambisome, and ciprofloxacin. Cultures and studies to
look for CMV, crypto, PCP, [**Name10 (NameIs) 41783**], and fungi were sent. A
sputum culture grew back yeast and mold - later identified as
zygomycetes/cunninghamella and aspergillus.
.
# Stroke: As Mr. [**Known lastname 41769**] was weaned from sedation, it was
noted that his mental status did not improve as expected. Head
CT showed a large right MCA and PCA stroke, which was later
better characterized with MRI. Stroke team was consulted and
provided prognostic information to the family regarding the
deficits Mr. [**Known lastname 41769**] could expect if he recovered from his
acute illness. On [**2143-11-4**], he was noted to have a blown pupil,
and repeat head CT showed hemorrhagic conversion of the stroke
with uncal and subfalcine herniation.
.
# Tachycardia/Hypertension - This was thought to be in part from
benzo withdrawal and also from heart failure. An echo obtained
on admission showed an EF of 20-25% with moderate to severe MR.
The patient was diuresed with CVVH as above with improvement in
his hypoxia. However, he remained tachycardic and hypertensive.
His benzo withdrawal was treated as above, and he was given
some fluid back.
.
# Hct drop: Most concerning for pulmonary hemorrhage in setting
of known vasculatis with significant lung lesion. No indication
of GI bleed or other source of blood loss, although dilution
could certainly be contributing to decreased counts.
Stabilized.
.
# Acute on chronic [**Date Range **] failure - The patient's creatinine on
admission was 2.5, up from a baseline of 1.0. He was started on
CVVH, which was stopped after 4 days. His urine output
significantly improved after he was stabilized.
.
# Goals of care: Multiple family meetings were held with the
family and with the primary MICU team as well as consultants
from ID, Rheum, and Stroke. The family was clear that Mr.
[**Known lastname 41769**] would not have wanted invasive measures to prolong his
life without meaningful hope of recovery, and decided to move to
DNR/CMO. He was terminally extubated on [**2143-11-4**], and passed
away shortly thereafter in the presence of his family. His son,
the next of [**Doctor First Name **], was notified, and requested an autopsy.
Medications on Admission:
alendronate
clotrimazole
cyclophosphamide
furosemide
mesna
mvi w/ caffeine
nifedpine
ondansetron
prednisone
bactrim
testosterone
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Respiratory failure
2. Invasive fungal infection
3. Brain herniation
Discharge Condition:
Deceased.
Discharge Instructions:
-
Followup Instructions:
-
|
[
"257.2",
"995.92",
"443.0",
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"38.91",
"38.95",
"96.72",
"33.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9454, 9463
|
5745, 9247
|
344, 469
|
9579, 9591
|
4752, 4752
|
9641, 9646
|
3829, 3993
|
9426, 9431
|
9484, 9558
|
9273, 9403
|
9615, 9618
|
4008, 4733
|
277, 306
|
497, 2868
|
4761, 5722
|
2890, 3673
|
3689, 3813
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,087
| 150,996
|
28981
|
Discharge summary
|
report
|
Admission Date: [**2181-7-20**] Discharge Date: [**2181-7-27**]
Date of Birth: [**2121-10-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Increasing SOB and chest pain
Major Surgical or Invasive Procedure:
[**2181-7-20**] Single Vessel Coronary Artery Bypass Grafting(utilizing
left internal mammary to left anterior descending) and Aortic
Valve Replacement with a [**Street Address(2) 17167**]. [**Male First Name (un) 923**] Mechanical Valve.
[**2181-7-22**] Placement of Chest Tube
History of Present Illness:
Mrs. [**Known lastname 18036**] is a 59 year old female with history of aortic
stenosis. In [**2181-1-24**], she noticed an increase in her
shortness of breath, palpitations and atypical chest pains. She
describes her chest discomfort as infrequent, very brief,
non-radiating chest pressure lasting no more then 5 minutes. She
went to her cardiologist who had her wear an event monitor for
one month to evaluate her palpitations. This revealed no
arrhythmias. He also sent her for a follow-up echocardiogram to
evaluate the progression of her aortic stenosis. The
echocardiogram revealed that her aortic valve area was estimated
at 0.9 cm2. Subsequent cardiac catheterization confirmed severe
aortic stenosis with a peak gradient of 89 and a mean gradient
of 55 mmHg. Coronary angiography revealed only single vessel
coronary artery disease with a 50% stenosis in the left anterior
descending artery. Left ventriculography demonstrated normal LV
systolic function with an EF of 57%. There was no mitral
regurgitation. Based on the above results, she was referred for
cardiac surgical intervention.
Past Medical History:
Aortic Stenosis, Coronary artery Disease, Hypertension, Asthma,
Arthritis, Hemorrhoids, s/p Bladder Suspension, History of
Cadmium Poisoning, Carpal Tunnel Syndrome, IV Contrast Allergy
Social History:
Denies tobacco. Admits to occasional ETOH. She is married with
children. She is an artist, no currently employed.
Family History:
No premature CAD before age 55. Mother died at age 79 following
CABG operation. Father died of lung cancer at age 62.
Physical Exam:
Vitals: BP 110/65, HR 87, RR 18, SAT 97 on room air
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, crisp click, no rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, trace edema,
Pulses: 2+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2181-7-27**] 06:45AM BLOOD WBC-8.1 RBC-2.78* Hgb-8.5* Hct-24.4*
MCV-88 MCH-30.7 MCHC-34.9 RDW-14.9 Plt Ct-491*
[**2181-7-27**] 06:45AM BLOOD PT-19.7* PTT-33.4 INR(PT)-1.9*
[**2181-7-26**] 06:40AM BLOOD PT-18.3* PTT-29.9 INR(PT)-1.7*
[**2181-7-25**] 07:00AM BLOOD PT-20.4* PTT-55.5* INR(PT)-2.0*
[**2181-7-24**] 10:12AM BLOOD PT-15.4* PTT-27.8 INR(PT)-1.4*
[**2181-7-23**] 01:36PM BLOOD PT-13.1 PTT-26.0 INR(PT)-1.1
[**2181-7-27**] 06:45AM BLOOD Glucose-112* UreaN-11 Creat-0.7 Na-140
K-4.6 Cl-102 HCO3-30 AnGap-13
[**2181-7-26**] 06:40AM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-141
K-4.7 Cl-103 HCO3-31 AnGap-12
[**2181-7-24**] 10:12AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.2
[**2181-7-26**] Chest x-ray: There is a tiny left-sided pneumothorax
with small left effusion, left retrocardiac and basilar
atelectasis persists. The right lung field is clear. Heart size
is normal. Normal alignment of the sternal sutures.
Brief Hospital Course:
On the day of admission, Mrs. [**Known lastname 18036**] underwent replacement of
her aortic valve and coronary artery bypass grafting surgery by
Dr. [**First Name (STitle) **]. For further surgical details, please see seperate
dictated operative note. Following the operation, she was
brought to the CSRU for invasive monitoring. Within 24 hours,
she awoke neurologically intact and was extubated. She
maintained stable hemodynamics as beta blockade was initiated.
She required placement of a left sided chest tube on
postoperative day two for a postoperative hemothorax. Close to
one liter of bloody fluid was drained. She was intermittently
transfused with packed red blood cells to maintain hematocrit in
the mid 20 to 30 range. Her CSRU course was otherwise uneventful
and she transferred to the SDU on postoperative day three. She
remained in a normal sinus rhythm as beta blockade was advanced
as tolerated. Warfarin was dosed daily and adjusted for a goal
INR between 2.0 - 2.5. She temporarily required Heparin for a
subtherapeutic INR. She experienced a small amount of sternal
drainage which was treated with empiric antibiotics and betadine
occlusive dressings. Over several days, she continued to make
clinical improvements on medical therapy and made steady
progress with physical therapy. She was eventually cleared for
discharge on postoperative day seven. Prior to discharge,
arrangements were made with her PCP to adjust Warfarin as an
outpatient.
Medications on Admission:
Spironolactone/HCTZ ??mg qd
Zantac 150 qd
Motrin prn
Aspirin 81 qd
Multivitamin qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-3**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*50 Tablet(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day for
1 days: 4mg today, [**7-27**], then INR check on Sat, [**7-28**] & call
results for continued dosing.
Disp:*120 Tablet(s)* Refills:*0*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA [**Hospital3 **]
Discharge Diagnosis:
Aortic Stenosis and Coronary artery Disease - s/p AVR/CABG,
Postop Hemothorax, Post op Pneumothorax, Postop Anemia,
Hypertension, Asthma, Arthritis, Hemorrhoids, s/p Bladder
Suspension, History of Cadmium Poisoning, Carpal Tunnel
Syndrome, IV Contrast Allergy
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Call our office for sternal drainage, temp>101.5.
Take Warfarin as directed by MD.
Followup Instructions:
Make appt. with Dr. [**Last Name (STitle) 5310**] in [**12-29**] weeks
Make an appointment with Dr. [**Last Name (STitle) 58201**] for 1-2 weeks.
Make an appointment with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1504**] for 4 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-9-24**]
|
[
"414.01",
"511.8",
"746.3",
"E879.8",
"401.9",
"413.9",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.04",
"35.22",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6687, 6738
|
3532, 4999
|
308, 588
|
7041, 7049
|
2590, 3509
|
7361, 7728
|
2072, 2191
|
5133, 6664
|
6759, 7020
|
5025, 5110
|
7073, 7338
|
2206, 2571
|
239, 270
|
616, 1716
|
1738, 1925
|
1941, 2056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,240
| 178,917
|
49479
|
Discharge summary
|
report
|
Admission Date: [**2137-9-6**] Discharge Date: [**2137-9-11**]
Date of Birth: [**2062-10-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Cough, nasal congestion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 31102**] is a 74yo male with h/o polio, prostate cancer, and
type 2 DM who presents with nasal congestion and non-productive
cough. Per patient, his symptoms started last Saturday and have
not improved. He was concerned since he has been hospitalized in
the past for bronchitis given his history of polio. He denies
any fevers, chills, chest pain, SOB, abdominal pain, or dysuria.
In the ED her initial vitals were T 97.7 BP 146/34 AR 62 RR 18
O2 sat 95%RA. He received Levaquin 750mg PO x1. Cxray suggested
RML pneumonia.
On the floor, the patient states that he's feeling ok now. He
states that last week, he had some congestion, rhinorrhea, which
eventually cleared, but he has had a non-productive cough. He
states that he feels mucous in his chest, but has not been able
to produce anything. He denies fevers, chills, joint pains,
nausea, vomiting, headaches, SOB, CP, or pleuritic chest pain.
He states he otherwise feels well.
Past Medical History:
1)Klebsiella urosepsis ([**1-/2135**]) resulting in [**Hospital1 112**] ICU stay, shock
liver, MI and azotemia with placement of ureteral stent--now
recovered
2)Prostate ca s/p exploratory laparotomy with positive nodes and
[**Hospital **] medical managment, [**2124**]. PSA now wnl.
3)Renal cell ca s/p right nephrectomy '[**20**]
4)Type 2 DM
5)Depression
6)Carpal tunnel syndrome, s/p L-wrist release [**2113**]
7)Rheumatoid arthritis
8)h/o basal cell cancer (s/p excision)
9)h/o appendectomy
Social History:
Lives in [**Location 86**]. [**Hospital 8735**] rehab counselor. Divorced. Denies
tobacco, alcohol, or IVDA. Wheelchair dependent, has nursing
assistance at home.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
vitals Tm 98.8 130/56 (125-130) 69 (63-69) 24 O2 sat 94% RA
Gen: Pleasant male, lying in bed
HEENT: MMM, no LAD
Heart: RRR 1/6 systolic flow murmur at base
Lungs: poor inspiratory effort, breath sounds throughout with
increased crackles on R>L
Abdomen: obese, soft, NT/ND, normal BS
Extremities: 1+ LLE edema to knee, no edema on Right, 1+ DP/PT
pulses bilaterally. low muscle mass BLE
Pertinent Results:
Relevant Imaging:
CXRAY:IMPRESSION: Question opacity medial right middle lobe
which may represent a pneumonia particularly in light of given
symptoms. Repeat radiography recommended following appropriate
therapy to document resolution
[**2137-9-6**] 06:20AM GLUCOSE-117* UREA N-26* CREAT-0.8 SODIUM-137
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2137-9-6**] 06:20AM WBC-12.8* RBC-3.40* HGB-10.7* HCT-31.2*
MCV-92 MCH-31.3 MCHC-34.1 RDW-15.0
Brief Hospital Course:
Pt was admitted with non-productive cough of 6 days duration and
was found to have a
RML pneumonia.
.
Pneumonia: Pt was treated empirically for CAP with levofloxacin
started on [**2137-9-6**]. On the 3rd day of admission, pt was
transferred to the MICU after an episode of hypoxia to 50% on RA
during chest PT. Pt was placed on NRB with improvement of O2
Sat to 95%. Sputum cultures were contaminated x 2 and thus
levofloxacin was continued. Pt was continued on chest PT with
symptomatic improvement. Pt was also evaluated by speech and
swallow for possible aspiration. He was cleared by speech and
swallow, however pt may benefit from further work up with outpt
video swallow to evaluate for possible microaspiration. Pt
should be continued on levofloxacin for a full 10 day course
([**2137-9-6**] to [**2137-9-16**]). Pt will also need a repeat x-ray in [**5-3**]
weeks. Prior to discharge, the patient's O2 sats had improved
to >95% on RA.
.
Medications on Admission:
Flutamide 250mg PO TID
Effexor 150mg PO daily
Atenolol 25mg PO daily
ASA 81mg PO daily
Simvastatin 40mg PO daily
Metformin 250mg PO daily
Vitamin B6 50mg PO daily
Vitamin B12 25mg PO daily
Discharge Medications:
1. Flutamide 125 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: Until [**2137-9-16**].
Disp:*5 Tablet(s)* Refills:*0*
8. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
9. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
11. Metformin 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Flutamide 125 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnosis:
Prostate Ca, DM type 2, Depression
Discharge Condition:
Good
Discharge Instructions:
You were admitted with a pneumonia. You were treated with
levofloxacin, and you should continue this medication for a full
10 day course.
.
Levofloxacin was added to your medication regimen. You will
need to take this medication until [**2137-9-16**].
.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pain, shortness of breath,
fevers, chills, worseing cough, nausea, or vomiting.
Followup Instructions:
We have scheduled an appointment with your primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 103527**] [**Telephone/Fax (1) 355**] on [**9-16**] at 1:20 pm.
.
You will also need a repeat chest x-ray, arranged by your PCP [**Last Name (NamePattern4) **]
[**5-3**] weeks.
Completed by:[**2137-9-16**]
|
[
"486",
"V10.52",
"V10.46",
"714.0",
"138",
"934.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5396, 5453
|
2998, 3954
|
338, 344
|
5582, 5589
|
2511, 2511
|
6075, 6406
|
2053, 2071
|
4193, 5373
|
5474, 5474
|
3980, 4170
|
5613, 6052
|
2101, 2492
|
275, 300
|
2529, 2975
|
372, 1335
|
5524, 5561
|
5493, 5503
|
1357, 1856
|
1872, 2037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,426
| 152,014
|
34368
|
Discharge summary
|
report
|
Admission Date: [**2125-11-14**] Discharge Date: [**2125-11-30**]
Date of Birth: [**2064-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Bacteremia/sepsis s/p Left PCN replacement
Major Surgical or Invasive Procedure:
nephrostomy tube (left) replaced [**11-14**]
History of Present Illness:
This is 61 year-old male with a history of obstructing left
renal stone, suprapubic catheter, numerous UTIs who presents
from day care center with fever, tachycardia.
Pt was scheduled for an appointment with Dr. [**Last Name (STitle) 770**] [**11-15**] for
treatment of his obstructing left stone. Day of admission at the
nursing home his left perc nephrostomy was noted to have
migrated out and he was brought to [**Hospital1 18**] where IR replaced his
tube ~1:30pm. In the day care unit he was noted to be ill
appearing, spiked a temperature to 102.6 and began vomiting. Pt
c/o pain, given oxycodone, urology called said urostomy outpt
fine. Pt became tachy to 130's. BP in 130's. Pt given dose of
cefepime. BCx/UCX taken.
.
Currently, pt reports LLQ pain, s/p vomiting, chronic b/l foot
pain. Denies headache/LH/CP/SOB/diarrhea, melena, brbpr,
dysuria, rash.
Past Medical History:
s/p CVA
Neurogenic bladder s/p suprapubic cath
Recurrent UTIs with Klebsiella/Pseudomonas
Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03
(s/p R-CHOP x 6 cycles)
Bells Palsy
BPH
Hypertension
Partial Bowel obstruction s/p colostomy
Hepatitis C
Cryoglobulinemia
SLE with transverse myelitis, anti-dsDNA Ab+
Insulin Dependant Diabetic
Fungal Esophagitis Stage IV?
Urinary Tract Infections-pseudomonas & enterococcus
Social History:
Lives in a nursing home since [**3-9**]. Denies smoking, ETOH, drug
use. Has sister close by ([**Name (NI) 79061**]) who he is close to. Is a
Jehova's Witness and does not agree to blood transfusions.
Family History:
Non-Contributory
Physical Exam:
on discharge
Vitals: Tm 99.7 Tc 98.9 130/70 94 18 95%RA
Pain: [**3-12**] b/l LE
Access: R PICC
Gen: nad, lying in bed
HEENT: mm dry
CV: RRR, no m appreciated
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +colostomy prolapse with brown/green
stool, +BS, L PCN yellow urine, SPT in place
Ext; no edema, hyperpig changes, onychomycosis, b/l shins ttp
Neuro: A&OX3, slow to respond, stable mild L facial droop
psych: flat
skin: new erythematous rash over R abdomen to upper thigh with
numerous very small white pustules (white heads), no skin
breakdown, no bullae
Pertinent Results:
Chem panel BUN/creat 4/1.0 (baseline 0.8), Phos 3.5, Mag 1.8
WBC 9s
INR 1.3
hgb 9s
.
UA [**11-27**] large LE, SPT 227 wbc, PCN 672 wbc, mod bacteria
UCx negative X2
UCx in past pseudomonas and providencia.
suprapubic UCx [**11-22**] wth 3,000-5,000 GNR (suggestive of
pseudomonas)
Blood Cx [**11-19**] 1 of 3 sets with corneybacterium (contaminant)
Blood cx [**11-22**] X2 NTD, [**11-24**] X1 [**Month/Year (2) **], [**11-25**] X2 NTD
C-diff [**11-20**] pos, [**11-21**] neg
.
.
Imaging/results:
LENI bilateral LE: negative.
.
CXR [**11-22**]: L pleural effusion improving. no PNA
.
CT a/p noncontrast [**11-27**]:
No significant interval change compared with [**2125-11-22**]:
No abscess, stable subcapsular left renal hematoma, stable
bilateral non- obstructing renal calculi, persistent
cholelithiasis, likely AVN of the right femoral head, fat
stranding in the sigmoid area and bilateral pleural effusions.
.
CT a/p noncontrast [**11-22**]:
Study limited due to lack of IV contrast administration. There
is no
obvious evidence of abscess. There is no obvious evidence of
acute colitis.
2. No significant interval change compared to [**2125-11-16**],
with some mild decrease in fluid collection in the abdominal
cavity and pelvic tracking of the left perirenal space. Stable
subcapsular left renal hematoma.
3. Status post left nephrostomy tube in placement, stable since
[**2125-11-16**].
4. Stable dilatation of the left ureter compared to [**2125-11-16**].
5. Small bilateral pleural effusion, unchanged, with some
dependent
atelectasis.
6. Stable bilateral renal calculi, nonobstructing.
7. Cholelithiasis without evidence of acute cholecystitis.
8. Fatty liver infiltration, diffuse, stable.
9. Presumable AVN of the right femoral head, unchanged.
10. Minimal wall thickening and fat stranding in the sigmoid
area unchanged since [**2125-11-16**].
.
[**2125-11-15**] CT Abd/pelvis: IMPRESSION:
1. Large subcapsular renal hematoma with acute hemorrhage
expanding the
perinephric space and extending into the anterior perirenal
space and likely in the pelvis.
2. Status post left nehrostomy tube exchange, which terminates
in the left
renal pelvis. No evidence of hydroureter or hydronephrosis.
3. Focal area of hyperdensity in the pelvis surrounding sigmoid
colon, likely related to bleedin from the renal hematoma.
Although less likely, a focal colonic process cannot be
excluded. Clinical correlation advised.
4. Bilateral pleural effusions.
5. Stable bilateral renal calculi.
6. Cholelithiasis without evidence of cholecystitis.
7. Fatty liver infiltration.
[**2125-11-16**] CT abd/pelvis:IMPRESSION:
1. Slight interval increase in fluid collection in the right
lower quadrant and pelvis tracking from the left pararenal space
consistent with small amount of intraperitoneal hemorrhage.
Stable subcapsular left renal hematoma.
2. Status post left nephrostomy tube exchange which demonstrates
stable
position in the left renal pelvis compared to [**2125-11-15**].
3. Stable dilation of the left ureter compared to [**2125-11-15**].
4. Bilateral pleural effusions, unchanged from [**2125-11-15**]. No evidence of hemothorax.
5. Stable bilateral renal calculi that are nonobstructing.
6. Cholelithiasis without evidence of cholecystitis.
7. Fatty liver infiltration.
8. Probable early AVN of the right femoral head, unchanged from
[**2125-10-1**].
Brief Hospital Course:
Brief hospital course: Per report the patient's nephrostomy
tube fell out at nursing home and replaced on [**11-14**] by IR. Pt
was intially admitted to MICU with ever, tachycardia, LLQ pain
and ?pus at perc tube site later that day. given h/o
Pseudomonas UTI's, recurrent urosepsis, nephrolithiasis,
suspected source of sepsis and fevers were the urinary tract. He
was initially started on Cefepime (later switched to Ceftaz) and
Vanco ([**11-17**] d/c'd). The pt continued to have LLQ pain.
Initially thought was possible C-diff and he was empirically
started on PO flagyl (c-diff toxin subsequently positive,
continued diarrhea, changed to PO vanc, plan to continue until
1week post Abx around [**12-12**]). Pt continued to c/o LLQ pain and
thus underwent a CT Abd [**11-15**] showing a subcapsular hematoma
without focal abcess. This was rechecked after a drop in Hct
[**11-16**] and found to be stable and has been stable with repeat CTs
during hospital stay. CT scans were also negative for abcess to
explain persistant fevers. Urinary Cultures finally came back
with Pseudomonas and Providenci Stuartii and pt remained
febrile-->ID consulted, Abx changed to meropenem, and plan is
for 2weeks (until [**12-6**]). Definitive treatment would be removal
of kidney stones that are likely infected (UA persistantly
dirty, though may be colonization). Urology was following and
did not want to remove stones while pt was still having fevers.
Decision made to f/u urology after 2weeks of Abx and he has f/u
arranged with Dr. [**Last Name (STitle) 770**] [**12-6**]. Initially was afebrile for
3days after a couple days on meropenem, then again started
having fevers. Blood Cx [**11-24**] with [**Last Name (LF) **], [**First Name3 (LF) **] old PICC removed
([**11-27**]) and vanc restarted, planned until [**11-22**]. Pt has not had
temp spike for 2days now, though continues to have low grade
temps to 100. His latest cultures are all negative and he is on
vanc/meropenem/PO vanc. His appetite is very poor and he is
started on sugar free shakes TID, PO hydration is encouraged to
prevent volume depletion. He has chronic b/l LE pain from
neuropathy and PAD, his neurontin was increased. If his issues
become stable, he should follow up with vascular to see if
anything can be down with blood flow to the area. He is stable
and being transfered back to [**Hospital1 1501**] with plans for urology f/u.
.
.
.
Please see progress note below for details:
.
61 year old male with MMP including DM, CVAs, SLE with
myelopathy, neurogenic bladder s/p SPT, recurrent
nephrolithiasis/urosepsis s/p L PCN admitted [**11-14**] for dislogded
PCN, replaced, post-procedure urosepsis, now on meropenem unitl
[**12-6**]. Post procedure also developed a subcapsular
hemmorhage/anemia (stable). Hospital course complicated by
c-diff on PO vanc, PICC associated [**Month/Day (4) **] bacteremia on IV vanc.
Continues to have intermittent low grade temps, likely [**2-3**]
infected stones. Overall stable and plan to discharge back to
[**Hospital1 1501**] today.
.
.
Fevers: recurrent/intermittent: initially on vanc/ceftaz, then
meropeneum since [**11-22**] for presumed urosepsis (ESBL,
pseudomonas, etc). PO Vanco for c-diff. Again started IV Vanc
[**11-26**] for [**Month/Year (2) **] bacteremia ([**2-3**] PICC). Last fever [**11-27**] (PICC
removed). CT scan repeat [**11-27**] stable hemmorhage, no abcess.
b/l LENIs also negative. Most likley poss is infected stone that
remains as repeat UAs still very dirty
-blood cx [**11-24**] [**Month/Year (2) **] (PICC removed [**11-27**], last temp spike). BC
[**11-25**] and [**11-26**] NTD. New R PICC placed [**11-27**]
-cont Vanc (started [**11-26**]) for [**Month/Year (2) **] bacteremia, plan till [**12-2**]
-cont meropenem for total 2weeks (until [**12-6**]) for urosepsis.
However, concern is that stone is infected (repeat UA SPT and
PCN dirty) and removal is only definitive treatment as patient
is having persistant intermittent fevers. has appt with Dr.
[**Last Name (STitle) 79062**] on [**12-6**], so continue Abx till this.
-C-diff, plan to cont PO vanc for 1-2weeks after above Abx
(approx [**12-12**]) per ID recs.
-tylenol q6 prn
-appreciate ID reccommendations, signed off.
.
.
R Abdominal wall rash: benign appearing. ?fungal vs contact
dermatitis
-antifungal powder, keep area dry and clean
.
.
Acute blood loss anemia: subcapsular hemmorhage. pt is [**Name (NI) 79063**]
witnes. no further bleeding. holding AC.
-hgb stable around 9s
.
.
[**Last Name (un) **] c mild CKD: creat up to 1.7, now back to baseline, monitor
closely as creat 0.8->1.0, not much PO hydration. Encourage PO
hydration.
.
.
Recurrent nephrolithiasis, obstructing L stone s/p L PCN,
recurrent urosepsis.
-Abx as above. Still with intermittent temps. dirty UAs ([**2-3**]
catheter vs infected stones). Regardless, needs stone removal.
-again urology would like to wait for 2weeks, has appt [**12-6**] with
Dr. [**Last Name (STitle) 770**], [**First Name3 (LF) **] keep on Abx till then (2weeks total)
-Note, repeat CT [**11-27**] (and [**11-22**]) with stable hematoma and
fluid collection w/o mention of abcess (fevers).
.
.
DM: lantus and lispro 4U tid and SSI
-chronic b/l LE pain [**2-3**] neurolpathy and likely PAD. increased
neurontin to 600mg TID, consider vascular follow up to eval
blood flow.
.
.
C-diff: PO vanco (for 1-2weeks after completion of ABx),
decreased ostomy output so plan till [**12-12**]. bowel regimen if
constipation on narcotics
.
.
LLQ Abd Pain- CT Abd on [**11-15**] and [**11-16**] revealed subcapsular
left renal hematoma and a slight interval increase in fluid
collection in the right lower quadrant and pelvis tracking from
the left pararenal space consistent with small amount of
intraperitoneal hemorrhage. In addition there was stable
dilation of the left ureter and stable bilateral renal calculi.
Repeat CTs duing hospitalization showed stable hematoma and his
pain improved throughout his stay with tylenol and oxycodone
prn.
.
.
Depression: celexa (dose increased), ambien prn
.
.
FEN/proph: HLIV, encourage PO hydration, monitor lytes, diabetic
diet as tolerated with ensure tid, TEDs/SCDs, no AC, PPI, bowel
regimen as needed with pain meds, pt refusing PT, OOB to chair
TID
.
.
Dispo: full code. Pt is stable, plan in place for course of Abx,
continues to have low temps. Plan to send to [**Hospital1 1501**] ([**Hospital **]
health care) today with urology f/u [**12-6**] with Dr. [**Last Name (STitle) 11189**].
Medications on Admission:
Insulin 18units QHS, lispro 8 units breakfast, lunch, dinner
MVI
Citalopram 10mg daily
folic acid 1mg daily
gabapentin 300mg TId
oxycodone 5mg Q6hr
simvastatin 10mg daily
acetaminophen
bisacodyl
calcium 600+D
iron
mag citrate prn
prilosec 20mg daily
senna
simethicone
thiamine
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): end date: 7 days after completion of other
antibiotics.
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): for oral thrush.
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
15. Lantus 100 unit/mL Solution Sig: Eighteen (18) units
Subcutaneous at bedtime.
16. Insulin Lispro 100 unit/mL Insulin Pen Sig: Four (4) Units
Subcutaneous TID before meals: Also sliding scale.
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
18. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
six (6) hours: until [**12-6**].
19. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours: until [**12-2**].
20. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO at bedtime.
21. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
1. UTI/sepsis (pseudomonas, providencia), [**Location (un) **] bacteremia (PICC)
2. Clostridium difficile colitis
3. left renal capsule hematoma
4. bilateral nephrolithiasis, s/p nephrostomy tube placement
5. DM with chronic neuropathy (b/l LE)
6. colostomy with prolapse
7. SLE with myelopathy
8. history of stroke with late effects
Discharge Condition:
STABLE
Discharge Instructions:
You were admitted after nephrostomy tube replacement with fevers
and hypotension. Your urine was infected. The kidney stones
must be removed, so please assure you follow up with Dr. [**Last Name (STitle) 770**]
as scheduled on [**12-6**]. You will be on IV meropenem until [**12-6**]
.
You also have c.difficile colitis, and should continue to take
the vancomycin until at least 7 days beyond finishing your other
antibiotics ([**12-12**] or so)
.
You also had bleeding around the kidney where the nephrostomy
tube was placed, but did not have any blood transfusions.
.
You also had an infection associated with the PICC, you will be
on IV vanc for 5days
.
You have a new rash over your Rside of abdomen and upper thigh.
It looks like you skin is irritated but nothing too serious,
keep the area dry and clean, and use topical powder that is
ordered. If your skin starts to open up with big blisters,
please tell the doctors at the nursing home.
.
Please call your primary care physician with any concerns or
questions. Please return to the hospital if you have persistant
fever greater than 101, increased abdominal pain, worsened
diarrhea, low blood pressure or any other concerns.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 6015**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6019**] Call for follow up.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2125-12-6**] 3:40
Provider: [**Name10 (NameIs) **] RM 2 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2125-12-4**]
11:00
Provider: [**Name10 (NameIs) 454**],ONE [**Name10 (NameIs) 454**] Date/Time:[**2125-12-20**] 7:00
|
[
"E878.1",
"584.9",
"710.0",
"250.60",
"443.9",
"285.1",
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"357.2",
"599.0",
"403.90",
"323.9",
"038.43",
"733.42",
"070.54",
"592.0",
"596.54",
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"600.00",
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"V44.6",
"996.39",
"585.3",
"V10.79",
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"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.93",
"87.75"
] |
icd9pcs
|
[
[
[]
]
] |
14743, 14819
|
6027, 12497
|
360, 407
|
15196, 15204
|
2619, 5979
|
16439, 16940
|
1987, 2005
|
12825, 14720
|
14840, 15175
|
12523, 12802
|
15228, 16416
|
2020, 2600
|
278, 322
|
435, 1300
|
1323, 1753
|
1769, 1971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,537
| 179,801
|
45191
|
Discharge summary
|
report
|
Admission Date: [**2158-5-28**] Discharge Date: [**2158-6-7**]
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old man
with a history of coronary artery disease status post
coronary artery bypass grafting in [**2151**] who presented to [**Hospital6 1760**] with substernal chest pain
that started upon awakening on the day of admission. The
pain was in his lower chest and radiated down his arm and was
not associated with shortness of breath, nausea, vomiting, or
diaphoresis. The patient denied having prior episodes of
angina in the past. He was also noted to be tachycardiac to
the 120s. He received two sublingual Nitroglycerin with good
relief of pain. He was also given Lopressor 5 mg IV 24 mg
p.o. with resolution of his tachycardia to 71 beats per
minute. He was pain free on arrival to the Emergency
Department.
His last catheterization was [**2158-3-22**]. He had a
rotational atherectomy of the left main and proximal left
anterior descending stenting. His LIMA was totally occluded
at that time. Saphenous vein graft to ramus intermedius was
patent, saphenous vein graft to posterior descending artery
was also patent. The initial plan for this admission was to
send for repeat cardiac catheterization.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post coronary artery bypass grafting in [**2151**] with LIMA to the
left anterior descending, saphenous vein graft to the
posterior descending artery, and saphenous vein graft to R1.
2. Congestive heart failure with an ejection fraction of
30%. 3. Hypertension. 4. High cholesterol. 5.
Parkinson's disease. 6. Benign prostatic hypertrophy. 7.
Gastroesophageal reflux disease. 8. Chronic renal
insufficiency with a baseline creatinine of 1.3. 9.
Melanoma. 10. Pancreatic cyst.
MEDICATIONS ON ADMISSION: Lopressor 25 mg p.o. b.i.d.,
Plavix 75 mg p.o. q.d., Aspirin 325 mg p.o. q.d.,
.................... 5 mg p.o. q.d., Buspar 100 mg p.o.
b.i.d., Lisinopril 40 mg p.o. q.d., Lansoprazole 30 mg p.o.
b.i.d., Colace 100 mg p.o. b.i.d., Sinemet 25/100 one tab
p.o. q.i.d., Lipitor 10 mg p.o. q.d., Vitamin E 400 IU p.o.
q.d., Proscar 5 mg p.o. q.d., Mirtazapine 15 mg p.o. q.d.
ALLERGIES: INTRAVENOUS DYE AND QUINIDINE.
SOCIAL HISTORY: Never married. Remote tobacco history.
Occasional alcohol. He recently moved to ...................
He has a healthcare proxy who is actively involved in his
care; his name is [**Name (NI) 3065**] [**Name (NI) 24253**], cellular [**Telephone/Fax (1) 96575**],
home [**Telephone/Fax (1) 96576**], office [**Telephone/Fax (1) 96577**].
HOSPITAL COURSE: The patient was premedicated with
Prednisone and Mucomyst prior to cardiac catheterization. He
became slightly confused during the first night of his
admission after receiving steroids. His mental status had
improved by the following morning. The patient went for
cardiac catheterization which showed a 40% left main,
in-stent restenosis, 90% left anterior descending in-stent
restenosis, and also significant with a diagonal of 80%
lesion. All three lesions were ballooned Rotobladed. He had
a totally occluded LIMA to the left anterior descending which
had been seen to be totally occluded on a prior
catheterization. He had a patent saphenous vein graft to
posterior descending artery, and a patent saphenous vein
graft to RI.
The initial plan was to perform brachy therapy during the
catheterization; however, because the patient became
hypotensive, he was sent to the CCU, and brachy therapy was
not done. His right atrial pressure at catheterization was
15, pulmonary pressure 43/22, wedge 17, cardiac index of 1.9.
His CCU course was mainly notable for transfusion of several
units of packed red cells for a small hematocrit drop, but he
had no evidence of a major bleed. He had a chest x-ray which
showed mild congestive heart failure and a right-sided
effusion, and he was aggressively diuresed with intravenous
Lasix. He became agitated and combative in the CCU and had
to be restrained. He was given Haldol and Benzodiazepines
with worsening of agitation. He was observed overnight, and
his congestive heart failure improved, and he was sent back
up to the floor.
On the floor he remained confused, not oriented to place or
person, unable to recognize his heathcare proxy. Psychiatry
was consulted and recommended starting Zyprexa and avoiding
Benzodiazepines. He also began to have an increase in
creatinine, so his ACE inhibitor was stopped, and his Lasix
was also continued. He was also gently hydrated with half
normal saline.
His creatinine drifted back to baseline over the next several
days, and was at his baseline at the time of discharge. His
hematocrit also remained stable during the remainder of his
hospital course without any need for further transfusion.
Over the next three days, his mental status gradually
improved, and he was able to understand discussions with his
healthcare proxy. [**Name (NI) **] was completely alert and oriented times
three at the time of discharge. He also complained of some
shortness of breath, although his oxygen saturation greatly
improved. He also had some mild lower extremity edema over
the last two days of his hospitalization. A repeat chest
x-ray on the day of discharge showed that his right-sided
effusion was still present, although his pulmonary edema was
decreased. Thoracentesis was discussed, and it was decided
instead to restart his Lasix, as this effusion is most likely
due to heart failure, and he will have a follow-up chest
x-ray in [**1-11**] weeks.
DISCHARGE STATUS: Discharged to [**Hospital1 **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Lasix 40 mg p.o. q.d., Aspirin 325 mg
p.o. q.d., Buspar 100 mg p.o. b.i.d., Colace 100 mg p.o.
q.d., Sinemet 25/100 one tab p.o. q.i.d., Lipitor 10 mg p.o.
q.d., Vitamin E 400 IU p.o. q.d., ................... 5 mg
p.o. q.d., Mirtazapine 15 mg p.o. q.h.s., Albuterol MDI 1-2
puffs q.4-6 hours p.r.n., Metoprolol 15 mg p.o. b.i.d.,
Protonix 40 mg p.o. b.i.d., sliding scale Insulin, Atrovent 2
puffs p.o. q.i.d., Zyprexa 2.5 mg p.o. q.h.s., Maalox 15-30
cc p.o. t.i.d. p.r.n.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting in [**2151**] with LIMA to left anterior
descending, saphenous vein graft to posterior descending
artery, and saphenous vein graft to RI.
2. Congestive heart failure with an ejection fraction of
30%.
3. Hypertension.
4. High cholesterol.
5. Parkinson's disease.
6. Benign prostatic hypertrophy.
7. Gastroesophageal reflux disease.
8. Diabetes.
9. Chronic renal insufficiency with a baseline creatinine of
1.3.
10. Melanoma.
11. Pancreatic cyst.
12. Anemia.
13. Right pleural effusion.
14. Mental status changes.
15. Acute renal failure.
FOLLOW-UP: With Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in two weeks. He is to
have a follow-up chest x-ray in [**1-11**] weeks to assess for
improvement of his pleural effusion. He should follow-up
with his primary care physician.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-300
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2158-6-7**] 14:38
T: [**2158-6-7**] 14:50
JOB#: [**Job Number 93642**]
|
[
"428.0",
"332.0",
"530.81",
"414.02",
"511.9",
"292.81",
"996.72",
"414.01",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"36.01",
"37.21",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
5762, 6238
|
6259, 7370
|
1907, 2323
|
2695, 5704
|
131, 144
|
173, 1331
|
1354, 1880
|
2340, 2677
|
5729, 5738
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,524
| 121,336
|
36685
|
Discharge summary
|
report
|
Admission Date: [**2157-11-3**] Discharge Date: [**2157-11-11**]
Date of Birth: [**2088-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x
4(LIMA-LAD,SVG-DG,SVG-OM2,SVG-PDA) [**2156-11-3**]
History of Present Illness:
This 69 year old white male has a history of hypertension,
hyperlipidemia, prior cornary angioplasty and noninsulin
dependent diabetes with recurrent angina during cold weather and
bilateral lower extremity claudication. A Persantine stress test
was abnormal and he was referred for cardiac catheterization.
This revealed triple vessel disease with intact LV function
(50-55%). He was evaluated for surgical revascularization for
which he was electively admitted at this time.
Past Medical History:
hypertension
Hyperlipidemia
s/p coronary angioplasty
noninsulin dependent diabetes mellitus
Renal Insufficiency
Peripheral Neuropathy
Cataracts
degenerative joint disease
Social History:
Lives with: alone, divorced has one daughter
Occupation: Retired chemist
Tobacco: 1ppd x 30 yrs
ETOH: [**1-28**] glasses of wine a week
Family History:
parents both alive 97 and [**Age over 90 **] years old
Physical Exam:
Admission:
Pulse:55 Resp:18 O2 sat: 99%RA
B/P Right: 153/55 Left: 150/54
Height:5'7" Weight:150 lbs
General:AAOx3
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RR [x] Sinus brady Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2157-11-11**] 05:35AM BLOOD WBC-8.5 RBC-3.03* Hgb-9.1* Hct-27.7*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.0 Plt Ct-307
[**2157-11-3**] 01:37PM BLOOD PT-13.6* PTT-39.4* INR(PT)-1.2*
[**2157-11-11**] 05:35AM BLOOD Glucose-201* UreaN-50* Creat-1.6* Na-137
K-4.9 Cl-102 HCO3-28 AnGap-12
CHEST RADIOGRAPH
INDICATION: Evaluation for pleural effusions, status post CABG.
COMPARISON: [**2157-11-6**].
FINDINGS: As compared to the previous examination, there is no
relevant
change. Moderate cardiomegaly and elevation of the left
hemidiaphragm. Mild
left-sided pleural effusion with moderate retrocardiac areas of
atelectasis
showing several air bronchograms. Mild hypoventilation at the
right lung
bases.
No interval appearance of focal parenchymal opacities suggesting
pneumonia.
No other changes.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82968**] (Complete)
Done [**2157-11-3**] at 11:40:01 AM PRELIMINARY
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: [**2088-10-10**]
Age (years): 69 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Valvular heart
disease.
ICD-9 Codes: 440.0, 424.1, 396.9, 424.0
Test Information
Date/Time: [**2157-11-3**] at 11:40 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mildly dilated LV cavity.
Moderate-severe regional left ventricular systolic dysfunction.
Moderately depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (?#). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
PRE-BYPASS: Mild spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. The left ventricular cavity is mildly dilated.
There is moderate to severe regional left ventricular systolic
dysfunction with XXX. Overall left ventricular systolic function
is moderately depressed (LVEF= 30-35 %). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
There are simple atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Brief Hospital Course:
Following admission he was taken to the Operating Room where
revascularization was accomplished. See operative note for
details. He weaned from bypass on epinephrine, neosynephrine and
Propofol. He was somewhat labile, but was able to be extubated
on POD 1. The epinephrine weaned off as did the neosynephrine.
He developed atrial fibrillation (controlled rate)with mild
hypotension. Beta blockade resulted in conversion to SR and his
BP was adequate. Oral hyperglycemics and insulin were utilized
to control his hyperglycemia. He was diuresed towards his
preoperative weight.
On POD 3 his CTs were removed uneventfully and he was
transferred to the floor where diuresis was continued along with
Lopressor. he again had controlled rate atrial fibrillation and
oral Amiodarone was started, with conversion to and with
maintenance of SR. Physical Therapy worked with him for
mobility and strengthening prior to discharge.
He developed urinary retention after the foley was removed on
two occassions, necessitating replacement of the catheter.
Tamsulosin was started and on [**11-10**] midnight it was again
removed. He voided successfully. His creatinine on [**11-10**] was
1.7 and his Lasix was discontinued. On [**11-12**] his creatinine was
1.6 and he was discharged to home in stable condition. The VNA
will draw a chem 7 tomorrow and call the results to the floor.
Medications on Admission:
Simvastatin 80 mg po daily
Glipizide 7.5mg po BID
Metformin 1000mg po BID
Lisinopril 40mg po daily
Atenolol 50mg po daily
Benicar 40mg po daily
ASA 162 mg po daily
Viagra PRN
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: After 1 week decrease the dose to 1 pill
daily.
Disp:*70 Tablet(s)* Refills:*0*
9. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
12. 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:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
noninsulin dependent diabetes mellitus
s/p coronary artery bypass grafts
hyperlipidemia
hypertension
degenerative joint disease
cataracts
mild chronic renal insufficiency
s/p coronary angioplasty
diabetic neuropathy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 17753**]) in [**1-28**] weeks
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Please call for appointments
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2157-11-11**]
|
[
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"276.52",
"356.9",
"413.9",
"272.4",
"E878.2",
"414.01",
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icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.64",
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icd9pcs
|
[
[
[]
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10199, 10257
|
7119, 8499
|
346, 431
|
10541, 10548
|
2059, 7096
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10952, 11433
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1303, 1359
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8725, 10176
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10278, 10520
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8525, 8702
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10572, 10929
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1374, 2040
|
283, 308
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459, 938
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960, 1132
|
1148, 1287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,489
| 108,888
|
35629
|
Discharge summary
|
report
|
Admission Date: [**2195-7-21**] Discharge Date: [**2195-7-22**]
Date of Birth: [**2141-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Right carotid artery stenosis
Major Surgical or Invasive Procedure:
Carotid Angiography
Right Carotid Artery stent placement
History of Present Illness:
Mr. [**Name14 (STitle) 81077**] is a 53 year old man with a history of hypertension,
hyperlipidemia, tobacco abuse, alcohol abuse, and carotid artery
disease s/p bilateral carotid endarterectomy in the past who
presents for elective carotid angiography and stent placement
for critical re-stenosis of the right ICA. The patient
initially presented with transient right sided vision loss in
[**2189**] and was found to have 90% right sided carotid artery
stenosis, for which he underwent a CEA. In [**2192**], the patient
underwent CEA of his left carotid artery when he was discovered
to have an 80% stenosis on serial ultrasounds. He had been
following up regularly for his carotid artery disease with no
further neurologic symptoms, and was noted to have an 80% right
ICA stenosis on surveillance ultrasound at [**Hospital **] hospital in
[**Month (only) 956**] of this year. The patient followed up on [**2195-3-28**] with
a neck CTA here at [**Hospital1 18**] where it was confirmed that he had a
significant right ICA stenosis, though CTA estimated the
stenosis to be ~55-60% at the origin of the right ICA/ carotid
bulb. Given the results of his CTA, he was referred for
elective carotid stent placement and also enrolled in the [**Last Name (un) 81078**]
study.
.
Prior to admission, the patient states that he has been feeling
well without any neurologic symptoms of blurred vision, amarosis
fugax, slurred speech, facial droop, or focal extremity
weakness. He denies any history of stroke, pulmonary embolism,
chest pain, palpitations, shortness of breath, syncope, cough,
abdominal pain, diarrhea, black stools, paresthesias, muscle
weakness, or recent fevers, chills or rigors. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
.
#Carotid artery disease
- s/p right carotid endarterectomy in [**2189**] and a left carotid
endarterectomy in [**2192**]
- Amarosis Fugax of the Right eye prior to R CEA in [**2189**]
- [**2195-3-11**]: Carotid Duplex ([**Hospital **] Hospital) tight right 80% ICA
carotid stenosis, minimal (20-49%) Left ICA stenosis.
- [**2195-3-28**] [**Hospital1 18**] ~55-60% stenosis at the origin of the right ICA/
carotid bulb with a calcified plaque.
# Laryngeal CA Dx in '[**93**] s/p XRT, no chemo, no surgical
resection
Social History:
-Tobacco history: (+) - 60 pk year history of tobacco use, but
quit in '[**93**] after laryngeal CA diagnosis
-ETOH: (+) 4-8 beers daily, up to 20 beers in one day, last
drink the evening prior to admission 1.5 beers. Denies history
of DTs or seizures related to alcohol withdrawl.
-Illicit drugs: None
- Lives at home with his wife, works as a tractor [**Last Name (un) 28523**] driver
6 days/week driving up to 400 miles/day
Family History:
Mother died of MI age 53, Father with asbestosis related lung
CA, sister with skin CA, no other family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T=afebrile BP=142/83 HR=72 RR=17 O2 sat=97% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Poor dentition with no upper teeth.
NECK: Supple without distended JVP. Carotid endarterectomy scars
noted bilaterally.
CARDIAC: Regular rate, normal S1, S2. No extra heart sounds, no
rubs, no thrills, or lifts.
LUNGS: Unlabored respirations, no accessory muscle use. Mild
upper airway inspiratory/expiratory wheezes near trachea, no
crackles, or rhonchi.
ABDOMEN: Soft, NTND. No tenderness. Abd aorta not enlarged by
palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Warm and well perfused without rash
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Morning of [**7-22**]:
WBC 6.5, Hct 36.9, Plt 242
Na 138, K 4.3, Cl 105, CO2 23, BUN 14, Cr 1.0, Gl 105, Ca 8.7,
Mg 2.2, PO4 4.3
Brief Hospital Course:
53 year old man with history of tobacco abuse, alcohol abuse,
carotid artery disease s/p bilateral endarterectomies, who
presents for elective carotid angiography and stent placement
for asymptommatic critical right ICA stenosis.
Hospital course by problem:
.
#Carotid artery disease: Had successful stent placement to the
right carotid artery [**7-21**] without complications. When he first
arrived he was on a Nitro drip for blood pressure control. This
was weaned off without any need for additional medications. The
morning of [**7-22**] he was slightly hypertensive after walking
around and was given an extra 10mg of lisinopril on top of his
home dose of 20mg. His neurologic status did not change and his
peripheral pulses remained strong. He continued his home dose
of Aspirin, Plavix and Lipitor and was discharged on 30mg of
lisinopril daily. The morning prior to discharge he had some
soreness at his femoral access site that resolved with Percocet.
.
#Alcohol abuse: Patient has a history of heavy alcohol use,
typically 4-8 beers a day. He denies any previous history of
withdrawal symptoms or seizures, and says that his last drink
was [**7-20**], the day prior to surgery. He was monitored closely
with a CIWA scale, and was given three 10mg doses of Valium
because he was feeling anxious and was noted to be tremulous.
He did not want to talk to social work about his drinking habit.
Medications on Admission:
Lipitor 10 mg po daily
Plavix 75 mg po daily (started [**2195-7-14**])
Lisinopril 20mg po daily
Aspirin 325mg po daily
Folic Acid 3mg po daily
Vitamin B daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Carotid Artery Stenosis
Discharge Condition:
Stable
Discharge Instructions:
You had a stent placed in your right carotid artery because
increasing stenosis (blockage) of the artery was putting you at
risk for a stroke. You were then admitted to the cardiac care
unit overnight for close observation of your blood pressure and
neurologic status. Your blood pressure was high at first, but
stabilized and you are now ready to go home.
.
The following changes were made to your medication regimen:
1) Your dose of lisinopril was increased from 20mg once daily to
30mg once daily.
2) You were given a small amount of Percocet for pain relief for
the next day. You should only take this medication as needed for
severe pain. You should not drive, operate heavy machinery, or
make important decisions while taking this medication.
Please make sure you continue taking Aspirin, Plavix, Crestor,
Folic Acid and Vitamin B every day. Do not stop taking any of
your medications without checking with your doctor.
.
Please call you doctor immediately or go to the emergency room
if you develop any symptoms of slurred speech, weakness of your
legs or arms, blindness, or drooping of one side of your face.
Followup Instructions:
Please follow up with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3100**], the nurse practitioner who
works with Dr. [**Last Name (STitle) 911**] in one month. They will contact you to
make an appointment, but if they do not, please call ([**Telephone/Fax (1) 3942**].
.
You should also follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 31446**] [**Name (STitle) 8521**] from [**Hospital **] Medical Associates within 1-2 weeks.
You can contact his office at [**Telephone/Fax (1) 54268**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2195-7-23**]
|
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icd9cm
|
[
[
[]
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[
"00.63",
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"94.62",
"00.45",
"00.40"
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icd9pcs
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[
[
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6805, 6811
|
4610, 4840
|
345, 404
|
6885, 6894
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4457, 4587
|
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|
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|
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|
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2933, 3361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,373
| 185,699
|
46329+58898
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-3-6**] Discharge Date: [**2116-3-12**]
Service:
CHIEF COMPLAINT: Orthostatic hypotension.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 82-year-old
male with a past medical history significant for benign
prostatic hypertrophy (status post transurethral resection of
the prostate in [**2092**]), gout, hypertension, chronic renal
insufficiency ?, hypothyroidism and thrombocytopenia, status
post cerebrovascular accident, and anemia requiring
transfusion of packed red blood cells.
He was most recently hospitalization on [**2115-11-23**],
during which time he was treated for dehydration and acute
renal failure. In addition, during that hospitalization, the
was noted to have a systolic blood pressure in the 85-110
range and all of his antihypertension medications were
discontinued. In addition, he was noted to have a left
facial droop, and right tongue deviation, and MRI was ?
lacunar stroke. The patient was then placed on Aggrenox. He
was discharged to rehabilitation, and had been doing well and
had been at home with [**Hospital6 407**].
On [**2116-3-6**], VNA found the patient supine, blood pressure
100/60, sitting blood pressure 60/40, and standing blood
pressure 40/palpable. Although he lives in an
assisted-living facility. He has had a weight loss of
approximately 20 pounds over the past six months. He denied
any change in appetite. He denied any chest pain, shortness
of breath, or urinary signs or symptoms. He denied any
fevers, chills, nausea or shaking. He denied any bright red
blood per rectum. He denied any melena. He has positive
constipation alternating with loose bowel movements. He did
complain of dizziness when he changed positions from supine
to standing or supine to sitting, but he denied any loss of
consciousness and denied any confusion.
After the VNA found the patient to be orthostatic
hypotensive, the patient was sent to the Emergency
Department. He was given aggressive intravenous fluids, and
his orthostatic hypotension responded to three liters of
intravenous fluids. His initial examination was notable for
brown, guaiac negative stool, but several hours later, he had
sudden, explosive episodes of melena.
The patient then had a nasogastric lavage done, which was
clear. A GI consultation was obtained and evaluated the
patient and initially, an upper endoscopy was planned. A
type and cross was sent. The patient continued to have
profuse melena was admitted directly to the medical intensive
care unit.
PAST MEDICAL HISTORY: 1. Cerebrovascular accident. 2.
Transient ischemic attack. 3. Venous stasis ulcers. 4.
Chronic renal insufficiency ? 5. Benign prostatic
hypertrophy status post transurethral resection of the
prostate in [**2092**]. 6. Cataracts. 7. Hypertension. 8. Left
eye amaurosis. 9. Gout. 10. Hypothyroidism. 11. Anemia
requiring transfusion. 12. History of thrombocytopenia.
MEDICATIONS ON ADMISSION: 1. Levothyroxine 25 mcg p.o. q.d.
2. Tylenol p.r.n. 3. Aggrenox one tablet p.o. b.i.d. 4.
Allopurinol 100 mg p.o. q.d. 5. Tums. 6. ProMod one scoop
b.i.d. 7. Vitamin C 500 mg p.o. b.i.d. 8. Ensure.
SOCIAL HISTORY: He is a retired clerk. He denied any
alcohol or drug history. He denied any smoking history.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: None.
PHYSICAL EXAMINATION: On admission temperature was 98.8,
heart rate 108, blood pressure 91/58, respiratory rate 60, O2
saturation 98% on room air. HEENT: Mucous membranes were
dry. Neck: Jugular venous pressure flat. Lungs:
Bilaterally clear to auscultation. Cardiovascular: Normal.
Abdomen: Positive bowel sounds, soft, nontender,
nondistended abdomen. Guaiac negative stool initially. No
costovertebral angle tenderness. Extremities:
Lichenification of his hands with excoriation was noted;
erythema with venous stasis of bilateral lower extremities,
two small ulcers (1.5 cm), clearly demarcated, on the right
lower extremity, well granulated, one ulcer on the left lower
extremity/lateral calf, well granulated.
EKG: Normal sinus rhythm with a heart rate of 99, left
ventricular hypertrophy, normal intervals, no acute ST and T
wave changes. The EKG was compared with [**2115-11-23**].
LABORATORY DATA: On admission white blood cells was 12.6,
hematocrit 27.4, platelet count 211, MCV 95, sodium 141,
potassium 5.7 (slightly hemolyzed), chloride 109, bicarbonate
25, BUN 49, creatinine 1.1, glucose 106, PT 14.2, PTT 31.5,
INR 1.3.
IMPRESSION: An 82-year-old male with a history of
cerebrovascular accident and dehydration who was noted to
have orthostatic hypotension (standing blood pressure
40/palpable), when VNA visited him. His initial examination
was notable for negative guaiac and brown stool. However,
several hours later in the Emergency Department, he was noted
to have profuse episodes of melena. OGT lavage was done,
which revealed no bright red blood, and only brown-tinged
fluid, which cleared with lavage.
HOSPITAL COURSE: 1. GI bleed: The patient was admitted
directly to the medical intensive care unit and was typed and
crossed for blood, and was transfused initially five units on
hospital night number one. However, a repeat OGT lavage was
done which revealed again, no bright red blood, and
brown-tinged fluid, which cleared with lavage. Given the
fact that the nasogastric lavage was negative, and there was
no change in his acute condition, and there was no obvious
active life-threatening hemorrhage, the GI service deferred
on an emergent endoscopy.
The patient's hematocrit was checked q. 8 hours while in the
medical intensive care unit, and his hematocrit was stable
after transfusion of another unit of packed red cells (for a
total of six units) in the medical intensive care unit. The
question of an emergent/urgent endoscopy was approached again
with GI and since the patient was hemodynamically stable, and
his nasogastric lavage was negative, in the setting of a new
large pneumothorax, and without obvious life-threatening
active hemorrhage, GI deferred on endoscopy until the patient
was more medically stable. However, it was felt that if the
patient did become hemodynamically unstable, GI was always
available to do an emergent therapeutic intervention.
Throughout the patient's admission he had a rectal tube in
place, and large amounts of melena were produced every day.
Even though the patient had melena, his hematocrit was
checked initially q. 8 hours in the medical intensive care
unit and later q. 12 hours on the floor and his hematocrit
remained stable x 4 days. The patient will likely continue
to have melena for a couple of weeks, until his entire GI
system has been cleared out. Given that the patient's
hematocrit remained stable, there did not appear to be any
active blood loss.
On [**2116-3-11**], one day after the chest tube was pulled, GI did
an esophagogastroduodenoscopy to evaluate for the cause of
upper GI bleed. They found in the stomach, a single cratered
nonbleeding 15 mm ulcer in the pylorus. There were changes
of the ulcer base consistent with ulcer healing. There was
no visible vessel. There was distortion of the pylorus, and
edema of the surrounding mucosa. A cold forceps biopsy was
performed for histology. The duodenum was normal. GI
recommendations were to continue proton pump inhibitor, no
non-steroidal anti-inflammatory drugs, follow up the biopsy
results. In addition, the patient will be scheduled to have
a repeat endoscopy in eight weeks to document ulcer healing
and for possible repeat biopsy to exclude malignancy.
During the [**Hospital 228**] hospital course, he had two large-bore
peripheral IVs at all times. His hematocrit was checked q. 8
hours in the medical intensive care unit and q. 12 hours
while on the floor and has been stable at 29-31%. He was on
IV Protonix (PPI) 40 mg IV q. 12 hours. In addition, there
was no aspirin, no Aggrenox, no non-steroidal
anti-inflammatory drugs given. As an outpatient, the patient
should continue the Protonix, but will be changed to a p.o.
form. The patient should not have any aspirin, Aggrenox, or
any more non-steroidal anti-inflammatory drugs, until further
directed to do so by GI.
2. Pulmonary: The [**Hospital 228**] medical intensive care unit
course was complicated by an iatrogenic pneumothorax, which
was caused status post numerous left subclavian central line
placement attempts. The patient's pneumothorax was moderate
to large sized and cardiothoracic surgery was called to place
a chest tube. A chest tube was placed on [**2116-3-6**] without
event. Initially, the chest tube had air leaks, which later
resolved. The thoracic service continued to follow the chest
tube throughout his admission and repeat chest x-rays were
obtained to evaluate the progression/resolution of it. On
[**2116-3-10**], cardiothoracic surgery pulled the chest tube, and a
repeat chest x-ray obtained showed that the pneumothorax was
slightly smaller in size. The patient was stable on room air
and had O2 saturations of 95-99%. The patient was
comfortable on room air and did not require any supplemental
oxygen at that point in time. In addition, the patient had a
large amount of subcutaneous emphysema/crepitus on his left
hemithorax. This had decreased over several days of his
hospital admission, but was still present.
3. Hematology: The patient is a difficult crossmatch
secondary to numerous antibodies. The patient had a type and
screen sent every three days, and always had three units of
packed red cells ready/reserved for this patient. It took
several hours for the patient to be crossmatched for a unit,
secondary to his numerous antibodies. The patient was
transfused a total of......units of packed red cells in the
medical intensive care unit, and did not require any more
transfusions while on the floor.
4. Acidosis: The patient developed a nonanion gap acidosis
(low bicarbonate of 17), hyperchloremic (117). This was
likely secondary to an expansion acidosis, given his
aggressive IV fluid hydration with normal saline. When the
patient was transferred to the floor, the patient's
intravenous fluids were changed from normal saline to
lactated Ringer solution (which has bicarbonate in it), and
his intravenous fluids were continued at 125 cc an hour.
Over the next three to four days on the floor, his
bicarbonate slowly increased to 20, and his chloride
decreased to 110. There appeared to be resolving
hyperchloremic nonanion gap acidosis.
5. Bilateral leg ulcers/chronic venous stasis: The patient's
home regimen was continued with Bactroban ointment, and
normal saline wet-to-dry dressing changes on his ulcers q.
day. In addition, the patient's legs were wrapped with
Kerlix, because there was a significant amount of
oozing/weeping. Of note, the patient wears compression
stockings at home. He stated that in the rush to get him to
the hospital, these were left at home. If possible, the
patient should be continued on these compression stockings,
which the patient says help his leg edema and oozing a great
deal.
6. Prophylaxis: The patient was given subcutaneous heparin
for DVT prophylaxis. Pneumoboots were not placed on this
patient, secondary to them being too painful to his lower
extremities.
7. Fluids, electrolytes and nutrition: The patient was given
fluid resuscitation with normal saline at 150 cc/hour in the
medical intensive care unit, which was changed to lactated
Ringer solution at 125 cc/hour on the floor. The patient was
kept initially n.p.o. and as it seemed that his GI bleeding
had resolved, and hematocrit was stable, he was transitioned
to sips of clears. While on the floor, he was given sips of
clears as well. After his esophagogastroduodenoscopy, which
showed a healing ulcer, he was transitioned to clears, to
full liquids, and is now tolerating a regular diet well.
8. Ins and outs: The patient has no history of coronary
artery disease or congestive heart failure. Strict I's and
O's were kept on this patient, which included his rectal
tube, chest tube, intravenous fluids, and urine output. The
patient did not show any signs of pulmonary edema or elevated
jugular venous distension throughout his aggressive
intravenous fluids hydration. Urine output was good and
there were no problems with the discontinuation of his Foley
catheter. The patient had a transurethral resection of the
prostate in [**2092**]. The patient continued to have melena, have
his hematocrit was stable and it is likely that his melena
will continue for a while.
9. Hypothyroidism: The patient was continued on
levothyroxine 24 mg p.o. q.d.
DISPOSITION: The patient is status post EGD x 1 day and
doing well. His hematocrit is stable. He is afebrile and
hemodynamically stable. He is saturating 95-99% on room air.
He is comfortable breathing at room air. The patient feels
well, and is ready to go for rehabilitation. He has
expressed the desire to get out of bed and to begin walking
and working himself again. The patient is discharged to a
rehabilitation center.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed, secondary to pyloric ulcer.
2. Anemia, secondary to acute blood loss, requiring
transfusion.
3. Pneumothorax, status post chest tube placement and
removal.
4. Hypothyroidism.
5. Venous stasis disease/leg ulcers.
6. Intravenous fluid expansion acidosis.
7. Numerous antibodies and his blood, difficult crossmatch.
8. Fifteen mm pyloric ulcer, showing evidence of healing.
DISCHARGE FOLLOW UP: The patient will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient will
follow up with GI for a repeat EGD in eight weeks to document
ulcer healing, and possible repeat biopsy to exclude
malignancy.
DISCHARGE INSTRUCTIONS:
1. The patient should continue to use a proton pump
inhibitor.
2. Patient is absolutely not to use any non-steroidal
anti-inflammatory drugs, aspirin, or Aggrenox.
3. The patient should had a hematocrit checked twice a week.
If there is evidence of decreasing hematocrit (patient's
hematocrit is currently stable at the 29-31% range) to less
than 26-27%, recommend investigation.
*THE PATIENT'S PAST MEDICAL HISTORY INCLUDES THROMBOCYTOPENIA
AS WELL AS CHRONIC RENAL INSUFFICIENCY. HOWEVER DURING THIS
HOSPITAL ADMISSION, HIS PLATELET COUNT HAS BEEN IN THE RANGE
OF 140,000 TO 211,000. THE PATIENT DOES NOT SHOW SIGNS OF
THROMBOCYTOPENIA AT THIS POINT IN TIME. IN ADDITION, THE
PATIENT HAS A PAST MEDICAL HISTORY LISTED OF CHRONIC RENAL
INSUFFICIENCY. HOWEVER, ON THE DAY OF DISCHARGE, AS WELL AS
THE DAY BEFORE DISCHARGE, THE PATIENT'S CREATININE WAS 0.9 TO
1.0, WITH A BUN OF 16 TO 20. THESE LABORATORY VALUES DO NOT
REFLECT ANY ELEMENT OF CHRONIC RENAL INSUFFICIENCY.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. 12 hours.
2. Levothyroxine 25 mcg p.o. q. day.
3. Heparin 5,000 units subcutaneous q. 12 hours, while
patient is in bed. If the patient is ambulating with
physical therapy, this may be discontinued.
4. Tums.
5. Vitamin C 500 mg p.o. b.i.d.
6. Ensure.
7. ProMod one scoop b.i.d.
8. Allopurinol 100 mg p.o. q.d.
9. Bactroban ointment (mupirocin cream 2%), one application
b.i.d. to skin ulcers.
10. Tylenol 325-650 mg p.o. q. 4-6 hours p.r.n.
11. Miconazole powder 2% one application b.i.d. p.r.n. to his
taenia.
12. Protonix 40 mg p.o. q. 12 hours.
13. Absolutely no non-steroidal anti-inflammatory drugs,
aspirin, or Aggrenox.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. [**MD Number(1) 14612**]
Dictated By:[**Last Name (NamePattern1) 14484**]
MEDQUIST36
D: [**2116-3-12**] 12:07
T: [**2116-3-12**] 13:03
JOB#: [**Job Number 98489**]
Name: [**Known lastname 15715**], [**Known firstname **] Unit No: [**Numeric Identifier 15716**]
Admission Date: [**2116-3-6**] Discharge Date: [**2116-3-12**]
Date of Birth: [**2033-11-9**] Sex: M
Service:
ADDENDED DISCHARGE MEDICATIONS:
1. Levothyroxine 25 mcg p.o. q. day
2. Heparin 5000 units subcutaneously q. 12 hours, as long as
the patient is in bed, if the patient is up, and ambulating
with physical therapy, this may be discontinued
3. Bactroban 2% cream, topical b.i.d., apply to leg ulcers
4. Miconazole powder, apply b.i.d. as needed for tinea
5. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn
6. Protonix 40 mg p.o. b.i.d.
7. Allopurinol 100 mg p.o. q.d.
8. TUMS (calcium carbonate 500 mg p.o. b.i.d.)
9. ProMod powder, one scoop p.o. b.i.d.
10. Vitamin C 500 mg p.o. b.i.d.
11. Ensure one can p.o. t.i.d. with meals
12. Aquaphor ointment one application topical b.i.d., apply
to affected feet/arms/back
13. Silvadene 1%, apply topically b.i.d. to leg ulcers
14. Humalog (Triamcinolone) 0.1% cream, apply topical
b.i.d.-q.i.d., apply to affected areas on hands and arms
Primary care physician/Gastroenterology should follow up on
biopsy (duodenal ulcer), results and Helicobacter pylori
antibody resolved. Both of these are pending at the time of
discharge.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-852
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2116-3-12**] 14:42
T: [**2116-3-12**] 18:45
JOB#: [**Job Number 15717**]
|
[
"707.12",
"276.5",
"459.81",
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"531.40",
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"E878.8",
"512.1",
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] |
icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
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3349, 3356
|
13122, 13537
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16099, 17354
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3379, 5006
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101, 127
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156, 2532
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2555, 2933
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3182, 3332
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,233
| 134,999
|
6528
|
Discharge summary
|
report
|
Admission Date: [**2133-1-4**] Discharge Date: [**2133-1-12**]
Date of Birth: [**2063-6-17**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Phenergan / Percocet
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 yo M w/ locally advanced esophageal ca, copd with baseline
02 req., sever emphysema, htn. Initially presented on [**2133-1-4**]
to [**Hospital1 18**] ED with SOB, productive cough, DOE and chest pain a [**3-1**]
days. In the ED: initial vitals were 98.3, 107/65, 109, 30, 96%
on 3L. He was given ASA 325mg, atrovent neb, prednisone 40mg x1.
A bedside echo showed a new pericardial effusion. A CTA showed
no PE but was significant for a small-mod pericardial effusion
as well as some pericardial enhancement, small right-sided
pleural effusion, increased mediastinal lymphadenopathy (?mets
vs. CHF). CE were negative. He was initially admitted to the
medical floor. Now he is being transferred to the [**Hospital Unit Name 153**] for
respiratory distress. This morning, the patient was triggered
for hypoxia (desaturation to72% on 3L NC) and tachypnea. His 02
sats improved to 95% on NRB. He was given 125mg solumedrol IV
with improvement of RR. He was given 20IV lasix, and a foley
was placed. He was then transitioned to a humidified face mask
at 70% 02. His initial ABG is 7.46/41/77, lactatea 1.6. After
foley placement he immediately put out 525ml of UOP. He was
given another 10 IV lasix and 1mg morphine IV.
Of note: hospitalized in [**10-3**] for SOB, complete collapse of LLL,
a pleural catheter was placed and almost completely drained the
left-sided effusion, cytology and micro were negative. The
catheter was removed. There was only slight re-expansion of the
LLL.
Past Medical History:
PMH:
1. locally advanced esophageal adenocarcinoma diagnosed in
[**8-/2131**], status post 5FU and Cisplatin, s/p complete surgical
resection. No distant metastases.
2. COPD
3. History of recurrent gallstone pancreatitis with resultant
chronic pancreatitis, status post cholecystectomy.
4. DM type 2
5. GERD
6. Hypercholesterolemia
7. Status post port placement and J-tube placmement on [**9-20**].
8. h/o pneumonia
Past Surgical History:
[**2132-1-4**] Laparoscopic esophagectomy
[**2132-1-10**] Right VATS with evacuation of hematoma
Social History:
He lives at home with his wife and children. The patient quit
smoking about 15 years ago, although he smoked 1-2 packs per day
for about 30 years. He worked as a cook and a chef. Occasional
EtOH. Speaks Cantonese.
Family History:
Non-contributory.
Physical Exam:
VS: Temp: 99.5 BP:112 /64 HR:119 RR:25 O2sat 96 pulsus
paradoxis: 8
GEN: mildly tachypneic, but comfortable, high flow mask in
place, thirsty
HEENT: PERRL, MMM, JVD to ear, no carotid bruit.
RESP: rales 3/4 up on the right, bronchial breath sounds and
basal rales on left. Poor air-movement throughout. +egophany on
left mid and lower lung fields.
CV: regular rhythm, tachycardic, no murmurs or rubs
ABD: J -tube in place and dressed. normoactive BS, NT/ND
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3.
Pertinent Results:
[**2133-1-4**] 04:00PM CK(CPK)-48
[**2133-1-4**] 04:00PM cTropnT-<0.01
[**2133-1-4**] 04:00PM CK-MB-NotDone proBNP-695*
[**2133-1-4**] 09:25AM GLUCOSE-138* UREA N-27* CREAT-0.9 SODIUM-134
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
[**2133-1-4**] 09:25AM estGFR-Using this
[**2133-1-4**] 09:25AM CK(CPK)-67
[**2133-1-4**] 09:25AM CK-MB-NotDone cTropnT-<0.01 proBNP-631*
[**2133-1-4**] 09:25AM WBC-7.3 RBC-2.76* HGB-10.6* HCT-31.5*
MCV-114* MCH-38.2* MCHC-33.5 RDW-13.5
[**2133-1-4**] 09:25AM NEUTS-75.8* LYMPHS-14.0* MONOS-7.5 EOS-2.7
BASOS-0.2
[**2133-1-4**] 09:25AM PLT COUNT-188
AT DISCHARGE.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2133-1-12**] 06:10AM 7.0 3.05* 11.2* 34.3* 112* 36.8* 32.7
13.6 174
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2133-1-12**] 06:10AM 190* 31* 0.8 132* 4.3 96 30 10
.
[**1-12**] VIDEO SWALLOW
.
VIDEO FLUOROSCOPIC OROPHARYNGEAL SWALLOWING EVALUATION: The oral
phase was normal. The pharyngeal phase was notable for delayed
initiation of swallowing; however, there is normal hyoid
excursion and laryngeal elevation after initiation of the
swallow. No penetration or aspiration was seen. Limited
fluoroscopic images of the thorax show the gastric pull through.
Of note, the patient complained of fullness after swallowing,
however, no mass lesion was identified.
Limited fluoroscopic images also demonstrate degenerative
changes in the cervical spine.
IMPRESSION: No evidence of penetration or aspiration on
swallowing. For full details, please see the report by speech
and [**Hospital3 25040**] services of the same day.
.
ECHO [**2133-1-9**]
.
The estimated right atrial pressure is 0-10mmHg. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is a small pericardial effusion. There is an anterior space
which most likely represents a fat pad. There are no
echocardiographic signs of tamponade.
IMPRESSION: A very small pericardial effusion, without signs of
tamponade.
.
[**2133-1-4**] CTA CHEST
.
CTA CHEST: There is normal filling of the pulmonary arterial
vasculature without evidence of pulmonary embolism. There is
interval increase in the size of the pericardial effusion, now
small to moderate. Subtle pericardial enhancement is noted. The
patient is status post gastric pull-up for esophageal cancer.
There is mediastinal lymphadenopathy, which appears to have
increased in the short interval since [**2132-12-31**]. This is
concerning for either infection or may be caused by CHF. Again
noted is severe centrilobular emphysema bilaterally with
predominance in the upper lobes. There is stable left lower lobe
atelectasis and effusion. There is a new small right-sided
pleural effusion with associated mild compressive atelectasis.
In addition, there is worsening of bilateral basilar
atelectasis. No axillary lymphadenopathy.
Non-contrast images through the upper abdomen do not demonstrate
acute pathology. The patient is status post cholecystectomy.
BONE WINDOWS: No evidence of suspicious lytic or sclerotic
lesions.
IMPRESSION:
1. Increased pericardial effusion, now small to moderate. Note
is also made of subtle pericardial enhancement - in conjunction
with the FDG avidity of the pericard on the recent PET-CT this
raises the possibility of pericarditis. D/w Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
on [**2133-1-4**].
2. New small right-sided pleural effusion.
3. Increased bilateral basilar atelectasis.
4. Increased mediastinal lymphadenopathy in the short interval
since [**2132-12-31**]. While the lymphadenopathy per se is
concerning for metastatic disease, the rapid interval change is
more likely due to congestive heart failure or may due to
infection.
6. No evidence of PE.
Brief Hospital Course:
69 yo M w/ esophageal CA s/p resection, copd, emphysema, htn,
dysphagia w/ [**Hospital 12353**] transferred to [**Hospital Unit Name **] to hypoxia, tachypnea.
.
# hypoxia: Pt. exp. acute desat to 72% on 3L NC. His CXR was
suggestive of worsening pleural effusion. He was given
solumedrol 125mg IV. He resp. status improved w/ 30 IV lasix
(good UOP) and 1mg IV morphine. Differential for hypoxia is CHF,
pulmonary edema, tamponade, pna, copd exacerbation, PE (although
neg CTA 2 days ago), pneumothorax. The patient was breathig
comfortably on 40% facemask by the time he was transferred to
the [**Hospital Unit Name 153**]. he remained on facemask overnight and did not develop
respiratory distress or hemodynamic instability. CXR on [**1-7**]
showing less fluid overload s/p lasix compared to [**1-6**].
Pericardial effusion thought not to be contributing to resp
compromise. he was continued on broad spectrum antibiotics for
possible pneumonia. His steroids were tapered after patient was
stabilized. hE FINISHED VANCOMYCIN COURSE ON [**12-27**]
.
# Pericardial effusion: New moderate pericardial effusion (2cm)
without tamponade physiology seen on echo on [**2133-1-5**]. Pulsus at
presentation was 9. His pulsus was followed q6h and remained
between [**9-4**]. he did not develop any signs of hemodynamic
compromise. It is unclear why he has developed a pericardial
effusion. Differential is idiopathic, malignancy, viral
(presents with cough for several days), bacterial, pericarditis
(pt presented with CP, some enhancement seen on CTA),
hypothyroidism. Cardiology following and did not believe
effusion was large enough to tap for diagnostic testing. They
reccommended repeat echo on [**1-9**]. PPD was also placed.
.
# esophageal ca: Plans for followup with outpatient oncologist
Dr. [**Last Name (STitle) **].
.
# DMII: SSI, restarted actos on discharge.
.
# pancreatic insufficiency: continued replacement panc enzymes
.
# gastroparesis: continue reglan.
.
# pain control: continued fentanyl patch.
Medications on Admission:
flovent 44mcg 2 puffs [**Hospital1 **]
actos 45 qd
spiriva 18mcg qday
reglan 10mg tid
iron
enulose 45 ml q day
mvi
senna
fentanyl patch 25mcg
prevacid 30 qday
replete w/ fiber 5 cans@ 90
LIPRAM-PN20 1 cap qday
Discharge Medications:
1. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
2. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
3. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: One (1) PO DAILY
(Daily).
4. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
8. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*30 Suppository(s)* Refills:*0*
9. Actos 45 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. Flovent Diskus 50 mcg/Actuation Disk with Device [**Last Name (STitle) **]: Two
(2) puffs Inhalation twice a day.
11. Enulose 10 gram/15 mL Solution [**Last Name (STitle) **]: Forty Five (45) ml PO
once a day.
12. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
13. Prednisone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
14. Prednisone 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
15. Saliva Substitute 0.15-0.15 % Solution [**Last Name (STitle) **]: One (1) swab
Mucous membrane every four (4) hours as needed for dry mouth:
Use to moisten mouth as needed.
Disp:*1 bottle* Refills:*3*
16. Combivent 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**1-29**] inhalation
Inhalation four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aspiration Pneumonia due to dysphagia
COPD flare
HF, diastolic, acute on chronic
Esophageal adenocarcinoma with increasing mediastinal
lymphadenopathy.
Discharge Condition:
Good. Afebrile. At baseline oxygen
Discharge Instructions:
You were admitted for a COPD exacerbation and possible lung
infection associated with not being able to swallow.
You cannot take any food or drink by mouth. You must get all
your nutrition through the J-tube. You can use mouth swabs to
make your mouth more comfortable. Get the tube feeds always
while in an upright position>45 degrees.
.
You also have a bit of fluid around your heart and must see a
heart doctor to monitor it. You have an appointment with Dr
[**Last Name (STitle) 171**], see below.
.
Finish the prednisone: 10 mg a day for 3 days, 5 mg a day for 3
days, and then 2.5 mg day for 2 days.
Keep using your medications and don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 21334**]
[**Name5 (PTitle) 4314**]. Please return to the Emergency Department for any
concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2133-2-4**] 1:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2133-2-4**] 1:40
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2133-2-4**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2133-1-21**]
10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2133-1-21**]
1:30
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
[
"196.1",
"577.8",
"491.21",
"511.9",
"428.33",
"530.81",
"536.3",
"V44.4",
"507.0",
"428.0",
"V10.03",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11246, 11301
|
7067, 9089
|
312, 318
|
11497, 11534
|
3226, 7044
|
12381, 13180
|
2639, 2658
|
9350, 11223
|
11322, 11476
|
9115, 9327
|
11558, 12358
|
2291, 2391
|
2673, 3207
|
252, 274
|
347, 1829
|
1851, 2268
|
2407, 2623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,021
| 194,116
|
26943
|
Discharge summary
|
report
|
Admission Date: [**2149-3-21**] Discharge Date: [**2149-3-25**]
Date of Birth: [**2074-7-25**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Phenytoin / Phenobarbital / Augmentin / Aspirin / Zithromax /
Cefazolin / Sudafed / Clindamycin / Vancomycin
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Left elbow failed fixation
Major Surgical or Invasive Procedure:
[**2149-3-21**]: Left elbow removal of hardware, total elbow
arthroplasty, ulnar nerve transposition, extensor mechanism
History of Present Illness:
Ms. [**Known lastname 3647**] is a 74-year-old female with who sustained a distal
humerus fracture. She underwent 2 operative fixations at an
outside hospital. She presented to Dr. [**Last Name (STitle) 1005**] with a failure
of fixation. She now presents for operative repair.
Past Medical History:
1. RA on chronic low dose prednisone, methotrexate and
etanercept which was held recently secondary to bacterial
sinusitis and ORIF
*SLE with no known renal involvement, on chronic prednisone
2. Raynaud's syndrome ?
3. Osteoporosis with spontaneous rib fractures in [**2143**]
4. COPD [**November 2144**] FEV1 1.46 L FEV1/FVC of 61 c/w mod COPD
5. GERD with Schatzki ring requiring endoscopy
6. Hiatal Hernia
7. Anxiety
8. Oral HSV
9. Chronic anemia, on folate, B12, colonoscopy normal 3-4 years
ago, SPEP, UPEP negative
10. exercise stress test that per the patient were negative as
well as multiple ED-ROMIs.
12.?Mild AS by echo per patient
Social History:
Lives alone but family nearby
Family History:
NC
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: LUE incision healed, + pulses
Pertinent Results:
[**2149-3-25**] 07:45AM BLOOD WBC-8.8 RBC-2.99* Hgb-9.9* Hct-30.1*
MCV-101* MCH-33.1* MCHC-32.9 RDW-17.8* Plt Ct-276
[**2149-3-24**] 11:00AM BLOOD WBC-8.5 RBC-2.92* Hgb-9.8* Hct-29.6*
MCV-102* MCH-33.4* MCHC-32.9 RDW-18.1* Plt Ct-276
[**2149-3-23**] 06:25AM BLOOD WBC-9.5 RBC-2.69* Hgb-8.9* Hct-26.9*
MCV-100* MCH-33.0* MCHC-33.0 RDW-18.6* Plt Ct-270
[**2149-3-22**] 02:55AM BLOOD WBC-12.3*# RBC-2.50* Hgb-8.5* Hct-25.7*
MCV-103* MCH-33.8* MCHC-32.9 RDW-17.0* Plt Ct-298
[**2149-3-21**] 05:56PM BLOOD WBC-7.6 RBC-2.73* Hgb-9.1* Hct-28.0*
MCV-102*# MCH-33.4* MCHC-32.6 RDW-16.6* Plt Ct-316
[**2149-3-23**] 06:25AM BLOOD Glucose-90 UreaN-20 Creat-1.2* Na-139
K-4.3 Cl-109* HCO3-25 AnGap-9
[**2149-3-22**] 02:15AM BLOOD Glucose-128* UreaN-22* Creat-1.1 Na-139
K-5.0 Cl-109* HCO3-24 AnGap-11
[**2149-3-21**] 05:56PM BLOOD Glucose-163* UreaN-23* Creat-1.2* Na-140
K-4.8 Cl-110* HCO3-24 AnGap-11
Brief Hospital Course:
Ms. [**Known lastname 3647**] presented to the [**Hospital1 18**] on [**2149-3-21**] for an elective
removal of hardware, total elbow arthroplasty with ulnar nerve
transposition and extensor mechanism repair. Prior to surgery
she was prepped and consented, and taken to surgery. She
tolerated the procedure well, was extubated, transferred to the
recovery room. In the recovery room she was reintubated due to
respiratory failure. She was transfused with 1 unit of packed
red blood cells due to acute blood loss anemia. She was weaned
an extubated and then transferred to the floor. On the floor
she was seen by physical and occupational therapy to improve her
strength and mobility. She was fitted in an orthoplast splint.
The rest of her hospital stay was uneventful with her lab data
and vitals signs within normal limits and her pain controlled.
She is being discharged today in stable condition.
Medications on Admission:
Albuterol prn, Amiodarone 100qod, Beclomethasone, fexofenadine
180', Flonase 50mcg', Folic acid 1', Formoterol fumarate,
Levothyroxine 50mcg', Methotrexate 5(5d/wk), Minocycline 100'',
Singulair 10', Protonix 40', prednisone 6', Forteo 750mcg',
Spiriva 18'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Prednisone 1 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO Q48 H ().
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
9. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Methotrexate Sodium 2.5 mg Tablet Sig: Five (5) Tablet PO
1X/WEEK (FR).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
20. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
21. Medication
Please continue taking all other medications as directed by your
primary care [**Provider Number 66259**]. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
Left elbow painful hardware
Acute blood loss anemia
Respiratory failure requiring reintubation
Discharge Condition:
Stable
Discharge Instructions:
Continue to be non-weight bearing on your left arm.
Continue your medications as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: Ambulate
Left upper extremity: Non weight bearing
will need orthoplast splint at that point and ROM exercises ONLY
0-90 DEGREES BY PT/OT no flexion past 90deg
Treatment Frequency:
Staples/sutures out 14 days after surgery or at follow up
appointment.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics on
[**2149-4-8**], please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2149-4-15**] 10:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2149-9-16**] 10:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2149-9-16**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2149-3-25**]
|
[
"996.78",
"492.8",
"714.0",
"V58.65",
"285.1",
"518.81",
"733.82",
"530.81",
"443.0",
"733.00",
"710.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.6",
"81.84",
"96.04",
"77.43",
"83.21",
"96.71",
"78.63"
] |
icd9pcs
|
[
[
[]
]
] |
5776, 5834
|
2695, 3605
|
401, 524
|
5972, 5980
|
1781, 2672
|
6572, 7342
|
1561, 1565
|
3912, 5753
|
5855, 5951
|
3631, 3889
|
6004, 6265
|
1580, 1762
|
6283, 6456
|
335, 363
|
552, 832
|
6477, 6549
|
854, 1498
|
1514, 1545
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,935
| 176,163
|
8760
|
Discharge summary
|
report
|
Admission Date: [**2132-1-25**] Discharge Date: [**2132-2-2**]
Date of Birth: [**2074-5-8**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines / Carbamazepine / Levaquin
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
MRSA bacteremia, endocarditis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 yo male with ESRD on HD (via dialysis line) s/p 2 failed
kidney transplants, HTN, WPW, PVD s/p PTCA of R proximal
posterior tibialis artery [**9-17**], s/p left femoral anterior-tibial
bypass 7/200, pelvic fx [**2125**] wheelchair-bound s/p left hip
replacement who initially presented to [**Hospital6 33**] on
[**2132-1-14**] with mental status change x 12 hours and generalized
weakness x 24 hours. Except for chronic low back pain, a
decubitus ulcer and a heel ulcer, ROS was negative. In the ED he
was febrile. A CXR was clear and he does not make urine. He was
found to be bacteremic with MRSA presumed to be dialysis line
sepsis. His tunneled Dialysis line was removed in the OR on
[**1-14**]. Line tip and 2 sets of blood cultures from [**1-14**] grew MRSA.
He was treated with multiple antibiotics including ceftriaxone,
zosyn, vancomycin, and gentamicin. Surveillance blood cultures
following removal of the HD line grew MRSA. Subsequent TEE
reportedly revealed three vegetations on the patient??????s mitral
valve with 1+MR, LVEF 55%. He has been noted to have embolic
phenomena involving L thumb biopsied and debrided (thought to be
infected) and on the penis throught to be vascular in nature.
Spine MRI reportedly negative for epidural abscess. Patient has
been treated with vancomycin. Gentamicin not included in
treatment regimen. Patient continues to be bacteremic thus far
with blood cultures still positive as recently as [**1-24**].
He has been dialyzed with temporary catheters since still
bacteremic. Before today, he was last successfully dialyzed
Monday [**1-21**] due to inability to gain IV access. Today he had a
temporary femoral line placement today [**1-25**] and was dialyzed
prior to transfer for a K of 6.1 but reportedly not volume
overloaded or acidotic. Other active issues have been his sacral
decubitus ulcer which has been receiving aggressive wound care.
He also has a necrotic, infected R heel ulcer that per vascular
surgery consult at OSH, may require amputation (followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]). He has also has been delerious at the OSH
with negative head CT which has been attributed to toxic
metabolic encephalopathy.
The patient did have a MICU course for hypotension/septic
physiology during which the patient was briefly on pressors. The
patient had been on the medical floor at the OSH for two days
but was transferred to the MICU Tuesdsay [**1-22**] for closer
monitoring for blood pressures in the 90s systolic. He was to be
transferred to the medical floor today, [**1-25**] but a medical bed
became available here at [**Hospital1 18**] and family requested transfer.
Upon arrival to the medical floor at [**Hospital1 18**], patient continues to
be disoriented. He is A+Ox1. His T was 99, BP 84/50, HR 120s, RR
20, O2 100% 2LNC. Given hypotension, he was given a 500 cc NS
bolus and was transferred to the MICU. Upon arrival to the MICU,
patient continues to be delerius but BPs improved to 100s.
Past Medical History:
PMH:
# ESRD on HD since '[**11**] s/p failed transplant x2 ([**2112**], [**2123**])
# PVD s/p LT femoral a. tibial bypass, PTCA Rt prox post
tibialis artery.
# Hypertension
# CAD
- ETT MIBI [**12-17**]: partially rev. apical/inf wall defect
# Hx fibrocystocytoma in the Lt axilla s/p removal in [**2118**] at
[**Hospital1 2025**]-> treated with XRT
# Depression
# Back pain 2nd T11/12 wedge compression
# Restless leg syndrome
# Peripheral Neuropathy
# Secondary hyperparathyroidism
# Psoriatic arthritis
# Hx [**Doctor Last Name **] Parkinson white
.
PSH:
# s/p L hip replacement
# L fem-at bypass [**2124**]
# R AT atherectomy and PTA [**6-16**]
# RT PT PTA [**2130-10-5**]
# failed renal tx x2
Social History:
Per OSH records, has occasional EtOH use. Denies tobacco and
other drugs. Married with 3 children.
Family History:
heart disease in father and brothers.
Physical Exam:
PE: T: 99.6 BP: 103/65 HR: 105 RR: 12 O2 100% 2LNC
Gen: Laying in bed, comfortable. Falling asleep easily but
arousable.
HEENT: No conjunctival pallor. No icterus. MMM. Poor dentition
NECK: Supple, No LAD. JVP low.
CV: regular w/ early beats. tachycardic. [**3-20**] sys murmur.
LUNGS: CTAB, good BS BL
ABD: NABS. Soft, NT, ND. No HSM
EXT: Chronic venous stasis in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. Mult scabbed skin
breaks in legs. Contracture of digits in UEs w/ sclerosis of
skin. R heel ulcer dressed. L thumb dressed.
GU: necrotic penile tip w/o drainage. R femoral HD line intact
SKIN: Multiple hypokeratotic circular lesions on upper and lower
extremities. Stage 1-2 sacral decub.
NEURO: A&Ox1 to self. Agitated but redirectable. CN 2-12 intact.
Strength and sensory exam limited by patient cooperativeness but
moving all extremities.
Pertinent Results:
ECG [**1-25**]: sinus tach @ 110 w/ PVCs. LAD. Borderline LBBB +/-
LAFB. Borderline 1st degree AVB. QW in III. Poor RW progression.
TWI in I, aVL, V4-6. Compared to ECG from [**2132-1-14**], PR interval
is prolonged.
OSH STUDIES:
TEE:
1. L ventricle normal w/ mildly reduced sys function and mild
global HK, more pronounced inferoseptal HK
2. mitral valve leaflets thickened, particularly anterior valve.
3 mobile, somewhat calcific echodensities seen under leaflets
associatd with chordae c/w vegetation. Largest is 1 cm/0.6 cm.
Mild MR. [**First Name (Titles) **] [**Last Name (Titles) 30646**] are MV to suggest abscess.
3. Aortic valve trileaflet. Nodular calcification at base of
leaflets. Mild AS w/ peak gradietnt 25 mmHg. No AI. No
vegetation
4. No thrombus in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**].
5. No significant TR
6. interatrial septum is aneurysmal. No color flow abnormalitiy.
A Chiari network is seen in R atrium w/ is normal embryologic
remnant.
7. RV appears preserved in size and function
8. No pericardial effusion
9. Mild atherosclerotic plaque in descending thoracic aorta
CT lumbar spine:
1. No evidence of discitis osteomyelitis. Destructive changes
noted at L2/3 level are essentially unchanged when compared to
MRI performed on [**2131-5-9**] and CT dated [**2129**]. These findings most
likely represent dialysis-associated amyloid spondylarthropathy.
2. multilevel degenerative change as described resultant severe
central canal stenosis at multiple levels as well as bilateral
foraminal stenosis as described above. Byunching of the nerve
root surrounding the conus is visualized likely reflecting
severe central canal stenosis at more inferior levels.
3. The kidneys are atrophic and largely replaced by cysts
consistent with the history of long standing renal failure and
dialysis.
TTE:
1. EF 50-55%. Concentric LVH. 1+ MR. 1+TR. PASP estimatd at 17
mmHg.
CT head [**1-23**]:
No acute intracranial process or significant change from [**1-14**].
Some central atrophy. Small basal gangioonic lacunar infarct as
before. New inflammatory changes within the R mastoid air cells
and R inner ear.
CT head [**1-14**]: negative for ICH
CXR [**1-25**]: small focu sof air space disease R medial chest base,
slightly worse. L perihilar atelectasis. No evidence of CHF.
Brief Hospital Course:
This is a 57 yo male with ESRD on HD (via dialysis line) s/p 2
failed kidney transplants, HTN, WPW, PVD who was transferred
from OSH w/ MRSA bacteremia and mitral valve endocarditis.
Based on all of the issues below, the family decided on [**2132-1-31**]
to make the patient comfort measures only. He was terminally
extubated and pressors turned off on [**2132-1-31**] at 6:30pm. The
patient passed away on [**2132-2-2**].
# ID - Patient with persistent MRSA bacteremia with evidence of
vegetations on mitral valve with septic emboli to the hand and
penis. Presumed source was infected HD line, which was removed
at the OSH. A temporary right femoral HD line was placed on
[**1-23**] prior to transfer to [**Hospital1 18**]. Continued to have persistent
positive cultures depsite therapeutic treatment with vancomycin.
ID was consulted upon admission to [**Hospital1 18**] and antibiotics were
changed to Daptomycin and Gentamicin for synergistic effect. CT
surgery was consulted regarding possibility of surgical
intervention. At this time, they recommended following TTE q3
days and obtaining a TEE here to assess clot burden on the
mitral valve. The patient also complained of left hip pain, over
the area of prior hip replacement. Hip films were obtained as
well as an ortho consult, who recommended IR-guided aspiration
to assess for seeding of the prosthesis. A CT of the head was
obtained to assess for septic emboli and was negative for any
acute intracranial processes. A CTA of the head was ordered to
assess the vasculature to r/o mycotic aneurysms. The patient was
initially hypotensive upon admission, which resolved with IVF
initially but then required pressors to keep his MAP>60. This
was in the setting of the LGIB (see below).
# UGIB - on [**2132-1-30**] the patient was found to be hypotensive
with copious melena. He required pressors and received 6 units
PRBC, 3 units FFP, DDAVP, and vitamin K. GI performed an urgent
EGD and found a visible vessel on that they put 2 clips on. His
hct continued to trend down.
# Cardiac Arrest - Immediately following the patients UGIB, he
was found to be in VFib and received shocks x 2. He coverted to
NSR and was started on an amiodarone drip.
# LGIB - on [**2132-1-27**], the patient developed an acute, sudden and
significant BRBPR with hemodynamic instability (hypotension to
the 80's systolica and tachycardia to the 110's). GI was
consulted who recommended a tagged RBC scan, given the distal
and active bleed. The scan demonstrated an active bleed in the
recto-sigmoid area. Surgery was also consulted who evaluated the
patient and determined the source to be a ?exposed vessel vs.
fissure at the anus. The bleeding resolved with 1 suture to the
exposed area. Angio was also consulted, however the patient did
not require IR intervention. He received a total of 5 U PRBCs, 2
U FFP, and ddAVP between [**Date range (1) 18370**] with estimated loss of
blood approximately 3 units.
# ESRD on HD - currently only with temporary HD access given
persistent bactermia at OSH. Renal has been following with plans
for HD on M/W/F. Due to persistent bacteremia, the plan is to
keep the current temp line in place for HD and avoid further
lines if possible. Continued sevelamer and cinecalcet.
# Delirium - patient presented with delirium upon arrival and at
the OSH as well, with symptoms of confusion, hallucinations,
disorientation, and mild agitation. CT head on admission did not
demonstrate any intra-cranial pathology. Other ddx included
uremia, drug-induced, ICU delirium. The patient's sinemet and
comtan (taken for RLS) were d/c'd on [**1-27**] as they may
potentially exacerbate his existing delirium.
# Heel ulcer - patient has significant h/o peripheral vascular
disease with chronic right heel ulcers. He had a vascular
surgery evaluation at OSH and there was concern he may need an
amputation electively. He is at high risk for peri-operative
complications. Both vascular surgery and podiatry were consulted
upon admission here and recommended NIAS prior to possible
debridement of the right heel ulcer.
Medications on Admission:
HOME MEDS:
renagel
zonisamide 500 mg qhs
xanax 0.25 mg TID
flexeril 5 mg TID
ativan 0.5 mg qhs
sinemet (25mg/100 mg) 2 tabs TID
comtan 200 mg TID
MEDS ON TRANSFER:
tylenol prn
oxycodone 5 mg Q6H prn
comtan 200 mg TID
sinemet 25/100 mg 2 tabs TID
sevelamer 2400 mg TID w/ meals
hydroxyzine 25 mg qhs
percocet 1 tab Q8H
cinacalcet 60 mg daily
aspirin 325 mg daily
zonisamide 500 mg qhs
xenaderm ointment to buttocks [**Hospital1 **]
amoxicillin 500 mg Qday
? vancomycin per HD (not on records)
Discharge Medications:
The patient expired on [**2132-2-2**].
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA Endocarditis
UGIB
LGIB
Cardiac Arrest
ESRD
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
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"996.62",
"585.6",
"285.1",
"414.01",
"403.91",
"707.07",
"458.9",
"349.82",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"44.43",
"99.62",
"88.72",
"49.95",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12194, 12203
|
7498, 11587
|
328, 334
|
12294, 12303
|
5150, 7475
|
12359, 12369
|
4207, 4247
|
12131, 12171
|
12224, 12273
|
11613, 11760
|
12327, 12336
|
4262, 5131
|
259, 290
|
362, 3353
|
3375, 4074
|
4090, 4191
|
11778, 12108
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,784
| 118,746
|
7554
|
Discharge summary
|
report
|
Admission Date: [**2127-8-22**] Discharge Date: [**2127-9-4**]
Date of Birth: [**2057-4-23**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
LE edema, anemia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
70 yo f w/ h/o ESLD [**1-16**] etoh and grade I varices, who presented
to her PCP c/o lower extremity swelling and discomfort over the
past 2 weeks. Reports that she was having increased LE edema
accompanied by some "pain over" her "shins". Did not increase
w/ ambulation. Pt was otherwise feeling well but noted fatigue
which she attributed to stress at home. Denied LH, dizziness
when standing, cp/sob/doe. States that she would walk down to
the mailbox to get the paper and has not noticed change in
ability to do this. no N/V/D, no dark stools, abd pain,
BRBPR,no increased abdominal swelling. no f/chills/ rashes.
.
In ED, vs: 96.2, 108, 138/55, 16, 100%ra. Stool was brown heme +
and NG lavage negative w bilious return. pt was noted to have
hct of 14, plts 77, down from 34 and 164 respectively. Rec'd 1U
PRBC, 40mg iv lasix, protonix, K repletion. repeat stat hct of
17, receiving 2nd in route to ICU
Past Medical History:
-ESLD [**1-16**] etoh
-Irritable bowel syndrome
-Diverticulitis
-Diverticulosis (colonoscopy [**11-18**])
-s/p cataract surgery b/l
-Barretts esophagus (egd [**2125**])
-Gastritis (egd [**2125**])
-Grade I Varices GEJ (egd [**2125**])
-PUD (egd [**2123**], not seen on repeat [**2125**])
-L hip fx with screw placement in [**State 108**] [**2123**], now w/ OA and
possible AVN
-Atypical CP > stress test negative in [**7-18**]
Social History:
lives with husband, has 2 children, 25 pack year smoking
history, she reports drinking [**1-17**] vodka tonics per day, but
daughter and husband report that she actually drinks a lot more
than that and hides ETOH in the house. Has been able to quit for
a few months at a time in the past usu after hospitalizations,
but then goes back to it. No h/o drug use.
Family History:
mother died of pancreatic cancer, father with heart disease.
Physical Exam:
97.6, 115/76, 96, 18, 100% ra
well appearing nad
perrl, +icteric
op clr
7 cm jvp
regular s1,s2. no m/r/g
lca b/l
+bs. soft. nt. nd. no fluid wave.
1+ le edema. + warm, confluent erythema over anterior surface
b/l
alert and oriented x1.
[**4-18**] upper and lower ext strength
2+ dtrs.
[**Name (NI) 14451**] toes b/l
+asterixis.
Pertinent Results:
Initial labs:
140 104 17 /102 AGap=16
2.6 23 0.9 \
.
CK: 164 MB: 6 Trop-*T*: 0.03
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
ALT: 25 AP: 130 Tbili: 1.9 Alb: 3.5
AST: 80 LDH: Dbili: TProt:
[**Doctor First Name **]: 76 Lip: 92
Serum ASA 5
Serum EtOH, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
Comments: 80 (These Units) = 0.08 (% By Weight)
Vit-B12:1087 Folate:9.0
Other Blood Chemistry:
proBNP: 450
Hapto: 98
.
68
6.2 \4.3 /77
/14.5\
N:74 Band:0 L:11 M:12 E:2 Bas:1
.
Imaging:
[**8-22**]-pulm vasc engorgement, mild interstitial edema at right lung
base ? RLL PNA
[**8-23**]- increase in edema
[**8-25**] cxr: 1. Multifocal pneumonia with interval improvement in
the right upper lobe opacity and left lower lobe opacity.
2. Placement of NG tube with the tip in gastric fundus, side
hole above GE junction. Advancement of approximately 10 cm is
recommended.
[**8-27**]- interval improvement in multifocal PNA
[**8-24**] Abd US- cirrhotic liver without focal hepatic mass and no
ascites
Discharge labs:
137 104 15
----------<88
4.3 24 0.7
Ca 8.8 Phos 1.8 Mg 1.8
wbc 8.8 hgb 10.3 hct 30.7 plt 288
AST 51, ALT 26, AP 78, Tbili 1.5
PT 14.7* PTT 41.7* INR 1.3*
H.Pylori negative
2 sets of blood cultures negative
urine cx negative
Brief Hospital Course:
Impression: 70 yo f w/ h/o ESLD and grade I varices who p/w
weakness, LE edema, and anemia.
.
1) anemia- felt likely [**1-16**] slow GIB given guiac + stool. Egd
showed gastritis and grade I varices, and GI consult felt this
was the explanation for the patient's hct drop. H. pylori
negative. The patient was transfused 2U PRBC, and her hct
remained stable throughout her hospital course. She should have
a f/u EGD which is already scheduled with Dr. [**First Name (STitle) 572**] in [**Month (only) **].
She was also started on iron supplementation and [**Hospital1 **] protonix.
.
2) thrombocytopenia- likely [**1-16**] liver dz +/- splenomegaly.
Seemed unlikely to be related to med effect and there was no
evidence of ongoing infection. Also could be related to acute
etoh effect (particularly given elevated AST). Very low
suspicion for diffuse marrow process or malignancy. Platelets
remained stable and were actually trending up during this
hospital course.
.
3) ischemia - mild troponin and ecg changes c/w low grade
ischemia. No evidence of ACS. Ecg changes resolved w/ support
of her hct.
.
4) copd- no pfts on record but exam on HD3 and 4 c/w flair and
patient has significant smoking history. started on nebs and
completed a 5d course of steroids. On transfer to the floor, the
patient had clear lungs and did not require O2, nebs or endorse
SOB. Discharged patient on combivent inhaler.
.
5) esld- initially held lasix/aldactone while in house and this
was then resumed. She was also given lactulose for hepatic
encephalopathy which was d/c'd when her mental status cleared.
She was started back on lasix/aldactone at home dose on [**8-27**] but
became hypernatremic so subsequently held again. We restarted
these medications on discharge and patient should have her
electrolytes rechecked within the next week at rehab. She was
also started on thiamine and folate.
.
6) encephalopathy- likely [**1-16**] esld and etoh w/d. Head ct
performed given that pt had recent fall and it was negative for
ICH. She was treated w/ 3d iv thiamine for possible Wernicke's.
Mental status changes resolved w/ aggressive lactulose and
clearing of benzodiazepenes. We stopped lactulose when patient's
mental status cleared and her NH4 was normal. On discharge, she
was at her mental status baseline.
.
7) etoh w/d with DTs- req'd extremely large doses of ativan
(chosen over valium due to impaired liver fxn), on HD 2 the
patient req'd 60 mg ativan througout the day. Titrated off over
the subsequent 6 days. On transfer to floor on [**8-31**], patient
has not req'd any ativan and was in the clear in terms of ETOH
withdrawl. Patient is to be discharged to [**Hospital **] rehab center. We
had a family meeting and discussed all the issues and patient
wants treatment for alcoholism and will be discharged to
[**Hospital 27596**] Rehab.
.
8) ppx- maintained on pneumoboots given thrombocytopenia
initially, then sub q heparin. ppi [**Hospital1 **]
Medications on Admission:
lasix 20 mg QD
spirinolactone 50 mg QD
Prilosec 20 mg QD
Folic acid
meclizine
minocycline
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg 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. 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*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*qs qs* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary
1. ESLD
2. ETOH Withdrawl with DTs
3. Pneumonia
4. COPD flare
5. Anemia
6. Coagulopathy
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
Please take all your medications as directed.
Please follow-up with all outpatient appointments.
Please return to the ED if you experience dizziness, chest pain,
shortness of breath or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1007**] when you leave the rehab center.
His phone number is [**Telephone/Fax (1) 10492**].
You will need a follow-up Endoscopy. You have an appointment on
Wednesday [**10-22**] at 8:30 with Dr. [**First Name (STitle) 572**] on the [**Hospital Ward Name 517**]
of [**Hospital1 18**]. The phone number for the office is [**Telephone/Fax (1) **] if you
questions or need to reschedule. You should also receive an
information packet. Please call the above number with your new
address so they can mail it to the appropriate place.
Please see Dr. [**Last Name (STitle) **] to pick up your hearing aids. You have an
appointment scheduled with her already. Her number is
[**Telephone/Fax (1) 27597**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
|
[
"571.2",
"280.0",
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"211.1",
"564.1",
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"303.01",
"562.11",
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"276.8",
"348.39",
"530.85",
"491.21",
"291.81",
"287.5",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
7766, 7781
|
3851, 6805
|
298, 303
|
7921, 7960
|
2514, 3580
|
8226, 9106
|
2088, 2150
|
6945, 7743
|
7802, 7900
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6831, 6922
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7984, 8203
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3597, 3828
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2165, 2495
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242, 260
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331, 1246
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1268, 1696
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1712, 2072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,340
| 111,666
|
18982
|
Discharge summary
|
report
|
Admission Date: [**2103-3-9**] Discharge Date: [**2103-3-11**]
Date of Birth: [**2052-4-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Heparin Agents / Dapsone / Atovaquone /
Levaquin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Altered Mental status
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
Mr [**Known lastname **] is a 50 year old man with history of HIV (last CD4
393 last month), Type 2 diabetes, and CRI who presents from OSH
with confusion and agitation. The patient was brought in by his
partner after he was noted to be confused and combative
overnight. Patient is unable to provide history at this time and
history was obtained from chart and patient's family. per the
patient's mother he was in his USOH last evening. He came home
from work and watched tv and then went to bed. As far as she
knows he was without complaints. He awkoe in the night and went
to the bathroom with ? diarrhea. He was then noted to go
immediately back in the bathroom and vomited. After this he
became combative with his partner and insisted that he was ok.
He was then brought to an OSH. At the OSH the patient was noted
to be alert, but confused and unable to follow commands. FS in
ED was 126. He was intubated for "behavior". He received ativan
2mg IV, 2gm ceftriaxone IV, Flagyl 500mg IV, Acyclovir 800mg IV.
He was then transferred to [**Hospital1 **].
.
In the emergency department Temp 98, HR 76, BP 150/76,
intubated. An LP was performed that was notable for 2 WBC (80%
Lymphs), 0 RBC, prot 32 and glu 92. Serum tox was negative and
urine tox was pos. only for benzos. CT head showed no acute
process. He received 3L IV NS, and was placed on propofol for
sedation. He was given vancomycin 1gm IV, Azithromycin 500mg IV
and 2mg versed. He was then admitted to the [**Hospital Unit Name 153**] for further
management. On arrival to the ICU the patient is intubated and
sedated.
Past Medical History:
# HIV: Diagnosed in [**2097-5-26**], (CD4 393, VL undetectable [**Month (only) **]
[**2102**]) On Atripla
# Type 1 diabetes, hemoglobin A1C 8.0 in [**1-4**]
# Peripheral neuropathy
# h/o orthostatic hypotension, previously tx w/ midodrine and
Florinef
# Chronic renal insufficiency, baseline Cr 1.2-1.5
# History of PCP pneumonia treated with pentamidine,
Solu-Medrol, and prednisone in [**2097-5-26**].
# History of perforated peptic ulcer in [**2096**] s/p oversewing
# History of coag-negative Staph catheter related infection.
# Clostridium difficile colitis
# CMV viremia
# Magnesium wasting possibly secondary to pentamidine
# Anal condylomata
# h/o HIT
Social History:
Lives in [**Location 8072**] with his partner. [**Name (NI) 1403**] as IT manager. No h/o
tobacco use. Drinks alcohol rarely.
Family History:
maternal GF had MI in 60s
Physical Exam:
T 96.5 BP 115/73 HR 59 RR 11 O2 100% on AC
GENERAL: Intubated, sedated
HEENT: Normocephalic, atraumatic. No scleral icterus. Pupils
pinpoint, slightly reactive. ETT/OG tube in place. Neck Supple,
No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTA anteriorly
ABDOMEN: hypoactive BS, soft, ND. No HSM
EXTREMITIES: No edema, warm, well-perfused, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Sedated, does not respond to voice.
Discharge:
Afebrile, VSS
Gen -- middle aged male, NAD
HEENT -- anicteric op clear
Heart -- regular
Lungs -- clear
Abd -- soft, benign
Ext -- no edema
Neuro/psych -- alert, oriented x 3, stable gait, normal
coordination and strength
Pertinent Results:
[**2103-3-9**] 03:00AM PT-12.1 PTT-21.9* INR(PT)-1.0
[**2103-3-9**] 03:00AM PLT COUNT-195
[**2103-3-9**] 03:00AM NEUTS-83.9* LYMPHS-13.8* MONOS-2.0 EOS-0.3
BASOS-0.1
[**2103-3-9**] 03:00AM WBC-9.1 RBC-4.52* HGB-14.7 HCT-42.8 MCV-95
MCH-32.5* MCHC-34.4 RDW-15.1
[**2103-3-9**] 03:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2103-3-9**] 03:00AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-2.5*
MAGNESIUM-2.7*
[**2103-3-9**] 03:00AM CK-MB-4
[**2103-3-9**] 03:00AM cTropnT-<0.01
[**2103-3-9**] 03:00AM LIPASE-191*
[**2103-3-9**] 03:00AM ALT(SGPT)-25 AST(SGOT)-21 LD(LDH)-226
CK(CPK)-139 ALK PHOS-131* AMYLASE-148* TOT BILI-0.2
[**2103-3-9**] 03:00AM estGFR-Using this
[**2103-3-9**] 03:00AM GLUCOSE-167* UREA N-36* CREAT-1.9* SODIUM-136
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 POLYS-0
LYMPHS-80 MONOS-20
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-92
[**2103-3-9**] 07:00AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2103-3-9**] 07:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2103-3-9**] 07:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2103-3-9**] 07:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2103-3-9**] 07:00AM URINE GR HOLD-HOLD
[**2103-3-9**] 07:00AM URINE HOURS-RANDOM
[**2103-3-9**] 07:00AM URINE HOURS-RANDOM
[**2103-3-9**] 09:53AM URINE HOURS-RANDOM CREAT-55 SODIUM-87
POTASSIUM-61 CHLORIDE-119
[**2103-3-9**] 10:49AM CK-MB-4 cTropnT-<0.01
[**2103-3-11**] 09:25AM BLOOD WBC-7.2 RBC-3.99* Hgb-13.0* Hct-36.8*
MCV-92 MCH-32.7* MCHC-35.4* RDW-14.4 Plt Ct-159
[**2103-3-11**] 09:25AM BLOOD Glucose-92 UreaN-18 Creat-1.3* Na-142
K-3.9 Cl-109* HCO3-24 AnGap-13
[**2103-3-9**] 03:00AM BLOOD WBC-9.1 Lymph-14* Abs [**Last Name (un) **]-1274 CD3%-69
Abs CD3-879 CD4%-13 Abs CD4-166* CD8%-55 Abs CD8-706*
CD4/CD8-0.2*
[**2103-3-9**] 03:00AM BLOOD ALT-25 AST-21 LD(LDH)-226 CK(CPK)-139
AlkPhos-131* Amylase-148* TotBili-0.2
[**2103-3-9**] 10:49AM BLOOD CK-MB-4 cTropnT-<0.01
[**2103-3-9**] 03:00AM BLOOD cTropnT-<0.01
[**2103-3-11**] 09:25AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.3
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-80 Monos-20
[**2103-3-9**] 04:45AM CEREBROSPINAL FLUID (CSF) TotProt-32 Glucose-92
HERPES SIMPLEX VIRUS PCR
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus, Type 1 & 2 DNA, Real-Time PCR
HSV 1 DNA DETECTED Not
Detected
HSV 2 DNA Not Detected Not
Detected
----------
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with acute onset confusion, rule
out mass or
encephalitis.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion
axial images obtained before gadolinium. T1 axial and MP-RAGE
sagittal images
acquired following gadolinium. Comparison was made with the
previous study of
[**2097-7-28**].
FINDINGS: There has been no significant interval change seen.
Subtle
hyperintensities in the white matter are again noted indicating
minimal
changes of small vessel disease. No midline shift, mass effect
or
hydrocephalus seen. Following gadolinium no evidence of abnormal
parenchymal,
vascular or meningeal enhancement seen. No evidence of acute
infarct seen or
slow diffusion identified to indicate encephalitis.
IMPRESSION: Minimal changes of small vessel disease. No abnormal
enhancement
or mass effect. Overall no significant change since [**2097-7-28**].
Brief Hospital Course:
50 year old man with history of HIV, diabetes, presenting with
acute altered mental status, combative, without clear source of
infection.
#. Altered mental status: Differential is broad including
infection, toxic-metabolic, CNS, cardiac ischemia, hypoglycemia.
No clear etiology at this point. FS at OSH was 126. Given
immunosupression from HIV, most concerning for acute CNS
infection including bacterial, viral and fungal etiologies,
however LP is unremarkable. LP not c/w bacterial picture. CT
head negative for acute process. MRI more sensitive to look for
encephalitis, and given MS changes this is possible. MRI was
normal. EKG unchanged and CE negative x1 so less likely primary
cardiac event. Tox screen negative. BZ on tox likely from OSH.
Given h/o vomiting an acute GI process is in differential as
well. Currently afebrile, normal WBC which is reassuring. LFTs,
lipase, with the exception that alk phos was 131, and amylase
was 148. Acyclovir was started and continued overnight for risk
of HSV encephalitis. And
given low suspicion for bacterial meningitis will held vanc/ctx,
and not covered for Listeria meningitis. In the morning pt was
more alert and and extubated in the morning. By the afternoon pt
was A&Ox3 and in his USOH. ID consulted earlier does not beleive
that the etiolgy was infectious since his recovery was so quick,
and LP, MRI were negative. Acyclovir was d/c. They suggested
that the cause may be neurological- migraine variant vs. sz.
After Mr. [**Known lastname **] transferred to the floor from the [**Hospital Unit Name 153**], his
affect and mood were entirely normal. After discussion with the
ID team, he was discharged home on his previous medications.
Given the normal brain MRI and normal CSF cell count, there was
low suspicion for a positive HSV PCR on discharge, although the
result remained pending. His HSV PCR returned the day following
discharge as "detected." The ID fellow and his primary
outpatient ID physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**] were contact[**Name (NI) **] and
readmission was in coordination at the time of this discharge
summary.
.
#. HIV: On Atripla as an outpatient. Last CD4 count 394 and VL
<48 in [**2-5**]. Patient received pnemovax and hepatitis A and B
vaccines. Per discussion with ID will cont. his outpatient
HAART. Repeating CD4. Cont. HAART, given Atripla is NF will give
efavirenz 600mg daily and emtricitabine-tenofovir (truvada).
Renally dosed truvada during acute renal failure, but discharged
on his previous dose after renal function recovered.
.
#. DIABETES: insulin dependent. Previous A1c 8.0 one year ago.
He resumed his home lantus and ISS set up for follow up at
[**Last Name (un) **] on discharge.
.
#. ACUTE ON CHRONIC RENAL INSUFFICIENCY: Unclear etiology of
nephropathy, likely diabetic given h/o microabluminuria.
Baseline Cr 1.2, now 1.9 however was 1.8 last month. Unclear if
this represents a new baseline, however appears to have worsened
over last year. [**Month (only) 116**] have had progression of his underlying renal
disease. Acute bump may be pre-renal in setting of vomiting,
also on ACEi at home which appears to have been uptitrated. UA
normal. Most recently Cr 1.4. Likely resolving [**1-29**] prerenal.
Medications on Admission:
Atripla 600-200-300mg daily
Epipen prn bee stings
Lantus 47 units qhs
Humalog SS
Lisinopril 20mg daily (recently increased per OMR)
Aspirin 81mg
ALLERGIES: Sulfa (Sulfonamides) / Heparin Agents / Dapsone /
Atovaquone / Levaquin
Discharge Medications:
1. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Insulin Glargine 100 unit/mL Solution Sig: Forty Seven (47)
units Subcutaneous at bedtime.
5. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
qAC and qHS: by sliding scale as previously prescribed by Dr.
[**Last Name (STitle) 2148**].
Discharge Disposition:
Home
Discharge Diagnosis:
1. altered mental status
2. DMI
3. acute/chronic kidney disease
4. hypertension
5. HIV
Discharge Condition:
stable, baseline mental status
Discharge Instructions:
You were hospitalized with altered mental status. The tests
performed did not show any infection that could have caused your
problems.
Please follow up with your physicians as scheduled and take all
medications as prescribed. Call your primary doctor or return
to the emergency department if you have recurrence of confusion
or altered behavior, fever greater than 101, headache, chest
pain, dark urine or any other alarming symptoms.
Followup Instructions:
Call PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 457**] for a follow up
appointment in the next two weeks.
Neurology: Dr. [**Last Name (STitle) 2442**]. Phone: [**Telephone/Fax (1) 3506**]
|
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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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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,598
| 137,884
|
36013
|
Discharge summary
|
report
|
Admission Date: [**2138-8-4**] Discharge Date: [**2138-8-12**]
Date of Birth: [**2098-11-21**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Morphine
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Transfer from outside hospital for management of intracranial
mass.
Major Surgical or Invasive Procedure:
1. Neurosurgical drainage of brain abscess [**2138-8-7**].
History of Present Illness:
Ms [**Known lastname 40230**] is a 39-year-old woman with history of diabetes, IVDU
(ongoing), recently discharged ([**2138-7-10**]) from [**Hospital1 18**] for MRSA
aortic valve endocarditis complicated with endopthalmitis,
septic emboli, and SAH. She is being transferred from OSH for
management of brain abscess.
Recent [**Hospital1 18**] hospitalization [**6-29**] - [**7-10**] for MRSA endocarditis.
She had presented for severe headache x3 days, "fogginess" of
left eye, intermittent right arm twitching, and right sided
numbness of face, arm, body and leg. Found to have aortic valve
vegetation on TEE and MRSA bacteremia. She was found to have a
subarachnoid hemorrhage, thought to be possibly mycotic
aneurysm. This was managed conservatively with pain control
(Tylenol, oxycodone SR, Dilaudid for breakthrough, and
verapramil for prophylaxis) and seizure prophylaxis (Phenytoin
250 [**Hospital1 **] started for total 4-week course). Had evidence of septic
cerebral emboli on brain MRI imaging, and she was started on
vancomycin with course to end in the second week of [**Month (only) **].
The infection was further complicated by endophalmitis for which
she underwent vitrectomy and intravitreous vancomycin injection.
Blood cultures cleared on [**7-4**]. A PICC was placed on [**7-8**]. From
[**Hospital1 18**] she went to [**Hospital **] hospital for antibiotic
administration, then to [**Hospital 46555**] rehab.
Patient saw ophthalmology a few weeks after discharge [**2138-7-25**],
which revealed clear right eye vitreous fluid and scarring of
prior infection. Right eye vision is still at finger count
level. They d/c-ed her scopolamine drops and began taper of her
Pred Forte drops to twice a day.
Had recent PICC line infection growing Alcaligenes so PICC was
removed and IJ replaced.
She was in rehab until she developed persistent fevers (on and
off for a week)/headaches/chest pain/SOB, and was admitted to
[**Hospital3 7362**]. An MRI there showed a new left parietal abscess
measuring 1.6 x 1.7 x 2.9. Also [**12-9**] blood cultures grew GNR, for
which she was started on ceftazidime.
Per OSH report, patient had asthma exacerbation in days prior to
transfer, requiring 65%FM with nasal cannula. She was initially
in the OSH ICU, where she was started on nebs and intravenous
Solumedrol. She was also given 1 dose of Lasix. Vitals at time
of transfer are BP 118/79, sat 92% 2L, HR 80, afebrile,
otherwise normal exam. Her antibiotics at time of transfer are
ceftazadime day 4, and vancomycin from her prior admission.
Cultures from [**7-29**] were negative, per OSH.
At OSH patient was seen by ID and neurosurgery - team felt that
she should be transferred to [**Hospital1 18**] given the complexity of her
recent medical history and the fact that she has received most
of her recent care at [**Hospital1 18**].
Past Medical History:
--diabetes mellitus
--polysubstance abuse including EtOH
--EtOH withdrawal seizures in the past
--asthma
--hepatitis C infection
--MRSA aortic valve endocarditis [**6-/2138**] complicated with
endophalmitis, SH, septic emboli, right sided weakness and
numbness
Social History:
Patient lives with her boyfriend and his mother. She has three
children with part-time custody with her ex-husband. She used IV
heroin and cocaine recently. She smokes 1 ppd x20 years.
Family History:
Father had CAD and CHF. Mother has HTN. Sister has DM and
Cushings.
Physical Exam:
Admission PE:
VS - Temp 98.2F, BP 116/80, HR 77, RR 16, O2-sat 94% RA
GENERAL - awake, alert, appears fatigued, but otherwise in NAD
HEENT - staples in L cranium, no obvious blood or drainage from
strips
LUNGS - good air movement, resp unlabored, no accessory muscle
use, CTAB
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - hypoactive BS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ DP pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact except for
continued R facial droop, continued dilated R pupil, muscle
strength 4+/5 RUE, similar to previous exam
.
Discharge PE:
VS - Tm 99.4 Tc 99.4 HR 94 range 68-100 BP 108/74 BP range
102/68-118/82 RR 16 O2 sat 94% RA
24H I's po 1000 IV 770 O's 1900 urine --
8H po -- IV 140 O's 180 urine
GENERAL - awake, walking around in room, appears comfortable
HEENT - staples in L cranium, no blood or drainage
LUNGS - good air movement, resp unlabored, no accessory muscle
use, few inspiratory wheezes on right side
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ DP pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact except for
continued R facial droop, continued dilated R pupil, muscle
strength 4+/5 RUE, similar to previous exam
Pertinent Results:
Admission Labs:
[**2138-8-5**] 05:15
Report Comment:
Source: Line-picc
COMPLETE BLOOD COUNT
White Blood Cells 13.7* 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.43* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 9.7* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 28.4* 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 83 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 28.4 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 34.3 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 15.3 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
DIFFERENTIAL
Neutrophils 38* 50 - 70 %
PERFORMED AT WEST STAT LAB
Bands 0 0 - 5 %
Lymphocytes 25 18 - 42 %
PERFORMED AT WEST STAT LAB
Monocytes 0 2 - 11 %
PERFORMED AT WEST STAT LAB
Eosinophils 35* 0 - 4 %
PERFORMED AT WEST STAT LAB
Basophils 0 0 - 2 %
PERFORMED AT WEST STAT LAB
Atypical Lymphocytes 0 0 - 0 %
Metamyelocytes 2* 0 - 0 %
Myelocytes 0 0 - 0 %
RED CELL MORPHOLOGY
Hypochromia NORMAL
Anisocytosis 1+
Poikilocytosis NORMAL
Macrocytes NORMAL
Microcytes 1+
Polychromasia NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Smear HIGH
Platelet Count 450* 150 - 440 K/uL
PERFORMED AT WEST STAT LAB
.
Discharge Labs:
Test Name Value Reference Range Units
[**2138-8-12**] 07:00
Report Comment:
Source: Line-picc
COMPLETE BLOOD COUNT
White Blood Cells 9.5 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.48* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 9.8* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 29.4* 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 85 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 28.3 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 33.4 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 16.8* 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count [**Telephone/Fax (3) 81745**] K/uL
PERFORMED AT WEST STAT LAB
Studies:
CXR [**2138-8-4**]:
IMPRESSION: AP chest compared to [**7-8**]:
Previous left pleural effusion has resolved. Tiny right pleural
effusion may remain. Lungs are clear. Heart size normal. Left
PIC catheter ends at the junction of the brachiocephalic veins.
MRI [**2138-8-7**]:
IMPRESSION: Interval improvement with decreased size of the two
rim-enhancing left parietal lesions compared to the MRI of
[**2138-7-27**]. There are no new lesions identified.
CT head w/o [**2138-8-7**]:
IMPRESSION: Expected postoperative change following left
parietal
craniectomy/mass excision without significant hemorrhage.
.
Microbiology:
[**2138-8-5**] 12:26 am URINE Source: Catheter.
**FINAL REPORT [**2138-8-6**]**
URINE CULTURE (Final [**2138-8-6**]):
YEAST. >100,000 ORGANISMS/ML..
BCx [**8-5**], [**8-6**] - NGTD
BCx [**2138-8-7**] - pending on discharge
.
Time Taken Not Noted Log-In Date/Time: [**2138-8-7**] 4:32 pm
ABSCESS DEEP SITE LEFT SIDE. MCU ADDED ON [**2138-8-8**] AT
2115.
GRAM STAIN (Final [**2138-8-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2138-8-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2138-8-8**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
[**2138-8-7**] 4:35 pm ABSCESS DEEP SITE.
GRAM STAIN (Final [**2138-8-7**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2138-8-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2138-8-8**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
.
[**2138-8-7**] 4:20 pm SWAB LEFT SIDE. MCU ADDED ON [**2138-8-8**] AT
2115.
GRAM STAIN (Final [**2138-8-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2138-8-10**]):
PROBABLE MICROCOCCUS SPECIES. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
ACID FAST SMEAR (Final [**2138-8-8**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
Brief Hospital Course:
39 y.o. F with h/o IDDM, IVDU, MRSA endocarditis complicated
with septic embolic, SAH, endopthalmitis, who is transfered from
OSH for management of intracranial abscess.
# Brain abscess: Per the OSH records, there was a notable
difference between interval MRI's. This MRI was compared with
her prior MRI and it was found that the abscess had increased in
size and in mass effect/edema. Her neurologic exam appeared
improved compared to prior OMR notes. She had near 4-5/5 right
sided strength in extremities, right face still with CN 7 palsy.
ID was consulted who recommended to continue the IV vancomycin.
Neurology was also consulted who recommended to continue Keppra
for seizure prophylaxis and discontinue Dilantin. Neurosurgery
also evaluated the patient and recommended surgical resection.
The patient went to the OR on [**8-7**] for a L craniotomy for
drainage of the abscess. The patient tolerated the procedure
well and went to the ICU following. She was transferred back to
the medicine service on [**2138-8-8**] for further management.
Neurosurgery followed the patient and recommended to repeat
imaging one month from the date of surgery.
She has a follow-up appointment with neurosurgery scheduled for
[**2138-9-9**] with Dr. [**Last Name (STitle) **] and a CT brain as well on [**2138-9-9**].
Per ID, she was scheduled to complete an additional 2-4 weeks of
intravenous vancomycin from the previous stop date. Weekly labs
include CBC with diff, BUN/creatinine, ESR/CRP, and vancomycin
trough. The next trough should be on [**8-14**]. Labs should be faxed
to [**Hospital 18**] [**Hospital **] clinic at [**Telephone/Fax (1) 1419**]. This course should be
completed on [**9-11**]. She has a follow-up appointment in infectious
diseases clinic on [**8-29**] at 9:30. She should have a follow-up
brain MRI on [**8-25**] or [**8-26**] (this can be scheduled at [**Hospital 61392**] Center or at [**Hospital1 18**] ([**Telephone/Fax (1) 327**]) - whichever is more
convenient.
# Gram negative rod bacteremia: Blood grew Stenotrophomonas, S.
viridans, and
Alcaligenes from the OSH. She presented on day 4 of ceftazidime.
Per ID recs, she was continued on Ceftazadime. The source was
thought to be blood stream infection from history of IVDU (self
injecting crushed opiates from her mouth into her PICC). Urine
cultures were negative and only grew yeast. Blood cultures were
sent and were negative. ID recommended a 14-day course of
antibiotics ([**8-1**] through [**8-15**]).
# MRSA Endocarditis, AV: She was diagnosed with MRSA aortic
valve endocarditis in late [**2138-6-5**]. It was complicated by
SAH, septic embolic, right sided weakness/numbness,
endopthalmitis of her right eye. There were no signs of heart
failure on exam. She was continued on Vancomycin with trough
levels checked. Blood cultures were sent, and on the day of
discharge the cultures from [**8-5**] and [**8-6**] showed no growth. The
blood cultures from [**2138-8-7**] were pending on the day of discharge.
She was scheduled to continue a course of IV Vancomycin until
[**2138-9-11**] per the ID team (as above).
# MRSA Endophalmitis: S/p vitrectomy and intravitreous
vancomycin injection. Recently seen by ophtho in [**2138-7-25**]. Pt
continues to have diminished vision of right eye- only able to
count fingers. Her vision was stable during this admission and
she was continued on prednisolone eye drops.
# Asthma: At the OSH she had recent respiratory distress and had
been on solumedrol 20 IV BID with a brief MICU stay there. She
was breathing comfortably on admission. She was started on a
prednisone taper during this admission. She was continued on
nebulizer treatments, and Advair. She did not require oxygen.
# Diabetes mellitus, type 1, poorly controlled: Has DM1 since
early 30s, per patient. Give 12 U glargine and ISS. On NPH 12
[**Hospital1 **] from OSH. She was started on a diabetic diet. Her blood
sugars were difficult to control this admission given prednisone
and dexamethasone that was started by neurosurgery. [**Last Name (un) **]
Diabetes team was consulted and helped to adjust her blood
sugars. On discharge, her blood sugars were better controlled.
She was receiving 28 units of glargine in the morning in
addition to an insulin sliding scale, beginning at 81-150 BG
with humalog of 7 units and increasing by 2 units per every
change in 50 BG. This dosing will likely need to be altered on
discharge given that she is no longer on steroids.
# Polysubstance abuse: Her last reported drug use was in [**Month (only) 205**],
with use of cocaine. SW was consulted during this admission, but
per SW, she was refused having a drug or alcohol problem.
Medications on Admission:
MEDICATIONS (on transfer from OSH):
-ceftazadime 2g q8hr start [**2138-8-1**]
-lorazepam 0.5 [**Hospital1 **]
-baclofen 5mg TID
-salemterol discus 50 mcg
-fluticasone MDI 220 2 puff [**Hospital1 **]
-citalopram 20mg qday
-Ferrous sulfate 325 TID
-omeprazole 20mg qday
--vancomycin 1250 mg [**Hospital1 **] x6 weeks (day 1 = [**7-4**])
-phenytoin 300 [**Hospital1 **]
-aspirin 81
-pred forte eye drop right eye 1 drop [**Hospital1 **]
-metamucil
-senna 2 tabs at night
-keppra 500 [**Hospital1 **]
-verapamil 60 q8hr
-albuterol neb 2.5 QID
-ipatroprium neb 0.02% neb QID
-NPH 12 U 4:30pm, 12 U at 7:30am
-ISS
-sub q heparin
-methylprednisolone Solumedrol 20mg q 12 hr
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB, wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (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. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation DAILY (Daily).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for anxiety, tremor.
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
11. Verapamil 40 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
16. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous qam: This dose was recently increased in the
setting of steroids. This dose may need to be decreased in the
next couple of days given now discontinued steroid use.
Disp:*30 solution* Refills:*2*
18. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours) for 4 days: Antibiotics to
complete on [**2138-8-15**].
Disp:*12 Recon Soln(s)* Refills:*0*
19. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q 12H (Every 12 Hours) for 30 days: 750mg q12hrs,
with dose altered by trough level. Trough to be checked next
[**2138-8-14**]. Tentatively should be continued until [**2138-9-11**]. Duration
may be changed by [**Hospital **] clinic, after appt on [**2138-8-29**].
Disp:*90 Recon Soln(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) **] [**Doctor First Name **] - [**Location (un) 4047**]
Discharge Diagnosis:
Primary Diagnoses:
1. Brain abscess
2. Gram negative bacteremia
Secondary Diagnoses:
1. Endocarditis
2. Endophthalmitis
3. Diabetes Mellitus Type I
4. Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 40230**],
It was a pleasure taking care of you during this admission. You
were admitted with headaches and concern for a brain abscess at
the outside hospital. You were continued on intravenous
antibiotics for this. Neurosurgery evaluated you and recommended
a surgical procedure. You were also continued on your
antibiotics. Your blood sugars were elevated during this
admission, and your insulin was adjusted.
The following medications were changed during this admission:
STOP Phenytoin 300mg by mouth twice daily
STOP Aspirin 81mg by mouth daily (this was held given the recent
neurosurgery)
STOP Solumedrol 20mg twice daily (this was tapered from your
asthma flair)
START Clonidine 0.1mg by mouth three times daily (This was
started by neurosurgery to control your blood [**Known lastname 1934**]. Please
have your doctors follow your [**Name5 (PTitle) 1934**] and tailor this
medication down as needed, just to keep your blood [**Name5 (PTitle) 1934**]
<140 systolic)
START Hydromorphone 4-8mg by mouth every 4 hours as needed for
pain
DOSE CHANGED:
Baclofen 5mg by mouth three times daily to 10mg by mouth three
times daily
Citalopram 20mg by mouth daily to 30mg by mouth daily
Keppra (Levetiracetam) 500mg by mouth twice daily to 1000mg by
mouth twice daily
Insulin Glargine 12 units in the morning to 28 units in the
morning
Your insulin sliding scale was also adjusted. Please have your
doctors monitor and adjust this scale.
CONTINUE:
--Ceftazidime 2g intraveneously every 8 hours through [**2138-8-15**].
Duration of therapy is two weeks; course to be finished on
[**8-15**].
--Intravenous Vancomycin. Duration of therapy to be determined
by infectious diseases clinic after your follow-up on [**8-29**].
Followup Instructions:
Please follow-up with the following appointments:
Department: INFECTIOUS DISEASE
When: THURSDAY [**2138-8-29**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2138-8-25**] at 2:00 PM
With: ECHOCARDIOGRAM [**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 SURGERY
When: TUESDAY [**2138-9-2**] at 1 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
NEUROSURGERY:
[**2138-9-9**] 10:30a [**Last Name (LF) **],[**First Name3 (LF) **] M.
LM [**Hospital Unit Name **], [**Location (un) **]
NEUROSURGERY WEST
[**2138-9-9**] 10:00a XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **]
CC CLINICAL CENTER, [**Location (un) **]
RADIOLOGY
Completed by:[**2138-8-12**]
|
[
"041.12",
"346.90",
"V58.67",
"300.4",
"421.0",
"305.60",
"360.00",
"V58.62",
"493.90",
"238.71",
"285.29",
"250.03",
"070.70",
"305.1",
"324.0",
"348.5",
"041.85",
"790.7",
"305.00",
"V12.51",
"728.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
17680, 17802
|
9792, 14461
|
353, 414
|
18005, 18005
|
5245, 5245
|
19928, 21205
|
3787, 3856
|
15178, 17657
|
17823, 17888
|
14487, 15155
|
18156, 19905
|
6427, 8332
|
3871, 4489
|
17909, 17984
|
8994, 9290
|
9509, 9769
|
9473, 9473
|
4503, 5226
|
246, 315
|
442, 3285
|
5261, 6411
|
9326, 9440
|
18020, 18132
|
3307, 3569
|
3585, 3771
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,774
| 157,665
|
45221+58781
|
Discharge summary
|
report+addendum
|
Admission Date: [**2147-9-1**] Discharge Date: [**2147-9-9**]
Date of Birth: [**2084-9-1**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old
female with a history of right lower lobe lung nodule likely
metastatic breast cancer presented with shortness of breath,
worsening hyponatremia, hyperkalemia to the Emergency Room.
The patient was recently admitted on [**2147-3-1**] for syncope and
found to have hyponatremia of unknown etiology with decreased
urine sodium and euvolemia. At that time her Lasix was
discontinued and her [**Last Name (un) **] was decreased and the patient's
hyponatremia improved. The patient was found to have
exudative pleural effusion positive for adenocarcinoma with
ER positivity. The patient was to follow up with oncology,
however, did not make her appointments. She was seen by her
primary care physician [**Last Name (NamePattern4) **] [**2147-8-25**] and at that time was found
to have a sodium of 126 and a potassium of 5.5. At that time
her [**Last Name (un) **] was discontinued and Hydralazine was started. The
patient's laboratories subsequently revealed a sodium of 125
and a K of 6.0. The patient was asked by her primary care
physician [**Last Name (NamePattern4) **] [**2147-8-30**] to come to the Emergency Room, but did
not present until [**2147-8-31**]. In the Emergency Department the
patient was complaining of shortness of breath. Her chest
x-ray revealed bilateral pleural effusion right greater then
left. A CTA was negative for pulmonary embolus. The patient
was treated with Ativan and experienced respiratory
depression with an arterial blood gas revealing 7.22, 63, 81.
The patient was brought to the MICU and was intubated. The
patient was extubated approximately eight hours later and her
workup for hyponatremia was initiated. The patient's TSH was
checked, a cord stem test was performed and urine lytes were
also sent off. The patient was also seen by psychiatry and
was felt not to be currently unstable, but to have
depression. The patient was transferred to the Medicine
Service on [**2147-9-3**] for further medical management of her
metastatic breast cancer, pleural effusions as well as
electrolyte abnormalities.
PHYSICAL EXAMINATION: On the date of transfer the patient's
temperature maximum was 98 degrees, T current was 96.5, pulse
90 to 115. Blood pressure 144/70 and oxygen saturation was
97 to 98% on 2 liters of oxygen. Generally, the patient was
in no acute distress, was teary eyed and appeared depressed.
Normocephalic, atraumatic. Extraocular movements intact.
Mucous membranes are moist. Oropharynx was clear.
Additionally, no thyromegaly was palpated. There was no neck
lymphadenopathy. Neck was supple. Heart was regular rate
and rhythm. There was no JVD. The JVP was approximately 6
cm. On lung examination the patient had decreased breath
sounds at the bases bilaterally, right greater then left and
crackles bilaterally right greater then left. There was no
clubbing, cyanosis or edema in her extremities. Her belly
was soft, nontender, nondistended with normoactive bowel
sounds.
PAST MEDICAL HISTORY:
1. Right lower lobe lung nodule malignant pleural effusion.
2. Atrial fibrillation on Coumadin.
3. Congestive heart failure with ejection fraction less then
20% on [**6-29**]. [**10-28**] had catheterization with no coronary
artery disease found.
4. Diabetes mellitus.
5. Chronic renal insufficiency.
6. Breast cancer status post mastectomy in [**2138**], status post
Tamoxifen treatment.
7. Hypercholesterolemia.
8. Multinodular goiter.
ALLERGIES: Vasotec, which cause a cough.
MEDICATIONS:
1. Prozac 10 mg one po q day.
2. Digoxin 125 mg one q.d.
3. FES04 325 t.i.d.
4. NPH 25 in the morning and 8 at night.
5. Levoxyl 100 mcg q day.
6. Nasacort 55 b.i.d.
7. Coumadin 5/3.75 on alternating days.
SOCIAL HISTORY: The patient lives with daughter. Forty pack
year history of smoking. No tobacco currently. Quit twenty
years ago. No ETOH.
LABORATORY DATA: White blood cell count was 8.9, hematocrit
33.1, platelets count 207, INR 1.2, sodium 133, potassium
5.1, chloride 99, bicarb 24, BUN 30, creatinine 1.3. The
patient has a history of renal insufficiency and glucose 129.
HOSPITAL COURSE: 1. Respiratory failure: The patient
remained on minimal oxygen requiring initially sating at 99
to 100% on 1 to 2 liters. Subsequently hematology/oncology
was contact[**Name (NI) **] as well as interventional pulmonology and it
was felt that the patient was not currently a candidate for
chemotherapy and that hormonal therapy with Arimidex was
indicated. Hence, the patient had a talc pleurodesis on the
right side with chest tube placement. The plan is to pull the
tube when drainage is < 150cc/24 hours. The patient's pain was
very well controlled with minimal pain medication requirement.
2. Metastatic breast cancer: The patient was discussed with
Dr. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) 2148**] and it was felt that the
patient's functional capacity was quite bad and that she was
not an ideal candidate for chemotherapy and it was decided
that the patient would continue on Arimidex therapy at 1 mg q
day and follow up with Dr. [**Last Name (STitle) **] upon discharge.
3. Hyponatremia, hyperkalemia: The patient's urine
electrolytes were recent and a TTEKG was calculated. This
was consistent with type 4RTA felt likely secondary to [**Last Name (un) **]
use. In the hospital no [**Last Name (un) **] was used and the patient's
hyponatremia and hyperkalemia completely normalized with
entirely normal sodiums and potassiums by the time of
discharge.
4. Endocrine: The patient was continued on regular sliding
scale of insulin and had very good glycemic control with
blood sugars ranging from 98 to approximately 130. Otherwise
the patient was continued on her Synthroid and her q.i.d.
finger sticks.
5. Hematology: The patient's Coumadin was restarted at the
time of discharge. Her INR will need to be followed up and
the patient will need to stay in the range of approximately
2.5 to 3.
6. Prophylaxis: The patient was maintained on an H2 blocker
and subq heparin with no complications.
DISPOSITION: The patient will be discharged to a
rehabilitation center for further physical therapy as well as
pulmonary therapy as the patient is considerably
deconditioned. The patient is to follow up as an outpatient
with Dr. [**Last Name (STitle) 1968**] as well as Dr. [**Last Name (STitle) **] for her primary care
and further oncology workup.
MEDICATIONS ON DISCHARGE:
1. Digoxin 125 po q day.
2. FES04 325 mg po t.i.d.
3. NPH 25 in the morning and 8 at night.
4. Levoxyl 100 mcg one po q day.
5. Lipitor 20 mg one po q day.
6. Coumadin 5 mg on Tuesday, Thursday, Saturday and Sunday
and 3.75 on Monday and Wednesday.
DISCHARGE STATUS: Stable at the time of this dictation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 47748**]
MEDQUIST36
D: [**2147-9-8**] 07:17
T: [**2147-9-8**] 08:07
JOB#: [**Job Number 96642**]
Name: [**Known lastname 4647**], [**Known firstname 1683**] Unit No: [**Numeric Identifier 15291**]
Admission Date: [**2147-9-1**] Discharge Date: pending
Date of Birth: [**2084-9-1**] Sex: F
Service:
ADDENDUM:
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (ADDENDUM): The
patient also developed a urinary tract infection given the
fact that she had a Foley catheter in place for multiple
days. She was initiated on ciprofloxacin 500 mg by mouth
twice per day based on creatinine clearance and was to
continue this until she finishes her course of antibiotics.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2147-9-27**] at 12:10 (who is her primary care physician).
2. The patient was to see Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1426**] (from
Cardiology) on [**2147-9-28**].
3. The patient was to see Dr. [**First Name8 (NamePattern2) 1612**] [**Last Name (NamePattern1) **] (from
Oncology) on [**2147-9-15**].
MEDICATIONS ON DISCHARGE: (The patient's medications on
discharge at this time included the following)
1. Ferrous sulfate 325 mg by mouth three times per day.
2. Levothyroxine 100 mcg by mouth once per day.
3. Atorvastatin 20 mg by mouth once per day.
4. Multivitamin one tablet by mouth once per day.
5. Heparin 5000 units subcutaneously q.8h.
6. Aspirin 81 mg by mouth once per day.
7. Senna one tablet by mouth twice per day as needed (20
tablets)
8. Digoxin 125 mcg by mouth every other day.
9. Anastrozole 1 mg by mouth once per day.
10. Hydralazine 25 mg by mouth q.6h.
11. Bisacodyl 5-mg tablets two tablets by mouth once per
day.
12. Propoxyphene/acetaminophen 10/650 mg one to two tablets
by mouth q.4-6h. as needed (for pain).
13. Pantoprazole 40 mg by mouth once per day.
14. Ciprofloxacin 500 mg by mouth twice per day.
[**First Name8 (NamePattern2) 77**] [**Name8 (MD) **], M.D. [**MD Number(1) 3616**]
Dictated By:[**Last Name (NamePattern1) 694**]
MEDQUIST36
D: [**2147-9-8**] 07:21
T: [**2147-9-8**] 08:02
JOB#: [**Job Number 15292**]
|
[
"197.2",
"518.81",
"V58.61",
"428.0",
"599.0",
"427.31",
"197.0",
"276.1",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.92",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8356, 9444
|
4323, 6624
|
7858, 8329
|
2304, 3180
|
146, 168
|
197, 2281
|
3202, 3920
|
3937, 4305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,531
| 164,623
|
25893
|
Discharge summary
|
report
|
Admission Date: [**2116-6-4**] Discharge Date: [**2116-6-9**]
Date of Birth: [**2069-12-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2116-6-5**] - CABGx3 (Left internal mammary artery->Left anterior
descending artery, Vein->Ramus, Vein->Diagonal artery)
[**2116-6-4**] - Cardiac Catheterization
History of Present Illness:
46 year old gentleman with known coronary artery disease s/p
multiple PCI's, past MI and VF arrest who has been experiencing
jaw pain over the past few weeks. He underwent a cardiac
catheterization which revealed severe left main and three vessel
disease. Given these findings, he was referred for surgical
management.
Past Medical History:
CAD
PCI/Stent [**8-8**], [**4-9**]
Myocardial infarction [**8-8**]
Cardiomyopathy
VF Arrest [**2113**]
PVD
HTN
Hyperlipidemia
Social History:
Tobacco: 0.5 pack X 15 years
EtOH: 1qwk
Limited exercise
Publisher of a magazine, lives in [**Location 5028**] with wife
Family History:
Mother w/ CAD
Physical Exam:
55 SB 16 115/72 117/74 72" 284lbs
GEN: NAD
Skin: Unremarkable
HEENT: Unremarkable
NECK: Supple, FROM
LUNGS: CTA
HEART: RRR, Nl S1-S2, No M/R/G
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no C/C/E. 2+ Pulses. No varicosities.
NEURO: Nonfocal. No carotid bruits
Pertinent Results:
.
[**2116-6-9**] 05:55AM BLOOD WBC-12.2* RBC-3.15* Hgb-10.4* Hct-29.4*
MCV-93 MCH-33.0* MCHC-35.4* RDW-13.8 Plt Ct-304#
[**2116-6-5**] 06:47PM BLOOD PT-15.1* PTT-37.4* INR(PT)-1.3*
[**2116-6-9**] 05:55AM BLOOD Glucose-135* UreaN-21* Creat-1.1 Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
[**2116-6-4**] Carotid duplex ultrasound
No stenosis of the carotid arteries bilaterally.
[**2116-6-4**] Cardiac Catheterization
1- Selective coronary angiography of this right-dominant system
reveald
progression of known multivessel CAD. The LMCA had a distal 80%
lesion
with haziness suggestive of an active lesion. The LAD stent was
widely
patent with mild disease in the distal vessel. The D1 was a
large branch
with mild disease. The LCX had a 90% origin stenosis. The RCA
was a
dominant vessel with widely patent stent. There was mild disease
involving the proximal and distal RCA segments. Additionally, a
60%
stenosis was apparent in the RPDA.
2- Limited hemodynamic assessment revelaed mildly elevated LVEDP
(14
mmHg) at baseline. Following left ventriculography, the LVED was
moderately elevated to 20 mmHg. The systemic arterial blood
pressure
was normal 125/79 mmHg.
3- left ventriculography revealed normal left ventricular
systolic
function with LVEF 55%.
[**2116-6-5**] Echocardiogram
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is moderate regional left
ventricular systolic dysfunction with apical hypokinesis
excepting the apical lateral segment.. Overall left ventricular
systolic function is moderately depressed (LVEF= 35 %). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in
person of the results on Mr.[**Known lastname 2819**] at 1330hrs before CPB.
Post_Bypass:
Overall LVEF 40%. Patient is on no inotropes.
Mild MR, Trivial TR.
Normal RV systolic function.
Thoracic aortic contour is well preserved
CHEST (PORTABLE AP) [**2116-6-8**] 9:25 AM
CHEST (PORTABLE AP)
Reason: ? ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
46 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p ct removal
HISTORY: Status post chest tube removal following CABG.
FINDINGS: In comparison with study of [**6-5**], all of the tubes have
been removed. Low lung volumes but no evidence of pneumothorax.
Residual atelectatic changes are seen, especially at the left
base
Brief Hospital Course:
Mr. [**Known lastname 2819**] was admitted to the [**Hospital1 18**] on [**2116-6-4**] for further workup
of his angina. He underwent a cardiac catheterization which
revealed severe left main and three vessel coronary artery
disease. Given the severity of his disease, the cardiac surgical
service was consulted for surgical management. He was worked-up
in the usual preoperative manner including a carotid duplex
ultrasound which showed no significant carotid artery stenosis.
On [**2116-6-5**], Mr. [**Known lastname 2819**] was taken to the operating room where he
underwent coronary artery bypass grafting to three vessels.
Please see operative note for details. Postoperatively he was
taken to the cardiac surgical intensive care unit for
monitoring. By postoperative day one, Mr. [**Known lastname 2819**] had awoke
neurologically intact and was extubated. Beta blockade, aspirin
and a statin were resumed. Plavix was also resumed as he had
prior stents. On postoperative day two, he was transferred to
the step down unit for further recovery. He was gently diuresed
towards his preoperatived weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. Mr. [**Known lastname 2819**] continued to make steady progress and was
discharged home on postoperative day four. He will follow-up
with Dr. [**Last Name (STitle) 914**], Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 64402**] as an outpatient.
Medications on Admission:
Plavix 75'
Lipitor 80'
Lisinopril 10'
Toprol XL 100'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD s/p CABGx3
Hyperlipidemia
HTN
STEMI [**8-8**]
VF arrest
PTCA/STenting [**8-8**] and [**4-9**]
Cardiomyopathy
Obesity
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4022**] Follow-up
appointment should be in 2 weeks
Provider: [**Name10 (NameIs) 64403**],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 32949**] Follow-up appointment
should be in 2 weeks
Completed by:[**2116-6-9**]
|
[
"425.4",
"401.9",
"414.01",
"V15.82",
"412",
"272.4",
"V17.3",
"443.9",
"413.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"89.60",
"37.22",
"36.15",
"36.12",
"88.53",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7123, 7172
|
4430, 5902
|
325, 492
|
7337, 7346
|
1460, 4030
|
8088, 8580
|
1145, 1160
|
6005, 7100
|
4067, 4097
|
7193, 7316
|
5928, 5982
|
7370, 8065
|
1175, 1441
|
279, 287
|
4126, 4407
|
520, 840
|
862, 990
|
1006, 1129
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 183,350
|
15317
|
Discharge summary
|
report
|
Admission Date: [**2137-11-4**] Discharge Date: [**2137-11-21**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 44522**]
Chief Complaint:
blurry vision
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 20 year old female with a past medical history
significant for systemic lupus erythematosis who woke on day of
admission with blurry vision. The patient was initially
diagnosed at age 16 when her fingers swelled up and 6 months
later a kidney biopsy confirmed the lupus nephritis. She's been
medically managed on prednisone and had a trial of cytoxan which
she did not tolerate due to nausea and vomitting. Her
hypertension has been controlled with enalopril, atenolol, and
nifedipine until about 7 days prior to admission when she ran
out of medication and for that reason has been non-adherent.
On the day of admission, Ms. [**Known lastname **] called 911 and en route to
this facility developed an intense headache, localizing to the
right temporal region. In the ambulance she was discovered to
have a systolic blood pressure of about 300. Upon arrival at the
ED, she developed chest pain and shortness of breath. Morphine,
labetelol 20 IV, atenolol 50 PO, and enalapril 20 PO were
administered. She was then started on a nifedipine drip. Later,
the nifedipine was weaned for a concern of renal insufficiency
and a NTG drip was started at which point her systolic blood
pressure decreased to 180. A head CT was obtained which was
negative but she did have papilledema per the ED notes. An EKG
showed strain. The patient was admitted to the MICU overnight.
Of note, it was discovered that her creatnine was up to 5 from a
baseline of 1.5.
Past Medical History:
SLE pregnancy termination in [**Month (only) **]
CRI s/p cytoxan Q 3months 2 years ago
HTN
Social History:
lives with Mom and 14 year old brother
does not work but is considering going to college in [**Month (only) 404**]
occasional EtOH, no tobacco, heroin, cocaine
Family History:
aunts with hypertension
grandmother died of myeloma
several men with prostate cancer
Physical Exam:
Vitals: 98.6, BP 142/95, HR 88 RR 20 O2 saturation 100% on RA wt
58.3 kg
Gen: pleasant cooperative watching TV
HEENT: moon facies, PERRLA, MMM, dentition with caries, sclera
nonicteric
CV: RRR II/VI murmur heard throughout the precordium
Pulm: CTAB, no murmurs
Abd: +BS, soft, ND, NT
Ext: WWP, 2+DP bilaterally
Skin: jaws and upper extremities with coalescing annular plaques
with a pink
annular border and an atrophic hyperpigmented center consistent
with discoid
lupus.
Pertinent Results:
[**2137-11-4**] 07:50PM CK(CPK)-55
[**2137-11-4**] 07:50PM cTropnT-0.04*
[**2137-11-4**] 04:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2137-11-4**] 04:35PM URINE RBC-[**6-20**]* WBC-[**6-20**]* BACTERIA-OCC
YEAST-NONE EPI-[**11-30**]
[**2137-11-4**] 01:15PM GLUCOSE-129* UREA N-31* CREAT-5.2*#
SODIUM-138 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2137-11-4**] 01:15PM LD(LDH)-517* TOT BILI-0.4
[**2137-11-4**] 01:15PM HAPTOGLOB-<20*
[**2137-11-4**] 01:15PM WBC-3.8* RBC-3.32* HGB-8.5* HCT-26.8*
MCV-81*# MCH-25.7* MCHC-31.9 RDW-18.7*
[**2137-11-4**] 01:15PM PLT SMR-VERY LOW PLT COUNT-69*#
[**2137-11-4**] 01:15PM PT-12.3 PTT-28.0 INR(PT)-1.0
RENAL ULTRASOUND: IMPRESSION: Echogenic texture of both kidneys
with nonspecific ill-defined bilateral areas. The arterial and
venous flow are normal and there is no hydronephrosis.
CXR: Cardiac and mediastinal contours are normal. The lungs are
clear. Pulmonary vasculature is normal. The osseous structures
are unremarkable. No CHF
EKG: LV strain and inverted T waves in limb leads
----
ADAMTS13 (VWF Cleaving Protease)
Results Units
Reference Interval
------- -----
------------------
ADAMTS13 Inhibitor <0.4 Inhibitor Units < =
0.4
ADAMTS13 Activity 55 % (low) > =
67
[**2137-11-16**] 02:44PM BLOOD PTH-98*
[**2137-11-17**] 04:12AM BLOOD HBsAg-NEGATIVE
[**2137-11-11**] 02:17PM BLOOD HCG-<5
[**2137-11-5**] 02:31PM BLOOD dsDNA-POSITIVE A
[**2137-11-5**] 11:41AM BLOOD C3-46* C4-8*
[**2137-11-9**] 09:25AM BLOOD SCLERODERMA ANTIBODY-Test
ANTICARDIOLIPIN Ab
ANTI-CARDIOLIPIN IgG : 12.1
0 - 15 GPL
ANTI-CARDIOLIPIN IgM : 8.1
0 - 12.5 MPL
RO & [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] Result Reference
Range/Units
SSA ANTIBODY NEGATIVE NEGATIVE
SSB ANTIBODY NEGATIVE NEGATIVE
Mycophenolic Acid, Serum
Mycophenolic Acid 1.9 1.0 - 3.5
ug/mL
MPA Glucuronide 74 35 - 100
ug/mL
Brief Hospital Course:
Ms. [**Known lastname **] is a 20 year old woman with hypertensive emergency,
lupus nephritis, and TTP vs. malignant hypertension inducing
thrombocytopenia.
HTN: Ms. [**Known lastname **] had a hypertensive emergency, as evidenced by EKG
changes, papilledema, and head CT changes. This was thought
likely secondary to a lupus flare, ARF and poor medication
compliance. She was started back on metoprolol and nifedipine,
but her ACE I was held for the renal failure. The metoprolol was
changed to toprol xl and a clonidine patch were added for better
control and a simplified regimen as there was concern for
patient compliance. Titration of these medications on the
medical floor and addition of hydralazine did not result in
adequate BP control as the patient had several systolic blood
pressure readings in the 250s. She was then transferred to the
intensive care unit for uncontrolled BP accompanied by head
ache. Once there, she received IV antihypertensives and HD was
initiated. Several lbs were taken off, facilitating BP control
with oral medications. She was transferred back to the medical
floor and stabilized on a regimen of clonidine patch Qweek, TID
labetolol, and QD lisinopril.
Rheum: Ms. [**Known lastname **] has SLE with discoid rash and ARF. She was
started on a prednisone burst with calcium supplementation. She
was also started on plaquanil for 1-2 months for her discoid
rash. She will be followed by Dr. [**Last Name (STitle) **] in clinic, who will
arrange for her to see an ophthalmologist. Of note, her
complement levels were low, her DS DNA was positive and her
anti-cardiolipin IgG and IgM were within normal limits.
Renal: Ms. [**Known lastname **] presented with acute on chronic renal
insufficiency. Her rise in creatinine was dramatic, from
baseline of 1.2 in [**Month (only) 958**] to 5.2 at presentation. This was
thought to be multifactorial, from both HTN and an exacerbation
of SLE. Her ACE inhibitor was initially held, and her creatinine
continued to worsen. Of note, her UA remained somewhat bland,
without acanthocytes. Her blood pressure remained difficult to
control, requiring another trip to the MICU for administration
of IV antihypertensives. It was decided that some of this was
attributed to volume overload, so HD was initiated. A tunnel
line was placed and the patient tolerated the procedure and the
HD well. It was thought that the HD would be temporary but that
the patient would eventually progress to ESRD in the near
future. She was also started on mycophenolate mofetil in the
hopes of slowing her progression to ESRD and giving her a few
months before having to start HD as more permanent renal
replacement. She was discharged with instructions to come for HD
Mondays, Wednesdays, and Fridays.
Heme: Ms. [**Known lastname **] presented with ARF, thrombocytopenia, anemia,
and leukopenia. Her haptoglobin was low and LDH was high,
concerning for hemolysis. DIC was considered unlikely since her
coagulation studies were within normal limits but [**Doctor First Name **], TTP/HUS
were considered a possibility. A peripheral smear showed
schistocytes, so the Heme service was consulted, however this
presentation could also be secondary to a malignant hypertension
inducing shearing of erythrocytes and platelets. Her ARF could
be attributed to her hypertension as well. Given the concern for
TTP, the heme service initiated plasmapheresis with the
assistance of the blood bank. The patient had 7 plasmapheresis
treatments, one of which was complicated by symptomatic
hypocalcemia evidenced by abdominal pain. She was plasmapheresed
until her platelets reached 150. Of note, her ADAMST 13 studies
were not consistent with TTP, although these studies are still
investigational. She was also started on folate and iron for her
anemia.
GI: Ms. [**Known lastname **] had one episode of hematemesis during
plasmapheresis. This was comprised of approximately 5 cc of
clots of blood concurrently with a hematocrit drop. With this
concern for GIB, Ms. [**Known lastname **] was transferred back to the MICU
where an EGD showed diffuse linear erythema of the mucosa with
no bleeding in the stomach body. These findings were compatible
with mild gastritis but did not account for the HCT drop. She
was started on a PPI and asked to avoid NSAIDs.
Medications on Admission:
atenolol 50 [**Hospital1 **]
nefedipine and enalopril in unknown quantities
prednisone 10 QD
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: start 30 mg each day for a week after you've
finished your week of prednisone 40 mg.
Disp:*21 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days: start 20 mg each day for a week after you've finished
your week of prednisone 30 mg.
Disp:*7 Tablet(s)* Refills:*0*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): this may turn your stool dark, be sure to take
colace if you need a stool softener.
Disp:*qs Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. 1 blood pressure cuff
please take your blood pressure once per day. Call the doctor if
your blood pressure is 160/100 or greater.
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: start 10 mg each day for a week after you've
finished your week of prednisone 20 mg.
Disp:*7 Tablet(s)* Refills:*0*
11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a month.
Disp:*4 4* Refills:*2*
13. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*
14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
16. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
17. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
18. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
malignant hypertension with hypertensive emergency
discoid lupus nephritis
acute renal failure
TTP vs. malignant hypertension induced thrombocytopenia
Discharge Condition:
good
Discharge Instructions:
Your new PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2423**]. You can reach her at [**Telephone/Fax (1) 6301**].
Take your blood pressure medications every day. Measure and
record your blood pressure every day. Since you don't yet have a
cuff at home that works, try having your pressure checked at a
pharmacy until you get your own cuff. Please bring your record
to your appointment.
Please come to the [**Location (un) **] of [**Company 191**] [**Hospital Ward Name 23**] on Monday to have
your blood drawn to check your renal function. The lab is open
starting at 7:30 AM.
You will be taking an increased dose of prednisone for now, but
it will be tapered weekly. Please also take your MMF,
nifedipine, clonodine, and labetolol. These medicines are all
available on the Mass Health Formulary and we are working with
case management to accelerate this for you.
Please come to hemodialysis at [**Hospital1 1426**] on [**2137-11-22**].
Please call [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] when you get home for an appointment
to schedule the placement of your AV fistula. You should have
this placed as soon as possible. Her number is [**Telephone/Fax (1) 7207**].
Stick to a low salt renal diet as described in the materials
given to you last week. Avoid chinese food, prepared foods, TV
dinners, lunch meats etc.
Your forms have been filled out for the RIDE.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2137-12-18**] 11:00
Provider: [**First Name4 (NamePattern1) 2428**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2137-12-10**] 3:30
|
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icd9cm
|
[
[
[]
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icd9pcs
|
[
[
[]
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11869, 11875
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|
287, 293
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12070, 12076
|
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12100, 13559
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2205, 2678
|
234, 249
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321, 1797
|
1819, 1911
|
1927, 2088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,597
| 164,760
|
53982
|
Discharge summary
|
report
|
Admission Date: [**2122-5-19**] Discharge Date: [**2122-5-22**]
Date of Birth: [**2070-2-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 7835**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: For full history, please see MICU
admission note dated [**2122-5-19**]. Briefly, Patient is a 52 yo male
with PMH of anoxic brain injury secondary to substance overdose
(baseline posturing and nonverbal) s/p trach and PEG in [**1-/2122**]
(at [**Hospital 5503**] Rehab), recent admission for G-tube related
complications, discharged on [**2122-5-4**], then admitted for
cholecystitis with placement of perc chole tube ([**Date range (2) 110687**])
who presents from rehab after he was found by nursing staff to
be tachycardic with HR 140, tachypneic, hypoxic with o2
saturation 77% on RA via trach, and febrile to 101F on [**2122-5-19**]
afternoon. He was initially taken to [**Location (un) **] ED, where labs
showed wbc 21.5; hct 43.6; creat 0.8. Pt was diagnosed with UTI
and had one episode of vomiting at 5pm and transferred to [**Hospital1 18**]
for further care.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: VS on arrival to ED from OSH were 98.4
122 107/75 32 98% 4L
-Exam: mild erythema around R picc site, scant pus and erythema
around gtube site, no erythema around perc chole.
-Patient received 1L NS in [**Location (un) **] and then 1LNS in the ED.
-ct abd: Perc Cholecystostomy tube terminates in the intercostal
muscles. The gallbladder is not significantly distended
-surgery saw the patient and felt the g-tube site looks fine;
perc chole was not in the gallbladder, although GB looks good on
CT scan. They removed the perc chole tube at the bedside and
recommended admission to medicine and IV abx. Pt was started
empirically on tigicycline/vanc due to previous infections with
highly resistant klebsiella and pseudomonas in the urine.
Pt was admitted initially to the ICU due to septic physiology
with fever and white count, but patient was very stable in the
MICU. His CXR was clear, leukocytosis resolved, and he remained
afebrile. His O2 sat was 97% on 5L trach mask, and his vital
signs normalized. He did have some diarrhea, but his C diff
stool PCR was negative. Surgery service discussed patient and
felt that there was no need for additional imaging and signed
off. Pt has continued to do well, and initial event attributed
to aspiration pneumonitis vs mucous plug. Pt's tube feeds and
home medications were restarted, and Pt was transferred to the
medical floor on [**2122-5-20**].
Upon arrival to the floor, vitals were:
98.8F, 122/84, 99, 28, 99% on 40% TM.
Pt was awake with eyes open, in no apparent distress.
Review of systems: unable to obtain
Past Medical History:
- TBI secondary to anoxia during substance overdose
- s/p Tracheostomy and PEG placement [**1-/2122**]
- Sepsis secondary to acute cholecystitis with placement of
drain [**4-/2122**]
- s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1003**] G tube placement [**2122-4-18**]
- s/p exploratory G tube tract incision and drainage of the
retro-rectus/peri-rectus space and drain placement [**2122-4-14**]
- multiple highly resistent urinary tract infections
Social History:
according to guardian
- from [**Name (NI) **]
- h/o substance abuse, was on methadone
- unclear if used EtOH or smoked
- no kids
Family History:
could not obtain
Physical Exam:
Admission exam:
Vitals: T100, HR112, BP106/74, RR26, O2sat 97% 10L trach
General: non-responsive, not obeying commands
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
anisocoric R > L
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: PERRL, does not obey commands, toes upgoing bilaterally,
decorticate posturing, no withdrawl to painful stimuli though
winced to painful stimulus of RUE, no hyperreflexia
SKIN: erythemetous macular rash of back confuent on upper back
and more macular further down
Discharge exam:
Physical Exam:
Vitals: tm 99.7F, tc 98.6f, 122-142/80-90, HR 94-112, 20-26, sat
99% on 20% trach mask.
General: middle-aged man, awake but non-responsive, not obeying
commands, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, left pupil 5mm,
right pupil 2 mm, both briskly reactive, blink reflex
bilaterally
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or
guarding. G tube site looks clean.
GU: foley in place
Ext: Warm, well perfused, no clubbing, cyanosis or edema, 2+
radial and dp pulses. boots on heels.
Neuro: does not obey commands, toes upgoing bilaterally,
decorticate posturing, no withdrawl to painful stimuli
SKIN: erythemetous rash on back, improved, some desquamation
Pertinent Results:
Admission labs:
[**2122-5-19**] 01:10AM PT-12.9* PTT-28.5 INR(PT)-1.2*
[**2122-5-19**] 01:10AM PLT COUNT-556*
[**2122-5-19**] 01:10AM NEUTS-82.8* LYMPHS-11.9* MONOS-4.7 EOS-0.2
BASOS-0.5
[**2122-5-19**] 01:10AM WBC-15.8*# RBC-4.29* HGB-13.9* HCT-42.8
MCV-100* MCH-32.5* MCHC-32.6 RDW-14.0
[**2122-5-19**] 01:10AM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-2.5
[**2122-5-19**] 01:10AM ALT(SGPT)-116* AST(SGOT)-90* ALK PHOS-59 TOT
BILI-0.5
[**2122-5-19**] 01:10AM GLUCOSE-117* UREA N-23* CREAT-0.8 SODIUM-141
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2122-5-19**] 01:11AM LACTATE-2.0
[**2122-5-19**] 01:15AM URINE RBC-2 WBC-151* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2122-5-19**] 01:15AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.023
.
DISCHARGE labs:
[**2122-5-22**] 06:40AM BLOOD WBC-5.8 RBC-3.81* Hgb-12.6* Hct-37.8*
MCV-99* MCH-33.2* MCHC-33.5 RDW-14.2 Plt Ct-312
[**2122-5-22**] 06:40AM BLOOD Neuts-70.2* Lymphs-21.0 Monos-5.9 Eos-2.0
Baso-0.9
[**2122-5-22**] 06:40AM BLOOD PT-11.1 PTT-27.4 INR(PT)-1.0
[**2122-5-22**] 06:40AM BLOOD Glucose-101* UreaN-16 Creat-0.5 Na-136
K-4.5 Cl-101 HCO3-25 AnGap-15
[**2122-5-21**] 07:15AM BLOOD ALT-57* AST-28 AlkPhos-49 TotBili-0.5
[**2122-5-21**] 05:10PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2122-5-21**] 05:10PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2122-5-21**] 05:10PM URINE RBC-3* WBC-48* Bacteri-FEW Yeast-NONE
Epi-0
Micro:
[**2122-5-19**] blood cultures x 2: no growth to date
[**2122-5-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {GRAM NEGATIVE ROD #1, GRAM NEGATIVE ROD #2,
STAPH AUREUS COAG +}
[**2122-5-19**] 1:26 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2122-5-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of commensal respiratory flora.
GRAM NEGATIVE ROD #1. MODERATE GROWTH. - NOT
PSEUDOMONAS
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
[**2122-5-19**] PICC TIP culture negative
[**2122-5-19**] C diff stool PCR - negative
[**2122-5-21**] URINE URINE CULTURE-PENDING
Images:
[**2122-5-19**] Radiology CHEST (PORTABLE AP) 1AM
IMPRESSION: 1. Low lung volumes, with linear right basilar
atelectasis. No acute cardiopulmonary pathology. 2. Right upper
extremity PICC tip in the right axillary vein.
[**2122-5-19**] Radiology CT ABD & PELVIS WITH CONTRAST
FINDINGS: A 8 mm nodular subpleural opacity in the right lower
lobe, likely represents a foci of atelectasis. No pleural or
pericardial effusion is detected. The liver enhances
homogeneously, without focal lesions. There is no intra- or
extra-hepatic biliary dilatation. The percutaneous
cholecystostomy tube has been retracted and the tip now lies
within the right anterior intercostal muscles (2:14). The
gallbladder is not significantly distended, as before. A single
gallstone in the neck of the gallbladder, isunchanged. Very
minimal residual gallbladder wall thickening is noted. No
significant pericholecystic fat stranding is detected. The
adrenal glands, spleen, and pancreas are normal. Both kidneys
enhance and excrete contrast symmetrically, without evidence of
hydroureteronephrosis. A percutaneous gastrostomy tube is in
place. Stomach, small and large bowel loops are otherwise
unremarkable. The appendix is normal. There is no free fluid or
air. CT OF THE PELVIS: The urinary bladder is nearly empty with
a Foley catheter in place. The rectum and sigmoid colon are
normal. No pelvic adenopathy is seen. BONES AND SOFT TISSUES: No
bone lesions suspicious for infection or malignancy are
detected. Mild degenerative changes are seen in the lumbar
spine. IMPRESSION: 1. Previously placed cholecystostomy tube has
seen malpositioned, with the tip terminating in the right
anterior intercostal muscles. 2. The gallbladder is not
significantly distended compared to the prior study. Mild
residual wall edema persists. No definite evidence of recurrent
cholecystitis. 3. Percutaneous gastrostomy tube in place. No
other acute abdominal pathology.
[**2122-5-19**] Radiology CHEST (PORTABLE AP) 10 AM
FINDINGS: Lung volumes are low causing bibasilar atelectasis.
Tracheostomy is in unchanged position. No focal opacities
concerning for an infectious process. Small pleural effusions
bilaterally.
[**2122-5-21**] Radiology CHEST (PORTABLE AP
Compared to the prior study, there has been increased opacity at
both lung bases. Opacity at the right lung base is linear and is
most consistent with atelectasis. Opacity at the left lung base
is less linear and may represent consolidation secondary to
aspiration or pneumonia. There is blunting of the left
costophrenic angle which has increased consistent with pleural
effusion. Tracheostomy tube remains in good position.
IMPRESSION: Findings consistent with right lower lobe
atelectasis, left pleural effusion, and left lower lobe opacity
consistent with pneumonia and/or aspiration.
Brief Hospital Course:
52M w/ PMH of anoxic brain injury (baseline non-verbal and
posturing) and recent cholecystitis with placement of perc chole
tube who presents from [**Hospital1 1501**] with tachycardia, tachypneia, and in
hypoxic respiratory distress, found to have displaced perc chole
tube, now removed.
#Hypoxic respiratory distress: Patient developed tachypnea and
sats of 77% on room air trach, later improving to 95% sats on 5L
via trach. Clear CXR and rapidly improving sypmtoms suggest
aspiration pneumonitis versus mucous plugging, less likely
pneumonia. Also less likely pulmonary embolism given rapid
resolution, and Pt was on heparin prophylaxis. Patient now in no
respiratory distress and is satting well on trach mask, but is
growing moderate gram neg rods on sputum culture, possibly
commensals, and gram positive cocci. Pt also vomited [**2122-5-21**]
morning, but very low residuals (10mL). Pt currently has a G
tube and has been using it without issue. Pt has not had any
further emesis. Repeat CXR on [**2122-5-21**] showed right lower lobe
atelectasis, left pleural effusion, and left lower lobe opacity
consistent with pneumonia and/or aspiration. Pt has not had any
fevers, and white cell count remains normal at 5.8k on [**2122-5-22**].
Sputum culture from [**2122-5-19**] showed > 3 different species
consistent w/ mixed flora, further speciation showed gram
negative rods but no evidence of Pseudomonas, and gram positive
cocci, likely Staph aureus. Pt has had intermittent tachypena,
but O2 requirements are close to baseline, and he is being
treated with [**Month/Day/Year **] for suspected UTI (see below), which
will cover Staph aureus (including MRSA), Strep, and atypical
organisms. Will continue [**Month/Day/Year **] for 2 weeks total, so if Pt
has HCAP, course for UTI will cover.
#Tachycardia: Patient presented with tachycardia from [**Hospital1 1501**].
Possible early sepsis vs. reaction to pain or pulmonary event
(aspiration, mucous plug, pulmonary embolism), or primary
neurological cause. Currently afebrile without leukocytosis and
no clear infectious source, does not look to be in pain. Patient
appears euvolemic on exam and is having good urine output. Low
suspicion for pulmonary embolism given no longer hypoxic and on
anticoagulation prior to admission. Pt may be having paroxysmal
autonomic instability w/ dystonia (PAID) syndrome [Arch Neurol.
[**2114**];61:321-328], which is associated w/ severe brain injury of
any sort and includes episodic symptoms of marked agitation,
diaphoresis, hyperthermia, hypertension, tachycardia, and
tachypnea accompanied by hypertonia and extensor posturing. His
home metoprolol 25 mg q6 hrs was continued without issue.
#Fever / UTI: Patient was febrile to 101F at [**Hospital1 1501**]. However, he
has been afebrile since admission. Leukocytosis now improved. UA
negative, and CXR without consolidation. CT abdomen negative for
acute process. [**Month (only) 116**] have been due to dislodged perc chole tube
causing inflammatory reaction being lodged in intercostals
muscle. PICC line was removed. Also patient now c/o diarrhea,
but C diff stool PCR negative. Pt w/ elevated LFTs, which may be
due to infection, obstruction or medications. [**Month (only) 116**] also be
component of PAID syndrome (see above). All cultures are
negative for > 48 hours and other studies are unrevealing. LFTs
improving. UA on [**2122-5-19**] showed significant pyuria w/ 151 WBCs,
but no urine culture was sent from ED. Attempted to add on urine
culture to [**2122-5-19**] sample, but specimen was lost by the lab.
Repeat UA on [**2122-5-21**] showed improved pyruia with 48 WBCs, and
urine culture still pending, but given that he already received
two days of [**Last Name (LF) **], [**First Name3 (LF) **] need to presume complicated UTI
and continue to treat with [**First Name3 (LF) **] 50mg iv bid for full 2
week course ending [**2122-6-2**]. Blood culture have shown no growth
to date, and Pt's white blood cell count resolved to normal on
[**2122-5-19**]. NOTE: Pt had a MIDLINE IV placed in R upper extremity,
with heparin dependent flushes. Pt's foley catheter was also
changed just prior to discharge on [**2122-5-22**]. Since he is on
[**Date Range **], Pt will need weekly AST, ALK, Alkaline phosphatase,
total bilirubin, BUN, Creatinine, phosphate while on [**Date Range **]
as these values may increase with this medication. He will also
need weekly complete blood count as [**Date Range **] may cause
thrombocytopenia.
#Rash: Patient has a rash over his back of unclear etiology. It
is a macular rash with confluence at upper back. Possible
exanthem vs. drug rash vs. dependent rubor/stage 1. Was
improving prior to discharge with mild desquamation.
# Pressure ulcer: Stage I, over buttock, will need good wound
care and frequent repositioning as per wound care recs (see
below).
# Nutrition/G-tube: The patient has a history of infections at
the site of his G-tube. It will be important to closely monitor
the site, with routine care. It is a stoma and is chronically
macerated. Pt's famotidine and tube feeds were continued without
issue. Dressings as per wound care instructions below.
# Code Status: The patient is Full Code, with a court appointed
guardian. Changes in clinical status should be discussed with
the guardian. The prognosis overall of the patient's grim chance
of neurological recovery was discussed on previous admission,
and the guardian is exploring options through the court system
to make the patient DNR/DNI. Currently he is full code.
# wound care: per inpatient wound care consult:
Pressure ulcer care per guidelines: 1) Turn and reposition off
back q 2 hours and prn. 2) Limit sit time to 1 hour at a time
using a pressure redistribution cushion
For gtube site: 1) cleanse skin/ulcer and pat dry. 2) barrier
wipe to periwound
tissue. 3) fill/cover wound with aquacel sheet or rope followed
by allevyn foam trach sponge, secure with Medipore H soft cloth
tape, change daily
For perianal, thighs and gluteal tissues: 1) cleanse gently with
foam cleanser then pat dry, apply thin layers of critic aid
clear antifungal [**Hospital1 **]
waffle or MPS to bilateral heels as pt has hx of heel ulcers
# dvt prophylaxis: heparin 5000 units sc tid
TRANSITIONAL ISSUES:
-final urine culture still pending
-Pt will need weekly AST, ALK, Alkaline phosphatase, total
bilirubin, BUN, Creatinine, phosphate while on [**Hospital1 **] as
these values may increase with this medication. He will also
need weekly complete blood count as [**Hospital1 **] may cause
thrombocytopenia.
-Pt's court-appointed guardian is working with court to change
Pt's code status to do not resuscitate, currently remains full
code.
Medications on Admission:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation.
8. Fleet enema
1 enema PR PRN constipation
9. Oxygen Therapy
Continuous bland aerosol mask 40 % Via Trach Mask
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): hold for sbp < 90 or HR < 55.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): hold for loose stool.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as
needed for constipation.
8. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once
a day as needed for constipation.
9. oxygen therapy Sig: 40% via trach mask continuous.
10. [**Hospital1 **] 50 mg Recon Soln Sig: Fifty (50) mg Intravenous
Q12H (every 12 hours) for 11 days: end after [**2122-6-2**] evening
dose.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Primary:
urinary tract infection
pneumonia vs. aspiration
paroxysmal autonomic instability with dystonia
Secondary:
anoxic brain injury
Discharge Condition:
Activity Status: Bedbound
Level of Consciousness: awake, but not interactive
Mental Status: not interactive
Discharge Instructions:
Mr. [**Known lastname 110682**],
You were sent to [**Hospital1 18**] from your facility because you had signs
of a severe infection. Upon further workup at our hospital, you
were found to have a urinary tract infection, similar to ones
you have had previously, and possibly a an infection of your
lungs. You were treated with IV antiobiotics, which you will
need to continue at your facility, and you made a rapid
recovery.
We have made the following changes to your medications:
-START [**Hospital1 **] 50mg IV every 12 hours for 11 more days,
stopping on [**2122-6-2**]. (You will need to have your liver, blood
count, and blood chemistry labs to be checked by your facility
weekly while on this medication.)
We have not made any changes to your other medications. Please
continue to take them as previously prescribed.
We also noticed that your heart rate, respiratory rate, and
blood pressure are at times highly variable, even when you do
not have any other evidence of infection. This is likely due to
a dysfunction of your autonomic nervous system.
Followup Instructions:
Please arrange to be seen by the doctor at your facility within
one week.
Completed by:[**2122-5-24**]
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56,552
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Discharge summary
|
report
|
Admission Date: [**2151-1-5**] Discharge Date: [**2151-1-20**]
Date of Birth: [**2077-3-23**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
LLQ pain, presented for chemotherapy
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Intra aortic ballon pump
Bare metal stent placement (x 2)
Hemodialysis
History of Present Illness:
Pt is a 73 y.o male with h.o NHL, CHF with EF 30%, AS, ESRD on
HD MWF, afib, DM2, hypogammuloglobulinema who presents with LLQ
abdominal pain. Per patient he has been doing okay since his
discharge to rehab earlier this month but over this past weekend
felt overall unwell. He developed LLQ pain that radiates around
left side to back, similar in nature to the pain he had during
his last admission that was felt to be d/t mesenteric/RP
lymphadenopathy and responded well to chemotherapy. Pain can be
[**10-24**] at times, but responds to oxycodone. No other abdominal
pain, nausea, emesis, melena, hematochezia, diarrhea, or
constipation. Also feels completely worn out, fatigued, with a
decreased appetite and feels like 'my whole body is exploding'.
Concerned that his cancer is progressing and was sent from rehab
for evaluation and chemotherapy.
.
Recently admitted [**Date range (1) 101001**] for chest pain and was found to
have unstable angina with stenosis of LAD and PDA at cath, s/p
BMS. He also had enlarging supraclavicular and cervical lymph
nodes and back pain and had evidence of rapidly progressive
lymphoma on CT with concern for high grade transformation. He
received IV dexamethasone, Oncovin ([**12-3**]) and Bendamustine
([**12-3**]), and Rituximab ([**12-4**]). His chemotherapy was complicated
by pancytopenia for which he was started on neupogen, tumor
lysis for which he received allopurinol and rasburicase, and
febrile neutropenia of unknown etiology treated with vanc/zosyn.
.
In ED, SBPs 80-90s (one [**Location (un) 1131**] in 70s), HR 102, 19, 97% 3L NC.
Received 250 mL fluid, although upon arrival to floor 1L bag
hanging at 250cc/hr and nearly finished. CXR showed resolving
CHF.
Past Medical History:
1. Non-Hodgkin's Lymphoma, slowly progressive (follicular
low-grade B-cell NHL grade I, diagnosed in [**2142**]), on
Bendemustine with partial response, has had recurrence on other
meds, over past month or so palpable lymphadenopathy seems to
have returned
2. Congestive heart failure likely secondary to combination of
moderate aortic stenosis and adriamycin cardiomyopathy EF 30%;
EFs have been improving recently, have been as low as 25% in
past
3. Aortic Stenosis (moderate)
4. End-stage kidney disease on HD MWF (secondary to diabetic
nephropathy; has had trauma to one kidney in childhood)
5. Atrial fibrillation, recently diagnosed
6. Type 2 diabetes mellitus (on glipizide)
7. Gout
8. Meningioma
9. Spinal stenosis- s/p surgery [**51**] yrs ago
10. Osteoarthritis of the hips s/p b/l THR
11. hypogammaglobulinemia (gets monthly IVIG)
Social History:
The patient is married and lives in [**Location 1439**], [**State 350**]. He
has four children. He quit smoking cigarettes 43 years ago after
80 pack yrs. He does not drink alcohol and denies the use of
illicit or illegal drugs. He works as a kosher butcher in
[**Location (un) **].
Family History:
Mother had diabetes mellitus and died at the age of [**Age over 90 **] years.
Father died at the age of [**Age over 90 **] years. He has three brothers and
three sisters who are basically healthy. There is no family
history of sudden death or premature atherosclerotic
cardiovascular disease
Physical Exam:
VS: 97.0, 101/56, 93, 16, 92% RA
GENERAL: NAD
HEENT: NCAT. Anicteric. OP clear.
NECK: Supple, no appreciable cervical or supraclavicular LAD
CARDIAC: RRR, normal S1, S2, III/VI SEM at RUSB
LUNGS: crackles at bases bilaterally
ABDOMEN: Soft, NTND, + BS, no rebound or guarding
EXTREMITIES: No c/c/e.
SKIN: no rashes
NEURO: A&O x 3, MAE
Pertinent Results:
[**2151-1-5**] 03:30PM WBC-5.9# RBC-3.57*# HGB-10.7*# HCT-34.2*#
MCV-96 MCH-29.9 MCHC-31.2 RDW-21.1*
[**2151-1-5**] 03:30PM PLT COUNT-53*
[**2151-1-5**] 03:30PM NEUTS-77.9* LYMPHS-15.9* MONOS-3.4 EOS-2.5
BASOS-0.4
.
[**2151-1-5**] 03:30PM GLUCOSE-94 UREA N-34* CREAT-5.4*# SODIUM-140
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-16
.
[**2151-1-5**] 04:59PM PT-14.3* PTT-29.6 INR(PT)-1.2*
.
[**2151-1-5**] 03:30PM ALT(SGPT)-19 AST(SGOT)-44* LD(LDH)-1667* ALK
PHOS-78 TOT BILI-0.3
[**2151-1-5**] 03:30PM LIPASE-22
[**2151-1-5**] 03:30PM URIC ACID-5.5
.
[**2151-1-7**] 06:36PM BLOOD CK-MB-4 cTropnT-0.28*
[**2151-1-8**] 06:00AM BLOOD CK-MB-4 cTropnT-0.21*
[**2151-1-9**] 12:36AM BLOOD CK-MB-4 cTropnT-0.18*
[**2151-1-10**] 03:31AM BLOOD CK-MB-8 cTropnT-0.30*
.
[**2151-1-8**] 06:51PM BLOOD freeCa-0.99*
.
EKG: Sinus rhythm. Left axis deviation. Intraventricular
conduction delay. ST-T wave abnormalities. Since the previous
tracing of [**2150-12-8**] the P-R interval is shorter. Differences in
precordial R wave progression may be related to lead position,
seen better on the present study.
.
EKG: Normal sinus rhythm, rate 99, with first degree A-V block.
Left axis
deviation. Intraventricular conduction delay of left
bundle-branch block type.
Cannot exclude anteroseptal and/or inferior myocardial
infarction of
indeterminate age. Borderline left atrial abnormality. Compared
to the
previous tracing of [**2150-12-16**] R waves are markedly diminished
across the
anterior precordium consistent with possible interval anterior
myocardial
infarction. Clinical correlation is suggested. Also, first
degree A-V block
is new.
.
CXR PA/LAT [**1-5**]
No evidence of new infiltrates.
.
CXR [**1-11**]
1. Increased left basilar consolidation. Elevated left
hemidiaphragm with
probable elevated stomach bubble beneath. However, gas in the
pleural space cannot be excluded on this single-view exam. If
there is clinical concern for empyema or other cause of gas in
the pleural space, further evaluation with PA and lateral
radiographs or with chest CT would be recommended.
2. Unchanged small bilateral pleural effusions.
.
MICRO:
sputum gram stain and cx neg x 2
C. dif and stool cx neg
Brief Hospital Course:
73 year-old gentleman with history of ESRD on HD, chronic sCHF
(EF 30%), moderate to severe AS (valve area 0.9), CAD with BMS
to RCA on [**2150-11-27**], recent NSTEMI on [**2150-12-7**], and B-cell
lymphoma with recent chemotherapy with vincritine and rituximab
c/b tumor-lysis syndrome presents for chemo with symptoms of LLQ
pain consistent with prior lymphoma symptoms.
.
Patient presented with LLQ pain thought [**2-16**] progressive
lymphoma. This pain was improved with chemotherapy, but after 1
day of chemo his course was complicated by hospital-acquired
pneumonia, as well as cardiac pain found to be an anterior STEMI
requiring IABP placement and multiple stents to the LAD.
Although at baseline the patient had low SBP (100s-110s),
following his cardiac intervention and CCU stay his SBPs began
to gradually deteriorate over the course of the next week.
Initially this resulted in no changes in mental status and did
not interfere with HD, but eventually once his SBPs began to dip
into the high 60s, Nephrology felt that they could not proceed
with HD and the patient began to have transient episodes of
confusion. Dr. [**Last Name (STitle) **], the patient's oncologist, agreed with
this assessment and felt that there was no other medical
treatment for his NHL that could be offered in his present
state. Discussion was held with family that [**Hospital 228**] medical
condition was rapidly deteriorating. After discussion, pt was
made DNR/DNI. The patient expired in the early hours on [**1-20**], [**2151**].
Medications on Admission:
Acet prn
Albuterol prn
Maalox prn
Aspirin 325 daily
Atorvastatin 80 daily
Vit B/C/folic acid
Calcium acetate 667 TID
Plavix 75 daily
Digoxin 125 mcg every three days (last on [**1-4**])
Colace [**Hospital1 **]
Glipizide 5 mg [**Hospital1 **]
Ipratroprium 1 IH Q6H prn
Lisinopril 10 mg daily
Metoprolol 12.5 [**Hospital1 **]
Oxycodone 5 mg PO Q6H prn
Ranitidine 150 mg daily
Miralax prn
Senna prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2151-1-20**]
|
[
"403.91",
"202.08",
"250.40",
"799.02",
"276.8",
"428.22",
"425.4",
"275.3",
"785.51",
"414.01",
"272.4",
"585.6",
"486",
"277.88",
"428.0",
"790.6",
"424.1",
"E933.1",
"427.31",
"410.72",
"279.00",
"V45.11",
"287.5",
"411.1",
"276.7",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.66",
"88.57",
"37.61",
"38.93",
"00.46",
"36.06",
"39.95",
"00.40",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
8224, 8233
|
6218, 7750
|
304, 401
|
8280, 8285
|
3994, 6195
|
8337, 8371
|
3330, 3623
|
8196, 8201
|
8254, 8259
|
7776, 8173
|
8309, 8314
|
3638, 3975
|
228, 266
|
429, 2146
|
2168, 3012
|
3029, 3314
|
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